Every finding on record at Corn Heritage Village and Rehab

On 11/10/25 at 2:33 p.m., the OSDH was notified and verified the existence of an immediate jeopardy situation related to the facility's failure to ensure monitoring and intervention for Resident #3 who was on a routine long-term anticoagulant. This resulted in the resident being admitted to the ICU with an acute subdural hemorrhage after a fall.On 11/10/25 at 3:34 p.m., the administrator and interim executive director were notified of the immediate jeopardy and was provided the immediate jeopardy template. On 11/13/25 at 12:39 p.m., an acceptable plan of removal was approved by the OSDH.The plan of removal read in part,Staff will identify residents on anticoagulants at shift change by notifying oncoming staff at shift change of all residents on anticoagulants starting 11/14/2025 7:00 am at shift change and going to continue for 4 weeks and then reevaluate at that time.Administration will post a roster in the medication room of all residents on anticoagulants.Administration will post a roster in the medication room of all anticoagulant medications.Will adjust EHR resident dashboard to indicate the use of anticoagulant medicationImmediate In-Service Education of medication management with a focus on high-risk drugs like anticoagulants for nursing staff and CMAs.Competency assessments will be completed by nursing administration including demonstrations of skills, med-administration, side effects and monitoring requirements.All residents were reassessed for changes in condition and care plans were updated for discrepancies.Nursing staff were educated on monitoring residents through routine assessments (Every shift for 72 hours), ongoing observation, and documentation. This includes checking vital signs, evaluating physical and mental status, and noting any changes in behavior, appearance, or function. Staff are now trained to recognize both subtle and obvious changes in residents' health, such as increased confusion, changes in mobility, altered appetite, new or worsening pain, or unusual sleep patterns.Nursing Staff were educated on promptly notifying the physician whenever there is a significant change in the condition of a nursing home resident on anti-coagulants. This includes any acute medical events, substantial changes in physical or mental status, or any situation that may require a change in treatment or intervention. Notification should occur as soon as reasonably possible after the change has been identified by nursing staff, in accordance with regulatory guidelines and the facility's policies. Nursing home nursing staff will receive dedicated training focused on the indications for commonly used medications, with special emphasis on blood thinners. The training will cover: Overview of blood thinners: indications, expected outcomes, and common side effects. Recognizing signs and symptoms of adverse reactions or complications (e.g., bleeding, bruising, changes in mental status, or unexplained pain). Monitoring protocols for residents on blood thinners, including vital signs, laboratory values, and physical assessments. Documentation requirements and communication procedures for reporting changes in resident conditions. Emergency response procedures for suspected medication-related complications. The training will be delivered by the facility's Director of Nursing, in collaboration with the facility pharmacist consultant and CHV nurse consultant. These professionals have specialized knowledge in pharmacology, geriatric care, and clinical practice, ensuring nursing staff receive accurate and practical information.The IJ was lifted, effective 11/14/25 at 11:59 p.m., when all components of the plan of removal had been verified as completed. Records of staff training showed all staff, including administration, had received training in intervening when there were changes in residents' condition as well as completed an annual competency skill checklist. Records of nurse competency skill checks and nurse tests regarding new training were verified to be complete. Review of a current resident assessment log showed residents who were identified to receive high risk drugs such as anticoagulants were reassessed by the DON and ADON and care plans were updated. Interviews conducted with staff showed they had received training in falls, medications, and changes in condition. The deficiency remained at an isolated level with the potential for more than minimal harm.Based on observation, record review and interview, the facility failed to ensure monitoring and intervention was implemented for a change in condition for 1 (#3) of 1 sampled resident reviewed for monitoring and intervention.The administrator identified 54 residents resided in the facility.Findings:On 10/23/25 at 11:50 a.m., Resident #3 was observed to be lying in bed. The resident was pleasant and smiling. A facility policy titled Neurologic Observation dated 10/12/17, read in part, a resident that receives any type of head wound or trauma involving the head, a neurologic assessment will be performed for the period of 72 hours. The physician will be notified immediately and with any changes in neurological status.An initial incident report made to OSDH, dated 06/28/25, showed Resident #3 had an unwitnessed fall from the recliner in their room, which occurred on 06/23/25. The report read in part, per nurses notes resident was getting out of her recliner and fell forward, hitting her head and causing a large goose egg .nursing notes reported increased bruising to periorbital region .Resident is up and about as desired in the room but is a fall risk.A progress note for Resident #3, dated 06/24/25 at 7:47 p.m., read in part, B/P 111/49, T-96.2, P-74, oxygen saturation 87%, dark purple bruising around eyes and resident requiring more assistance. There was no documentation to indicate the physician was notified of the change in condition. A progress note, dated 06/25/25 at 7:45 p.m., read in part, resident has pinpoint pupils and mental status change. [Family Member] is present and physician notified. Received orders to send resident to hospital via ambulance. Physician orders for Resident #3, dated October 2025, showed diagnoses which included rheumatoid arthritis, atrial fibrillation, hypertension and transient ischemic attack.A quarterly MDS assessment, dated 10/08/25, showed a BIMS score of 8 indicating moderate cognitive impairment. On 10/23/25 at 11:50 a.m., Resident #3 stated all the staff were nice and they were treated with dignity and respect. Resident #3 was asked what they could recall about their fall in June. Resident #3 stated, I'm just a delicate person.On 10/27/25 at 2:45 p.m., the DON stated the resident should have been sent to hospital immediately after the fall due to being on blood thinners. On 11/10/25 at 10:50 a.m., Resident #3's physician's nurse stated the charge nurse (LPN #2) had reported Resident #3's fall on 06/23/25 but was told Resident #3 was not on a blood thinner. The physician's nurse stated no other information regarding Resident #3 was reported to the physician.On 11/10/25 at 11:38 a.m., Resident #3's family member stated when they came to visit during the evening on 06/25/25, they observed a significant change in Resident #3's mental status and called the nurse to the room. They stated since the fall, Resident #3 stayed in bed more than in the chair. On 11/10/25 at 12:17 p.m., LPN #2 stated they did not notify the physician Resident #3 was on a blood thinner when they reported their fall. LPN #2 was asked to verify the indication for Xarelto. They stated, It's a blood thinner and I overlooked it. LPN #2 stated Resident #3 should have been sent out immediately after the fall due to hitting their head and taking blood thinners. LPN #2 stated the physician should also have been notified of Resident #3's two black eyes that were not observed the day of the fall. LPN #2 was asked about Resident #3's blood pressure readings after the fall. LPN #2 stated that should have been communicated to the physician as a change in condition as the blood pressure readings were abnormal.

On 11/10/25 at 2:33 p.m., the OSDH was notified and verified the existence of an immediate jeopardy situation related to the facility's failure to ensure nursing staff were competent to effectively assess, monitor, and intervene for Resident #3 who was on a routine blood thinner and sustained a fall with injury causing an acute subdural hemorrhage resulting in being admitted to ICU.On 11/10/25 at 3:34 p.m., the administrator and interim executive director were notified of the immediate jeopardy and was provided the immediate jeopardy template. On 11/13/25 at 12:39 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,Plan of removal: 11/14/25 11:59 p.m.All nursing staff have completed Skills Competency proficiency of change of condition with a focus on high-risk drugs like anticoagulants for nursing staff.DON and ADON have been In-service on training and completing nursing skills competency education for nursing staff by administrator.All residents were reassessed for changes in condition and care plans were updated for discrepancies.DON and ADON have been educated on auditing nursing staff annual skills competency educationDON and ADON have been educated on auditing nursing staff new hire skills competency educationNursing staff will complete testing regarding changes in condition, medication drug class identification, and recognizing vital signs.Nursing staff are educated on what constitutes a significant change in condition that requires reporting by Corn Heritage Village Nurse Consultant. These changes include, but are not limited to: Sudden onset of symptoms (chest pain, shortness of breath, acute confusion)Significant changes in vital signs (high fever, low blood pressure, rapid heart rate)New or worsening painChanges in mobility, such as inability to walk or standAltered level of consciousness or responsivenessSigns of infection (redness, swelling, discharge)Unexplained weight loss or gainChanges in skin integrity, such as new wounds or pressure sores.The IJ was lifted, effective 11/14/25 at 11:59 p.m., when all components of the plan of removal had been verified as completed. Records of staff training showed all staff, including administration, had received training in intervening when there were changes in residents' condition as well as completed an annual competency skill checklist. Review of a current resident assessment log showed residents who were identified to receive high risk drugs such as anticoagulants were reassessed by the DON and ADON and care plans were updated. Interviews conducted with staff showed they had received training in falls and changes in condition. The deficiency remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility failed to ensure staff were competent to effectively assess, monitor, and intervene for residents with a change in condition for 1 (#3) of 1 sampled resident reviewed for monitoring and intervening.The administrator identified 54 residents resided in the facility. Findings: A policy titled Neurological Observation, updated 10/12/17, read in part, A resident that receives any type of head wound or trauma involving the head, a neurologic assessment will be performed for the period of 72 hours. The physician will be notified immediately and with any changes in neurological status.A policy titled Notification of Changes, dated 10/24/24, read in part, All pertinent information will be made available to the provider by the health care team. Team members are educated to identify changes in a resident's status and define changes that require notification .of the resident's physician, to ensure best outcomes of care for the resident. Requirements for notification of .physician: A significant change in the resident's physical, mental, or psychosocial status. A significant change includes deterioration in health, a need to alter treatment significantly.A Medication Administration Record, dated June 2025, showed Resident #3 was taking Xarelto (a blood thinner) 20mg one tablet at bedtime every day. The medication administration record showed the Xarelto was given 06/01/25 through 06/24/25 and never held.An Incident Note, dated 06/23/25 at 7:00 a.m., read in part, Late entry: Resident was getting up out of [their] recliner and fell forward to the floor, hitting [their] head and causing a large goose egg. Bruising is noted to area. Resident wasn't sure what happened or why [they] fell. Was found in a sitting position by CNA. Resident also has bruising to upper left arm as well as an abrasion to left hand. Neuros WNL. Systolic BP elevated. Resident does report pain at the site of the knot on [their] head.A Neurological Flow Sheet, dated 06/23/25 at 10:30 a.m., showed Resident #3's blood pressure was 127/49.An Incident Note, dated 06/23/25 at 7:00 p.m., read in part, Focus charting on IR of unwitnessed fall in room on 6/23/25 with neuro checks. Resident awake and verbal with [family member] to visit. Resident with hematoma and discoloration to left side of forehead, bruising to left arm, and middle finger to left hand. Voiced of slight pain per generalized areas. Meds and tx per order, staff to monitor for changes. 132/53 97.1 84 18 92%.An Incident Note, dated 06/24/25 at 1:57 a.m., read in part, Focus charting on IR of unwitnessed fall in room on 6/23/25 with neuro checks. Resident awake and verbal with [family] to visit. Resident with hematoma and discoloration to left side of forehead, bruising to left arm, and middle finger to left hand. Voiced of slight pain per generalized areas. Meds and tx per order, staff to monitor for changes. 111/49 96.2 74 18 87%.An Incident Note, dated 06/24/25 at 8:00 a.m., read in part, Focused evaluation related to unwitnessed fall on 06/22/2025. New injury noted. Resident now has 2 black eyes that didn't show up yesterday. Resident also has bruised, tender left foot. Resident is able to move foot up and down. VS are as follows: 125/53,97.9, 76, 18, 90%.A Neurological Flow Sheet, dated 06/24/25 at 11:30 a.m., showed Resident #3's blood pressure was 103/43.A Nurse Progress Note, dated 06/24/25 at 7:47 p.m., read in part, Staff reported resident requiring more assistance with ambulating. Possibly needing walker to steady self.A Transfer to Hospital Summary Note, dated 06/25/25 at 7:45 p.m., read in part, Resident continues on neuro check. This nurse entered resident room. Resident's [family member] at bedside. Resident noted to have a change in neuro status. Pupils pinpoint and resident confused and slow to respond. Reported to [physician name withheld]. New order received to send resident to ER via ambulance.A Discharge summary, dated [DATE], read in part, admission diagnosis acute subdural hematoma. Bruising on entire face. Past medical history of atrial fibrillation on Xarelto, admitted to neuro ICU on 06/25/25 for traumatic left subdural hematoma after a fall at [their] nursing home. Patient's anticoagulation was reversed.An MDS Assessment, dated 10/08/25, showed Resident #3 was admitted to the facility on [DATE] with diagnoses to include atrial fibrillation and heart failure.On 10/27/25 at 2:45 p.m., the DON stated Resident #3 should have been sent to the hospital immediately after the fall on 06/23/25 due to being on a blood thinner. On 11/10/25 at 10:50 a.m., Resident #3's physician's office was contacted. The physician's nurse stated the charge nurse (LPN #2) had reported Resident #3's fall on 06/23/25, but was told Resident #3 was not on a blood thinner. The physician's nurse stated no other information regarding Resident #3 was reported to the physician.On 11/10/25 at 12:17 p.m., LPN #2 stated they did not notify the physician Resident #3 was on a blood thinner when they reported their fall on 06/23/25. When LPN #2 was asked to verify the indication for Xarelto, they stated, It's a blood thinner and I overlooked it. LPN #2 stated Resident #3 should have been sent out immediately after the fall due to hitting their head and taking blood thinners. LPN #2 stated the physician should also have been notified of Resident #3's two black eyes that were not observed the day of the fall. When asked about Resident #3's blood pressure readings after the fall, LPN #2 stated that should have been communicated to the physician as a change in condition as the blood pressure readings were abnormal.On 11/10/25 at 12:46 p.m., the ADON was asked what the facility's process was for notifying a physician after a fall. They stated, Any injuries and if they're on a blood thinner. The ADON was asked what their policy was regarding reporting abnormal vital signs to physicians. They stated, Every physician has their own parameters and it's in the residents' charts. The ADON was asked if a blood pressure of 111/49 should have been reported to the physician. They stated, Definitely if they're on neuro checks. The ADON stated if a blood pressure or any other vital sign continues to decrease it would need to be reported to the physician as a change in condition.On 11/10/25 at 12:49 p.m., the ADON was asked what systemic breakdowns were identified after Resident #3's fall. They stated, We implemented the part about being on blood thinners in the fall policy and we did in-services. The ADON was asked if nursing staff completed competency check offs yearly. They stated, Not to my knowledge.On 11/10/25 at 1:14 p.m., the administrator was asked how they ensured the nurses were competent in providing care to residents. They stated the facility provided in-services throughout the year. The administrator was asked if there were any specific trainings required of the nurses. They stated, No.

Based on record review and interview, the facility failed to ensure the physician was notified of a change in condition for 1 (#3) of 3 sampled residents reviewed for change in condition.The administrator identified 54 residents resided in the facility. Findings:A policy titled Neurological Observation, updated 10/12/17, read in part, A resident that receives any type of head wound or trauma involving the head, a neurologic assessment will be performed for the period of 72 hours. The physician will be notified immediately and with any changes in neurological status.A policy titled Notification of Changes, dated 10/24/24, read in part, All pertinent information will be made available to the provider by the health care team. Team members are educated to identify changes in a resident's status and define changes that require notification .of the resident's physician, to ensure best outcomes of care for the resident. Requirements for notification of .physician: A significant change in the resident's physical, mental, or psychosocial status. A significant change includes deterioration in health, a need to alter treatment significantly.A Medication Administration Record, dated June 2025, showed Resident #3 was taking Xarelto (a blood thinner) 20mg one tablet at bedtime every day. The medication administration record showed the Xarelto was given 06/01/25 through 06/24/25 and never held.An Incident Note, dated 06/23/25 at 7:00 a.m., read in part, Late entry: Resident was getting up out of [their] recliner and fell forward to the floor, hitting [their] head and causing a large goose egg. Bruising is noted to area. Resident wasn't sure what happened or why [they] fell. Was found in a sitting position by CNA. Resident also has bruising to upper left arm as well as an abrasion to left hand. Neuros WNL. Systolic BP elevated. Resident does report pain at the site of the knot on [their] head.A Neurological Flow Sheet, dated 06/23/25 at 10:30 a.m., showed Resident #3's blood pressure was 127/49.An Incident Note, dated 06/23/25 at 7:00 p.m., read in part, Focus charting on IR of unwitnessed fall in room on 6/23/25 with neuro checks. Resident awake and verbal with [family member] to visit. Resident with hematoma and discoloration to left side of forehead, bruising to left arm, and middle finger to left hand. Voiced of slight pain per generalized areas. Meds and tx per order, staff to monitor for changes. 132/53 97.1 84 18 92%.An Incident Note, dated 06/24/25 at 1:57 a.m., read in part, Focus charting on IR of unwitnessed fall in room on 6/23/25 with neuro checks. Resident awake and verbal with [family] to visit. Resident with hematoma and discoloration to left side of forehead, bruising to left arm, and middle finger to left hand. Voiced of slight pain per generalized areas. Meds and tx per order, staff to monitor for changes. 111/49 96.2 74 18 87%.An Incident Note, dated 06/24/25 at 8:00 a.m., read in part, Focused evaluation related to unwitnessed fall on 06/22/2025. New injury noted. Resident now has 2 black eyes that didn't show up yesterday. Resident also has bruised, tender left foot. Resident is able to move foot up and down. VS are as follows: 125/53,97.9, 76, 18, 90%.A Neurological Flow Sheet, dated 06/24/25 at 11:30 a.m., showed Resident #3's blood pressure was 103/43.A Nurse Progress Note, dated 06/24/25 at 7:47 p.m., read in part, Staff reported resident requiring more assistance with ambulating. Possibly needing walker to steady self.A Transfer to Hospital Summary Note, dated 06/25/25 at 7:45 p.m., read in part, Resident continues on neuro check. This nurse entered resident room. Resident's [family member] at bedside. Resident noted to have a change in neuro status. Pupils pinpoint and resident confused and slow to respond. Reported to [physician name withheld]. New order received to send resident to ER via ambulance.A Discharge summary, dated [DATE], read in part, admission diagnosis acute subdural hematoma. Bruising on entire face. Past medical history of atrial fibrillation on Xarelto, admitted to neuro ICU on 06/25/25 for traumatic left subdural hematoma after a fall at [their] nursing home. Patient's anticoagulation was reversed.An MDS Assessment, dated 10/08/25, showed Resident #3 was admitted to the facility on [DATE] with diagnoses to include atrial fibrillation and heart failure.On 10/27/25 at 2:45 p.m., the DON stated Resident #3 should have been sent to the hospital immediately after the fall on 06/23/25 due to being on a blood thinner. On 11/10/25 at 10:50 a.m., Resident #3's physician's office was contacted. The physician's nurse stated the charge nurse (LPN #2) had reported Resident #3's fall on 06/23/25, but was told Resident #3 was not on a blood thinner. The physician's nurse stated no other information regarding Resident #3 was reported to the physician.On 11/10/25 at 12:17 p.m., LPN #2 stated they did not notify the physician Resident #3 was on a blood thinner when they reported their fall on 06/23/25. When LPN #2 was asked to verify the indication for Xarelto, they stated, It's a blood thinner and I overlooked it. LPN #2 stated Resident #3 should have been sent out immediately after the fall on 06/23/25 due to hitting their head and taking blood thinners. LPN #2 stated the physician should also have been notified of Resident #3's two black eyes that were not observed the day of the fall. When asked about Resident #3's blood pressure readings after the fall, LPN #2 stated that should have been communicated to the physician as a change in condition as the blood pressure readings were abnormal.On 11/10/25 at 12:46 p.m., the ADON was asked what the facility's process was for notifying a physician after a fall. They stated, Any injuries and if they're on a blood thinner. The ADON was asked what their policy was regarding reporting abnormal vital signs to physicians. They stated, Every physician has their own parameters and it's in the residents' charts. The ADON was asked if a blood pressure of 111/49 should have been reported to the physician. They stated, Definitely if they're on neuro checks. The ADON stated if a blood pressure or any other vital sign continued to decrease it would need to be reported to the physician as a change in condition.

Based on observation, record review, and interview the facility failed to ensure allegations of abuse were reported to the OSDH no later than 24 hours of the alleged abuse for 2 (#1 and #2) of 2 sampled residents reviewed for abuse.The administrator identified 54 residents resided in the facility.Findings:Findings:On 10/22/25 at 2:45 p.m., during facility tour, Resident #1 was observed to have 1:1 supervision with staff.An undated facility policy titled Reporting Resident Neglect, Mistreatment, Exploitation, Abuse or Misappropriation of a Resident's Property read in part, It is the responsibility of Corn Heritage Village to accept reports of incidents or suspected incidents .from any source. Any alleged violations involving abuse must be reported immediately to the administrator and Director of Nursing. This notification shall apply to any time of day or night. The Administrator or Director of Nursing is responsible for reporting any allegations of abuse to officials in accordance with state law.An initial report made to the OSDH, dated 10/21/25, showed alleged abuse occurred on 10/19/25. The report showed staff heard Resident #1 stated, Give it to me to Resident #2. The report showed as staff approached the two residents who were sitting in the common area, they observed Resident #1 placed Resident #2's hands in Resident #1's groin area over their clothes. The report showed the two were immediately separated. 1. Resident #1's annual MDS, dated [DATE], showed a BIMS score of 9, which indicated moderate cognitive impairment, was alert to self only, and required assistance with most ADL's including transfers, but was independent with wheelchair mobility.A comprehensive care plan, dated 08/15/25, showed Resident #1 had history of sexual inappropriate statements and placed their hands in their own pants in public areas.Resident #1's October 2025 physician orders showed diagnoses which included dementia, hypertension, restless leg syndrome, and diabetes mellitus. 2. An admission MDS for Resident #2, dated 09/15/25, showed a BIMs score of 3, which indicated severe cognitive impairment and the resident was alert to self only. The assessment showed Resident #2 required assistance with most ADL's including transfers and was dependent with wheelchair mobility. Resident #2's October 2025 physician orders showed Resident #2 was admitted on [DATE] with diagnoses which included intellectual disabilities and hypertension.On 10/22/25 at 4:05 p.m., Resident #2 stated everyone was nice and denied being approached by a resident of the opposite sex.On 10/27/25 at 2:45 p.m., the DON verified the allegation of resident-to-resident sexual abuse should have been reported to OSDH within 24 hours.

Based on observation, record review, and interview the facility failed to administer physician ordered medications for one (#14) of five sampled residents reviewed for medications. The administrator reported 52 residents resided in the facility. Findings: A Medication Administration and General Guidelines policy, dated 07/10/23, read in part, Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication seems to be unrelated to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. Resident #14 had diagnoses which included senile degeneration of brain, anxiety disorder, and polyarthritis. Resident #14's physician order, dated 11/06/24, read in part, Give 0.5 mg PLO gel q 4 hours. A drug label for Resident #14, dated 11/06/24, documented, apply 0.5 ml (0.5 mg) to the inside of one wrist and rub in well with the other wrist every four hours. lorazepam (benzodiazepine) 1 mg/1 ml-PLO. Resident #14's physician order list, dated November 2024, documented, (lorazepam 1 ml) PLO transdermal external cream (transdermal base) apply to wrist or neck topically four times a day related to anxiety. The order was not transcribed correctly per the physician's order of 11/06/24. A November 2024 Controlled Narcotic Administration Record, documented lorazepam 1 mg/1 ml-PLO, frequency 0.5 ml every 4 hours. The controlled narcotic administration record documented an accurate count for 53 pre-filled syringes measuring 0.5 ml of medication and documented the medication was administered four times a day and not every four hours as ordered. A Medication Error Report, dated 11/06/24, documented the order on the prescription label did not match the order in the chart and no clarification was made. On 11/18/24 at 1:05 p.m., CMA #2 was observed to administer Lorazepam topical medication to Resident #14's wrist. On 11/19/24 at 1:25 p.m., the DON reported there was a discrepancy between the medication label and the physician's order. The DON reported they would need to contact the physician for clarification of the order.

Based on record review and interview, it was determined the facility failed to implement an antibiotic stewardship program for three (#17, 39. and #44) of five residents sampled for medication review. The DON identified 52 residents resided in the facility. Findings: 1. Resident #17 had diagnoses which included chronic systolic congestive heart failure, permanent A-Fib, and recurrent depressive disorders. Resident #17's care plan, dated 07/31/24, documented frequently incontinent of bowel and occasional incontinent of urine. A Culture Urine for resident #17, dated 08/17/24, read in part, Culture Colony count > 100,000 CFU/ml Escherichia Coli (Abnormal). Resident #17's physician order, dated 08/19/24, documented to give Macrobid oral capsule 100 mg (Nitrofurantoin), 100 mg by mouth, two times a day for five days, related to urinary tract infection. 2. Resident #39 had diagnoses which included chronic obstructive pulmonary disease, acute kidney disease, and senile degeneration of the brain. Resident #39's care plan, dated 01/02/24, documented the resident was frequently incontinent of bowel and bladder. A physician order for Resident #39, dated 08/02/24, documented to give Cephalexin 500 mg tablet, one (500 mg) by mouth, three times per day. A Culture Urine for Resident #39, dated 08/03/24, read in part, Culture Colony count 10,000-50,000 CFU/ml Escherichia Coli (Abnormal). On 11/21/24 at 10:19 a.m., the DON was interviewed regarding the facility's infection control program. The DON reported the facility was not conducting antibiotic stewardship. 41873 3. Resident #44 had diagnoses which included congestive heart failure and atrial fibrillation. A comprehensive assessment, dated 09/06/24, documented, Resident #44's cognition was severly impaired and was dependent on staff for most activities of daily living. A physician order, dated 08/02/24, read in part, Piperacillin sodium-Tazobactam sodium solution reconstituted 4-0.5 gram, use 4.5 gram intravenously every 8 hours for infection related to abscess of liver and cholangitis (severe infection of the liver's bile ducts) until 08/30/24. On 11/20/24 at 3:44 p.m., the ADON reported the infection preventionist should be completing the Mcgreer criteria for infection surveillance of residents receiving antibiotics. On 11/20/24 at 3:44 p.m., the infection preventionist reported no Mcgreer criteria checklist had not been completed on Residents #17, #39, or #44 with the prescribed antibiotics. The infection preventionist reported not being aware that Mcgreer criteria checklist should have been completed with antibiotics use. On 11/20/24 3:55 p.m., the DON reported due to a change in staff, the Mcgreer criteria had not been completed for residents prescribed antibiotics. The DON reported Mcgreer criteria should be used for residents prescribed antibiotics and a pip would be done to correct this.

Based on record review and interview, the facilty failed to ensure new mental illness diagnoses were reported to the OHCA for one (#6) of one sampled resident reviewed for PASARR. The administrator reported 52 residents resided in the facility. Findings: A Preadmission Screening and Annual Resident Review policy, revised 06/25/21, read in part, [Name withheld] will refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related or possible serious mental disorder, intellectual disability, or related condition for a level II review upon a significant change in status assessment to the State PASARR representative. Resident #6 was admitted to the facility on [DATE]. A level I PASARR screen, dated 08/22/23, documented primary diagnoses of chronic obstructive pulmonary disease and secondary of acute on chronic systolic heart failure. The level I PASARR screen documented no level II screening was required. Resident #6's face sheet documented the following diagnoses dates: anxiety disorder on 09/24/20, recurrent depressive disorder on 12/01/23, hallucinations on 12/14/23, and psychosis on 02/02/24. A comprehensive assessment, dated 08/14/24, documented resident #6's cognition was intact. The assessment documented diagnoses of anxiety, depression, and psychotic disorder. On 11/20/24 at 1:29 p.m., the DON reported the OHCA was contacted on 11/18/24. The DON reported a level II screen was not required. The DON reported they were not aware if the new mental illness diagnoses had been reported to the OHCA previously. The DON reported they were not aware until recently that new mental health diagnoses needed to be reported to the OHCA.

Based on record review and interview, the facility failed to include hospice services on a care plan for one (#9) of one sampled resident reviewed for hospice. The administrator reported 52 residents resided in the facility. Findings: A Care Plans policy, dated 10/12/17, read in part, Comprehensive care plans will be revised and updated upon any new changes in a resident's condition within 7 days .Care Plans will address all areas pertinent to providing care to that resident. Resident #9 had diagnoses which included congestive heart failure and chronic obstructive pulmonary disease. A physician order for Resident #9, dated 06/27/24, documented the resident was admitted to hospice with the diagnosis of hypertensive heart disease with heart failure. A comprehensive assessment for Resident #9, dated 10/02/24, documented the resident's cognition was intact. The assessment documented the resident received hospice services. A care plan for Resident #9, dated 10/02/24, did not address hospice or document the resident received hospice services. On 11/20/24 at 12:33 p.m., MDS coordinator #1 reported hospice services should be included on the resident's care plan under its own care area.

Based on observation and interview, the facility failed to ensure incontinent care was provided to dependent residents at least every two hours for three (#2, 3, and #4) of three dependent residents observed for receiving incontinent care. The DON identified 61 residents resided in the facility. RN #1 identified 27 residents that were totally dependent on staff for incontinent care. Findings: 1. A 'Functional Abilities & Goals' assessment for Resident #2, dated 05/16/24, documented they had impaired ROM to both upper and both lower extremities, was incontinent of bowel and bladder, and was dependent on staff for all ADL's. 2. A 'Functional Abilities & Goals' assessment for Resident #3, dated 07/02/24, documented they had impaired ROM to both upper and both lower extremities, was incontinent of bowel and bladder, and was dependent on staff for all ADL's. 3. A 'Functional Abilities & Goals' assessment for Resident #4, dated 07/29/24, documented they had impaired ROM to both upper and both lower extremities, was incontinent of bowel and bladder, and was dependent on staff for all ADL's. On 07/30/24 at 10:32 a.m., Resident #2, Resident #3, and Resident #4 were observed sitting in the facility common area outside of the main dining room. On 07/30/24 at 11:57 a.m., after uninterrupted observation from 10:32 a.m. to this time, Residents #2, #3, and #4 were observed being escorted to the dining room by facility staff. On 07/30/24 at 1:00 p.m., after uninterrupted observation from 11:57 a.m. to this time, Residents #2, #3, and #4 were observed being escorted to the activity area adjacent to the common area outside of the dining room by facility staff. On 07/30/24 at 1:15 p.m., Resident #3 was observed being taken from the activity area and provided incontinent care by CNA #1 and CNA #3. Resident #3's brief and padding were observed to be grossly saturated when removed. On 07/30/24 at 1:22 p.m., Resident #4 was observed being taken from the activity area and provided incontinent care by CNA #2 and Rehab Aide. Resident #4's brief and padding were observed to be grossly saturated when removed. On 07/30/24 at 1:32 p.m., Resident #2 was observed being taken from the activity area and provided incontinent care by CNA #2 and CNA #6. Resident #2 was observed to have a small BM and be grossly saturated when brief was removed. On 07/30/24 at 2:01 p.m., CNA #6 was asked how often dependent residents received incontinent care. They stated every two hours. After informing CNA #6 of my observations, they acknowledged incontinent care had not been provided at least every two hours to Resident #2, Resident #3, nor Resident #4. On 07/30/24 at 3:23 p.m., RN #1 was asked the facility policy regarding incontinent care for dependent residents. They reported dependent residents should be checked at least every two hours and acknowledged facility policy had not been followed for the above residents.

Based on record review and interview, the facility failed to ensure dietary staff received training in safe food handling practices for the prevention of foodborne illness for eight (Cook #1, [NAME] #2, [NAME] #3, [NAME] #4, Dietary Aide #1, Dietary Aide #2, Dietary Aide #3, Dietary Aide #4) of nineteen dietary staff. The DON identified 61 residents resided in the facility. All residents received meals prepared in the facility dietary department. Findings: On 08/01/24 at 9:00 a.m., the Administrator was asked for verification of Food Handlers training for all dietary staff. On 08/01/24 at 9:08 a.m., the Administrator submitted a copy of in-service training for eleven of nineteen dietary staff and acknowledged [NAME] #1, [NAME] #2, [NAME] #3, [NAME] #4, Dietary Aide #1, Dietary Aide #2, Dietary Aide #3, and Dietary Aide #4 had not received the required training.

Based on observation, record review, and interview, the facility failed to ensure emergency call lights were accessible and/or in working order for eight (#1, 3, 5, 6, 7, 10, 11, and #54) of eight residents reviewed for an emergency call light system. The Administrator reported 80 residents resided in the facility. Findings: On 09/19/22 at 10:00 a.m., a tour of the facility was conducted. Resident bathrooms on the E Unit, for residents #1, 3, 5, 6, 7, 10, and #11, were observed to have missing pull cords, short pull cords, or cords wrapped around the hand bar. On 09/19/22 at 10:10 a.m., resident #54 reported utilizing the bathroom during the daytime. The resident's bathroom call light was observed to be missing a cord. The maintenance log was reviewed and documented no reported issues with bathroom call light repairs. The facility reported no policy and procedure related to the call light system. On 09/22/22 at 10:14 a.m., an interview with the DON was conducted. She was asked to review the September 2022 work log for maintenance issues. The DON stated there had been no reports of missing or out-of-reach call light cords for the E unit. The DON toured the E unit and viewed the emergency call light in the identified resident bathrooms. She reported she would educate her staff and report the call light issues to the maintenance department.

Based on record review, observation, and interview, the facility failed to adhere to the facility's policy and procedure to label and date oxygen tubing for three (#49, 48, and #71) of three residents sampled for oxygen therapy. The Resident Census and Condition of Residents, report, dated 09/19/22, documented 80 residents resided in the facility. Findings: The Oxygen System Change Out Policy, revised on 10/11/17, read in parts, .It is the policy of Corn Heritage Village and Rehab that the oxygen setups including the nasal cannula, any extension tubing, and humidifier bottle will be changed out every 2 weeks for infection control purposes. Each new oxygen set will be labeled with the date of change and the nurses initials . 1. Resident #49 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician Orders, dated 07/30/20, read in parts, . may have oxygen 2 L. Do NOT increase oxygen without discussing with PCP first. as needed for shortness of breath related to DYSPNEA [Shortness of breath] .May have NC PRN for SHOB. May keep at bedside. Do NOT increase oxygen without discussing with PCP first . Physician Orders, dated 07/30/20, read in parts, .change nebulizer/oxygen tubing every evening shift every 2 weeks on Sun for O2/Nebulizer Therapy Date and initial . The resident's Quarterly MDS Assessment, dated 08/18/22, documented the resident's cognition to be intact. The resident's Plan of Care, dated 08/23/22, read in parts, .Congestive Obstructive Pulmonary Disease/Cough: Res #49 has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She also has a cough from time to time. Res #49 receives medication to combat these issues as prescribed by her PCP. She does not like to have cleaning agents or chemicals that can cause fumes used in her room. She also chooses to have a humidifier going in her room. She often refuses to take [MEDICATION(S)] stating, It makes me lose my mind. Res #49 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/19/22 at 1:08 p.m., the tape wrapped around Res #49's oxygen tubing was observed to be dated 07/03/22 and without staff initials. On 09/21/22 at 9:27 a.m., Res #49 reported she usually wore her oxygen at night and when needed. 2. Resident #48 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan, dated 08/17/22, documented, . Resident has [CONDITION(S)], wheezing, and cough as per her PCP's orders .Resident has orders for to wear her [CONDITION(S)] nightly, staff to observe that it is functioning properly when worn .Resident is not able to self-administer her own breathing treatment .Resident may use oxygen as prescribed by her PCP . The resident's Quarterly MDS Assessment, dated 08/17/22, documented the resident's cognition to be intact. The resident's Monthly Physician Orders, dated 09/01/22, read in parts, .May have O2 @1-2 LPM/NC for SAT's =or> 92% every shift for SAT'S BELOW 89% .Clean oxygen concentrator every night shift starting on the 15th and ending on the 15th every month for maintenance .[MEDICATION(S)] Nebulization Solution 2.5 MG/0.5ml 1 unit inhale orally via nebulizer every 4 hours as needed for shortness of breath .[CONDITION(S)] 1 time daily at bedtime related .Change oxygen tubing every 2 weeks every night shift every 15 days for O2/nebulizer therapy .Clean oxygen concentrator every night shift starting on the 15th and ending on the 15th every month for maintenance . On 09/20/22 at 10:41 a.m., resident #48 reported she wore oxygen at night and as-needed for shortness of breath. The resident's oxygen tubing and nebulizer tubing was observed and was not labeled with the date and staff initials of when it had been changed. On 09/21/22 at 11:42 a.m., LPN #2 reported O2 tubing and nebulizer tubing was changed monthly and she was not aware the tubing should be dated when changed out. The LPN reported night shift was responsible for that task and stated she did not work the night shift. On 09/21/22 at 11:44 a.m., the DON reported the facility's policy was to label the oxygen/nebulizer tubing with the date and staff initials when changed. The DON verified resident #48's oxygen/nebulizer tubing was not labeled. 3. Resident #71 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Monthly Physician Orders, dated 09/01/22, read in part, .May have oxygen 1-4 LPM to maintain SATs >89%; .Apply oxygen via NC if Sp02 is below 90% every shift . The resident's Care Plan, dated 09/07/22, documented, .Oxygen settings: O2 via nasal prongs @ 1-4 LPM to maintain oxygen saturation greater than 89%. Obtain SpO2 routinely and maintain oxygen/nebulizer machine and tubing . The resident's Quarterly MDS Assessment, dated 09/07/22, documented the resident had severely impaired cognition. On 09/20/22 at 10:31 a.m., resident #71 was observed to be up in a chair wearing oxygen. The oxygen/nebulizer tubing was not labeled to indicate when it was last changed. On 09/21/22 at 11:45 a.m., the DON verified resident #71's oxygen tubing was not properly labeled. The DON reported the facility's policy was to change oxygen/nebulizer tubing every two weeks and should be labeled with the date and staff initial of when it was changed.

Based on record review and interviews, it was determined the facility failed to ensure residents were assisted with transfers for one (#9) of three sampled residents reviewed for certain injuries. Resident #1 required physical asssistance of two staff members with the use of a sit to stand lift. CNA #11 self transferred the resident in the sit to stand lift. As a result of not obtaining the assistance of another staff member, the resident hit her arm on the doorway and received a distal radial [MEDICAL CONDITION] wrist. The facility identified 13 residents who required transfer assistance with a sit to stand lift. Findings: Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/30/19, documented the resident's cognition was moderately impaired, required extensive assistance of two staff members for transfers and toilet use. The assessment documented the resident was frequently incontinent of her bladder and had no falls since admission. A care plan documented the resident was at risk for falls due to her occasional incontinence and cognitive impairment. Interventions documented she required extensive assistance of two staff for transfers. An incident report, dated 09/08/19, documented a CNA reported to the charge nurse when she was taking the resident to the bathroom for toileting using the sit to stand lift, the residents elbow bumped into the door frame. The resident then complained of left wrist pain. Upon entering the room for an assessment, the resident was holding her left wrist with her right hand and complained of pain to the left wrist. The resident was moving her fingers but stated It hurts when I do that. Steps to prevent re-occurrence documented staff were instructed to ensure that residents elbows were tucked in when transferring with a sit to stand lift to avoid hitting the elbows. On 09/09/19, an inservice was conducted with CNA #11 on resident safety and the proper safe usage of equipment. A final incident report sent to OSDH documented the resident was sent to the emergency room and returned with a left distal radius fracture with an order to wear wrist/forearm splint at all times until a follow up appointment. The CNA and staff were educated and in serviced over safe care for residents and proper use of equipment on 09/09/19. On 12/31/19 at 9:23 a.m., the DON was asked how many staff were required to assist residents while the sit to stand lift was to be used. She stated it depended on the resident. She stated with resident #1, only one staff due to she can assist and stand. She was asked for documentation of the assistance required with the resident for transfers. She stated she would look at the care plan. She was asked for a copy of the care plan as well. At 9:43 a.m., a copy of the care plan was provided. The DON stated the assistance was documented under the falls area. She was asked what the care plan documented related to the required assistance. She stated two persons but she believe that would be at the resident's worst. She was asked for documentation of what the resident's level of need was at the time of the incident. At 10:23 a.m., the DON and ADON stated the care plan provided was updated on 05/23/19. She was asked if CNA #11 was still an employee. She stated no. They were asked how staff were instructed on what care the resident's require. They stated they have a pocket care plan on their halls. They were asked to provide a copy of the pocket care plan for resident #1. At 10:43 a.m., they provided a C Hall assignment sheet. They were asked when the CNA was provided this information to know what assistance was needed. They stated prior to her shift. They were asked if she used two staff members for this transfer. They stated no. The DON was asked if the CNA stated why she did not use assistance. She stated the CNA did not say why she did not get another CNA to help. They were asked if a care plan had been developed for the use of the sit to stand lift for resident #1. The ADON stated she could not see one but she would ask the MDS coordinator if she would have completed one. The DON and the ADON were asked, based on the documentation the resident was transferred with one staff and the resident received a fracture to her wrist, should there have been two staff members present during this transfer. They stated yes. At 10:52 a.m., the DON and the ADON stated there was no care plan developed for the use of the sit to stand lift for this resident. They were asked if one should have been developed. They stated yes.

Based on observation, record review and interview, it was determined the facility failed to ensure one (#2) of two sampled residents who received nebulizer breathing treatments were monitored for changes in condition during the breathing treatment. The facility identified 80 residents resided in the facility. Findings: The facility policy titled 'Self-Administration of Medications by Residents documented if the resident desired to self-administer medications, an assessment was to be conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. The interdisciplinary team determines the resident's ability to self-administer by means of a skill assessment and the results were recorded on the medication self-administration assessment form, which was placed in the resident's medical record. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission physicians order documented the resident was to be administered [MEDICATION NAME] 1.25 mg/3mL via nebulizer four times a day. On 12/30/19 at 9:03 a.m., LPN #1 initiated a breathing treatment for [REDACTED]. The resident was left unattended for 5 minutes during her breathing treatment. At 9:08 a.m., the LPN returned to stop the breathing treatment. At 9:53 a.m., the LPN was asked if was okay to initiate a breathing treatment for [REDACTED]. She stated it was okay if the resident was cognitive and had a high enough cognitive function. The LPN was not able to say what level of cognitive function the resident had. On 12/31/19 at 9:58 a.m., resident #2 was asked about her breathing treatments and whether she has asked to self-administer them. She stated no, the nurse comes in to start the breathing treatment and then usually steps out there (resident points to hallway) to do other things and then comes back to turn it off. The resident further stated she gets intermittent chest pain and that can happen at any time and it was very scary to be left alone when it happens. The clinical record was reviewed. There was no documentation to indicate an assessment for self medication was conducted.

Based on observation, record review and interview, it was determined the facility failed to provide timely incontinent care and/or repositioning for two (#1 and #5) of three sampled residents observed for ADLs. The facility identified 63 residents who required assistance with ADLs. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/30/19, documented the resident's cognition was moderately impaired, required extensive assistance of two staff members for transfers, toilet use and was frequently incontinent of her bladder. A care plan documented the resident was at risk of falls due to her occasional incontinence and cognitive impairment. Interventions documented she required extensive assistance of two staff for transfers. On 12/20/19 at 6:57 a.m., CNA #9 transferred the resident out of the shower room and left her in the common area. The CNA stated they have to use a sit to stand lift with her due to she does not stand good. At 7:26 a.m., the resident was transferred to the dining room for breakfast. At 8:44 a.m., the resident remained in the dining room. At approximately 9:10 a.m., the resident was transferred into her room. At 10:56 a.m., the resident was transferred into the common area for exercise. At 11:07 a.m., the resident was transferred into the dining room for the noon meal. At 12:20 p.m., the ADON was asked how long should dependent residents wait to be toileted. She stated they should be toileted every two hours. At 12:24 p.m., the resident was observed to slowly wheel herself out of the dining room. At 12:26 p.m., a staff member transferred the resident to her room and left her at the bedside. The resident was observed up in her wheelchair from 6:57 a.m. until 12:30 p.m. without being toileted or repositioned. At 12:30 p.m., CNA #1 and CNA #10 entered the room with the sit to stand lift. CNA #1 was asked how often the resident should be toileted. She stated every two hours and after meals. She was asked when the resident was last toileted. She stated after breakfast. She was asked if she had toileted the resident. She stated no, maybe CNA #2 had done that. The resident was assisted to the toilet and the brief was observed to have urine and a small amount of feces on the brief. 2. Resident #5 had [DIAGNOSES REDACTED]. An annual assessment, dated 12/04/19, documented the resident's cognition was severely impaired, required extensive assistance of two staff members for transfers, dressing and toilet use. The assessment further documented the resident was frequently incontinent of bowel and bladder. The care plan documented the resident was frequently incontinent of her bladder and her bowel. Interventions documented she was severely impaired in her cognitive function, required extensive assistance of two staff with toileting, nursing staff were to check on her when walking down the hallway and on rounds to assist her to the toilet to prevent urinary infection. On 12/30/19 at 6:00 a.m., the resident was observed to be up in a recliner asleep in the common area. At 7:01 a.m., she began moving about in the chair talking to herself. At 7:09 a.m., the resident was asking when she could get up. At 7:11 a.m., as the resident was attempting to get up, she informed the housekeeping staff, who was cleaning the her area, that she wanted to get up. At 7:13 a.m., she again asked the housekeeper when could she get up. The housekeeper stated, They will come and get you when it is time The resident stated she was ready. At 7:34 a.m., the resident continued to move about in her chair. At 7:36 a.m., the restorative aide and a CNA assisted the resident to her wheelchair and transferred her to the dining room. At 8:24 a.m., the resident was transferred back into the common area and left at the activity table. At 8:56 a.m., CNA #1 and #2 transferred the resident to her room to use the bathroom. The CNAs were asked how often the resident was to be assisted with toileting. CNA #1 stated every two hours and after meals. They were asked how many staff were required to transfer when the sit to stand lift was utilized. They stated two. At 9:03 a.m., the resident was transferred into the bathroom. The brief was observed to have urine and a small amount of feces on the brief. The resident was not observed to be toileted from 6:00 a.m. until 9:03 a.m.

Based on observation, record review and interviews, it was determined the facility failed to ensure a resident's physician ordered fluid restriction was implemented for one (#70) of one sampled resident reviewed with a fluid restriction. The facility identified eight residents with current physician ordered fluid restrictions. Findings: Resident #70 had a [DIAGNOSES REDACTED]. An undated nutrition care plan documented the resident was on a no added salt diet with a 1200 milliliter (ml) fluid restriction. An undated care plan documented, Problems .[MEDICAL CONDITION] .has the dx (diagnoses) of [MEDICAL CONDITION] and is treated as prescribed by his PCP (primary care physician) .interventions .The CMA (certified medication aide) will monitor and record intake and output each shift d/t (due to) .being on a 1200 ml fluid restriction . A nurse's progress note, dated 04/08/19, documented the resident had [MEDICAL CONDITION] to his right hand, right elbow and to his bilateral lower extremities. The note further documented the resident received 80 milligrams (mg) of [MEDICATION NAME] daily. The primary care physician had been notified and placed the resident on a 1200 ml fluid restriction with a low salt diet. A physician's orders [REDACTED]. A review of the ADL (activities of daily living) Verification Worksheet for 04/09/19 through 04/30/19, documented the resident received an average of 800 ml of fluids daily from meals. A review of the treatment administration record (TAR) for 04/09/19 through 04/30/19, documented the resident received an average of 850 ml per day of fluid from all other sources. The resident's average daily fluid intake from 04/09/19 through 04/30/19 was on average 450 ml over the 1200 ml limit. A quarterly assessment, dated 05/01/19, documented the resident's cognition was intact and was independent with eating and required only set up assistance. A review of the ADL Verification Worksheet for 9, documented the resident received fluids each meal and averaged 850 ml for the day from meals. A review of the TAR for 05/2019, documented the resident received an averaged of 900 ml per day of fluid from all other sources. The resident's average daily fluid intake for 05/2019 was 550 ml over the 1200 ml limit. A review of the ADL Verification Worksheet for 06/2019 documented the resident had the following fluid totals for meals through 06/04/19: ~ 06/01/19 - 600 ml total intake. There was no documentation of the evening meal; ~ 06/02/19 - 1250 ml for all meals; ~ 06/03/19 - 890 mls total intake. There was no documentation of the noon or evening meal; ~ 06/04/19 - 760 ml documented with no documented in take for the evening meal. A review of the TAR for 06/2019, documented the resident had the following fluid totals from all other fluid sources through 06/04/19: ~06/01/19 840 ml; ~06/02/19 960 ml; ~06/03/19 900 ml; ~06/04/19 580 ml. The resident had received greater then 1200 ml for each day in June. There was no documentation in the clinical record the facility had notified the physician of the excessive fluid intake since the restriction had been ordered. On 06/04/19 at 10:56 a.m., the resident was observed in his room in the recliner. On the door was a bright sign which documented the resident was on a 1200 ml fluid restriction. The sign was located in the center of the door, easy to read and view. On 06/05/19 at 3:22 p.m., the resident was observed in his recliner. There was a water pitcher on the over bed table with 450 ml of fluid. Located next to the water pitcher were two 16 ounce bottles of water (946 mls) and a Styrofoam cup (118 mls) half filled with water. On 06/06/19 at 8:55 a.m., the resident stated he could have two water pitchers a day plus what he received for his meals. He stated he was restricted to 1200 mls a day and some days he received more and other days less. He then stated, I know what I can have because they tell me and I drink what they give me. At 8:58 a.m., the resident's meal tray was delivered by dietary aide #1. The resident had an 8 ounce (237 ml) cup of hot cocoa, and a 16 ounce (473 mls) glass of water and orange juice. The dietary aide stated the resident was not on a fluid restriction. She then looked at the door and stated, Oh, I didn't realize that. She then stated it should be listed on the dry ease board in the kitchen. At 9:05 a.m., the dry ease board was observed with the resident listed as a 1200 ml fluid restriction. At 9:11 a.m., the dietary manager stated all residents with a fluid restriction was listed on the dry ease board in the kitchen and the resident was currently on 1500 ml restriction. She then stated the dietary staff documented the meal percentages each meal which included fluids consumed. She then stated dietary did not communicate with nursing on the fluid consumption and was not aware of fluid intake outside of meal times. She stated the resident gets approximately 780 ml in fluids each day from his meals. At 9:33 a.m., licensed practical nurse (LPN) #1, the charge nurse for the resident, stated he had a 1200 ml fluid restriction per day. She then stated the certified medication aides would chart the amount of fluids consumed each shift in the treatment record. At 9:35 a.m., the resident's morning meal tray was observed. The resident had consumed all beverages provided on his morning meal tray. At 11:21 a.m., the director of nursing (DON) and assistant director of nursing were interviewed. The DON confirmed the resident was on the 1200 ml fluid restriction and had been since 04/08/19 due to his large weight gain and [MEDICAL CONDITION]. She stated the charge nurses were responsible for monitoring the intake to make sure the restriction was being followed. The DON and ADON were made aware of the observations of the resident's meal and room with all the fluids. The ADON stated the resident should not have a water pitcher in the room with the fluid restriction. The DON looked through the meal percentages and treatment records and stated the fluid restriction had not been followed. She then stated the physician had not been notified of the failure to follow to the fluid restriction, but should have been. The ADON added, Communication between dietary and nursing is definitely a process that needs to be worked on.

Based on observation, record review and interviews, it was determined the facility failed to ensure a resident's physician was notified when daily intake exceeded the ordered fluid restriction for one (#70) of one sampled resident reviewed with a fluid restriction. The facility identified eight residents with current physician ordered fluid restrictions. Findings: Resident #70 had a [DIAGNOSES REDACTED]. An undated nutrition care plan documented the resident was on a no added salt diet with a 1200 milliliter (ml) fluid restriction. An undated care plan for [MEDICAL CONDITION] documented, Problems .[MEDICAL CONDITION] .has the dx (diagnoses) of [MEDICAL CONDITION] and is treated as prescribed by his PCP (primary care physician) .interventions .The CMA (certified medication aide) will monitor and record intake and output each shift d/t (due to) .being on a 1200 fluid restriction . A nurse's progress note, dated 04/08/19, documented the resident had [MEDICAL CONDITION] to his right hand, right elbow and to his bilateral lower extremities. It further documented the resident received 80 milligrams (mg) of [MEDICATION NAME] daily. The primary care physician had been notified and placed the resident on a 1200 ml fluid restriction with a low salt diet. A physician's orders [REDACTED]. A review of the ADL (activities of daily living) Verification Worksheet for 04/09/19 through 04/30/19, documented the resident received an average of 800 ml of fluids daily from meals. A review of the treatment administration record (TAR) for 04/09/19 through 04/30/19, documented the resident received an average of 850 ml per day of fluid from all other sources. The resident's average daily fluid intake from 04/09/19 through 04/30/19 was on average 550 ml over the 1200 ml limit. A quarterly assessment, dated 05/01/19, documented the resident's cognition was intact. A review of the ADL Verification Worksheet for (MONTH) 2019, documented the resident received fluids each meal and averaged 850 ml for the day from meals. A review of the TAR dated 05/2019, documented the resident received an average 900 ml per day of fluid from all other sources. The resident's average daily fluid intake for (MONTH) 2019 was on average 550 ml over the 1200 ml limit. A review of the ADL Verification Worksheet for 06/2019, documented the resident had the following fluid totals for meals through 06/04/19: ~ 06/01/19 - 600 ml total intake. There was no documentation of the evening meal; ~ 06/02/19 - 1250 ml for all meals; ~ 06/03/19 - 890 ml total intake. There was no documentation of the noon or evening meal; ~ 06/04/19 - 760 ml total intake. There was no documentation of the evening meal. A review of the TAR for 06/2019, documented the resident had the following fluid totals from all other sources through 06/04/19: ~ 06/01/19 840 ml; ~ 06/02/19 960 ml; ~ 06/03/19 900 ml; ~ 06/04/19 580 ml. The resident had received greater then 1200 ml for each day in June. There was no documentation in the clinical record the facility had notified the physician of the excessive fluid intake since the restriction had been ordered. On 06/04/19 at 10:56 a.m., the resident was observed in his room in the recliner. On the door was a bright sign documented the resident was on a 1200 ml fluid restriction. The sign was located in the center of the door easy to read and view. On 06/05/19 at 3:22 p.m., the resident was observed in his recliner. There was a water pitcher on the over bed table with 450 ml of fluid. Located next to the water pitcher were two 16 ounce (946 mls) bottles of water and a Styrofoam cup (118 ml) half filled with water. On 06/06/19 at 8:58 a.m., the resident's meal tray was delivered by dietary aide #1. The resident had an 8 ounce (237 ml) cup of hot cocoa, and a 16 ounce (473 ml) glass of water and orange juice. At 9:35 a.m., the resident's morning meal tray was observed. The resident had consumed all beverages provided on his morning meal tray. At 11:21 a.m., the director of nursing (DON) and assistant director of nursing (ADON) were interviewed. The DON confirmed the resident was on the 1200 ml fluid restriction and had been since 04/08/19 due to his large weight gain and [MEDICAL CONDITION]. She stated the charge nurses were responsible for monitoring the intake to make sure the restriction was being followed. The DON and ADON were made aware of the observations of the resident's meal and room with all the fluids. The ADON stated the resident should not have a water pitcher in the room with the fluid restriction. The DON looked through the meal percentages and treatment records and stated the fluid restriction had not been followed. She then stated the physician had not been notified of the failure to follow to the fluid restriction, but should have been.

Based on record review and interview, it was determined the facility failed to provide quarterly statements and/or account balances for seven (#9, 20, 24, 79, 43, 79 and #81 ) of seven sampled residents for whom the facility managed personal funds and whose quarterly statements and account balances were reviewed. The facility identified 17 residents who held their money in the facility trust account. Finding: A review of the trust account records for resident #9, 20, 24, 79, 43, 79 and #81 contained no documentation the residents' received quarterly statements of their account balances and spending. On 06/04/19 at 1:28 p.m., resident #43 stated she did not receive any statements from the facility on her account. On 06/06/19, resident #9 and #24 stated they do not receive any statements from the facility. At 1:17 p.m., the assistant administrator stated each resident that came into her office and requested their balance was shown their ledgers. She then stated no statements were provided quarterly to any of the residents.

Based on record review and interview, it was determined the facility failed to ensure residents money was placed in an interest bearing account for three (#20, 24, and #81) of seven sampled residents whose trust accounts were reviewed. The facility identified 17 residents who held their money in the facility trust account. Finding: A review of the ledgers for residents #20, 24, and #81 contained no documentation their money received interest credited to their account. On 06/06/19 at 1:17 p.m., the assistant administrator stated each resident had their own account at the bank. She then stated all accounts were to have interest. After reviewing the ledgers for the three identified residents, she stated they are not receiving interest.

Based on record review and interview, it was determined the facility failed to ensure a discharge assessment was completed and transmitted for one (#1) of one sampled resident who was reviewed for resident assessments. The facility identified 7 residents who had expired in the last 90 days. Findings: On [DATE], the clinical record was reviewed for resident #1. The record did not contain documentation an assessment had been completed in the last 120 days. At 10:55 a.m., minimum data set (MDS) coordinator #1 was asked when the last assessment was completed and submitted. She stated on [DATE] a significant change assessment was completed. She was asked if the resident resided in the facility. She stated no she was deceased . She was asked if a discharge assessment had been completed. She stated no, that was her mistake.

On 01/05/17 an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to maintain safe hot water temperatures in one of one hall bathroom accessible to residents. The hot water temperature exceeded 160 degrees Fahrenheit. At 3:42 p.m., the maintenance supervisor was asked how often he checked water temperatures. He stated every week in the resident rooms. He was asked if he could check the temperature in the hall bathroom across from the laundry room. He stated he did not even need to check this temperature. He stated he already knew because it was connected to the laundry. He was asked what the temperature should be for the bathroom. He stated it should be the same as the laundry, 100 and ridiculous. He was asked if he would go ahead and check the water temperature anyway. After checking the water temperature in the sink, the maintenance supervisor pulled the thermometer out after a reading of 130 degrees Fahrenheit (F) was reached. He was asked if he was previously aware of the high water temperature. He stated he could not say he did not know it. It is hooked up to the laundry which has to be 160 degrees F. The maintenance supervisor was asked if he was aware what the water temperature should be rooms accessible to residents. He stated 115 degrees and in the kitchen 120, right? He was asked the reading for the temperature of the bathroom he just checked. He stated he got to 130 degrees and he quit. At 3:49 p.m., after bringing the concern to his attention he stated, for now he will lock it. At 3:56 p.m., the administrator was informed of the IJ situation related to the facility's hot water temperatures. At 7:19 p.m., the administrator provided an acceptable plan of removal. The plan of removal documented the following: ALL EMPLOYEES OF CORN HERITAGE VILLAGE AND REHAB WILL BE INSERVICED ON THE REGULATIONS OF HOT WATER TEMPERATURES FOR THE SAFETY OF OUR RESIDENTS BY THE END OF THE DAY TODAY, 01/05/17, by phone or in person by 7:00pm. WATER TEMPERATURES FOR RESIDENT USE SHALL NOT EXEED (sic) 115 DEGREES, AND THE LAUNDRY AREA BATHROOM IS SECURED WITH A LOCKING DEVICE. 1610 (4:10 p.m.): Maintenance Director immediately secured bathroom with a padlock. 16:15 (4:15 p.m.): Department Heads in-serviced and educated both verbally & written 16:30 (4:30 p.m.): Department Heads and office staff started calling ALL employees to: 1) Immediately come to facility to be in-serviced on proper water temperatures and lock safety, or 2) Verbally in-serviced all employees not able to come to facility by phone on water temperatures and lock safety. 3) Each employee will be given a paper on the regulations of proper water temperatures and a typed paper written by the administrator on lock safety. ALL DEPARTMENTS, ADMINISTRATIVE, OFFICE, NURSING, DIETARY, MAINTENANCE, HOUSEKEEPING, LAUNDRY, ACTIVITIES, AND SOCIAL SERVICES WILL BE VERBALLY INSERVICED AND EDUCATED THROUGH WRITTEN DOCUMENTATION 1) water temperatures and 2) Making sure all areas needing to be secured are locked. THE LOCKING OF ALL AREAS PROVIDED WITH A LOCKING DEVICE, PREVENTING ENTRANCE OF RESIDENTS OR VISITORS. SIGNAGE WILL BE PLACED ON LAUNDRY AREA BATHROOM DOOR INTERIOR (DOOR MUST BE LOCKED WHEN LEAVING) AND EXTERIOR (EMPLOYEE USE ONLY, DOOR MUST BE LOCKED AT ALL TIMES) WHERE IT IS VISIBLE TO ALL EMPLOYEES THAT MIGHT USE THIS BATHROOM, INDICATING THE BATHROOM IS FOR EMPLOYEE USE ONLY AND IS TO REMAIN LOCKED AT ALL TIMES. THE HOT WATER HAS BEEN TURNED OFF COMPLETELY AND A MIXING VALVE WILL BE INSTALLED WHEN IT ENTERS THE BUILDING. At this time the Maintenance Director has installed a padlock for safety until the valve is installed so we will meet the regulation requirements needed for resident safety with water usage from the sink. The IJ was removed on 01/05/17 at 7:00 p.m., after all the components of the plan of removal were carried out. The deficient practice remained at a pattern with the potential for more than minimal harm. Based on observation, record review and interview, it was determined the facility failed to ~ ensure water temperatures were maintained at a safe level. The facility identified 48 residents who had access to the hall bathroom, and ~ provide supervision to prevent falls, identify the root cause of falls and to consistently identify and implement interventions to aid in the prevention of falls for one (#70) of three sampled residents who were reviewed for falls. The facility identified 15 residents as being at high risk for falls. Findings: 1. On 01/05/17 at 1:45 p.m., the door to the hall bathroom across from the laundry department on hall F was observed to be open. There were no staff observed monitoring the door. The temperature of the water in the sink was documented to be 160.0 degrees Fahrenheit. At 2:15 p.m., the door remained open. At 2:40 p.m., CNA #1 was observed to use the bathroom across from the laundry room and exit without closing the door. She was asked who had access to the bathroom. She stated she did not know, she just used it for emergencies. She further stated residents like to come down the hall and look out the door. She was asked if the bathroom door was to be shut and locked. She stated no, it was not usually shut unless someone was in there. At 2:45 p.m., a maintenance staff member was observed to walk by the door of the hall bathroom. The door remained open. At 2:47 p.m., a CNA was observed to go into the bathroom, wash her hands then leave with the bathroom door remaining open. At 2:51 p.m., a maintenance staff member was observed to use the bathroom and then exit without shutting the door. At 2:53. p.m., maintence staff member #3 was observed to use the hall bathroom. After using the bathroom, he left the door open. The maintenance staff member was asked who had access to the hall bathroom. He stated laundry staff, maintenance, nurse aides and nurses. He was asked if residents had access the area. He stated every once in a while a resident would come back and go to the laundry room (across from the bathroom identified) and see about clothes. He was asked if the bathroom door was to be shut and locked. He stated no, it stays open. At 2:58 p.m. laundry staff #1 was observed coming out of the laundry department. She was asked if residents came back to the area. She stated yes, they come back there looking for clothes. She was asked if residents used the bathroom across the hall. She stated not that she knew of. She was asked if the bathroom door was to be locked. She stated no. At 3:22 p.m., a maintence staff member was observed to go into the bathroom for paper towels then exit without shutting the door. At 3:26 p.m., a staff member was observed to walk by the hall bathroom and did not acknowledge the door was open. On 01/05/17 at 3:42 p.m., the maintenance supervisor was asked what the temperature should be for resident accessible rooms. He stated 115 degrees Fahrenheit. He further stated the temperature for the bathroom is going to be the same as the laundry room as they are same hot water heater. The temperature is kept above 160 degrees F. The weekly fire sprinkler gauge reading documented the water temperatures for the laundry room from 10/03/16 through 01/02/17 ranged from 160.1 to 173.5 degrees F. 2. Resident #70 was admitted to the facility with [DIAGNOSES REDACTED]. A reportable incident was received at the Oklahoma State Department of Health (OSDH) on 07/08/16. The report documented the resident fell going to the recliner and hit the back of her head. The resident's personal safety alarm (PSA) and non-skid socks were placed on the resident. Neurological checks were initiated, the call-light was placed in the resident's reach and she was advised to use the call-light and ask for assistance. Tylenol was given for aches/pains. Staff was counseled on the importance of checking placement of alarms and non-skid socks. A nurse's note, dated 07/11/16 at 2:42 p.m., documented, Virginia has been having multi (multiple) falls. Will place her on a bowel and bladder re-training program to see if we can help her to have less falls. The clinical record documented the resident was placed on a bowel and bladder program on 07/14/16 and discontinued from the program on 07/24/16 due to failure to attain a positive outcome. A reportable incident was received at the OSDH on 08/10/16. The report documented the resident fell and was found in the floor of the bathroom with a laceration to the right side of her forehead. A steri-strip and ice pack were applied to the wound. Neurological checks were initiated. Staff were educated on the increased visualization schedule and non-skid socks. Non-skid strips were placed in the bathroom and in front of the resident recliner. A nurse's note, dated 08/10/16 at 8:13 a.m., documented the resident had a fall resulting in a laceration 3 inches by 1 inch on the right side of the forehead. The medication aide was instructed to give the resident pain medication. A steri-strip and ice pack were applied to the wound. Neurological checks were initiated. Staff were educated on the increased visualization schedule and non-skid socks. A reportable incident was received at the OSDH on 08/20/16. The report documented the resident fell at bedside, hitting her head, while getting up to go to the bathroom. Non-skid socks and PSA were put on the resident. Neurological checks were initiated. The call-light was within reach and the resident was counseled to use the call light and ask for assistance. Staff were instructed to ensure resident had on non-skid footwear and alarms. A nurse's note, dated 08/20/16 at 8:37 a.m., documented the resident had a fall with head injury. Neurological checks were initiated. The resident was not wearing non-skid socks. The resident's PSA was placed and she was counseled on using the call-light for assistance. The staff were instructed to ensure the resident had on non-skid footwear and proper alarms were in place and working. A reportable incident was received at the OSDH on 08/23/16. The report documented the resident fell in front of her husband's recliner and had a large knot on the back of her head. The report further documented neurological checks were initiated and the resident was transported to the emergency room . The family agreed to the placement of a camera in the resident's room related to the resident's increased falls. A nurse's note, dated 08/23/16 at 3:30 p.m., documented the resident fell in front of her husband's recliner and had a large knot on the back of her head and the resident was transported to the emergency room . The note further documented the resident's daughter had spoken with the director of nurses about the camera in the resident's room and had agreed to its use. An incident report, dated 09/07/16 at 5:15 a.m., documented the resident fell on the floor of the bathroom without injury. Non-skid socks and call-light were in place. The non-skid strip was replaced in the bathroom and staff were educated on the increased visualization schedule. A nurse's note, dated 09/07/16, documented the resident had a fall without injury. Non-skid socks and call-light were in place. The non-skid strip was replaced in the bathroom and staff were educated on the increased visualization schedule. An incident report, dated 10/02/16 at 2:00 p.m., documented the resident fell on the floor in front of the recliner and verbalized right thigh pain. Shoes, call-light and PSA were in place. A nurse's note, dated 10/02/16 at 2:00 p.m., documented a resident fall without injury. Shoes, call-light and PSA were in place. A significant change assessment, dated 10/05/16, documented the resident's cognition was severely impaired, she required limited assistance with bed mobility, transfers and ambulation off the unit. The assessment documented she required extensive assistance with ambulation in her room, on the unit, dressing and toilet use. She was frequently incontinent of her bladder, was not steady with balance and required the use of a wheelchair and walker for mobility. A falls risk assessment, dated 10/05/16, documented a score of 14. A resident with a score greater than 8 should be placed on fall precautions and a potential for falls listed on the care plan. The clinical record documented a bowel and bladder program was initiated again on 10/06/16. An incident report, dated 10/07/16 at 8:15 p.m., documented the resident fell on the floor then assisted by staff to the bathroom. The fall resulted in no injury. Staff were instructed to increase visual checks on the resident. A nurse's note, dated 10/07/16 at 9:16 p.m., documented the resident had a fall without injury. Staff were instructed to increase visual checks on the resident. An incident report, dated 10/12/16 at 6:00 p.m., documented the resident fell on the floor of the bathroom without injury. Staff were instructed to increase visualization. A nurse's note, dated 10/12/16 at 9:16 p.m., documented the resident had a fall without injury. Staff were instructed to increase visualization. A review of the clinical record documents that the bowel and bladder program was discontinued on 10/19/16 due to failure to attain a positive outcome. A reportable incident was received at the OSDH on 10/19/16. The report documented the resident fell when she rolled out of the recliner going to the bathroom. The report documented the resident received a scratch and hematoma to the right side of the face. Neurological checks were initiated. The resident's PSA and call-light were in place. A nurse's note, dated 10/20/16 at 2:36 a.m. (late entry by nursing staff), documented the resident had a fall resulting in a scrape to the right side of the resident's face. Neurological checks were initiated and the resident was instructed not to get up without help. An incident report, dated 10/22/16 at 1:20 p.m., documented the resident fell in front of the recliner without injury. The resident's PSA and call-light were in place. A nurse's note, dated 10/22/16 at 1:20 p.m., documented the resident had a fall without injury. The resident's PSA was re-attached. A care plan, dated 10/24/16, documented a problem as, Falls .She has a wander guard in place d/t (due to) oblivious to own safety aeb (as evidenced by) wandering and trying to leave the facility secondary to Alzheimer's. She also may have a pressure pad alarm in bed and a clip alarm while in her w/c (wheelchair) or recliner d/t oblivious to own safety aeb falls secondary to Alzheimer's . Interventions: (resident #70) should always wear non slip footwear anytime she is up or when transferred to prevent slips, falls and injuries. (Resident #70) has a wander alarm d/t oblivious to own safety/wandering secondary to Alzheimer's . Anyone who hears a pressure alarm sounding should locate it immediately. If the staff member is unable to physically help assist (resident #70), a nursing staff member needs to be alerted immediately. Every staff member working together when an alarm is heard may reduce falls . Encourage (resident #70) to use the call light if she should drop an item on the floor. Instruct her not to try and retrieve the dropped and fallen item herself as this could cause a fall and/or injury. Have her use the call light anytime she needs assistance and as soon as she feels the urge to use the restroom. Check on her often as you go down the hall, as she may forget to use the call light when she needs assistance d/t her severe cognitive impairment . (Resident #70) may have a personal safety alarm/clip alarm in place when in w/c and in recliner d/t oblivious to own safety AEB falls secondary to Alzheimer's . WILL CHANGE THE BED TO TWO SINGLE BEDS . Assist her to go to the toilet before and after every meal, before going to bed and at least every 2 hours in between . A nurse's note, dated 11/08/16 at 11:00 a.m., documented a request to the resident's daughter to allow the resident to move to the memory care unit. The resident's daughter declined and asked if the physician could make some medication changes to address the resident's wandering behavior. A nurse's note, dated 11/10/16 at 12:27 p.m., documented a special care plan conference with daughter. It was decided to change out the resident's bed with a hospital bed to give more room to move around. The note further documented the physician had increased the resident's Namenda (Alzheimer's medication) and placed the resident on Zyprexa (Antipsychotic). A reportable incident was received at the OSDH on 11/11/16. The report documented the resident fell next to the bed while attempting to go to the bathroom resulting in a reddened area to the back of the resident's head. Neurological checks were initiated. The staff were instructed to ensure non-skid foot wear was in place. A nurse's note, dated 11/11/16 at 10:07 p.m., documented the resident had a fall resulting in a reddened area to the back of the resident's head. Neurological checks were initiated. The staff were instructed to ensure non-skid foot wear was in place. An incident report, dated 11/13/16 at 1:00 p.m., documented the resident fell in another resident's room without injury. The resident's PSA was in place. A nurse's note, dated 11/13/16 at 3:15 p.m., documented the resident had a fall without injury while in another resident's room. The resident's PSA was in place. An incident report, dated 11/16/16 at 3:45 p.m., documented the resident fell in front of the recliner attempting to go to the restroom. The fall resulted in no injury. The resident was educated on use of the call-light and safety. A nurse's note, dated 11/16/16 at 4:23 p.m., documented the resident had a fall without injury. The resident was educated on the use of the call-light and safety. A nurse's note, dated 11/19/16 at 10:53 p.m., documented the resident had a fall without injury. The staff were instructed to ensure the pressure pad was in place when resident was in bed. A reportable incident was received at the OSDH on 11/20/16. The incident report documented the resident fell getting off the bed to go to the bathroom resulting in a hematoma to the crown of the head. Neurological checks were initiated. The resident was educated on the call-light and safety. A nurse's note, dated 11/21/16 at 3:24 a.m., documented the resident had a fall resulting in a hematoma to the crown of the resident's head. Neurological checks were initiated. The resident was educated on the call-light and safety. Call-light and PSA in place. On 01/10/17 at 8:36 a.m., certified nursing assistant (CNA) #2 was asked if there were any residents on F-hall who were on fall precautions. She stated resident #70. The CNA was asked if she knew why the resident was on fall precautions. She stated the resident had a history of [REDACTED]. She stated she looks for signs of anxiety, watches to see if the resident was attempting to get out of the recliner, make sure to take care of the resident's hygiene so the resident doesn't have to do things herself. CNA #2 was asked what interventions were in place to ensure the resident did not fall. She stated she was told to take her to the bathroom every two hours and make sure her needs were met. She was asked if those were the only interventions used. She stated the resident had a clip alarm when she was in the recliner and wheelchair, a bed alarm at night and signs in the room for her to read to remember to call for help. 01/10/17 at 8:44 a.m., licensed practical nurse (LPN) #3 was asked if there were residents on fall precautions on her halls (F and B). She stated there were several. She was asked how she knew which residents were on fall precautions. She stated she obtained the information from shift report. The LPN was asked what specific interventions were in place for resident #70. She stated, toileting before every meal, check her every two hours, make sure alarms were being used, and use of a camera in the resident's room to find out why she was falling. They also got rid of the one big bed in the room which gave the resident more room to move around. On 01/10/17 at 4:56 p.m., minimum data set (MDS) coordinator #2 and LPN #1 were asked their process to care plan falls. MDS coordinator #2 stated they would receive MDS data which would notify them of past falls. She further stated they would review incident reports related to falls or the physician would order fall precautions, then it would be added to the care plan. They were asked if each fall was added to the care plan. LPN #1 stated she tried to get all of them onto the care plan, but since an employee had left recently, she was behind in getting all the incident reports added into the computer. They were asked if new interventions were initiated after each fall. They stated, no. They were asked who analyzed the data, and determined the root cause for the falls. They both stated the director of nurses (DON). At 6:06 p.m., the DON was asked what interventions had been implemented to prevent further falls for resident #70. She stated that they had instituted multiple interventions such as placing skid-strips on the floor of the bathroom, in front of the recliner and next to the bed. They put up signs from the family to remind the resident to use the call-light when needing help, changed out the single large bed for hospital beds to allow more room to move around, placed a camera in the room to determine why falls were taking place. Placed alarms on the chair and bed, and toileting her before meals and every two hours. The DON was asked to review the incident reports. After reviewing the reports, she was asked if there was any commonalities in the falls. (8 of the 14 falls were related to the resident's need to be toileted). The DON stated sometimes the resident would not know why she fell or could not remember and the falls had taken place in several areas. The DON was asked if she had determined a root cause for the resident's falls and implemented appropriate interventions. She stated she believed the falls were due to the resident's cognitive status and they had instituted multiple interventions.

On 08/24/11 at 5:35 p.m., an immediate jeopardy (IJ) situation was determined to exist due to the facility's failure to develop and implement interventions, and evaluate the effectiveness of current interventions to protect residents, who had been assessed for being at risk for falls, from frequently reoccurring falls. The Oklahoma State Department of Health (OSDH) was notified on 08/24/11 at 5:35 p.m., and verified the existence of the IJ. The administrator and the DON (director of nursing) were notified at 6:00 p.m., of the IJ situation existing in the facility. An acceptable plan of removal was received on 08/24/11 at 7:55 p.m. The acceptable plan of removal was as follows: "1. August 24th at 7pm, the staffing ratios changed to increase the number of staff in the Special Care Unit (SCC). There will be four certified personnel in the unit on 7/3 shift at all times. There is three certified personnel in the unit on the 3/11 shift at all times. There will be two certified personnel in the unit during the 11/7 shift at all times. a. DON in serviced current staff on new policy at 7pm on 8/24/11 b. DON got CMA (certified medication aide) to agree to stay from 3/11 shift instead of 3/9 at 7pm on 8/24/11. c. DON contacted 11/7 CNA (certified nurse aide) and she agreed to come in at 9pm at 7pm on 8/24/11. (DON called her at 7pm and she agreed to come in at 9pm) d. DON insured (sic) that 3 certified personnel in the unit as of 8/24/11 e. DON reviewed schedule and instructed charge nurse to assign two certified personnel on 11/7 shift at 7pm on 8/24/11. f. Charge nurse will in-service the 11/7 staff before starting duties at 11pm on 8/24/11. 2. Effective 8/24/11 at 7pm the charge nurse will complete a Fall Risk Evaluation and documentation of interventions initiated with each incident report regarding a fall. 3. Effective 8/24/11 at 7pm the fall risk evaluation will be done on all residents in SCC (special care center) by 8/25/11 at 4pm. 4. Effective 8/24/11 care plans will be updated to include fall interventions for those that are fall risks in SCC by 8/26/11 at 12pm." On 08/25/11 at 8:25 a.m., the DON provided copies of fall risk assessments and inservices of the staff for staffing patterns in the SCC. At 10:45 a.m., the DON provided an addition to the POC as follows: "...g. 90% of nursing staff will be inserviced by 12pm on 08/25/11..." An interview was conducted on 08/25/11 at 9:30 a.m., with the DON. She was asked where the SCC staff documented the every fifteen minute visualization of the residents. She stated the documentation was on the ADL sheets. This was verified by the survey team. She was asked if falls had occurred overnight on the SCC. She stated there were no falls overnight. The DON was asked to provide time sheets for confirmation of the staff who had worked in the SCC on the 11:00 p.m. to 7:00 a.m. shift. At 12:20 p.m., the DON provided the time sheets for staff who had worked in the SCC the previous night shift. The time sheets confirmed two staff members worked the shift. An observation was made on the SCC, from 1:10 p.m. to 1:35 p.m., of staff walking the hallway every fifteen minutes. There were four CNAs and an LPN in the unit. At 4:05 p.m., the DON was asked about the plan for the staff members that had not been reached yet. She stated she had three she had texted and they would be inserviced over the weekend prior to the start of their shifts. The IJ was removed on 08/25/11 at 12:00 p.m., when the facility's staff (except for the three unavailable) had completed the inservices. The deficient practice remained at a level of harm with more than a very limited number of residents affected. Based on observation, record review and staff interviews, it was determined the facility failed to ensure: ~ interventions were developed and implemented, and current interventions were evaluated for their effectiveness to protect the residents from frequently reoccurring falls for five (#1 - #3, 5 and #12) of ten sampled residents with frequent falls. This resulted in an IJ situation for two (#1 and #3) residents. The facility identified 17 of 18 residents residing in the SCC as being at risk for falls through fall risk assessments. ~ cabinets containing chemicals in the whirlpool rooms were locked for four (hall B, hall C, hall E and hall F) of five sampled whirlpool rooms observed. The facility did not identifiy any residents who wandered without regard for safety. ~ a mechanical closet door was locked for one (hall B) of five mechanical closets observed. The facility did not identifiy any residents who wandered without regard for safety. Findings: POLICIES The Staffing and Environment of the Special Care Center, dated May 2007, documented, "A. Staffing Ratio and Training of Staff 1. This facility staffs the special care center as follows: A. 7:00AM-3:00PM......1:7 B. 3:00PM-11:00PM....1:15 C. 11:00PM-7:00AM....1:20..." The SCC Resident Visualization, dated May 2007, documented, "The residents of SCC need specialized, individual care. These residents are at risk for falls and injury at any given time. The following are methods to prevent resident injury and falls. Procedure: 1. All CNAs in SCC are required to walk the hall every 15 mins (minutes) while not providing direct patient care to observe resident activity... 3. CNAs will be responsible for charting that each resident has been visualized every 15 mins through out his/her shift..." The Fall Prevention, dated May 2007, documented, "Residents in our facility are at risk for falls on a daily basis. Corn Heritage Village will take the following steps to prevent these falls in our residents. Procedure: 1. Each resident will have a fall risk evaluation completed every three months to evaluate his/her risk for sustaining a fall. these evaluations will take into consideration the resident's ability to ambulate, vision, cognition and medications. 2. If the resident is deemed a fall risk, then the resident will have a "falling star" magnet placed on his/her doorframe to alert staff that this particular resident is at risk for falls. 3. These residents with falling stars are to be observed more frequently to assure that he/she is not in a situation where a fall is likely to occur. 4. At a resident's admission conference, the family will be asked about the resident's fall history at home. If the resident has had numerous falls at home, then he/she can be made a falling star at that point. 5. Any information received regarding a resident's fall risk will be relayed to the careplan coordinator so that measures can be implemented to prevent future falls. If the measures implemented are not effective, then the careplan will be modified to better suit the resident. 6. Incident reports regarding falls will be analyzed to correlate falls with certain situations to help prevent future falls." 1. Resident #3 had [DIAGNOSES REDACTED]. The Evaluation of Resident at Risk for Falls Form, dated 11/02/10, documented a fall risk score of 16. The facility's Fall Tracking Log (no date provided) documented the resident had falls on: ~ 12/25/10, without injury, ~ 01/18/11, without injury, ~ 04/23/11, without injury, ~ 06/22/11, sustained left hip fracture which required surgery and ~ 08/02/11, without injury. The facility Incident Reports for each of the above dates contained no documentation of corrective interventions having been initiated to protect the resident from injuries as a result of multiple falls. The nurse's notes, dated 12/25/10 at 4:30 p.m., documented the resident was found sitting on the floor in front of her recliner. The note documented the resident stated that she was, "OK." No additional comments and/or corrective interventions to prevent falls and/or injuries were documented. The nurse's notes, dated 01/18/11 at 1:50 p.m., documented the resident was found sitting on the floor of her room. The note documented the resident was assisted to her recliner, and the call light was placed within reach. No injuries were observed. No additional comments and/or corrective interventions to prevent falls and/or injuries were documented. The care plan, dated 01/31/11, documented, Problem: The resident had fallen 7 times since her admission on 03/03/10. Most of her falls had occurred in her room or bathroom during various times. Goal: She will have no falls in the next 3 months. "Approach: Nursing and other staff will need to observe for risk of falls due to possible side effects of medications. Observe for an unsteady gait or balance when she is ambulating about the secured unit. To help prevent falls be aware of her whereabouts at all times. She will need extensive assistance by one staff member with transfers, dressing and bathing She will need some assistance by one staff with toileting and personal hygiene to help prevent falls. She needs supervision with her other ADL needs to help prevent falls. Eliminate potential environmental hazards. Encourage safety precautions. Keep her call light in reach at all times but check on her at least Q 15 to 30 minutes because she may not remember to use her call light. Encourage appropriate behaviors to help prevent falls. The charge nurse will need to let the (Resident's) physician and responsible party know when falls &/or injuries occur." The facility Evaluation of Resident at Risk for Falls Form, dated 04/18/11, documented the resident had a fall risk score of 13. Residents with a score of 8 or higher should be placed on fall precautions. A nurse's note, dated 04/23/11 at 4:30 p.m., documented the resident was found kneeling on the floor beside her bed. The resident stated that she was trying to straighten her bed when she fell . The resident complained of pain to her knees and lower back. The resident's blood sugar was obtained. She had a blood sugar of 87 and was shaky. The resident was assisted to bed and encouraged to let staff help her with transfers and ambulation. No injuries were noted. No additional comments and/or corrective interventions to prevent falls and/or injuries were documented following the fall of 04/23/11. The care plan, dated 01/31/11, had a quarterly review dated 04/29/11. There were no changes made to the care plan. A quarterly resident assessment, dated 05/03/11, documented the resident's cognition was severely impaired with short and long term memory loss. She required limited assistance with transfers and supervision with walking. A nurse's note, dated 06/22/11 at 3:55 p.m., documented the resident was ambulating to the dining room when she lost her balance and fell on her left side. A popping noise was heard when the resident hit the floor. She was evaluated and the left leg was observed to be rotated outward. The resident was screaming in pain. The family was notified and was asked for permission to obtain X-rays. At 4:05 p.m., the physician was notified and issued new orders to transport the resident to the hospital for evaluation and treatment. At 8:15 p.m., according to the hospital and daughter the resident was transferred to an orthopedic specialty hospital for surgery due to a left hip fracture. A nurses's note, dated 06/28/11 at 6:50 p.m., documented the resident had been readmitted to the facility. A physical therapy evaluation, dated 06/29/11, documented the resident ambulated independently without the use of a rolling walker prior to the hip fracture, but she was a high fall risk. The resident was referred to physical therapy due to a functional decline. The facility Evaluation of Resident at Risk for Falls Form, dated 07/02/11, documented the resident had a fall risk score of 14. The significant change in condition assessment, dated 07/08/11, documented the resident was severely impaired in cognition. She usually made herself understood and sometimes understood others. She required extensive assistance with transfers and no longer ambulated. The care plan, dated 07/08/11, documented, "Problem: ...She has fallen 10 times since being admitted to CHV (Corn Heritage Village). Her last fall was 06/22/11. When she fell she fractured her left hip, requiring ORIF (open reduction internal fixation). She returned to CHV on skilled services for therapy. She is very unsteady with balance during transitions so she needs human assistance to stabilize her. She is not walking at this time with staff but she has been working with physical therapy and occupational therapy for strengthening. She has limited range of motion in her lower left extremity due to the fracture... She is in a wheelchair for locomotion needs now with assist, but she has orders to be weight bearing as tolerated to left hip so she can work with PT and OT as tolerated... Goal: The resident will have no falls and/or injuries in the next three months. Approach: Observe for risk of falls or tendency to fall such as unsteady balance when sitting or transferring x 2 person assist, or riding in her geri-recliner. Observe for possible side effects to medications that may cause falls. Observe and report any signs of pain &/or discomfort that may cause restlessness, causing her to fall, then treat as per doctors orders. Monitor for side effects and effectiveness of any pain medication given. Nursing staff will need to get (Resident) up slowly from a lying or sitting position to help prevent falls. Encourage morning and afternoon rest periods. Encourage safety precautions by eliminating potential environmental hazards. Keep her call light within reach at all times while she is in bed, in her recliner, or the geri-recliner in her room, but check on her every 15-30 minutes as she will not remember to use the call light d/t (due to) her severe cognitive impairment. Nursing staff needs to assist her to get around facility when she is in her wheelchair d/t weakness, dementia and hip fracture with limited ROM (range of motion). She may also have one/half side rail up on the outside of the bed to aid her in repositioning...(Resident) can now walk with her walker and assist using a gait belt." The only intervention added following the hip fracture of 06/22/11, was to "encourage morning and afternoon rest periods." The care plan continued to document, "keep her call light within reach at all times..." as an approach when they had assessed the resident's cognition as severely impaired and had short and long term memory loss. A physical therapy weekly progress note, dated 08/02/11, documented a barrier to the resident's progress was her decreased endurance as a result of the surgical repair of her left hip fracture. It also documented the resident's response to care was fair. A nurse's note, dated 08/02/11 at 10:35 p.m., documented the resident was found sitting on the foam mat on the floor beside her roommate's bed. The note documented she was positioned on her knees and bottom. The resident stated that she was attempting to go to the restroom. No injuries noted. The resident was cleaned up and assisted to bed. No additional comments and/or corrective interventions to prevent falls and/or injuries were documented. The care plan, dated 07/08/11, was reviewed on 08/18/11. There were no changes made to the care plan even though the resident had experienced another fall. On 08/25/11 at 1:30 p.m., the director of nurses was asked if falls had been discussed in the Quality Assurance meetings. She stated she didn't know she would have to check. She was asked what precautions had been initiated to prevent the residents in the unit from falling. She stated it was an Alzheimer's unit. They wander; they are going to fall. While residing in the facility the resident experienced five falls between 12/25/10 and 06/22/11. The fall on 06/22/11, resulted in a fractured hip which required the resident to undergo surgery. The resident sustained [REDACTED]. 2. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Evaluation Of Resident At Risk For Falls Form, dated 01/17/11, documented a score of 15. The form documented, "Patients who rate greater than 8 should be placed on fall precautions and a problem listed on the patient plan of care for potential for falling." A care plan, dated 02/04/11, documented, "Falls: gait problem, such as unsteady gait, even with mobility aid or personal assistance, slow gait, takes small steps, takes rapid steps, or lurching gait. Goal: will have no further falls &/or injuries in the next 3 months. Approach: Nursing and other staff will need to observe for risk of falls that may be caused by unsteady gait/balance while she's ambulating about the secured unit. Be aware of her whereabouts at all times. Staff will need to observe for safety precautions by eliminating potential environmental hazards that could cause her to fall." An incident report, dated 03/30/11, documented an incident occurred at 12:30 a.m.: "Alerted to room by CNA resident sitting on floor. Resident unable to state what happened d/t mental status...urine noted on floor and resident gown wet. instructed to use call light for assistance and staff to monitor more frequently." An incident report, dated 04/03/11, documented an incident occurred at 1:50 p.m., "Visitor reported to CNA res. fell in hallway, upon assess res. sitting on bottom leaning against wall..." No intervention was addressed to prevent further falls. An incident report, dated 04/05/11, documented an incident occurred at 3:45 p.m., "Summoned to residents room. Upon arrival resident sitting in the floor in front of her recliner. res is unable to explain what occurred..." No intervention was addressed to prevent further falls. A comprehensive assessment, dated 04/22/11, documented the resident's cognition as moderately impaired. She required extensive assistance with dressing and bathing. She required limited assistance with transfers, ambulation and bathing. An incident report, dated 06/24/11, documented an incident occurred at 5:55 a.m.: "CNA walking past res room looked in room and saw res loose balance and fall in front of bed landing on L (left) side. Res L foot slightly turned out. ROM (range of motion) performed with res c/o (complains of) pain when knee bent. assisted up into recliner res would not put any weight onto L leg...called daughter and daughter stated wanting to send res in for x-ray." A nurse's note, dated 06/24/11, documented at 9:40 a.m.: "Res returned to facility no fx (fracture) noted n/o (new order) 1. no (new order) wt (weight bearing) bearing with assistance..." At 11:50 a.m., "(Hospital) called and stated that radiologist read report and felt needed to come back for CT (computerized axial tomography) of L hip through ER (emergency room )." At 1:30 p.m., "Transportation called stated hip is fix (sic/fractured) and hospital wanting to send to (Hospital) in OKC (Oklahoma City)." The resident was transferred to a city hospital for surgery on 06/24/11 and returned on 06/27/11. The incident reports verified the resident fell on [DATE], 04/03/11 and 04/05/11. The care plan was not updated and no new interventions were initiated after these three falls to prevent additional falls. The fourth fall which occurred on 06/24/11, resulted in a hip fracture and constituted an actual harm for the resident. A comprehensive assessment, dated 07/04/11, documented the resident's cognition as severely impaired. She required extensive assistance with transfers, ambulation, dressing, eating and bathing. The resident's care plan, dated 07/08/11, documented, Falls: Impaired balance during transitions. Goal: will have no further falls &/or (and/or) injuries in the next 3 months. Approach: Observe for risk of falls such as unsteady balance when sitting transferring x2 person assist, or riding in her geri-recliner. Nursing staff will need to get resident up slowly from a lying or sitting position to help prevent falls. Be aware of her whereabouts at all times. Staff will need to observe for safety precautions by eliminating potential environmental hazards that could cause her to fall. Encourage morning & afternoon rest periods. Encourage safety precautions by eliminating potential environmental hazards. Keep her call light within reach at all times while she is in bed, recliner or the geri-recliner in her room, but check on her at every 15-30 minutes as she will not remember to use her call light d/t (due to) her severe cognitive impairment. The fall care plan, dated 07/08/11, continued to document, "keep her call light in reach at all times" when the assessment, dated 07/04/11, documented the resident's cognition as severely impaired. 3. Resident #5 was admitted to the SCC on 01/05/11, with [DIAGNOSES REDACTED]. An admission resident assessment, dated 01/24/11, documented the resident's cognition was moderately impaired with short and long term memory loss. He required extensive assistance with transfers. The incident report, dated 04/03/11 at 12:15 a.m., documented, "...Upon entering resident seen lying on L side on floor. States he was going to the bathroom..." This was the fall which resulted in the hip fracture. The resident was readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident was not placed on the SCC. The comprehensive care plan, dated 04/20/11, documented, "...Falls... Goal... (Resident) will have no falls &/or injuries in the next 3 months... Approach...make sure he has pressure alarm under him while in bed, his recliner or w/c (wheelchair). Make sure a floor mat is beside his bed anytime you put him to bed... 6/1/11 PT (physical therapy) to treat (Resident) 3 times a week for 30 days... 6/2/11...OT (occupational therapy) 3 times a week for 30 days... 6/20/11...DC (discontinue) from PT and OT services 06/16/11, 06/17/11 to LTC (long term care) d/t progress plateau. (Resident) very difficult to arouse at times for therapy with participation..." A nurse's note, dated 05/24/11 at 5:10 a.m., documented, "...This nurse heard resident's pressure alarm. Responded to res. (resident's) room. Res. laying on floor mat beside bed..." A nurse's note, dated 05/27/11 at 10:00 p.m., documented, "...@ (at) 2115 (9:15 p.m.) Res alarm was sounding, CN (charge nurse) entered room (and) found res lying on floor on top of mat c (with) top half of body off of mat..." A nurse's note, dated 07/15/11 at 5:00 p.m., documented, "...Resident lying on his R (right) side in the floor. (upper) body on floor mat (and) (lower) body off of the floor mat..." The incident report, dated 07/19/11 at 8:10 p.m., documented, "...CN walked by res. room et noted res. on floor mat lying on R side. Res has pressure alarm but alarm (not) alerting..." On 08/25/11 at 1:40 p.m., the DON was asked if any new interventions had been initiated since the resident had experienced several falls since his readmission on 04/08/11, after surgery for [REDACTED]. On 08/29/11 the resident experienced a fall from his bed. The incident report, dated 08/29/11 at 1:50 p.m., documented, "...ER (emergency) light going off in res. room. Upon entering, res on R side on floor next to recliner c head on floor mat. CNAs (certified nurses aides) reported that res roommate alerted them to the room. When they entered res was in same position. Roommate stated res was standing by recliner when he fell ..." The resident continued to fall with no interventions being used other than pressure alarms which only alerted the staff after the resident had fallen. 4. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An evaluation of resident at risk for falls form, dated 02/09/11, documented a score of 19. A annual resident assessment, dated 02/12/11, documented the resident's cognition was severely impaired. She required limited assistance with transfers and supervison with ambulation and a walker. An incident report, dated 03/26/11, documented, "1640 (3:40 p.m.) res lying supine in the floor in the dining room. Res stated she slipped and fell ..." No interventions were care planned after this fall. An incident report, dated 04/01/11, documented, "2235 (10:35 p.m.) alerted to res room. Upon entering res sitting on bottom up against recliner. Swollen area noted to L cheek..." No interventions were care planned after this fall. A care plan, dated 04/04/11, documented, Problem: resident needs extensive assist for most adls, but when she feels better she thinks she can do things for herself and does not call for help. She has had multiple falls, most of them in her room at various times of the day. She is unsteady with balance when she moves from seated to standing position, transfers on & off the toilet, surface to surface transfers & walking. She has a pressure alert pad on her bed & chair to alert staff when she is trying to get up because she does not call for help. Goal: Will have no further falls &/or injuries in the next 3 months. Approach: Observe for risks of falls that may be caused by unsteady balance while standing or transferring to help prevent falls. Make sure she always has her security alarm in her bed, w/c or recliner to warn staff if she tries to get up by herself. Encourage & assist her to get up slowly from a lying or sitting position to help prevent dizziness or causing her to pass out. Encourage morning & afternoon rest periods. Encourage safety precautions & eliminate potential environmental hazards. Keep her call light within reach at all times while she is in her bed, recliner or w/c in her room, but check on her at least every 15-30 minutes as she may not remember to use her call light when she needs help. Be aware of her whereabouts at all times as she likes to wander around the unit in her w/c. An incident report, dated 04/27/11, documented, "1910 (7:10 p.m.) alerted to resident's room by CNA who states she had heard noise in room and upon entering found res on floor....Apx (approximately) 2cm x 2cm noted to right side of head." No interventions were care planned after this fall. An incident report, dated 05/05/11, documented, "1325 (1:25 p.m.) Resident lying on floor at end of hallway. States she doesn't know if she bumped her head and doesn't know how she fell . No injury or bruising noted at this time. There is an imprint on her left cheek bone where she was lying on her oxygen tubing." No interventions were care planned after this fall. An incident report, dated 05/23/11, documented, "1550 (3:50 p.m.) CN alerted to another room, upon arriving to room res on floor in bathroom lying on left side, res trying to get up and kept saying help me...raised red area noted on left temple..." No interventions were care planned after this fall. A care plan, dated 05/31/11, documented, Falls: impaired balance during transitions. Goal: will have no further falls &/or injuries in the next 3 months. Approach: Observe for risks factors that may cause her to fall such as unsteady balance. She needs supervision to walk behind her walker in the secured facility. Monitor for proper use of her walker when she uses it to walk. She needs supervision for transfers & extensive assist for all other adl's. Nursing staff may need to encourage & assist her to get up slowly from a lying or sitting position to help prevent falls. Be aware of her whereabouts at all times. She walks behind her w/c around the secured unit. So monitor for proper use of w/c. Eliminate potential environmental hazards. Encourage safety precautions, behaviors. Nursing staff will need to assist her to the toilet when she ask to go or every 2 hours to prevent falls. Encourage morning & afternoon rest periods. Encourage safety precautions & eliminate potential environmental hazards. Keep her call light within reach at all times while she is in her bed, recliner or w/c in her room, but check on her at least every 15-30 minutes as she will not remember to use her call light when she needs help. She needs supervision for transfers & needs extensive assist with all other adl's. An incident report, dated 06/01/11, documented, "0600 (6:00 a.m.) alerted to res. room noted on floor on left side..." No interventions were care planned after this fall. An incident report, dated 06/02/11, documented, "1615 (4:15 p.m.) alerted to res room by CMA. Noted res on floor on left side...noted quarter size laceration on back of head with large amount of red blood..." No interventions were care planned after this fall. On 06/07/11, the care plan, documented, "Resident to have a pressure pad alarm while in bed d/t weakness and oblivious to own safety." A physician order, dated 06/24/11, documented the resident to be transferred out of the SCC. On 07/01/11, a low bed with floor mat was added to the care plan. A comprehensive assessment, dated 07/03/11, documented the resident's cognitive status as severely impaired. She required extensive assistance with transfers, ambulation, dressing, eating and bathing. The care plan, dated 07/07/11, documented the resident had declined; she was no longer ambulatory behind her wheelchair and she was now confined to a geri-recliner. On 08/23/11 at 9:05 a.m., the resident was observed in her room in a gerichair (geri-recliner). 5. A care plan for resident #12, dated 04/04/11, documented the resident needed extensive assist with ADLs, shuffled her feet when walking behind a wheelchair or a walker and had a pressure alert pad on her bed and chair. A comprehensive assessment, dated 06/24/11, documented the resident's cognitive status as moderately impaired. She required limited assistance with transfers and dressing. She required extensive assistance with ambulation, eating and bathing. She was frequently incontinent of bladder. An evaluation of resident at risk for falls form, dated 06/20/11, documented a score of 14. An incident report, dated 07/18/11, documented, "1915 (7:15 p.m.) resident lying supine in the floor near bathroom entrance...resident stated I hit my head..." No interventions were care planned after this fall. An incident report, dated 08/07/11, documented, "1545 (3:45 p.m.) summoned to resident's bathroom via emergency light, upon arrival resident lying supine on the bathroom floor...resident stated she hit her head..." No interventions were care planned after this fall. 6. A care plan for resident #15, dated 11/17/10, documented, "...History of Falling: Problem: (Resident) has a history of falling before coming to CHV and since he's been here. Most of his falls occur during the 7/3 (7:00 a.m. to 3:00 p.m.) shift when he is more active. He is unsteady with gait and balance. He is supposed to use a cane, but because of his cognitive status, he forgets. He has a pressure alarm pad when in bed or sitting in his recliner. His bed is low and he has a floor mat next to it. He needs extensive assist with bed mobility & transfers x 1. Sometimes staff uses a w/c, especially when he is tired. He takes Seroquel & Remeron, and has recently been started on Xanax prn (as needed). Goal: (Resident) will have no falls and /or injuries in the next 3 months. Approaches: Observe safety precautions by eliminating potential environmental hazards. Keep his call light in reach at all times while he's in the his room, but check on him at least Q. 15-30 minutes because he will not remember to use the call light when he needs help. Nursing staff will need to check him at least q 2 hours for bowel or bladder incontinence, provide good peri care & change his brief when wet or soiled. He needs extensive assist with most adl needs. Be aware of his whereabouts at all times. He may have a personal alarm

Based on observation, record review and interview, it was determined the facility failed to ensure residents did not experience unplanned weight loss for two (#3 and #5) of seven sampled residents for whom weight loss was reviewed. Resident #5 had a significant weight loss in the last six months of 15.3% (46 lbs.) and had a weight loss of 22.6% (53 lbs.) since admission on 01/05/11. The Resident Census and Condition, dated 08/22/11, documented the facility had thirteen residents who had experienced unplanned significant weight changes. Findings: The Weight Variance Policy, documented, "Policy: In recognition that general wellness is related to nutritional status, residents will have their weight monitored periodically. Those with significant variance will be assessed and the monitoring protocol implemented... Provisions:...The Registered Dietitian will complete the nutritional assessment in a timely manner..." 1. Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. A monthly dietary weight sheet documented the resident's weights were: January 2011, 235 pounds February 2011, 228 pounds March 2011, 215 pounds April 2011, 207 pounds May 2011, 200 pounds June 2011, 193 pounds July 2011, 189 pounds August 2011, 188 pounds and 08/29/11 was 182 The resident had a significant weight loss in the last six months of 15.3% (46 lbs.) and had a weight loss of 22.6% (53 lbs.) since admission on 01/05/11. The admission resident assessment completed by nursing, dated 01/24/11, documented the resident's height was 70 inches and his most current weight was 230 lbs. It documented that he had not, or it was unknown if he had, a weight lose of greater than 5% in the last month or a loss of 10% in the last 6 months. The first dietary progress note completed by the dietary manager (CDM) located in the record, dated 02/28/11, documented the resident's diet as a CCHO (consistent carbohydrate-CDM defined) diet. The first documentation completed by a registered/licensed dietitian (RD/LD) was a nutrition risk assessment dated [DATE] (over two months since his admission). It documented the resident was at high risk for nutritional deficits with a score of 13. A score greater than 8 was considered high risk. The risk assessment also documented the resident had a 5.7% weight loss in one month and the resident had a decreased appetite. The RD/LD dietary progress note, dated 03/14/11, documented, "...will recommend house supp. (supplement) BID (twice a day) between meals (secondary to decreased) appetite..." The April 2011 dietary progress note by the CDM documented, "...4/1 Order for house supplement BID between meals... 4/6 Weight conference today. The resident has lost weight. He has been more sleepy. [MEDICATION NAME] was DC'd (discontinued) but then his behaviors increased so it was restarted. The weight loss was needed. BMI (basal metabolic index) is 29.7 which is still overweight. Is currently in the hospital with a fx (fractured) hip... 4/12 Memo to change resident's diet to CCHO with puree texture. Resident was eating this at the hospital and doing well on this diet... 4/20...He is on a puree diet at this time..." The significant change in status resident assessment, dated 04/13/11, documented the resident's most recent weight was 205 lbs. It documented the resident had lost 5% or more within the last month or 10% or more within the last 6 months without being on a physician-prescribed weight-loss program. A letter addressed to (Physician), dated 04/19/11, documented, "...It is required that we inform you of the significant changes in our resident here at CHV (Corn Heritage Village)...He has had a weight loss from 230 on 01/24/11 to 205 on 04/13/11..." The comprehensive care plan, dated 04/20/11, documented the nutritional goal for this resident was "...(Resident) will have adequate nutritional intake evid (evidenced) by maintaining his weight between 200 -210 lbs. in the next 3 months..." The care plan also documents, "...05/03/11...showing a significant weightloss over 3 months of 12%. Will notify physician of the weight loss and wait for any new orders... 05/05/11 Decubavite...and Vit C... Dx(diagnosis):HX (history) of stage II pressure ulcers (and wt. loss) (in handwriting)... 05/09/[MEDICATION NAME] ...for appetite stimulant d/t (due to) weight loss... 06/03/11...showing a significant weight loss over a 3 month period of 10%...No recommendations or changes at this time... 07/08/11...(Resident) IS showing a significant weight loss over a 6 month period of 20% and over 3 months of 9%...No recommendations or changes at this time... 08/03/11...showing a significant weight loss over a 6 month period of 17.5%...No recommendations at this time..." The weight conference review note, dated 05/03/11, documented, "...His BMI is in the overweight category...(no) recommendations @ this time..." The RD/LD dietary progress note, dated 05/04/11, documented, "...Sig. (significant) wt. (weight) (loss) of 12% x 3 months... Appropriate interventions in place. Should sig. wt. (loss)cont. (continue) consider additional interventions. Follow as needed..." (April weight was 207 and May weight was 200 pounds.) The RD/LD dietary progress note, dated 06/01/11, documented, "...BMI - WNL (within normal limits). Sig. wt. (loss) of 10.2% x 3 months...(no) current between meal supplements...consider between meal supplements should additional wt (loss) occur. Monitor..." (The resident's clinical record documented he had been receiving supplements between meals. The resident was observed receiving a supplement on 08/23/11 at 9:47 a.m.) The June dietary progress notes by the CDM documented, "...The resident has been loosing (sic) weight..." The quarterly resident assessment, dated 07/07/11, documented the resident's most recent weight was 189 lbs. It documented the resident had lost 5% or more within the last month and/or 10% or more within the last 6 months without being on a physician-prescribed weight-loss program. The RD/LD dietary progress note, dated 07/15/11, documented, "...Sig. wt (loss) of 9% x 3 months, (loss) of 20% x 6 months...Wt. (loss) this month 4# (pounds), does not fall into sig. range. Should wt. (loss) continue consider alternate supplementation..." The RD/LD dietary progress note, dated 08/03/11, documented, "...Sig. wt (loss) of 17.6% x 6 months...Continue POC (plan of care)..." On 08/23/11 at 9:15 a.m., resident #5 was observed during the morning meal. He had eaten 100% of the meal and had drank two large glasses of apple juice and a full glass of water. He would set the spoon on the table, pick it back up, scrap at the empty plate, try to take a bite and then set the spoon back onto the table. He was observed going through this same routine several times. At 9:25 a.m., the resident was observed receiving incontinent care. His frame was observed to have skin hanging and his spine was seen beginning to protrude on his back. At 11:55 a.m., resident #5 was observed during the noon meal. He was observed scraping his plate once he had eaten 100% of the meal. He would set the spoon on the table, pick it back up, scrap at the empty plate, try to take a bite and then set the spoon back onto the table. He was observed going through this same routine several times. On 08/24/11 at 8:35 a.m., resident #5 was observed during the breakfast meal. He was observed scraping his plate once he had eaten 100% of the meal. He would set the spoon on the table, pick it back up, scrap at the empty plate, try to take a bite and then set the spoon back onto the table. He was observed going through this same routine several times. On 08/25/11 at 1:40 p.m., the DON was asked if she knew why the resident's diet had been changed from mechanical soft to pureed upon readmission from the hospital following the [MEDICAL CONDITION]. She stated she thought he had choking problems, but would check on it. She did not present any documentation of the resident having choking problems. On 08/29/11 at 11:50 a.m., resident #5 was observed during the noon meal. He was observed scraping his plate once he had eaten 100% of the meal. He would set the spoon on the table, pick it back up, scrap at the empty plate, try to take a bite and then set the spoon back onto the table. He was observed going through this same routine several times. The resident was not offered second helpings of the food during the four observed meals. On 08/30/11 at 1:20 p.m., the DON was asked if a baseline nutritional assessment was conducted on admit. She stated she thought it was, but was hearing it might not be. At 1:55 p.m., the CDM was asked if there was a dietary evaluation or dietary notes prior to 03/14/11 for resident #5. She stated if there were, they would be in the record. There was no documentation found in the record. She was asked about the lack of documentation of the resident's weight loss prior to 02/28/11 and/or failure to request a dietician consult since she documented the resident had a history of [REDACTED]. She stated he was a large man and the physician knew he was losing weight and wasn't concerned, so she wasn't either. On 09/01/11 at 4:20 p.m., the DON was again asked if she knew the reason the resident was changed from a mechanical soft diet to a pureed diet when he returned from the hospital on [DATE]. She stated the CDM stated something about his teeth. At 4:35 p.m., the CDM stated the family said his dentures were missing some teeth and were chipped so they took them home. She stated the son had said the resident had been on a pureed diet in the hospital and did fine with it so they changed him to a pureed diet. She was asked if the resident had any problems eating the mechanical soft diet prior to the hospital stay. She said, "No." She was asked if they had assessed the resident's ability to eat the mechanical soft before changing his diet. She stated the son said he did well on the pureed diet so we changed him to a pureed diet. At 5:15 p.m., the CDM stated there were no dietitian notes prior to March 13, 2011. 2. Resident #3 had [DIAGNOSES REDACTED]. The significant change in condition assessment, dated 07/08/11, documented the resident was severely impaired in cognition. She usually made herself understood and sometimes understood others. The resident required limited assistance with the help of one staff member with eating and she was not on a physician planned weight loss. The facility weight records documented the resident weighed 154 pounds in July of 2011 and 144 pounds in August of 2011. This represented a 6.49% severe weight loss for one month. The care plan, dated 07/08/11, documented the resident's physician was notified on 08/03/11, about the resident's "significant" weight loss over a one month period of 6%. The care plan documented no recommendations were made at that time and no new orders were received. On 08/08/11, the resident weighed 142 pounds, on 08/15/11 she weighed 140 pounds, and on 08/22/11 she weighed 139 pounds. The August 2011 monthly physician's orders [REDACTED]. The care plan approach documented the resident was to be asked what she would like to be served to eat. The staff were to let her try to feed herself, but if she had trouble the staff would need to feed her and encourage her to eat and drink all the food and fluids offered on her plate. The resident would be allow her to eat and drink at her own pace and offer a replacement meal if she refused to eat or ate less than 50% of her meal. Staff would record the percentage she ate after each meal and let the charge nurse know if she refused her meal or needed a replacement. On 08/22/11 at 4:45 p.m., the evening meal in the secured unit was observed. Resident #3 was observed to have eaten a serving of fruit, one bite of macaroni with cheese and half a glass of juice. She had been offered Glucerna prior to her meal but she didn't drink it. At 5:45 p.m., a certified nurse aide #6 asked the resident, "Were you not hungry?" The resident responded, "No." She was removed from the table by staff without having been offered encouragement to eat or offered a replacement meal. The dietary intake record, dated 08/22/11, documented the resident consumed 25% of the evening meal and 50% of a replacement meal. On 08/29/11 at 11:00 a.m., the noon meal was observed. At 11:15 a.m., a food tray was placed in front of the resident as she was being removed to her room by staff for a finger stick to determine her blood sugar. At 11:25 a.m., staff returned the resident to the dining room table. She received no set up or encouragement and no attempt was made to rewarm the food. At 11:55 a.m., the resident was requested to be removed from the table. Staff told the resident to, "Wait," and no encouragement to eat was provided to the resident. She had consumed only one half of a chicken finger stick, a fourth of the mashed potatos and gravy and a third of the vegetables and bread. At 12:00 p.m., staff assisted the resident out of the dining room. The resident did not receive any encouragement to eat and no replacement meal was provided. The dietary intake record, dated 08/29/11, documented the resident consumed 30% of the noon meal and 100% of a replacement meal. The resident was not observed to receive a replacement meal. Staff was not observed delivering any replacement meals to the unit. On 08/23/11 at 2:15 p.m., the DON was asked if the resident should have been encouraged to eat. She said, "Yes."

Based on record review and interview, it was determined the facility failed to notify the physician for 36 hours of a resident's complaint of leg pain, back pain and pain upon weightbearing following a fall for one (#5) of 15 sampled residents with prescribed pain medications. The Resident Census and Conditions, dated 08/22/11, identified 40 residents on a pain management program. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A pain evaluation, dated 01/05/11, documented, "...res (resident) able to verbalize when in pain...pain profile on initial evaluation: arthritis pain in hands, general aches and pains..." The initial resident assessment, dated 01/24/11, documented the resident had no pain. A pain evaluation, dated 03/10/11, documented, "...Abbey Pain Scale... for measurement of pain in people with dementia who cannot verbalize... scores Absent - 0, Mild - 1, Moderate - 2, Severe - 3... Vocalization - 0 Facial expression - 0 Change in body language - 0 Behavior change - 0 Physiological change - 0 Physical changes - 0..." No documentation of pain was located in the nurses' notes prior to 04/03/11. The incident report, dated Sunday 04/03/11 at 12:15 a.m., documented a fall and "...c/o (complaint of) R (right) leg pain..." On 04/03/11 at 12:15 a.m., a nurse's note documented a fall and , "...c/o pain when in bed to R leg..." At 8:00 a.m., a nurse's note documented, "...PCP (primary care physician) notified via fax." At 8:30 a.m., a nurse's note documented, "...Res. (resident) having difficulty standing & amb. (ambulating), c/o pain in both hips & back, complaint not consistent...Res. c/o leg pain bilat. (bilaterally) acutely..." At 5:00 p.m., a nurse's note documented, "...up in w/c (wheelchair) @ (at) table. c/o pain to (lower) ext (extremities) while sitting..." On 04/04/11 at 12:05 p.m., a nurse's note documented, "...Res c/o pain to R leg all the way up to back. Res (not) wanting to stand up straight or bear wt (weight) on R leg. Res refused to stay in recliner so res transferred to w/c x (times) 2 person assist. PCP notified of res c/o pain. N.O. (new order) may send to (Hospital) ER (emergency room ) for eval (evaluation) & tx (treatment)...CHV (Corn Heritage Village) to transport..." At 2:20 p.m., a nurse's note documented, "...Dr. said R hip is Fx (fractured)..." On 04/04/11, a hospital history and physical documented, "...The patient is non-weightbearing...They took him to the emergency department because he complained of continued pain..." On 08/25/11 at 1:40 p.m., the DON (director of nursing) was asked about the physician not being notified of the resident's complaint of hip and back pain and refusal to bear weight for 36 hours after his fall. She stated she would have to look at the record to see. On 08/26/11 at 9:15 a.m., the DON presented the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated they had given the resident some Tylenol during this period. She was asked if she would consider a possible [MEDICAL CONDITION] [DIAGNOSES REDACTED]. She stated, " Yes." At 9:30 a.m., LPN #1 (licensed practical nurse) was asked if she had any information regarding the resident's fall on 04/03/11. She stated the CMA (certified medication aide) had given the resident some Tylenol about 8:00 a.m. and she had not been made aware of this until the CMA asked about giving another dose at noon, when he refused to get up for lunch. The LPN stated she had observed him trying to get up from his recliner and had placed him in a wheelchair. She stated he complained of pain to both hips when he tried to bear weight. She stated she then reported the pain to the DON and notified the physician, who ordered for the resident to be sent to the emergency room . LPN #1 was asked to describe how she had assessed the resident when he complained of hip pain. She stated she had done passive range of motion on his legs, like bending his knees towards his chest. She was asked if she had assessed the skin around the hip area for any bruising. She stated she didn't think so because the resident wouldn't allow the staff to pull his pants down. The resident was observed during the survey being toileted and exhibited no resistance to having his pants lowered. On 08/30/11 at 2:45 p.m., RN #1 (registered nurse) was asked how she had assessed the resident when he complained of hip pain. She stated she did passive range of motion, "leg lifts, knees to chest" and assessed for objective/subjective signs of pain. She was asked if there was a reason she had not called the physician with the resident's complaints of pain. She stated because he sometimes complained of pain. The RN was also asked if she had considered the possibility of a [MEDICAL CONDITION] with the resident's complaint of pain on weight bearing and ambulation. She stated she did not think the resident had a [MEDICAL CONDITION] because the pain was not consistent. She stated she had seen lots of [MEDICAL CONDITION] and this didn't present as one because the leg didn't rotate out.

Based on observation, record review and interview, it was determined the facility failed to assess, evaluate and intervene when a resident complained of hip pain, back pain and pain upon weightbearing after a fall for one (#5) of 10 sampled residents who experienced falls. Seventeen of 18 residents residing in the SSC (Special Care Center) had a history of [REDACTED]. Resident #5 was admitted to the SCC on 01/05/11, with [DIAGNOSES REDACTED]. A pain evaluation, dated 01/05/11, documented, "...res (resident) able to verbalize when in pain...pain profile on initial evaluation: arthritis pain in hands, general aches and pains..." The initial resident assessment, dated 01/24/11, documented the resident had no pain. The comprehensive care plan, dated 02/02/11, did not address pain. A pain evaluation, dated 03/10/11, documented, "...Abbey Pain Scale... for measurement of pain in people with dementia who cannot verbalize... scores Absent - 0, Mild - 1, Moderate - 2, Severe - 3... Vocalization - 0 Facial expression - 0 Change in body language - 0 Behavior change - 0 Physiological change - 0 Physical changes - 0..." No documentation of pain was located in the nurse's notes prior to 04/03/11. The incident report, dated Sunday 04/03/11 at 12:15 a.m., documented a fall and "...c/o (complaint of) R (right) leg pain..." An incident report faxed to the health department, dated 04/03/11, documented, "...res was found on the floor...c/o R leg pain...On 04/04/11 res c/o pain to right leg radiating to back and refusing to stand or bear weight on right leg...res requires x 1 assist for transfers and x 1 standby assist to ambulate...Res was sent to the ER upon increased pain and refusal to bear weight on right leg on 04/04/11...resident had a fractured right hip..." On 04/03/11 at 12:15 a.m., a nurse's note documented a fall and, "...c/o pain when in bed to R leg..." At 8:00 a.m., a nurse's note documented, "...PCP (primary care physician) notified via fax." At 8:30 a.m., a nurse's note documented, "...Res. (resident) having difficulty standing & amb. (ambulating), c/o pain in both hips & back, complaint not consistent...Res. c/o leg pain bilat. (bilaterally) acutely..." At 5:00 p.m., a nurse's note documented, "...up in w/c (wheelchair) @ (at) table. c/o pain to (lower) ext (extremities) while sitting..." On 04/04/11 at 12:05 p.m., a nurse's note documented, "...Res c/o pain to R leg all the way up to back. Res (not) wanting to stand up straight or bear wt (weight) on R leg. Res refused to stay in recliner so res transferred to w/c x (times) 2 person assist. PCP notified of res c/o pain. N.O. (new order) may send to (Hospital) ER (emergency room ) for eval (evaluation) & tx (treatment)...CHV (Corn Heritage Village) to transport..." At 2:20 p.m., a nurse's note documents, "...Dr. said R hip is Fx (fractured)..." On 04/04/11, a hospital history and physical documented, "...The patient is non-weightbearing...They took him to the emergency department because he complained of continued pain..." On 08/25/11 at 1:40 p.m., the DON (director of nursing) was asked about the physician not being notified of the resident's complaint of hip and back pain and refusal to bear weight for 36 hours after his fall. She stated she would have to look at the record to see. On 08/26/11 at 9:15 a.m., the DON presented the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated they had given the resident some Tylenol during this period. She was asked if she would consider a possible [MEDICAL CONDITION] [DIAGNOSES REDACTED]. She stated, " Yes." At 9:30 a.m., LPN #1 (licensed practical nurse) was asked if she had any information regarding the resident's fall on 04/03/11. She stated the CMA (certified medication aide) had given the resident some Tylenol about 8:00 a.m. and she had not been made aware of this until the CMA asked about giving another dose at noon, when he refused to get up for lunch. The LPN stated she had observed him trying to get up from his recliner and had placed him in a wheelchair. She stated he complained of pain to both hips when he tried to bear weight. She stated she then reported the pain to the DON and notified the physician, who ordered for the resident to be sent to the emergency room . LPN #1 was asked to describe how she had assessed the resident when he complained of hip pain. She stated she had done passive range of motion on his legs, like bending his knees towards his chest. She was asked if she had assessed the skin around the hip area for any bruising. She stated she didn't think so because the resident wouldn't allow the staff to pull his pants down. The resident was observed during the survey being toileted and exhibited no resistance to having his pants lowered. On 08/30/11 at 2:45 p.m., RN #1 (registered nurse) was asked how she had assessed the resident when he complained of hip pain. She stated she did passive range of motion, "leg lifts, knees to chest" and assessed for objective/subjective signs of pain. She was asked if there was a reason she had not called the physician with the resident's complaints of pain. She stated this was because he sometimes complained of pain.