Every finding on record at Countryside Estates

Based on record review and interview, the facility failed to ensure a qualified employee was assigned to perform the duties of infection preventionist in the facility.The DON identified 76 residents resided in the facility. Findings:A policy titled Infection Preventionist, dated 07/2016, read in part, The Infection Preventionist is responsible for coordinating the implementation and updating of our established infection prevention and control policies and procedures.A facility employment record, dated 07/22/26, showed the infection preventionist had been terminated on 07/22/26 and their last day worked was 07/20/26.On 07/22/26 at 5:20 p.m., the administrator stated their infection preventionist had resigned that morning (07/22/26) via an email. The administrator stated they had not assigned anyone to perform the duties of the facility infection preventionist at that time.On 07/28/26 at 10:21 a.m., the DON stated the former infection preventionist had abruptly resigned on 07/22/26. They stated they had not found anyone to accept the duties of the position as of 07/28/26.On 07/28/26 at 3:38 p.m., the administrator stated the position of infection preventionist had not been filled, and no one had taken on the duties of the position as of 07/28/26.

Based on record review and interview, the facility failed to ensure residents did not fall during transfers for 1 (#1) of 3 sampled residents reviewed for accident hazards.The director of nursing identified 82 residents resided in the facility.Findings:A policy titled Safe Resident Handling/Transfers, revised 12/29/25, read in part, It is the policy of this facility to ensure that residents are transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines.A CNA [certified nursing assistant] Care Plan (OLD) for Resident #1, dated 10/02/25, showed the resident would wrap their arms around a staff member's neck and the staff member would wrap their arms around Resident #1's torso during transfers. The care plan showed a second staff member was to be present during transfers for safety.An annual assessment for Resident #1, dated 10/03/25, showed the resident was dependent on staff for transfer. The assessment showed the resident had diagnoses including osteogenesis imperfecta (brittle bone disease) and cerebral palsy.An incident report form for Resident #1, dated 12/05/25, showed the resident fell during a staff assisted transfer from the bed to a chair. The form showed the resident was assessed and no injuries were noted.On 07/15/26 at 10:10 a.m., the chief nursing officer stated only one staff member was in the room when Resident #1 was transferred on 12/05/26. They stated the facility policy was to always utilize two staff members for transfers.On 07/15/26 at 1:30 p.m., licensed practical nurse #2 stated two staff members should be used to transfer dependent residents.On 07/15/26 at 1:40 p.m., the director of nursing stated two staff members should be used to transfer dependent residents.

Based on record review and interview, the facility failed to ensure residents were offered the right to formulate an advanced directive for five (#6, 12, 14, 31, and #35) of eight sampled residents reviewed for advanced directives. DON #1 identified 70 residents resided in the facility. Findings: 1. Res #6 admitted to the facility on [DATE]. Res #6's medical record did not contain an advanced directive acknowledgement form. 2. Res #14 admitted to the facility on [DATE]. Res #14's medical record did not contain an advanced directive acknowledgement form. 3. Res #31 admitted to the facility on [DATE]. Res #31's medical record did not contain an advanced directive acknowledgement form. 46582 4. Res #12 admitted to the facility on [DATE]. Res #12's medical record did not contain an advanced directive acknowledgement form. 46216 5. Res #35 admitted to the facility on [DATE]. Res #35's medical record did not contain an advanced directive acknowledgment form. On 01/08/25 at 11:07 a.m, the social services director reported they were unable to locate advanced directive acknowledgement forms for Residents #6, 12, 14, 31, and #35.

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed, a care plan was completed, and a physician order was obtained for the use of a physical restraint for one (#25) of one sampled resident reviewed for physical restraints. The ADON identified one resident who utilized a wheelchair lap seat belt. Findings: An undated Use of Restraints policy, read in parts, All restraints must have a physician's order and an order for evaluation by designee for the least restrictive device that is appropriate for the resident .Restraints shall be used only for safety or postural support of a resident to prevent injury to self or others .An assessment regarding the need of restraint for the resident will be completed and documented .The physician's restraint order must be detailed and specific; the order must include type of device, specific duration of use, reason for use and frequency of release .Informed consent for physical restraint will be obtained from the resident or legal representative .The plan of care will identify the need for restraint use .At least every three months an assessment will be completed by the therapist to determine if the restraint continues to be the only viable option for care .Quarterly updates and care plan entries are the responsibility of the interdisciplinary care plan team. Res #25 had diagnoses which included reduced mobility, impulse disorders, and seizures. An annual assessment, dated 09/26/24, documented the resident was severely cognitively impaired, had impairment in bilateral upper and lower extremities, utilized a wheelchair, and was dependent on staff with transfers. The assessment documented the resident had no physical restraints. On 01/07/25 at 12:27 p.m., Res #25 was observed sitting in a wheelchair with a quick release seat belt fastened across their lap. Res #25 stated they wanted the lap seat belt to help prevent them from sliding out of the wheelchair. Res #25 independently unfastened the quick release belt upon request. On 01/08/25 at 10:30 a.m., Res #25 was observed sitting in a wheelchair with a quick release seat belt fastened across their lap. Res #25 independently unfastened the quick release belt upon request. There was no physician order, assessment, or documentation in the care plan regarding the lap seat belt found in Res #25's medical record. On 01/09/25 at 9:15 a.m., the ADON stated the lap belt was requested by Res #25. They stated Res #25 utilized the lap belt to feel more secure in their wheelchair. On 01/09/25 at 10:09 a.m., the ADON stated they did not know when the lap belt had been implemented for Res #25. They stated physical therapy should have assessed the resident prior to implementation and a physician order should have been obtained. On 01/09/25 at 10:32 a.m., DON #2 stated the lap seat belt was not documented in the care plan, but should have been. On 01/09/25 at 10:39 a.m., DON #1 stated the facility was unable to provide documentation of a physician order or an assessment prior to the implementation of the lap seat belt for Res #25.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed for one (#21) of 18 sampled residents reviewed for comprehensive care plans. DON #1 identified 70 residents resided in the facility. Findings: A facility policy titled Care Planning - Interdisciplinary Team, revised 09/2013, read in parts, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .A comprehensive care plan for each resident is developed with seven (7) days of completion of the resident assessment (MDS) .The care plan is based on the resident's comprehensive assessment. A facility policy titled Care Plans, Comprehensive Person-Centered, revised 12/2016, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #21 admitted on [DATE] with diagnoses which included cerebral palsy and severe intellectual disabilities. Resident #21's admission assessment, dated 11/26/24, documented Resident #21 was dependent upon staff for all aspects of their ADLs. Resident #21's EHR contained no documentation of a comprehensive care plan. On 01/08/25 at 12:05 p.m., DON #1 stated Resident #21 did not have a comprehensive care plan.

Based on record review and interview, the facility failed to update the care plan related to wound/treatment care for one (#6) of 18 sampled residents reviewed for care plans. DON #1 identified 70 residents who resided in the facility. Findings: Res #6 admitted to the facility with diagnoses which included traumatic brain injury, dependence on respirator, and tracheostomy. A physician's order, dated 12/14/24, documented to apply Betadine to scabbed area to left dorsal lateral foot daily until resolved. The resident's record was reviewed and the care plan had not been revised to document the wound to the left foot. On 01/09/25 at 8:40 a.m., DON #2 was asked to review the resident's care plan. They stated it should have been revised to document the area to the left foot.

Based on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The DON documented 40 residents received meals from the kitchen. Findings: 1. On 10/19/23 at 9:21 a.m., an initial tour of the kitchen was conducted. A cut tomato in a sealed bad, dated 10/17/23, a cut up onion in a sealed bad, dated 10/13/23, and vegetable soup in a sealed container, dated 10/09/23 were observed in the refrigerator. On 10/19/23 at 9:30 a.m., Cook #1 entered the kitchen with a sack containing salad and other items. Cook #1 was not observed to wash their hands when they entered the kitchen. Cook #1 was observed to start dating the bags of salad and placing them in the refrigerator. On 10/25/23 at 11:09 a.m., Cook #1 was observed to touch their face and put their hand on their hip and then continue to prepare the pureed meals. Cook #1 was not observed to wash their hands during this observation. On 10/25/23 at 11:14 a.m., Cook #1 was observed to touch their glasses, cleaned the can opener, opened another can of milk, and poured some more milk in the noodles puree. Hand washing was not observed. On 10/25/23 at 11:21 a.m., Cook #1 was observed to rub their her nose with the back of their hand, did not wash their hands, and continued the puree. On 10/25/23 at 11:50 a.m., Cook #1 was observed to touch their glasses and continue the puree without washing their hands. On 10/25/23 at 12:11 p.m., DA #2 and DA #3 were observed to enter the kitchen without washing their hands. At 12:13 p.m., they were observed to return a cart to the kitchen and take another cart of meals to the dining room without washing their hands. On 10/25/23 at 12:17 p.m., DA #2 and #3 returned a cart to the kitchen, hand washing was not observed, and another cart with meals was taken to the dining room. On 10/25/23 at 12:23 p.m., DA #2 returned to the kitchen with a cart which had been out to the dining room. DA #2 was not observed to wash their hands. DA #2 was observed retrieving a bowl from the cabinet in the kitchen and take the bowl to the dining room. DA #2 returned to the kitchen and hand washing was not observed. 2. On 10/19/23 at 12:00 p.m., 16 residents were observed in the dining room. On 10/19/23 at 12:11 p.m., CNA #1 was observed to use hand hygiene then the CNA touched their hair. At 12:15 p.m., CNA #1 was observed to assist a resident eat their meal. The CNA was not observed to use hand hygiene before assisting the resident. On 10/19/23 at 12:14 p.m., DA #1 was observed returning a cart to the kitchen. DA #1 used hand sanitizer before entering the kitchen and returning with more resident meals. DA #1 was not observed to wash their hands when they entered the kitchen. On 10/19/23 at 12:23 p.m., DA #1 was observed to use hand sanitizer, entered the kitchen, did not wash their hands. The DA was observed to retrieve a drink and return to the dining room. DA #1 was observed to use hand sanitizer again and entered the kitchen for a straw and was observed to not wash their hands before getting bread. The DA was then observed to touch their clothing and continue with meal service without performing hand hygiene. On 10/19/23 12:27 p.m., DA #1 was observed to use hand sanitizer and enter the kitchen without hand washing. On 10/25/23 at 2:09 p.m., the DM stated stated when the staff entered the kitchen they should have washed their hands. The DM stated the staff used the sanitizer before they entered the kitchen to get more trays to pass. The DM stated they were not aware you could not use hand sanitizer and then go into the kitchen. The DM stated when preparing meals, if staff touched something dirty, they had to change your gloves, and wash your hands. The DM stated if glasses or faces were touched they should have washed their hands. The DM stated they believed food could be kept 48 hours unless it was in its original container then it could be kept longer. The DM stated any items should be dated when they were received and before putting items away.

Based on observation, record review, and interview the facility failed to ensure residents with limited ROM received the appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for four (#12, 23, 53, and #69) of six residents reviewed for position/mobility. The DON documented 41 resident with contractures resided in the facility. Findings: 1. Res #23 had diabetes mellitus, cerebral palsy, CVA, and TIA. A quarterly assessment, dated 08/09/23, documented the resident was intact in cognition and required extensive assistance with ADLs. The assessment documented the resident had limited ROM of the upper and lower extremity on one side. A care plan, updated 09/18/23, documented the resident had limited mobility due to left side hemiparesis related to CVA. A physical therapy discharge summary, dated 09/19/23, documented the resident would discharge from physical therapy to the care of restorative nursing. A order for restorative care was not found in the EHR. On 10/19/23 at 11:11 a.m., Res #23 was observed in bed with contractures noted to left fingers. Res #23 stated they used to get therapy but not now. Res #23 stated they could not move their left side. On 10/26/23 at 2:08 p.m., the DON stated they could not find where the resident had been on restorative nursing after PT was completed in September of 2023. The DON stated the physician should have signed the PT discharge and then PT would have taken the notes back to the PT office. On 10/26/23 at 2:14 p.m., the restorative aide stated they did not know the resident was to receive restorative care following the completion of PT in September. On 10/26/23 at 2:29 p.m., MDS Coordinator #2 stated they typically did not get the discharge summary from therapy. 2. Res #69 had diagnoses which included seizure disorder, neuromuscular scoliosis thoracolumbar region, and spastic quadriplegic cerebral palsy. Hospital discharge instructions, dated 04/29/22, documented the resident had splints discharged with the resident. A admit nurse note, dated 01/17/23, documented the resident was non-verbal and unable to make wants or needs known. The assessment documented the resident had contractures to bilateral upper extremities and limited ROM to the lower extremities. A quarterly assessment, dated 07/28/23, documented the resident was severely impaired with cognition and required total assistance with ADLs. The assessment documented the resident had impaired ROM upper and lower on both sides. A care plan, last reviewed 08/02/23, documented Res #69 had impaired physical mobility in bilateral upper and lower extremities related to cerebral palsy, scoliosis, and contractures. The care plan documented the resident was totally dependent on staff for all aspects of mobility. The care plan documented the resident sat up in their own personal wheelchair and required staff to propel them. The care plan did not include the resident wrist and hand splints. A weekly nurse assessment, dated 10/22/23, documented the resident was unable to make need know but did track with their eye and smiled when saying their name. The assessment documented the resident had limited ROM to bilateral upper and bilateral lower extremities. Contractures were not identified in the assessment. The assessment documented the resident required a lift with two staff for transfers. On 10/19/23 at 11:42 a.m., the resident was observed lying in the bed awake and when the resident was spoke to, they smiled. An observation was made of the resident's right hand which was contracted the rest of the resident's extremities were not observed at that time. The resident was asked if they could move their fingers which they did not. The resident did not have any splints on. On 10/25/23 at 2:37 p.m., a restorative aide stated the resident had splints which were to be used when the resident was up in the chair. The restorative aide stated they were going to pick up the resident on the restorative program. On 10/25/23 at 3:34 p.m., the ADON stated the resident had splints for their hands. They confirmed the discharge instructions from the hospital documented splints to discharge with resident. On 10/26/23 at 9:33 a.m., the resident was observed in bed on their back with tube feeding running and the head of bed was elevated. The resident was observed to not have on splints at that time. On 10/26/23 at 9:52 a.m., CNA #1 stated they had worked at the facility three weeks and did not know when the resident got out of bed. CNA #2 stated they had worked at the facility five years and the resident was to get up on Mondays and Tuesdays. CNA #2 stated when they got Res #69 up, the splints were placed on the resident's hands. CNA #2 stated they had worked on the 200 hall during that week and did not know if the resident had been up. On 10/26/23 at 9:50 a.m., the DON stated the resident was up in their chair over the weekend. The DON stated the resident needed to be up daily but had not been up since Sunday. The DON stated the resident was very social and loved getting up and going to activities. The DON stated the resident had splints when they arrived at the facility but were missed getting an order for the splints. 46909 3. Res #12 had diagnoses which included shaken infant syndrome and dependence on respirator status. An annual assessment, dated 12/01/22, documented the resident was severely impaired with cognition and required total assistance with all ADLS. The assessment documented the resident was impaired in ROM on both sides of the upper and lower extremities. The assessment documented Res #12 was always incontinent of bladder and bowel, and required continuous feeding through a gastrostomy tube. A care plan, dated 12/05/22, documents Res #12 had pain related to contractures. The care plan did not document a plan of care related to prevention of worsening of the resident's contractures. On 10/23/23 at 11:06 a.m., observation was made of the resident's bilateral hand contractures. On 10/27/23 at 12:17 p.m., the restorative aide stated Res #12 had never been on any type of restorative program while residing in the facility. On 10/27/23 at 12:21 p.m., an interview with LPN #1 was conducted and they stated Res #12 had contractures in their hands for a long time and they should have placed washcloths in the resident's hands to prevent worsening contractures but now they could not get washcloths in either hand. On 10/27/23 at 12:27 p.m., MDS coordinator #1 stated Res #12 did not have contractures on the care plan therefore no interventions were on the resident's care plan to prevent contractures from worsening. 4. Res #53 had diagnoses which included cerebral palsy, congenital hydrocephalus, dependence on respirator status, and unspecified intellectual disabilities A quarterly assessment, dated 09/05/23, documented the resident was severely impaired with cognition and required total assistance with all of ADLs. The assessment documented ROM was impaired on both sides of the resident's upper and lower extremities. The assessment documented Res #53 had a catheter, incontinent of bowel, and required continuous feeding through a gastrostomy tube. A care plan, dated 03/13/23, documented Res #53 had alteration in function due to cerebral palsy and required oral care, hair care, turning and repositioning every two hours and as needed. On 10/23/23 at 11:0 a.m., an observation was made of the resident's upper and lower contractures bilaterally. On 10/27/23 at 12:17 p.m., the restorative aide stated Res #53 had never been on any type of restorative program. On 10/27/23 at 12:27 p.m., MDS coordinator #1 stated Res #53 did not have a care plan for contractures but there should have been one added.

Based on record review and interview, the facility failed to have a program designed to help prevent the development of Legionellosis and Pontiac fever caused by Legionella Bacteria. The Resident Census and Conditions of Residents form documented 77 residents resided in the facility. Findings: A policy titled Legionella Surveillance and Detection documented .Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella . On 10/26/23 at 10:08 a.m., the maintenance staff stated they did not have a documented plan for Legionella. On 10/26/23 at 10:19 a.m., the ADON stated the plan for Legionella was a work in progress.

Based on observation, record review, and interview, the facility failed to ensure regular inspection of all bed frames, mattresses, and bed rails, were conducted as part of a regular maintenance program to identify areas of possible entrapment. The DON documented 75 residents living in the facilty had bed rails in use. Findings: A Proper Use of Side Rail policy, undated, read in part, .2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents .13. When side rail usage is appropriate, the facility will assess the space between mattress and side rail to reduce the risk for entrapment (the amount of safe space may very, depending on the type of bed and mattress being used) . On 10/26/23 at 10:09 a.m., the maintenance man stated the side rails on the beds were not inspected as the policy stated. The maintenance man stated if there was a problem with the bed or rails nursing would report the problem to them and the problem would be fixed immediately.

Based on record review and interview, the facility failed to ensure recommendations from a resident's PASRR II was incorporated into the resident's plan of care for one (#56) of one sampled resident whose PASRR was reviewed. The DON documented 29 residents with PASRR II evaluations resided in the facility. Findings: Res #56 had diagnoses which included post traumatic stress disorder and schizophrenia. A PASRR level II, dated 11/14/22, documented the resident should receive a dental evaluation and treatment as required; visual examination and treatment as required; the residents room should be personalized and appear non institutional; and the resident should be encouraged to make independent choices regarding room decorations like bedding. The PASRR level II documented the resident to have ADL training in dining skills and dressing and have community integration including but not limited to shopping at a variety of stores, movie rental, going out to eat at a variety of restaurants. The PASRR evaluation documented community outings should be provided to include medical appointments; staff should continue to encourage the resident to complete as much of their care as possible; and staff should provide cuing and physical assistance as needed and encourage daily decision making even in regard to meals, clothing, and activities. A significant change assessment, dated 03/21/23, documented the resident had a PASRR II for serious mental illness. The assessment documented the resident had modified independence some difficulty in new situations only and required extensive assistance with most ADLs. The assessment documented the resident had no behaviors in the look back period. A care plan, dated 06/26/23, documented the resident had been identified as having a PASRR positive status related to a severe mental illness: PTSD and schizophrenia. The care plan documented to evaluate the resident for additional specialized services. The care plan did not incorporate the recommendations documented in the PASRR II of dental evaluation, decoration the residents room, have community integration including but not limited to shopping at a variety of stores, movie rental, going out to eat at a variety of restaurants. Community outings should be provided to include medical appointments into the POC. A quarterly assessment, dated 09/19/23, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident had diagnoses of depression, schizophrenia, and PTSD. The assessment documented the resident received an antipsychotic medication. The assessment documented the resident had no behaviors during the assessment period. On 10/19/23 at 2:03 p.m., Res #56 was observed in the bed playing video games and did not appear depressed at this time. Res #56 was cooperative and answered questions during the interview. On 10/24/23 at 11:13 a.m., MDS Coordinator #2 stated they had never seen the resident's PASRR II. The MDS coordinator stated they had not incorporated the PASRR II in the resident's POC. The MDS coordinator stated they were not aware the PASRR II needed to be care planned. On 10/24/23 at 11:44 a.m., MDS Coordinator #1 stated they were not aware the PASRR level II needed to be incorporated into the care plan.

Based on observation, record review, and interview, the facility failed to ensure residents with a diagnosis of PTSD received culturally competent trauma informed care in order to eliminate or mitigate triggers which could cause re-traumatization of the resident for one (#56) of one resident reviewed for behaviors. The DON documented one resident with PTSD resided in the facility. Findings: Res #56 had diagnoses which included paraplegia, PTSD, and schizophrenia. A significant change assessment, dated 03/21/23, documented the resident had a PASRR II for serious mental illness. The assessment documented the resident had modified independence with some difficulty in new situations only and required extensive assistance with most ADLs. The assessment documented the resident had no behaviors during the look back period. A care plan, dated 06/26/23, documented the resident received antipsychotic medications for diagnosis of schizophrenia for target behaviors of anger, hostility, and self-harm. The care plan documented the resident had been identified as having a PASRR positive status related to a severe mental illness, PTSD, and schizophrenia. The care plan did not incorporate the recommendations in the PASRR II into the POC. A quarterly assessment, dated 09/19/23, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident had diagnoses of paraplegia, depression, schizophrenia, PTSD. The assessment documented the resident received and antipsychotic medication seven days in the assessment period. The assessment documented the resident had no behaviors in the assessment period. On 10/19/23 at 2:03 p.m., Res #56 was observed in the bed playing video games and did not seem depressed at this time. Res #56 was cooperative and answered questions during the interview. On 10/24/23 11:15 a.m., MDS Coordinator #2 stated they were not sure what the resident's triggers would be for their PTSD. MDS Coordinator #2 stated the only thing they knew of was when the resident did not get their way they would act out.

Based on record review and interview, the facility failed to permit a resident to return to the facility after a hospitalization for one (#126) of three residents reviewed for hospitalization . The facility identified nine residents who had been discharged in the past three months. Findings: A form titled Admission, Transfer and Discharge Rights, read in part, .You may not be transferred or discharged unless your needs cannot be met, your safety is endangered, or services are no longer required .Notice of transfer or discharge must be given to you 30 days prior, except in cases of health and safety needs . Res #126 was admitted to the facility with diagnoses which included methicillin susceptible staphylococcus aureus infection, non-pressure chronic ulcer of right foot, and diabetes mellitus. The admission assessment, dated 12/25/22, documented the resident was cognitively independent for decision making and required extensive assistance with dressing and toileting. A progress note, dated 03/15/23 at 9:16 p.m., documented the resident requested to be sent to the hospital. The note documented the resident was out of the facility via emergency medical services at 9:16 p.m. A discharge summary for the resident documented the resident was discharged from the facility on 03/15/23. On 10/27/23 at 12:29 p.m., the DON stated beds were available when the resident was ready to return to the facility. The DON stated they thought passing the bed hold time allowed was a reason not to allow the resident to return to the facility.

Based on interview and record review, the facility failed to provide written information concerning the right to formulate an advanced directive for three (#55, 56, and #122) of three sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 01/31/22, documented 71 residents resided in the facility. Findings: The Advance Directive policy read in part, .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . 1. Resident (Res) #55 was admitted to the facility on [DATE]. There was no documentation the resident had been provided information related to formulating an advance directive. On 02/01/22 at 4:40 p.m., the director of nurses (DON) stated an advance directive acknowledgement form was in the resident's clinical record, but had not been signed by the resident or the resident's representative. She stated information regarding formulating an advance directive should be offered and if the resident declined an advance directive acknowledgment form should be signed. 2. Res #56 was admitted to the facility on [DATE]. There was no documentation the resident had been provided information related to formulating an advance directive On 02/02/22 at 3:57 p.m., the business office manager (BOM) reviewed the resident's clinical record and stated no documentation could be found related to the resident being offered information to formulate an advance directive. 3. Res #122 was admitted to the facility on [DATE]. There was no documentation the resident had been provided information related to formulating an advance directive On 02/01/22 at 4:18 p.m., the social services director (SSD) stated she was responsible for completing the admission packet information for the residents. She stated the admission packet no longer contained information to formulate an advance directive. At 4:20 p.m., the DON stated the information to formulate an advance directive was removed from the admission packet a few months ago. She stated the information regarding formulating an advance directive would be returned to the admission packet.

Based on observation, interview, and record review, it was determined the facility failed to provide baths/showers as scheduled for four (#14, 25, 68 and #10) of five sampled residents. The census and condition, dated 1/31/22, documented census of 71 residents residing in the facility. Findings: A facility policy and procedure, revised February 2018, documented female residents would shower on Monday, Wednesday, and Friday. The policy documented male residents would shower on Tuesday, Thursday, and Saturday. The policy documented the staff would report to the supervisor/charge nurse if the resident refused a shower, and the staff would document the refusal and why the resident refused. 1. Resident (Res) #14 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 11/27/21, documented the resident was cognitively intact and required one person assist for bathing. On 01/31/22 at 9:42 a.m., the resident reported she had one bath since she moved rooms. On 02/01/22 at 2:00 p.m., the ADON was asked about resident's getting showers while in isolation/quarantine. She reported they are offered bed baths because they only have one working shower and they did not want to mix isolated/quarantined residents with the other residents. Res #14's record documented the resident went 14 days without a shower/bed bath. 2. Res #25 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A change in status assessment, dated 11/15/21, documented the resident was intact with cognition. The assessment documented the resident required one person assist with bathing. On 02/01/22 at 1:30 p.m., the resident reported she had not had a shower in three weeks. The resident reported she was not offered a bed bath while in isolation. The resident reported she was removed from isolation this morning. On 02/01/22 at 2:00 p.m., the ADON/IP was asked if residents getting showers/bed baths while in isolation. She reported they were given bed baths during quarantine/isolation because the facility only had one working shower and did not want to expose the other residents. CNA #1 was shown the shower log for resident #25 and was asked if she gave the resident a shower on 01/24/22 and 01/31/22. CNA #1 reported she did not give the resident a shower on those days because she was in isolation. CNA #1 reported she did not work with the covid positive residents on 01/31/22. CNA #1 reported she did not fill out the log for 01/31/22 and it was not her handwriting. The record documented the resident was in isolation from 01/21/22 through 01/31/22. The record documented the resident went seven or more days without a shower/bed bath. 3. Res #68 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 01/18/22, documented the resident's cognition was moderately intact. The assessment documented the resident required one person assist with bathing. On 02/01/22 at 9:19 a.m., the resident complained he did not get his showers like he should. The record documented the resident did not receive a shower for the month of January 2022. The record of the shower log documented one refusal for a shower and no documentation the resident was out of the facility. On 02/01/22 at 2:00 p.m., the ADON reported the resident refuses showers at times. The ADON was shown the resident's shower log and asked if there should be documentation for refusal. The ADON reported it should have been documented if he refused. 4. Res #10 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented the resident required one person assist with bathing. On 01/31/22 at 8:48 a.m., the resident reported getting one shower a week or one shower every two weeks. The record documented the resident received two showers for the month of January 2022. On 02/01/22 at 2:00 p.m., the ADON reported the resident refused showers at times. The ADON was shown the resident's shower log and asked if there should be documentation for refusal. The ADON reported it should have been documented if she refused. On 02/07/22 at 10:11 a.m., the DON was asked what the procedure was for when a resident refused a shower. The DON reported the CNA's are supposed to have the resident sign a refusal sheet and notify the charge nurse. The DON reported the staff are supposed to ask the resident three times with the resident refusing each time.

Based on interview, and record review it was determined the facility failed to ensure a comprehensive care plan was in place for one (#68) of 16 residents who were reviewed for care plans. The administrator reported there were 71 residents in the facility. Findings: Resident #68 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 01/18/22, documented the resident's cognition was moderately intact and required assistance with ADLs. The clinical record contained no comprehensive care plan. On 02/07/22 10:25 a.m., the minimum data set (MDS) coordinator reported the resident's comprehensive care plan had not been completed.

Based on observation, interview, and record review, it was determined the facility failed to implement their infection control program to prevent potential spreading of COVID-19 infection for all staff and residents. The facility failed to: ~ maintain Centers for Disease Control (CDC) recommended infection control practices related to the proper use of personal protective equipment (PPE) for three (#8, #10, and #11) of four sampled residents observed being assisted with eating; and ~ maintain proper hand hygiene for one (#9) of four sampled residents who were being assisted with eating. The facility identified four residents as requiring assistance with eating. Findings: The CDC recommendation for masks, updated 06/29/21, included: . Completely cover your nose and mouth . Fit snugly against the sides of your face and don't have gaps . Have a nose wire to prevent air from leaking out of the top of the mask . A revised facility policy on the use of PPE, dated 09/2010, documented, . Be sure that face mask covers the nose and mouth while performing treatment or services for the patient . Handle mask only by the strings (ties) . Never touch the mask while it is in use . A revised facility policy on assistance with meals, dated 07/2017, documented, . All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling . A revised facility policy on handwashing and hand hygiene, dated 08/2017, documented, . All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections . All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . Before and after assisting a resident with meals . 1. On 07/22/21 at 12:13 p.m., the noon meal service was observed. Licensed practical nurse (LPN) #2 and certified nurse aide (CNA) #2 were observed assisting residents #8, #10, and #11 to eat. LPN #2 had a mask on below her nose and below her chin. At no time did the LPN attempt to adjust her mask to above her nose. At 12:43 p.m., CNA #2, using her right hand, pulled her mask down below her chin by grasping it in the middle of the mask. She then spoke to another staff that entered the dining room, while facing the resident she was feeding, and pulled it back up over her nose in the same fashion. On 07/22/21 at 12:51 p.m., a kitchen staff entered the dining room wearing her mask below her nose and began cleaning tables. On 07/22/21 at 12:55 p.m., LPN #2 and CNA #2 both had their masks below their noses while continuing to feed the residents. On 07/27/21 at 2:54 p.m., the Infection Preventionist (IP) was asked what the policy was for properly wearing a face mask. She stated it should be worn above the nose and under the chin. The IP was asked how she monitored to ensure staff wore the PPE correctly. She stated she conducted surveillance rounds every two weeks. She stated she had not observed a problem with staff wearing their masks correctly previously. 2. On 07/22/21 at 12:28 p.m., CNA #1 was observed assisting resident #9 to eat. She opened a folding chair and sat at the bedside. Without performing hand hygiene, she touched the resident's bread with her bare hand and moved the bread to the napkin on the overbed table. She then moved the bread back to the plate and placed it on top of the meatloaf. She moved it again to the top of the green beans. She then touched the bread and moved it to the top of the mashed potatoes. She put butter on the bread, holding the bread with her bare hands. She pulled the crust off of the bread and fed some of the buttered bread to the resident. CNA #1 then pulled down her shirt in the back and continued feeding the resident. She scratched her face with her left hand and gave the resident a drink. She touched the bread with her left hand and fed the resident the rest of the bread. CNA #1 then fed the resident a soft, cream filled sandwich cookie with her bare hand. CNA #1 was not observed to perform hand hygiene at any time while assisting the resident with the meal. On 07/22/21 at 12:59 p.m., CNA #1 stated she should not have touched the resident's food with her hands. She stated she should have used the fork or spoon. On 07/27/21 at 2:54 p.m., the IP was asked what the policy was for hand hygiene while assisting a resident to eat. She stated they were to wash their hands prior to and after assisting or feeding a resident. The IP stated she conducted surveillance rounds, related to infection control practices, every two weeks. The IP stated she utilized the information from her surveillance rounds and infection control tracking and trending to monitor the facility's infection control program. She stated the facility employed various methods of keeping the facility's staff up to date on infection control concerns and changes to the program.

Based on interview and record review, it was determined the facility failed to notify the resident or resident's representative of the facility's bed hold policy upon transfer for one (#2) of four sampled residents reviewed for transfers. The facility identified 66 residents as residing at the facility. Findings: The facility's policy on bed holds, dated 08/2012, documented, . hereby request that the facility hold my bed space during my absence from the facility for the maximum period of 5 days. In the event my absence exceeds the 5 day maximum I understand I will be eligible for readmission to the first available semi-private room if I continue to meet the facility's admission criteria . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 06/11/21 at 6:57 a.m., documented, . nursing in resident's room for suctioning and noted large amount of loose, bloody bm [bowel movement] between legs. CNA's [certified nurse aide] started cleaning him up and it continued to flow out with large amount of clots and dark red blood. Resident very pale. Notified Dr [name withheld] with orders received to send out to ER [emergency room ]. Notified EMS [emergency medical service] of need to transport. Arrived and transferred him to gurney x 4 assist. Left facility with EMS at 0655 [6:55 a.m.]. Notified RN/DON [registered nurse/director of nursing]. Attempted to notify NOK [next of kin], no answer and no voicemail. At the top of the printed copy of the nurses' note, the facility's bed hold policy was documented. A nurse's note, dated 06/11/21 at 4:10 p.m., documented, . Received phone call from [hospital name withheld] resident admitted at Tulsa . Unable to contact POA [power of attorney] per nurse. This nurse tried as well no answer. Was told by 100 hall nurse believes [family member] is in nursing home also . The resident's discharge assessment, dated 06/11/21, documented the resident was discharged to the hospital, and his return was anticipated. A social services note, dated 06/15/21, documented a bed hold policy was mailed to the resident's family member. Review of the resident's summary page in the medical record revealed an address for the resident's representative. The address was the same as another nursing facility. No other address was in the medical record. A hospital discharge summary, dated 07/16/21, documented, . Primary Diagnosis [CONDITION(S)] ulcer with upper GI [gastrointestinal] bleed. Secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Healthcare associated pneumonia . Asymptomatic COVID-19 infection . The plan was for patient to be discharged back to nursing facility however COVID-19 testing was done in preparation for discharge and this was positive for COVID-19 and therefore he is not being accepted by the nursing facility . Review of the resident's clinical record revealed no documentation the resident had been informed of the facility's bed hold policy when he left the facility to go to the hospital. On 07/22/21 at 4:12 p.m., the nursing home located at the address that was listed as the resident representative's address was called. The nursing home stated the representative was not, and had never been, a resident at that facility. On 07/22/21 at 4:15 p.m., the resident's representative was interviewed. She stated the resident had been transferred to another hospital since the facility would not allow him to return. She stated she had received a phone message from the facility but had not returned the call. She stated she was waiting to hear from the resident's physician at the hospital he was currently at. She stated she had not received any mail from the facility. The resident's representative verified her address, and it was not the address listed on the resident's clinical record. On 07/27/21 at 2:54 p.m., the Infection Preventionist (IP), administrator, and director of nursing (DON) were asked if the facility had discharged the resident. The IP stated, Yes. She stated the resident was discharged because he had exceeded his bed hold policy. The IP was asked where that was documented. The DON stated the facility's bed hold policy was documented on the top portion of all pages in a resident's clinical record. The DON was asked if that notation explained the resident was being discharged because he had exceeded the bed hold policy. She stated she would have to look. On 07/27/21 at approximately 3:00 p.m., the DON and IP were asked if the resident had been notified of the facility's bed hold policy when he left the facility for the hospital. The DON stated the bed hold policy was on the top of all pages sent with the emergency personnel when the resident left the facility. She was asked if the resident had those papers. She stated, No. She stated they were sent with the emergency personnel. She was asked if the resident would have access to those papers. She stated no. The DON and IP were asked if the resident's representative had been notified of the bed hold policy. The IP stated the bed hold policy had been mailed to the representative. She stated it was mailed to the address on file. She stated they had made attempts to call the representative with no return call. The IP was informed the address on file was for a facility where the resident had formerly resided, and the representative had never lived there. No comment was made.

Based on interview and record review, it was determined the facility failed to notify the resident and resident representative before discharge from the facility for one (#2) of four sampled residents who were reviewed for discharge concerns. The facility identifed 66 residents as residing at the facility. Findings: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's policy on bed holds, dated 08/2012, documented, . hereby request that the facility hold my bed space during my absence from the facility for the maximum period of 5 days. In the event my absence exceeds the 5 day maximum I understand I will be eligible for readmission to the first available semi-private room if I continue to meet the facility's admission criteria . A nurse's note, dated 06/11/21 at 6:57 a.m., documented, . nursing in resident's room for suctioning and noted large amount of loose, bloody bm [bowel movement] between legs. CNA's [certified nurse aide] started cleaning him up and it continued to flow out with large amount of clots and dark red blood. Resident very pale. Notified Dr [name withheld] with orders received to send out to ER [emergency room ]. Notified EMS [emergency medical service] of need to transport. Arrived and transferred him to gurney x 4 assist. Left facility with EMS at 0655 [6:55 a.m.]. Notified RN/DON [registered nurse/director of nursing]. Attempted to notify NOK [next of kin], no answer and no voicemail. The resident's discharge assessment, dated 06/11/21, documented the resident was discharged to the hospital, and his return was anticipated. A leave of absence note, dated 06/11/21, documented, stable in muskogee [sic] and transferred to tulsa [sic]. A social services note, dated 06/15/21, documented a bed hold policy was mailed to the resident's family member. Review of the resident's summary page in the medical record revealed an address for the resident's representative. The address was the same as another nursing facility. No other address was in the medical record. A hospital discharge summary, dated 07/16/21, documented, . Primary Diagnosis [CONDITION(S)] ulcer with upper GI [gastrointestinal] bleed. Secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Healthcare associated pneumonia . Asymptomatic COVID-19 infection . The plan was for patient to be discharged back to nursing facility however COVID-19 testing was done in preparation for discharge and this was positive for COVID-19 and therefore he is not being accepted by the nursing facility . Review of the resident's clinical record revealed no documentation the resident and the resident's representative had been notified of the discharge, the reason for the discharge, where the resident was being discharged to, a statement of the resident's appeal rights, or the contact information for the Long-Term Care Ombudsman. There was no documentation the resident had been informed of the facility's bed hold policy when he left the facility to go to the hospital. There was no documentation the resident's representative had been sent the information related to the facility's bed hold policy. On 07/22/21 at 4:12 p.m., the nursing home located at the address that was listed as the resident representative's address was called. The nursing home stated the representative was not, and had never been, a resident at that facility. On 07/22/21 at 4:15 p.m., the resident's representative was interviewed. She stated the resident had been transferred to another hospital since the facility would not allow him to return. She stated she had received a phone message from the facility but had not returned the call. She stated she was waiting to hear from the resident's physician at the hospital he was currently at. She stated she had not received any mail from the facility. The resident's representative verified her address, and it was not the address listed on the resident's clinical record. On 07/27/21 at 2:54 p.m., the Infection Preventionist (IP), administrator, and director of nursing (DON) were asked if the facility had discharged the resident. The IP stated, Yes. She stated the resident was discharged because he had exceeded his bed hold policy. The IP was asked where that was documented. The DON stated the facility's bed hold policy was documented on the top portion of all pages in a resident's clinical record. The DON was asked if that notation explained the resident was being discharged because he had exceeded the bed hold policy. She stated she would have to look. On 07/27/21 at approximately 3:00 p.m., the IP was asked if the resident or representative was notified of the discharge. She stated it would just be that they exceeded the bed hold. She was asked if the notice included information related to how to contact the Ombudsman or how to appeal the discharge. The Administrator stated, I believe I spoke with the Ombudsman, but didn't document that. She was asked what she gave him as the reason. She stated the bed hold.

Based on interview and record review, it was determined the facility failed to ensure the discharge was documented in the resident's medical record for one (#2) of four sampled resident's for discharge. The facility identified 66 residents reside in the facility. Findings: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 06/11/21 at 6:57 a.m., documented, . nursing in resident's room for suctioning and noted large amount of loose, bloody bm [bowel movement] between legs. CNA's [certified nurse aide] started cleaning him up and it continued to flow out with large amount of clots and dark red blood. Resident very pale. Notified Dr [name withheld] with orders received to send out to ER [emergency room ]. Notified EMS [emergency medical service] of need to transport. Arrived and transferred him to gurney x 4 assist. Left facility with EMS at 0655 [6:55 a.m.]. Notified RN/DON [registered nurse/director of nursing]. Attempted to notify NOK [next of kin], no answer and no voicemail. The resident's discharge assessment, dated 06/11/21, documented the resident was discharged to the hospital, and his return was anticipated. A leave of absence note, dated 06/11/21, documented, stable in muskogee [sic] and transferred to tulsa [sic]. A social services note, dated 06/15/21, documented a bed hold policy was mailed to the resident's family member. Review of the resident's summary page in the medical record revealed an address for the resident's representative. The address was the same as another nursing facility. No other address was in the medical record. A hospital discharge summary, dated 07/16/21, documented, . Primary Diagnosis [CONDITION(S)] ulcer with upper GI [gastrointestinal] bleed. Secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Healthcare associated pneumonia . Asymptomatic COVID-19 infection . The plan was for patient to be discharged back to nursing facility however COVID-19 testing was done in preparation for discharge and this was positive for COVID-19 and therefore he is not being accepted by the nursing facility . Review of the resident's clinical record revealed no documentation why the resident could not return to the facility. There was no documentation to show the resident's needs could not be met by the facility; other residents would be in danger if the resident returned to the facility; or that the health of others would be endangered if the resident returned to the facility. There was no physician's documentation of the basis for not allowing the resident to return to the facility. Review of the resident's clinical record revealed no documentation the resident and the resident's representative had been notified of the discharge, the reason for the discharge, where the resident was being discharged to, a statement of the resident's appeal rights, or the contact information for the Long-Term Care Ombudsman. There was no documentation the resident had been informed of the facility's bed hold policy when he left the facility to go to the hospital. There was no documentation the resident's representative had been sent the information related to the facility's bed hold policy. Review of the resident's clinical record revealed no documentation the facility did not have the capacity or capability to care for the resident upon discharge from the hospital. On 07/22/21 at 4:12 p.m., the nursing home located at the address that was listed as the resident representative's address was called. The nursing home stated the representative was not, and had never been, a resident at that facility. On 07/22/21 at 4:15 p.m., the resident's representative was interviewed. She stated the resident had been transferred to another hospital since the facility would not allow him to return. She stated she had received a phone message from the facility but had not returned the call. She stated she was waiting to hear from the resident's physician at the hospital he was currently at. She stated she had not received any mail from the facility. The resident's representative verified her address, and it was not the address listed on the resident's clinical record. On 07/27/21 at 2:54 p.m., the Infection Preventionist (IP), administrator, and director of nursing (DON) were asked if the facility had discharged the resident. The IP stated, Yes. She stated the resident was discharged because he had exceeded his bed hold policy. The IP was asked where that was documented. The DON stated the facility's bed hold policy was documented on the top portion of all pages in a resident's clinical record. The DON was asked if that notation explained the resident was being discharged because he had exceeded the bed hold policy. She stated she would have to look. The DON was asked where it was documented in the clinical record why the resident could not return to the facility and where the resident's physician had notated the basis for the discharge. She stated it was not documented. The DON stated the resident had received blood [CONDITION(S)] while in the hospital, and therefore, the facility did not feel they could meet his needs. She was asked to provide the documentation of that. She stated there was not any. On 07/27/21 at approximately 3:00 p.m., the administrator, DON, and IP were asked if the resident or representative was notified of the discharge. The IP stated it would just be that they exceeded the bed hold. She was asked if the notice included information related to how to contact the Ombudsman or how to appeal the discharge. The Administrator stated, I believe I spoke with the Ombudsman, but didn't document that. She was asked what she gave him as the reason. She stated the bed hold. The DON and IP were asked if the resident had been notified of the facility's bed hold policy when he left the facility for the hospital. The DON stated the bed hold policy was on the top of all pages sent with the emergency personnel when the resident left the facility. She was asked if the resident had those papers. She stated, No. She stated they were sent with the emergency personnel. She was asked if the resident would have access to those papers. She stated no. The DON and IP were asked if the resident's representative had been notified of the bed hold policy. The IP stated the bed hold policy had been mailed to the representative. She stated it was mailed to the address on file. She stated they had made attempts to call the representative with no return call. The IP was informed the address on file was for a facility where the resident had formerly resided, and the representative had never lived there. No comment was made.

On [DATE] at 4:40 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failures to prevent further potential neglect. Oklahoma State Department of Health (OSDH) was notified and verified the IJ situation. On [DATE] to [DATE], licensed practical nurse (LPN) #3 was the night shift nurse for the 300 hall. Resident #1 had a new onset of left sided abdominal pain, generalized body pain, and increased humming and fidgeting. The nurse did not notify the physician of the acute change in the resident's condition. The resident had a fall and was found lying on his floor mat. The nurse did not assess, monitor, contact the physician, administrator, or family. The nurse did not document the incident in the nurse notes or in an incident report. The resident had another fall and was found on the mat beside his bed. The resident's head and shoulders were on the mat and his lower extremities were on the bed. The resident hit his head and his back was red. The nurse did not assess, monitor, provide increased supervision, call the physician, administrator, or family. The nurse did not document the incident in the nurse notes or in an incident report. The resident had another fall. The nurse did not assess, monitor, provide increased supervision, call the physician, administrator, or family. The nurse did not document the incident in the nurse notes or in an incident report. During the morning shift change, the nurse stated to three staff members, if the resident woke up after what she had given him, then he was one bad ass mother f****r. The staff discussed the comment made by the nurse but did not report the allegation of abuse to the administrator. On [DATE] the oncoming morning nurse LPN #4 did not assess the resident. The resident slept through the morning and was found in his bed prior to lunch with greenish/yellow emesis coming from his nose and mouth. On [DATE] at 12:31 p.m., the nurse was summoned to the room to assess the resident. The nurse left the resident in the care of the certified medication aid and went to seek help from another nurse. The resident went into [MEDICAL CONDITION] and cardiopulmonary resuscitation was initiated. The resident was transported to the hospital via emergency medical services. The hospital emergency records documented the resident presented with [MEDICAL CONDITION], a possible head injury, and was unresponsive on arrival to the emergency department. A CT scan of the head documented the resident had a new contusion to the back of his head and an [MEDICATION NAME] hemorrhage. On [DATE] the resident expired at the hospital. On [DATE] at 10:10 a.m., the administrator (ADM) stated she had discussed the situation with staff and did not feel the comment made by the nurse was an allegation of abuse. The administrator stated the nurse was still working in the facility. On [DATE] at 4:51 p.m., the ADM and director of nurses (DON) were notified of the IJ situation related to prevention of further potential neglect. On [DATE] at 7:32 p.m., the plan of removal for the Immediate Jeopardy pertaining to the prevention of further potential neglect was accepted by the survey team. The plan of Removal for the Immediate Jeopardy documented: 1. Neglect All residents in the building will be assessed for changes in baseline condition. The Fall Protocol has been reviewed and extensively revised, to include, but not be limited to, supervision, monitoring, ongoing assessment, physician notification, and documentation of incident. All nursing staff will be educated on changes to Fall Protocol. Education will begin immediately and be completed by midnight. If a staff member is unable to be educated by midnight, they will be suspended until education can be completed. Nurses B.C. and C.H. will be reported to their governing board. CNA T.L. and CMA K.D. will be reported to their governing board. Disciplinary action has been taken by the facility, to include both nurses being indefinitely suspended until a full investigation can be completed. Further disciplinary action may result from the findings of investigation. All nursing staff will be educated on reporting changes in resident condition to the physician. If a staff member is unable to be educated by midnight, they will be suspended until education can be completed. Regional Administrator will educate the Administrator and DON regarding neglect and monitoring/supervising staff by midnight. 2. Reporting/Investigating Abuse All staff will be educated regarding forms of abuse, timely reporting of allegations of abuse, and abuse policy. If a staff member is unable to be educated by midnight, they will be suspended until education can be completed. State reporting will be completed and submitted to the Oklahoma State Department of Health (OSDH) regarding alleged incident of abuse. Any further allegations of abuse will be reported in the designated time frame set by OSDH. Regional Administrator will educate DON and Administrator on Abuse Policy and state regulation regarding reporting of abuse. On [DATE] at 11:45 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a pattern level with potential for more than minimal harm. On [DATE] interviews were conducted with the nursing staff regarding the education in-services pertaining to abuse/neglect, reporting abuse/neglect, and the fall protocol for immediate jeopardy removal. The staff stated an in-service was provided on [DATE]. The staff was able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on interview, observation, and record review, it was determined the facility failed to thoroughly investigate, prevent further potential neglect and/or report an allegation of neglect for one (#1) of three residents reviewed for allegations of abuse/neglect. The facility failed to: a) Thoroughly investigate an allegation of abuse/neglect. b) Prevent further potential abuse/neglect by allowing the staff in question to continue working in the facility. c) Report an allegation of abuse/neglect to the administrator immediately. d) Report the allegation and investigation of abuse and/or neglect to the Oklahoma State Department of Health (OSDH). e) Take appropriate corrective measures. On [DATE] to [DATE], licensed practical nurse (LPN) #3, was the night shift nurse for the 300 hall. Resident #1 had a new onset of left sided abdominal pain, generalized body pain, and increased humming and fidgeting. The resident had a fall and was found lying on his floor mat. The resident had another fall and was found on the mat beside his bed. The resident's head and shoulders were on the mat and his lower extremities were on the bed. The resident hit his head and his back was red. During the morning shift change, the nurse stated to three staff members, if the resident woke up after what she gave him, then he was one bad ass mother f****r. The staff discussed the comment made by the nurse but did not report the allegation of abuse/neglect to the administrator. The resident slept through the morning and was found in his bed prior to lunch with greenish/yellow emesis coming from his nose and mouth. On [DATE] at 12:31 p.m., the nurse was summoned to the room to assess the resident. The resident went into [MEDICAL CONDITION] and cardiopulmonary resuscitation was initiated. The resident was transported to the hospital via emergency medical services. The hospital emergency records documented the resident presented with [MEDICAL CONDITION], a possible head injury, and was unresponsive on arrival to the emergency department. A CT scan of the head documented the resident had a new contusion to the back of his head and an [MEDICATION NAME] hemorrhage. On [DATE] the resident expired at the hospital. The facility identified four allegations of abuse/neglect in the past three months. The facility identified 79 residents who resided in the facility. Findings: The facility policy for abuse documented the facility would not condone any form of resident abuse. The policy documented the facility would monitor staff on all shifts to identify inappropriate behaviors toward residents. The policy documented the facility would assess, care plan, and monitor residents with needs and behaviors which could lead to conflict or neglect. The policy documented the facility would assess residents with signs and symptoms of behavior problems and develop and implement care plans to address behavioral issues. The policy documented the facility would encourage all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately. The policy documented Neglect was defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The policy documented examples of actual physical neglect as inadequate provision of care, caregiver indifference to resident's personal care and needs, and leaving a resident unattended who needed supervision. The policy documented employees must immediately report any suspected abuse or incidents of abuse to the DON. The policy documented all suspected violations and all substantiated incidents of abuse will be immediately reported to the appropriate state agencies and other entities or individuals as may be required by law. The policy documented all reports of resident abuse, neglect, and injuries of unknown source would be promptly and thoroughly investigated by the facility management. The facility policy for falls documented the facility would assist the resident post fall, ensure immediate safety, and intervene as necessary. The policy documented the staff would notify the physician, next of kin, director of nurses, and administrator of the fall. The policy documented the staff would complete an incident report and ensure a new resident specific fall intervention was implemented with each fall. The policy documented staff would document a narrative account in the nurse note. The policy documented residents with a suspected fall would be monitored for 48 hours to assist with identifying delayed effects to the resident from the fall. The policy documented neurological checks would be initiated. The policy documented the physician would be notified immediately of any suspected head injury or change in the resident's condition. The policy documented the nurse would re-evaluate the resident within two hours post fall and prior to the end of shift. The policy documented both the oncoming and off going nurses would evaluate the resident together at change of shift. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The fall risk assessment, dated [DATE], documented the resident had two to three falls in the past three months, had a balance problem when walking, had intermittent confusion, and had a change in medications. The assessment documented the resident was a fall risk. The resident's fall risk assessments were reviewed. The records did not document a fall risk assessment for the current month or quarter. The behavior monitoring assessment, dated [DATE], documented the resident had behaviors of hallucinations, delusions, and aggression. The resident's behavior monitoring assessments were reviewed. The records did not document a behavior monitoring assessment for the current month or quarter. The pain assessment, dated [DATE], documented the resident had no pain. The resident's pain assessments were reviewed. The records did not document a pain assessment for the current month or quarter. The behavior monitoring occurrence sheet, dated [DATE] thru [DATE], documented the resident had no behaviors. The admission assessment, dated [DATE], documented the resident was moderately impaired for daily decision making. The assessment documented the resident required limited assistance for activities of daily living (ADLs). The assessment documented the resident used a wheelchair for mobility. The assessment documented the resident had no [MEDICAL CONDITION] or behaviors. The assessment documented the resident had no pain. The assessment documented the resident had no falls. The assessment documented the resident was receiving an antipsychotic medication. The quarterly assessment, dated [DATE], documented the resident was moderately impaired for daily decision making. The assessment documented the resident required supervision to limited assistance with ADLs. The assessment documented the resident used a walker and a wheelchair for mobility. The assessment documented the resident had no [MEDICAL CONDITION] or behaviors. The assessment documented the resident had no pain. The assessment documented the resident was receiving an antipsychotic medication. The care plan, dated [DATE], documented the resident was a fall risk and was on the falling star program. The care plan documented the resident was receiving an antipsychotic medication. The care plan documented the resident required assistance with activities of daily living. The care plan documented the resident had a loss of cognition. The care plan documented the resident had the potential for acute pain. The nurse note, dated [DATE] at 12:31 p.m., documented licensed practical nurse (LPN) #4 was summoned to the resident's room by the certified nurse aid (CNA). The note documented the nurse observed a large amount of green emesis coming from the resident's nose and mouth. The note documented the resident was nonresponsive with shallow breathing and was grayish in color. The note documented the resident had a faint pulse less than 40 beats per minute. The note documented cardiopulmonary resuscitation was initiated and the emergency medical service was notified. The note documented the physician, the director of nurses, and the administrator were notified. The note documented the resident was transported via emergency medical services to the nearest hospital and the family was notified. The emergency medical services record, dated [DATE] at 12:52 p.m., documented the resident was unresponsive upon arrival to the facility. The record documented the staff was performing cardiopulmonary resuscitation. The record documented the resident was found at approximately 12:00 p.m. The record documented the resident was unresponsive, was still breathing, and had a palpable radial pulse. The record documented the resident stopped breathing at approximately 12:10 p.m. An administrative investigative statement, dated [DATE], documented the resident fell out of bed three times. The statement documented the resident fell out of bed at midnight, at 12:47 a.m., and 1:15 a.m. The report documented the resident had hit his head on the bedside. The report documented the resident was moaning and saying he was hurting. The incident reports for the three falls which occurred on [DATE] and [DATE] were requested. The facility was not able to provide the incident reports for the falls. The nurse notes for the three falls which occurred on [DATE] and [DATE] were requested. The facility was not able to provide the nurse notes. A late nurse note, dated [DATE] at 10:17 a.m., documented an entry for [DATE]. The note documented the resident had a fall at 10:30 p.m. The note documented the resident was lying on the fall mat. The note documented the resident had no redness or bruising. The note documented the resident's level of consciousness was within normal limits for the resident. The note documented the resident was oriented to person only. The note documented the resident's roommate had reported the resident was going from lying to sitting to standing frequently. The note documented the resident was complaining of pain all over and left side stomach pain feeling like muscle spasms. The note documented the resident's pain level was nine out of ten on a scale of 0 to 10 with 10 being the worst. The note documented the resident was educated to use the call light and to wait on staff to assist if he needed to get out of bed. The note documented the resident was not able to adequately verbalize understanding of the instructions. The note did not document the notification of the resident's change in condition to the physician, administration, or family. A late nurse note, dated [DATE] at 10:35 a.m., documented an entry for [DATE]. The note documented the resident was lying in bed and continued with loud humming and fidgeting. The note documented the resident was turning back and forth in bed still trying to get comfortable. The note documented the nurse administered Tylenol for pain. The note documented the resident's roommate reported the resident continued to be restless but had not tried to stand up out of bed. The note documented the resident was educated to use the call light. The note documented the resident was still unable to verbalize adequate understanding of instructions to use the call light. The note did not document the notification of the resident's change in condition to the physician, administration, or family. The medication administration report (MAR) for (MONTH) (YEAR) did not document the resident received medication for pain on [DATE]. A late nurse note, dated [DATE] at 10:52 a.m., documented an entry for [DATE]. The note documented the resident's humming was not as loud and the resident was not fidgeting as much as reported by the resident's roommate. The note documented the resident was responding to the pain medication. The note documented the resident's pain level was six out of ten. The note documented the resident had no signs of injury from the fall. The note documented the resident's assessment indicated all vital signs were within normal limits except the resident's pain level. The note did not document the notification of the resident's change in condition to the physician, administration, or family. The medication administration report (MAR) for (MONTH) (YEAR) did not document the resident received medication for pain on [DATE]. A late nurse note, dated [DATE] at 11:23 a.m., documented an entry for [DATE]. The note documented the certified nurse aide (CNA) had reported the resident's roommate had used his call light to report the resident had rolled out of bed. The note documented the CNA reported the resident was found with his head and upper body on the floor and his legs were up in the bed. The note documented the resident was assessed with [REDACTED]. The note documented the resident had a reddened area to his upper back. The note did not document the notification of the resident's change in condition to the physician, administration, or family. A late nurse note, dated [DATE] at 11:40 a.m., documented an entry for [DATE]. The note documented the resident continued to complain of pain rated six out of ten. The note documented the nurse administered pain medication. The note documented the resident was humming less and had less fidgeting. The note documented the resident was resting more comfortably after the last fall but continued with complaints of pain to his general body area and the left side of his stomach. The note documented there was still no indication of an injury to the head or body related to the two falls during that shift. The note did not document the notification of the resident's change in condition to the physician, administration, or family. The medication administration report (MAR) for (MONTH) (YEAR) did not document the resident received medication for pain on [DATE]. The investigative statement for CNA #2, dated [DATE], documented the aide worked the 300 hall. The statement documented at midnight the resident's roommate had initiated the call light. The statement documented the resident was on the floor mat by his bed and he had hit his head on the bottom part of the bed. The statement documented the resident was making moaning noises. The statement documented the CNA helped to put the resident back into bed. The statement documented the CNA reported the fall to LPN #3. The statement documented at 12:37 a.m., CNA #8 requested her assistance to put the resident back in bed after another fall. The statement documented the resident did not look like he had bumped anything when they helped him up off of the floor and put him back into the bed. The statement documented the resident was still making moaning noises. The statement documented the CNA reported the incident to LPN #3. The investigative statement for CMA #1, dated [DATE], documented she had received the morning report from LPN #3. The statement documented the resident had been up and down all through the night. The statement documented the resident had three falls. The statement documented the nurse had given the resident medication to help him sleep through the night and if he woke up anytime soon he was a bad ass mother f****r. The statement documented the CMA went to administer the resident's 7:00 a.m. medications but the MAR indicated [REDACTED]. The statement documented the CMA had gone to LPN #4 and asked if it would be okay to give the medications to the resident when staff got him up for lunch. The statement documented LPN #4 stated it would be okay to wait until lunch for the 10:00 a.m. medications to be given to the resident. The statement documented the staff did not get the resident up for lunch. The statement documented the CMA and CNA #4 had gone to the resident's room and found the resident lying on his right side with green spit next to him. The statement documented the CMA rolled the resident over onto his back and performed a sternal rub. The statement documented the the resident did not move. The statement documented the CMA tried again and yelled out the resident's name with no response. The statement documented the CMA felt for a pulse and found one. The statement documented the resident's pupils were unresponsive. The statement documented the CMA had gone to the dining room to get LPN #4. The statement documented they went to the resident's room and took his blood pressure. The statement documented the CMA checked the resident's Medication Administration Record [REDACTED]. The statement documented there was no medication checked off of the MAR for the resident. The statement documented the resident was cleaned up to be sent out of the facility. The investigative statement for LPN #4, dated [DATE], documented she received the morning shift report from LPN #3 on [DATE]. The statement documented LPN #3 had reported the resident had a couple of falls during the night. The statement documented LPN #3 had verbalized she had taken care of it. The statement documented LPN #4 stated, So he is going to be comatose for awhile then. The statement documented LPN #3 then stated, If he ain't he is one strong bad ass mother f****r. The statement documented LPN #4 stated the resident did not want to get up for breakfast which was out of the ordinary. The statement documented CMA #1 had reported the resident's vital signs were normal. The statement documented when the staff was getting ready for lunch, the nurse was called to the resident's room. The statement documented upon entering the resident's room, the nurse observed the resident was gray in color, was breathing, but was unresponsive with yellowish/green emesis coming from his mouth and nose. The statement documented the nurse instructed the CNA to stay with the resident while she went to get assistance from LPN #1. The statement documented LPN #1 stepped out of the room to call the DON and the CNA was instructed to clean the resident up for transport to the hospital. The statement documented when they left the room the resident quit breathing. The statement documented the resident was moved to the floor and cardiopulmonary resuscitation was initiated until the emergency medical service arrived. On [DATE] at 7:28 a.m., CNA #3 was interviewed. The CNA stated resident #1 would wander around the facility and was very confused. The CNA stated the resident would get violent at times and would have to be calmed down. The CNA stated the resident really was not a problem. On [DATE] at 9:23 a.m., CNA #4 was interviewed. The CNA stated she was listening to the morning shift report and heard LPN #3 state the resident would be one bad ass mother f****r if he woke up from what she had given him. The CNA stated the resident coded later the same morning. On [DATE] at 9:58 a.m., the administrator (ADM) was interviewed. The ADM stated the incident related to LPN #3 and resident #1 was discussed. The ADM stated she had not done a full investigation. The ADM stated LPN #3 was verbally suspended until her documentation could be completed. The ADM stated the incident had been reported to her by a CMA and a nurse. On [DATE] at 10:10 a.m., the ADM stated she had discussed the situation with LPN #4 several times and her story was inconsistent. The ADM stated she had discussed the situation with CMA #1 and she did not feel there was a problem with LPN #3. The ADM stated she did not fill out an incident report or send and incident report to the OSDH. The ADM stated she did not feel the comment made by LPN #3 was an allegation of abuse. The ADM stated she did not suspend LPN #3 because she wasn't scheduled to work for a few days. The ADM stated when the nurse returned to work she had to complete her documentation related to the incident first before returning to regular duties. The ADM stated they discussed the incident but no formal investigation had been completed. On [DATE] at 12:03 p.m., CMA #2 was interviewed. The CMA stated LPN #3 told her she had given resident #1 enough medication to put him down and if he woke up from that he would be one bad ass mother f****r. The CMA stated at first she thought the nurse must have had a bad night. The CMA stated after she thought about it that wasn't a normal thing for the nurse to say. The CMA stated she reported the comment to her charge nurse LPN #4. On [DATE] at 12:16 p.m., LPN #4 was interviewed. The LPN stated during the shift change report, LPN #3 stated resident #1 had one or two falls the previous night and if he didn't sleep all day he was a bad ass mother f****r. The LPN stated no neurological checks had been initiated since he had not hit his head. LPN #4 stated the resident did not get up for breakfast. The nurse stated the CMA had taken a set of vital signs and they were within normal limits. The nurse stated the resident had not had his morning snack. The nurse stated they had decided it was best to let the resident sleep. The nurse stated right before lunch it was brought to her attention the resident was unresponsive. The nurse stated the CMA started cardiopulmonary resuscitation on the resident. The nurse stated the resident did have a bruise on his forehead. On [DATE] at 2:05 p.m., the DON stated there was no documentation for neurological checks for resident #1. On [DATE] at 9:25 a.m., the ADM stated LPN #3 was still employed as a nurse at the facility. On [DATE] at 11:49 a.m., the resident's physician (physician #1) was interviewed. The physician stated it was the practice of the facility to notify him if a resident had a fall or a change in condition. The physician stated he could not remember if he was contacted related to resident #1. On [DATE] at 1:05 p.m., CMA #2 was interviewed. The CMA stated she reported the comment made by LPN #3 to her charge nurse LPN #4 about 30 minutes after the comment was made. The CMA stated after the resident left the facility she went to the administrator's office and had a complete mental breakdown because she did not think the resident's condition was an accident. The CMA stated LPN #3 had come back to work and was providing resident care. On [DATE] at 1:10 p.m., LPN #4 was interviewed. The LPN stated she reported the comment made by LPN #3 to the director of nurses after the resident had a change in condition. This was approximately three and a half hours later. The LPN stated when the comment was made she did not think much about the comment but when the resident had a change in condition she thought maybe the nurse had been serious. On [DATE] at 4:00 p.m., the emergency room physician was interviewed. The physician stated the resident had a small hemorrhage of the brain due to [MEDICAL CONDITION] of the brain secondary to [MEDICAL CONDITION]. The physician stated the resident had a scalp contusion. The physician stated he could not say for certain the resident's cause of death. The physician stated the cardiology report documented the resident had acute [MEDICAL CONDITION]. The physician stated the new onset of left sided abdominal pain, general body pain, and increased restlessness could have been signs of cardiac issues. On [DATE] at 10:15 a.m., CNA #5 stated the resident was pretty independent and would get up to go to the bathroom independently. The CNA stated they had to keep a close watch on him. The CNA stated the resident would not use the call light. On [DATE] at 11:03 a.m., the director of nurses (DON) stated the resident had only had one fall and one pain assessment since admission. The DON stated the resident should have had quarterly assessments performed. The DON stated documentation for resident #1 related to his falls and his change in condition had not been performed until after the resident was deceased . The DON stated a new onset of pain and falls should have been reported to the resident's physician. The DON stated LPN #3 had not reported the pain and falls to the resident's physician, the DON, the ADM, or the resident's family. On [DATE] at 2:59 p.m., the ADM stated no medication reconciliation had been performed for resident #1. The ADM stated the resident's medications had already been destroyed.

On [DATE] at 4:40 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failures to ensure resident #1 was free from neglect. Oklahoma State Department of Health (OSDH) was notified and verified the IJ situation. On [DATE] to [DATE], licensed practical nurse (LPN) #3 was the night shift nurse for the 300 hall. Resident #1 had a new onset of left sided abdominal pain, generalized body pain, and increased humming and fidgeting. The nurse did not notify the physician of the acute change in the resident's condition. The resident had a fall and was found lying on his floor mat. The nurse did not assess, monitor, contact the physician, administrator, or family. The nurse did not document the incident in the nurse notes or in an incident report. The resident had another fall and was found on the mat beside his bed. The resident's head and shoulders were on the mat and his lower extremities were on the bed. The resident hit his head and his back was red. The nurse did not assess, monitor, provide increased supervision, call the physician, administrator, or family. The nurse did not document the incident in the nurse notes or in an incident report. The resident had another fall. The nurse did not assess, monitor, provide increased supervision, call the physician, administrator, or family. The nurse did not document the incident in the nurse notes or in an incident report. During the morning shift change, the nurse stated to three staff members, if the resident woke up after what she had given him, then he was one bad ass mother f****r. The staff discussed the comment made by the nurse but did not report the allegation of abuse/neglect to the administrator. On [DATE] the oncoming morning nurse LPN #4 did not assess the resident. The resident slept through the morning and was found in his bed prior to lunch with greenish/yellow emesis coming from his nose and mouth. On [DATE] at 12:31 p.m., the nurse was summoned to the room to assess the resident. The nurse left the resident in the care of the certified medication aid and went to seek help from another nurse. The resident went into [MEDICAL CONDITION] and cardiopulmonary resuscitation was initiated. The resident was transported to the hospital via emergency medical services. The hospital emergency records documented the resident presented with [MEDICAL CONDITION], a possible head injury, and was unresponsive on arrival to the emergency department. A CT scan of the head documented the resident had a new contusion to the back of his head and an [MEDICATION NAME] hemorrhage. On [DATE] the resident expired at the hospital. On [DATE] at 10:10 a.m., the administrator (ADM) stated she had discussed the situation with staff and did not feel the situation was an allegation of abuse/neglect. The administrator stated the nurse was still working at the facility. On [DATE] at 4:51 p.m., the ADM and director of nurses (DON) were notified of the IJ situation related to neglect. On [DATE] at 7:32 p.m., the plan of removal for the Immediate Jeopardy related to neglect was accepted by the survey team. The plan of Removal for the Immediate Jeopardy documented: 1. Neglect All residents in the building will be assessed for changes in baseline condition. The Fall Protocol has been reviewed and extensively revised, to include, but not be limited to, supervision, monitoring, ongoing assessment, physician notification, and documentation of incident. All nursing staff will be educated on changes to Fall Protocol. Education will begin immediately and be completed by midnight. If a staff member is unable to be educated by midnight, they will be suspended until education can be completed. Nurses B.C. and C.H. will be reported to their governing board. CNA T.L. and CMA K.D. will be reported to their governing board. Disciplinary action has been taken by the facility, to include both nurses being indefinitely suspended until a full investigation can be completed. Further disciplinary action may result from the findings of investigation. All nursing staff will be educated on reporting changes in resident condition to the physician. If a staff member is unable to be educated by midnight, they will be suspended until education can be completed. Regional Administrator will educate the Administrator and DON regarding neglect and monitoring/supervising staff by midnight. 2. Reporting/Investigating Abuse All staff will be educated regarding forms of abuse, timely reporting of allegations of abuse, and abuse policy. If a staff member is unable to be educated by midnight, they will be suspended until education can be completed. State reporting will be completed and submitted to the Oklahoma State Department of Health (OSDH) regarding alleged incident of abuse. Any further allegations of abuse will be reported in the designated time frame set by OSDH. Regional Administrator will educate DON and Administrator on Abuse Policy and state regulation regarding reporting of abuse. On [DATE] at 11:45 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a pattern level of actual harm. On [DATE] interviews were conducted with the nursing staff regarding the education in-services pertaining to abuse/neglect, reporting abuse/neglect, and the fall protocol for immediate jeopardy removal. The staff stated an in-service was provided on [DATE]. The staff was able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on interview, observation, and record review, it was determined the facility failed to prevent neglect for one (#1) of three residents reviewed for neglect. The facility failed to: a) Assess, monitor, and intervene for a resident with a new onset of left sided abdominal pain, generalized body pain, three falls, and increased humming and fidgeting. b) Identify a resident with an acute change in condition. c) Notify the physician of an acute change in the resident's condition. d) Provide ongoing monitoring and supervision for a resident with three subsequent falls. On [DATE] at 12:31 p.m., the nurse was summoned to the room to assess the resident. The resident went into [MEDICAL CONDITION] and cardiopulmonary resuscitation was initiated. The resident was transported to the hospital via emergency medical services. The hospital emergency records documented the resident presented with [MEDICAL CONDITION], a possible head injury, and was unresponsive on arrival to the emergency department. A CT scan of the head documented the resident had a new contusion to the back of his head and an [MEDICATION NAME] hemorrhage. An emergency room lab report documented the resident's potassium level was elevated and the resident's hemoglobin was very low. On [DATE] the resident expired at the hospital. The facility identified four allegations of abuse in the past three months. Findings: The facility policy for abuse documented the facility would not condone any form of resident abuse. The policy documented the facility would monitor staff on all shifts to identify inappropriate behaviors toward residents. The policy documented the facility would assess, care plan, and monitor residents with needs and behaviors which could lead to conflict or neglect. The policy documented the facility would assess residents with signs and symptoms of behavior problems and develop and implement care plans to address behavioral issues. The policy documented the facility would encourage all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately. The policy documented Neglect was defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The policy documented examples of actual physical neglect as inadequate provision of care, caregiver indifference to resident's personal care and needs, and leaving a resident unattended who needed supervision. The policy documented employees must immediately report any suspected abuse or incidents of abuse to the DON. The policy documented all suspected violations and all substantiated incidents of abuse will be immediately reported to the appropriate state agencies and other entities or individuals as may be required by law. The policy documented all reports of resident abuse, neglect, and injuries of unknown source would be promptly and thoroughly investigated by the facility management. The facility policy for falls documented the facility would assist the resident post fall, ensure immediate safety, and intervene as necessary. The policy documented the staff would notify the physician, next of kin, director of nurses, and administrator of the fall. The policy documented the staff would complete an incident report and ensure a new resident specific fall intervention was implemented with each fall. The policy documented staff would document a narrative account in the nurse note. The policy documented residents with a suspected fall would be monitored for 48 hours to assist with identifying delayed effects to the resident from the fall. The policy documented neurological checks would be initiated. The policy documented the physician would be notified immediately of any suspected head injury or change in the resident's condition. The policy documented the nurse would re-evaluate the resident within two hours post fall and prior to the end of shift. The policy documented both the oncoming and off going nurses would evaluate the resident together at change of shift. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The fall risk assessment, dated [DATE], documented the resident had two to three falls in the past three months, had a balance problem when walking, had intermittent confusion, and had a change in medications. The assessment documented the resident was a fall risk. The resident's fall risk assessments were reviewed. The records did not document a fall risk assessment for the current month or quarter. The behavior monitoring assessment, dated [DATE], documented the resident had behaviors of hallucinations, delusions, and aggression. The resident's behavior monitoring assessments were reviewed. The records did not document a behavior monitoring assessment for the current month or quarter. The pain assessment, dated [DATE], documented the resident had no pain. The resident's pain assessments were reviewed. The records did not document a pain assessment for the current month or quarter. The behavior monitoring occurrence sheet, dated [DATE] thru [DATE], documented the resident had no behaviors. The admission assessment, dated [DATE], documented the resident was moderately impaired for daily decision making. The assessment documented the resident required limited assistance for activities of daily living (ADLs). The assessment documented the resident used a wheelchair for mobility. The assessment documented the resident had no [MEDICAL CONDITION] or behaviors. The assessment documented the resident had no pain. The assessment documented the resident had no falls. The assessment documented the resident was receiving an antipsychotic medication. The quarterly assessment, dated [DATE], documented the resident was moderately impaired for daily decision making. The assessment documented the resident required supervision to limited assistance with ADLs. The assessment documented the resident used a walker and a wheelchair for mobility. The assessment documented the resident had no [MEDICAL CONDITION] or behaviors. The assessment documented the resident had no pain. The assessment documented the resident was receiving an antipsychotic medication. The care plan, dated [DATE], documented the resident was a fall risk and was on the falling star program. The care plan documented the resident was receiving an antipsychotic medication. The care plan documented the resident required assistance with activities of daily living. The care plan documented the resident had a loss of cognition. The care plan documented the resident had the potential for acute pain. The nurse note, dated [DATE] at 12:31 p.m., documented licensed practical nurse (LPN) #4 was summoned to the resident's room by the certified nurse aid (CNA). The note documented the nurse observed a large amount of green emesis coming from the resident's nose and mouth. The note documented the resident was nonresponsive with shallow breathing and was grayish in color. The note documented the resident had a faint pulse less than 40 beats per minute. The note documented cardiopulmonary resuscitation was initiated and the emergency medical service was notified. The note documented the physician, the director of nurses, and the administrator were notified. The note documented the resident was transported via emergency medical services to the nearest hospital and the family was notified. The emergency medical services record, dated [DATE] at 12:52 p.m., documented the resident was unresponsive upon arrival to the facility. The record documented the staff was performing cardiopulmonary resuscitation. The record documented the resident was found at approximately 12:00 p.m. The record documented the resident was unresponsive, was still breathing, and had a palpable radial pulse. The record documented the resident stopped breathing at approximately 12:10 p.m. An administrative investigative statement, dated [DATE], documented the resident fell out of bed three times. The statement documented the resident fell out of bed at midnight, at 12:47 a.m., and 1:15 a.m. The report documented the resident had hit his head on the bedside. The report documented the resident was moaning and saying he was hurting. The incident reports for the three falls which occurred on [DATE] and [DATE] were requested. The facility was not able to provide the incident reports for the falls. The nurse notes for the three falls which occurred on [DATE] and [DATE] were requested. The facility was not able to provide the nurse notes. A late nurse note, dated [DATE] at 10:17 a.m., documented an entry for [DATE]. The note documented the resident had a fall at 10:30 p.m. The note documented the resident was lying on the fall mat. The note documented the resident had no redness or bruising. The note documented the resident's level of consciousness was within normal limits for the resident. The note documented the resident was oriented to person only. The note documented the resident's roommate had reported the resident was going from lying to sitting to standing frequently. The note documented the resident was complaining of pain all over and left side stomach pain feeling like muscle spasms. The note documented the resident's pain level was nine out of ten on a scale of 0 to 10 with 10 being the worst. The note documented the resident was educated to use the call light and to wait on staff to assist if he needed to get out of bed. The note documented the resident was not able to adequately verbalize understanding of the instructions. The note did not document the notification of the resident's change in condition to the physician, administration, or family. A late nurse note, dated [DATE] at 10:35 a.m., documented an entry for [DATE]. The note documented the resident was lying in bed and continued with loud humming and fidgeting. The note documented the resident was turning back and forth in bed still trying to get comfortable. The note documented the nurse administered Tylenol for pain. The note documented the resident's roommate reported the resident continued to be restless but had not tried to stand up out of bed. The note documented the resident was educated to use the call light. The note documented the resident was still unable to verbalize adequate understanding of instructions to use the call light. The note did not document the notification of the resident's change in condition to the physician, administration, or family. The medication administration report (MAR) for (MONTH) (YEAR) did not document the resident received medication for pain on [DATE]. A late nurse note, dated [DATE] at 10:52 a.m., documented an entry for [DATE]. The note documented the resident's humming was not as loud and the resident was not fidgeting as much as reported by the resident's roommate. The note documented the resident was responding to the pain medication. The note documented the resident's pain level was six out of ten. The note documented the resident had no signs of injury from the fall. The note documented the resident's assessment indicated all vital signs were within normal limits except the resident's pain level. The note did not document the notification of the resident's change in condition to the physician, administration, or family. The medication administration report (MAR) for (MONTH) (YEAR) did not document the resident received medication for pain on [DATE]. A late nurse note, dated [DATE] at 11:23 a.m., documented an entry for [DATE]. The note documented the certified nurse aide (CNA) had reported the resident's roommate had used his call light to report the resident had rolled out of bed. The note documented the CNA reported the resident was found with his head and upper body on the floor and his legs were up in the bed. The note documented the resident was assessed with [REDACTED]. The note documented the resident had a reddened area to his upper back. The note did not document the notification of the resident's change in condition to the physician, administration, or family. A late nurse note, dated [DATE] at 11:40 a.m., documented an entry for [DATE]. The note documented the resident continued to complain of pain rated six out of ten. The note documented the nurse administered pain medication. The note documented the resident was humming less and had less fidgeting. The note documented the resident was resting more comfortably after the last fall but continued with complaints of pain to his general body area and the left side of his stomach. The note documented there was still no indication of an injury to the head or body related to the two falls during that shift. The note did not document the notification of the resident's change in condition to the physician, administration, or family. The medication administration report (MAR) for (MONTH) (YEAR) did not document the resident received medication for pain on [DATE]. The investigative statement for CNA #2, dated [DATE], documented the aide worked the 300 hall. The statement documented at midnight the resident's roommate had initiated the call light. The statement documented the resident was on the floor mat by his bed and he had hit his head on the bottom part of the bed. The statement documented the resident was making moaning noises. The statement documented the CNA helped to put the resident back into bed. The statement documented the CNA reported the fall to LPN #3. The statement documented at 12:37 a.m., CNA #8 requested her assistance to put the resident back in bed after another fall. The statement documented the resident did not look like he had bumped anything when they helped him up off of the floor and put him back into the bed. The statement documented the resident was still making moaning noises. The statement documented the CNA reported the incident to LPN #3. The investigative statement for CMA #1, dated [DATE], documented she had received the morning report from LPN #3. The statement documented the resident had been up and down all through the night. The statement documented the resident had three falls. The statement documented the nurse had given the resident medication to help him sleep through the night and if he woke up anytime soon he was a bad ass mother f****r. The statement documented the CMA went to administer the resident's 7:00 a.m. medications but the MAR indicated [REDACTED]. The statement documented the CMA had gone to LPN #4 and asked if it would be okay to give the medications to the resident when staff got him up for lunch. The statement documented LPN #4 stated it would be okay to wait until lunch for the 10:00 a.m. medications to be given to the resident. The statement documented the staff did not get the resident up for lunch. The statement documented the CMA and CNA #4 had gone to the resident's room and found the resident lying on his right side with green spit next to him. The statement documented the CMA rolled the resident over onto his back and performed a sternal rub. The statement documented the the resident did not move. The statement documented the CMA tried again and yelled out the resident's name with no response. The statement documented the CMA felt for a pulse and found one. The statement documented the resident's pupils were unresponsive. The statement documented the CMA had gone to the dining room to get LPN #4. The statement documented they went to the resident's room and took his blood pressure. The statement documented the CMA checked the resident's Medication Administration Record [REDACTED]. The statement documented there was no medication checked off of the MAR for the resident. The statement documented the resident was cleaned up to be sent out of the facility. The investigative statement for LPN #4, dated [DATE], documented she received the morning shift report from LPN #3 on [DATE]. The statement documented LPN #3 had reported the resident had a couple of falls during the night. The statement documented LPN #3 had verbalized she had taken care of it. The statement documented LPN #4 stated, So he is going to be comatose for awhile then. The statement documented LPN #3 then stated, If he ain't he is one strong bad ass mother f****r. The statement documented LPN #4 stated the resident did not want to get up for breakfast which was out of the ordinary. The statement documented CMA #1 had reported the resident's vital signs were normal. The statement documented when the staff was getting ready for lunch, the nurse was called to the resident's room. The statement documented upon entering the resident's room, the nurse observed the resident was gray in color, was breathing, but was unresponsive with yellowish/green emesis coming from his mouth and nose. The statement documented the nurse instructed the CNA to stay with the resident while she went to get assistance from LPN #1. The statement documented LPN #1 stepped out of the room to call the DON and the CNA was instructed to clean the resident up for transport to the hospital. The statement documented when they left the room the resident quit breathing. The statement documented the resident was moved to the floor and cardiopulmonary resuscitation was initiated until the emergency medical service arrived. On [DATE] at 7:28 a.m., CNA #3 was interviewed. The CNA stated resident #1 would wander around the facility and was very confused. The CNA stated the resident would get violent at times and would have to be calmed down. The CNA stated the resident really was not a problem. On [DATE] at 9:23 a.m., CNA #4 was interviewed. The CNA stated she was listening to the morning shift report and heard LPN #3 state the resident would be one bad ass mother f****r if he woke up from what she had given him. The CNA stated the resident coded later the same morning. On [DATE] at 9:58 a.m., the administrator (ADM) was interviewed. The ADM stated the incident related to LPN #3 and resident #1 was discussed. The ADM stated she had not done a full investigation. The ADM stated LPN #3 was verbally suspended until her documentation could be completed. The ADM stated the incident had been reported to her by a CMA and a nurse. On [DATE] at 10:10 a.m., the ADM stated she had discussed the situation with LPN #4 several times and her story was inconsistent. The ADM stated she had discussed the situation with CMA #1 and she did not feel there was a problem with LPN #3. The ADM stated she did not fill out an incident report or send and incident report to the OSDH. The ADM stated she did not feel the comment made by LPN #3 was an allegation of abuse. The ADM stated she did not suspend LPN #3 because she wasn't scheduled to work for a few days. The ADM stated when the nurse returned to work she had to complete her documentation related to the incident first before returning to regular duties. The ADM stated they discussed the incident but no formal investigation had been completed. On [DATE] at 12:03 p.m., CMA #2 was interviewed. The CMA stated LPN #3 told her she had given resident #1 enough medication to put him down and if he woke up from that he would be one bad ass mother f****r. The CMA stated at first she thought the nurse must have had a bad night. The CMA stated after she thought about it that wasn't a normal thing for the nurse to say. The CMA stated she reported the comment to her charge nurse LPN #4. On [DATE] at 12:16 p.m., LPN #4 was interviewed. The LPN stated during the shift change report, LPN #3 stated resident #1 had one or two falls the previous night and if he didn't sleep all day he was a bad ass mother f****r. The LPN stated no neurological checks had been initiated since he had not hit his head. LPN #4 stated the resident did not get up for breakfast. The nurse stated the CMA had taken a set of vital signs and they were within normal limits. The nurse stated the resident had not had his morning snack. The nurse stated they had decided it was best to let the resident sleep. The nurse stated right before lunch it was brought to her attention the resident was unresponsive. The nurse stated the CMA started cardiopulmonary resuscitation on the resident. The nurse stated the resident did have a bruise on his forehead. On [DATE] at 2:05 p.m., the DON stated there was no documentation for neurological checks for resident #1. On [DATE] at 9:25 a.m., the ADM stated LPN #3 was still employed as a nurse at the facility. On [DATE] at 11:49 a.m., the resident's physician (physician #1) was interviewed. The physician stated it was the practice of the facility to notify him if a resident had a fall or a change in condition. The physician stated he could not remember if he was contacted related to resident #1. On [DATE] at 1:05 p.m., CMA #2 was interviewed. The CMA stated she reported the comment made by LPN #3 to her charge nurse LPN #4 about 30 minutes after the comment was made. The CMA stated after the resident left the facility she went to the administrator's office and had a complete mental breakdown because she did not think the resident's condition was an accident. The CMA stated LPN #3 had come back to work and was providing resident care. On [DATE] at 1:10 p.m., LPN #4 was interviewed. The LPN stated she reported the comment made by LPN #3 to the director of nurses after the resident had a change in condition. This was approximately three and a half hours later. The LPN stated when the comment was made she did not think much about the comment but when the resident had a change in condition she thought maybe the nurse had been serious. On [DATE] at 4:00 p.m., the emergency room physician was interviewed. The physician stated the resident had a small hemorrhage of the brain due to [MEDICAL CONDITION] of the brain secondary to [MEDICAL CONDITION]. The physician stated the resident had a scalp contusion. The physician stated he could not say for certain the resident's cause of death. The physician stated the cardiology report documented the resident had acute [MEDICAL CONDITION]. The physician stated the new onset of left sided abdominal pain, general body pain, and increased restlessness could have been signs of cardiac issues. On [DATE] at 10:15 a.m., CNA #5 stated the resident was pretty independent and would get up to go to the bathroom independently. The CNA stated they had to keep a close watch on him. The CNA stated the resident would not use the call light. On [DATE] at 11:03 a.m., the director of nurses (DON) stated the resident had only had one fall and one pain assessment since admission. The DON stated the resident should have had quarterly assessments performed. The DON stated documentation for resident #1 related to his falls and his change in condition had not been performed until after the resident was deceased . The DON stated a new onset of pain and falls should have been reported to the resident's physician. The DON stated LPN #3 had not reported the pain and falls to the resident's physician, the DON, the ADM, or the resident's family. On [DATE] at 2:59 p.m., the ADM stated no medication reconciliation had been performed for resident #1. The ADM stated the resident's medications had already been destroyed.

Based on observation, interview, and record review, it was determined the facility failed to provide adequate supervision to prevent falls for two (#1 and #7) of three sampled residents reviewed for falls. The facility failed to: a) Thoroughly assess and monitor the resident after three consecutive falls for resident #1. The resident hit his head on the second fall. b) To notify the physician of falls for resident #1. c) To identify a change in condition for resident #1. d) To complete incident reports for three of three falls for resident #1. e) To implement new interventions to prevent future falls for resident #1 and #7. On [DATE] to [DATE] during the night shift resident #1 sustained three falls. The medical record did not document incident reports were completed for each fall. The nurse notes did not document an account of the falls, resident assessments after the falls, or follow up monitoring after the falls. The nurse notes did not document the physician, administrator, or family was notified after each fall. Investigative statements documented the resident was more agitated, was moaning, and complained of pain. The nurse notes, dated [DATE] at 12:31 p.m., documented the resident became unresponsive and cardiopulmonary resuscitation (CPR) was initiated. The nurse notes documented the resident was transported to the hospital by ambulance. The emergency room records, dated [DATE] at 7:35 p.m., documented a computed tomography (CT) of the brain without contrast was obtained for resident #1 due to [MEDICATION NAME] trauma. A CT scan of the head documented the resident had a new contusion to the back of his head and an [MEDICATION NAME] hemorrhage. On [DATE] the resident expired at the hospital. The facility identified 24 residents had fallen in the last three months. Findings: The facility policy and procedures for falls documented a resident who was a fall risk would be placed on the falling star fall prevention program. The fall protocol documented the physician, family, director of nurses (DON), and administrator (ADM) would be notified when a resident fell . The fall protocol documented an incident report would be completed. The protocol documented a new intervention was to be implemented after each fall. The protocol documented the minimum data sets (MDS) coordinator and the DON would receive a copy of the incident report. The protocol documented the staff would require education regarding the newest fall prevention measures implemented. 1. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The fall risk assessment, dated [DATE], documented the resident was a high fall risk for falls. The physician orders [REDACTED]. The admission assessment, dated [DATE], documented the resident was moderately impaired for daily decision making. The assessment documented the resident had mild depression. The assessment did not document behaviors. The assessment documented the resident required limited assistance with most activities of daily living (ADLs). The assessment documented the resident required assistance with balance. The assessment documented the resident used a wheelchair for mobility. The assessment documented the resident required substantial assistance with ambulating. The assessment documented the resident was occasionally incontinent of urine. The assessment documented the resident received an antipsychotic. The care area assessment (CAAs) documented falls were identified. The care plan, dated [DATE], documented the resident required assistance with ADLs. The care plan documented the resident was on an antipsychotic medication. The care plan documented the resident had a cognitive impairment. The care plan documented the resident was a fall risk with interventions in place. The nurse note, dated [DATE] at 2:10 p.m., documented resident #1 was confused when returning from the bathroom and was attempting to get into the wrong bed. The note documented the roommate pushed the resident off the bed and the resident fell to the floor. The note documented the resident had no injuries. The note documented the resident was educated to utilize the call light before going to the bathroom. The note documented the staff was educated to use low lighting in the resident's room to prevent future falls. The care plan did not document a new intervention to prevent falls. The incident reports were reviewed. The reports did not document a fall for the resident on [DATE]. The quarterly assessment, dated [DATE], documented the resident was moderately impaired for daily decision making. The assessment documented the resident had mild depression. The assessment did not document behaviors. The assessment documented the resident required supervision to limited assistance with most ADLs. The assessment documented the resident used a walker or wheelchair for mobility. The assessment documented the resident was continent of both bowel and bladder. The assessment documented the resident had one fall since admission. The nurse note, dated [DATE] at 1:49 a.m., document the resident fell on the floor and bumped his head. The notes documented the resident had a half dollar size lump on the left temporal region. The note documented the resident had been increasingly confused that week and was sent to the hospital for evaluation. An incident report, dated [DATE], documented the resident fell . The incident report documented required notifications were completed. The report documented an investigation was completed and new interventions to prevent falls were implemented. The nurse note, dated [DATE] at 8:02 a.m., documented the resident was found on the floor in the hallway. The note documented the resident stated he fell . The note documented the resident did not have an injury but the resident did have bruising to both knees. The note documented the physician was notified. The care plan did not document a new intervention to prevent future falls. The incident reports were reviewed. The reports did not document a report for the resident's fall on [DATE]. The nurse notes, dated [DATE] at 1:30 a.m., documented the resident was found lying in the linen closet on the floor. The nurse notes did not document an injury to the resident. The care plan did not document a new intervention was implemented to prevent this type of occurrence. The incident reports were reviewed. The reports did not document a report for the occurrence on [DATE]. The reports did not document an investigation was completed. The nurse note, dated [DATE] at 10:00 a.m., documented the resident was sitting on the floor yelling for a nurse. The note documented a head to toe assessment was completed. The note documented the resident had no injuries. The note documented the resident was reoriented to the call light and a fall mat was placed next to his bed. The note documented the physician was notified and an attempt was made to notify the family. The care plan documented the new intervention to prevent falls was to place a fall mat next to the resident's bed. The incident report, dated [DATE], was completed and documented the resident fell . The incident report documented the resident was found on the floor by the housekeeper. The incident report documented the physician and administrator were notified regarding the fall. The incident report documented new interventions were implemented to prevent future falls. An incident report, dated [DATE] at 1:20 p.m., documented the resident fell out of a geri-chair. The report documented the resident did not have an injury. The report documented an investigation was completed, the physician, family, and administrator were notified, and new interventions were implemented to prevent future falls. The care plan did documented a new intervention to prevent falls. The nurse notes for [DATE] and [DATE] were reviewed. The notes did not document the resident's falls, the resident's assessments, or follow up monitoring for the night shift. The incident reports were reviewed. The reports did not document the resident's falls on [DATE] at 12:00 a.m., and on [DATE] at 12:47 a.m., and at 1:15 a.m. The nurse note, dated [DATE] at 12:31 p.m., documented licensed practical nurse (LPN) #4 was summoned to the resident's room by the certified nurse aid (CNA). The note documented the nurse observed a large amount of green emesis coming from the resident's nose and mouth. The note documented the resident was nonresponsive with shallow breathing and was grayish in color. The note documented the resident had a faint pulse less than 40 beats per minute. The note documented cardiopulmonary resuscitation was initiated and the emergency medical service was notified. The note documented the physician, the director of nurses, and the administrator were notified. The note documented the resident was transported via emergency medical services to the nearest hospital and the family was notified. The emergency medical services record, dated [DATE] at 12:52 p.m., documented the resident was unresponsive upon arrival to the facility. The record documented the staff was performing cardiopulmonary resuscitation. The record documented the resident was found at approximately 12:00 p.m. The record documented the resident was unresponsive, was still breathing, and had a palpable radial pulse. The record documented the resident stopped breathing at approximately 12:10 p.m. A facility investigative statement, dated [DATE], documented the resident had fallen out of bed three times. The falls occurred at 12:00 a.m., at 12:47 a.m., and at 1:15 a.m. The statement documented the resident had fallen and hit his head with the second fall. The report documented the resident had increased agitation and humming the night the falls occurred. The emergency room records, dated [DATE] at 7:35 p.m., documented a computed tomography (CT) of the brain without contrast was obtained for resident #1 due to [MEDICATION NAME] trauma. The document reported the resident had some questionable hemorrhages and changes to the back part of the brain compared to the previous scan. The hospital records documented the resident expired on [DATE]. A late entry nurse note, dated [DATE] at 10:17 p.m., documented an entry for [DATE] at 10:30 p.m. The note documented the resident was found lying on his fall mat. The note documented the resident had no injury to his head. The note documented the resident was complaining of all over pain and left sided stomach pain. The resident rated the pain at 9 out of 10 on a pain scale of 0 to 10 with 10 being the worst. The note documented the nurse educated the resident on the importance of using the call light. The note documented the resident was unable to adequately verbalize understanding of the instructions due to his pain and level of consciousness (L[NAME]). The note documented the resident would be given something for pain. The note did not document the physician, administrator, or family were notified. The note did not document a new intervention to prevent future falls. A late entry nurse note, dated [DATE] at 11:23 p.m., documented an entry for [DATE] at 12:40 a.m. The note documented the certified nurse aide (CNA) reported the resident was found with his head and his upper body on the floor and his legs were up on the bed. The note documented the resident had redness to his back but did not have an indication of a head injury. The note did not document the physician, administration, and family were notified. The note did not document a new intervention to prevent future falls. On [DATE] the incident reports related to the falls were requested. The facility was not able to provide the reports. On [DATE] the nurse notes for the three falls were requested. The facility was not able to provide nurse notes which were completed at the time of the fall or during the shift when the falls occurred. On [DATE] at 8:13 a.m., licensed practical nurse (LPN) #2 stated when a resident had a fall the nurse should assess the resident. The LPN stated they would fill out an incident report and call the DON, family, and physician. The LPN stated if the resident was injured they would also call an ambulance to transport the resident to the hospital. On [DATE] at 4:13 p.m., LPN #1 stated when a resident had a fall the nurse should assess the resident and decide what care the resident would need. The LPN stated the nurse should notify the physician and the administrator. The nurse stated the charge nurse for the shift should advise their staff which residents were on fall precautions. The LPN stated the care book should show if the resident was on a falling start program. The LPN stated the CNAs could see if a resident was a fall risk on their charting document. On [DATE] at 9:58 a.m., the ADM stated she had not completed a thorough investigation for the resident's falls which occurred on [DATE] and [DATE]. On [DATE] at 3:50 p.m., the DON and the ADM stated the documentation for resident #1 was not completed until the next week. The DON and the ADM stated they were both unaware of the falls resident #1 had sustained until the resident was sent to hospital. On [DATE] at 11:49 a.m., the physician was interviewed. The physician stated it was the facilities general practice to call him regarding falls. The physician stated he did not remember if he received a call on the night the three falls occurred. On [DATE] at 10:04 a.m., CNA #5 stated the resident was unsteady at times. The CNA stated she had checked on the resident more frequent and tried to watch him closely. The CNA stated she would make sure the resident had his call light and the fall mat was in place. The CNA stated the resident was independent and many times would not call for assistance. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical records for the resident did not document an admission assessment. The temporary admission care plan, dated [DATE], documented the resident was confused at times. The care plan documented the resident would require assistance with most ADLs. The care plan documented the resident was incontinent and would be toileted on a regular basis and as needed. The care plan documented the resident had a history of [REDACTED]. The care plan documented the resident required a wheelchair for mobility. The physician orders [REDACTED]. An incident report, dated [DATE], documented the resident had a fall. The report did not document the resident had an injury. The report documented the assistant director of nurses was notified. The report documented two interventions to prevent falls. On [DATE] at 11:38 a.m., the resident was sitting in her wheelchair in the common area. The resident was clean, groomed, and free of odor. The resident's room was clean and free of clutter. On [DATE] at 4:13 p.m., LPN #1 stated when a resident had a fall the nurse should assess the resident and decide what care the resident would need. The LPN stated the nurse should notify the physician and administrator. The nurse stated the charge nurse for the shift should advise their staff which residents were on fall precautions. The LPN stated the care book should document if a resident was on a falling start program. The LPN stated the CNAs could see which residents were a fall risk on their charting document. On [DATE] the medical record was reviewed. The medical record did not document a completed comprehensive admission care plan for the resident. On [DATE] at 10:38 a.m., the minimum data set (MDS) coordinator #2 was interviewed regarding the completion of assessments. The coordinator stated they did not complete the comprehensive assessment for the resident. On [DATE] at 9:30 a.m., the DON was interviewed regarding the interventions to prevent falls. The DON stated a comprehensive care plan was not documented in the computer. On [DATE] at 10:15 a.m., CAN #6 stated the resident was a one person assist. The CNA stated she knew resident #6 had one fall. The CNA stated she encouraged the resident to use the call light and ask for assistance when needed. The CNA stated resident #7 was not a fall risk prior to her fall but now has a star to indicate the resident was a fall risk. The CNA stated the fall list was in a binder at the nurse station. The CNA was unable to find the fall list. On [DATE] at 10:20 a.m., CNA #7 stated the residents at risk for falls were identified by a star on the door and in the care plan. On [DATE] at 9:22 a.m., the MDS coordinators were interviewed. The coordinators stated when a fall occurred the nurse should fill out an incident report and document new interventions. The coordinators stated they did not always know when a resident had a fall since the nurses did not always complete an incident report.

On [DATE] an Immediate Jeopardy (IJ) was determined to exist due to the facility's systemic failure to provide respiratory care and services for residents #1 and #3. The facility failed to: a) Provide respiratory care to ventilator dependent residents, including monitoring ventilator alarm functioning. b) Have a working back-up ventilator available when a ventilator malfunctioned for the residents. c) Have a system in place to monitor ventilator dependent residents when a ventilator was malfunctioning for resident #3. d) Implement corrective actions to prevent further incidence of ventilator care failure for resident #3. Resident #1 was ventilator dependent and on [DATE] the ventilator did not alarm when the tubing became disconnected from the ventilator. The resident became unresponsive, cardiopulmonary resuscitation (CPR) was initiated, and the resident was sent to the hospital by ambulance. The hospital discharge summary, dated [DATE], documented the resident #1 expired on [DATE]. Resident #3 was ventilator dependent. The resident became disconnected from the ventilator. The ventilator vibrated but the auditory alarm did not alarm properly. The facility nurse did not report the malfunction immediately to administration. The facility did not implement additional monitoring for the resident. Two days later the resident's [MEDICAL CONDITION] came out and the resident was disconnected from the ventilator. The alarm did not sound. The nurse stated an additional ventilator was not available in the facility to replace the malfunctioning ventilator. The IJ situation was verified with the Oklahoma State Department of Health. On [DATE] at 12:47 p.m., the corporate administrator (ADM) and the director of nurses (DON) were notified of the IJ situation regarding the failure to ensure respiratory care was provided and ventilator alarms functioned when tubing became disconnected from the ventilators. On [DATE] at 3:25 p.m., documentation was provided for the alarm function testing for all ventilators in the facility. On [DATE] at 4:18 p.m., the plan of removal for the Immediate Jeopardy was accepted. The Plan of Removal for Immediate Jeopardy documented: All HT70 ventilators have been removed from the facility. Nursing staff will perform ventilator alarm checks immediately and every shift thereafter. Record of these checks will be documented on the Vent/Alarm Checks form. The facility will develop a policy for increased resident monitoring in the event of equipment failure. In the event of equipment failure, the affected piece/pieces of equipment will be immediately removed from the resident care area. The serial number or other identifier will be logged, and the equipment returned to the durable medical equipment (DME) company or manufacturer. The facility will make available to all nursing staff the LTV operator's manual to use as reference. In addition, the facility will work to develop a comprehensive ventilator policy, with associated education, and a procedure for ventilator trouble-shooting. The facility will develop a policy regarding the number of back-up ventilators to be available at all times, to include a process that outlines monitoring of ventilator inventory. All nursing and respiratory therapy staff will be in-serviced, in person or by phone, regarding, but not limited to, the new protocol of alarm checks every shift, reporting equipment failure to administration will begin immediately for applicable staff currently in the building and for staff not present, they will be educated prior to the beginning of their next scheduled shift. The DON and/or designee will audit vent/alarm checks forms daily to ensure compliance. The QA committee will review the new policy and new process to ensure effectiveness at the next meeting and as needed. On [DATE] at p.m., the nursing staff was in-serviced on the facility policy for ventilator alarms to be checked and documented every shift, the policy for resident monitoring following equipment failure, and reporting equipment failure to the administration within eight hours. On [DATE] at 5:15 p.m., a copy of the policy and procedure was provided by the ADM. The policy documented the facility would have at a minimum two backup/emergency ventilators, the ventilators would be monitored daily, and documented on a log sheet. The policy documented following an incident of equipment failure the nursing staff would perform increased monitoring of the resident involved. The policy documented the monitoring would be documented in the resident's record and performed every 15 minutes times four, every hour times two, and then every shift. The policy documented any decline in the resident's condition would be reported to the resident's physician immediately. The policy documented ventilators would be assessed for equipment alarm function and parameters. On [DATE] at 4:45 p.m., the last employee was in-serviced in the facility. On [DATE] at 5:15 p.m., two back-up ventilators were observed in the facility. On [DATE] at 5:15 p.m., a copy of the ventilator/alarm checklist was provided with the ventilator alarm functioning added to the checklist. On [DATE] at 5:15 p.m., the last employee not present in the facility was in-serviced over the telephone. On [DATE] by 5:15 p.m., interviews with the staff were completed. The staff stated in-services for education pertaining to the content for the Immediate Jeopardy were provided. The staff stated an inservice was provided that day in the facility and some staff stated they had been in-serviced via the telephone. The staff was able to verbalize understanding of information provided in the in-service pertaining to the plan of removal. On [DATE] at 5:15 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a pattern level of actual harm. Based on observation, interview, and record review, it was determined the facility failed to provide respiratory care and services for two (#1 and #3) of three residents sampled for respiratory care. The facility failed to: a) Ensure respiratory care was provided to ventilator dependent residents, including monitoring ventilator alarm function for the residents. b) Have a working back-up ventilator available when a ventilator malfunctioned for the residents. c) Have a system in place to monitor ventilator dependent residents when a ventilator was malfunctioning for resident #3. d) implement corrective actions to prevent further incidence of ventilator care failure for resident #3. e) Develop policy and procedures for monitoring ventilators including ventilator alarm function. f) Develop a policy for emergency procedures when a ventilator malfunctioned. Resident #1 was ventilator dependent and on [DATE] the ventilator did not alarm when the tubing became disconnected from the ventilator. The resident became unresponsive, cardiopulmonary resuscitation (CPR) was initiated, and the resident was sent to the hospital by ambulance. The hospital discharge summary, dated [DATE], documented the resident #1 expired on [DATE]. Resident #3 was ventilator dependent. The resident became disconnected from the ventilator. The ventilator vibrated but the auditory alarm did not alarm properly. The facility nurse did not report the malfunction immediately to administration. The facility did not implement additional monitoring for the resident. Two days later the resident's [MEDICAL CONDITION] came out and the resident was disconnected from the ventilator. The alarm did not sound. The nurse stated an additional ventilator was not available in the facility to replace the malfunctioning ventilator. The facility identified 31 residents residing in the facility who were ventilator dependent. Findings: The facility policy for mechanical ventilation documented the facility felt it was essential for all nurses working in the facility to be trained and competent in caring for residents requiring mechanical ventilation and know how to trouble shoot ventilator problems. The facility job description for a respiratory therapist (RT) documented the RT was responsible for monitoring the ventilators for functionality and would report any equipment concerns to the administrator, supplier, or manufacturer as needed. The policy did not document how often the RT was to monitor the ventilators for alarm function. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual assessment, dated [DATE], documented the resident was independent for daily decision making. The assessment documented the resident required extensive assistance for activities of daily living (ADLs). The quarterly assessment, dated [DATE], documented the resident was independent for daily decision making. The assessment documented the resident required extensive assistance for ADLs. The care plan, dated [DATE], documented the resident was ventilator dependent, could mouth words/write for communication, and was dependent for all ADLs. On [DATE] at 8 a.m., the treatment administration record (TAR) documented the resident's oxygen saturation was 98%. The TAR, dated [DATE], documented the resident's oxygen saturation for the night shift was 100%. On [DATE] at 8:30 p.m., a nurse note documented the resident was found unresponsive, cyanotic, and staff was unable to obtain a pulse. The note documented cardiopulmonary resuscitation (CPR) was initiated and emergency medical services (EMS) was notified. The note documented the resident was unresponsive and the resident's pupils were fixed and dilated. The note documented EMS arrived at the facility and transported the resident to the hospital. The facility report for the camera review of the resident's room observation, dated [DATE], documented at 8:05 p.m. certified nurse aid (CNA) #1 leaned inside of the resident's room and then walked down the hall. The review documented at 8:19 p.m., CNAs #2 and #3 were present in the hallway outside of the resident's room gowning up to enter the resident's room and entered the room at 8:21 p.m. The review documented at 8:21 p.m., CNAs #2 and #3 were outside of the resident's room and licensed practical nurse (LPN) #1 was running down the hallway and entered the resident's room. The DON stated the camera footage was erased after 13 days and was no longer available for viewing. The incident report, dated [DATE], documented the resident was found unresponsive in her bed and nursing staff performed CPR and revived the resident. The report documented the resident was transferred to the hospital for evaluation and the facility was notified the next day the resident had expired. The report documented the resident's ventilator circuit had become disconnected from the ventilator at the base. The report documented the machine was still attempting to ventilate and vibrating but did not sound the auditory alarm. The report documented interviews were conducted with staff working the hall that evening. The report documented the ventilator had been removed from the facility and was sent for diagnostic testing. The report documented all remaining ventilators were tested for alarm functionality and all call lights were tested to ensure activation of the call light when the ventilator alarm trigger. The report documented all direct care staff were in-serviced regarding performing visualization of circuits during patient interactions and the need to report any suspected equipment malfunctions. The report documented the facility was actively working to change ventilator models due to concerns regarding the current model. The report documented the expected time frame for completion of the switch over was two weeks with the first group of new ventilators to arrive on [DATE]. The report documented during the transition the staff would perform ventilator alarm checks on the current vents every shift and two nurses would sign off on the alarm checks. The hospital discharge summary, dated [DATE], documented the resident was admitted to the hospital with [REDACTED]. The summary documented upon arrival to the hospital the resident was unresponsive to pain or verbal stimuli, had a pulse, and was hypotensive. The summary documented the resident was pronounced deceased on [DATE] at 9:42 a.m. with the cause of death being cardiopulmonary arrest secondary to acute on chronic [MEDICAL CONDITION]. The investigative statement, not dated, documented between 7:30 p.m. and 7:45 p.m. CNA #2 and CNA #3 went to the resident's room and the resident was alert, talking to the staff, and had no complaints. The statement documented between 8:15 p.m. to 8:30 p.m. CNA #2 and CNA #3 went to the resident's room to provide care and found the resident unresponsive. The statement documented the CNAs tried to wake the resident, reconnected the ventilator tubing, and call the nurse. The investigative statement, dated [DATE], documented CNA #2 had a brief conversation with the resident at 7:45 p.m. The statement documented the CNA went back to the resident's room between 7:15 p.m. and 7:30 p.m. to provide care. The statement documented the CNA knocked on the resident's door and entered the room. The statement documented the CNA heard the ventilator vibrating and air blowing, the resident's [MEDICAL CONDITION] was connected, and she nudged the resident to wake her up but got no response. The statement documented the CNA shouted for the nurse, walked around the bed, and noticed the ventilator tubing was disconnected at the machine. The statement documented the CNA reconnected the ventilator tubing to the machine and it started alarming with a high pressure alarm. The investigative statement, dated [DATE], documented certified medication aid (CMA) #1 stated about 7:54 p.m. she had gone into the resident's room to give the resident her medication and the resident was talking to her like always. The CMA stated the resident was trying to touch her with her suction tip and was telling the CMA not to leave her. The CMA stated she finished with her medication administration and saw the resident's call light was on and she turned it off but no alarm was sounding. The investigative statement, dated [DATE], documented CNA #4 stated she started her bed checks at 8:00 p.m. and heard the resident tapping on her bedside table when coming out of another resident's room. The investigative statement documented the CNA stated she stood in the hall close to the door while CNA #1 asked the resident if she needed anything. The investigative statement documented the CNA stated she did not enter the resident's room. The investigative statement, dated [DATE], documented CNA #1 was performing bed checks when she heard the resident tapping on her table with the call light. The investigative statement documented the CNA stated she walked to the resident's door, poked her head in, and asked if the resident needed anything. The investigative statement documented the CNA stated the resident requested [MEDICATION NAME] and the CNA told the resident she would tell the CMA. The investigative statement documented the CNA stated the alarm was not sounding and the resident was fine when she closed the door. The investigative statement, dated [DATE], documented LPN #1 stated about 8:15 p.m. she came out of a resident's room and CNA #2 and CNA #3 were gowning up to go in and check on the resident. The investigative statement documented the LPN stated she reached the front hall when the CNAs yelled for her to come into the resident's room. The investigative statement documented the LPN stated the resident was in her bed, the head of the bed was elevated, the resident was unresponsive, and cyanotic around her mouth. The investigative statement documented the LPN stated CPR was initiated. The investigative statement documented the LPN stated the ventilator alarm was not sounding to let staff know the resident was disconnected from the ventilator but it was vibrating and air was blowing out of the machine. The investigative statement, dated [DATE], documented LPN #2 was at the front hall when she heard the two aids yell out for a nurse. The investigative statement documented the LPN stated she entered the resident's room and the ventilator was not alarming and the resident was unresponsive. The investigative statement documented the LPN stated she found a faint pulse and CPR was initiated. The investigative statement documented the LPN stated EMS transported the resident to the hospital. The ventilator assessment sheets, dated [DATE], documented 21 ventilators on the 100 hall were checked for the alarm volume level and seven ventilators on the 200 hall were checked for the alarm volume level setting and the alarm function. The in-service record, dated [DATE], documented the staff was educated on ventilator setting management, call lights, and faulty equipment reporting. The quality assurance (QA) record, dated [DATE], documented a circuit was disconnected from a ventilator at the base and the alarm did not sound. The QA record documented the resident had expired. The QA record documented the action taken was to in-service all direct care staff, perform alarm/call light checks on all vents, check all vent alarms for volume setting at the level of ten, the above mentioned vent was sent to the manufacturer for analysis, and a continuous pulse ox would be applied to all ventilator residents. The QA preventative measure documented the facility would change the ventilators to the LTV model, all nursing staff was in-serviced and return demonstration was performed on the LTV model, a check list for ventilator functionality was initiated every 12 hours, and maintenance was to perform weekly call light checks. A mobility plus letter, dated [DATE], documented they were in a push to switch patients from the HT70 model to the LTV ,[DATE] model ventilators. The letter documented five patients were changed to the LTV model on [DATE]. The letter documented two patients were changed to the LTV model on [DATE]. The letter documented the vendor had assured them 15 new LTV models would be delivered on [DATE] and the eight remaining LTVs would be delivered on [DATE]. The letter documented they would maintain three to four back up ventilators. The letter was noted by the DON and documented the vent transition was completed on [DATE]. On [DATE] at 10:35 a.m., the director of nurses (DON) stated the facility did not have a respiratory therapist (RT) at the facility full time. The DON stated the nurses and the RT were responsible for the care and maintenance of the ventilators. On [DATE] at 11:47 a.m., the DON stated the resident was found in her bed and she was unresponsive. The DON stated the tubing was not attached to the ventilator and the machine was not audibly alarming but was vibrating. The DON stated since the incident with the resident, the vents had all been replaced with the new LTV model. The DON stated the staff was required to perform a check off calibration worksheet on each ventilator every shift. The DON stated the staff were checking for connections and alarm sound level but not for the alarm function. On [DATE] at 11:54 a.m., the DME representative stated they provided maintenance for the ventilators and equipment. The DME representative stated the malfunctioning ventilator was being sent to the manufacturer for diagnostics. The DME representative stated a detailed report of the machine could be provided after the diagnostics were performed. On [DATE] at 2:25 p.m., LPN #4 stated prior to the incident with the resident ventilator checks were not being performed by the staff. The LPN stated the ventilator alarms were quiet. The LPN stated the ventilators would continue to vibrate after the alarm went off. The LPN stated the resident refused to wear her oxygen saturation monitor, could use the call light, could verbally communicate with staff, and would tap on her table with the call light at times. On [DATE] at 2:40 p.m., LPN #5 stated the nurse staff and RT was responsible for checking the alarms. The LPN stated she checked the alarm function every time she was in a resident's room. The LPN stated the alarms would sound until they were disabled. The LPN stated if the tubing was disconnected from the ventilator and the alarm went off the machine would continue to vibrate but the vibration could not be heard in the hall. On [DATE] at 3:25 p.m., the DON stated the previous RT performed a diagnostic on the ventilators every six months but could not provide documentation of any diagnostics performed prior to the incident with the resident. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated [DATE], documented the resident was severely impaired for daily decision making. The assessment documented the resident required extensive assistance for activities of daily living (ADLs). The significant change assessment, dated [DATE], documented the resident was severely impaired for daily decision making. The assessment documented the resident required total assistance for ADLs. The nurse notes for [DATE] were reviewed. The notes did not document the incident in which the resident's ventilator did not sound the auditory alarm when the tubing became disconnected from the ventilator. The incident reports for [DATE] were reviewed. The incident reports did not document an incident in which the resident's ventilator did not sound the auditory alarm when the tubing became disconnected from the ventilator. The ventilator sheets for the day and night shifts, dated [DATE] through [DATE], documented the resident's circuit was connected to the ventilator, the alarm volume was set at a level of 10, and the call light was connected to the ventilator. The sheets did not document the ventilator alarm function was monitored. The care plan, dated [DATE], documented the resident required total assistance for ADLs. The care plan documented the resident was ventilator dependent and had a [MEDICAL CONDITION]. A handwritten communication note addressed to the DON was reviewed. The communication note was dated [DATE]. The note documented on [DATE] LPN #3 was in the resident's room when the ventilator alarm sounded. The LPN stated the resident had disconnected her circuit line from the ventilator and had it balled up under her left arm. The note documented while the LPN was untangling the circuit hose the alarm stopped sounding but the ventilator continued to vibrate. On [DATE] at 3:00 p.m., the RT was interviewed. The RT stated she was checking the function of the new ventilators every Saturday when she replaced the circuits. The RT stated she was at the facility the day after the incident on [DATE] and the old model ventilator was replaced with the new LTV model. The RT stated at least one replacement ventilator should be available in the facility for every ten residents requiring a ventilator. On [DATE] at 3:10 p.m., LPN #6 stated the ventilator function was checked by the RT. The LPN stated on [DATE] she was standing outside of the room for resident #3 when she heard the ventilator vibrating. The LPN stated the resident's [MEDICAL CONDITION] was out and the alarm was not sounding. The LPN stated there was not an extra ventilator in the facility and she could not change out the malfunctioning machine. The LPN stated she did not fill out an incident report. The LPN stated she checked the resident often but was not able to state the time interval. The LPN stated she did not document the completion of safety checks for the resident. The nurse notes for [DATE] were reviewed. The notes did not document the incident in which the resident's [MEDICAL CONDITION] came out and the ventilator did not sound the auditory alarm. The incident reports for [DATE] were reviewed. The incident reports did not document an incident in which the resident's [MEDICAL CONDITION] came out and the ventilator did not sound the auditory alarm. On [DATE] at 3:15 p.m., the DON stated she was told about the second incident with the resident's ventilator alarm on [DATE] but she did not write an incident report. The DON stated a replacement ventilator should have been in the facility but the staff could always call the DME company and have one delivered if there was an emergency. The DON stated the resident could be bagged until the replacement ventilator was delivered. The DON stated there was a replacement ventilator in the facility at that time of this interview ([DATE]). On [DATE] at 10:01 a.m., LPN #3 stated she was in the resident's room on [DATE] when the ventilator alarm sounded. The LPN stated the alarm stopped sounding prior to reconnecting the tubing back into the machine but the ventilator continued to vibrate and the lights flashed. The LPN stated she had not disabled the alarm, it had just stopped alarming. The LPN stated she wasn't aware if a replacement ventilator was available in the facility and it really never occurred to her to change the ventilator. The LPN stated she did not know how to contact the DME company but she reported the incident to the DON and the administrator (ADM) the next morning. The LPN stated she did not fill out an incident report. On [DATE] at 10:58 a.m., the DON stated after the first incident with the ventilator alarm malfunction on [DATE], the ventilator was replaced with another ventilator of the same model on [DATE]. The DON stated no extra monitoring was provided for the resident and no incident report had been initiated. The DON stated after the second incident with the ventilator alarm malfunction on [DATE], the ventilator was replaced with the new LTV model on [DATE]. The DON stated no extra monitoring was provided for the resident and an incident report had not been initiated. The DON stated the staff was not required to check the alarms for function just the sound level.

On 03/21/17 an Immediate Jeopardy (IJ) was determined to exist due to the facility's failure to provide supervision to prevent an accident for resident #5 related to the use of a heating pad. The resident developed large fluid filled burns. The IJ situation was verified with the Oklahoma State Department of Health. On 03/21/17 at 11:57 a.m., the administrator (ADM) and the director of nurses (DON) were notified of the IJ situation regarding supervision to prevent accidents related to the use of heating pads and a resident's development of large fluid filled burns. On 03/21/17 at 1:20 p.m., the plan of removal was accepted for the Immediate Jeopardy pertaining to supervision to prevent accidents and the use of heating pads. The Plan of Removal for Immediate Jeopardy documented: The heating pad has been removed from the resident's room. It is no longer available for use. The facility policy on Heating Pads will be reviewed and revised as necessary. Administration will educate facility staff currently in the building by 2:00 on facility policy regarding heating pads. All other staff will be educated prior to the start of their next shift. A room by room sweep will be completed to verify that there are no further heating pads or blankets in the facility by 3:00. A letter will go out to all responsible parties/families to educate them on the facility policy regarding heating pads and blankets in the next billing statement. As continued monitoring, a full room sweep will be conducted by housekeeping staff with each deep cleaning. All nursing staff will be required to monitor for heating pads and blankets and turn them in to administration if found. The QA Committee will review the incident at the next meeting and address with housekeeping staff on an ongoing basis. On 03/21/17 at 12:30 p.m., staff in the facility were inserviced on the facility policy for heating pads and electric blankets. On 03/21/17 at 12:45 p.m., documentation was provided for a room by room sweep of all resident's rooms for heating pads and electric blankets. On 03/21/17 at 1:20 p.m., a copy of the letter sent to resident families regarding the policy for heating pads and electric blankets was provided by the DON. On 03/21/17 at 1:20 p.m., a copy of the policy and procedure was provided by the ADM. The policy documented no resident would be permitted to use an electric heating pad or heating blanket due to burn and fire hazards. The policy documented as an alternative comfort measure the facility would provide heated towels or blankets for resident use. On 03/21/17 at 2:05 p.m., the letters regarding the facility policy for heating pads and electric blankets were observed to be in addressed and stamped envelopes for mailing. All cognitive residents in the facility had been notified of the policy regarding heating pads and electric blankets. On 03/21/17 staff not present in the facility were inserviced over the phone. On 03/21/17 at 4:03 p.m., the last employee was inserviced via the telephone. On 03/21/17 interviews were conducted with staff regarding inservices for education pertaining to content for Immediate Jeopardy removal. The staff stated an inservice was provided that day in the facility and some staff stated they had been inserviced via the telephone. The staff was able to verbalize understanding of information provided in the inservice pertaining to the plan of removal. On 03/21/17 interviews were conducted with residents regarding heating pads. The residents were able to verbalize understanding of the facility policy regarding heating pads and electric blankets. On 03/21/17 at 4:03 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm at a pattern level. Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent an accident for one (#5) of five residents reviewed for accidents. The facility failed to supervise a quadriplegic resident while a heating pad was in place. The resident experienced large fluid filled burns to his back. The facility identified one resident who used a heating pad. Findings: The facility policy and procedures were reviewed. There was no policy for the use of heating pads prior to the resident being burned. The policy and procedure for wound treatments documented the facility would perform all prescribed wound treatments by the nursing staff as ordered by the physician. The policy documented the wound status would be reported to the physician. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 09/14/16, documented the resident was independent for daily decision making. The assessment documented the resident required total assistance with activities of daily living (ADLs). The annual assessment, dated 12/01/16, documented the resident was independent for daily decision making. The assessment documented the resident required total assistance with ADLs. A nurse note, dated 12/31/16, documented the resident had been admitted to the hospital. A nurse note, dated 01/06/17, documented the resident had returned to the facility from the hospital. A nurse note, dated 01/08/17, documented the resident had blisters to his back measuring 25 cm X 7 cm and 15.5 cm X 7 cm and were fluid filled. The nurse note documented the resident had requested the use of the heating pad and it was set on high per norm. An incident report, dated 01/08/17, documented the resident had a heating pad in place per resident request and it was set on high per norm. A physician order, dated 01/09/17, documented to cleanse the blistered area to the back with warm water and pat dry, apply silvadene cream, cover with 4 X 4's and abdominal pads, and secure with tape twice daily until resolved. The treatment administration record (TAR) for January 2017 documented the resident had not received one wound care treatment. On 01/23/17 the wound measurements were 23 cm X 7 cm and 15 cm X 7 cm. The TAR for February 2017 documented the resident had not received ten of the prescribed wound care treatments. The care plan, updated 02/18/17, documented the resident required total assistance with ADLs. The care plan for skin integrity documented the resident had a potential for skin breakdown related to impaired mobility and incontinence. The care plan did not address the resident's burns or treatment for [REDACTED]. The TAR for March 2017 documented the resident had not received six of the prescribed wound care treatments. On 03/14/17 the wound measurements were 18 cm X 6.5 cm, 10 cm X 6 cm, 2 cm X 1.5 cm, and 1 cm X 0.5 cm. On 03/20/17 at 9:55 a.m., the resident was observed in his bed lying on his left side and was wearing a hospital gown. The resident was well groomed and had no odors. The resident stated he had used a heating pad and received burns on his back. The resident stated the burns were still being treated. On 03/20/17 at 2:50 p.m., the director of nurses (DON) stated she was not aware of the resident having a heating pad until after the burns had occurred. The DON stated there was no policy or procedure in place prior to the resident being burned. The DON stated the resident would not be able to use the heating pad or adjust the temperature independently. The DON stated the resident was dependent on staff for ADLs. The DON stated there was no physician order for [REDACTED]. The DON stated the resident's family had brought the heating pad to the facility years ago. The DON stated the staff and family had not received any education for the use of heating pads. The DON stated she did not know what the manufacturer's guidelines were for heating pads. On 03/20/17 at 3:00 p.m., licensed practical nurse (LPN) #1 was observed to perform wound care. The LPN was assisted by certified nurse aid (CNA) #1. The old dressings were removed and were saturated with a yellowish exudate. The burns were large, white to yellow in color with a dark area underneath. The edge of the burns were red. The area where the heating pad had been placed was a dark brown and had two smaller areas which were pink in color. The LPN was asked if the resident would be able to use the heating pad or adjust the temperature without assistance. The LPN stated the resident would not be able to perform those task. The LPN stated the resident was dependent of staff for all needs. The CNA stated the resident told them what to do and they just did it. The staff stated the resident had used the heating pad since he was admitted to the facility. On 03/20/17 at 3:45 p.m., LPN #1 stated the resident had asked for the heating pad to be in place and turned on. The LPN stated the resident usually used the heating pad on his neck and did not know why it was on his back. The LPN stated the heating pad was old. The LPN stated the burns were found when the resident was being turned and she had been called to the resident's room to assess the burns. The LPN stated the heating pad was not covered and was placed directly on the resident's skin. The LPN stated she did not know how long the heating pad had been in place but the resident used it all the time. The LPN stated the burns looked like water balloon blisters. The LPN stated there had been no education on heating pads but the residents were not allowed to use them any longer. On 03/20/17 at 3:57 p.m., CNA #2 stated the resident had used the heating pad since he came to the facility. The CNA said the previous DON stated he had special permission to use the heating pad. The CNA stated she had helped turn the resident and found the burns. The CNA stated she had gotten the nurse to assess the burns. The CNA stated the blisters were large and oozing fluid like a severe burn. The CNA stated the nurse had called the resident's physician for orders. The CNA stated she thought LPN #1 talked to her about not using heating pads. On 03/20/17 at 4:03 p.m., the DON stated the burns and treatments for the burns should have been on the plan of care. The DON stated the staff involved in the incident had been told the residents were not allowed to use heating pads. The DON stated the incident had not been reassessed and no inservice had been provided. The DON stated the incident had been discussed in their morning stand up meeting. On 03/21/17, at 9:55 a.m., the MDS/care plan coordinator #1 stated they were a little bit behind. The MDS/care plan coordinator stated the assessment was not done. The MDS/care plan coordinator stated the care plan was not up to date. The care plan coordinator stated the staff would write a communication form when a resident had a change in care. The care plan coordinator stated she tried to keep the forms as a reference. The communication form could not be found. On 03/21/17 at 10:43 a.m., the physician stated he was not aware the resident was using the heating pad prior to being burned. The physician stated a heating pad should have never been used. The physician stated the resident felt he received better pain control from the heating pad than from the use of medications. The physician stated the resident would not be able to place the heating pad himself or adjust the temperature. The physician stated he could not give a degree of the burn related to the eschar covering the wound. The physician stated eschars were deeper like an unstageable pressure ulcer. The physician stated he had not seen the burns for awhile but had received pictures that morning and the burns were not as healed as he thought they would have been. On 03/21/17 at 11:57 a.m., the administrator (ADM) stated during an inservice for pain recognition on 01/13/17 she had informed staff to notify their nurse if they knew of any patients using a heating pad. The ADM stated heating pads were not allowed to be used by residents in the facility. On 03/21/17, at 1:50 p.m., the MDS/care plan coordinator #1 stated they were behind. The MDS/care plan coordinator stated the ADM and the DON were aware of the situation.

Based on observation, interview, and record review, it was determined the facility failed to provide necessary care and services for one (#5) of five residents reviewed for highest levels of well-being. The facility failed to: a) Assess, monitor, and intervene to prevent the resident from [MEDICAL CONDITION] using a heating pad. b) Provide all ordered wound treatments. c) Measure wounds. d) Report non-healing of wounds to the physician. e) Implement a comprehensive plan of care and a comprehensive assessement. The facility identified one resident who [MEDICAL CONDITION] the use of a heating pad. The resident, a quadriplegic, requested the use of a heating pad. The facility staff placed the heating pad and turned it on high. On 01/08/17 staff documented the resident had [MEDICAL CONDITION] his back from a heating pad. [MEDICAL CONDITION] 25 centimeters (cm) X 7 cm and 15.5 cm X 7 centimeters. Findings: The facility policy and procedures were reviewed. There was no policy for the use of heating pads prior to the resident being burned. The policy and procedure for wound treatments documented the facility would perform all prescribed wound treatments by the nursing staff as ordered by the physician. The policy documented the wound status would be reported to the physician. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 09/14/16, documented the resident was independent for daily decision making. The assessment documented the resident required total assistance with activities of daily living (ADLs). The annual assessment, dated 12/01/16, documented the resident was independent for daily decision making. The assessment documented the resident required total assistance with ADLs. A nurse note, dated 12/31/16, documented the resident had been admitted to the hospital. A nurse note, dated 01/06/17, documented the resident had returned to the facility from the hospital. A nurse note, dated 01/08/17, documented the resident had blisters to his back measuring 25 cm X 7 cm and 15.5 cm X 7 cm and were fluid filled. The nurse note documented the resident had requested the use of the heating pad and it was set on high per norm. An incident report, dated 01/08/17, documented the resident had a heating pad in place per resident request and it was set on high per norm. A physician order, dated 01/09/17, documented to cleanse the blistered area to the back with warm water and pat dry, apply [MEDICATION NAME] cream, cover with 4 X 4's and abdominal pads, and secure with tape twice daily until resolved. The treatment administration record (TAR) for January 2017 documented the resident had not received one wound care treatment. On 01/23/17 the wound measurements were 23 cm X 7 cm and 15 cm X 7 cm. The TAR for February 2017 documented the resident had not received ten of the prescribed wound care treatments. The care plan, updated 02/18/17, documented the resident required total assistance with ADLs. The care plan for skin integrity documented the resident had a potential for skin breakdown related to impaired mobility and incontinence. The care plan did not address the resident'[MEDICAL CONDITION] treatment for [REDACTED]. The TAR for March 2017 documented the resident had not received six of the prescribed wound care treatments. On 03/14/17 the wound measurements were 18 cm X 6.5 cm, 10 cm X 6 cm, 2 cm X 1.5 cm, and 1 cm X 0.5 cm. On 03/20/17 at 9:55 a.m., the resident was observed in his bed lying on his left side and was wearing a hospital gown. The resident was well groomed and had no odors. The resident stated he had used a heating pad and [MEDICAL CONDITION] his back. The resident stated [MEDICAL CONDITION] still being treated. On 03/20/17 at 2:50 p.m., the director of nurses (DON) stated she was not aware of the resident having a heating pad until after [MEDICAL CONDITION] occurred. The DON stated there was no policy or procedure in place prior to the resident being burned. The DON stated the resident would not be able to use the heating pad or adjust the temperature independently. The DON stated the resident was dependent on staff for ADLs. The DON stated there was no physician order for [REDACTED]. The DON stated she did not know what the manufacturer's guidelines were for heating pads. On 03/20/17 at 3:00 p.m., licensed practical nurse (LPN) #1 was observed to perform wound care. The LPN was assisted by certified nurse aid (CNA) #1. The old dressings were removed and were saturated with a yellowish exudate. [MEDICAL CONDITION] large, white to yellow in color with a dark area underneath. The edge of [MEDICAL CONDITION] red. The area where the heating pad had been placed was a dark brown and had two smaller areas which were pink in color. The LPN was asked if the resident would be able to use the heating pad or adjust the temperature without assistance. The LPN stated the resident would not be able to perform those task. The LPN stated the resident was dependent of staff for all needs. The CNA stated the resident told them what to do and they just did it. The staff stated the resident had used the heating pad since he was admitted to the facility. On 03/20/17 at 3:45 p.m., LPN #1 stated the resident had asked for the heating pad to be in place and turned on. The LPN stated the resident usually used the heating pad on his neck and did not know why it was on his back. The LPN stated the heating pad was old. The LPN stated [MEDICAL CONDITION] found when the resident was being turned and she had been called to the resident's room to assess the burns. The LPN stated the heating pad was not covered and was placed directly on the resident's skin. The LPN stated she did not know how long the heating pad had been in place but the resident used it all the time. The LPN stated [MEDICAL CONDITION] water balloon blisters. The LPN stated there had been no education on heating pads but the residents were not allowed to use them any longer. On 03/20/17 at 3:57 p.m., CNA #2 stated the resident had used the heating pad since he came to the facility. The CNA said the previous DON stated he had special permission to use the heating pad. The CNA stated she had helped turn the resident and found the burns. The CNA stated she had requested for the nurse to assess the burns. The CNA stated the blisters were large and oozing fluid like a severe burn. The CNA stated the nurse had called the resident's physician for orders. The CNA stated she thought LPN #1 talked to her about not having heating pads. On 03/20/17 at 4:03 p.m., the DON stated [MEDICAL CONDITION] treatments for [MEDICAL CONDITION] have been on the plan of care. The DON stated the staff involved in the incident had been told the residents were not allowed to use heating pads. The DON stated the incident had not been reassessed and no inservice had been provided. The DON stated the incident had been discussed in their morning stand up meeting. On 03/21/17, at 9:55 a.m., the MDS/care plan coordinator #2 stated the resident's quarterly assessment should have been updated by 03/02/17. The MDS/care plan coordinator stated they were a little bit behind. The MDS/care plan coordinator stated the assessment was not done. The MDS/care plan coordinator stated the care plan was not up to date. The care plan coordinator stated the staff would write a communication form when a resident had a change in care. The care plan coordinator stated she tried to keep the forms as a reference. The communication form could not be found. On 03/21/17 at 10:43 a.m., the physician stated he was not aware the resident was using a heating pad prior to being burned. The physician stated a heating pad should never be used. The physician stated the resident felt he received better pain control from the heating pad than from the use of medications. The physician stated the resident would not be able to place the heating pad himself or adjust the temperature. The physician stated he could not give a degree of the burn related to the eschar covering the wound. The physician stated eschars were deeper like an unstageable pressure ulcer. The physician stated he had not seen [MEDICAL CONDITION] awhile but had received pictures that morning and [MEDICAL CONDITION] not as healed as he thought they would have been.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary supervision to prevent accidents for three (#2, #4, and #5) of three sampled residents reviewed for falls. The facility failed to: a) Provide the necessary supervision to prevent falls for resident #2 and #4. b) Complete a thorough investigation for falls for resident #2, #4, and #5. c) Implement resident specific interventions to prevent falls for residents #2, #4, and #5. d) Monitor the effectiveness of interventions and make changes as necessary for resident #4 and #5. Resident #4 sustained multiple falls including a fall resulting in a hip fracture which required surgical repair. The facility identified 10 residents who had fallen in the past six months. Findings: The facility policy for falls documented the facility was to identify residents at risk for falls and implement fall prevention measures. The policy documented each resident was to be evaluated for falls upon admission, upon a change in condition, and at least quarterly. The policy documented the risk for falls, goals, and interventions be identified and for staff to be trained to identify the risks and hazards for falls in the environment. The policy documented the interventions for fall prevention would be evaluated by the safety committee and changes would be implemented as necessary. The policy documented any resident with two or more falls in a 30 day period or a fall resulting in an injury would be referred for a fall assessment. The policy documented the nurse was to fill out an incident report, document the fall in the resident record, and document the fall on the 24 hour report. 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 06/08/16, documented the resident was independent for daily decision-making and required limited to total assistance with the activities of daily living. The assessment documented the resident was occasionally incontinent of bowel and bladder, had pain, received anti-depressant medication, and had limitations in one lower extremity. The assessment documented the resident did not receive therapy services and had not had any falls. The care plan, dated 06/14/16, documented the resident was at risk for falls. The care plan documented the goals were for the resident to be able to verbalize understanding of the need for assistance and demonstrate the ability to use his assistive devices safely and consistently. The care plan documented the interventions included for the staff to: 1. Have physical therapy (PT) or restorative services were to evaluate the resident for strength training, gait, or transfer training, and have occupational therapy (OT) to evaluate the resident as indicated. 2. Make sure all staff members were aware the resident was at risk for falls. 3. Educate the resident for safety awareness, instruct the resident to sit on the side of the bed for one minute before standing, ensure the resident wore well-fitting shoes with nonslip soles, ensure the resident wore gripper socks, and remind the resident to call when needing assistance. 4. Ensure the resident's wheelchair was removed or locked and keep the call light and most frequently used items within reach. 5. Assess the resident's medications for contributing factors. 6. Keep the resident's glasses clean and have adequate prescription. 7. Toilet the resident per schedule and upon request. 8. Ensure the resident used grab bars by tubs, showers, and toilets. 9. Maintain the resident's room and pathways free of clutter, clean up spills immediately, provide adequate lighting, and keep the resident's bed in the lowest position. The medication record documented the resident received Coreg (an anti-hypertensive medication), Trazadone (an anti-depressant), Depakene (anti-seizure medication), Norco (pain medication), and Vimpat (anti-seizure medication). The physician orders [REDACTED]. A fall risk assessment, dated 06/11/16, documented the resident had a fall risk score of 9. The assessment documented a score higher than 10 placed a resident at high risk for falls. An incident report, dated 09/14/16, documented the resident had a non-injury fall. The report documented the resident fell while holding onto the back of his wheelchair while ambulating. The report documented the physician, director of nurses (DON), and sister were notified. The report documented the resident was counseled on the importance of taking his time and to pay attention while he was ambulating. The resident reported he understood. The nurse notes, dated 09/14/16 at 8:36 p.m., documented the events of the resident's fall. The care plan was not updated with a new intervention to prevent falls. An incident report, dated 10/15/16 at 8:00 a.m., documented the resident was in his room and was noticed sitting on his buttocks in front of the sink. The report documented the resident stated he lost his balance and fell over. The report documented the resident denied pain and had no apparent injury. The report documented the DON and family were notified. The report documented the staff encouraged the resident to use his walker or wheelchair for mobility at all times. The nurse notes, dated 10/24/16 at 4:48 p.m., documented the events of the resident's fall and a resident assessment. The care plan was not updated with new interventions to prevent falls. The quarterly assessment, dated 12/08/16, documented the resident was independent for daily decision making and required minimal to moderate assistance with the activities of daily living (ADLs). The assessment documented the resident had limitations for one lower extremity. The assessment documented the resident was occasionally incontinent of bladder. The assessment documented the resident had two non-injury falls. The assessment documented the resident received antidepressants and antianxiety medications. The assessment documented the resident did not receive therapy but received restorative nursing for active range of motion. The care plan, updated on 12/11/16, did not document new interventions to prevent falls. An incident report, dated 12/16/16 at 4:30 p.m., documented the resident fell in the dining room. The report documented the resident was moving a dining room chair so he could place his wheelchair up to the table and he fell over. The report documented the physician was notified and an x-ray was ordered. The report documented the DON and family were notified. The report documented the steps to prevent additional falls were for the staff to remind the resident to ask for assistance when moving things. The nurse notes, dated 12/16/16 at 7:55 p.m., documented the resident's fall. The notes documented the nurse evaluated the resident, the resident complained of pain in his right hip, and was not able to bear weight. The notes documented the resident had a right hip fracture per x-ray report. The notes documented the resident went out of the facility for an evaluation. A hospital x-ray report, dated 12/16/16, documented the resident had a right hip fracture. A hospital orthopedic consultation note, dated 12/17/16, documented the resident had a right hip fracture requiring surgical repair. The physical therapy (PT) notes documented the resident received PT from 12/22/16 through 12/29/16. A significant change assessment, dated 12/28/16, documented the resident was independent for daily decision-making, required minimal to moderate assistance with ADLs, had no falls, and did not receive therapy services. The assessment documented the resident had lower extremity limitations on one side. The assessment documented the resident was unsteady for transfers, required assistance, and used a wheelchair or a walker for mobility. The care plan, updated on 01/15/17, did not document new interventions to prevent falls. The PT notes documented the resident received therapy from 01/02/17 through 01/31/17. The PT notes documented the resident received therapy form 02/01/17 through 02/10/17. On 02/23/17 at 9:50 a.m., the resident was observed and interviewed. The resident was resting in his bed reading the newspaper with a magnifying glass. The resident was difficult to understand. The resident was clean, shaven, and had no odors. The resident had a urinal at his bedside. The resident stated the staff answered his call light quickly. The resident's personal items and water were on the bedside table which was placed close to his bed. The resident had his call light. The resident had oxygen in use. The resident stated he fell , broke his hip, and did not walk anymore. The resident stated he fell trying to move a chair out of the way in the dining room so he could move his wheelchair into place at the table. On 02/23/17 at 11:45 a.m., an observation of the dining room was completed. One certified nurse aide (CNA) was assisting a resident with a meal. One dietary aide was serving meals and no licensed staff were in the dining room. On 02/23/17 at 3:15 p.m., CNA #1 was interviewed regarding fall prevention. The CNA had difficulty verbalizing fall preventions. The CNA stated she knew who was at fall risk through the CNA ADL care plan. The CNA stated gait belts were used, two person assistance was provided, the resident's way was kept clear, bed alarms were placed, assist devices were used, beds were kept low, and fall mats were placed. On 02/23/17 at 3:20 p.m., CNA #2 was interviewed regarding fall prevention. The CNA stated she knew who was a risk for falls by taking care of the residents and reviewing the CNA ADL care plan. The CNA stated she monitored the residents frequently when up and down the hall, listened for alarms, utilized bed rails, and placed fall mats for fall prevention. On 02/23/17 at 4:40 p.m., licensed practical nurse (LPN) #1 was interviewed regarding fall prevention. The LPN was asked how she ensured the fall prevention measures were implemented. The LPN stated she would orient any new employee to the residents and thought there were falling stars for identification of residents with a risk for falls. On 02/23/17 at 5:00 p.m., the DON was interviewed regarding fall prevention. The DON stated the staff were educated on fall prevention through in-services, care plans, and new nurses were oriented through walking rounds. The DON stated the staff identified who was at risk for falls through verbal reports. The DON stated the residents were assessed for falls on admission and quarterly. The DON stated the facility investigated falls through the incident reports, interviews, and cameras. The DON stated the administrator, the physician, and the DON were responsible for new interventions to prevent falls. The DON stated the reason for the resident's fall was impaired mobility without assistance. She stated the intervention implemented was to encourage the resident to ask for assistance before moving things. On 02/28/17 at 1:11 p.m., the resident was interviewed. The resident stated he did not ask for assistance for moving the chair in the dining room because he thought he could move it himself. The resident stated there was staff in the dining room that could have helped him. On 02/28/17 at 1:15 p.m., the DON was interviewed regarding fall investigations. The DON stated she investigated falls by interviewing the staff. The DON stated her fall investigations were not documented. The DON stated the fall would be discussed at the morning meeting and the nurse usually gave the account of the fall. The DON stated an intervention would be determined and implemented. The DON stated the facility did not usually discuss the interventions documented on the incident report. The DON stated the interventions for fall prevention should have been updated on the care plan. The DON stated the care plan was not updated with new interventions related to the resident's falls. The DON stated there had not been follow-up for the effectiveness of fall interventions. The DON stated the facility did not track and trend falls. The DON stated the nurse who took care of the resident on the day the resident fell was no longer employed by the facility. The DON stated a state report was not completed. The DON stated a fall risk assessment should have been completed when the resident returned from the hospital but was not completed. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall assessment, dated 05/13/16, documented the resident had intermittent confusion. The assessment documented the resident had balance problems, decreased muscular coordination, and required the use of assistive devices. The assessment documented the resident was a high risk for falls. An incident review, dated 05/25/16, documented the resident had reported a fall while transferring to the bedside commode. The review documented the physician, the administrator, the DON, and family were notified of the reported fall. The review documented an order was obtained for an x-ray of the resident's ankle. The review documented the fall was unwitnessed and no injury had occurred. The review documented steps to prevent reoccurrence were to reorient the resident to the call light system and place a tab alarm on the resident at all times. The admission assessment, dated 05/26/16, documented the resident was independent for daily decision making and required limited assistance with activities of daily living. The assessment documented the resident had one fall with injury. The care plan, dated 06/01/16, documented the resident had impaired physical mobility related to deformed joints from rheumatoid arthritis. The staff were to identify and address the underlying cause of impaired mobility, provide assistive devices, and provide appropriate level of assistance to promote safety. The care plan documented the resident had a history of [REDACTED]. The care plan documented the staff was to monitor the resident for steadiness, encourage the resident to call for assistance when ambulating, and ensure the call light was close to the resident and answered promptly. A fall assessment, dated 06/05/16, documented the resident was alert and had no history of falls the last three months. The assessment documented the resident required the use of assistive devices and was not a high risk for falls. A nurse note, dated 07/19/16, documented the resident was discharged home with family. On 02/28/17 at 1:50 p.m., the director of nurses (DON) was interviewed regarding the investigation of falls for the residents. The DON stated no formal investigation or documentation was completed after a resident fell . The DON stated no admission care plan was available. The DON stated a care plan was initiated on 06/01/16 after the resident had fallen. The DON stated the resident was not care planned for falls on admission after the resident was assessed as a high risk for falls. 3. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 02/04/13, documented the resident was at risk for injuries from falls related to recent history of falls. The care plan documented interventions were for the staff to place the call light close to the resident, monitor the resident for steadiness, place an alarm in the resident's wheelchair, and remind the resident to wait for assistance before transferring. A fall risk assessment, dated 08/12/13, documented the resident had intermittent confusion and had no falls the last three months. The assessment documented the resident was ambulatory and was not a high risk for falls. A fall risk assessment, dated 12/17/14, documented the resident was disoriented and had no falls the last three months. The assessment documented the resident was ambulatory and required the use of assistive devices for gait and balance. The assessment documented the resident was a high risk for falls. A fall risk assessment, dated 02/10/15, documented the resident was disoriented and had no falls the last three months. The assessment documented the resident was chair bound and was a high risk for falls. The fall risk assessment, dated 05/21/16, documented the resident was alert and had no falls the last three months. The assessment documented the resident was chair bound and was not a high risk for falls. The quarterly assessment, dated 11/10/16, documented the resident was severely impaired for daily decision making and required limited assistance with activities of daily living (ADLs). The assessment documented the resident had no falls. An incident review, dated 12/23/16, documented the resident reported to the charge nurse she was lying on the floor, on her knees, and her head was on the floor. The review documented the resident was oriented to self only and no injury had occurred with the fall. The review documented the physician, administrator, director of nurses (DON), and family were notified of the fall. The review documented the interventions to prevent reoccurrence was for the staff to counsel the resident on the importance of looking where she was going. The review documented a chair alarm was in place at the time of the fall. The fall assessment, dated 02/04/17, documented the resident was disoriented and had no falls the past three months. The assessment documented the resident was chair bound and was a high risk for falls. On 02/23/17 at 3:25 p.m., certified nurse aide (CNA) #3 was interviewed regarding residents who were at risk for falls. The CNA stated residents who were at risk for falls were identified by observation of their steadiness with activity and if mobility alarms were in place. The CNA stated residents who were at risk for falls were identified on their CNA care plan. The CNA could not recall why the resident had fallen in December 2016. On 02/28/17 at 11:40 a.m., the DON was interviewed regarding the incident review dated 12/23/16. The DON read the incident review and stated the review was poorly written. The DON stated the resident was found on the floor by staff and not reported by the resident. The DON stated no documentation was available to determine if the resident was being supervised when the fall occurred. The DON stated the resident was unable to communicate and had dementia. The DON stated the intervention documented to prevent future falls was not appropriate intervention.

On [DATE] a past-noncompliance immediate jeopardy (IJ) situation was determined to exist due to the facility's failure to provide care to maintain the resident's highest level of well being for resident #1. The facility failed to use correct procedures to initiate ventilator support. The facility failed to ensure the resident's ventilator was set up and initiated as ordered for the resident. Resident #1 had returned from the hospital by ambulance and was placed on a ventilator. The ventilator had been powered on by the nurse. The ventilations had not been initiated. The staff left the room. Approximately 10 minutes later two nurses returned to the room, found the resident unresponsive, and initiated cardiopulmonary resuscitation (CPR). The resident was without ventilations for approximately ten minutes. The resident was transported to the hospital via ambulance and expired on [DATE]. On [DATE] at 5:03 p.m. the Oklahoma State Department of Health (OSDH) verified the past-noncompliance IJ situation. On [DATE] at 6:05 p.m., the administrator and the DON were notified of the past noncompliance IJ situation which constituted substandard quality of care (SQC). Based on observation, interview, and record review, it was determined the facility failed to provide the care to maintain the resident's highest well-being for one (#1) of five residents reviewed for quality of care. The facility failed to ensure the ventilator was set up and initiated as ordered for resident #1. Resident #1 had returned from the hospital by ambulance and was placed on a ventilator. The ventilator had been powered on by the nurse. The ventilations had not been initiated. The staff left the room. Approximately 10 minutes later two nurses returned to the room, found the resident unresponsive, and initiated cardiopulmonary resuscitation (CPR). The resident was without ventilations for approximately 10 minutes. The resident was transported to the hospital via ambulance and expired on [DATE]. The facility identified 33 residents who were ventilator dependent. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan was unavailable for resident #1. The nurse responsible for completing care plans stated the resident had been in and out of the hospital so frequently a care plan was not completed. The assessment, dated [DATE], documented the resident was severely impaired for decisions of daily living and required total assistance with activities of daily living. A nurse note, dated [DATE] at 6:34 p.m., documented resident #1 returned from the hospital and the previous orders were to be continued. A nurse note, dated [DATE] at 7:36 p.m., documented the nurse returned to the resident's room at 6:40 p.m. with the oncoming nurse. The note documented the nurses found the resident unresponsive. The note documented CPR was begun, emergency medical service (EMS) was called, and the resident was transferred to the hospital. The hospital history and physical report, dated [DATE], for resident #1 was reviewed. The record documented EMS staff reported the resident had stable vital signs when the resident was returned to the nursing facility on [DATE] at 6:34 p.m. The record documented within 10 minutes the resident was found to be in [MEDICAL CONDITION]. The record documented the EMS staff returned to the facility, treated the resident with [MEDICATION NAME], electric shocks, and transported the resident back to the hospital. An Oklahoma State Department of Health (OSDH) incident report, dated [DATE], documented the investigation of an incident for the resident. The report documented the resident returned from the hospital, the ventilator was turned on, and the ventilator was connected to the resident. The report documented the the resident was transferred to the bed and the staff left the resident's room. The report documented the two nurses returned to the resident's room and found the resident unresponsive. The reported documented cardiopulmonary resuscitations were initiated and emergency serves were called. The report documented the nurse reported looking at the ventilator to identify any issues, discovered the ventilator was only on the start screen, and the ventilations had not been initiated. The report documented the nurse involved was immediately suspended for three days. The report documented the nurse would be allowed to return to work after she had completed ventilator training with the respiratory therapist. The report documented the nurse would be placed on probation for 90 days and would be randomly monitored twice weekly for 90 days in regard to ventilator compliance. The report documented a two person check would be required to verify the ventilators were working properly and the settings were as ordered. An Oklahoma Board of Nursing incident report, dated [DATE], was reviewed. The report documented when the resident was found unresponsive, the nurse reported looking at the ventilator to identify any issues and discovered it was only on the start screen and ventilation had not been initiated. An in-service report, dated [DATE], documented an in-service regarding new admissions and readmissions protocol for ventilator patients was provided for the staff. The report documented 30 nursing employees participated in the in-service. A nurse note, dated [DATE], documented the medical examiner had call and reported the resident had died . On [DATE] at 3:00 p.m., the director of nurses (DON), was interviewed regarding resident #1. The DON stated the nurse on duty at the time of the incident had been suspended for three days pending an investigation. The DON stated the nurse had resigned and did not return to the facility. The DON stated she completed an investigation of the incident. The DON stated the nurse had assisted the EMS staff to transfer the resident when she first returned from the hospital. The DON stated the nurse failed to turn on the ventilations after the transfer. On [DATE] at 3:30 p.m., the respiratory therapist (RT) was interviewed regarding the ventilators and stated the facility acquired new ventilators before the end of the year. The RT stated all the licensed staff were in-serviced and completed competency check off sheets before working with the ventilators. The RT stated she was responsible for putting the correct settings into the ventilators. The RT stated the nurses were trained to maintain the ventilators and troubleshoot problems which could arise. On [DATE], the licensed staff in the facility were interviewed regarding working with the ventilators. The staff stated they had been well trained and felt competent to care for residents who were ventilator dependent. The staff stated they received in-service training for the ventilators after the incident occurred. The ventilator checklists for [DATE] through [DATE] were reviewed. The checklists documented the checklists were completed for five new ventilator admissions. The checklists were signed by two nurses and reviewed by the DON. On [DATE] at 5:00 p.m., the DON was interviewed regarding quality assurance (QA). The DON stated every morning the administrative staff which included the QA members met. The DON stated the ventilator incident had been discussed with the team members and a plan of action had been determined. The DON stated the problem would be further discussed at the quarterly QA meeting.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident was transferred appropriately, which resulted in a fracture, for one (#1) of two sampled residents who had experienced falls with injuries. This resulted in harm to the resident. The facility identified 79 residents who required assistance with transfers. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 05/15/14, documented, "...is non-ambulatory and totally dependent on staff for all aspects of mobility... Approaches...staff to provide 1-2 person assist with transfers..." A quarterly assessment, dated 10/03/14, documented the resident required total assist of two persons with transfers, did not ambulate, had no deficits in upper or lower extremities, required a wheel chair for mobility, required extensive assistance with dressing, was occasionally incontinent of bowel, and frequently incontinent of bladder. A physical therapy evaluation, dated 10/23/14, documented, "Barriers to function: Weakness, Activity Tolerance, safety, Poor endurance Reason of Treatment: Pt requires PT to attain functional goals." A physician's orders [REDACTED]. A nurse's note, dated 10/26/14 at 12:47 a.m., documented, "Report on this resident from previous nurse summarized that resident was lowered to floor earlier in shift with zero injury apparent. Since 1900 (7:00 p.m.) resident has had multiple c/o heavy pain to left knee. PRN percocet given and reported ineffective. Some swelling and heat noted to left knee. Zero redness or bruising noted. Resident stated it was her right to go to the hospital and have this checked and if we would not help her she would call the cops. Resident refused ice pack and any further interventions at this facility until she could be seen at hospital. DON and Dr notified, n/o to send out to...ER for eval." A nurse's note, dated 10/26/14 at 4:52 a.m., documented, "Resident left facility @ 0100 (1:00 a.m.) via EMS to...ER. Called ER and nurse reported that resident was to be admitted for upper tibial fracture." An undated and untimed nurse's note, documented, "Late entry for 10-26-14 6:00 p.m. called to resident room by CNA. CNA stated she attempted to transfer resident into chair and resident could not stand so assisted her to the floor against her leg. No apparent injury noted. Resident C/O L leg pain per norm. PRN Percocet administered. CNAs were counseled to only transfer resident with lift. R/T unable to bear wt." A nurse's note, dated 10/29/14 at 8:00 p.m., documented, "Resident returned from...VIA EMS with a DX of L. tibial plateau FX., leg immobilizer intact, elevated on pillow. Bruising noted to L knee and below L. knee..." A care plan update for 11/03/14 documented, "...was assisted during transfer from bed to chair. Her legs gave out on her and she was assisted to the floor. This resulted in a broken tibia of the left leg. Due to inability to tolerate full weight bearing...must be transferred with a lift. Continue current plan of care and update prn...." On 11/05/14 at 11:00 a.m., LPN #1, who had been working at the time of the resident's fall, was asked to recall the events when the resident fell . The LPN stated CNA #1 had reported the resident had started to fall and she had eased her to the floor. She stated she had assessed the resident and put the resident back to bed. She stated the resident complained of left knee pain but the resident usually complained of leg pain. She stated she had given the resident pain medication but did not know the resident was hurt. She was asked if she had notified the physician. She stated, "No." On 11/05/14 at 12:10 p.m., the DON was asked if the physician had been notified at the time of the fall. She stated the physician was not notified until the resident insisted on going to the hospital. At 2:30 p.m., The RA was asked was the resident able to transfer self previous to the fall on 10/26/14. She stated the resident could only bear weight for approximately five seconds and could not move her feet. The RA was asked how she transferred the resident when she was working with her. She reported she always got someone to help her with the transfers because it was safer with two people. At 3:20 p.m., CNA #2, who worked the hall the resident resided on, was asked how she transferred the resident. She reported two people always transferred the resident. At 3:50 p.m., CNA #1, who had been with the resident when the fall occurred, was asked what happened when the resident fell . She stated the resident wanted to get up to go smoke, she was acting funny, and she had attempted to transfer the resident from the bed to the wheel chair. She stated the resident went limp and started to fall, she had eased the resident to the floor, and made sure the resident did not fall. CNA #1 stated the resident's knees were bent and she had straightened the resident's legs out in front of her. She stated the resident was screaming and crying and reported her leg was hurting. She stated the charge nurse had come into the room and they picked the resident up and put her back to bed. CNA #1 was asked was the resident to have a two person transfer. She stated, "Yes."

Based on observation, interview, and record review, it was determined the facility failed to: A. Assist one (#12) of one sampled residents receiving hospice services, in maintaining their highest practicable well-being when they did not coordinate hospice services with the hospice entity; seek clarification of hospice physician medication orders that were not within current standards of practice; and report increased pain with movement. This resulted in actual harm to the resident when he fell and suffered a fractured femur and when he experienced pain with movement that was not reported. This had the potential to affect one resident who was the only resident receiving services from this hospice company; and B. Ensure ongoing communication between the facility and [MEDICAL TREATMENT] centers regarding resident status and/or dietary recommendations and failed to assess and monitor residents after receiving [MEDICAL TREATMENT] services for one (#13) of one sampled resident who received [MEDICAL TREATMENT] services. The facility identified two residents as receiving [MEDICAL TREATMENT] services. Findings: ~ Drugs.com. [MEDICATION NAME], 2013. Web. 14 [DATE], documented, "...It is recommended that the dosage be limited to the smallest effective dose to preclude the development of ataxia or oversedation which may be a particular problem in elderly or debilitated patients...The usual precautions in treating patients with impaired renal, hepatic or [MEDICAL CONDITION] function should be observed... Dosage should be individualized for maximum beneficial effect. While the usual daily dosages given below will meet the needs of most patients, there will be some who require doses greater than 4 mg/day. In such cases, dosage should be increased cautiously to avoid adverse effects... treatment for [REDACTED]. The dose may be increased to achieve a maximum therapeutic effect, at intervals of 3 to 4 days, to a maximum daily dose of 4 mg, given in divided doses. The lowest possible effective dose should be employed... The successful treatment of [REDACTED]. In controlled trials conducted to establish the efficacy of [MEDICATION NAME] in panic disorder, doses in the range of 1 to 10 mg daily were used... Treatment may be initiated with a dose of 0.5 mg three times daily. Depending on the response, the dose may be increased at intervals of 3 to 4 days in increments of no more than 1 mg per day. Slower titration to the dose levels greater than 4 mg/day may be advisable to allow full expression of the pharmacodynamic effect of [MEDICATION NAME] Generally, therapy should be initiated at a low dose to minimize the risk of adverse responses in patients especially sensitive to the drug. Dose should be advanced until an acceptable therapeutic response (ie, a substantial reduction in or total elimination of panic attacks) is achieved, intolerance occurs, or the maximum recommended dose is attained..." ~ Drugs.com. [MEDICATION NAME], 2013. Web. 14 [DATE], documented, "[MEDICATION NAME] should generally be administered with an initial dose of 25 mg twice daily, with increases in total daily dose of 25 mg - 50 mg divided in two or three doses on the second and third day, as tolerated, to a total dose range of 300 mg to 400 mg daily by the fourth day..." ~ American Geriatrics.org. Beers Criteria, 2013. Web. 14 Apr, 2013, documented, "...Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. In general, all benzodiazepines increase risk of cognitive impairment, [MEDICAL CONDITION], falls, fractures, and motor vehicle accidents in older adults..." 1. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders [MEDICATION NAME]...25 mcq [MEDICATION NAME] q 72 (hours)[MEDICATION NAME] .5 mg (one) per GT q 6 (hours) [MEDICATION NAME]/[MEDICATION NAME] 10/500 mg (one) q 4 (hours) prn..." A nurse's note, dated 01/23/13 at 9:57 p.m., documented, "...res does get confused and up (increased) anxiety per report and family..." A nurse's note, dated 01/25/13 at 4:07 p.m., documented, "...Pt presents with increased anxiety. Pt states 'I feel like a (sic) can't breath (sic) without my nerve pill.' MD notified and [MEDICATION NAME] changed from PRN to routine..." A nurse's note, dated 01/25/13 at 10:38 p.m., documented, "...up on entering res room res noted up on side of bed using urinal, found H.L. (heplock) in bed by res. Asked res what happen. Res stated took it out didn't know what else to do with it..." A nurse's note, dated 01/26/13 at 12:16 p.m., documented, "...pt has been pulling IV access out munable (sic) to restrain..." A nurse's note, dated 01/28/13 at 4:59 a.m., documented, "...confused and disoriented frequently. Can be uncooperative with care, hits at staff a couple of times. Appears very frail and weak due to lung [MEDICAL CONDITION] off O2 sometimes..." Behavior monitoring notes, dated 01/28/13 at 6:45 a.m., documented the resident had one episode of anxiety. An admission assessment, dated 02/04/13, documented the resident was able to express ideas and wants, and usually understood others. It was documented the resident was cognitively intact and had no behaviors. It was also documented it was very important to the resident for his family or a close friend to be involved in discussion about his care. The resident was assessed to require limited assistance of one person for bed mobility and transfer; extensive assistance of two people for walking; and limited assistance of one person for toilet use. It was documented the resident was only able to stabilize himself with staff assistance when moving from a seated to standing position; walking, turning around, moving on and off the toilet, and when transferring from one surface to another. It was documented the resident was continent of bowel and bladder. It was also documented the resident was on a scheduled pain medication regimen but had not had pain during the previous five days. It was documented the resident had not fallen before admission to the facility or since admission. It was also documented the resident had received an antianxiety medication every day during the previous seven days. The resident did not receive an antipsychotic or hypnotic medication. The resident's care plan, dated 02/04/13, documented a problem, "...Falls...At risk for injuries from falls due to poor balance and limited mobility..." The goal was, "...Will not have a fall with injuries..." Approaches included, "...Monitor for side effects from medications, labs, appetite as a cause for falls...monitor resident for steadiness and balance...evaluate need for use of personal alarms to alert staff of unassisted rising..." Another problem was, "...Pain...related [MEDICAL CONDITION] of throat..." The goal was, "...will not have uncontrolled pain over the next 90 days...." Approaches included, "...Assess characteristics of pain: location, severity on a scale of 1-10, type of pain, frequency...discuss with (resident #12) factors that preipate (sic) pin (sic) and what may reduce it...If effectiveness of pain meds not working notify physician and obtain order..." Another problem was, "...chronic pain r/t dx of [MEDICAL CONDITION]" The goal was, "...resident's pain will be minimized, relieved or controlled as evidenced by relaxed facial expression, relaxed posturing and verbalizing of relief as pain occurs...encourage position of comfort..." Another problem was, "...currently on medication for [DIAGNOSES REDACTED]. A fall risk assessment, dated 02/04/13, documented the resident scored a "6." The form documented, "...A total score above 10 represents HIGH RISK..." A nurse's note, dated 02/12/13 at 7:34 p.m., documented, "...res having increased amount of pain, per resident, requesting more pain meds, text (physician name withheld), n/o received up [MEDICATION NAME] from 25 to 50 mcg..." A nurse's note, dated 02/17/13 at 5:30 p.m., documented, "...pt frail confused..." A nurse's note, dated 02/20/13 at 7:00 a.m., documented, "...pt has moments of confusion but usually a/o x 3..." A nurse's note, dated 03/04/13 at 7:00 a.m., documented, "...pt presents with increased confusion..." A five day pay per service assessment, dated 03/05/13, documented the resident was severely cognitively impaired, had no signs or symptoms of [MEDICAL CONDITION], and had no behaviors. The resident was assessed to require limited assistance of one person for bed mobility and transfers; toilet use, and personal hygiene. It was documented the resident required extensive assistance of two persons for walking. It was documented the resident was only able to stabilize himself with staff assistance when moving from a seated to standing position; walking, turning around, moving on and off the toilet, and when transferring from one surface to another. It was documented the resident was continent of bowel and bladder. It was documented the resident was on a scheduled pain management regimen and had moderate pain frequently. The resident rated his pain at a "7" on a 0 - 10 scale. It was documented the resident stated his pain did not keep him from sleeping or limit his day-to-day activities. It was also documented the resident had not fallen. A nurse's note, dated 03/06/13 at 10:21 a.m., documented, "...pt pulled emergency bathroom alarm, pt found sitting on toilet leaned over c/o sob...pt asked that someone call his wife and stated he wanted to go to the hospital...transferred at (7:40) a.m..." A nurse's note, dated 03/08/13 at 9:34 a.m., documented, "...pt had [MEDICATION NAME] feeding this AM due to pt disconnecting tube feeding during night shift. Feeding pump to be continued this afternoon..." A nurse's note, dated 03/09/13 at 3:00 p.m., documented, "...frequently removes O2 tubing and has to be reminded to keep it on..." A nurse's note, dated 03/10/13 at 5:01 p.m., documented, "...(9:00 a.m.) 3/10/13 a new bottle of [MEDICATION NAME] 1L was hung for continuous feeding, pump set at 60 ml/H...At 1240 the bottle was found empty, positioned at the opposite side of where it had been hung and the lines twisted around the pole. Pump settings were checked and found to be as ordered. Patient tampering is suspected, he denies. Patient has history of disconnecting self from feeding tube, milk found in the bed...discussed the importance of these feedings with patient and family. Pump checked at (3:00 p.m.) and (5:00 p.m.), running without difficulty. Will continue to monitor..." A nurse's note, dated 03/11/13 at 3:00 p.m., documented, "...Pt confused unable to articulate location or month. Pt thinks his wife lives in the facility...Pt has been reminded several times that he is in a nursing home, pt also reminded several time...keep O2 on. Pt pulled the end piece off of peg tube..." A nurse's note, dated 03/14/13 at 2:01 p.m., documented, "...pt is being dicacharged (sic) from SNF and admitted to ICF. He is also being picked up by hospice for respiratory dx. Pt has been complaining of stomach pain and being 'full.' Pt has also been vomiting regularly..." A hospice nursing home/facility coordination form, dated 03/14/13, documented the resident's primary [DIAGNOSES REDACTED]." The form did not document a time, location, or date the meetings would be held. The form documented, "...Our hospice team established a hospice plan of care and needs to provide the care as well as oversee it. To best coordinate our efforts, the following will occur: ~ Primary RN Case Manager will share copies of the hospice interdisciplinary plan of care, medications, treatments and pertinent information to facilitate the coordination of care. ~ Primary RN Case Manager will update your designated contact person with any updates to the hospice plan of care. It is reviewed at least every 2 weeks..." Review of the resident's hospice chart located at the facility revealed no clinical documentation concerning the resident. There was not a care plan, copies of skilled nursing or aide visits, hospice physician orders, or interdisciplinary group meeting notes. There was no documentation to show the resident's preferences and desires had been addressed. Review of the resident's facility care plan revealed no documentation to show hospice had been included as a problem. There were no goals or interventions. There was no documentation to show how hospice services would be coordinated between the hospice company and the facility. There was no documentation to show which entity would be responsible for specific issues related to the resident's care. Behavior monitoring notes, dated 03/19/13 at 2:35 p.m. and 2:36 p.m., documented the resident had an episode of anxiety, fear, and panic. A hospice nurse's note, dated 03/20/13 at 1:15 p.m., documented, "...SN received call from CG stating pt was having 'attitude problems' today. SN made visit. SN talked c pt and pt expressed frustration c (hospice aide). Pt was upset that he had to take bath on a daily basis. SN bargained c pt to take bath @ least qod to keep clean (and) comfortable even if only sponge bath. Pt agreed. SN spoke with (hospice aide) who agreed c POC..." An incident report, dated 03/22/13 at 11:50 p.m., documented, "...resident reported to CNA of fall, unwittnessed (sic). Res sitting in bed...states 'I was trying to get to that chair.' No chair..." A hospice nurse's note, dated 03/24/13 at 3:00 p.m., documented, "...agitates easily @ times especially when his (family member) comes to visit per nsg home staff..." A hospice nurse's note, dated 03/26/13 at 12:00 p.m., documented, "...Pt was slightly confused..." It was documented the resident was anxious, agitated, forgetful, and confused at times. A care plan update, dated 03/27/13, documented, "...Fall with skin tear to right forearm reported on March 22 2013 - nursing staff to orient (resident #12) to call light system frequently. Answer call light promptly. Leave head of bed light on. Instruct (resident #12) to wait on nursing staff prior to attempting to get up..." A hospice nurse's note, dated 03/27/13 at 9:45 a.m., documented, "...NH staff states that he messes c peg tube. SN instructed pt not to pull on tube or mess with it. SN talked c (LPN #2) at NH to report about pt. She states that earlier this am pt got up to bathroom sink c peg tube connected to feeding pump and pulled on peg tube..." It was documented the resident was anxious and agitated. A hospice nurse's note, dated 03/28/13 at 11:10 a.m., documented, "...pt was a (and) o c slight confusion @ x's..." It was documented the resident was anxious, agitated, forgetful, and confused at times. A physician's note, dated 03/28/13 at 11:43 a.m., documented, "...has been doing ok. He has had increased pain in left chest. Hurts more to breath. Does have known [MEDICAL CONDITION]" A hospice nurse's note, dated 03/28/13 at 8:05 p.m., documented, "...Spoke c (LPN #9) and pt about panic attacks and instructed pt to stay calm and breath (sic) slowly in through nose and out through mouth...(LPN #9)...states that pt gets anxious when family comes and he tells his family that he wants to be left alone and when they don't leave his anxiety (increases). SN talked c pt (family member) about respecting pt wishes and that it was good to visit but also to respect his wishes of being left alone..." A hospice nurse's note, dated 03/29/13 at 10:30 a.m., documented, "...SN assessment as noted. SN picked up and delivered [MEDICATION NAME] to (CMA #2). Pain rated at a '3' in stomach. He states it is dull pain and 'just comes and goes.' Pt states that his current pain control medications are adequate and they do help his pain...Pt states that he is going home today and seems somewhat anxious. SN and aide reinforced that pt was in his room and that his family/(family member) would be to see him later today..." A hospice physician's orders [REDACTED]. A nurse's note, dated 03/29/13 at 1:08 p.m., documented, "...Received new order for [MEDICATION NAME] increase from (hospice name withheld). Order put in and MAR updated..." A nurse's note, dated 03/29/13 at 3:45 p.m., documented, "...N/O received (sic) for increase in [MEDICATION NAME], up to 1 mg q 4 hrs, and [MEDICATION NAME] 25 mg gel q 6 hrs, prn, updated mars..." Review of the resident's clinical record revealed no documentation to show why the resident's [MEDICATION NAME] was increased from 0.5 mg every six hours to one mg every four hours. This was an increase from 2 mg per day to 6 mg per day with one dosage change. There was no documentation to show any non-pharmalogical interventions had been attempted for any behaviors prior to increasing the medication. Review of the resident's clinical record revealed no documentation to show the resident's family had been notified of the medication changes. A hospice nurse's note, dated 03/29/13 at 7:40 p.m., documented, "...anxiety/agitation when (family member) is around otherwise calm and relaxed...(family member) was sitting on extra bed in the patient's room. He was resting well and very calm. No s/s of anxiety or agitation seen..." Behavior monitoring notes, dated 03/29/13 at 9:53 p.m., documented the resident had an episode of anxiety. Review of MARS and narcotic count sheets, dated 03/29/13, documented the resident received [MEDICATION NAME] 0.5 mg as follows: 3:00 a.m. - one tablet; 9:00 a.m. - one tablet; 1:00 p.m. - one tablet; 5:00 p.m. - two tablets, for a total dose of one mg; and 9:00 p.m. - two tablets, for a total dose of one mg. This was a total of 3.5 mg [MEDICATION NAME] administered to the resident in an 18 hour period. A hospice nurse's note, dated 03/30/13 at 2:00 p.m., documented, "...Staff reports patient got really agitated and more confused after (family member) visit today. He pulled the feeding apart and milk went all over the floor. Urinated in the trash can. He was sitting up front by the nursing station and doing really good. He was watching everything...(LPN #9) the charge nurse feels that he does better out of the room sometimes..." Review of MARS and narcotic count sheets, dated 03/30/13 documented the resident received [MEDICATION NAME] 0.5 mg as follows: 1:00 a.m. - two tablets, for a total dose of one mg; 5:00 a.m. - two tablets, for a total dose of one mg; 9:00 a.m. - two tablets, for a total dose of one mg; 1:00 p.m. - two tablets, for a total dose of one mg; 5:00 p.m. - two tablets, for a total dose of one mg; and 9:00 p.m. - two tablets, for a total dose of one mg. This was a total of 6 mg [MEDICATION NAME] administered to the resident in a 24 hour period. A hospice nurse's note, dated 03/31/13 at 7:35 p.m., documented, "...Staff reports family was by to see him earlier today and has tired him out...(increased) risk for falls..." Review of MARS and narcotic count sheets, dated 03/31/13 documented the resident received [MEDICATION NAME] 0.5 mg as follows: 1:00 a.m. - two tablets, for a total dose of one mg; 5:00 a.m. - two tablets, for a total dose of one mg; 9:00 a.m. - two tablets, for a total dose of one mg; 1:00 p.m. - two tablets, for a total dose of one mg; 5:00 p.m. - two tablets, for a total dose of one mg; and 9:00 p.m. - two tablets, for a total dose of one mg. This was a total of 6 mg [MEDICATION NAME] administered to the resident in a 24 hour period. MARs and narcotic count sheets, dated 04/01/13 at 1:00 a.m., documented the resident received two tablets of [MEDICATION NAME], 0.5 mg, for a total dose of 1 mg. An incident report, dated 04/01/13 at 1:50 a.m., documented, "...resident confused states he was trying to 'get to chair' - no chair in room..." A nurse's note, dated 04/01/13 at 8:03 a.m., documented, "...01:50 a.m., Resident found on floor of his room calling out. Unwittnessed (sic) fall. Denies hitting head. Moves all 4 extremities, Rt upper thigh with pain...has pull off cont. feeding tube. Tube still intact but formula on clothes. Phys notified. Oder (sic) for XRay. 03:00 a.m. (X-ray company name withheld) here for views. 04:00 a.m. Nonangulated and nondisplaced fracture, intertrochanteric level of the proximal right femur. Physician, hospice notified. 4:20 a.m., (physician name withheld) ordered resident sent out for further eval. An x-ray report, dated 04/01/13, documented, "...There is evidence of fracture involving the intertrochanteric level of the proximal femur without significant angulation or displacement..." A hospice nurse's note, dated 04/01/13 at 9:00 a.m., documented, "...TC received from pt (family member) stating that (resident #12) was back at NH from hospital. She states that the hospital would not operate due to pt could not make it through an operation so they sent pt back to NH c some new orders that NH staff would be faxing to us. She also states that she is concerned about the increase in pt [MEDICATION NAME] that was (changed) Friday that it maybe could be causing pt to be staying up all night, being mean to the family and wandering so much. SN stated that when the hospice nurses are doing visits that the NH tells us that pt is sleeping well and that sometimes he does have some anxiety issues at times especially when he has visitors. SN stated that I would contact (hospice physician name withheld) and see about getting something different for pt that maybe will help him rest and if new orders obtained I will send them with (hospice nurse) who is seeing him today..." A hospice nurse's note, dated 04/01/13 at 9:15 a.m., documented, "...(hospice physician name withheld) notified of pt (family member) concern about medication...Dc'd [MEDICATION NAME] and ordered Serquil (sic) 50 mg BID..." A nurse's note, dated 04/01/13 at 10:43 a.m., documented, "...Resident returned from hospital at 9:10 a.m. Dx of right [MEDICAL CONDITION]" A nurse's note, dated 04/01/13 at 12:00 p.m., documented, "...Due to recent fall and resident current altered mental status and confusion one on one staff care has been initiated at 5 p.m. and will continue until notified by DON..." A hospice physician's orders [REDACTED]. Seroquil (sic) 50 mg BID..." A nurse's note, dated 04/01/13 at 1:59 p.m., documented, "...Hospice here with new orders. DC [MEDICATION NAME]. New order for serquil (sic) 50 mg via GTube bid for anxiety..." Review of the resident's clinical record revealed no documentation to show why the resident was placed on a starting dose of [MEDICATION NAME] 50 mg twice daily. A nurse's note, dated 04/01/13 at 2:16 p.m., documented, "...(family member) her (sic) with resident, (family member) refused medication new [MEDICATION NAME] order and Serquil (sic). She believed he was to (sic) medicated (sic)..." A nurse's note, dated 04/01/13 at 4:30 p.m., documented, "...nurse called to res room. Res noted in floor laying on rt side, res c/o rt shoulder pain and res stated 'hit my head' No swelling or brusing (sic) noted to either site, dr notified, family notified, hospice notified, n/o for rt shoulder x-ray...one on one also ordered per DON..." A hospice nurse's note, dated 04/01/13 at 5:20 p.m., documented, "...SN received call about hospice pt (resident #12) from on call nurse...stated (nursing home) had called about pt falling. SN called NH and spoke c (LPN #9) who stated pt had gotten out of bed and fallen hitting his (right) shoulder and (right) side of head. (LPN #9) stated pt was confused and requested hospice staff member to sit 'one on one' c pt. SN informed (LPN #9) that hospice was for crisis intervention related to pt's admitting [DIAGNOSES REDACTED]. SN made CV (unknown) to check on the status of pt. Pt was resting quietly in hospital bed...Pt stated he had 'no pain' and 'I want to be left alone.' SN advised NH staff to call in extra staff member if needed to sit c pt but that @ present assessment pt seemed very lethargic. NH staff stated they had given pt his first dose of [MEDICATION NAME] about 45 mins prior to SN arrival. SN advised NH staff to call hospice c any ques/concerns..." A nurse's note, dated 04/01/13 at 6:39 p.m., documented, "...received x-ray results...negative rt shoulder..." MARs, dated 04/01/13 at 9:00 p.m., documented the resident received [MEDICATION NAME] 50 mg. A nurse's note, dated 04/02/13 at 4:49 a.m., documented, "...Due to recent fall and altered mental status and confusion one on one care has been initiated. One on one care began at 5 p.m. on 04-01-2013. (Resident #12) has remained free of injury. One on one will remain plan of care until notified by DON..." A hospice nurse's note, dated 04/02/13 at 11:10 a.m., documented, "...lethargic...pt was resting quietly upon SN arrival...Pt c/o pain of (right) hip but refused to rate pain on numerical pain scale...SN observed pain of '4' from objective pt data...NH staff requested 'one on one' staffing from hospice agency. SN informed DON of (nursing home) that hospice does not do 24 (hour) continuous care for [DIAGNOSES REDACTED]. NH will provide 'one to one' staff member for pt's confused status. SN suggested that NH put pt in a 'on the ground' bed so pt would not be able to fall out of regular bed (and) harm himself. NH staff DON stated 'we are keeping pt's bed in the lowest position possible but we don't put mattresses on the floor.' SN instructed NH staff to call hospice c any ques/concerns 24/7..." A pain assessment, dated 04/02/13, documented the resident had a recent fall and stated his right hip was hurting. It was documented the resident was asked to rate his pain, and the resident stated "0." It was documented, "...(Resident #12) recently has displayed increase in confusion and does not answer questions appropriately. He is currently medicated for pain and shows no signs of uncontrolled pain. No facial grimacing, guarding or moaning present. Staff will continue to monitor for signs of pain..." A care plan update, dated 04/02/13, documented, "...April 1, 2013 (resident #12) sustained a fall with injury resulting in a right femur fracture. He reported he was trying to get to a chair. (No chair present in room at time of accident) Nursing staff informed of (resident #12)'s condition and instructed to use extreme caution during care and assistance with adl's/repositioning. Staff to monitor more frequently for pain, medicate as directed and notify physician if pain med becomes ineffective. 1/2 side rails to be used to promote feelings of safety. Keep call light within reach at all times. Frequently remind (resident #12) to use for assistance. Provide verbal ques (sic) and visual pictures reminding (resident #12) to use call light system prn. Review medication prn..." MARs, dated 04/02/13, documented the resident received [MEDICATION NAME] 50 mg at 9:00 a.m. and 9:00 p.m. MARs, dated 04/03/13, documented the resident received [MEDICATION NAME] 50 mg at 9:00 a.m. and 9:00 p.m. MARs, dated 04/04/13, documented the resident received [MEDICATION NAME] 50 mg at 9:00 a.m. A hospice nurse's note, dated 04/04/13 at 9:50 a.m., documented, "...Pt very confused this am and is picking at the wall. Pt denies any pain when asked however he tries to move around in bed he states that he just needs to move. (LPN #2) states that he has (increased) confusion at times and that pain medication is given q 4 (hours) and [MEDICATION NAME] is given BID...(LPN #2) states that they have someone sit 1 on 1 c pt at night and sometimes in the day depending on pt confusion level..." A physician's orders [REDACTED]. A nurse's note, dated 04/04/13 at 1:07 p.m., documented, "...pt a/ox 1 this morning. Pt presents with visual hallucinations. Pt laying bed swatting at the wall, flinching as if dodging something. Per (physician name withheld) [MEDICATION NAME] to be reduced to 50 mg at hs. Will continue to monitor for change in condition. Family and hospice notified..." A physician's orders [REDACTED]. A hospice nurse's note, dated 04/05/13 at 10:00 a.m., documented, "...Aide states that NH is sitting c pt 1 on 1 24 (hours) due to pt confusion and trying to get out of the bed...raising arms into air when SN arrived. NH aide states that he does that a lot and sometimes he will talk. Pt is restless according to NH staff...SN spoke c (LPN #2) about trying some [MEDICATION NAME] to maybe help pt rest along c the Seraquil (sic) She agreed..." A hospice physician's orders [REDACTED]. May increase oxygen to 6 liters via nasal cannula..." A hospice nurse's note, dated 04/05/13 at 9:45 p.m., documented, "...SN received call from on call nurse...NH staff was concerned about pts confusion/agitation. SN made (unknown) to check on pt status. Upon arrival SN found pt highly agitated/confused/aggressive. SN received order for 1 mg [MEDICATION NAME] q 4 (hours) as needed...SN sat c pt (and) turned off all lights (and) tv to reduce environmental stimuli (and) promote pts rest. Pt calmed down..." A hospice nurse's note, dated 04/06/13 at 1:30 p.m., documented, "...patient very lethargic since given the [MEDICATION NAME] earlier today...pt was anxious this am per staff. He was given his regular medications and [MEDICATION NAME] which he is now very lethargic...Explained to nsg home staff to monitor closely and contact hospice if any changes noted stat..." A hospice nurse's note, dated 04/07/13 at 7:40 p.m., documented, "...lethargic...seems to be resting well since getting medication routinely...current pain and anxiety medications working great...no mottling seen..." MARs, dated 04/07/13, documented the resident received [MEDICATION NAME], 1 mg, four times during the day. A hospice nurse's note, dated 04/08/13 at 12:00 p.m., documented, "...confused/agitated...SN talked with pts nurse (LPN #10) about pts behavior over the weekend. (LPN #10) states that 'pt has been very agitated (and) aggressive @ (times) (and) is still a one on one.' SN observed that pt was sitting up in bed c O2 tubing laying beside pt in bed alert disoriented (and) confused upon arrival. SN placed O2 tubing on pt (and) obtained pulse O2 of 78%. SN stayed c pt (and) turned up O2 6L to maintain O2 sats @ 90-91%. Somehow O2 had gotten turned down to 2 1/2 L. (LPN #10) stated she had (decreased) O2 from 8L to 2 1/2 when she come on shift. SN told (LPN #10) to leave O2 @ 6L all the time...Pt was very agitated (and) somewhat aggressive. Initially pt refused all vitals but when O2 sats (up) to 90-91% pt became more compliant..." An incident report, dated 04/08/13 at 8:20 p.m., documented, "...res found in floor on (left) side, (no) c/o pain. Res noted c s/t to (right) elbow, res unable to state how it happened...one on one placed c resident..." A hospice nurse's note, dated 04/09/13 at

Based on observation, interview, and record review, it was determined the facility failed to ensure three (#4, 12 and #17) of ten sampled residents who were reviewed for unnecessary medications, did not receive medications in excessive doses, without indications for use, and/or antipsychotic medications without gradual dose reductions. Resident #12 received an increase in [MEDICATION NAME], an anti-anxiety medication, from 2 mg per day to 6 mg per day without titration of the medication. This resulted in actual harm for the resident after the resident suffered a fall that resulted in a fractured femur two days after the initiation of 6 mg [MEDICATION NAME] per day. The facility identified 17 residents as receiving anti-psychotic medications and 35 residents as receiving anti-anxiety medications. Findings: Drugs.com. [MEDICATION NAME], 2013. Web. 14 [DATE], documented, "...It is recommended that the dosage be limited to the smallest effective dose to preclude the development of ataxia or oversedation which may be a particular problem in elderly or debilitated patients...The usual precautions in treating patients with impaired renal, hepatic or [MEDICAL CONDITION] function should be observed... Dosage should be individualized for maximum beneficial effect. While the usual daily dosages given below will meet the needs of most patients, there will be some who require doses greater than 4 mg/day. In such cases, dosage should be increased cautiously to avoid adverse effects... treatment for [REDACTED]. The dose may be increased to achieve a maximum therapeutic effect, at intervals of 3 to 4 days, to a maximum daily dose of 4 mg, given in divided doses. The lowest possible effective dose should be employed... The successful treatment of [REDACTED]. In controlled trials conducted to establish the efficacy of [MEDICATION NAME] in panic disorder, doses in the range of 1 to 10 mg daily were used... Treatment may be initiated with a dose of 0.5 mg three times daily. Depending on the response, the dose may be increased at intervals of 3 to 4 days in increments of no more than 1 mg per day. Slower titration to the dose levels greater than 4 mg/day may be advisable to allow full expression of the pharmacodynamic effect of [MEDICATION NAME] Generally, therapy should be initiated at a low dose to minimize the risk of adverse responses in patients especially sensitive to the drug. Dose should be advanced until an acceptable therapeutic response (ie, a substantial reduction in or total elimination of panic attacks) is achieved, intolerance occurs, or the maximum recommended dose is attained..." Drugs.com. [MEDICATION NAME], 2013. Web. 14 [DATE], documented, "[MEDICATION NAME] should generally be administered with an initial dose of 25 mg twice daily, with increases in total daily dose of 25 mg - 50 mg divided in two or three doses on the second and third day, as tolerated, to a total dose range of 300 mg to 400 mg daily by the fourth day..." American Geriatrics.org. Beers Criteria, 2013. Web. 14 Apr, 2013, documented, "...Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. In general, all benzodiazepines increase risk of cognitive impairment, [MEDICAL CONDITION], falls, fractures, and motor vehicle accidents in older adults..." 1. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders [MEDICATION NAME]...25 mcq [MEDICATION NAME] q 72 (hours)[MEDICATION NAME] .5 mg (one) per GT q 6 (hours) [MEDICATION NAME]/[MEDICATION NAME] 10/500 mg (one) q 4 (hours) prn..." A nurse's note, dated 01/23/13 at 9:57 p.m., documented, "...res does get confused and up (increased) anxiety per report and family..." A nurse's note, dated 01/25/13 at 4:07 p.m., documented, "...Pt presents with increased anxiety. Pt states 'I feel like a (sic) can't breath (sic) without my nerve pill.' MD notified and [MEDICATION NAME] changed from PRN to routine..." A nurse's note, dated 01/25/13 at 10:38 p.m., documented, "...up on entering res room res noted up on side of bed using urinal, found H.L. (heplock) in bed by res. Asked res what happen. Res stated took it out didn't know what else to do with it..." A nurse's note, dated 01/26/13 at 12:16 p.m., documented, "...pt has been pulling IV access out munable (sic) to restrain..." Behavior monitoring notes, dated 01/28/13 at 6:45 a.m., documented the resident had one episode of anxiety. A nurse's note, dated 01/28/13 at 4:59 a.m., documented, "...confused and disoriented frequently. Can be uncooperative with care, hits at staff a couple of times. Appears very frail and weak due to lung [MEDICAL CONDITION] off O2 sometimes..." An admission assessment, dated 02/04/13, documented the resident was able to express ideas and wants, and usually understood others. It was documented the resident was cognitively intact and had no behaviors. It was also documented it was very important to the resident for his family or a close friend to be involved in discussion about his care. The resident was assessed to require limited assistance of one person for bed mobility and transfer; extensive assistance of two people for walking; and limited assistance of one person for toilet use. It was documented the resident was only able to stabilize himself with staff assistance when moving from a seated to standing position; walking, turning around, moving on and off the toilet, and when transferring from one surface to another. It was documented the resident was continent of bowel and bladder. It was also documented the resident was on a scheduled pain medication regimen but had not had pain during the previous five days. It was documented the resident had not fallen before admission to the facility or since admission. It was also documented the resident had received an antianxiety medication every day during the previous seven days. The resident did not receive an antipsychotic or hypnotic medication. The resident's care plan, dated 02/04/13, documented a problem, "...Falls...At risk for injuries from falls due to poor balance and limited mobility..." The goal was, "...Will not have a fall with injuries..." Approaches included, "...Monitor for side effects from medications, labs, appetite as a cause for falls...monitor resident for steadiness and balance...evaluate need for use of personal alarms to alert staff of unassisted rising..." Another problem was, "...chronic pain r/t dx of [MEDICAL CONDITION]" The goal was, "...resident's pain will be minimized, relieved or controlled as evidenced by relaxed facial expression, relaxed posturing and verbalizing of relief as pain occurs...encourage position of comfort..." Another problem was, "...currently on medication for [DIAGNOSES REDACTED]. A fall risk assessment, dated 02/04/13, documented the resident scored a "6." The form documented, "...A total score above 10 represents HIGH RISK..." A nurse's note, dated 02/12/13 at 7:34 p.m., documented, "...res having increased amount of pain, per resident, requesting more pain meds, text (physician name withheld), n/o received up [MEDICATION NAME] from 25 to 50 mcg..." A nurse's note, dated 02/17/13 at 5:30 p.m., documented, "...pt frail confused..." A nurse's note, dated 02/20/13 at 7:00 a.m., documented, "...pt has moments of confusion but usually a/o x 3..." A nurse's note, dated 03/04/13 at 7:00 a.m., documented, "...pt presents with increased confusion..." A five day pay per service assessment, dated 03/05/13, documented the resident was severely cognitively impaired, had no signs or symptoms of [MEDICAL CONDITION], and had no behaviors. The resident was assessed to require limited assistance of one person for bed mobility and transfers; toilet use, and personal hygiene. It was documented the resident required extensive assistance of two persons for walking. It was documented the resident was only able to stabilize himself with staff assistance when moving from a seated to standing position; walking, turning around, moving on and off the toilet, and when transferring from one surface to another. It was documented the resident was continent of bowel and bladder. It was also documented the resident had not fallen. A nurse's note, dated 03/06/13 at 10:21 a.m., documented, "...pt pulled emergency bathroom alarm, pt found sitting on toilet leaned over c/o sob...pt asked that someone call his wife and stated he wanted to go to the hospital...transferred at (7:40) a.m..." A nurse's note, dated 03/08/13 at 9:34 a.m., documented, "...pt had [MEDICATION NAME] feeding this AM due to pt disconnecting tube feeding during night shift. Feeding pump to be continued this afternoon..." A nurse's note, dated 03/09/13 at 3:00 p.m., documented, "...frequently removes O2 tubing and has to be reminded to keep it on..." A nurse's note, dated 03/10/13 at 5:01 p.m., documented, "...(9:00 a.m.) 03/10/13 a new bottle of [MEDICATION NAME] 1L was hung for continuous feeding, pump set at 60 ml/H...At 1240 the bottle was found empty, positioned at the opposite side of where it had been hung and the lines twisted around the pole. Pump settings were checked and found to be as ordered. Patient tampering is suspected, he denies. Patient has history of disconnecting self from feeding tube, milk found in the bed...discussed the importance of these feedings with patient and family. Pump checked at (3:00 p.m.) and (5:00 p.m.), running without difficulty. Will continue to monitor..." A nurse's note, dated 03/11/13 at 3:00 p.m., documented, "...Pt confused unable to articulate location or month. Pt thinks his wife lives in the facility...Pt has been reminded several times that he is in a nursing home, pt also reminded several time...keep O2 on. Pt pulled the end piece off of peg tube..." A nurse's note, dated 03/14/13 at 2:01 p.m., documented, "...pt is being dicacharged (sic) from SNF and admitted to ICF. He is also being picked up by hospice for respiratory dx. Pt has been complaining of stomach pain and being 'full.' Pt has also been vomiting regularly..." Behavior monitoring notes, dated 03/19/13 at 2:35 p.m. and 2:36 p.m., documented the resident had an episode of anxiety, fear, and panic. A hospice nurse's note, dated 03/20/13 at 1:15 p.m., documented, "...SN received call from CG stating pt was having 'attitude problems' today. SN made visit. SN talked c pt and pt expressed frustration c (hospice aide). Pt was upset that he had to take bath on a daily basis. SN bargained c pt to take bath @ least qod to keep clean (and) comfortable even if only sponge bath. Pt agreed. SN spoke with (hospice aide) who agreed c POC..." An incident report, dated 03/22/13 at 11:50 p.m., documented, "...resident reported to CNA of fall, unwittnessed (sic). Res sitting in bed...states 'I was trying to get to that chair.' No chair..." A hospice nurse's note, dated 03/24/13 at 3:00 p.m., documented, "...agitates easily @ times especially when his (family member) comes to visit per nsg home staff..." A hospice nurse's note, dated 03/26/13 at 12:00 p.m., documented, "...Pt was slightly confused..." It was documented the resident was anxious, agitated, forgetful, and confused at times. A care plan update, dated 03/27/13, documented, "...Fall with skin tear to right forearm reported on March 22 2013 - nursing staff to orient (resident #12) to call light system frequently. Answer call light promptly. Leave head of bed light on. Instruct (resident #12) to wait on nursing staff prior to attempting to get up..." A hospice nurse's note, dated 03/27/13 at 9:45 a.m., documented, "...NH staff states that he messes c peg tube. SN instructed pt not to pull on tube or mess with it. SN talked c (LPN #2) at NH to report about pt. She states that earlier this am pt got up to bathroom sink c peg tube connected to feeding pump and pulled on peg tube..." It was documented the resident was anxious and agitated. A hospice nurse's note, dated 03/28/13 at 11:10 a.m., documented, "...pt was a (and) o c slight confusion @ x's..." It was documented the resident was anxious, agitated, forgetful, and confused at times. A physician's note, dated 03/28/13 at 11:43 a.m., documented, "...has been doing ok. He has had increased pain in left chest. Hurts more to breath. Does have known [MEDICAL CONDITION]" A hospice nurse's note, dated 03/28/13 at 8:05 p.m., documented, "...Spoke c (LPN #9) and pt about panic attacks and instructed pt to stay calm and breath (sic) slowly in through nose and out through mouth...(LPN #9)...states that pt gets anxious when family comes and he tells his family that he wants to be left alone and when they don't leave his anxiety (increases). SN talked c pt (family member) about respecting pt wishes and that it was good to visit but also to respect his wishes of being left alone..." A hospice nurse's note, dated 03/29/13 at 10:30 a.m., documented, "...SN assessment as noted. SN picked up and delivered [MEDICATION NAME] to (CMA #2). Pain rated at a '3' in stomach. He states it is dull pain and 'just comes and goes.' Pt states that his current pain control medications are adequate and they do help his pain...Pt states that he is going home today and seems somewhat anxious. SN and aide reinforced that pt was in his room and that his family/(family member) would be to see him later today..." A hospice physician's orders [REDACTED]. A nurse's note, dated 03/29/13 at 1:08 p.m., documented, "...Received new order for [MEDICATION NAME] increase from (hospice name withheld). Order put in and MAR updated..." A nurse's note, dated 03/29/13 at 3:45 p.m., documented, "...N/O received (sic) for increase in [MEDICATION NAME], up to 1 mg q 4 hrs, and [MEDICATION NAME] 25 mg gel q 6 hrs, prn, updated mars..." Review of the resident's clinical record revealed no documentation to show why the resident's [MEDICATION NAME] was increased from 0.5 mg every six hours to one mg every four hours at one time. This was an increase from 2 mg per day to 6 mg per day with one dosage change. There was no documentation to show any non-pharmalogical interventions had been attempted for any behaviors prior to increasing the medication. A hospice nurse's note, dated 03/29/13 at 7:40 p.m., documented, "...anxiety/agitation when (family member) is around otherwise calm and relaxed...(family member) was sitting on extra bed in the patient's room. He was resting well and very calm. No s/s of anxiety or agitation seen..." Behavior monitoring notes, dated 03/29/13 at 9:53 p.m., documented the resident had an episode of anxiety. Review of MARS and narcotic count sheets, dated 03/29/13, documented the resident received [MEDICATION NAME] 0.5 mg as follows: 3:00 a.m. - one tablet; 9:00 a.m. - one tablet; 1:00 p.m. - one tablet; 5:00 p.m. - two tablets, for a total dose of one mg; and 9:00 p.m. - two tablets, for a total dose of one mg. This was a total of 3.5 mg [MEDICATION NAME] administered to the resident in an 18 hour period. A hospice nurse's note, dated 03/30/13 at 2:00 p.m., documented, "...Staff reports patient got really agitated and more confused after (family member) visit today. He pulled the feeding apart and milk went all over the floor. Urinated in the trash can. He was sitting up front by the nursing station and doing really good. He was watching everything...(LPN #9) the charge nurse feels that he does better out of the room sometimes..." Review of MARS and narcotic count sheets, dated 03/30/13 documented the resident received [MEDICATION NAME] 0.5 mg as follows: 1:00 a.m. - two tablets, for a total dose of one mg; 5:00 a.m. - two tablets, for a total dose of one mg; 9:00 a.m. - two tablets, for a total dose of one mg; 1:00 p.m. - two tablets, for a total dose of one mg; 5:00 p.m. - two tablets, for a total dose of one mg; and 9:00 p.m. - two tablets, for a total dose of one mg. This was a total of 6 mg [MEDICATION NAME] administered to the resident in a 24 hour period. A hospice nurse's note, dated 03/31/13 at 7:35 p.m., documented, "...Staff reports family was by to see him earlier today and has tired him out...(increased) risk for falls..." Review of MARS and narcotic count sheets, dated 03/31/13 documented the resident received [MEDICATION NAME] 0.5 mg as follows: 1:00 a.m. - two tablets, for a total dose of one mg; 5:00 a.m. - two tablets, for a total dose of one mg; 9:00 a.m. - two tablets, for a total dose of one mg; 1:00 p.m. - two tablets, for a total dose of one mg; 5:00 p.m. - two tablets, for a total dose of one mg; and 9:00 p.m. - two tablets, for a total dose of one mg. This was a total of 6 mg [MEDICATION NAME] administered to the resident in a 24 hour period. MARs and narcotic count sheets, dated 04/01/13 at 1:00 a.m., documented the resident received two tablets of [MEDICATION NAME], 0.5 mg, for a total dose of 1 mg. An incident report, dated 04/01/13 at 1:50 a.m., documented, "...resident confused states he was trying to 'get to chair' - no chair in room..." A nurse's note, dated 04/01/13 at 8:03 a.m., documented, "...01:50 a.m., Resident found on floor of his room calling out. Unwittnessed (sic) fall. Denies hitting head. Moves all 4 extremities, Rt upper thigh with pain...has pull off cont. feeding tube. Tube still intact but formula on clothes. Phys notified. Oder (sic) for XRay. 03:00 a.m. (X-ray company name withheld) here for views. 04:00 a.m. Nonangulated and nondisplaced fracture, intertrochanteric level of the proximal right femur. Physician, hospice notified. 4:20 a.m., (physician name withheld) ordered resident sent out for further eval. An x-ray report, dated 04/01/13, documented, "...There is evidence of fracture involving the intertrochanteric level of the proximal femur without significant angulation or displacement..." A hospice nurse's note, dated 04/01/13 at 9:00 a.m., documented, "...TC received from pt (family member) stating that (resident #12) was back at NH from hospital. She states that the hospital would not operate due to pt could not make it through an operation so they sent pt back to NH c some new orders that NH staff would be faxing to us. She also states that she is concerned about the increase in pt [MEDICATION NAME] that was (changed) Friday that it maybe could be causing pt to be staying up all night, being mean to the family and wandering so much. SN stated that when the hospice nurses are doing visits that the NH tells us that pt is sleeping well and that sometimes he does have some anxiety issues at times especially when he has visitors. SN stated that I would contact (hospice physician name withheld) and see about getting something different for pt that maybe will help him rest and if new orders obtained I will send them with (hospice nurse) who is seeing him today..." A hospice nurse's note, dated 04/01/13 at 9:15 a.m., documented, "...(hospice physician name withheld) notified of pt (family member) concern about medication...Dc'd [MEDICATION NAME] and ordered Serquil (sic) 50 mg BID..." A nurse's note, dated 04/01/13 at 10:43 a.m., documented, "...Resident returned from hospital at 9:10 a.m. Dx of right [MEDICAL CONDITION]" A nurse's note, dated 04/01/13 at 12:00 p.m., documented, "...Due to recent fall and resident current altered mental status and confusion one on one staff care has been initiated at 5 p.m. and will continue until notified by DON..." A hospice physician's orders [REDACTED]. Seroquil (sic) 50 mg BID..." A nurse's note, dated 04/01/13 at 1:59 p.m., documented, "...Hospice here with new orders. DC [MEDICATION NAME]. New order for serquil (sic) 50 mg via GTube bid for anxiety..." Review of the resident's clinical record revealed no documentation to show why the resident was placed on [MEDICATION NAME], an antipsychotic medication, or why the starting dose exceeded the recommended initial dose. A nurse's note, dated 04/01/13 at 2:16 p.m., documented, "...(family member) her (sic) with resident, (family member) refused medication new [MEDICATION NAME] order and Serquil (sic). She believed he was to (sic) medicated (sic)..." A nurse's note, dated 04/01/13 at 4:30 p.m., documented, "...nurse called to res room. Res noted in floor laying on rt side, res c/o rt shoulder pain and res stated 'hit my head' No swelling or brusing (sic) noted to either site, dr notified, family notified, hospice notified, n/o for rt shoulder x-ray...one on one also ordered per DON..." A nurse's note, dated 04/01/13 at 6:39 p.m., documented, "...received x-ray results...negative rt shoulder..." MARs, dated 04/01/13 at 9:00 p.m., documented the resident received [MEDICATION NAME] 50 mg. A nurse's note, dated 04/02/13 at 4:49 a.m., documented, "...Due to recent fall and altered mental status and confusion one on one care has been initiated. One on one care began at 5 p.m. on 04-01-2013. (Resident #12) has remained free of injury. One on one will remain plan of care until notified by DON..." A care plan update, dated 04/02/13, documented, "...April 1, 2013 (resident #12) sustained a fall with injury resulting in a right femur fracture. He reported he was trying to get to a chair. (No chair present in room at time of accident) Nursing staff informed of (resident #12)'s condition and instructed to use extreme caution during care and assistance with adl's/repositioning. Staff to monitor more frequently for pain, medicate as directed and notify physician if pain med becomes ineffective. 1/2 side rails to be used to promote feelings of safety. Keep call light within reach at all times. Frequently remind (resident #12) to use for assistance. Provide verbal ques (sic) and visual pictures reminding (resident #12) to use call light system prn. Review medication prn..." MARs, dated 04/02/13, documented the resident received [MEDICATION NAME] 50 mg at 9:00 a.m. and 9:00 p.m. MARs, dated 04/03/13, documented the resident received [MEDICATION NAME] 50 mg at 9:00 a.m. and 9:00 p.m. MARs, dated 04/04/13, documented the resident received [MEDICATION NAME] 50 mg at 9:00 a.m. A hospice nurse's note, dated 04/04/13 at 9:50 a.m., documented, "...Pt very confused this am and is picking at the wall. Pt denies any pain when asked however he tries to move around in bed he states that he just needs to move. (LPN #2) states that he has (increased) confusion at times and that pain medication is given q 4 (hours) and [MEDICATION NAME] is given BID...(LPN #2) states that they have someone sit 1 on 1 c pt at night and sometimes in the day depending on pt confusion level..." A physician's orders [REDACTED]. A nurse's note, dated 04/04/13 at 1:07 p.m., documented, "...pt a/ox 1 this morning. Pt presents with visual hallucinations. Pt laying bed swatting at the wall, flinching as if dodging something. Per (physician name withheld) [MEDICATION NAME] to be reduced to 50 mg at hs. Will continue to monitor for change in condition. Family and hospice notified..." A physician's orders [REDACTED]. Review of the clinical record revealed no documentation to show why the [MEDICATION NAME] was increased again to 50 mg twice daily. A hospice nurse's note, dated 04/05/13 10:00 a.m., documented, "...Aide states that NH is sitting c pt 1 on 1 24 (hours) due to pt confusion and trying to get out of the bed...raising arms into air when SN arrived. NH aide states that he does that a lot and sometimes he will talk. Pt is restless according to NH staff...SN spoke c (LPN #2) about trying some [MEDICATION NAME] to maybe help pt rest along c the Seraquil (sic) She agreed..." A hospice physician's orders [REDACTED]. May increase oxygen to 6 liters via nasal cannula..." A hospice nurse's note, dated 04/05/13 at 9:45 p.m., documented, "...SN received call from on call nurse...NH staff was concerned about pts confusion/agitation. SN made (unknown) to check on pt status. Upon arrival SN found pt highly agitated/confused/aggressive. SN received order for 1 mg [MEDICATION NAME] q 4 (hours) as needed...SN sat c pt (and) turned off all lights (and) tv to reduce environmental stimuli (and) promote pts rest. Pt calmed down..." A hospice nurse's note, dated 04/06/13 at 1:30 p.m., documented, "...patient very lethargic since given the [MEDICATION NAME] earlier today...pt was anxious this am per staff. He was given his regular medications and [MEDICATION NAME] which he is now very lethargic...Explained to nsg home staff to monitor closely and contact hospice if any changes noted stat..." A hospice nurse's note, dated 04/07/13 at 7:40 p.m., documented, "...lethargic...seems to be resting well since getting medication routinely...current pain and anxiety medications working great...no mottling seen..." MARs, dated 04/07/13, documented the resident received [MEDICATION NAME], 1 mg, four times during the day. An incident report, dated 04/08/13 at 8:20 p.m., documented, "...res found in floor on (left) side, (no) c/o pain. Res noted c s/t to (right) elbow, res unable to state how it happened...one on one placed c resident..." On 04/10/13 at 3:04 p.m., resident #12 was observed lying in bed. CNAs #1 and #5 were in the resident's room. The CNAs were asked if the resident exhibited behaviors. CNA #1 stated, "Not bad ones. He gets combative when you try to change him or turn him." CNA #1 was asked if the resident had always exhibited those behaviors. She stated, "No, just after the fall. He used to be really sweet. He won't eat now." CNA #1 was asked if she had told anyone the resident became combative. She stated, "The night shift nurse charted it. I know (CNA #2) told someone." On 04/10/13 at 3:47 p.m., LPN #9 was asked who decided what medication changes would occur. She stated, "We call hospice, the nurse comes out and they call their doctor. We go by their recommendations and let (physician name withheld) know." LPN #9 was asked what behaviors resident #12 exhibited. She stated, "First there were no behaviors. He had pneumonia due to [MEDICAL CONDITION], and hospice later." LPN #9 was asked when the resident started exhibiting behaviors. She stated, "Right after getting hospice." LPN #9 was asked what behaviors the resident exhibited. She stated, "Reaching for the ceiling, pulling at his peg, trying to get up. He had a few falls." LPN #9 was asked who increased the resident's [MEDICATION NAME]. She stated, "Hospice." When asked why, LPN #9 stated, "His anxiety started increasing. His family increases his anxiety." LPN #9 was asked who initiated the use of [MEDICATION NAME]. She stated, "Hospice." When asked why, LPN #9 stated, "He couldn't take [MEDICATION NAME] the hospice doctor wanted him on [MEDICATION NAME]." LPN #9 was asked what [MEDICATION NAME] was used for. She stated, "Helps keep him calmed down." LPN #9 was asked what interventions were attempted prior to increasing his [MEDICATION NAME] dose or starting [MEDICATION NAME]. She stated, "Side rails up x 2, pressure pad, check routinely, one on one for falls, reposition, things like that." LPN #9 was asked if the resident was exhibiting behavior now. She stated, "No. Only with the family." On 04/10/13 at 4:02 p.m., The DON was asked who decided what medications would be changed. She stated, "The hospice doctor and (medical director)." When asked how the facility and hospice coordinated any changes, the DON stated, "We call, tell them this is going on. They get an order for [REDACTED]. The DON was asked what behaviors resident #12 exhibited. She stated the resident had no behaviors when he first came to the facility. She stated over the last few weeks, the resident had became very confused. She stated when the family leaves he gets worse. She stated at one point a family member had requested no medications be given. The DON was asked who implemented the use of [MEDICATION NAME] for the resident. She stated he had [MEDICATION NAME] 0.5 mg ordered every six hours when he arrived at the facility. The DON was asked why the resident needed the [MEDICATION NAME] increased to 1 mg every four hours. She stated, "I can't tell you that. It is not documented." The DON was asked who implemented the use of [MEDICATION NAME]. She stated that order came from hospice. The DON was asked what interventions had been attempted prior to the increase in [MEDICATION NAME] and starting the [MEDICATION NAME]. She stated the staff had tried to distract him. The DON was asked how often the resident received [MEDICATION NAME]. She reviewed the clinical record and stated, "BID." The DON was asked why there was a physician's orders [REDACTED]. The DON stated she had seen the order for [MEDICATION NAME] 50 mg twice daily and had asked the medical director about it. She stated the medical director said he would never have put someone on a dose like that and it should be decreased immediately and then discontinued as soon as possible. She stated she instructed the charge nurse to write the order to decrease it. The DON stated she did not know why the medication had been increased again, and the nurse responsible was no longer employed by the facility. On 04/11/13 at 9:27 a.m., the resident was observed lying in bed. A facility staff member was seated at his bedside. On 04/11/13 at 9:52 a.m., the medical director was asked if, in his professional opinion, the increase in [MEDICATION NAME] dosaging could have caused the resident's fall that resulted in a [MEDICAL CONDITION]. He stated, "It could be a reasonable cause of his falls." The medical director stated he would not have increased the medication in such a manner. When asked about the [MEDICATION NAME], the medical director stated, "I don't agree with that either." The medical director was asked if the resident had a [DIAGNOSES REDACTED]. He stated, "No." The medical director was asked what he expected staff to do if they received a questionable order from a hospice entity. He stated he expected them to call him. On 04/11/13 at 10:24 a.m., the hospice case manager was asked why the resident's [MEDICATION NAME] was increased from 0.5 mg every six hours to 1 mg every four hours. She stated the facility staff said the resident was having a lot of anxiety and agitation. She stated they were trying to prevent agitation, trying to relax the resident. She stated the resident was "trying to get up a lot." The hospice case manager was asked who hospice spoke with at the facility about increasing the resident's [MEDICATION NAME] to such a dose. She stated , "(CMA #2) and (LPN #4)." The hospice case manager was asked where the documentation was that hospice had spoken with the facility about the medication changes and a decision had been agreed upon. She stated, "I'm not seeing any for that day." The hospice case manager was asked why the resident was put on [MEDICATION NAME] 50 mg twice daily. She stated, "It's what the hospice doctor recommended when we told him what he (resident #12) was doing." When asked what the resident was doing, the hospice case manager stated the resident had been anxious and agitated. The hospice case manager was asked to provide documentation of the anxiet

Based on observation, interview, and record review, it was determined the facility failed to: A. Provide supervision to prevent falls for one (#12) of three sampled residents who were reviewed for falls. There was no evidence of increased supervision when the administration of Xanax, an antianxiety medication, was increased from two mg per day to six mg per day at one time, putting the resident at increased risk for falls. The resident received six mg of Xanax on two consecutive days prior to a fall that resulted in actual harm of a fractured femur. The facility identified 35 residents as receiving anti-anxiety medications; B. Identify and prevent potential accident hazards related to hot water for two (100 and 400 halls) of four resident halls. Twenty-six residents resided on the 100 hall. Twenty-two residents resided on the 400 hall.. No residents were identified as cognitively impaired who wandered; and C. Properly supervise and secure cleaning chemicals located on two of two housekeeping carts used for the cleaning of resident rooms and common areas during the day shift. The facility identified no resident that was cognitively impaired who wandered. Findings: Drugs.com. Xanax, 2013. Web. 14 [DATE], documented, "...It is recommended that the dosage be limited to the smallest effective dose to preclude the development of ataxia or oversedation which may be a particular problem in elderly or debilitated patients...The usual precautions in treating patients with impaired renal, hepatic or pulmonary function should be observed... treatment for [REDACTED]. The dose may be increased to achieve a maximum therapeutic effect, at intervals of 3 to 4 days, to a maximum daily dose of 4 mg, given in divided doses. The lowest possible effective dose should be employed... Treatment may be initiated with a dose of 0.5 mg three times daily. Depending on the response, the dose may be increased at intervals of 3 to 4 days in increments of no more than 1 mg per day. Slower titration to the dose levels greater than 4 mg/day may be advisable to allow full expression of the pharmacodynamic effect of Xanax... Generally, therapy should be initiated at a low dose to minimize the risk of adverse responses in patients especially sensitive to the drug. Dose should be advanced until an acceptable therapeutic response (ie, a substantial reduction in or total elimination of panic attacks) is achieved, intolerance occurs, or the maximum recommended dose is attained..." American Geriatrics.org. Beers Criteria, 2013. Web. 14 Apr, 2013, documented, "...Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. In general, all benzodiazepines increase risk of cognitive imparment, delirium, falls, fractures, and motor vehicle accidents in older adults..." 1. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders ...Fentanyl patch...25 mcq transderm q 72 (hours)...Xanax .5 mg (one) per GT q 6 (hours) prn...hydrocodone/acetaminophen 10/500 mg (one) q 4 (hours) prn..." A nurse's note, dated 01/23/13 at 9:57 p.m., documented, "...res does get confused and up (increased) anxiety per report and family..." A nurse's note, dated 01/25/13 at 4:07 p.m., documented, "...Pt presents with increased anxiety. Pt states 'I feel like a (sic) can't breath (sic) without my nerve pill.' MD notified and Xanax changed from PRN to routine..." A nurse's note, dated 01/25/13 at 10:38 p.m., documented, "...up on entering res room res noted up on side of bed using urinal, found H.L. (heplock) in bed by res. Asked res what happen. Res stated took it out didn't know what else to do with it..." A nurse's note, dated 01/26/13 at 12:16 p.m., documented, "...pt has been pulling IV access out munable (sic) to restrain..." A nurse's note, dated 01/28/13 at 4:59 a.m., documented, "...confused and disoriented frequently. Can be uncooperative with care, hits at staff a couple of times. Appears very frail and weak due to lung [DIAGNOSES REDACTED]...Takes off O2 sometimes..." Behavior monitoring notes, dated 01/28/13 at 6:45 a.m., documented the resident had one episode of anxiety. An admission assessment, dated 02/04/13, documented the resident was able to express ideas and wants, and usually understood others. It was documented the resident was cognitively intact and had no behaviors. The resident was assessed to require limited assistance of one person for bed mobility and transfer; extensive assistance of two people for walking; and limited assistance of one person for toilet use. It was documented the resident was only able to stabilize himself with staff assistance when moving from a seated to standing position; walking, turning around, moving on and off the toilet, and when transferring from one surface to another. It was documented the resident was continent of bowel and bladder. It was documented the resident had not fallen before admission to the facility or since admission. It was also documented the resident had received an antianxiety medication every day during the previous seven days. The resident did not receive an antipsychotic or hypnotic medication. The resident's care plan, dated 02/04/13, documented a problem, "...Falls...At risk for injuries from falls due to poor balance and limited mobility..." The goal was, "...Will not have a fall with injuries..." Approaches included, "...Monitor for side effects from medications, labs, appetite as a cause for falls...monitor resident for steadiness and balance...evaluate need for use of personal alarms to alert staff of unassisted rising..." Another problem was, "...currently on medication for [DIAGNOSES REDACTED]. A fall risk assessment, dated 02/04/13, documented the resident scored a "6." The form documented, "...A total score above 10 represents HIGH RISK..." A nurse's note, dated 02/12/13 at 7:34 p.m., documented, "...res having increased amount of pain, per resident, requesting more pain meds, text (physician name withheld), n/o received up fentanyl patch from 25 to 50 mcg..." A nurse's note, dated 02/17/13 at 5:30 p.m., documented, "...pt frail confused..." A nurse's note, dated 02/20/13 at 7:00 a.m., documented, "...pt has moments of confusion but usually a/o x 3..." A nurse's note, dated 03/04/13 at 7:00 a.m., documented, "...pt presents with increased confusion..." A five day pay per service assessment, dated 03/05/13, documented the resident was severely cognitively impaired, had no signs or symptoms of delirium, and had no behaviors. The resident was assessed to require limited assistance of one person for bed mobility and transfers; toilet use, and personal hygiene. It was documented the resident required extensive assistance of two persons for walking. It was documented the resident was only able to stabilize himself with staff assistance when moving from a seated to standing position; walking, turning around, moving on and off the toilet, and when transferring from one surface to another. It was documented the resident was continent of bowel and bladder. It was also documented the resident had not fallen. A nurse's note, dated 03/06/13 at 10:21 a.m., documented, "...pt pulled emergency bathroom alarm, pt found sitting on toilet leaned over c/o sob...pt asked that someone call his wife and stated he wanted to go to the hospital...transferred at (7:40) a.m..." A nurse's note, dated 03/08/13 at 9:34 a.m., documented, "...pt had bolus feeding this AM due to pt disconnecting tube feeding during night shift. Feeding pump to be continued this afternoon..." A nurse's note, dated 03/09/13 at 3:00 p.m., documented, "...frequently removes O2 tubing and has to be reminded to keep it on..." A nurse's note, dated 03/10/13 at 5:01 p.m., documented, "...(9:00 a.m.) 03/10/13 a new bottle of Pulmocare 1L was hung for continuous feeding, pump set at 60 ml/H...At 1240 (p.m.) the bottle was found empty, positioned at the opposite side of where it had been hung and the lines twisted around the pole. Pump settings were checked and found to be as ordered. Patient tampering is suspected, he denies. Patient has history of disconnecting self from feeding tube, milk found in the bed...discussed the importance of these feedings with patient and family. Pump checked at (3:00 p.m.) and (5:00 p.m.), running without difficulty. Will continue to monitor..." A nurse's note, dated 03/11/13 at 3:00 p.m., documented, "...Pt confused unable to articulate location or month. Pt thinks his wife lives in the facility...Pt has been reminded several times that he is in a nursing home, pt also reminded several time...keep O2 on. Pt pulled the end piece off of peg tube..." A nurse's note, dated 03/14/13 at 2:01 p.m., documented, "...pt is being dicacharged (sic) from SNF and admitted to ICF. He is also being picked up by hospice for respiratory dx. Pt has been complaining of stomach pain and being 'full.' Pt has also been vomiting regularly..." Behavior monitoring notes, dated 03/19/13 at 2:35 p.m. and 2:36 p.m., documented the resident had an episode of anxiety, fear, and panic. An incident report, dated 03/22/13 at 11:50 p.m., documented, "...resident reported to CNA of fall, unwittnessed (sic). Res sitting in bed...states 'I was trying to get to that chair.' No chair..." Steps taken to prevent recurrence were, "...Attempt to orient res to call light, leave overhead light on (and) educate on utilizing staff..." A hospice nurse's note, dated 03/24/13 at 3:00 p.m., documented, "...agitates easily @ times especially when his (family member) comes to visit per nsg home staff..." A hospice nurse's note, dated 03/26/13 at 12:00 p.m., documented, "...Pt was slightly confused..." It was documented the resident was anxious, agitated, forgetful, and confused at times. A care plan update, dated 03/27/13, documented, "...Fall with skin tear to right forearm reported on March 22 2013 - nursing staff to orient (resident #12) to call light system frequently. Answer call light promptly. Leave head of bed light on. Instruct (resident #12) to wait on nursing staff prior to attempting to get up..." A hospice nurse's note, dated 03/27/13 at 9:45 a.m., documented, "...NH staff states that he messes c peg tube. SN instructed pt not to pull on tube or mess with it. SN talked c (LPN #2) at NH to report about pt. She states that earlier this am pt got up to bathroom sink c peg tube connected to feeding pump and pulled on peg tube..." It was documented the resident was anxious and agitated. A hospice nurse's note, dated 03/28/13 at 11:10 a.m., documented, "...pt was a (and) o c slight confusion @ x's..." It was documented the resident was anxious, agitated, forgetful, and confused at times. A hospice nurse's note, dated 03/28/13 at 8:05 p.m., documented, "...Spoke c (LPN #9) and pt about panic attacks and instructed pt to stay calm and breath (sic) slowly in through nose and out through mouth...(LPN #9)...states that pt gets anxious when family comes and he tells his family that he wants to be left alone and when they don't leave his anxiety (increases). SN talked c pt (family member) about respecting pt wishes and that it was good to visit but also to respect his wishes of being left alone..." A hospice nurse's note, dated 03/29/13 at 10:30 a.m., documented, "...Pt states that he is going home today and seems somewhat anxious. SN and aide reinforced that pt was in his room and that his family/(family member) would be to see him later today..." A hospice physician's orders [REDACTED]. A nurse's note, dated 03/29/13 at 1:08 p.m., documented, "...Received new order for Xanax increase from (hospice name withheld). Order put in and MAR updated..." A nurse's note, dated 03/29/13 at 3:45 p.m., documented, "...N/O received (sic) for increase in Xanax, up to 1 mg q 4 hrs, and phenergan 25 mg gel q 6 hrs, prn, updated mars..." This was an increase from 2 mg per day to 6 mg per day. Review of the resident's clinical record revealed no documentation to show why the resident's Xanax was increased from 0.5 mg every six hours to one mg every four hours in one dosage change. There was no documentation to show any non-pharmalogical interventions had been attempted for any behaviors prior to increasing the medication. A hospice nurse's note, dated 03/29/13 at 7:40 p.m., documented, "...anxiety/agitation when (family member) is around otherwise calm and relaxed...(family member) was sitting on extra bed in the patient's room. He was resting well and very calm. No s/s of anxiety or agitation seen..." Behavior monitoring notes, dated 03/29/13 at 9:53 p.m., documented the resident had an episode of anxiety. Review of MARS and narcotic count sheets, dated 03/29/13, documented the resident received Xanax 0.5 mg as follows: 3:00 a.m. - one tablet; 9:00 a.m. - one tablet; 1:00 p.m. - one tablet; 5:00 p.m. - two tablets, for a total dose of one mg; and 9:00 p.m. - two tablets, for a total dose of one mg. This was a total of 3.5 mg Xanax administered to the resident in an 18 hour period. A hospice nurse's note, dated 03/30/13 at 2:00 p.m., documented, "...Staff reports patient got really agitated and more confused after (family member) visit today. He pulled the feeding apart and milk went all over the floor. Urinated in the trash can. He was sitting up front by the nursing station and doing really good. He was watching everything...(LPN #9) the charge nurse feels that he does better out of the room sometimes..." Review of MARS and narcotic count sheets, dated 03/30/13, documented the resident received Xanax 0.5 mg as follows: 1:00 a.m. - two tablets, for a total dose of one mg; 5:00 a.m. - two tablets, for a total dose of one mg; 9:00 a.m. - two tablets, for a total dose of one mg; 1:00 p.m. - two tablets, for a total dose of one mg; 5:00 p.m. - two tablets, for a total dose of one mg; and 9:00 p.m. - two tablets, for a total dose of one mg. This was a total of 6 mg Xanax administered to the resident in a 24 hour period. A hospice nurse's note, dated 03/31/13 at 7:35 p.m., documented, "...Staff reports family was by to see him earlier today and has tired him out...(increased) risk for falls..." Review of MARS and narcotic count sheets, dated 03/31/13 documented the resident received Xanax 0.5 mg as follows: 1:00 a.m. - two tablets, for a total dose of one mg; 5:00 a.m. - two tablets, for a total dose of one mg; 9:00 a.m. - two tablets, for a total dose of one mg; 1:00 p.m. - two tablets, for a total dose of one mg; 5:00 p.m. - two tablets, for a total dose of one mg; and 9:00 p.m. - two tablets, for a total dose of one mg. This was a total of 6 mg Xanax administered to the resident in a 24 hour period. MARs and narcotic count sheets, dated 04/01/13 at 1:00 a.m., documented the resident received two tablets of Xanax, 0.5 mg, for a total dose of 1 mg. An incident report, dated 04/01/13 at 1:50 a.m., documented, "...resident confused states he was trying to 'get to chair' - no chair in room..." The area of the form that documented, "Additional comments and/or steps taken to prevent recurrence", was blank. A nurse's note, dated 04/01/13 at 8:03 a.m., documented, "...01:50 a.m., Resident found on floor of his room calling out. Unwittnessed (sic) fall. Denies hitting head. Moves all 4 extremities, Rt upper thigh with pain...has pull off cont. feeding tube. Tube still intact but formula on clothes. Phys notified. Oder (sic) for XRay. 03:00 a.m. (X-ray company name withheld) here for views. 04:00 a.m. Nonangulated and nondisplaced fracture, intertrochanteric level of the proximal right femur. Physician, hospice notified. 4:20 a.m., (physician name withheld) ordered resident sent out for further eval. A x-ray report, dated 04/01/13, documented, "...There is evidence of fracture involving the intertrochanteric level of the proximal femur without significant angulation or displacement..." A hospice nurse's note, dated 04/01/13 at 9:00 a.m., documented, "...TC received from pt (family member) stating that (resident #12) was back at NH from hospital. She states that the hospital would not operate due to pt could not make it through an operation so they sent pt back to NH c some new orders that NH staff would be faxing to us. She also states that she is concerned about the increase in pt Xanax that was (changed) Friday that it maybe could be causing pt to be staying up all night, being mean to the family and wandering so much. SN stated that when the hospice nurses are doing visits that the NH tells us that pt is sleeping well and that sometimes he does have some anxiety issues at times especially when he has visitors. SN stated that I would contact (hospice physician name withheld) and see about getting something different for pt that maybe will help him rest and if new orders obtained I will send them with (hospice nurse) who is seeing him today..." A hospice nurse's note, dated 04/01/13 at 9:15 a.m., documented, "...(hospice physician name withheld) notified of pt (family member) concern about medication...Dc'd Xanax and ordered Serquil (sic) 50 mg BID..." A hospice physician's orders [REDACTED]. Seroquil (sic) 50 mg BID..." A nurse's note, dated 04/01/13 at 1:59 p.m., documented, "...Hospice here with new orders. DC Xanax. New order for serquil (sic) 50 mg via GTube bid for anxiety..." A nurse's note, dated 04/01/13 at 2:16 p.m., documented, "...(family member) her (sic) with resident, (family member) refused medication new Norco order and Serquil (sic). She believed he was to (sic) medicated (sic)..." A nurse's note, dated 04/01/13 at 4:30 p.m., documented, "...nurse called to res room. Res noted in floor laying on rt side, res c/o rt shoulder pain and res stated 'hit my head' No swelling or brusing (sic) noted to either site, dr notified, family notified, hospice notified, n/o for rt shoulder x-ray...one on one also ordered per DON..." A nurse's note, dated 04/01/13 at 5:00 p.m., documented, "...Due to recent fall and resident current altered mental status and confusion one on one staff care has been initiated at 5 p.m. and will continue until notified by DON..." A hospice nurse's note, dated 04/01/13 at 5:20 p.m., documented, "...SN received call about hospice pt (resident #12) from on call nurse...stated (nursing home) had called about pt falling. SN called NH and spoke c (LPN #9) who stated pt had gotten out of bed and fallen hitting his (right) shoulder and (right) side of head. (LPN #9) stated pt was confused and requested hospice staff member to sit 'one on one' c pt. SN informed (LPN #9) that hospice was for crisis intervention related to pt's admitting [DIAGNOSES REDACTED]. SN made CV (unknown) to check on the status of pt. Pt was resting quietly in hospital bed...Pt stated he had 'no pain' and 'I want to be left alone.' SN advised NH staff to call in extra staff member if needed to sit c pt but that @ present assessment pt seemed very lethargic. NH staff stated they had given pt his first dose of Seroquel about 45 mins prior to SN arrival. SN advised NH staff to call hospice c any ques/concerns..." A nurse's note, dated 04/01/13 at 6:39 p.m., documented, "...received x-ray results...negative rt shoulder..." A nurse's note, dated 04/02/13 at 4:49 a.m., documented, "...Due to recent fall and altered mental status and confusion one on one care has been initiated. One on one care began at 5 p.m. on 04-01-2013. (Resident #12) has remained free of injury. One on one will remain plan of care until notified by DON..." A hospice nurse's note, dated 04/02/13 at 11:10 a.m., documented, "...lethargic...pt was resting quietly upon SN arrival...Pt c/o pain of (right) hip but refused to rate pain on numerical pain scale...SN observed pain of '4' from objective pt data...NH staff requested 'one on one' staffing from hospice agency. SN informed DON of (nursing home) that hospice does not do 24 (hour) continuous care for [DIAGNOSES REDACTED]. NH will provide 'one to one' staff member for pt's confused status. SN suggested that NH put pt in a 'on the ground' bed so pt would not be able to fall out of regular bed (and) harm himself. NH staff DON stated 'we are keeping pt's bed in the lowest position possible but we don't put mattresses on the floor.' SN instructed NH staff to call hospice c any ques/concerns 24/7..." A care plan update, dated 04/02/13, documented, "...April 1, 2013 (resident #12) sustained a fall with injury resulting in a right femur fracture. He reported he was trying to get to a chair. (No chair present in room at time of accident) Nursing staff informed of (resident #12)'s condition and instructed to use extreme caution during care and assistance with adl's/repositioning. Staff to monitor more frequently for pain, medicate as directed and notify physician if pain med becomes ineffective. 1/2 side rails to be used to promote feelings of safety. Keep call light within reach at all times. Frequently remind (resident #12) to use for assistance. Provide verbal ques (sic) and visual pictures reminding (resident #12) to use call light system prn. Review medication prn..." A hospice nurse's note, dated 04/04/13 at 9:50 a.m., documented, "...Pt very confused this am and is picking at the wall. Pt denies any pain when asked however he tries to move around in bed he states that he just needs to move. (LPN #2) states that he has (increased) confusion at times and that pain medication is given q 4 (hours) and Seroquel is given BID...(LPN #2) states that they have someone sit 1 on 1 c pt at night and sometimes in the day depending on pt confusion level..." A hospice nurse's note, dated 04/05/13 at 10:00 a.m., documented, "...Aide states that NH is sitting c pt 1 on 1 24 (hours) due to pt confusion and trying to get out of the bed...raising arms into air when SN arrived. NH aide states that he does that a lot and sometimes he will talk. Pt is restless according to NH staff..." A hospice physician's orders [REDACTED]. A hospice nurse's note, dated 04/05/13 at 9:45 p.m., documented, "...SN received call from on call nurse...NH staff was concerned about pts confusion/agitation. SN made (unknown) to check on pt status. Upon arrival SN found pt highly agitated/confused/aggressive. SN received order for 1 mg Ativan q 4 (hours) as needed...SN sat c pt (and) turned off all lights (and) tv to reduce environmental stimuli (and) promote pts rest. Pt calmed down..." A hospice nurse's note, dated 04/06/13 at 1:30 p.m., documented, "...patient very lethargic since given the Ativan earlier today...pt was anxious this am per staff. He was given his regular medications and Ativan which he is now very lethargic...Explained to nsg home staff to monitor closely and contact hospice if any changes noted stat..." A hospice nurse's note, dated 04/07/13 at 7:40 p.m., documented, "...lethargic...seems to be resting well since getting medication routinely...current pain and anxiety medications working great...no mottling seen..." An incident report, dated 04/08/13 at 8:20 p.m., documented, "...res found in floor on (left) side, (no) c/o pain. Res noted c s/t to (right) elbow, res unable to state how it happened...one on one placed c resident..." On 04/10/13 at 3:04 p.m., resident #12 was observed lying in bed. There were signs in the room showing pictures as cues for the resident to use his call light. The bed was in the low position, and CNAs #1 and #5 were in the resident's room. On 04/10/13 at 3:47 p.m., LPN #9 was asked who decided what medication changes would occur. She stated, "We call hospice, the nurse comes out and they call their doctor. We go by their recommendations and let (physician name withheld) know." LPN #9 was asked what behaviors resident #12 exhibited. She stated, "First there were no behaviors. He had pneumonia due to lung cancer, and hospice later." LPN #9 was asked when the resident started exhibiting behaviors. She stated, "Right after getting hospice." LPN #9 was asked what behaviors the resident exhibited. She stated, "Reaching for the ceiling, pulling at his peg, trying to get up. He had a few falls." LPN #9 was asked who increased the resident's Xanax. She stated, "Hospice." When asked why, LPN #9 stated, "His anxiety started increasing. His family increases his anxiety." LPN #9 was asked what interventions were attempted prior to increasing his Xanax dose. She stated, "Side rails up x 2, pressure pad, check routinely, one on one for falls, reposition, things like that." LPN #9 was asked if the resident had experienced a fall on 04/08/13. She stated she would have to check. LPN #9 was asked if the resident was exhibiting behavior now. She stated, "No. Only with the family." On 04/10/13 at 4:02 p.m., the DON was asked who decided what medications would be changed. She stated, "The hospice doctor and (medical director)." When asked how the facility and hospice coordinated any changes, the DON stated, "We call, tell them this is going on. They get an order for [REDACTED]." The DON was asked what behaviors resident #12 exhibited. She stated the resident had no behaviors when he first came to the facility. She stated over the last few weeks, the resident had became very confused. She stated when the family leaves he gets worse. She stated at one point a family member had requested no medications be given. The DON was asked who implemented the use of Xanax for the resident. She stated he had Xanax 0.5 mg ordered every six hours when he arrived at the facility. The DON was asked why the resident needed the Xanax increased to 1 mg every four hours. She stated, "I can't tell you that. It is not documented." The DON was asked what interventions had been attempted prior to the increase in Xanax. She stated the staff had tried to distract him. On 04/11/13 at 9:27 a.m., the resident was observed lying in bed. A facility staff member was seated at his bedside. On 04/11/13 at 9:52 a.m., the medical director was asked if, in his professional opinion, the increase in Xanax dosaging could have caused the resident's fall that resulted in a hip fracture. He stated, "It could be a reasonable cause of his falls." The medical director stated he would not have increased the medication in such a manner. The medical director was asked what he expected staff to do if they received a questionable order from a hospice entity. He stated he expected them to call him. On 04/11/13 at 10:24 a.m., the hospice case manager was asked why the resident's Xanax was increased from 0.5 mg every six hours to 1 mg every four hours. She stated the facility staff said the resident was having a lot of anxiety and agitation. She stated they were trying to prevent agitation, try to relax the resident. She stated the resident was "trying to get up alot." The hospice case manager was asked who hospice spoke with at the facility about increasing the resident's Xanax to such a dose. She stated , "(CMA #2) and (LPN #4)." The hospice case manager was asked where the documentation was that hospice had spoken with the facility about the medication changes and a decision had been agreed upon. She stated, "I'm not seeing any for that day." On 04/11/13 at 2:00 p.m., the DON was asked what interventions were put into place after the resident fell and fractured his femur on 04/01/13. She stated, "One on one." The DON was asked if one on one was in place, why did the resident fall on 04/08/13. She stated, "They were supposed to be doing one on one. They had specific orders to stay with him unless family or hospice was in the room." 2. On 04/09/13 between 9:20 a.m. and 9:53 a.m., hot water temperatures were checked throughout the facility. The hot water temperatures on the 400 hall were: Room 408 - 121.0 degrees Fahrenheit (F.); Room 410 - 123.7 degrees F.; and Room 412 - 121.6 degrees F. No wandering residents were observed on the 400 hall. The hot water temperatures on the 100 hall were: Room 107 - 121 degrees F.; and Room 102 - 128 degrees F. No wandering residents were observed on the 100 hall. Review of monthly water temperature logs revealed no instance from 01/2013 through 03/2013 where water temperatures were above 115 degree F. At 9:57 a.m., the maintenance supervisor was asked how often water temperatures were checked. He stated he checked the water temperatures monthly. The maintenance supervisor was asked if and how he calibrated his thermometer. He stated he used the ice water method to calibrate the thermometer monthly. At 10:02 a.m., the administrator was notified of the hot water temperatures. At 10:38 a.m., the administrator stated the hot water tanks for the 100 and 400 halls had been drained. He stated a plumber had been called to assist in diagnosing the problem. 3. On 04/10/13 at 9:30 a.m., a housekeeping cart was observed in front of the visitor bathroom, located at the entrance to 400 hall. The housekeeper was in the bath room cleaning the sink, with her back to the cart. On the top of the cart was a liter spray bottle, titled Nutrel ph, disinfectant/detergent with the chemical of Betroth-ph7Q; and a liter spray bottle, titled glass-cleaner, non-ammoniated, that was labeled as 'Keep out of reach of children'; and On the second shelf of the cart there was a gallon of Sodium hypochlorite, bleach, that was labeled as 'Keep out of reach of children'. The house cleaning cart was observed for the next half hour, and no resident was observed approaching the cart. At 10:00 a.m., the housekeeper was asked how the cart was observed during her shift. She stated the cart was placed at the doorway and observed as the room was being cleaned. She stated the facility nursing staff was available on all halls and were able to visualize the residents and carts. The house keeper said the carts were stored in the locked storage closet when not in use. On 04/10/13 and 04/11/13, observations of cleaning carts were conducted each hour for ten minutes. The chemicals remained unsecured. Facility staff were observed to be in the general visual vicinity. No resident was observed to approach the chemicals on the carts. A facility policy of Hazardous Chemicals was not located by the surveyor. On 04/11/13 at 6:00 p.m., The DON was asked if there was a policy and procedure for storing hazardous chemicals, and after she reviewed the facility policy book, she stated, "No." She stated there were no residents who were cognitively impaired who wandered. At 7:30 p.m., the administrator was asked if he was aware of the unsecured chemicals on the housekeeping cart and he stated, "No." The administrator stated the chemicals would be sec

Based on observation, record review, and interview, it was determined the facility failed to ensure a resident maintained acceptable parameters of body weight for one (#1) of three sampled residents reviewed for weight loss. The facility failed to have a system in place for monitoring decreased meal intake and consistently implementing measures to prevent unplanned weight loss. The facility identified two residents with weight loss currently resided in the facility. Findings: The facility policy for preventing weight loss documented the residents would be offered a house supplement if less than 75% of the meal had been eaten. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual assessment, dated 10/02/10, documented the resident's cognition was severely impaired. The assessment documented the resident weighed 121 pounds (lbs). The assessment documented the resident required limited assistance with eating. The care plan, dated 10/02/10, did not identify the resident as being at risk for weight loss. The quarterly assessment, dated 07/02/11, documented the resident's cognition was severely impaired. The assessment documented the resident weighed 122 lbs. The assessment documented the resident required limited assistance with eating. A physician's telephone order, dated 07/30/11, documented an order to discontinue the [MEDICATION NAME] and start [MEDICATION NAME] 5 milligrams (mg) daily. The dietary progress note, dated 09/19/11, documented the resident's weight was down to 113.4 lbs and the resident's appetite had been poor. The note documented the resident was offered a supplement if less than 75% of the meals was eaten. The note did not document if other measures had been implemented. The dietitian's note, dated 09/27/11, documented the resident weighed 113.4 lbs and might benefit from [MEDICATION NAME] if the oral intake continued to decrease. The note documented the resident would be monitored closely. The resident continued to be weighed monthly. There were no dietary progress notes written on the resident for October. The monthly weight sheet documented the resident weighed 122 lbs in June 2011, 120.4 lbs in July, 120. 4 in August, 113.4 lbs in September, 111.8 lbs in October, and 110.8 lbs in November 2011. The meal intake percentage sheets documented the resident had eaten less than 75% of the meal on numerous occasions. A supplement was documented as being offered a minimal number of times but there was no documentation of the percentage of the supplement the resident consumed. The documentation did not indicate the resident had been offered and/or consumed the house supplement 83 times from September 1st through November 15th when less than 75% of the meal had been eaten. The care plan (10/02/10) did not document the resident had lost weight. The annual assessment, dated 10/02/11, documented the resident's cognition was severely impaired. The assessment documented the resident required limited assistance with eating. The assessment documented the resident weighed 112 lbs but had not had a 5% loss in the past month or a 10% loss in 6 months. The care plan, dated 10/02/11, did not address the resident's weight loss or identify measures to prevent weight loss. A physician's telephone order, dated 10/15/11, documented an order to change the resident's diet from a regular diet to a pureed diet per a request from the family. A comprehensive assessment to determine if the resident was having difficulty chewing or swallowing was not completed. On 11/16/11 at 12:25 p.m., the resident was observed in the dining room being fed by a staff member. The resident ate a few bites of the pureed diet and drank a portion of the house supplement that was offered to her. The resident was observed spitting out the food when she did not want to eat. On 11/16/11 at 1:00 p.m., licensed practical nurse (LPN) #1 was asked what they did when a resident did not eat well. The LPN stated the resident was to be offered a house supplement less than 75% of the meal was eaten and it was supposed to be documented on the meal percentage sheet. The LPN looked at the meal percentage sheet for the resident and stated there were no supplements consistently documented. On 11/16/11 at 1:55 p.m., the director of nurses (DON) stated the resident did not look like she had lost weight. The DON asked LPN #1 to have the resident reweighed. The DON reported the resident's weight was 115.2 lbs. On 11/16/11 at 2:25 p.m., the dietary manager was asked what measures had been implemented when she realized the resident had lost weight. The dietary manager stated supplements were sent to the resident if she ate less than 75% of the meal but no other measures had been implemented. On 11/17/11 at 11:30 a.m., the physician was interviewed regarding his knowledge of the resident's weight loss. The physician stated he reviewed the resident's weights at least monthly and was in constant contact with the facility if there were changes in the weights. The physician stated from his observations he felt the staff assisted and/or fed the residents that could not feed themselves. The physician stated he knew the facility offered supplements to those residents who did not eat 75% of the meal. The physician stated he did not know if the supplements had been documented. The physician was asked if the resident's weight loss had been avoidable. The physician stated he felt like the resident consciously chose not to eat at times when other times she ate everything.

Based on record review, observation, and interview, it was determined the facility failed to provide necessary care and services to maintain residents highest practicable levels of well-being for three (#1, #3, and #15) of eight sampled residents reviewed for pain. The facility failed to manage residents' pain when changes in the residents' conditions indicated the need for increased pain medication for residents #1, #3, and #15. The facility identified 53 residents on a pain management program who could be affected by this practice. Findings: 1. The closed record for resident #15 was reviewed. A hospital history and physical for resident #15, dated 06/16/10, documented the resident had fallen at home and sustained a fracture to the right hip. The history and physical documented the resident had significant short term memory loss. The note documented the resident had poor balance and had previously fallen multiple times. The admission assessment, dated 06/25/10, documented the resident had no cognitive impairment and had good memory recall. The assessment documented the resident did not have behavior symptoms. The assessment documented the resident experienced moderate pain daily. A pain management flow sheet, dated 06/10 (no day specified), documented the resident's pain level was a 4, but did not define the pain associated with the number value. The care plan, dated 07/02/10, documented the resident required minimal assistance for ADLs. Interventions included to provide help to the resident as needed and to check to assure that ADLs were being done. The care plan did not identify pain as a problem. A physician's progress note, dated 08/05/10, documented the resident complained of burning in her feet which was worse at night. The physician wrote an order for [REDACTED]. A nurse's note, dated 08/29/10 at 7:00 a.m., documented the resident stated she had fallen and hit her chest. The note documented no other injuries were noted, vital signs were stable, and the resident was transferred to the emergency room for evaluation. A nurse's note, dated 08/29/10 at 12:00 noon, documented the resident returned from the hospital with a [DIAGNOSES REDACTED]. A nurse's note, dated 09/19/10 at 8:00 a.m., documented the resident reported she had fallen around 6:30 a.m., but had not told anyone. The note documented the resident complained of pain in the left hip and could not bear weight. The note documented the resident had a bruise on the left elbow. The note documented the family and physician were notified. The note documented the resident was transported to the hospital via the ambulance. A nurse's note, dated 09/22/10 at 4:00 p.m., documented the resident was readmitted to the facility. A hospital patient discharge record, dated 09/22/10, documented the resident had a fractured elbow and pelvic fracture. A doctor's orders and progress note, dated 09/23/10, documented an order for [REDACTED]. A nurse's note, dated 09/24/10 at 11:00 p.m., documented the resident stated, "I'm hurting so bad." The note documented the resident was given Tylenol, positioned for comfort, and given the call light. A nurse's note, dated 09/25/10 at 12:30 a.m., documented the resident complained of pain in the arm and back and tried to get out of bed without assistance. A nurse's note, dated 09/25/10 at 2:30 a.m., documented the resident tried to get out of bed. The note documented the resident stated "I'm hurting to (sic) bad to stay here." A nurse's note, dated 09/25/10 at 4:30 a.m., documented the resident complained of pain and tried to get out of bed without using the call light for assistance. The note documented the physician was paged to request a different pain medication because the Tylenol was not effective. A nurse's note, dated 09/25/10 at 5:00 a.m., documented the resident was on the floor by the door. The note documented the resident stated, "I just had to get up I'm hurting so bad now(.) I fell & can't go." The note documented the resident had increased pain to the back and the left hip area, the physician was notified and the resident was transferred to the hospital. A nurse's note, dated 09/25/10 at 11:30 a.m., documented the resident returned from the hospital with a [DIAGNOSES REDACTED]." The care plan was not updated to include the sacral pressure ulcer and the low bed and mattress on the floor. A clinical health record, dated 09/25/10, documented the resident had increased pain related to a fall on that date. The record documented the resident had a history of [REDACTED]. The record documented the resident was reminded frequently to call for assistance. Nurses' notes from 09/25/10 through 09/27/10, documented the use of a low bed, a mattress on the floor, and a bed alarm. A physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The routine pain medication was changed to as needed (prn) when the resident returned from the hospital on [DATE]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A pain management flow sheet, dated 09/10 (no day specified), documented the resident had increased pain from the previous month. A quarterly assessment, dated 10/02/10, documented the resident was severely impaired for cognition, required limited assistance with ADLs and her balance was unsteady. The assessment documented the resident had functional limitation in range of motion of the lower extremity on one side. The assessment documented the resident was on routine pain medication. The assessment documented the resident experience pain of moderate intensity occasionally. The assessment documented the resident had fallen since the last assessment. The assessment did not document the resident had falls with injuries. The assessment did not document the resident had fallen and sustained bone fractures. A nurse's note, dated 11/14/10 at 12:00 a.m., documented the resident was found on the floor by the bed. The note documented the resident had skin tears. The note documented the resident stated "I took that thing off so I didn't bother you. I don't need help (.) If you help me I can't go home." The note documented the nurse requested the resident not take the alarm off and to use the call light. The care plan was not updated. A nurse's note, dated 11/14/10 at 7:00 p.m., documented the resident complained of low back pain. The note documented an order had been obtained for an x-ray of the back and hip. A nurse's note, dated 11/15/10 at 8:20 p.m., documented the resident was crying and throwing things off of her table. The note documented the resident complained of severe back pain. Pain medication was administered. The care plan was not updated. A nurse's note, dated 11/15/10 at 9:30 a.m., documented the resident was calmer, but was afraid to move due to the pain. A nurse's note, dated 12/05/10 at 1:45 p.m., documented the resident returned from the hospital with an order for [REDACTED]. A nurse's note, dated 12/17/10 at 10:55 a.m., documented the resident had fallen and had two skin tears. A nurse's note, dated 12/19/10 at 11:45 a.m., documented a family member requested the resident be given pain medication for pain in the hip and leg. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. A pain management flow sheet, dated 12/10 (no day specified), documented the resident's pain level was a 5. A doctor's orders and progress note, dated 01/10/11, documented an order to discontinue (DC) the [MEDICATION NAME] 50 mg TID and give [MEDICATION NAME] 50 mg two times a day (BID) for pain. A doctor's orders and progress note, dated 01/12/11, documented an order to increase the [MEDICATION NAME] 50 mg from BID to TID. A nurse's note, dated 01/17/11 (no time specified), documented the resident was found on the floor and complained of her head hurting. The care plan was not updated. A pain management flow sheet, dated 01/11 (no day specified), documented the resident's pain level was a 4, but did not define the pain associated with the number value. A nurse's note, dated 02/01/11 (no time specified), documented the resident had fallen and had a skin tear to the right wrist. On 03/03/11 at 10:00 a.m., the DON was interviewed regarding the pain assessments for the resident. The DON stated anytime a resident needs more pain medication, they should be reassessed to make sure the medication was effective. 2. The medical record to resident #3 documented the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A pain assessment, dated 04/2010, documented the resident was non-verbal and expressed pain by grimacing. The assessment documented the resident was not showing any evidence of pain at the time of the assessment. An admission assessment, dated 04/29/10, documented the resident had [DIAGNOSES REDACTED]. The assessment documented the resident was comatose and required total assist with all activities of daily living. The assessment documented the resident had full loss of range of motion to the upper and lower extremities. The assessment documented the resident did not have pain and had not received any restorative range of motion exercise. The resident's care plan, dated 04/29/10, did not address pain or the potential for pain. physician's orders [REDACTED]. The December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A check list for non-verbal pain indicators, dated 12/2010, documented no vocal complaints, non-verbal expression of pain such as moans or groans, no bracing, no restlessness, no rubbing affected area, or vocal complaints such as "ouch" or "that hurts." The assessment documented facial grimaces/winces. The assessment documented a total score of 2. There was no scale to indicate what a score of 2 meant. A quarterly assessment, dated 01/29/11, documented the resident was comatose and required total assist with all activities of daily living. The assessment documented the resident had bilateral loss of range of motion to upper and lower extremities and was totally incontinent of bowel and bladder. The assessment documented the resident had not been on a scheduled pain medication regimen. The assessment documented the resident had received a PRN pain medication. The assessment documented the resident had not received non-medication interventions for pain. The section on the assessment for staff assessment for pain had not been completed. A check list for non-verbal pain indicators dated, 01/29/11, documented no vocal complaints, non-verbal expression of pain such as moans or groans, no bracing, no restlessness, no rubbing affected area, or vocal complaints such as "ouch" or "that hurts." The assessment documented facial grimaces/winces. The assessment documented a total score of 2. There was no scale to indicate what a score of 2 meant. The assessment documented the resident shows evidence of pain and is prescribed [MEDICATION NAME] 5/500 as needed for pain. The January 2011, MAR indicated [REDACTED]. A check list for non-verbal pain indicators dated February 2011 documented no vocal complaints, non-verbal expression of pain such as moans or groans, no bracing, no restlessness, no rubbing affected area or vocal complaints such as "ouch" or "that hurts." The assessment documented facial grimaces/winces. The assessment documented a total score of 2. There was no scale to indicate what a score of 2 meant. The MAR for February 2011 documented the resident had received [MEDICATION NAME] 5/500 mg for pain daily. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The medical record documented the resident had received pain medication daily during the month of February. The resident had not received any pain medication during the month of Janurary. The resident had not been re-assessed for the increased incidence of pain or for the cause of the pain. There was no assessment of possible interventions, either pharmacological or non pharmacological, to assist the resident with pain management. The resident's care plan did not address the increased pain or the increased use of pain medication. The medical record did not document the physician had been notified of the increased pain for the need of a routine pain medication to manage the resident's pain. On 03/01/11 at 9:30 a.m., the resident was observed in his bed in his room. LPN #1 was observed providing a dressing change and [MEDICAL CONDITION] suctioning for the resident. The resident tolerated the treatments with little movement. There was no verbal response, but the resident opened his eyes during the procedures. The only discernable reaction by the resident was displayed when he was suctioned. The resident's legs were stiff and his feet were observed to have foot drop. The resident's left foot was observed to have extensive deformity with the toes curling downward toward the ball of his foot. The resident's hands were closed. Slight movement was observed in the resident's right hand. On 03/02/11 at 9:45 a.m., the director of nurses (DON) was interviewed regarding the resident's increase in pain during February and the lack of a re-assessment of the resident's pain. The DON reported the resident should have been re-assessed and the physician notified. She reported the resident should have been assessed for a routine pain medication and it should have been addressed on the resident's care plan. 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment, dated 11/05/10, documented the resident rarely/never understood. The assessment documented the resident required total assistance with two persons for most activities of daily living (ADLs). The assessment documented the resident had no pain. A care plan, dated 11/05/10, documented the resident exhibited noisy, disruptive behavior. The interventions included to give medication for disruptive behaviors, monitor, record the response, and to assess for a cause (e.g. pain). The intervention was the only reference to pain documented in the care plan. Nurse's notes, dated 12/22/10, documented the resident was confused, noisy at times, yelled, and was hitting himself. A protective helmet was placed on the resident. A physician's telephone order, dated 12/26/10, documented Tylenol 650 milligrams (mg) every 4 hours as needed for pain. Nurse's notes, dated 01/13/11 at 12:45 a.m., documented, "(Resident) Hitting self in forehead. Protective helmet in place..." Social service progress notes, dated 01/27/11, documented, "(The resident) has been hitting himself more lately. I think he(')s in pain. I've brought this to the nurses(') attention..." The January 2011 medication record did not have documentation that Tylenol 650 mg had been given during the month of January. A quarterly assessment, dated 02/05/11, documented the resident rarely/never understood. The assessment documented the resident required total assistance with two persons for most activities of daily living (ADLs). The assessment documented the resident had no pain. The nurse's notes, dated 02/16/11 (no time given), documented the resident was hitting himself in the head and face. A new helmet replaced the old one due to the resident tearing it up. The last nurse's note was dated 02/24/11. The note documented a new order had been noted. Pain symptoms were not documented in the nurse's note. Nothing was documented related to pain. The February medication record documented a new order, dated 02/24/11, for Tylenol #3 to be given every 6 hours as needed for pain. The medication record documented it had been given one time on 02/24/11 at 8:00 p.m. On 02/25/11 the medication was documented as given at 1:00 p.m. and at 7:00 p.m. On 02/26/11 it was documented as given at 7:00 a.m. On 02/27/11 it was documented as given at 7:00 p.m. Nothing was documented in the nurses' notes related to pain on the dates the medications were documented as given on the medication administration record. On 02/28/11 at 10:00 a.m., the surveyor observed the resident in his room. He was non-verbal and resting on his low bed with mats at the bedside. He was observed with a soft helmet on his head. He did not become agitated when introductions were made. There were no facial expressions. The resident was observed several times during the survey. He was not observed hitting his head, and his helmet was in place. On 03/01/11 at 10:35 a.m., the pain assessments for the resident were requested. The assistant director of nursing (ADON) and the surveyor reviewed the checklist of non-verbal pain indicators. The scores for the indicators were all documented zero on the monthly assessments, dated 02/11 back to 09/10. The form documented the resident had a history of [REDACTED]. On 03/02/11 at 8:35 a.m., the social worker was questioned about her progress notes, dated 01/27/11, and why she had documented she thought the resident was in pain. She stated she thought it might be pain because he was hitting one side of his head more than the other. She stated that she had informed the nurses. On 03/02/11 at 9:45 a.m., the ADON stated the resident had a long history of hitting his head. She stated, "The staff knows when he is in pain. He yells."

Based on observation, record review, and interview, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents. The facility failed to thoroughly investigate and implement measures to prevent falls for 1 (#15) of 6 residents sampled for falls. Resident #15 fell and fractured her elbow and pelvis. The facility identified 49 residents who were independent with ambulation or used assistive devices. Findings: The closed record for resident #15 was reviewed during the survey. A hospital history and physical for the resident, dated 06/16/10, documented the resident had fallen at home and sustained a fracture to the right hip. The history and physical documented the resident had significant short term memory loss. The note documented the resident had poor balance and had previously fallen multiple times. A doctor's orders and progress note, dated 06/22/10, documented an order for [REDACTED]. The admission assessment, dated 06/25/10, documented the resident had no cognitive impairment and had good memory recall. The assessment documented the resident did not have behavior symptoms. The assessment documented the resident required oversight for bed mobility and extensive assistance of two staff members for activities of daily living (ADLs). The assessment documented the resident experienced moderate pain daily. The assessment documented the resident had fallen in the previous 30 days. The assessment did not document the resident had a hip fracture prior to admission to the facility. A fall risk assessment, dated 06/10 (no day specified), documented the resident was not a high risk for falls. The care plan, dated 07/02/10, documented the resident required minimal assistance with ADLs. Interventions included to provide help to the resident as needed and to check to assure that ADLs were being done. The care plan documented the resident had a history of [REDACTED]. Interventions included to remind the resident to ask for or wait for assistance with transfers and ambulation and to keep the call light in the resident's reach. Undated interventions included to use a bed and chair alarm. A nurse's note, dated 08/29/10 at 7:00 a.m., documented, "CNA (certified nurse aide) came to report res. (resident) having CP (chest pain). (U)pon assessment res stated 'I got tangled up in that walker(.') (A)sked her for clarification if she fell . (S)tated she did. Asked where exactly did she hurt. She patted her chest. Said that was the only place. Stated she hit her chest when she fell , but doesn't know on what. (No) other inj. (injuries) noted. vs (vital signs) taken & stable. EMS (emergency medical services) called to transfer to ER (emergency room ) for eval (evaluation)." A nurse's note, dated 08/29/10 at 12:00 noon, documented the resident returned from the hospital with a [DIAGNOSES REDACTED]. The 07/02/10 care plan had not been updated after the fall except for the undated interventions to use a bed and chair alarm. A fall risk assessment, dated 09/10 (no day specified), documented the resident was not a high risk for falls. A nurse's note, dated 09/19/10 at 8:00 a.m., documented the resident reported she had fallen around 6:30 a.m., but had not told anyone. The note documented the resident complained of pain in the left hip and could not bear weight. The note documented the resident had a bruise on the left elbow. The note documented the family and physician were notified. The note documented the resident was transported to the hospital via the ambulance. An incident report, dated 09/19/10, documented the resident had fallen at 6:30 a.m., but she had not reported it to anyone. The report documented the resident complained of hip pain and was transported to the hospital via the ambulance. The report documented the family was notified. The report documented to prevent recurrence the resident would be encouraged to use the call light for assistance. The 07/02/10 care plan had not been updated after the fall except for the undated interventions to use a bed and chair alarm. A nurse's note, dated 09/22/10 at 4:00 p.m., documented the resident returned from the hospital. The note documented the resident was alert and oriented and had multiple bruises on the bilateral upper and lower extremities due to the fall. The note documented the resident's left arm was wrapped with an ACE bandage and edema was noted to her left hand. The note documented the resident answered questions appropriately and was able to make her needs known. The note documented the resident was instructed on the importance of using the call light. A hospital patient discharge record, dated 09/22/10, documented the resident had a fractured elbow and pelvic fracture. The 07/02/10 care plan had not been updated after the fall except for the undated interventions to use a bed and chair alarm. A doctor's orders and progress note, dated 09/23/10, documented an order for [REDACTED]. A nurse's note, dated 09/25/10 at 12:30 a.m., documented, "Res noted sitting up @ (at) bedside this nurse assisted to lay back in bed. Informed that she should not try to get up (without) assistance. Conts (continues) to have c/o (complaints of) pain to back and (Lt) (left) arm. Will cont to monitor." A nurse's note, dated 09/25/10 at 2:30 a.m., documented the resident continued to try to get out of the bed. The note documented the resident stated, "I'm hurting to (sic) bad to stay here." The note documented the resident was given Tylenol (amount not documented). The note documented the resident was positioned for comfort and was given the call light. A nurse's note, dated 09/25/10 at 4:30 a.m., documented the resident complained of pain and tried to get out of bed without using the call light for assistance. A nurse's note, dated 09/25/10 at 5:00 a.m., documented the resident was found on the floor by the door to her room. The note documented the resident stated, "I just had to get up I'm hurting so bad now. I fell & can't go." The note documented the resident had increased complaints of pain to her back and left hip area, the doctor was paged, the emergency medical services (EMS) was called, and the resident was sent to the hospital. A nurse's note, dated 09/25/10 at 11:30 a.m., documented the resident returned from the hospital with a [DIAGNOSES REDACTED]. The note documented Morphine immediate release had been ordered for the resident's pain. The note documented the resident's bed should be placed in the lowest position and a mattress should be placed on the floor next to the bed to decrease fall risk. A clinical health record, dated 09/25/10, documented the resident had increased pain related to a fall on that date. The record documented the resident had a history of [REDACTED]. The record documented the resident had a history of [REDACTED]. The record documented the resident was reminded frequently to call for assistance. The 07/02/10 care plan had not been updated after the fall except for the undated interventions to use a bed and chair alarm. Nurses' notes from 09/25/10 through 09/27/10, documented the use of a low bed, a mattress on the floor, and a bed alarm. A doctor's orders and progress note, dated 09/27/10, documented an order for [REDACTED]. A quarterly assessment, dated 10/02/10, documented the resident had severe impairment with cognition, had difficulties with memory, required limited assistance with ADLs, and her balance was unsteady. The assessment documented the resident had functional limitation in range of motion of the lower extremity on one side. The assessment should have documented a functional limitation in range of motion for the upper extremity on one side. The assessment documented the resident had a hip fracture (prior to admission). The assessment should have documented the resident had other fractures (elbow and pelvis). The assessment documented the resident had fallen since the last assessment had been completed. The assessment documented the resident had not had falls that resulted in injuries. The assessment should have documented the resident had fallen and sustained bone fractures. The 07/02/10 care plan had not been updated after the fall except for the undated interventions to use a bed and chair alarm. A nurse's note, dated 10/06/10, documented the family was aware the resident frequently removed the bed and chair alarms and transferred herself without assistance. A nurse's note, dated 10/31/10 (no time specified), documented the resident was found on the floor in a sitting position. The note documented the resident told the nurse she slid out of her wheelchair. The note documented the resident did not have any injuries. An incident report, dated 10/31/10, documented the resident had fallen. The family and physician were notified. The report documented to prevent recurrence the resident would be instructed to use the call light for assistance. The 07/02/10 care plan had not been updated after the fall except for the undated interventions to use a bed and chair alarm. A nurse's note, dated 11/03/10 at 2:30 p.m., documented the resident was found in a sitting position on the floor between the wheelchair and couch. The note documented the resident had no signs or symptoms of injury. An incident report, dated 11/03/10, documented the resident was found sitting on the floor. The report documented the physician and family had been notified. The report documented to prevent recurrence the resident would be encouraged to use the call light for assistance and yell if no one responded to the call light. The report documented the aides were cautioned to watch the resident closer. The 07/02/10 care plan had not been updated after the fall except for the undated interventions to use a bed and chair alarm. A physical therapy form, dated 11/05/10 through 11/11/10, documented the resident refused therapy three days. A nurse's note, dated 11/14/10 at 12:00 a.m., documented the resident was found on the floor by the bed. The note documented the resident had skin tears. The note documented the resident stated, "I took that thing off so I didn't bother you. I don't need help(.) (I)f you help me I can't go home." The note documented the nurse requested the resident not take the alarm off and to use the call light. A nurse's note, dated 11/14/10 at 7:00 p.m., documented the resident complained of low back pain. The note documented an order had been obtained for an x-ray of the back and hip. An incident report, dated 11/14/10, documented the resident was found on the floor in her room. The report documented to prevent recurrence the resident would be taught the importance of receiving assistance with transfers. An x-ray report, dated 11/14/10, documented compression type deformities at L3 and L1 (lumbosacral) of indeterminate age and fractures involving the left superior and inferior pubic rami (pelvis) which were acute/subacute in age. The 07/02/10 care plan had not been updated after the fall except for the undated interventions to use a bed and chair alarm. A nurse's note, dated 12/09/10 at 1:10 a.m., documented the resident's alarm was intact. The note documented the resident kept her wheelchair by the bed and attempted to transfer without assistance. A nurse's note, dated 12/17/10 at 10:55 a.m., documented the resident got up to go to the bathroom without assistance. The note documented the resident did not lock the brake on the wheelchair, causing her to fall to the floor. The note documented the resident sustained [REDACTED]. The 07/02/10 care plan had not been updated after the fall except for the undated interventions to use a bed and chair alarm. A nurse's note, dated 12/19/10 at 11:45 a.m., documented a family member requested the resident be given pain medication for pain in the hip and leg. A nurse's note, dated 12/20/10 at 1:40 p.m., documented the resident was found on sitting on the floor. The note documented the resident denied pain in her hips. The note documented range of motion to the lower extremities was within normal limits, the resident's hands were equal in grip and strength, and denied any pain to the head. The note documented the resident denied hitting head and her eyes were equal to light. The note documented the resident was assisted to the couch, the personal alarm was placed on the resident's shoulder, the call light was within reach, and the resident was encouraged to use the call light when getting up. The 07/02/10 care plan had not been updated after the fall except for the undated interventions to use a bed and chair alarm. A nurse's note, dated 01/17/11 (no time specified), documented the resident was found on the floor and complained of her head hurting. The note documented the resident did not have signs and symptoms of injury. An incident report, dated 01/17/11, documented the resident was found on the floor. The report documented the physician and the family had been notified. To prevent recurrence the aides were instructed to keep the resident's door open and monitor the resident more closely. A nurse's note, dated 01/22/11 at 12:00 p.m., documented the resident was found in a sitting position on the bathroom floor. The note documented the resident stated she slid down. The note documented the resident did not have signs and symptoms of injury. An incident report, dated 01/22/11, documented the resident was found on the bathroom floor. The report documented the physician and the family had been notified. To prevent recurrence the resident was instructed to use the call light. The 07/02/10 care plan had not been updated after the fall except for the undated interventions to use a bed and chair alarm. A nurse's note, dated 02/01/11 (no time specified), documented the resident was found in a sitting position on the floor by the bed. The note documented the resident stated, "I was getting in my chair (w/c) (wheelchair) & it moved." The note documented the resident was wearing socks, denied pain to the hip area, and had a 0.25 x 0.25 centimeter skin tear to the right wrist. The note documented the range of motion was within normal limits in all four extremities and the doctor and daughter were notified. The 07/02/10 care plan had not been updated after the fall except for the undated interventions to use a bed and chair alarm. A nurse's note, dated 02/09/11 at 11:45 (not specified if a.m. or p.m.), documented the resident was self sufficient with moderate help from the certified nurse aides for most ADLs. On 03/03/11 at 9:00 a.m., the physician was interviewed regarding the resident's falls. The physician stated the resident had been admitted to the facility after a fall at home which resulted in a fractured hip. The physician acknowledged the resident had fallen an sustained a fractured elbow and pelvis. The physician stated he was not sure what specific measures had been implemented to prevent falls for the resident. On 03/03/11 at 10:00 a.m., the director of nurses (DON) was interviewed regarding what measures had been implemented to prevent falls for the resident. The DON stated the resident had been on a low bed with a mattress on the floor and a bed and chair alarm had been used for the resident.

Based on record review, observation, and staff interview, it was determined the facility failed to provide restorative services to increase range of motion (ROM) and/or prevent further decrease in range of motion for two (#3 and #12) of 11 sampled residents with limitations in ROM. This had the potential to affect 13 residents identified by the facility as being on a restorative program and 16 residents identified by the facility as having contractures. Findings: 1. The medical record for resident #3 contained a physician's progress note, dated 04/12/10, from the hospital which the resident had been transferred. The progress note documented the resident had contractures with foot drop. The medical record documented the resident was admitted to the facility on [DATE]. An admission assessment, dated 04/29/10, documented the resident had [DIAGNOSES REDACTED]. The assessment documented the resident was comatose and required total assistance with all activities of daily living (ADLs). The assessment documented the resident had full loss of range of motion to upper and lower extremities. The assessment documented the resident did not have pain and had not received any restorative range of motion exercise. The care plan, dated 04/29/10, documented a problem of being totally dependent on the staff for ADLs. Approaches included turning and repositioning every two hours, transferring with a lift, and providing bathing and hygiene for the resident. Another problem identified the resident as having restricted mobility. The care plan did not identify any deficits in ROM or contractures. A restorative care flow record for November 2010 documented the resident was on a restorative plan to prevent further contractions and was to receive passive ROM three to five times a week. The assessment documented the resident had not received restorative services from the 21st through the 30th. The form documented the restorative aide (RA) was off on those days. A occupational therapy (OT) note, dated 12/12/10 through 12/18/10, documented the resident was to be discharged from OT to long term care with instructions for the restorative nursing to provide passive range of motion (PROM) and bed mobility. A restorative nursing referral form, dated 12/20/10, documented the resident was no longer appropriate for therapy but would benefit from ongoing intervention. The suggested programs were marked for bed mobility, communication, and ROM. The restorative care flow record found with the December 2010 records, but not dated, documented the RA had been pulled from restorative seven times during the month. The resident did not receive restorative services on those days. The January 2011 restorative care flow record documented the resident had received restorative services only three times during the entire month. The form documented the RA had been pulled 16 days and was off eight days. The restorative nursing care plan and progress notes documented the problem or need was to prevent further contractures in the upper and lower extremities. An approach was listed to provide PROM three to five times a week. A quarterly assessment, dated 01/29/11, documented the resident was comatose and required total assistance with all ADLs. The assessment documented the resident had bilateral loss of range of motion to the upper and lower extremities. There was no restorative care flow record for the month of February 2011. On 03/01/11 at 9:30 a.m., the resident was observed in bed in his room. LPN #1 was observed to provide a dressing change and suction the resident's [MEDICAL CONDITION]. The resident tolerated the treatments with little movement. There was no verbal response, but the resident opened his eyes during the procedures. The only discernable reaction by the resident was displayed when suctioned. The resident coughed extensively during the procedure. The resident's legs were stiff and his feet were observed to have foot drop. The resident's left foot was observed to have extensive deformity with the toes curling downward toward the ball of his foot. The resident's hands were closed. Slight movement was observed in the resident's right hand, but the resident did not move his arms during the entire procedure. After observing the resident's physical condition, the medical record was reviewed for documentation of the resident's contractures on admission to determine if the resident's contractures had increased or worsened. There was no documentation regarding the resident's contractures. The only documentation was an admission note on 04/16/10 which documented the resident's arrival, vital signs, wounds from a chest tube, no skin issues, and that the resident was dependent on staff. There was no mention the resident had any contractures. On 03/01/11 at 10:00 a.m., the director of nursing (DON) was interviewed regarding the resident's contractures and the lack of nursing assessments regarding the contractures. The DON reviewed the medical record and reported the only mention of the contractures she could find was the progress note from the hospital, dated 04/12/10, which documented the resident had contracture/foot drop prior to admission. The DON was asked how the facility could determine if the resident's contractures had declined if the facility was not documenting any measurements of the contractures. The DON stated, "I see what you mean." The DON reported they could not determine if there had been a decline and she was aware the documentation needed to improve. On 03/01/11 at 11:40 a.m., licensed practical nurse (LPN) #3 was interviewed regarding the lack of any documentation of restorative services for the month February. The LPN reported the RA had quit a month ago and they were looking for someone to take the position. The LPN reported no one had been doing the restorative since the RA left. On 03/02/11 at 9:30 a.m., certified nurse aide (CNA) #2 was interviewed regarding the restorative flow record documenting "pulled." The CNA reviewed the restorative documentation and reported the RA had been pulled to work on the floor and was not able to do the restorative program with the resident. On 03/03/11 at 8:40 a.m., the resident's physician was interviewed regarding the resident's contractures and lack of restorative services. The physician reported restorative recommendations were made by physical therapy (PT). He reported the nursing staff sometimes asked for a restorative plan. The physician reported the restorative should be doing something with everyone. The lack of assessment of the resident's contractures for any decline was discussed with the physician. The physician reported the contractures should have been assessed and documented. The physician then stated the resident's contractures had increased. He stated the resident's legs were stiffer now. The physician reported the resident should be getting ROM daily. 2. The medical record for resident #12 documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. An admission assessment, dated 04/14/10, documented the resident had no memory problems and required limited assistance with transfers, ambulation, dressing, hygiene, and extensive assistance with bathing. The assessment document the resident had partial loss of range of motion (ROM) in the arm, hand, leg, and foot on one side of the body. The assessment documented no restorative ROM was provided during the seven days of the assessment period. The resident's care plan, dated 04/14/10, documented the resident required limited assistance with transfers. Approaches documented checking to assure activities of daily living (ADLs) had been completed to the usual standard, to verbally prompt the resident to perform self-care, and to offer assistance as needed. A hand written notation on the bottom of the approach section documented to use a gait belt with one person assistance. An occupational therapy (OT) note, dated 12/19/10 through 12/25/10, documented the resident was to be discharged from OT services to restorative services. The form documented therapeutic exercise of assistive range of motion (AROM) to the bilateral upper extremity. The restorative care flow record for November 2010 documented the goal for the resident was to increase mobility and strength. The form documented services were to be provided three to five times a week. The form documented ROM and a section with weights and bicycle had been written on the form. The form documented the resident received the services from 12/01 to 12/19. The form had "off" written on 12/21 through 12/30 indicating the restorative aide (RA) had been off and the restorative services had not been provided. The restorative care flow record for December 2010 documented an additional section for ambulation. The form documented the resident had ambulated only one time during the entire month. The restorative care flow record for January 2011 documented the RA had been off eight days during the month and had been pulled 17 times. The form documented the resident had received restorative only three times during the entire month. A quarterly assessment, dated 01/14/11, documented the resident continued to have limitations in ROM in the upper and lower extremities. The assessment documented the resident had not received any restorative care during the seven day assessment period. There was no restorative care flow record for the month of February 2011. On 03/01/11 at 11:40 a.m., LPN #3 was interviewed regarding the lack of documentation of restorative services for the month February. The LPN reported the RA had quit a month ago and they were looking for someone to take the position. The LPN reported no one had been doing the restorative since the RA left. On 03/02/11 at 9:30 a.m., certified nurse aide (CNA) #2 was interviewed regarding the resident's restorative flow record documenting "pulled." The CNA reported pulled meant the RA had been pulled to work on the floor and was not able to do the restorative program with the resident. The CNA reported there had not been any restorative services since the last RA had left. On 03/02/11 at 12:30 p.m., the resident was observed in her room. The resident was asked if she received any restorative services. The resident reported she used to, but had not had any restorative since the restorative person quit. The resident reported she needed the restorative ambulation and wished she could have restorative ambulation. The resident reported no one was walking her at that time.