Every finding on record at Elk Crossing

Based on observation, record review, and interview, the facility failed to ensure infection control practices were followed for residents with urinary catheters for 2 (#1 and #13) of 2 sampled residents reviewed for urinary catheters.The administrator identified two residents with urinary catheters resided in the facility. Findings:1. On 04/20/26 at 1:41 p.m., Resident #1 was observed being pushed into their room by a staff member. Resident #1's urinary catheter bag was observed to hang under their high-back wheelchair and drag on the floor.On 04/22/26 at 2:44 p.m., Resident #1 was observed lying in bed. Resident #1's urinary catheter bag was observed to hang from the bed frame and touch the floor.A care plan intervention for Resident #1, dated 07/07/20, showed the resident had a suprapubic catheter and was dependent on staff participation to maintain, such as cleaning and emptying.A quarterly assessment for Resident #1, dated 02/02/26, showed the resident's cognition was severely impaired with a BIMS score of six. The assessment showed Resident #1 had an indwelling urinary catheter and a diagnosis of obstructive uropathy.A physician's order for Resident #1, dated 04/05/26, showed to change the suprapubic catheter every month.On 04/22/26 at 2:45 p.m., LPN #1 stated Resident #1's urinary catheter bag should not touch the floor due to infection control concerns. 2. On 04/22/26 at 2:38 p.m., Resident #13 was observed in their wheelchair. The urinary catheter bag was observed to hang under the wheelchair and lay on the floor.A physician order for Resident #13, dated 04/16/26, showed urinary catheter care was to be provided every shift and as needed. A face sheet, dated 04/22/26, showed Resident #13 was admitted to the facility on [DATE] with a diagnosis of urinary retention.On 04/22/26 at 2:40 p.m., LPN #2 stated Resident #13's urinary catheter bag lying on the floor was an infection control issue. On 04/22/26 at 2:46 p.m., the DON stated urinary catheter bags in contact with the floor were an infection control concern.

Based on observation, record review, and interview, the facility failed to ensure food was prepared and served in a sanitary manner that minimized the risk of infection/cross contamination during 2 of 2 meal preparation and service observations.The dietary manager identified 109 residents received nutrition from the kitchen. Findings:On 04/20/26 at 10:50 a.m., [NAME] #2 and a dietary aide were observed in the kitchen performing tasks without wearing beard guards covering their facial hair. The dietary aide was observed to scrub the sink and walls in the dish room. [NAME] #2 was observed to set up dishes and prepare the lunch meal. On 04/20/26 at 12:08 p.m., the following observations were made: a. [NAME] #1 was observed to prepare a sandwich using their bare hands, b. [NAME] #2 was observed to touch the ice scoop, cups, lids, straws, and plates while serving resident meals without washing their hands, and c. [NAME] #2 was observed to wear a beard guard but did not have a hair restraint over their mustache. A facility policy titled Food Safety and Sanitation, dated 2021, read in part, All staff will use safe food handling practices .Beard nets are required when facial hair is visible .Employees will wash their hands just before work and any time after they touch their face, hair, or other surfaces with potential for contamination. On 04/20/26 at 11:24 a.m., the dietary manager stated, They are supposed to wear guards. On 04/20/26 at 1:30 p.m., the dietary manager stated staff were supposed to avoid touching food with their ungloved hands. On 04/21/26 at 10:00 a.m., the registered dietician stated facial hair restraints and food handling was discussed often with dietary staff.

Based on observation, record review, and interview, the facility failed to develop a baseline care plan for a urinary catheter for 1 (#13) of 2 sampled residents reviewed for urinary catheters.The administrator identified 2 residents with urinary catheters resided in the facility. On 04/22/26 at 12:50 p.m., Resident #13 was observed in their wheelchair with a catheter bag hanging under the wheelchair and lying on the floor.An undated policy titled Baseline Care Plan, showed the baseline care plan will include immediate care needs, activities of daily living assistance needs, and any required precautions or equipment.A baseline care plan for Resident #13, dated 04/15/26, contained no documentation of a urinary catheter. The baseline care plan showed Resident #13 required two or more staff assistance with toileting.A physician order for Resident #13, dated 04/16/26, showed urinary catheter to gravity, and catheter care every shift and as needed.A face sheet for Resident #13, dated 04/22/26, showed the resident was admitted to the facility on [DATE] with a diagnosis of urinary retention.On 04/22/26 at 9:52 a.m., CNA #1 and CNA #2 stated Resident #13 had the urinary catheter when they were admitted to the facility.On 04/22/26 at 2:45 p.m., the DON stated a catheter should have been included on Resident #13's baseline care plan.

Based on record review and interview, the facility failed to ensure allegations of abuse were reported to the OSDH as required for 1 (#7) of 1 sampled resident reviewed for abuse. The administrator identified 109 residents who resided in the facility. Findings:The facility policy titled Reporting Abuse, revised 2014, read in part, It is the responsibility of our employees, facility consultants, physicians, family members, etc., to promptly report any incident of resident abuse to facility management .Staff members shall not knowingly withhold information from reporting agencies .Abuse investigations, reporting abuse to state agencies and other entities/individuals.A significant change assessment for Resident #7, dated 03/26/26, showed the resident had a BIMS score of15 indicating intact cognition. The assessment showed Resident #7 required moderate assistance with activities of daily living.An investigation report, dated 03/30/26, showed Resident #7 reported that an aide had slapped her. The report read in part, Upon immediate assessment and investigation, the statement was evaluated and determined not to constitute a credible allegation of abuse based on lack of specificity, absence of physical findings, and inconsistence observed with care and staff interaction. Therefore, it does not meet criteria for mandatory reporting under abuse regulations.A care plan for Resident #7, updated 04/06/26, showed the resident had impaired thought processes related to metabolic encephalopathy.On 04/21/26 at 12:24 p.m., Resident #7 stated about a month ago, a nurse aide slapped them while assisting with a shower. Resident #7 stated it was one of those traveling nurses. Resident #7 stated they still work here but they don't take care of me. Resident #7 stated they were not afraid for safety or retaliation.On 04/21/26 at 12:45 p.m., the DON stated an immediate investigation was initiated regarding the allegation of abuse for Resident #7. They stated they had determined the allegation was not substantiated. The DON stated the abuse allegation was not reported to the OSDH. On 04/22/26 at 9:38 a.m., CNA #3 stated a hospice aide had been assisting Resident #7 with a shower. CNA #3 stated they entered the shower room to inquire if the hospice aide needed help because Resident #7 had particular requests when finishing and would become agitated if a person did not meet their demands timely. CNA #3 stated they began assisting Resident #7 by untangling the oxygen tubing. CNA #3 stated when they bent down to unplug the oxygen concentrator, Resident #7 yelled you slapped me. CNA #3 stated the hospice aide was in the other part of shower room cleaning up and they were confused as to whom Resident #7 was referring to. CNA #3 stated they immediately reported the allegation of abuse to the DON.On 04/22/26 at 12:50 p.m., the DON and administrator provided an internal investigation report for the abuse allegation. The DON stated they should have sent the report to the OSDH.On 04/23/26 at 1:00 p.m., a family member of Resident #7 stated the facility had called them and reported Resident #7's allegation of being slapped by a staff member on the day it happened. The family member stated they observed Resident #7 daily for a week for any signs of bruising since the resident bruised easily. The family member stated Resident #7 made up the allegation of abuse because she got mad and didn't get her way. The family member stated the resident had a history of falsely accusing people of wrong doings.

Based on observation and interview, the facility failed to ensure proper food service sanitation and storage requirements were followed. The Long Term Care Facility Application for Medicare and Medicaid, dated 04/22/24, documented 83 residents resided in the facility. The CDM identified one resident received nutrition and hydration solely through a feeding tube. Findings: On 04/22/24 at 11:15 a.m., a tour of the kitchen was conducted. The following observations were made. a. a oven hood light was burned out and/or not working, b. there was an accumulation of black and brown residue on the floor and the wall in the dish wash area, c. the metal back splash was not secure to the wall in the dish wash area, d. the gasket on the walk in freezer door was split and in bad repair, e. there were two plastic storage bags of ready to eat hot dogs with open dates of April 7th and April 8th in the walk in cooler, and f. there was a plastic storage bag of ready to eat turkey with a discard date of April 20th in the walk in cooler. On 04/22/24 at 11:25 a.m., the CDM was asked what was the date marking policy. They stated the date on the hot dogs was the date they were opened. They stated the the hot dogs were to be held for seven days once opened. They stated the turkey should have been discarded. On 04/22/24 at 11:31 a.m., a tour of the long term care serving and dining area was conducted. The gasket on the Delfield one door reach in cooler was observed split and in bad repair. On 04/22/24 at 11:40 a.m., a tour of the skilled serving and dining area was conducted. The gasket on the ice cream freezer was observed split and in bad repair. On 04/24/24 at 12:22 p.m., the CDM was asked how staff ensure food service areas were kept clean and maintained in good repair. They stated they cleaned daily and maintenance concerns were reported to the maintenance department. They were made aware of the cleaning and maintenance concerns. On 04/24/24 at 12:33 p.m., there was a blanket on the floor around the garbage disposal drain. The CDM stated there were plumbing issues and water flood the floor.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for one (#59) of 18 sampled residents whose resident assessments were reviewed. The Long Term Care Facility Application for Medicare and Medicaid, dated 04/22/24, documented 83 residents resided in the facility. Findings: Res #59 had diagnoses which included hyperlipidemia and non-ruptured cerebral aneurysm. A quarterly assessment, dated 04/03/24, documented the resident had received an anticoagulant during the last seven days or since admission/entry or reentry if less than seven days. There was no documentation the resident had received an anticoagulant during the last seven days or since admission/entry or reentry if less than seven days. On 04/23/24 at 2:32 p.m., the DON was made aware the resident's 04/03/24 quarterly assessment documented the resident received an anticoagulant during the last seven days or since admission/entry or reentry if less than seven days. They stated the resident received aspirin and clopidogrel bisulfate. They were coded as anticoagulants instead of antiplatelets.

Based on record review and interview, it was determined the facility failed to: a. maintain documentation in the resident's medical record regarding the education provided to the resident or resident's representative regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine before administration, and; b. maintain documentation of a signed consent or refusal in the resident's medical record for the COVID-19 vaccine for one (#17) of five residents reviewed for vaccinations. The Resident Census and Conditions of Residents, dated 03/20/23, documented 66 residents resided in the facility. Findings: The facility's Vaccination of Residents policy, dated 04/01/13, read in parts, .All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated .Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations .Provision of such education shall be documented in the resident's medical record . Resident #17 was admitted to the facility on [DATE]. The medical record for resident #17 documented a COVID-19 vaccine was administered on 09/09/22. The resident's medical record documented no proof of the education provided to the resident or resident's representative on the benefits, risks, and side effects of the COVID-19 vaccine before administration. The resident's medical record contained no consent signed by the resident or resident's representative for the COVID-19 vaccine before administration of the vaccine. On 03/23/22 at 10:00 a.m., the Administrator reported a nurse documented a vaccine consent or refusal in progress notes of the resident's medical record. The Administrator reported the vaccines administered in the facility were documented in the resident's medical record with the vaccine type, administration location, and the vaccine lot number. The Administrator reported the resident's medical record did not contain a signed consent or the education provided. The Administrator reported the facility had an outside pharmacy, or other medical facility, administer vaccines and the facility did not keep vaccines in the facility. On 03/23/22 at 10:59 a.m., the IP/ADON reported no signed vaccination consents or declinations had been kept in the facility for any residents. The IP/ADON reported the pharmacy which provided resident vaccinations supplied a consent form and the form contained education regarding the vaccine for residents or the resident's representative to sign for consent or refusal of the vaccine before administration. The IP/ADON reported a facility nurse rounded with the pharmacy staff to educate and obtain consent for the vaccine, but the facility did not keep a copy of the pharmacy's form for the resident's medical record.

Based on record review and interview, the facility failed to: a. document the provision of information and education regarding the risks, benefits, and potential side effects of the influenza and/or pneumococcal vaccinations, and; b. maintain a signed consent or declination from the resident or resident's representative for four (#17, 47, 53, and #60) of five residents reviewed for vaccinations. The Resident Census and Conditions of Residents, dated 03/20/23, documented 66 residents resided in the facility. Findings: The facility's Vaccination of Residents policy, dated 04/01/13, read in parts, .All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated .Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations .Provision of such education shall be documented in the resident's medical record . 1. Resident #17 was admitted to the facility on [DATE]. The medical record for resident #17 documented an influenza vaccine was given on 10/13/22. The resident's record did not contain a signed consent, or contain documentation to indicate education was provided to the resident or their representative before administration of the influenza vaccine. 2. Resident #47 was admitted to the facility on [DATE]. The medical record for resident #47 documented no proof the resident or resident's representative had been offered, provided education, and no signed a consent or refusal for the influenza vaccination. The resident's record did not document the influenza vaccine had been given before admission. 3. Resident #53 was admitted to the facility on [DATE]. The medical record for resident #53 documented an influenza vaccine was given on 11/02/22. The resident's record did not contain a signed consent or document education was provided to the resident or resident's representative before administration of the influenza vaccine. 4. Resident # 60 was admitted to the facility on [DATE]. The medical record for resident #60 documented the pneumococcal vaccine was refused. The resident's record did not contain a signed refusal or document education was provided to the resident or resident's representative before refusal of the vaccine. On 03/23/22 at 10:00 a.m., the Administrator reported a nurse documented a vaccine consent or refusal in progress notes of the resident's medical record. The Administrator reported the vaccines administered in the facility were documented in the resident's medical record with the vaccine type, administration location, and the vaccine lot number. The Administrator reported the resident medical records did not contain a signed consent or the education provided. The Administrator reported the facility had an outside pharmacy, or other medical facility, come in to administer vaccines and the facility did not keep the vaccines in the facility. On 03/23/22 at 10:59 a.m., the IP/ADON reported no signed vaccination consents or declinations had been kept in the facility. The IP/ADON reported the pharmacy which provided resident vaccinations supplied a consent form, and the consent form contained education regarding the vaccine for residents or their representative to sign for consent or refusal of the vaccine before administration. The IP/ADON reported a facility nurse rounded with the pharmacy staff to educate and obtain consent for the vaccine, but the facility did not keep a copy of the pharmacy's form for the resident's medical record.

Based on record review and interview, it was determined the facility failed to ensure the minimum data set (MDS) assessment was accurate for four (#3, #19, #26 and #50) of nine records whose assessments were reviewed, This had the potential to affect all 80 residents. Finding: 1. Resident #3 was admitted with [MEDICAL CONDITION] and a stage four pressure ulcer. An admission/re-admit form, dated 08/04/18, documented the resident had a stage four pressure ulcer to the buttock measuring 4.5 centimeters x 5 centimeters x 2.5 centimeters. A care plan, dated 08/21/18, documented the resident had a stage four pressure ulcer to his left buttock and to administer treatments as ordered and monitor for effectiveness. An assessment, dated, 02/08/19, documented the resident was cognitively intact and had a stage four pressure ulcer that was not present on admission. During an interview with resident #3 on 02/11/19 at 9:54 a.m., he stated he had developed the pressure ulcer at home and was admitted to the facility with it. During and interview with the MDS coordinator #1 on 02/12/19 at 2:28 p.m., she stated the the MDS should have been marked that the pressure ulcer was present on admission. 2. Resident #19's significant change assessment, dated 11/30/19, documented the resident had received an anticoagulant medication every day for the prior seven-day look back period. Review of the clinical record had not documented the resident had received an anticoagulant medication. On 02/12/19 at 11:48 a.m., MDS coordinator #1 was asked if the resident had received an anticoagulant medication during the seven-day look back period. She stated, No. The assessment was incorrect. 3. Resident #26 had [DIAGNOSES REDACTED]. The resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The resident's quarterly assessment, dated 12/14/18, had not documented on the medication seven-day look back period the resident had taken an anti-anxiety or an anti-coagulant. On 02/12/19 at 10:05 a.m., MDS coordinator #2 was shown the (MONTH) (YEAR) Medication Administration Record [REDACTED]. She was in agreement they should have been documented. 4. Resident #50 had a [DIAGNOSES REDACTED]. The (MONTH) 2019 physician orders [REDACTED]. The annual assessment, dated 01/08/19, had not documented the resident had received an anticoagulant in the prior seven-day look back period. The (MONTH) 2019 Medication Administration Record [REDACTED]. On 02/12/19 at 11:52 a.m., assessment coordinator #1 was asked if the anticoagulant had been documented on the 01/08/19 assessment as having been received daily the prior seven days. She stated, No.

Based on observation and interview, it was determined the facility failed to ensure drinking glasses, silverware and an ice scoop were stored in a sanitary manner. This had the potential to affect 52 residents who received meals and iced beverages from the long term care bistro area. Findings. On 11/29/17 at 10:58 a.m., an initial tour of the kitchen was conducted. The drinking glasses were stored upside down and they were wet. On 11/30/17 at 10:51 a.m., the ice machine was observed with the ice scoop handle touching the ice. Also the drinking glasses were stacked wet. On 12/05/17 at 10:00 a.m., the ice machine was observed with the ice scoop handle touching the ice. Drinking glasses were stacked wet. On 12/06/17 at 9:34 a.m., the ice machine was observed with the ice scoop handle touching the ice. Drinking glasses were stacked wet. At 9:38 a.m., the spoons, knives and forks were all stored with eating surface facing up in round containers. The only way to have removed them from the containers was to have touched the eating surface. At 11:10 a.m., cook #1 and the director of nurses were shown the wet glasses and the ice scoop touching the ice. They were both in agreement the glasses should not have been stored wet, the ice scoop handle should not have been touching the ice and the silverware had been stored improperly.

Based on record review and interview, it was determined the facility failed to ensure residents received the supervision and the assistance needed with toileting to prevent falls, which resulted in harm for one (#1) of four residents whose records were reviewed for supervision and assistance. Resident #1 had experienced multiple falls. The last fall resulted in a hip fracture, which led to her death 3 days later, according to the official death certificate. This had the potential to affect 33 residents who were identified at risk for falls. Findings: Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. An admission assessment, dated 08/04/16, documented the resident had a brief interview for mental status and had scored a 6, which indicated the resident was severely cognitively impaired. It documented the resident needed extensive assistance, requiring weight bearing support by staff for transfers, toilet use, and dressing with two person assistance. It documented the resident needed extensive assistance with ambulation and hygiene with one person assistance, physical help in part with bathing with one person assistance, supervision with setup only with eating, and was frequently incontinent of bowel and bladder. A 14-day assessment, dated 08/11/16, documented the resident needed extensive assistance with transfers with one person assistance. A care plan, dated 08/17/16, documented a problem of the resident having had an actual fall with minor injury r/t (related to) poor balance, poor communication/comprehension, and unsteady gait. There were no documented interventions for supervision. An incident report, dated 08/17/16, documented the resident was being transferred from her wheelchair to her bed. The resident had begun to slip and the licensed practical nurse (LPN) assisted the resident to the floor. The resident's left leg was caught on a bar underneath the bed, causing a large, deep laceration. The resident was sent to a local emergency room (ER) for treatment. A fall intervention put in place by the facility upon her return was for the resident to have worn proper footwear and grip tape was added to the side of the bed. A daily skilled nurse's note dated 08/17/16, documented Res (resident) alert and oriented to self only. Denies pain at this time .Fall today, left lower leg skin tear to the bone. Sent to ER. Continue to Monitor. Continues on skilled therapy . A nurse's note, dated 08/17/16, documented Resident Sent To ER, Fall in Room. Injury to Left Shin. Sent Via Ambulance . A physical therapy treatment encounter note, dated 08/19/16, documented, .Nurse reported that the pt (patient) needed max (maximum) A (assistance) x (times) 2 to transfer to toilet . The care plan, dated 09/02/16, documented the resident had impaired cognitive function/dementia or impaired thought processes related to dementia and needed assistance with all of her decision making. It documented the resident had an activities of daily living self care performance deficit related to immobility and she required extensive assistance with one staff participation with transfers. She required extensive assistance with one staff to turn and reposition in bed and required extensive assistance of one staff to dress. The care plan also documented the resident had physical mobility problems related to falls and arthritis. She required extensive assistance with one staff participation for mobility. A fall risk assessment, dated 09/06/16, documented the resident was a moderate fall risk. A facility incident report, dated 09/06/16, documented Resident noted on the floor beside her bed .Resident was yelling out for help, call light on pillow at this time. Resident assisted back to bed, no injuries apparent at this time. Resident states she was trying to get to the bathroom .Resident placed on falling star program at this time. Continues with PT (physical therapy)/OT (occupational therapy) 5 x (times)/week The care plan, revised on 09/08/16, documented the resident had a fall on 09/06/16 and was discovered on the floor on her bottom next to her bed. Her call light was on the pillow. Resident reports she was trying to get to the bathroom and lost balance. .Re-educated resident and demonstrated the use of the call light . An incident report, dated 09/16/16, documented .Was called to resident's room, noted resident on floor in bathroom in front of toilet yelling help me, help me. No injuries noted. Family notified . The care plan, updated 09/16/16, documented the resident experienced a fall and the nurse was called to resident's room and observed the resident sitting on the floor in front of her toilet. The resident was yelling help me, help me. No injuries were noted. The resident reported she was trying to get to the bathroom and lost her balance. An incident report sent to the State, dated 09/24/16, documented, .CNA (certified nurse aide) observed resident on floor in bathroom and came and got this lpn (licensed practical nurse). alarm was undone, wheel chair and walker sitting beside the bed. assessment was done no injuries noted. neuros (neurological checks) started . A facility incident report, dated 09/24/16, documented, .talked to resident about using call light . The care plan, updated 09/24/16, documented the resident experienced a fall and the CNA observed the resident on the floor in the bathroom. The resident stated I just got up to go to the restroom .talked to resident about using call light . An incident report sent to the State, dated 09/29/16, documented the resident was observed on the floor. The resident had stated she slid off the bed when she had sat up. The resident denied hurting herself. A mobility bar was placed on the bed to help prevent future falls and help the resdient with transfers and positioning. The care plan, updated 09/29/16, documented, .educated resident again on using call light for assist . An incident report sent to the State, dated 10/04/16, documented .This nurse was called to the resident's room by staff. When I entered the residents bathroom staff had assisted her off the floor and into her wheelchair. Upon assessment resident started yelling that her leg was broke and the pain was awful .(mobile X-ray name) mobile X-ray was called for a portable X-ray to be done. The X-ray tech (technician) called back and stated that it would be an hour or more before he could get here, canceled that X-ray. Notified (Name deleted) that the mobile X-ray was canceled and sending resident to (local hospital name) ER. (Name of ambulance service deleted) ambulance was called and resident was transported to (local hospital) ER . A physician's progress note, dated 10/04/16, documented Resident was attempting to transfer from her W/C (wheelchair) to the commode w/o (without) assistance. Staff had observed patient in the floor of her bathroom lying on her left side by the commode. Patient then raised upright onto her bottom and began trying to raise herself up .Mobile X-ray was unable to complete a STAT X-ray. Patient sent to (local hospital) ER r/t uncontrollable pain. Patient was yelling out in pain and inconsolable. An incident report, dated 10/04/16, documented .Patient admitted to (local hospital name) for left hip fracture There was no documentation of any supervision interventions put in place to prevent falls. The resident was severely cognitively impaired and was unable to use the call light. On 07/20/17 at 9:15 a.m., certified medication aide (CMA) #2 was asked about the fall the resident experienced on 10/04/16. She stated CMA #1 had assisted the resident onto the toilet. Both of them were outside the resident's room when they had heard the resident yelling out for help. She stated when they entered the resident's restroom, they observed the resident was on the floor and had pulled her pants up and was attempting to get up into her wheelchair. They got the charge nurse and the charge nurse came in along with other aides and she left the resident's room. On 07/20/17 at 10:08 a.m., CMA #1 was asked about the fall the resident experienced on 10/04/16. She stated CMA #2 had assisted the resident onto the toilet. Both of them were outside the resident's room when they had heard the resident yelling out for help. She stated when they entered the resident's restroom, they observed the resident was on the floor and had pulled her pants up and was attempting to get up into her wheelchair. They got the charge nurse who came in with other aides and she then left the resident's room. At 10:33 a.m., the physical therapy assistant that had assisted the resident with therapy was interviewed and stated the resident was frail and she had to go slow with her therapies. She stated she could not transfer by herself without assistance from the staff. Her memory was not well enough to self-transfer. A State of Oklahoma Certificate of Death, dated 11/17/16, documented the resident's date of death was 10/07/16 and the cause of death was left hip fracture sequelae from a fall. On 07/20/17 at 10:53 a.m., the director of nurses and the assistant director of nurses was asked if any interventions for supervision were put in place for the resident for the restroom after she had experienced multiple falls in the restroom. Both stated that no supervision interventions had been put in place for the resident. They were asked if supervision for the resident should have been put in place to help prevent falls in the restroom. They stated the resident should have had supervision.

Based on record review and interview it was determined the facility failed to ensure assessments were accurate for two (#23 and #62) of 24 residents whose assessments were reviewed for accuracy. This had the potential to affect all 56 residents residing in the facility. Findings: 1. Resident #23 had [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. The original date of both of these medication orders was 07/12/16. The discharge assessment, dated 09/12/16, had not documented the resident had received an antidepressant or an anticoagulant on the seven day look back from the assessment date. The September 2016 Medication Administration Record [REDACTED]. On 09/30/16 at 09:55 a.m., the assessment coordinator was in agreement the assessment was incorrect. 2. Resident #62 had [DIAGNOSES REDACTED]. The resident's physician had ordered the resident to be placed on hospice services on 03/16/16, prior to the resident being admitted to the facility. The resident was admitted to the facility on [DATE]. The admission assessment, dated 06/05/16, had not documented the resident had a life expectancy of six months or less. The quarterly assessment, dated 09/05/16, had not documented the resident had a life expectancy of six months or less. On 09/28/16 at 2:46 p.m., the assessment coordinator was asked if this resident's prognosis had been documented correctly on the assessments. She stated the assessments should have documented the resident had a life expectancy of six months or less. At 3:30 p.m., the assistant director of nurses was shown both assessments and the prognosis that had been documented. She stated the assessments had been documented incorrectly.

Based on record review and interview, it was determined the facility failed to ensure a resident's care plan accurately reflected the resident's current medications for one (#62) of 5 residents who were reviewed for unnecessary medications. This had the potential to affect 8 residents currently receiving an antipsychotic medication according to the Resident Census and Conditions of Residents form. Findings: Resident #62 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/05/16, documented the resident's cognition was severely impaired. He required limited assistance to eat. He required extensive assistance with all other activities of daily living. He was frequently incontinent of bowel and bladder. The current physician's orders [REDACTED]. The medication was ordered to be discontinued on 08/23/16. He was then ordered [MEDICATION NAME] with a start date of 08/24/16, and the medication was ordered to be discontinued on 8/25/16. The resident had not currently been receiving [MEDICATION NAME]. The resident's care plan, dated 09/06/16, documented the resident was receiving [MEDICATION NAME] 0.5 mg 1 by mouth in the afternoon for a mood problem related to anxiety. On 09/29/16 at 4:10 p.m., the assessment/care plan coordinator was interviewed and asked if [MEDICATION NAME] should have been on his care plan dated 09/06/16. She stated, No, it shouldn't be. At 4:15 p.m., the director of nurses was interviewed and asked if this resident was still on [MEDICATION NAME] when the 09/06/16 assessment was completed. She stated, No, he was not on it, it should not be on his careplan.