Every finding on record at Enid Senior Care

Based on record review and interview, the facility failed to have full-time DON coverage for the facility from 04/01/26 through 08/24/26. The administrator identified 47 residents resided in the facility.Findings: A letter from RN #1, dated 08/27/26, read in part, I provided RN consultant services for [NAME] Senior Care from 04/01/26 through 08/24/26 .During that time the ADON was acting in the role of LPN/DON with my RN oversight. On 08/27/2026 at 1:19 p.m., the administrator stated they were not able to find documentation the facility had DON coverage in the facility from 04/01/26 through 08/24/26. On 08/27/26 at 1:52 p.m., RN #1 stated they were not working in the facility for eight consecutive hours, most of their work was performed remotely.

Based on record review and interview, the facility failed ensure a staff member identified in an allegation of abuse was immediately removed from the facility to protect residents from the potential for further physical abuse for 1 (#10) of 3 sampled residents reviewed for abuse. The administrator identified 47 residents resided in the facility.Findings:A policy titled Abuse - Neglect - Misappropriation - Mistreatment, dated 02/16/24, read in part, The facility will act immediately to protect the resident when being notified of any Allegation .Any staff member found to have been a part of the allegation will be immediately suspended and remain suspended throughout the investigation.A quarterly assessment for Resident #10, dated 02/16/26, showed the resident's cognition was severely impaired with a BIMS score of 00. The assessment showed Resident #10 had diagnoses which included dementia and anxiety.An incident form for Resident #10, dated 04/09/26, showed an allegation of abuse that CNA #1 slapped the resident on the face on 04/08/26 around 1:00 p.m. The incident form showed the allegation was reported to administration on 04/09/26 at 9:30 a.m. The incident form showed CNA #1 was suspended on 04/09/26.A timecard report for CNA #1, dated 04/01/26 through 05/15/26, showed CNA #1 worked 6:05 a.m. to 2:15 p.m. on 04/08/26. The timecard report showed CNA #1 worked 6:00 a.m. to 9:55 a.m. on 04/09/26. The timecard showed CNA #1 continued to work for five hours and 10 minutes after the abuse allegation was reported to LPN #1.On 08/27/26 at 11:30 a.m., Housekeeper #1 stated they heard a slap from the hallway from outside the shower room. Housekeeper #1 stated Resident #10 came out of the shower room holding their cheek and said CNA #1 slapped them. Housekeeper #1 stated they went and immediately reported the incident to LPN #1.On 08/27/26 at 11:32 a.m., LPN #1 stated Housekeeper #1 reported they thought CNA #1 had slapped Resident #1. LPN #1 stated they believed they had reported the incident to the previous administrator later that day, but they were not sure. LPN #1 stated they had checked on Resident #10 and due to the language barrier, did not believe the resident was slapped or abused.On 08/27/26 at 12:35 p.m., the administrator stated CNA #1 should have been sent home immediately after Housekeeper #1 reported the abuse allegation to LPN #1 and not allowed to return to the facility until an investigation had been completed.

Based on record review and interview, the facility failed to ensure an allegation of physical abuse was reported to the OSDH within two hours for 1 (#10) of 3 sampled residents reviewed for abuse. The administrator identified 47 residents resided in the facility.Findings:A policy titled Abuse - Neglect - Misappropriation - Mistreatment, dated 02/16/24, read in part, An OSDH form 283 will be sent to OSDH as well as OSDH Adult Protective Services within 2 hours of being notified of any allegation.A quarterly assessment for Resident #10, dated 02/16/26, showed the resident's cognition was severely impaired with a BIMS score of 00. The assessment showed Resident #10 had diagnoses which included dementia and anxiety.An incident form for Resident #10, dated 04/09/26, showed an allegation that CNA #1 slapped Resident #10 on the face on 04/08/26 around 1:00 p.m. The incident form showed the allegation was reported to administration on 04/09/26 at 9:30 a.m. The incident form showed the allegation was reported to the OSDH on 04/09/26 at 11:35 a.m.On 08/27/26 at 11:30 a.m., Housekeeper #1 stated they heard a slap from the hallway from outside the shower room. Housekeeper #1 stated Resident #10 came out of the shower room holding their cheek and said CNA #1 slapped them. Housekeeper #1 stated they went and immediately reported the incident to LPN #1.On 08/27/26 at 11:32 a.m., LPN #1 stated Housekeeper #1 reported they thought CNA #1 had slapped Resident #1. LPN #1 stated they believed they had reported the incident to the previous administrator later that day, but they were not sure. LPN #1 stated they had checked on Resident #10 and due to the language barrier, did not believe the resident was slapped.On 08/27/26 at 12:35 p.m., the administrator stated the incident should have been reported within two hours of the abuse allegation being reported to LPN #1 to the OSDH.

Based on record review and interview, the facility failed to ensure a resident was free from physical abuse for 1 (#10) of 3 sampled residents reviewed for abuse. The administrator identified 47 residents resided in the facility.Findings:A policy titled Abuse - Neglect - Misappropriation - Mistreatment, dated 02/16/24, read in part, It is the policy of [NAME] Senior Care that the residents of this facility will be free of abuse, neglect, mistreatment, and misappropriation of property.A quarterly assessment for Resident #10, dated 02/16/26, showed the resident's cognition was severely impaired with a BIMS score of 00. The assessment showed Resident #10 had diagnoses which included dementia and anxiety.An incident report for Resident #10, dated 04/09/26, showed on 04/08/26, Housekeeper #1 heard a loud smack from outside the bathroom. The incident report showed Resident #10 told Housekeeper #1 that CNA #1 had slapped their face and the resident's cheek was red. The incident report showed an investigation was completed, the abuse allegation was substantiated, and CNA #1 was terminated.A witness statement from Housekeeper #1, dated 04/09/26, showed the housekeeper heard CNA #1 screaming at Resident #10 to sit down in the bathroom. The statement showed Housekeeper #1 heard a loud smack, and Resident #10 started crying. The statement showed Resident #10 was holding their face and said CNA #1 hit them as they exited the bathroom. The statement showed the resident was crying and their cheek was red.On 08/25/26 at 10:34 a.m., Family Member #1 stated a police investigation was being conducted due to the physical abuse and the staff member had been terminated. On 08/27/26 at 11:03 a.m., the administrator stated in-service training related to abuse was conducted with staff after the incident, but no quality assurance and performance improvement plan had been conducted related to the incident.On 08/27/26 at 11:30 a.m., Housekeeper #1 stated they heard a slap from the hallway outside the shower room. Housekeeper #1 stated Resident #10 came out of the shower room holding their cheek and said CNA #1 slapped them. Housekeeper #1 stated they went and immediately reported the incident to LPN #1. Housekeeper #1 stated they reported the incident to their supervisor the next day.On 08/27/26 at 11:32 a.m., LPN #1 stated Housekeeper #1 reported they thought CNA #1 had slapped Resident #1. LPN #1 stated they went and checked on the resident, and it did not look like the resident had been slapped, so they did not feel like the reported incident was abuse.

On 02/21/25, an Immediate Jeopardy (IJ) was determined to exist related to the facility's failure to ensure the safety of Resident #1. The facility did not have a care plan which reflected smoking on admit. The facility failed to ensure interventions were in place when Resident #1 continued to smoke in their room. On 02/05/25 at 3:29 p.m., facility staff noted a fire had started in the trash can in Resident #1's room. Resident #1 had lit a cigarette and had disposed of the cigarette in the trash can in their room. Staff extinguished the fire. At the time of the fire Resident #1 was wearing oxygen. Staff extinguished the fire and evacuated other residents safely. The fire department was called and came to the facility. Resident #1 was sent to the ER for possible smoke inhalation. On 02/21/25 at 5:06 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 02/21/25 at 5:12 p.m., the administrator and ADON were notified of the IJ situation and the IJ template was provided. On 02/24/25 at 4:36 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal showed the total number of residents at risk for the same deficient practice was 59. It showed the actions to remove the immediacy of the alleged deficient practice were the following: a. on 02/05/25, Resident #1's care plan was updated to show the one-on-one intervention implemented, b. on 02/21/25 and 02/22/25, all staff were educated in person and by phone on the updates to the smoking policy put into place, the changes made to what staff could supervise smokers outside, and steps staff were to take if lighters and cigarettes were found in residents' room, and c. all smoking residents were counseled on the smoking policy and the changes made. It showed all smokers care plan interventions were updated for smoking supervision. The plan of removal showed the action taken to prevent recurrence of the alleged deficient practice were the following: a. on 02/24/25, the facility smoking policy would be located at the staff time clock and in the staff break room for review at any time. It showed the master list for smokers would be in a binder kept at the nurses desk, b. the ADON and MDS nurses were re-educated in the process of smoking assessments and smoker safety care plans, c. the director of nursing/ADON/administrator/designee would make routine rounds of smokers' rooms to ensure there were no smoking materials in rooms. The plan of removal showed they would also check with smokers when returning from outings to have them surrender any smoking materials/lighters, d. new residents admitted to the facility would be assessed upon admission and their smoking status determined. It showed a smoking evaluation would be completed and the care plan would be updated quarterly or with significant change in condition, e. the administrator/designee would review the smoking policy with residents who wished to smoke and ensure understanding of all aspects of the policy, f. smoking policy updated showing smoking was not allowed inside the facility and/or any resident room or bathroom under any circumstances, and h. the interdisciplinary team would meet monthly, and review the list of smokers, and address any concerns noted. The IJ was lifted, effective 02/24/25 at 5:27 p.m., when all components of the plan of removal had been verified as completed. The deficient practice remained isolated with the potential for more than minimal harm. Based on record review, and interview, the facility failed to ensure the safety of a resident who smoked for 1 (#1) of 3 sampled residents reviewed for smoking. The administrator identified 59 residents resided in the facility and 21 residents whom were current smokers in the facility. Findings: An undated facility Smoking policy, read in part, this facility will establish and maintain safe resident smoking practices .smoking is only permitted in designated resident smoking areas, which are located outside the building, smoking is not allowed inside the facility and (or in any resident room or bathroom) under any circumstances. Resident #1 had diagnoses which included anxiety, nicotine dependence, and chronic obstructive pulmonary disease. A care plan, date initiated 10/25/23, showed no focus regarding Resident #1 being a smoker. A behavior note, dated 12/26/23, read in part, resident continues to smoke in [their] room and bathroom. Resident continues to not abide by the smoking rules. A Quarterly Smoking Evaluation, dated 01/12/24, showed the resident was safe to smoke with supervision. A quarterly MDS assessment, dated 01/24/25, showed the resident's cognition was intact. An incident note, dated 02/05/25 at 3:29 p.m., read in part, staff called to room by staff member yelling fire down the hallway. Upon entering room, fire alarm was sounding, flames observed coming from area surrounding O2 [oxygen] concentrator, flames also noted coming from trash can in sink. Resident noted sitting in power chair in between two flames but was not attempting to remove [themselves]. An incident note, dated 02/05/25 at 3:55 p.m., read in part, resident was in room when staff observed a fire flamed coming from residents trash can. Staff explaining to resident they needed to get out of the room so we can put the fire out, resident would not leave at first and then staff manually pulled resident out of room from back of electric wheel chair. Resident sent to ER for evaluation. An initial state reportable incident report, dated 02/05/25, showed a fire was found in Resident #1's room. The incident showed the fire was caused by a cigarette that was improperly extinguished in Resident #1's trash can in their room. The report showed Resident #1 was sent to theER on [DATE] at 3:55 p.m. for evaluation of possible smoke inhalation. A care plan, date initiated 02/10/25 and revised 02/10/25, showed the resident was one-on-one with staff monitoring related to the incident with the fire in their room on 02/05/25. A Quarterly Smoking Evaluation, dated 02/20/25, showed the resident was safe to smoke with supervision. On 02/20/25 at 10:31 a.m., Resident #1 was asked what was the facility smoking policy. The resident stated they could not have lighters in their room and could not smoke in their room. The resident stated last summer they smoked in their room and staff caught them. On 02/21/25 at 10:37 a.m., MDS coordinator #1 was asked what the policy was for residents smoking. They stated to keep all cigarettes and lighters in a locked box until smoking times which were every two hours. MDS Coordinator #1 was then asked how staff was keeping Resident #1 safe from having cigarettes or lighters in their room. They stated if it was known the resident had such items they were to be surrendered to the administrator or nurse. MDS Coordinator #1 was then asked to review Resident #1's admit care plan. After review, MDS coordinator #1 was asked if the care plan reflected Resident #1 being a smoker and Resident #1 would hide cigarettes and lighters in there room. They stated, No. MDS Coordinator #1 was then asked to review the care plan and asked if the care plan was updated after the behavior note on 12/26/23 regarding Resident #1 was continuing to smoke in their room and/or bathroom. They stated no it was not. On 02/21/25 at 1:48 p.m., the administrator was asked what was the policy for residents smoking. They stated residents could only smoke outside in the designated area with staff during the designated smoke times. The administrator was then asked what the facility had put in place for Resident #1 to ensure another incident would not occur regarding lighting a cigarette in the resident's room. They stated Resident #1 was placed on one-on-one monitoring with staff 24 hours a day until the facility could find proper placement for them at another facility. On 02/24/25 at 4:38 p.m., CMA #3 was asked the facility policy for smoking. The CMA stated all residents that smoked had to be supervised at the designated smoking times. The CMA was asked where the residents kept their cigarettes and lighters. The CMA stated those items were locked up in a smoke box that was locked up in the medication room. The CMA stated CMAs and nurses had access to unlock the medication room to remove the box. The CMA stated staff would light cigarettes for the residents.

Based on record review and interview, the facility failed to update/revise a care plan for a resident who smoked for 1 (#1) of 6 sampled residents reviewed for care plans. The administrator identified 59 residents resided in the facility. Findings: An undated Smoking policy, read in part, this facility will establish and maintain safe resident smoking practices .smoking is only permitted in designated resident smoking areas, which are located outside the building, smoking is not allowed inside the facility and (or in any resident room or bathroom) under any circumstances. A Care Plans Person-Centered policy, revised December 2016, read in part, the interdisciplinary team must review and update the care plan when there has been a significant change, when the desired outcome is not met, and at least quarterly .incorporate identified problem areas .identifying problem areas and their causes. Resident #1 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, nicotine dependence, and anxiety. A care plan, date initiated 10/25/23, showed no focus added to the care plan for an issue of smoking. Resident #1 had a ongoing issue with smoking at the time of admit, going out to the store for cigarettes and lighters, and hiding those items from staff. A behavior note, dated 12/26/23, read in part, resident continues to smoke in room and/or bathroom. A Smoking Evaluation, dated 01/12/24, showed Resident #1 was safe to smoke with supervision. A quarterly MDS assessment, dated 01/26/25, showed Resident #1's cognition was intact. On 02/20/25 at 10:31 a.m., Resident #1 was asked what was the facility's smoking policy. The resident stated they could not have lighters in their room and could not smoke in their room. The resident stated last summer they smoked in their room and staff caught them. On 02/21/25 at 10:37 a.m., MDS coordinator #1 was asked the facility policy for updating and revision of a care plan. They stated they added a focus if needed to the care plan when a resident was admitted or after a resident had a incident. MDS Coordinator #1 was asked if the care plan was updated to reflect the behavior note on 12/26/23 regarding Resident #1 continuing to smoke in their room and bathroom. They stated, No.

Based on record review and interview, the facility failed to ensure a care plan was revised and/or updated for three (#5, #11 and #63) of sixteen sampled residents reviewed for care plans. The administrator identified 65 residents resided in the facility. Findings: A Care Plans, Comprehensive Person-Centered policy, revised December 2020, read in part, Care Plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration. 1. Resident #5 had diagnoses which included bipolar, heart failure, and osteomyelitis. A Comprehensive Care Plan, dated 11/12/24, documented there were no updates or revisions completed on the care plan for any focus areas following the resident's annual assessment on 10/28/24. Review of care plan documented the last revision on the resident's care plan was 11/08/22 and 02/23/23. 2. Resident #11 had diagnoses which included chronic obstructive pulmonary disease, epilepsy, and history of falls. A Comprehensive Care Plan dated 08/22/24, documented there were no updates or revisions completed for interventions for falls. A review of Resident #11's record documented they had a fall on 11/08/24 with minor injury. There was no documentation interventions were updated on the care plan. A Fall Risk assessment, dated 11/12/24, documented the resident was a high fall risk with a score of 65. 3. Resident #63 had diagnoses which included chronic obstructive pulmonary disease, vascular dementia, and cerebral infarction. A Smoking Evaluation, dated 06/07/24, documented Resident #63 was safe to smoke with supervision. A Comprehensive Care Plan, dated 09/25/24, documented no focus for smoking on the care plan. On 11/14/24 at 9:44 a.m., the DON was asked what was the policy for updating and revision of care plan interventions. They stated they tried to update the interventions with every incident. The DON was asked to review Resident #11 care plan and asked if the interventions for falls had been updated. They stated, No. On 11/15/24 at 8:28 a.m., the DON was asked to review the care plan for Resident #63 and asked if the care plan documented a focus for smoking. They stated No On 11/15/24 at 10:29 a.m., MDS Coordinator #1 was asked what was the facility policy for updating and/or revising a care plan after an annual assessment was completed. They stated the care plan was reviewed after each annual, significant change, or quarterly assessment was completed and then they personalized the care plan for each resident need. They were then asked to review the care plan for Resident #5. They were then asked if the care plan was updated after annual assessment was completed on 10/28/24. They stated, No, it was not.

Based on record review and interview, the facility failed to ensure post-dialysis assessments were completed for one (#12) of one sampled resident receiving hemodialysis. The DON identified one resident residing in the facility who received hemodialysis. Findings: Resident #12 had diagnoses that included chronic kidney disease. A physician's order, dated 11/03/24, documented Resident #12 received hemodialysis three times weekly. On 11/15/24 at 11:20 a.m., the DON was asked how information was communicated between the facility and the dialysis center. They stated the resident took a dialysis communication form with them on each visit and returned the form to the facility after visits. When asked if assessments were done before and after dialysis visits, the DON stated, Yes. They stated they documented on the dialysis communication form and the forms were scanned into the EHR. A review of Resident #12's clinical record revealed the 'Resident Specific Post-Dialysis Assessment' section of the dialysis communication forms for Resident #12 were not completed upon their return from dialysis on 10/31/24, 11/05/24,11/07/24, and 11/09/24. On 11/15/24 at 1:07 p.m., the DON was asked to review the dialysis communication forms for Resident #12 dated 10/31/24, 11/05/24, 11/07/24, and 11/09/24. After reviewing the forms, the DON acknowledged post-dialysis assessments had not been completed on the dates in question and staff had not followed facility policy.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed for one (#117) of sixteen sampled residents reviewed for care plans. The administrator identified 65 residents resided in the facility. Findings: Resident #117 was admitted to the facility on [DATE] and had diagnoses which included encounter for orthopedic aftercare (right artificial hip joint) and type 2 diabetes. A review of the clinical record for Resident #117 revealed a baseline care plan had not been completed. On 11/14/24 at 1:00 p.m., the DON was asked what was the policy on completion of a baseline care plan for newly admitted residents. They stated the baseline care plan should be completed within the first 24 hours of admission by the admitting nurse or the nurse taking responsibility for the resident immediately after. The DON was asked if a baseline care plan had been completed for Resident #117. They stated, No. They stated the ADON was the admitting nurse. On 11/14/24 at 1:05 p.m., the ADON stated they were the admitting nurse for Resident #117 and should have completed a baseline care plan. They acknowledged a baseline care plan had not been completed and facility policy had not been followed.

Based on record review and interview, the facility failed to ensure annual competency reviews were completed for one (CNA#1) of two sampled CNAs who were reviewed for annual competency review. The HR director identified 38 CNAs were employed at the facility. Findings: The Competency of Nursing Staff policy, revised 10/2017, read in part, Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based upon the facility assessment. On 11/14/24 at 8:54 a.m., CNA #1's employee file was reviewed. The last competency review was completed in 07/2023. There was no documentation an annual competency review was completed annually after 07/2023. On 11/14/24 at 9:00 a.m., the HR director stated that they visited with the administrator and they realized the annual competency review was not completed for CNA#1 after the last review in 07/2023. On 11/14/24 at 10:00 a.m., the administrator stated CNA #1's annual competency review was not completed.

Based on record review and interview, the facility failed to ensure a significant change MDS assessment was completed for one (#12) of one sampled resident started on hemodialysis. The DON identified one resident residing in the facility who received hemodialysis. Findings: Resident #12 had diagnoses which included chronic kidney disease. A physician's order, dated 11/03/24, documented Resident #12 was to start hemodialysis three times weekly. A care plan, dated 11/04/24, documented Resident #12's risk of complications from kidney failure, new status of attending hemodialysis, and the care of their shunt/fistula. No significant change assessment was present in the clinical record documenting Resident #12's decline in kidney function and starting dialysis treatments. On 11/15/24 at 1:07 p.m., the DON was asked if a significant change assessment should have been completed for Resident #12. They stated, Yes. On 11/15/24 at 1:18 p.m., MDS Coordinator #1 was asked when significant change assessments were done. They stated if a resident had experienced a change in condition that was not expected to resolve within the next 120 days. They were asked if Resident #12 had experienced a significant change. They stated, Yes. They acknowledged a significant change MDS should have been completed.

Based on observation, record review, and interview, the facility failed to adhere to EBP while providing care for one (#33) of one sampled resident reviewed for enhanced barrier precautions. The administrator identified 65 residents resided in the facility. The DON identified five residents on enhanced barrier precautions. Findings: An Enhanced Barrier Precautions policy, revised 07/01/24, read in part, staff will perform hand hygiene and don PPE before entering resident's room .staff will remove PPE and perform hand hygiene before exiting resident's room .examples of high contact resident care are changing linens, device care, and wound care. Resident #33 had diagnoses which included stage 4 pressure ulcer to sacrum, chronic pain, diabetes mellitus type two, and obesity. Resident #33's care plan for EBP, revised 11/05/24, documented the resident was at risk for skin breakdown and pressure ulcers related to decreased mobility, fragile skin, incontinence, and current stage 4 pressure ulcer to sacrum. On 11/14/24 at 10:45 a.m., RN #1 and CNA #2 entered Resident #33's room to perform a dressing change to the resident's pressure ulcer to their sacrum. Upon entering the room both RN #1 and CNA #2 washed their hands and donned gloves. RN #1 and CNA #2 did not don gowns prior to providing incontinent care or the dressing change to the resident's pressure ulcer to their sacrum. RN #1 was asked what was the policy for EBP while providing hands on direct care and if a gown was required while providing hands on direct care. RN#1 stated they were not aware of needing to wear a gown when providing residents' treatment. On 11/14/24 at 11:34 a.m., LPN #1 was asked what was the policy and procedure for EBP, and when did staff use PPE. They stated PPE was used anytime a resident had a wound, Foley, peg tube, or if staff were providing direct care for the resident. They stated staff were to wear gowns and gloves. On 11/14/24 at 11:46 a.m., CNA #3 was asked what did the EBP sign mean when posted outside a resident's room door. They stated they were to wear gowns and gloves if providing direct resident care. On 11/14/24 at 11:50 am., the DON was asked what was the policy for ensuring EBP was followed by staff. They stated the staff should wear gowns and gloves for all direct care. The DON was then asked what did the EBP sign mean outside a resident's door. They stated the staff were to wear gowns and gloves.

On 06/29/22 at 12:18 p.m., the OSDH confirmed the existence of an immediate jeopardy related to the facility failed to ensure a resident was provided a physician ordered puree diet with restriction for use of straws for Resident #57 who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were interviewed and were unable to verbalize why straws should not be used when assisting Resident #57 with fluid intake. Resident #57's dietary card did not document a diet change to puree. On 06/29/22 at 12:30 p.m., the Administrator was informed of the existence of the immediate jeopardy. A request was made for an acceptable plan to remove the immediacy. On 06/29/22 at 3:28 p.m., the Administrator provided a plan of removal. On 06/29/22 at 4:09 p.m., the plan of removal was accepted by the OSDH. The plan of removal was as follows: .Step #1 DON/ADON/Designee made rounds upon notification of incorrect diet served on Resident #57 to ensure no other resident were served incorrect diet, with no further negative findings. Step #2 Resident #57 tray card was update upon notification of incorrect diet to reflect correct prescribed diet with proper utensils . Step #3 All Nurses, CNA/CMA and Dietary staff educated on Interdepartmental Notification of Diet (including changes and reports) along with utilization of communication forms from nursing department and dietary department. Dietary manager/Designee and Dietary staff educated that when changes come from nursing department regarding changed in diet, utensils, and preferences, reporting nurse will be updating tray cards and educating all dietary staff of these changes, as well as removing old tray card from the kitchen. Nurses, CNA/CMAs educated to match tray card diet to actual meal sent to resident upon serving. If any aspects of the meal provided are not correct, they are to return to kitchen to correct immediately to match prescribed diet. Step #4 Complete audit of all resident diet orders completed and compared to tray cards to ensure no further inappropriate diets or utensils in use with no further negative findings. Interdepartmental Notification of Diet (including changes and records) policy was printed and given to survey team with plan of removal. Step #5 Upon receiving new orders for dietary changes, nursing staff will fill out dietary communication form and take to dietary manager or place in designated area in dietary managers office. At this time old tray card is removed and given to nursing, nursing will fill out new tray care with updated diet information. DON/Designee will report all diet changes and special utensil use to Administrator after ensuring MD order is correct and care plan is updated. Administrator will take changes to dietary manager to ensure changes were made timely to tray cards and dietary staff is educated. Upon approval of plan of removal, a current staff in the facility will be in-serviced immediately to ensure safety of all resident on 06/29/22 by 7 pm. All other staff will be in-serviced prior to reporting for next shift . On 07/05/22 at 4:35 p.m., after all the components of the plan of removal had been completed, the Administrator was notified the immediacy had been lifted as of 06/30/22 at 3:46 p.m. The deficiency remained isolated with more than minimal potential for harm. Based on observation, record review and interview the facility failed to ensure A. A puree diet was served as ordered by the physician, B. Ensure dietary cards were updated to reflect the current diet, and C. Ensure staff did not use a straw for a resident who had a dietary restriction for the use of straws for one (#57) of six sampled residents reviewed for nutrition. The Resident Census and Condition of Residents identified 59 residents lived in the facility. The clinical director identified two residents received nutrition via enteral feedings and did not receive dietary services from the kitchen. Findings: A policy and procedure, titled, Interdepartmental Notification of Diet (Including Changes and Reports), read in part, .Nursing services shall notify the food and nutrition services department of a resident's diet order, including any changes in the resident's diet, meal service, and food preferences .or a diet has been changed, the nurse supervisor shall ensure that the food and nutrition services department receives a written notice of the diet order .The food and nutrition services department will be notified verbally if the diet change or report occurs one hour or less before a scheduled meal, or if circumstances indicate that the written procedures will not be adequate to ensure service at the next meal . Resident #57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, last updated 05/17/21, read in parts, .Mechanical Soft diet as ordered with thin liquids and no straws. Med pass/Healthshakes with all meals as ordered. (History of eating with her hands, no sandwiches, eats in dining room - will get up from table and then later return during mealtimes.) . A document titled, ST-Therapist Progress and Discharge Summary, dated 12/23/19, read in parts, a.Safely Consume Liquids .GOAL MET - 12/20/2019 .The patient safely consumes thin liquid consistency utilizing cup while facilitating chin tuck exhibiting modified independence(1-10%impairment; diet may be modified due to medical and/or dental status) . b.Safely Consume Solids .Goal met-on 12/20/2019 .The patient safely consumes mechanical soft consistency utilizing spoon while facilitating chin tuck exhibiting minimal impairment (10-25% impairment; risk of trace aspiration, diet may need modified due to medical/dental status) .Area of treatment provided per treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . An ST Clarification Order dated 01/06/20 read in part, . ST recommends change in diet consistency to mechanical soft foods with ground meats, continue finger foods when available. Continue thin liquids, no straws . A Physicians Order, dated 01/08/20, read in part, .Regular diet, Mechanical Soft texture, Regular consistency No Straws/ Ground meat /Finger Foods .related to DYSPHAGIA, OROPHARYNGEAL PHASE . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Regular diet mechanical soft texture, Regular consistency, No Straws/Ground meat/Finger Foods Dinner related to dysphagia, Oropharyngeal Phase . A Nutrition/Dietary Note, dated 06/15/22, read in part, .Good PO intake on regular mech (sic) soft diet with ground meat .monitor and continue POC . An Annual assessment, dated 06/19/22, documented Resident #57 had severe cognitive impairment, required extensive assistance of one person for eating, and had no signs and symptoms of possible swallowing disorder. A physician's progress note, dated 06/25/22, read in part, .[Resident] diet was changed to pureed .[Resident]seems better with a pureed diet so I am ordering a diet change to pureed .Assessment and Plan .Dysphagia change diet to pureed . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Regular diet, pureed texture, Regular consistency. No Straws related to DYSPHAGIA, OROPHARYNGEAL PHASE . A Health Status Note, dated 06/25/22 at 6:02 p.m., read in part, .[doctor name] here to see resident. N.O. to change diet to pureed . Documented by the DON. On 06/28/22 at 12:01 p.m., staff was observed feeding resident chopped mandarin oranges, chopped ham, smashed sweet potatoes, and pieces of fried green beans. The diet card documented, ground meat, finger foods, no straws or plastic ware. Staff was observed assisting resident to drink fluid with a straw. On 06/29/22 at 8:10 a.m., CMA #1 was observed feeding Resident #57 chopped sausage, scrambled eggs, blueberry muffin/cake, and orange juice with a straw. The continued observations included: a. Staff was observed giving resident a drink of orange juice with a straw. CMA #1 left room to obtain a small glass of apple juice, and put a straw in glass. CMA #1 fed Resident #57 bites of chopped sausage, scrambled, egg, and blueberry muffin, then provided a drink of Apple juice with the straw. b. Resident #57 had a small cough/cleared throat. c. CMA #1 gave Resident #57 a bite of egg, sausage, drink of apple juice with a straw, and a bite of sausage. d. Resident #57 had audible sounds to clear throat. e. CMA #1 provided a bite of egg, f. Resident #57 began to cough. g. CMA #1 gave drink apple juice with a straw. CMA #1 gave a bite of muffin. h. Resident #57 coughed. On 06/29/22 at 8:40 a.m., Resident #57 was observed seated in a recliner, coughing. CMA #1 was asked to show #57's diet card. The card documented .regular diet, ground consistency, thin liquids, regular portions. ground meat, finger foods if possible, no straw or plastic ware On 06/29/22 at 10:17 a.m., CMA #1 was asked, did you assist Resident #57 with fluids using a straw. CMA #1 replied, yes. On 06/29/22 at 10:17 a.m., CMA #1 was asked what diet is Resident #57 supposed to be on. CMA #1 replied, ground. On 06/29/22 at 10:17 a.m., CMA #1 was asked what did her diet card say regarding straws. CMA #1 stated, I don't know why they put straws on there, the straw is the only way [resident] drinks good. CMA #1 was asked why is the resident not allowed to have straws. CMA #1 stated, My guess, because of the plastic, when I saw that on the card. I been meaning to ask the nurse. On 06/29/22 at 10:17 a.m., CMA #1 was asked if the resident had a diet change recently. CMA #1 stated, Not that I am aware of. CMA #1 was asked when the resident was eating/drinking, did Resident #57 cough or clear throat. CMA #1 stated, Yes, I gave her a drink. On 06/29/22 at 10:20 a.m., CNA #2 was asked how do you know what diet to serve to residents. CNA #2 stated each resident has a meal card on the tray at every meal, and knows the residents. CNA #2 was asked who is responsible to ensure the cards are up to date. CNA #2 stated the nurse and therapy decide and if aides see the resident is having a cough or trouble to eat/drink they tell the nurse and the nurse gets the information to therapy. On 06/29/22 at 10:22 a.m., CNA #1 was asked how the nurse aides help to ensure residents receive the diet ordered by the physician. CNA #1 stated the nurses make cards for dietary and each resident has a card on the meal tray. CNA #1 was asked who is responsible to ensure the cards are current. CNA #1 stated the charge nurse. On 06/29/22 at 10:25 a.m., LPN # 1 was asked why Resident #57 is not allowed to have straws. LPN #1 stated, [resident] clamps down on them with .teeth, it's not necessarily the straw's, [resident] bites plastic silverware. LPN #1 was asked what was the residents' current diet. They stated [resident] was on regular with ground, but is now on puree. LPN #1 was asked who ensured the resident gets the correct meal as ordered. LPN #1 stated, we give dietary the order and the aide on the hall getting the tray should check the card. LPN #1 was asked if scrambled eggs, ground sausage and a blueberry muffin is a pureed diet. LPN #1 stated, No. On 06/29/22 at 10:30 a.m., the ADON was asked who is responsible to ensure residents receive the correct physician ordered diet. The ADON stated the charge nurse do the final check of the orders and the orders and the card should match. The ADON was asked if the meal card and/or order stated no straws, should the staff use straws to offer liquids. The ADON stated, No. The ADON stated, when there is an order (verbal/written) they completed/update the dietary card. The ADON was asked if anyone ever completed an audit to ensure the order/diet served was correct. The ADON stated they did approximately 1 ½ months ago and dietary has completed one since and made new cards. The ADON was asked why Resident #57 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated if Resident #57 was provided fluid through a straw, [resident] would drink all of the liquid without getting a breath, so no straws. The ADON was asked what is Resident #57's diet order. After review of the computer orders, stated regular/pureed texture, thin liquid, which was a new order on 6/25/22. ADON was asked if Resident #57 could be served fried green beans. The ADON stated, not if they are not pureed. The ADON was asked if the Resident #57 could be served sausage, they stated no. On 06/29/22 at 10:37 a.m., DA #1 was asked how it is determined what food was served to a resident. The DA #1 stated, I just know the residents, it is in my memory. DA #1 was asked if they utilized the dietary card system. They stated, we should. DA #1 was asked how new (diet) orders were communicated. They stated, nurses will bring the information and the diet is changed. They were asked if anyone does an audit of the orders/cards to ensure they are correct. DA #1 did not know. They were asked who would be responsible, they stated the dietary manager. On 06/29/22 at 10:40 a.m., the DM was asked how dietary ensured residents receive the correct diet. The DM stated, We use cards with the diet orders, supposed to look at with each meal but I have them memorized. The DM was asked what if the resident has a diet change. The DM stated, nursing will bring another card and get the tray card changed. The DM was asked who was responsible to audit orders/diet cards to ensure accuracy. The DM stated I did one a couple of weeks ago. The DM was asked if dietary puts straws on the trays served. The DM stated, no, nursing has access to straws. The DM was asked if any of the residents have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/29/22 at 11:50 a.m., the DON was asked for a policy/procedure on diet changes. The DON stated the nurse should give a copy to dietary. The DON was asked who makes the cards. They stated, dietary should but since they haven't been, the ADON has been doing them. The DON was unsure if there was a policy, but would look for one. On 06/30/22 at 8:07 a.m., the DON was asked why the doctor had made the diet change for Resident #57. The DON stated, staff said [resident] was coughing. The DON was asked if there was a copy of the dietary communication change. The DON stated, on Saturday I took it to the kitchen staff.

Based on record review and interview the facility failed to routinely test staff, who were not up to date on COVID-19 vaccinations, to prevent the spread of COVID-19 according to CDC/CMS guidelines. The Resident's Census and Condition of Residents documented 59 residents resided in the facility. Findings: An undated policy and procedure, titled, COVID 19 Corporate Policy/Procedure, read in part, .Routine testing for staff: Staff will be tested at minimum per CDC/CMS guidance using the county positivity rates .Vaccination status does not affect this currently due to increased frequency of positive cases in fully vaccinated individuals . A policy update, dated 03/10/22, read in part, .Definition: Fully vaccinated refers to a person who is: [greater than/equal to] 2 weeks following receipt of the second dose in a 2-dose series, or [greater than/equal to] 2 weeks following receipt of one dose of a single-dose vaccine .Up to date: Residents or staff that have completed the initial series, and have had all the recommended boosters as well . [NAME] County community transmission level was high/red on 06/28/22. CDC website, https://covid.cdc.gov/covid-data-tracker/#county-view? CDC QSO-20-38 NH, revised 3/10/22, red in part, .Routine Testing Intervals by County COVID-19 Level of Commujnity Transmission .High(red) .Twice a week . Staff testing record, dated June 2022, documented one exempt employee and one new hire who were not fully vaccinated (temporary delay) was tested routinely one time a week. An undated document titled, Staff Covid Vaccinations documented 12 staff had initial vaccination series and one booster, 60 staff had received the initial vaccination series, and one exempt staff and one temporary delay staff. On 07/07/22 at 9:45 a.m., the IP was asked prior to outbreak testing was staff who were not fully vaccinated tested according to positivity rate. The IP stated, one staff was exempt and a new hire and was tested weekly. The IP stated, Prior to you coming into the facility there was no weekly testing for staff. On 07/07/22 at 11:57 a.m., the administrator was asked if staff does not have all of the vaccinations that they are eligible for, should they be tested . The administrator stated, We started doing that because we realized it. On 07/07/22 at 3:53 p.m., the IP was asked when was the last time vaccinated (not up to date) were tested prior to 07/01/22. The IP stated, At last big outbreak in February or March. The IP reviewed testing records and confirmed February 2022.

Based on record review, observation and interview, the facility failed to ensure all staff wore the proper PPE during a COVID positive outbreak within the facility. This had the potential to affect all residents. The Resident Census and Condition of Residents documented 59 residents lived in the facility. Findings: A document titled, What to do in an outbreak, dated 03/10/22, .All staff, no matter their vaccination status, will wear a mask (Kn95 or greater) and eye wear throughout the facility during the outbreak time . On 07/05/22 at 9:30 a.m., upon arrival to the facility, the DON stated the facility had 2 staff test positive for COVID. The DON stated the facility was in outbreak status and all persons entering the building are required to wear an N-95 mask and a face shield. On 07/07/22 at 9:43 a.m., a follow-up visit was conducted in the kitchen. Upon entering the kitchen, the following were observed: 1. The DM wore a black mask with a small colored design, positioned under her nose. A face shield had been placed over the top of the DM's head, and exposed her nose/face as she chopped/diced onions to prepare for the noon meal. 2. DA #1 wore an N-95 mask. A face shield had been placed over the top of the DA's head, while putting clean items on the shelves. 3. The Food Service Director wore an N-95 mask but no face shield while assisting/monitoring dietary staff in the kitchen to prepare for the noon meal. The Food Service Director was asked when were staff to wear N-95 masks and face shields. The Food Service Director stated staff are to wear an N-95 and a face shield when they are out of the kitchen/dietary department or in resident areas. The Food Service Director stated all staff are to keep the PPE on as much as they can. The Food Service Director was asked if the DM had an N-95 mask on. The Food Service Manager stated, do not know and instructed the DM to obtain a new N-95 like other staff were wearing. On 07/07/22 at 12:33 p.m., the Clinical Director and Administrator were asked if all staff were to wear an N-95 and a face shield at all times during a COVID outbreak within the facility. They stated, Yes. The Clinical Director and Administrator were asked if this included dietary staff. They stated, Yes. The Clinical Director and Administrator were informed of the surveyor observations in the kitchen. They were asked what PPE should the dietary staff have been wearing. They stated the dietary staff should wear the same as other staff, an N-95 mask and face shield.

Based on observation and interview, the facility failed to 1. date/label unused foods; 2. discard unused foods within 5 days; and 3. maintain a clean/sanitary kitchen. The Resident Census and Condition of Residents documented the facility census of 59. The Clinical Director identified two residents that received nutrition via enteral feeding and did not receive food service from the kitchen. Findings: On 06/28/22 at 9:48 a.m., during the brief initial kitchen observation, the refrigerator contained undated contents to include pepperoni, cheese slices, and salami. The DM was asked and confirmed there were no dates on these items. The DM was asked what the date was on the sausage in the refrigerator. The DM stated, the 14th. DM was asked what the policy was for keeping food. The DM stated, Some things you can keep for seven days and some are 72 hours. The DM pointed to the sausage and stated, these should have been gone after 72 hours. The DM was asked how long the hamburger patties (dated 06/17/22) can be kept. The DM stated, I believe 24 hours if they are cooked. On 07/07/22 at 9:43 a.m., a follow-up visit to the kitchen was conducted. The two-door refrigerator contained a full cream pie dessert and half of a cream pie dessert dated 07/01/22. The three-door refrigerator contained an undated plastic coned shaped dispenser with a white substance, labeled, On Top. The dispenser tip was opened to air. A window air conditioning unit was located above the toaster. The air conditioning unit had gray dust/debris on the outside of the grates and along the ledge under the unit. A yellow electrical cord, approximately five inches in length, was covered with gray debris and the end/tip was not grounded/covered. A window air conditioning unit was located near the drink station. There was a red grainy build-up on the outside of the grates and along the ledge under the unit. The utensil rack, over the stainless steel work station, contained a black substance and gray build-up along the upper edges. On 07/07/22 at 10:05 a.m., the food service director, and RD/LD were shown the above findings. They were asked if there was a policy for how long unused foods could remain in the refrigerators. The RD/LD stated unused foods should be dated when opened/prepared and discarded if unused within five days. When looking for the On Top container, DA #2 stated the container had been opened before today, was not dated and did not have the required covering over the open tip. When DA #2 had identified surveyor activities, the item was discarded. The Food Service Manager was asked if the facility had a cleaning schedule. The Food Service Manager stated the air conditioning units should be cleaned monthly. The Food service Manager stated the units need to be cleaned. A cleaning schedule was not provided. The Food Service Manager and RD/LD stated there were issues in the kitchen/dietary areas that needed to be addressed by management.

Based on record review and interview the facility failed to monitor for antipsychotic medication side effects for one ( #43) of six sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Residents documented 40 residents were administered anti-psychotic medications. Findings: A policy and procedure, titled, Antipsychotic Medication Use, revised December 2016, read in part, .Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician .constipation, blurred vision, dry mouth, [CONDITION(S)], sedation .[CONDITION(S)], arrythmias, Akathisia, [CONDITION(S)], extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA . Resident #43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physicians order, dated 05/23/22, read in part, .[MEDICATION(S)] Tablet 1 MG ([MEDICATION(S)]) Give 1 tablet by mouth one time a day for Dementia with behavioral issues/anger issues AND Give 2 tablet by mouth in the evening for Dementia with behavioral issues/anger issues . On 07/06/22 at 10:00 a.m., the clinical director was asked if side effects should have been monitored for Resident #43's [MEDICATION(S)]. The clinical director stated, yes. Resident #43's June 2022 TAR was reviewed for monitoring of side effects. The clinical director stated, They missed it, I will have them add it now. On 07/06/22 at 11:00 a.m., the clinical director was asked was the resident monitored in May, June and July 2022 for side effects of [MEDICATION(S)]. The clinical director stated, there was no monitoring for the antipsychotic medication ([MEDICATION(S)]) with the new order in May. On 07/06/22 at 2:21 p.m., Resident #43 was observed sitting in a recliner in their room watching television.

Based on observation, record review and interview the facility failed to follow a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident Census and Conditions of Residents identified 33 residents were in a chair all/most of the time. Findings: Resident #42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's progress note, dated 04/28/22, read in part, .Assessment/Plan .[resident] needs a new custom-fit headrest, or a new chair-due to severe Left neck side-bending .New, ongoing and previous .Leaning severely to the Left . The progress note was noted by a licensed nurse on 05/02/22. A physician's progress note, dated 05/31/22, read in part, .Assessment/Plan .PT Eval to attempt to place the headrest on the Left of the w/c, where [resident] naturally lays [resident] head . New, ongoing and previous, reviewed every visit .Leaning severely to the Left . The progress note was noted by a licensed nurse on 06/23/22. A physician's progress note, dated 06/21/22, read in part, .Assessment/Plan .[resident] needs a new custom-fit headrest, or a new chair-due to severe Left neck side-bending .New, ongoing and previous, reviewed every visit .Still leaning severely to the Left . The progress note was noted by a licensed nurse on 06/24/22. A health status note, dated 06/30/22 at 3:50 p.m., read in part, .[Physician] replied with clarification [resident] leans [residents] head so far to the side and it is not resting on anything. [Resident] headrest needs to move from the top of the chair over to support her head. PT to evaluate for headrest of wheelchair . A health status note, dated 07/05/22 at 12:03 p.m., read in part, .wheelchair headrest evaluation done by therapy. Recommended referral out to w/c seating specialist. Temporary corrective measure is to use cervical support pillow until evaluation can be obtained . On 06/28/22 at 3:22 p.m., Resident #42 was observed sitting in a highback w/c. On 07/05/22 at 11:29 a.m., the clinical director, provided a copy of a PT evaluation for w/c headrest for positioning. The clinical director, stated the order was put in on 06/30/22. PT was unavailable on 06/30/22 and the evaluation was just done today. Residents w/c is more than five years old and they will have to order one. The PT visit today was for evaluation of the head rest only. The clinical director was asked if prior to 06/30/22 was the evaluation completed, as ordered. They stated, No.

Based on record review, observations and interviews, the facility failed to maintain an effective pest program to prevent flies. This affected nine (#3, 9, 13, 28, 30, 42, 47, 51 and #210) of nine residents observed during the screening process of the survey for fly infestation. The Resident's Census and Condition of Residents documented a census of 59 residents. Findings: A policy and procedure, Revised May 2008, read in part, .Our facility shall maintain an effective pest control program .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . Monthly Pest Control invoices, dated 01/03/22, 02/01/22, 03/08/22, 04/05/22 05/11/22, and 06/01/22, did not document any services were provided for flies. 1. Resident #9 had diagnoses which included [CONDITION(S)] and muscle weakness. Resident #9's care plan, dated 04/18/22, read in part, .is at risk for skin breakdown and pressure ulcers r/t decreased mobility .Assist resident with turning and positioning PRN and as requested by resident . On 06/29/22 at 8:35 a.m., during an interview with Resident #9, multiple flies were observed in the room. Resident #9 stated there have been a lot of flies 2. Resident #47 had diagnoses which included hypertension, and anxiety. Resident #47's care plan, dated 06/14/22, read in part, .requires assistance with ADL's r/t weakness .requires limited to extensive assistance with bathing, toileting, and transfers . On 06/29/22 at 2:53 p.m., during an interview with Resident #47, several flies were observed in the resident room. Resident #47 stated, I don't like these flies. 3. Resident #13 had diagnoses which included fluid overload, respiratory failure with [CONDITION(S)], and heart failure. Resident #13's care plan, dated 04/14/22, read in part, .the resident occasionally needs assistance with ADL's . On 06/29/22 at 2:49 p.m., Resident #13 was observed to be on the bed asleep. Several flies were observed in the room, and on the linens that covered Resident #13. On 06/30/22 at 12:52 p.m., Resident #13 was observed with a fly swatter and was asked if there are a lot of flies. Resident #13 replied, sometimes. 4. Resident #210 had diagnoses which included dementia with behavioral disturbance, physical debility, and altered mental status. Resident #210's undated care plan, read in part, .provide assistance that is needed with mobility .resident does not have the cognitive ability to use the call light .is totally dependent on staff for all ADL's . On 06/28/22 at 11:43 a.m., Resident #210 was seated in a geri-chair in the common area. Four flies were observed on Resident #210's pant legs. On 06/28/22 at 2:28 p.m., Resident #210 was observed to be resting in bed. Multiple flies were observed in the resident's room, and on the linens that covered the resident. 5. Resident #30 had diagnoses which included [CONDITION(S)] of skin, pain and polyosteoarthritis. Resident #30's undated care plan, read in part, .[Resident] is at risk for falls/injuries r/t needed assistance with mobility .Frequent monitoring and anticipation of needs if resident is unable to or forgets to use call light .Provide assistance that is needed with mobility . On 06/28/22 at 10:51 a.m., during an interview with Resident #30, several flies were observed in the room. Resident #30 had a crumpled napkin, smoothed the napkin and placed inside an insulated drinking mug. The mug contained crushed ice with a small amount of dark liquid. After the napkin was placed over the ice, Resident #30 stated, Now, that will help keep flies out of it while we talk. 6. Resident #3 had diagnoses which included major depressive disorder, heart failure and Alzheimer's disease. Resident #3's care plan, dated 04/08/22, read in part, .assist resident with turning and repositioning every two hours .Resident has impaired cognitive skills r/t Alzheimer's, BIMS score 3 .Encourage routine daily decision making and provide coaching through process as needed . On 06/30/22 at 10:23 a.m., Resident #3 was observed lying in the bed. A fly was observed crawling on the residents cheek. Resident #3 attempted to swish the fly away, it crawled towards the resident's eye. Resident #3 was able to swish the fly away. 7. Resident #28 had diagnoses which included [CONDITION(S)], front temporal dementia, and dementia with behavioral disturbance. Resident #28's care plan, dated 05/09/22, read in part, .Assist resdient[sic] as needed when eating .Assist as needed with ADL's . On 06/28/22 at 11:59 a.m., CMA #2 was observed swishing flies from Resident #28's food. 8. Resident #42 had diagnoses which included profound intellectual disability, [CONDITION(S)], and dysphagia. A physician's progress note, dated 06/21/22, read in part, .New, ongoing and previous, reviewed every visit .Flies are landing on [resident] face . 9. Resident #51 had diagnoses which included unspecified [CONDITION(S)], depressive disorder, and [CONDITION(S)]. Resident #51's care plan, dated 06/16/22, read in part, .Requires supervision/assistance with ADL's r/t poor safety awareness, weakness .Resident requires staff assistance with bathing, dressing and toileting . On 06/28/22 at 11:52 a.m., Resident #51 was observed swiping a fly away from [resident] food. On 07/06/22 at 3:06 p.m., the clinical director approached this surveyor and stated, they flipped on the two fly lights in the dining room, one was flickering and one was out, but would be replaced. The clinical director was asked if pest control treats for flies. The clinical director was unsure. Pest control invoices were reviewed with the clinical director. The invoices did not document any treatment for flies. The clinical director was asked if it is acceptable for a resident to have flies crawling on their face if the resident is not physically able to remove them. The clinical director stated, No. The clinical director was asked if it is acceptable for staff or residents to have to swish flies from food. The clinical director stated, No.

Based on record review and interview, the facility failed to have a procedure in place to obtain a consent /declination of the COVID-19 vaccination for a resident who is cognitively impaired and has no power of attorney or other representative for one (#3) of three sampled residents reviewed for immunizations. Resident #3 was cognitively impaired and had no legal representative to make decisions for them. The Resident Census and Condition of Residents documented 59 residents resided in the facility. Findings: A policy and procedure, updated 03/10/22, read in part, .Vaccines will be offered upon admit for residents and upon hire for staff. Upon refusal of vaccination .will be offered and educated on risks vs. benefits monthly during in-service for staff and when the pharmacy comes for COVID clinic for residents Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was documented as own responsible party. An admission assessment, dated 07/30/21, documented Resident #3 had severe cognitive impairment for daily decision making. Resident #3 face sheet documented she was her own representative and had no other parties making decisions. A health status note, dated 12/27/21 at 1:36 p.m., read in part, .message left for [family member] .emergency contact, regarding COVID vaccine for resident. awaiting return call . Resident #3's care plan, dated 04/08/22, read in part, .Resident has impaired cognitive skills r/t Alzheimer's, BIMS score 3[severe cognitive impairment for daily decision making] .Encourage routine daily decision making and provide coaching through process as needed . On 07/07/22 at 12:02 p.m., the clinical director was asked if there was documentation of communication with Resident #3's family member. The clinical director stated, the [family member] is no longer returning calls. The clinical director stated staff members reported the resident's cognition was not intact to determine the risk vs benefits of the COVID vaccination. On 07/07/22 at 12:05 p.m., the clinical director was asked, being her advocate, why has it been a year to pursue someone who is in charge or an advocate for medical care. The clinical director stated, it should not have went that long, and had instructed staff to call APS. On 07/07/22 at 2:25 p.m., the clinical director stated, there was no documentation available for consent or decline for COVID vaccinations that were performed by the outside provider who offered the vaccinations. On 07/07/22 at 3:07 p.m., SS was asked if there was any documentation the facility had attempted to contact a family member regarding the COVID vaccination. SS stated, When the vaccine was available I tried to get hold of the family, I keep notes. The SS provided handwritten documentation, undated, read in part, .resident own RP unable to make descicns [sic] for .self .unable to contact [family member] after several attempts .7/6/22 left message with [family member] to return call if unable to reach by business day tomorrow APS will be contacted . SS was asked who made the decision for [resident] to receive or decline the COVID vaccine. SS stated, I don't know that would be nursing. No COVID-19 immunization consent/decline for Resident #3 was provided by the facility.

On 02/06/13, an Immediate Jeopardy (IJ) situation was determined to exist related to the failure of the facility to provide thickened liquids for one resident who had physician ordered thickened liquids, had a history of [REDACTED]. The Oklahoma State Department of Health verified the existence of the IJ related to thickened liquids. At 5:54 p.m., the administrator and charge nurse #5 were informed of the IJ related to thickened liquids. At 7:50 p.m., an acceptable plan of removal for the IJ situation was received from the facility administrator. The plan of removal documented: IJ Plan of removal 02/06/2013 "Notification of family or resident involved @ 6:20 pm, Notification of Medical Director 6:15 pm, no new order and notification of physicians Doctor @ 6:35 p.m., Dr. (Name deleted) instructed to monitor Vital Signs denied chest CXR. IN service will be given by RN (Name deleted) and RN (Name deleted) at 7:30 pm Monitoring of dining process in main dining room and memory unit will be done by Charge Nurse or designee. Thickened liquids will be identified by list provided to staff members in the following manner. A list of thickened liquids will be posted on the inside of the food carts and on a clipboard carried by the monitors in the main dining area and the memory care unit dining room. Staff will be provided with list to carry in pocket to check before serving. In-service for all staff present will be at 7:30 PM 2/6/13 oncoming shift at 9:45 PM 2/6/13 and at 5:00 AM 2/7/13 before staff takes the floor. All staff will be in-serviced by 2/7/13 by 10:00AM The following staff live in (Name deleted) and attend school during the week. They have been contacted and are aware that they must arrive one hour before on the day that they are scheduled to work to be in-serviced before they will be allowed to work the floor." (A list of the staff were provided.) The IJ was removed on 02/07/13 at 10:00 a.m., when all components of the plan of removal had been completed. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to ensure thickened liquids were provided for one (#9) of seven sampled residents who had physicians' orders to receive thickened liquids. The resident had a history of [REDACTED]. This resulted in an Immediate Jeopardy situation. The facility identified seven residents who had physicians' orders to receive thickened liquids. Findings: Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. An RD nutrition risk assessment, dated 05/21/12, documented the resident's [DIAGNOSES REDACTED]. A comprehensive assessment, dated 12/11/12, documented the resident scored a five on the BIMS, which indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with meals. A physician's orders [REDACTED]. A nurse's note, dated 01/27/13 at 2:15 p.m., documented, "...Res. family alerted this nurse to come to the res bedroom asap. Res was coughing up water. Res. family requested that he have a swallow study done...Res sitting upright in recliner with call light in reach..." A nurse's note, dated 01/28/13 at 11:25 a.m., documented, "...Faxed order received/noted - ST to eval/tx et swallow study. Therapy notified..." A hospital radiology report, dated 01/30/13, documented, "...Modified barium swallow study: Indication: Aspiration, difficulty swallowing and coughing while eating. Conclusion: Aspiration of thin liquids to below the level of the vocal cords while ingesting a 13 mm barium pill. This did elicit a cough response..." The physician signed and dated the radiology report on 01/31/13. A new physician's orders [REDACTED]. The physician's orders [REDACTED]. There were no dietary notes or an updated RD nutritional assessement to address the physician's orders [REDACTED]. A physician's orders [REDACTED]. On 02/06/13 at 5:20 p.m., the resident was observed during the evening meal. The resident was observed sitting in his wheelchair at the dining room table. Three glasses of liquid were observed on the table in front of the resident. One glass contained iced water, one glass contained a red liquid, and the third contained water, with no ice. All liquids were observed to be of a thin consistency. The residen'ts dietary card was observed on the table in front of the resident, and documented, "...Regular ground meat, and Nectar thick fluids..." At 5:30 p.m., dietary aide #1 asked CNA #2 if the resident could have water. The CNA stated, "Yes." The dietary aide served the resident a glass of thin, iced water. CNA #1 was observed to place a straw in the resident's glass of iced water. The resident was observed to push the water away, move up to the table and drink two ounces of the red drink. The resident then began to drink the iced water through the straw. CNA #1 was asked what consistency of liquids the resident was drinking. The CNA stated he was to receive nectar thick liquids. The CNA was asked if the liquid the resident was drinking was thin and she stated, "Yes." The drinks were removed from the resident. CNA #1 was asked if she knew what type of liquids he was to receive. She stated, "I've taken care of him for years and no one told me he was nectar thick when he came back from the hospital last week. No one told me." At 7:10 p.m., CNA #2 was asked if she had informed the dietary aide (#1) that the resident could have thin iced water. She stated, "The resident had three different dietary cards. I thought he could have it, so I told him, yes."

Based on resident and staff interview, clinical record review, and review of facility policies and procedures, it was determined the facility failed to implement written policies and procedures to: a. thoroughly investigate an allegation of abuse for one (#2) of one sampled resident with an allegation of abuse; b. investigate suspicious bruising of unknown origin for one (#8) of one sampled resident with suspicious bruises; c. protect residents from further abuse during an investigation for two (#2 and #8) of two sampled residents with allegations of abuse; and d. protect residents from abuse by hiring staff with a felony conviction. This deficient practice resulted in a determination of immediate jeopardy to resident health and safety, and had the likelihood to affect all residents residing in the facility. Findings: A facility policy, titled "Abuse/Neglect", documented, "Policy: To ensure all residents entrusted in our care will be free from mental, verbal, physical or sexual abuse, neglect, mistreatment and misappropriation of property. Procedure: Screening: a.) All prospective employees will be required to sign a release for a criminal history check. Employment is temporary until this form verified employee history is free of any negligence or abuse of a resident... Identification: a.) Any events noted by staff such as bruising, behavioral problems, and/or further accidents will be reported immediately to the charge nurse for further evaluation... The charge nurse will document the event in the resident's clinical record and notify the resident's attending physician and family/responsible party... Investigation: a.) If an event is suspicious in nature, the attending physician, resident's family/responsible party, facility Director of Nursing and facility administrator will be notified by the charge nurse. b.) When a suspicious event occurs or an observed incident is reported, the facility will begin an immediate investigation into the event/incident. c.) The investigation will include, at a minimum, interviews with all witnesses, collection of written statements from all involved individuals, interviews with any residents involved and/or interviews with additional residents to determine any similar occurrences. Additional investigative steps will be implemented based on the results of the immediate investigation. d.) The results of all the investigative steps will be documented and maintained in a confidential file in the Administrator's office... Protection: a.) Any incident involving facility staff will result in the immediate suspension of all involved personnel pending the results of the investigation. The staff member(s) will not be allowed to be in the facility during the course of the investigation unless supervised by a member of management... Reporting/Response: a.) Staff will report any observed incidents of physical, verbal, mental or sexual abuse, evidence of neglect, or misappropriation of property to their immediate supervisor, the Director of Nursing, the Assistant Director of Nursing, or the Administrator immediately... f.) Administration will evaluate and analyze any event/incident and make any necessary changes in operation or procedures to prevent the situation from recurring..." 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly review assessment, dated 09/08/11, documented the resident was cognitively intact and had no memory problems. The assessment documented the resident required assistance with activities of daily living (ADLs) including transfers. The resident's care plan, dated 06/22/11 and updated on 09/11/11, documented facility staff would assist the resident with ADLs and transfers as needed. An initial incident report form to OSDH, dated 09/22/11, documented, "... Allegations of abuse/mistreatment... Description of Incident... This facility received a visit from (ombudsman) who stated that a call was received by (resident) regarding an allegation of verbal abuse by (CNA #3). Upon interviewing (resident) along with (administrator)(resident stated) that the incident began when (CNA #3) came on shift at 10:00 p.m. (Resident) stated that (CNA#3) came marching down the hallway to her room and got right in her face and said, "What are you doing calling all of the 10/6 CNAs dummies?" (Resident) said that (CNA #3) said that she didn't appreciate that and it wasn't true and it hurt her feelings. (Resident) stated that she never said anything like that to anybody. Then at 3:00 a.m., (resident) said that (CNA#3) came to her room to assist her to the bathroom. (Resident) stated that (CNA #3) put her left arm under her shoulders and her right arm under her knees and proceeded to lift her and swing her around to a sitting position on the side of the bed. (Resident) stated that (CNA #3) didn't do it right and she told her she knew how to do it right because everyone else did. (CNA #3) then wrapped her arms around (resident's) trunk to assist in transferring her to the commode and (resident) stated that (CNA #3) hand was resting on her wound on her spine and she said that it hurt and she shrugged her shoulders and spread her arms and then (CNS #3) let go and fell a couple of steps backwards and stated, "Don't you ever push or shove me again!" (Resident) stated she didn't push her because she's too little and weak. (Resident) stated that (CNA #3) was yelling at her with her finger really close to her face. (Resident) stated that (CNA #3) said that she had a witness outside of the door when all of this was going on. (Resident) stated that the nurse was aware of the situation. (CNA #3) was suspended from her shift last night and is off for 2 more nights pending investigation. Staff will go in pairs to assist with resident's care till further notice... Relevant resident history:... is alert and oriented x 3... is anorexic and weak... shows signs of depression daily noted by her disdain of most care given by staff..." A final report to OSDH, dated 09/22/11, documented, "... CNA was disciplined with suspension x 3 days and all staff was immediately informed when attending to (resident) to have 2 staff attend to her needs to ensure her the best possible care. (CNA #3) does not go into resident's room unless other staff is busy and she always has another staff member with her... as do all. At this time, (resident) denies most of the incident and has apologized to all staff. She continues to have her bad days fighting her situation and depression. Staff will remain patient and attentive to her needs..." There were no nurses' notes regarding the incident found in the clinical record. There was no documentation in the resident's care plan regarding an allegation of abuse and the facility's plan to have two staff care for the resident at all times. A facility document faxed to the ombudsman, dated 09/24/11, documented, "... I'm compiling statements from staff and (CNA name deleted) went out of town during her suspension so I can't get her written statement until she returns..." On 11/08/11 at 2:00 p.m., an interview was conducted with the resident. She was asked to talk about the problem she had with CNA #3 on 09/21/11. She stated CNA #3 came on shift at 10:00 p.m., and shortly thereafter, entered the resident's room and confronted her about talking bad about the CNAs. The resident stated she did not talk bad about any CNAs and later that night, CNA #3 came to her room to assist her to the commode. The resident said the CNA did not lift her properly and placed her hand over a wound on her upper spine. She stated this was painful and she tried to move away from the CNA's hand by raising her shoulders. At this time, the resident said the CNA jerked away from her, backed away quickly and said, "Don't you ever shove me!" The resident said the CNA came closer to her and pointed her finger in the resident's face and said, "Don't you ever do that! I have a witness outside this door!" The resident stated she didn't know what the CNA was talking about but felt intimidated and shocked by the interaction. The resident was asked what she did about the incident. She stated she did nothing until a day later when she told a CNA about it. She stated she did not remember the CNA's name, but the CNA gave her the telephone number to the ombudsman and told her to call. The resident stated she didn't know what an ombudsman was, but learned about it later. She stated the ombudsman came to her room and she told her about the incident. The resident was asked what happened next. She stated some time later (she couldn't remember when), the administrator and the DON came to her room and asked her to repeat her story. She stated she was never questioned again and she did not know what the facility did about the incident. She stated it was at this time the staff began to enter her room two at a time. She stated she was not told why two staff people were coming in to care for her, and she felt like it was punishment for something. She was asked if she had any further contact with the CNA who was verbally abusive to her. She stated the CNA was moved to morning and evening shifts and had given her medicines during those times. She stated the CNA had been in her room alone on three occasions after the abuse incident. She was asked how she felt about that. She stated, "It makes me uncomfortable. It stresses me out. But it keeps going on." On 11/09/11 at 8:55 a.m., the ombudsman was asked about her interview with the resident and the resident's allegation of abuse. She stated the resident told her what happened and that she had reported the incident to a nurse or a CNA. The ombudsman stated she found the resident to be cognitively aware and her allegations seemed credible. The ombudsman stated she took the resident's allegation to the facility administrator. She stated the facility had not received a report from any staff member about the resident's allegation of abuse. She stated the administrator and the DON assured her the CNA would be suspended until the investigation was completed and would have no further contact with the resident. She stated the facility believed the resident to be a chronic complainer. At 9:30 a.m., the DON was asked about the facility's investigation of the resident's allegation of verbal abuse. She stated the incident report to OSDH contained all the information about the investigation. She was asked if the resident had ever made an allegation of abuse before this incident. She stated she had not. She was asked if the resident was cognitively aware. She stated, "She is alert and oriented times four. She knows exactly what is going on." She was asked if the resident's allegation seemed credible. She stated, "She makes lots of complaints about a lot of staff." She was asked if interviews had been conducted with all the staff who worked on the night of the incident. She stated she had only talked to the CNA who was accused. She stated no other staff were interviewed. She was asked if the CNA had provided a written statement. She stated she had not. She was asked if interviews had been conducted with other residents on the same hall about what they might have seen or heard, or about their care by the CNA. She stated no residents had been interviewed. She was asked if she had tried to determine what staff member the resident reported the allegation to initially. She stated she had not. She was asked what action was taken by the facility. She stated the CNA was suspended for three days during the investigation and that she was told not to go into the resident's room when she returned to work. The DON was asked if she was aware the CNA had been in the resident's room alone on three occasions. She stated she was not aware. At 12:45 p.m., LPN #3, who was the charge nurse on the night shift, was asked about the night of the allegation. She stated she recalled aides from the 2:00 p.m. to 10:00 p.m. shift talking to CNA #3 about the resident. She stated the aides told CNA #3 the resident was calling the aides "dumb-asses." She stated the resident made a comment to her during the night, saying, "I never called anyone a dumb-ass." She was asked if she questioned the resident about this subject. She stated, "No." She was asked if administration had interviewed her about the resident's allegations. She stated they had not. She stated she remembered that about a week later, at a regular payday staff meeting, the staff were told to go into the resident's room two at a time and to document anything that happened. She further stated the staff were told at that meeting that CNA #3 was not to go into the resident's room. She was asked if the resident had ever made an allegation of abuse before. She stated she had not. She stated, "She just complained the staff were rough sometimes." She was asked if she reported that to anyone. She stated she had not. On 11/09/11 at 1:45 p.m., OSDH was notified and verified the existence of an immediate jeopardy (IJ) situation related to the facility's failure to implement their policies and procedures to thoroughly investigate the resident's allegation of abuse, and failure to follow policy and procedure to protect the resident during the abuse investigation. At 2:04 p.m., the administrator and the DON were notified of the IJ situation related to the facility's failure to follow their policies and procedures to thoroughly investigate the resident's allegation of abuse, and failure to follow policy and procedure to protect the resident during the abuse investigation. They were notified the IJ situation indicated a substandard quality of care and the facility would enter into an extended survey. At 7:53 p.m., an amended plan of removal was submitted and accepted by the survey team. The plan documented, "... Administrator and DON were inserviced by (corporate regional clinical director and corporate officer) today at 3:02 p.m., on investigation process and follow up on accusation of abuse/neglect and proper investigative procedures and recording of data, written statements along with who, what, when, and how. Department Heads and Administration Staff were trained as Train the Trainers to educate staff on abuse and neglect policy and procedures... All employees will be inserviced on Abuse/Neglect Policy in person or by call in service by midnight tonight 11/09/11. (All employees will be in serviced before allowed to return to work.) This will be done by the Administrator, DON and Administrative Staff. Teaching on how to and when to collect statements from Employees and others. Interviewing of Residents and others was done with Administrator, DON, and Administrative Staff... Reporting Guidelines for Abuse/Neglect was done with Administrator, DON and Administrative Staff... How to protect residents in question and others as to abuse/neglect immediate and prevention of further abuse training was done with Administrator and DON... 'Passing the Sniff Test' for outcome and protection of residents and others training was done with Administrator, DON and Administrative Staff... Outcomes, i.e., when to bring employee back to work (versus) suspension done with Administrator, DON and Administrative Staff... Incident of allegation of abuse of (resident) has been reported to the Administrator. An immediate through (sic) investigation of the allegation will be done with statements and interviews by midnight 11/09/11. Allegations will be reported to appropriate agencies by 11/09/11 midnight. Employee (CNA #3) has been suspended and has been educated as to such by (Administrator). Protection of the resident... will be achieved by Staff member (CNA #3) being suspended and to have a night light in place. This outcome was achieved by interview with resident and having discussion with Administrator and (staff name deleted) as to what would make resident feel safe in the facility. Other clients are being interviewed by (staff name deleted) for ruling out further potential of abuse/neglect. (Administrator) will review interviews of other residents that have been done by (staff name deleted) along with completed interview and statement of the (resident) incident for competition (sic) by midnight tonight 11/09/11. The Plan of Removal will be monitored and ensured for completion by (corporate regional clinical director)..." On 11/10/11 at 3:35 p.m. the facility was notified the immediate jeopardy situation was removed effective 11/10/11 at 12:00 a.m. midnight. The deficiency remained at a level of actual harm with more than a very limited number of residents affected. 2. Resident #8 had [DIAGNOSES REDACTED]. The care plan, dated 07/14/11, and last updated on 10/08/11, did not address injuries of unknown origin. A nurse's note, dated 10/19/11 at 3:20 a.m., documented, "...Apap 325mg (2) po for general discomfort rt s/s. Bruises noted/found @ this x (time) (during toileting & incont. care)...Purple bruising to R nipple & x 2 areas to R shin, older brownish bruising x 2 to L abdomen. Res. stated 'I don't know' when asked if she knew how they happened..." A quarterly assessment, completed on 10/21/11, documented the resident had short and long term memory problems and had moderately impaired cognitive skills for daily decision making. The assessment documented the resident had physical behavioral symptoms directed toward others and other behavioral symptoms not directed toward others, which occurred on one to three of the previous seven days. The assessment documented the resident wandered daily. The resident was independent in bed mobility, transfers, walking and locomotion. The assessment documented the resident had experienced two or more falls without injury and two or more falls with injury (except major) since the previous assessment. On 11/10/11 at 8:50 a.m., the DON was asked about the bruising to the resident's nipple area on 10/19/11. She stated she did not know how it occurred. She was asked if an investigation was conducted due to the unknown injury and the area of bruising . She stated she talked to the staff but did not document anything. On 11/08/11 at 1:30 p.m., a review of the facility's personnel records was conducted. A random sample composed of employees hired within the last four months was reviewed. CNA #4 had a felony conviction for larceny and had pled guilty. The sentence of two years had been suspended. At 2:00 p.m., an interview was conducted with the Administrator. He was shown the felony record of CNA #4. He stated his initials were not on the employee's application which meant he did not give the approval to hire the staff. He stated it must have happened when he was out of the facility. He further stated some things fell through the cracks and the staff did have a felony. At 2:10 p.m., the DON was interviewed. She stated she was not aware of the OSBI report regarding the felony conviction.

Based on clinical record review, policy and procedure review, and resident and staff interviews, it was determined the facility failed to: a. thoroughly investigate an allegation of verbal abuse for one (#2) of one sampled resident with an allegation of verbal abuse; b. investigate suspicious bruises of unknown origin for one (#8) of one sampled resident with suspicious bruises; c. protect residents from further abuse during an investigation for two (#2 and #8) of two sampled residents with allegations of abuse; and d. protect residents by hiring staff with a felony conviction. This deficient practice resulted in a determination of immediate jeopardy to resident health and safety, and had the likelihood to affect all residents who resided in the facility. Findings: A facility policy, titled "Abuse/Neglect", documented, "Policy: To ensure all residents entrusted in our care will be free from mental, verbal, physical or sexual abuse, neglect, mistreatment and misappropriation of property. Procedure: Screening: a.) All prospective employees will be required to sign a release for a criminal history check. Employment is temporary until this form verified employee history is free of any negligence or abuse of a resident... Identification: a.) Any events noted by staff such as bruising, behavioral problems, and/or further accidents will be reported immediately to the charge nurse for further evaluation... The charge nurse will document the event in the resident's clinical record and notify the resident's attending physician and family/responsible party... Investigation: a.) If an event is suspicious in nature, the attending physician, resident's family/responsible party, facility Director of Nursing and facility administrator will be notified by the charge nurse. b.) When a suspicious event occurs or an observed incident is reported, the facility will begin an immediate investigation into the event/incident. c.) The investigation will include, at a minimum, interviews with all witnesses, collection of written statements from all involved individuals, interviews with any residents involved and/or interviews with additional residents to determine any similar occurrences. Additional investigative steps will be implemented based on the results of the immediate investigation. d.) The results of all the investigative steps will be documented and maintained in a confidential file in the Administrator's office... Protection: a.) Any incident involving facility staff will result in the immediate suspension of all involved personnel pending the results of the investigation. The staff member(s) will not be allowed to be in the facility during the course of the investigation unless supervised by a member of management... Reporting/Response: a.) Staff will report any observed incidents of physical, verbal, mental or sexual abuse, evidence of neglect, or misappropriation of property to their immediate supervisor, the Director of Nursing, the Assistant Director of Nursing, or the Administrator immediately... f.) Administration will evaluate and analyze any event/incident and make any necessary changes in operation or procedures to prevent the situation from recurring..." 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly review assessment, dated 09/08/11, documented the resident was cognitively intact and had no memory problems. The assessment documented the resident required assistance with activities of daily living (ADLs) including transfers. The resident's care plan, dated 06/22/11 and updated on 09/11/11, documented facility staff would assist the resident with ADLs and transfers as needed. A nurse's note, dated 09/22/11 at 4:30 a.m., documented, "... CNA toileted resident..." An initial incident report form to OSDH, dated 09/22/11, documented, "... Allegations of abuse/mistreatment... Description of Incident... This facility received a visit from (ombudsman name deleted) who stated that a call was received by (resident name deleted) regarding an allegation of verbal abuse by (CNA #3). Upon interviewing (resident name deleted) along with (administrator name deleted)(resident stated) that the incident began when (CNA #3) came on shift at 10:00 p.m. (Resident) stated that (CNA#3) came marching down the hallway to her room and got right in her face and said, "What are you doing calling all of the 10/6 CNAs dummies?" (Resident) said that (CNA #3) said that she didn't appreciate that and it wasn't true and it hurt her feelings. (Resident) stated that she never said anything like that to anybody. Then at 3:00 a.m., (resident) said that (CNA#3) came to her room to assist her to the bathroom. (Resident) stated that (CNA #3) put her left arm under her shoulders and her right arm under her knees and proceeded to lift her and swing her around to a sitting position on the side of the bed. (Resident) stated that (CNA #3) didn't do it right and she told her she knew how to do it right because everyone else did. (CNA #3) then wrapped her arms around (resident's) trunk to assist in transferring her to the commode and (resident) stated that (CNA #3's) hand was resting on her wound on her spine and she said that it hurt and she shrugged her shoulders and spread her arms and then (CNA #3) let go and fell a couple of steps backwards and stated, "Don't you ever push or shove me again!" (Resident) stated she didn't push her because she's too little and weak. (Resident) stated that (CNA #3) was yelling at her with her finger really close to her face. (Resident) stated that (CNA #3) said that she had a witness outside of the door when all of this was going on. (Resident) stated that the nurse was aware of the situation. (CNA #3) was suspended from her shift last night and is off for 2 more nights pending investigation. Staff will go in pairs to assist with resident's care till further notice... Relevant resident history:... is alert and oriented x 3... is anorexic and weak... shows signs of depression daily noted by her disdain of most care given by staff..." A final report to OSDH, dated 09/22/11, documented, "... CNA was disciplined with suspension x 3 days and all staff was immediately informed when attending to (resident) to have 2 staff attend to her needs to ensure her the best possible care. (CNA #3) does not go into resident's room unless other staff is busy and she always has another staff member with her... as do all. At this time, (resident) denies most of the incident and has apologized to all staff. She continues to have her bad days fighting her situation and depression. Staff will remain patient and attentive to her needs..." There were no nurses' notes regarding the incident found in the clinical record. There was no documentation in the resident's care plan regarding an allegation of abuse and the facility's plan to have two staff care for the resident at all times. A facility document faxed to the ombudsman, dated 09/24/11, documented, "... I'm compiling statements from staff and (CNA name deleted) went out of town during her suspension so I can't get her written statement until she returns..." A nurse's note, dated 09/27/11 at 9:40 a.m., documented, "... Res. crying, 'I don't know what's going on, why 2 people have to be in my room all the time?'... Requested to see nurse..." A nurse's note, dated 09/27/11 at 9:45 a.m., documented, "...(CNA name deleted and nurse name deleted) to res room. Resident crying... asked (resident) what was wrong. Resident stated 'What's going on. I don't understand why 2 or 3 people have to be in my room @ all x's?' Nurse stated (resident) you stated to... ombudsman that you felt unsafe last week so per (administrator) to ensure your safety & safety of staff that would have to be 2 people in your room @ all x's. Resident began crying 'But I will be claustrophobic with them in here.' Explained to resident that this is how it had to be per administration. Res began crying again 'Well why wouldn't anybody else tell me what was going on? They acted like they didn't know!' Nurse stated I don't know (resident). Maybe they felt uncomfortable. That's why they told you to talk to nurse. Res. stated 'I don't know what to believe.' Nurse asked what she meant. (Resident) stated 'I've been told so many things.' Nurse stated... would you like to speak with (administrator)? Resident stated 'Yes...'' There was no further documentation in the clinical record that indicated the administrator spoke with the resident about her concerns. On 11/08/11 at 2:00 p.m., an interview was conducted with the resident. She was asked to talk about the problem she had with CNA #3 on 09/21/11. She stated CNA #3 came on shift at 10:00 p.m., and shortly thereafter, entered the resident's room and confronted her about talking bad about the CNAs. The resident stated she did not talk bad about any CNAs and later that night, CNA #3 came to her room to assist her to the commode. The resident said the CNA did not lift her properly and placed her hand over a wound on her upper spine. She stated this was painful and she tried to move away from the CNA's hand by raising her shoulders. At this time, the resident said the CNA jerked away from her, backed away quickly and said, "Don't you ever shove me!" The resident said the CNA came closer to her and pointed her finger in the resident's face and said, "Don't you ever do that! I have a witness outside this door!" The resident stated she didn't know what the CNA was talking about but felt intimidated and shocked by the interaction. The resident was asked what she did about the incident. She stated she did nothing until a day later when she told a CNA about it. She stated she did not remember the CNA's name, but the CNA gave her the telephone number to the ombudsman and told her to call. The resident stated she didn't know what an ombudsman was, but learned about it later. She stated the ombudsman came to her room and she told her about the incident. The resident was asked what happened next. She stated some time later (she couldn't remember when), the administrator and the DON came to her room and asked her to repeat her story. She stated she was never questioned again and she did not know what the facility did about the incident. She stated it was about this time the staff began to enter her room two at a time. She stated she was not told why two staff people were coming in to care for her, and she felt like it was punishment for something. She was asked if she had any further contact with the CNA who was verbally abusive to her. She stated the CNA was moved to morning and evening shifts and had given her medicines during those times. She stated the CNA had been in her room alone on three occasions after the abuse incident. She was asked how she felt about that. She stated, "It makes me uncomfortable. It stresses me out. But it keeps going on." On 11/09/11 at 8:55 a.m., the ombudsman was asked about her interview with the resident and the resident's allegation of abuse. She stated the resident told her what happened and that she had reported the incident to a nurse or a CNA. The ombudsman stated she found the resident to be cognitively aware and her allegations seemed credible. The ombudsman stated she took the resident's allegation to the facility administrator. She stated the facility had not received a report from any staff member about the resident's allegation of abuse. She stated the administrator and the DON assured her the CNA would be suspended until the investigation was completed and would have no further contact with the resident. She stated the facility believed the resident to be a chronic complainer. At 9:30 a.m., the DON was asked about the facility's investigation of the resident's allegation of verbal abuse. She stated the incident report to OSDH contained all the information about the investigation. She was asked if the resident had ever made an allegation of abuse before this incident. She stated she had not. She was asked if the resident was cognitively aware. She stated, "She is alert and oriented times four. She knows exactly what is going on." She was asked if the resident's allegation seemed credible. She stated, "She makes lots of complaints about a lot of staff." She was asked if interviews had been conducted with all the staff who worked on the night of the incident. She stated she had only talked to the CNA who was accused. She stated no other staff were interviewed. She was asked if the CNA had provided a written statement. She stated she had not. She was asked if interviews had been conducted with other residents on the same hall about what they might have seen or heard, or about their care by the CNA. She stated no residents had been interviewed. She was asked if she had tried to determine what staff member the resident reported the allegation to initially. She stated she had not. She was asked what action was taken by the facility. She stated the CNA was suspended for three days during the investigation and that she was told not to go into the resident's room when she returned to work. The DON was asked if she was aware the CNA had been in the resident's room alone on three occasions. She stated she was not aware. At 12:45 p.m., LPN #3, who was the charge nurse on the night shift, was asked about the night of the allegation. She stated she recalled aides from the 2:00 p.m. to 10:00 p.m. shift talking to CNA #3 about the resident. She stated the aides told CNA #3 the resident was calling the aides "dumb-asses." She stated the resident made a comment to her during the night, saying, "I never called anyone a dumb-ass." She was asked if she questioned the resident about this subject. She stated, "No." She was asked if administration had interviewed her about the resident's allegations. She stated they had not. She stated she remembered that about a week later, at a regular payday staff meeting, the staff were told to go into the resident's room two at a time and to document anything that happened. She further stated the staff were told at that meeting that CNA #3 was not to go into the resident's room. She was asked if the resident had ever made an allegation of abuse before. She stated she had not. She stated, "She just complained the staff were rough sometimes." She was asked if she reported that to anyone. She stated she had not. On 11/09/11 at 1:45 p.m., OSDH was notified and verified the existence of an immediate jeopardy (IJ) situation related to the facility's failure to thoroughly investigate the resident's allegation of abuse and failure to protect the resident during the abuse investigation. At 2:04 p.m., the administrator and the DON were notified of the IJ situation related to the facility's failure to thoroughly investigate the resident's allegation of abuse and failure to protect the resident during the abuse investigation. They were notified the IJ situation indicated a substandard quality of care and the facility would enter into an extended survey. At 7:53 p.m., an amended plan of removal was submitted and accepted by the survey team. The plan documented, "... Administrator and DON were inserviced by (corporate regional clinical director and corporate officer) today at 3:02 p.m., on investigation process and follow up on accusation of abuse/neglect and proper investigative procedures and recording of data, written statements along with who, what, when, and how. Department Heads and Administration Staff were trained as Train the Trainers to educate staff on abuse and neglect policy and procedures... All employees will be inserviced on Abuse/Neglect Policy in person or by call in service by midnight tonight 11/09/11. (All employees will be in serviced before allowed to return to work.) This will be done by the Administrator, DON and Administrative Staff. Teaching on how to and when to collect statements from Employees and others. Interviewing of Residents and others was done with Administrator, DON, and Administrative Staff... Reporting Guidelines for Abuse/Neglect was done with Administrator, DON and Administrative Staff... How to protect residents in question and others as to abuse/neglect immediate and prevention of further abuse training was done with Administrator and DON... 'Passing the Sniff Test' for outcome and protection of residents and others training was done with Administrator, DON and Administrative Staff... Outcomes, i.e., when to bring employee back to work (versus) suspension done with Administrator, DON and Administrative Staff... Incident of allegation of abuse of (resident) has been reported to the Administrator. An immediate through (sic) investigation of the allegation will be done with statements and interviews by midnight 11/09/11. Allegations will be reported to appropriate agencies by 11/09/11 midnight. Employee (CNA #3) has been suspended and has been educated as to such by (Administrator). Protection of the resident...will be achieved by Staff member (CNA #3) being suspended and to have a night light in place. This outcome was achieved by interview with resident and having discussion with Administrator and (staff name deleted) as to what would make resident feel safe in the facility. Other clients are being interviewed by (staff name deleted) for ruling out further potential of abuse/neglect. (Administrator) will review interviews of other residents that have been done by (staff name deleted) along with completed interview and statement of the (resident) incident for competition (sic) by midnight tonight 11/09/11. The Plan of Removal will be monitored and ensured for completion by (corporate regional clinical director)..." On 11/10/11 at 3:35 p.m., the facility was notified the immediate jeopardy situation was removed effective 11/10/11 at 12:00 a.m. midnight. The deficiency remained at a level of actual harm with more than a very limited number of residents affected. 2. Resident #8 had [DIAGNOSES REDACTED]. The care plan, dated 07/14/11, and last updated on 10/08/11, did not address injuries of unknown origin. A nurse's note, dated 10/19/11 at 3:20 a.m., documented, "...Apap 325mg (2) po for general discomfort rt s/s. Bruises noted/found @ this x (time) (during toileting & incont. care)...Purple bruising to R nipple & x 2 areas to R shin, older brownish bruising x 2 to L abdomen. Res. stated 'I don't know' when asked if she knew how they happened..." A quarterly assessment, completed on 10/21/11, documented the resident had short and long term memory problems and had moderately impaired cognitive skills for daily decision making. The assessment documented the resident had physical behavioral symptoms directed toward others and other behavioral symptoms not directed toward others, which occurred on one to three of the previous seven days. The assessment documented the resident wandered daily. The resident was independent in bed mobility, transfers, walking and locomotion. The assessment documented the resident had experienced two or more falls without injury and two or more falls with injury (except major) since the previous assessment. On 11/10/11 at 8:50 a.m., the DON was asked about the bruising to the resident's nipple area on 10/19/11. She stated she did not know how it occurred. She was asked if an investigation was conducted due to the unknown injury and the area of bruising. She stated she talked to the staff but did not document anything. 3. On 11/08/11 at 1:30 p.m., a review of the facility's personnel records was conducted. A random sample composed of employees hired within the last four months was reviewed. CNA #4 had a felony conviction for larceny and had pled guilty. The sentence of two years had been suspended. At 2:00 p.m., an interview was conducted with the Administrator. He was shown the felony record of CNA #4. He stated his initials were not on the employee's application which meant he did not give the approval to hire the staff. He stated it must have happened when he was out of the facility. He further stated some things fell through the cracks and the staff did have a felony. At 2:10 p.m., the DON was interviewed. She stated she was not aware of the OSBI report regarding the felony conviction.

Based on observation, review of clinical records and staff interviews, it was determined the facility failed to: a. ensure a resident who was admitted to the facility without limitations in range of motion, did not have a decline in range of motion; b. identify the resident was at risk for contractures; c. identify developing contractures; and d. failed to identify and implement interventions to prevent contractures for one (#1) of three sampled residents who had limitations in range of motion. This had the potential to affect four residents identified on the facility's census and condition report who were identified as having contractures. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 04/12/07, documented the resident was moderately impaired in cognitive skills for daily decision making, was independent in ADLs except that she required the limited assistance of one for bathing, was continent of both bowels and bladder and had no limitations in range of motion. An annual assessment, dated 11/28/10, documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent on others for transfers, was not ambulatory and had impairment in range of motion to lower extremity on one side. A care plan, dated 12/02/10, documented, "Falls Problem I have a potential for alteration in mobility d/t taking antidepressant medication. Goals I will have no falls and or injuries reported and or observed over the next 90 days. Approach Keep my room free of clutter and obstructions. Keep my room and hallways well lit. Assist me with ADLs and toileting (sic) as needed. Ensure that I understand how to use my call light and can demonstrate a return... 8/11 (Resident) has had (no) falls observed et or reported over the last 90 days. Staff uses total lift for transfers. Restorative provides passive ROM 3 x wkly (weekly). (No) chg (change) in POC @ this x..." There was no care plan related to range of motion or how to prevent a decline in range of motion. An annual assessment, dated 05/28/11, documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent on others for transfers, was not ambulatory and had impairment in range of motion to the lower extremity on one side. An annual assessment, dated 08/28/11, documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent on others for transfers, was not ambulatory and had impairment in range of motion to the upper extremity on one side. Another annual assessment, also dated 08/28/11, documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent on others for transfers, was not ambulatory and had impairment in range of motion to the lower extremity on one side. The October 2011 monthly physician's orders [REDACTED]...05/02/11: Restorative Therapy -Active ROM to upper and lower ext (extremities) x 20 rep (repetitions) 3x weekly..." The October MAR indicated [REDACTED]. There was no further documentation the resident received range of motion for the rest of October 2011. The November MAR indicated [REDACTED]. On 11/07/11 at 12:45 p.m., the resident was observed as she sat in her gerichair in her room. The resident was asleep. The resident's left hand was clenched into a fist. On 11/08/11 at 10:45 a.m., the resident was observed sitting in her gerichair near the nurse's station. Again the resident's left hand was observed to be closed into a tight fist. No movement was noted. At 3:30 p.m., CNA #2 was asked if the resident had a decline in range of motion to her extremities. She stated the resident had good and bad days. She stated the resident's range of motion to her lower extremities was good if the resident would let the staff move her legs. She stated the resident was unable to use her left hand. She stated the resident's right hand was better. She was asked if the resident's range of motion was worse than it was one year ago. She stated the resident's left hand was a little worse than it had been a year ago. On 11/09/11 at 9:15 a.m., the RA (restorative aide) was asked how long he had worked with the resident's range of motion. He stated he had worked with her for almost a year. He was asked what he did for the resident. He stated he did range of motion on the resident's legs, arms and hands. He stated the resident's hands were worse now then when he first started doing restorative with her. He stated, "I try not to mess with her a whole lot." The RA was asked if he was pulled to the floor to work as a CNA at times. He stated he was frequently unable to perform his duties as a restorative aide, because he was needed to work as a CNA on the floor. He was asked how long it had been since he had performed as a restorative aide. He stated the residents had not received therapy for a while. He stated it was close to a month that restorative care had not been provided to the residents. The RA was asked if resident #1 ever refused restorative care. He stated, "No, she doesn't refuse much." He was asked if the resident had declined. He stated the resident had declined in general. He was asked if the resident could move her lower extremities. He stated she could move them pretty well. He stated it was mainly the left hand that had a decline in range of motion. At 10:20 a.m., the RA was asked to demonstrate how he performed range of motion on resident #1. The RA demonstrated range of motion on the resident. The resident had good range of motion to her lower extremities. He stated the resident's hands had gotten worse over the past six months. He stated the resident used to be able to move all her fingers partially open in June of this year. He demonstrated the resident was only able to extend her index finger and middle finger on her left hand to approximately 30 degrees. He was unable to extend the resident's left ring finger and little finger at all. On 11/10/11 at 8:15 a.m., the DON was asked if the restorative aide was always able to be assigned to do restorative care. She stated he could not always do restorative as he was needed on the floor to work as a CNA. She stated the RA had not done any restorative care for the month of November 2011. The DON was asked if the resident's range of motion in her left hand had declined. She stated the resident used to be able to extend all of her fingers of her left hand in the past. The DON stated the resident's range of motion had declined in the past year.

Based on observation, review of clinical records and staff and resident interviews, it was determined the facility failed to prevent a decline in ambulation, transfers, bathing and toileting, resulting in actual harm for two (#2 and #9) of two sampled residents with a decline in ambulation, transfers, bathing and toileting. This had the potential to affect 11 residents identified by the facility with a decline in ADLs. Findings: 1. Resident #2 was admitted to the facility with a history of a cervical spine fracture with surgical repair and placement of a halo device, [MEDICAL CONDITION] arthritis, [MEDICAL CONDITIONS] and depression. A history and physical report, dated 05/19/11, documented, "...History: The patient is a... female who initially came to medical attention with progressive weakness and multiple falls... The patient... underwent a C1-C2 transarticular screw... The patient did very well from this procedure and was ambulatory and moving quite well. Several days prior to admission, she had a fall after which she began to have pain in the neck and head. She also reports that her legs 'got wobbly' making it difficult for her to walk... Review of Systems:... positive for recent falls, neck pain, frequency, joint swelling, contractures and generalized weakness... Physical Examination: The patient is a... female in moderate acute distress. She is very small and cachectic... Musculoskeletal: The patient is tender to palpation in the cervical spine. There is ulnar deviation of the fingers at the metacarpophalangeal joints and some boutonniere deformities... Neurologic: The patient is awake and oriented x 3. Speech is clear and appropriate. Motor examination reveals 4/5 strength in all muscle groups of bilateral upper extremities and 4+/5 strength in all muscle groups of bilateral lower extremities..." An admission nursing assessment, dated 05/26/11, documented the resident was a one person assist with transfers, had full weight-bearing and was a one person assist with a walker. The assessment did not document contractures to both hands. An initial assessment, dated 06/08/11, documented the resident was independent in cognitive skills for daily decision-making, was ambulatory with a walker, was independent with eating, and was able to toilet herself with minimal or no assistance. The assessment documented the resident needed limited assistance of one person with transferring, dressing, toileting, hygiene and bathing. A physician's telephone order, dated 06/21/11, documented, "Physical therapy for mobility and strengthening..." There was no documentation of physical therapy services provided to the resident. A care plan, developed on 06/22/11, documented, "Problem: I require minimal assistance with transfers, ADLs, bathing, D/T I have to wear a halo for a cervical fracture and it makes me off balance. Goal: I will have all my ADLs met daily over the next 90 days. Approach:...Assist me with grooming only to the extent required. Allow me ample time to perform self care to the best of my ability..." An ADL Flowsheet, dated June 2011, documented the resident was independent or needed limited assistance with ambulation, needed total assistance with bathing, was independent with bed mobility, and needed limited assistance with dressing. An ADL Flowsheet, dated July 2011, documented the resident needed limited assistance with ambulation, needed total assistance with bathing, was independent with bed mobility, and needed limited assistance with dressing. A consultation report from the neurosurgeon to the primary physician, dated 08/23/11, documented, "... (resident) is a cachectic ... female... She has approximately 3 to 4-/5 strength in the bilateral upper extremities and 4/5 strength in the bilateral lower extremities. This is an on-going problem. She appears to have intact sensation..." An ADL Flowsheet, dated August 2011, documented the resident needed limited assistance with ambulation, was totally dependent for bathing, needed limited assistance with bed mobility and total assistance with dressing. A significant change assessment, dated 09/08/11, documented the resident needed extensive assistance with transfers, assistance with ambulation, and extensive assistance with dressing, toileting, hygiene and bathing. A care plan quarterly review, dated 09/11/11, documented, "... (Resident) came into the facility she required minimal assist D/T having a halo for spinal fusion repair. Since admission she has declined et requires mod. assist of staff. Staff believes a lot of this attention-seeking behavior. She doesn't have the initiative to do any of her ADLs. She enjoys or wants the attention of the staff @ all xs (times). (No change in plan of care) @ this x (time)..." A comprehensive monthly evaluation, dated 09/15/11, documented the resident needed extensive assistance with bed mobility, transfers, toileting, hygiene and bathing. It documented the resident was now totally dependent on staff for dressing. A physician's telephone order, dated 09/23/11, documented, "RA (restorative assistance) program 3 (times a week) for (bilateral upper and lower extremity) strengthening and ambulation..." A facility flowsheet, titled "[DATE]", documented the resident received ambulation training and strengthening exercises of the upper and lower extremities on 09/26/11, 09/27/11, 09/28/11 and 09/30/11. Another facility flowsheet, titled "[DATE]", documented the resident received ambulation training and strengthening exercises of the upper and lower extremities on 10/04/11, 10/05/11, 10/07/11, 10/08/11, 10/11/11, 10/15/11, and 10/21/11. There was no other documented restorative services provided for the resident. On 11/08/11 at 2:00 p.m., the resident was asked about the assistance she received from staff. She stated, "They tell me they have to help me. They can't wait for me to do it myself because they say they don't have time. They just pick me up and dress me." She went on to say, "They put diapers on me. I don't know why. Except it's more convenient for them. I just started wearing my own underwear anyway." She stated, "I asked them to wake me up between 3:00 and 4:00 a.m. to take me to the toilet. This is so I won't wake up wet in the morning. Sometimes they do it, sometimes they don't." She was asked about her ability to walk. She stated, "I used to walk really pretty well, even though I had that halo on. I walked in the hall and to the lobby. I can't do that now. I can't even raise my head up very well. Can't extend my arms very well. I'm weaker now." The resident was asked if she received regular exercises and practice with walking. She stated she did for two or three sessions, then the aide was moved to another shift and he couldn't do them anymore. She stated no one else had provided any guided exercises or had helped develop her walking skills. She stated, "I think it's easier for the staff if you are in a wheelchair. I've seen other people who came in here walking, who got put in a wheelchair and never got out." On 11/09/11 at 8:40 a.m., the MDS coordinator was asked if the resident had a decline in her ADLs. She stated she did. On 11/09/11 at 8:40 a.m., the DON was asked if the resident was receiving restorative services. She stated she was not, as there was not enough staff available to provide a restorative program. 2. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Incident/Accident Reports were reviewed. The resident was found to have had sixteen falls from 04/09/11 through 09/25/11. An admission assessment, dated 04/21/11, documented the resident was severely impaired in cognitive skills for daily decision making, required limited assistance with transfers, ambulating, and toileting and required extensive assistance with bathing. It also documented the resident had two or more falls without injury since admission to the facility. A care plan, dated 04/24/11, documented, "Problem I require minimal assist at times with ADLs d/t my disease process. Goals I will have assist with my ADLs as needed and will have no decline in ADL function over the next 90 days. Approach Staff to make sure bath room is warm, appropriate lit, and with all necessary items for me to take a bath with. Staff to anticipate and meet my needs as promptly as possible. Keep my call light within reach at all times while I am in my room. Instruct me in the use of call light with each interaction and have me demonstrate my ability to use it. Fall Risk Assessment to be done each quarter and prn. Turn and reposition me every 2 hours and prn and as I request. Quarterly Review #1: 5/11 (Resident) requires minimal - moderate assist c transfers d/t safety issues. Although she continues to get (up) et (down) on her own. Will continue POC @ this x. Quarterly Review #2: 8/11 (Resident) continues to require min - mod assist c all ADLs. She is forgetful. If she is given directions regarding ADL she can do c a lot of encouragement. (No) chg in POC @ this x." A quarterly assessment, dated 08/06/11 documented the resident was severely impaired in cognitive skills for daily decision making, and now required extensive assistance with transfers and ambulation in her room. It also documented the resident no longer ambulated in the corridor. The resident now required extensive assistance with toileting and was totally dependent on others for bathing. It also documented the resident had two or more falls without injury since the last assessment. The September 2011 monthly physician's orders [REDACTED]. On 11/10/11 at 10:05 a.m., the resident was observed asleep in her room on her bed. At 10:55 a.m., the resident was observed up in her wheelchair at the door to her room. She was moving her wheelchair back and forth a few feet during the conversation. She was asked if she had any problems with pain. She responded, "No." She was asked if she had any problems with falling a lot in the past. She stated, "No. I get up with a girl." The resident then propelled herself in her wheelchair into the dining room. At 11:01 a.m., LPN #1 was asked if the resident had a problem with falls. She stated, "Yes, she's had a lot, but not so much recently." She was asked why she thought the resident wasn't falling as much. She stated, "Because she's declining. She's weaker. Can't get up without help now." She was asked if the resident was able to do less for herself now. She stated, "Yes. She needs more help."

Based on clinical record review and staff and resident interview, it was determined the facility failed to provide restorative services in order to increase range of motion and/or to prevent an avoidable decline in range of motion, resulting in actual harm for two (#2, and #5) of five sampled residents with orders for restorative services. The facility did not identify any residents with a need for restorative services. Findings: 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A telephone physician's orders [REDACTED]. A telephone physician's orders [REDACTED]. A monthly summary, dated 05/10/11, documented the resident needed passive and active range of motion exercises. A quarterly assessment, dated 05/31/11, documented the resident was severely impaired in cognitive skills for daily decision-making, was not ambulatory, and was totally dependent on staff for transfers, dressing, toileting, hygiene and bathing. The assessment documented the resident had functional limitation in range of motion to a lower extremity. It did not document a problem with the resident's left hand. Comprehensive monthly evaluations, dated 06/07/11, 07/04/11 and 08/01/11 documented the resident needed passive and active range of motion exercises. An annual assessment, dated 08/29/11, documented the resident was severely impaired in cognitive skills for daily decision-making, was not ambulatory, and was totally dependent on staff for transfers, dressing, toileting, hygiene and bathing. The assessment documented the resident had functional limitation in range of motion to a lower extremity. It did not document a problem with the resident's left hand. A comprehensive monthly evaluation, dated 09/01/11, documented the resident needed active range of motion exercises. A care plan, developed on 09/06/11, did not address limits on range of motion or the need for restorative nursing services. It did not address ambulation and transferring training. It did not address limitations with the resident's left hand. A comprehensive monthly evaluation, dated 10/04/11, documented the resident needed passive and active range of motion exercises. A facility form, titled "[DATE]", dated October 2011, documented the resident received passive range of motion exercises to the left hand, and active range of motion to the upper and lower extremities on 10/01/11, 10/05/11, 10/06/11, 10/07/11, 10/11/11, 10/15/11, and 10/21/11. There was no documentation of assessment of the resident's abilities or progress with the restorative program. A facility form, titled "[DATE]", dated November 2011, had no documentation of restorative services provided during the month. On 11/09/11 at 8:40 a.m., the DON was asked if the residents were receiving restorative services. She stated they were not, as there was not enough staff available to provide a restorative program. She was asked to provide any other documentation of restorative services, such as ambulation and transfer training, provided to resident #5. No documentation was provided. 2. Resident #2 was admitted to the facility with a history of a cervical spine fracture with surgical repair and placement of a halo device, [MEDICAL CONDITION] arthritis, [MEDICAL CONDITIONS] and depression. A history and physical report, dated 05/19/11, documented, "...History: The patient is a... female who initially came to medical attention with progressive weakness and multiple falls... The patient... underwent a C1-C2 transarticular screw... The patient did very well from this procedure and was ambulatory and moving quite well. Several days prior to admission, she had a fall after which she began to have pain in the neck and head. She also reports that her legs 'got wobbly' making it difficult for her to walk... Review of Systems:... positive for recent falls, neck pain, frequency, joint swelling, contractures and generalized weakness... Physical Examination: The patient is a... female in moderate acute distress. She is very small and cachectic... Musculoskeletal: The patient is tender to palpation in the cervical spine. There is ulnar deviation of the fingers at the metacarpophalangeal joints and some boutonniere deformities... Neurologic: The patient is awake and oriented x 3. Speech is clear and appropriate. Motor examination reveals 4/5 strength in all muscle groups of bilateral upper extremities and 4+/5 strength in all muscle groups of bilateral lower extremities..." An admission nursing assessment, dated 05/26/11, documented the resident was a one person assist with transfers, had full weight-bearing and was a one person assist with a walker. The assessment did not document contractures to both hands. The "Restorative Programs Indicated" portion of the nursing assessment was left blank. An initial assessment, dated 06/08/11, documented the resident was independent in cognitive skills for daily decision-making, needed limited assistance of one person with transferring, dressing, toileting, hygiene and bathing. The assessment documented the resident had no functional limitation on range of motion, although the resident was admitted to the facility with a halo brace that prevented movement of her head, neck and torso and had contractures of both hands from [MEDICAL CONDITION] arthritis. The assessment also documented the resident was not receiving any physical therapy or restorative nursing programs. A physician's telephone order, dated 06/21/11, documented, "Physical therapy for mobility and strengthening..." A care plan, developed on 06/22/11, did not document the resident's halo brace, contractures of the hands, or any other limits on range of motion. There was no documentation of a plan for physical therapy or restorative nursing services. There was no documentation in the clinical record that physical therapy was provided by the facility. A consultation report from the neurosurgeon to the primary physician, dated 08/23/11, documented, "... (resident) is a cachectic ... female... She has approximately 3 to 4-/5 strength in the bilateral upper extremities and 4/5 strength in the bilateral lower extremities. This is an on-going problem. She appears to have intact sensation..." A significant change assessment, dated 09/08/11, documented the resident needed extensive assistance with transfers, assistance with ambulation, and extensive assistance with dressing, toileting, hygiene and bathing. A comprehensive monthly evaluation, dated 09/15/11, documented the resident needed extensive assistance with bed mobility, transfers, toileting, hygiene and bathing. It documented the resident was now totally dependent on staff for dressing. A physician's telephone order, dated 09/23/11, documented, "RA (restorative assistance) program 3 (times a week) for (bilateral upper and lower extremity) strengthening and ambulation..." A facility flowsheet, titled "[DATE]", documented the resident received ambulation training and strengthening exercises to the upper and lower extremities on 09/26/11, 09/27/11, 09/28/11 and 09/30/11. Another facility flowsheet, titled "[DATE]", documented the resident received ambulation training and strengthening exercises to the upper and lower extremities on 10/04/11, 10/05/11, 10/07/11, 10/08/11, 10/11/11, 10/15/11, and 10/21/11. There were no other documented restorative services provided for the resident. There was no documentation of an assessment of the resident's abilities or progress with the restorative program. A comprehensive monthly evaluation, dated 10/17/11, documented the resident needed extensive assistance with bed mobility, transfers, toileting, hygiene and bathing. The assessment also documented the resident was no longer walking in the corridor and was totally dependent for dressing. On 11/08/11 at 2:00 p.m., the resident was asked if she received regular exercises and practice with walking. She stated she did receive exercises for two or three sessions until the aide was moved to another shift and couldn't do them anymore. She stated no one else provided any guided exercises or had helped improve her walking skills.

Based on clinical record review and staff and resident interview, it was determined the facility failed to provide restorative services to maintain upper and lower extremity strength resulting in actual harm for one (#2) of five sampled residents who required restorative services. This had the potential to affect all residents residing in the facility, as the facility did not identify any residents who required restorative services. Findings: Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A history and physical report, dated 05/19/11, documented, "...History: The patient is a... female who initially came to medical attention with progressive weakness and multiple falls... The patient... underwent a C1-C2 transarticular screw... The patient did very well from this procedure and was ambulatory and moving quite well. Several days prior to admission, she had a fall after which she began to have pain in the neck and head. She also reports that her legs 'got wobbly' making it difficult for her to walk... Review of Systems:... positive for recent falls, neck pain, frequency, joint swelling, contractures and generalized weakness... Physical Examination: The patient is a... female in moderate acute distress. She is very small and cachectic... Musculoskeletal: The patient is tender to palpation in the cervical spine. There is ulnar deviation of the fingers at the metacarpophalangeal joints and some boutonniere deformities... Neurologic: The patient is awake and oriented x 3. Speech is clear and appropriate. Motor examination reveals 4/5 strength in all muscle groups of bilateral upper extremities and 4+/5 strength in all muscle groups of bilateral lower extremities..." An initial assessment, dated 06/08/11, documented the resident was independent in cognitive skills for daily decision-making, needed assistance with transferring, dressing, toileting, hygiene and bathing. The assessment also documented the resident had severe pain daily and had a history of [REDACTED]. A physician's telephone order, dated 06/21/11, documented, "Physical therapy for mobility and strengthening..." There was no documentation of physical therapy services provided to the resident. A significant change assessment, dated 09/08/11, documented the resident needed extensive assistance with transfers, assistance with ambulation, and extensive assistance with dressing, toileting, hygiene and bathing. A physician's telephone order, dated 09/23/11, documented, "RA (restorative assistance) program 3 (times a week) for (bilateral upper and lower extremity) strengthening and ambulation..." A facility flowsheet, titled "[DATE]", documented the resident received ambulation training and strengthening exercises of the upper and lower extremities on 09/26/11, 09/27/11, 09/28/11 and 09/30/11. Another facility flowsheet, titled "[DATE]", documented the resident received ambulation training and strengthening exercises of the upper and lower extremities on 10/04/11, 10/05/11, 10/07/11, 10/08/11, 10/11/11, 10/15/11, and 10/21/11. There was no other documented restorative services provided for the resident. On 11/08/11 at 2:00 p.m., the resident was asked if she received regular exercises and practice with walking. She stated she did for two or three sessions, then the aide was moved to another shift and he couldn't do them anymore. She stated no one else had provided any guided exercises or had helped develop her walking skills. On 11/09/11 at 8:40 a.m., the DON was asked if the resident was receiving restorative services. She stated she was not, as there was not enough staff available to provide a restorative program.

Based on observation, review of clinical records and staff interviews, it was determined the facility failed to: a. identify the presence of a stage II pressure ulcer for two (#1 and #2) of two sampled residents with pressure ulcers; and b. prevent the development of a recurrent stage II pressure ulcer for one (#1) of two sampled residents with pressure ulcers. This deficient practice resulted in actual harm for both residents and had the potential to affect two residents identified by the facility with pressure ulcers. Findings: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 04/13/07, documented the resident was moderately impaired in cognitive skills for daily decision making, was independent in bed mobility and had no pressure ulcers. An E-Z Graph Wound Assessment System form, dated 11/23/10, documented the resident had two stage II pressure ulcers, one to the left buttock and one to the left coccyx. The left buttock ulcer was 1.3 x 2.0 cm and the left coccyx ulcer was 1.0 x 1.0 cm. An annual assessment, dated 11/28/10, documented the resident was severely impaired in cognitive skills for daily decision making, required extensive assistance for bed mobility with the assistance of two persons, and had one stage II pressure ulcer. A care plan, dated 12/02/10, documented, "Problem: I have a Stage ii on my coccyx area Goal: I will have no further breakdown observed and or reported over the next 90 days. Approach: Apply skin barrier ung (unguent) to coccyx as needed. Reposition every 2 hours and prn. Remind me to drink plenty of fluids daily. Provide good perineal care after each episode of incontinence and prn. Quarterly Review 08/11: (Resident) conts (continues) to have stage II on L sacrum approx 0.5 x 0.5 x 0.1 healing. Wound care nurse sees her wkly. Daily wound care to buttocks c DWC (dermal wound cleanser), apply Criticaid AF bid et prn. Vaseline constant care to buttocks prn... Turn q 2 (hrs) when in bed. [MEDICATION NAME] bid. (No) chg in POC @ this x." A Braden Scale form, dated 06/10/11, documented the resident had a total score of "11." A score of 10-12 indicated the resident was at a high risk of developing a pressure sore. An E-Z Graph Wound Assessment System form, dated 08/23/11, documented the resident had a scabbed stage II pressure ulcer to the left buttock which measured 1.4 x 0.9 cm. A quarterly assessment, dated 08/28/11, documented the resident was severely impaired in cognitive skills for daily decision making, required extensive assistance for bed mobility with the assistance of two persons and had one stage II pressure ulcer. An E-Z Graph Wound Assessment System form, dated 09/06/11, documented the resident had a stage II pressure ulcer to the left buttock which measured 0.9 x 0.3 cm. An E-Z Graph Wound Assessment System form, dated 10/04/11, documented the resident had a stage II pressure ulcer to the left buttock which measured 1.1 x 1.2 cm. A Wound Care Progress Note form, dated 10/19/11, documented, "...Wound 100% covered c epithelium. No visible break in skin. No drainage. No pain c cleansing. No peri wound [DIAGNOSES REDACTED]." A physician's telephone order, dated 10/19/11, documented "Criticaid AF bid to buttocks x 14 days," then "Criticaid AF to buttocks bid prn..." An E-Z Graph Wound Assessment System form, dated 10/25/11, documented, "Area closed. (No) open area. Red/pink. Cont (with) Cirtric (sic) AF as ordered." The November 2011 monthly physician's orders [REDACTED]...03/02/2011: Up in chair a maxium (sic) of 1 hr tid @ 8, 12, 17 (5:00 p.m.)..." A Wound Care Progress Note form, dated 11/02/11, documented, the resident had a Stage III pressure ulcer to the left sacrum which measured 0.9 x 0.4 x 0.1 cm. The form documented, "Wounds to left buttock covered c soft exudate. Satellite distal wound adjacent (no) (illegible) covered c soft exudate. Mod amt periwound [DIAGNOSES REDACTED]. Some reports of pain c cleansing..." The November 2011 MAR, documented the resident did not receive Criticaid AF to buttocks between 11/02/11 at 10:00 a.m. and 11/07/11. On 11/07/11 at 12:45 p.m., the resident was observed sitting up in her gerichair in her room sleeping. She was leaning to her left with the call cord across her lap. She had just returned from eating lunch. She had been placed in the gerichair at approximately 11:00 a.m. At 3:45 p.m., the resident was observed still up in her gerichair sleeping. The resident was in the same position as she was at 12:45 p.m. The head of the resident's gerichair was upright with resident leaning to her left. At 4:10 p.m., the resident was observed sitting in her gerichair in the same position as previously. The resident continued to be asleep. At 4:35 p.m., the resident was observed as she was brought to the dining room in her gerichair. She continued to be in the same position as previously. At 5:48 p.m., the resident continued to be sitting in her gerichair in the dining room being assisted with her meal. (The resident at this time had been up in her gerichair for over five hours.) On 11/08/11 at 9:45 a.m., LPN #1 was asked if the resident had any open areas on her skin. She stated the resident had reddened areas but had no open areas. She stated the resident received Criticaid to her buttocks. She also stated she had not observed the resident's buttocks today, but had yesterday. At 10:02 a.m., CNA #4 and CNA #5 performed catheter care for the resident. During the care, a stage II pressure ulcer was observed on the resident's left buttock. The open area was approximately 1.0 cm x 0.5 cm. At 2:01 p.m., LPN #1 was asked if she had seen the resident's buttocks yet today. She stated she had not had a chance to check the resident's skin today, but that the resident's skin was intact yesterday. She stated the two CNAs who did her catheter care had told her there were no open areas. The LPN was informed there was an open area to the resident's buttocks. She prepared her wound care supplies and entered the resident's room to check the resident. After turning the resident on her left side, the LPN stated, "Yep. It's (the pressure ulcer) where it was before." She stated the pressure ulcer was a stage II. She then stated the resident received Criticaid prn and would continue to receive this until the next day, 11/09/11, when the wound nurse was scheduled to make visits. The LPN stated she would get an order from the wound care nurse the next day, and would continue Criticaid until then. The LPN did not contact the physician about the recurring stage II pressure ulcer. An E-Z Graph Wound Assessment System form, dated 11/08/11, documented the resident had a new re-opened stage II to the left sacral area which measured 0.4 x 0.6 cm. On 11/09/11 at 9:00 a.m., LPN #1 was asked if there was a certain way to use the E-Z graph paper for measuring pressure ulcers. She stated the wound grids were supposed to be used by putting the dot over the center of the ulcer. She was informed it was not being done that way. She stated, "I know." At 10:45 a.m., the wound care nurse was asked about the resident's pressure ulcer to her buttocks. She stated that last week the wound had been healed. She stated the ulcer would come and go. She stated she felt the open area was caused by shearing from the lift. She stated that Criticaid worked the best on the resident. On 11/10/11 at 8:15 a.m., the DON was asked if the resident should be left sitting up for over one hour. She stated she expected her to be put into bed between meals. She was asked if the physician should have been contacted about the recurring pressure ulcer. She stated "Yes." She stated the physician should have been called instead of waiting for the wound care nurse the next day. She also stated the pressure ulcer was in the same place it had been before. 2. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A history and physical report, dated 05/19/11, documented, "... Review of Systems:... positive for recent falls, neck pain, frequency, joint swelling, contractures and generalized weakness... Physical Examination: The patient is a... female in moderate acute distress. She is very small and cachectic... Musculoskeletal: The patient is tender to palpation in the cervical spine. There is ulnar deviation of the fingers at the metacarpophalangeal joints and some boutonniere deformities... Neurologic: The patient is awake and oriented x 3. Speech is clear and appropriate. Motor examination reveals 4/5 strength in all muscle groups of bilateral upper extremities and 4+/5 strength in all muscle groups of bilateral lower extremities... An Operative Report, dated 05/20/11, documented, "...Procedures: 1. Removal of posterior cervical hardware... 3. Closed reduction of C1-C2 subluxation. 4. Placement of halo vest..." An admission nursing assessment, dated 05/26/11, documented the resident had a halo device. There was no documentation on the skin condition portion of the form. A Braden Scale for Predicting Pressure Sore Risk, dated 05/26/11, documented a score of "22 No Risk", although the resident: - had a [DIAGNOSES REDACTED]. - had a brace that could retain moisture and was not removable; - had physical activity limitation due to the halo frame; - could not change positions freely; - was under-weight and described by the physician as cachectic; and - because of the halo frame, was at risk for friction and sheer. A skin assessment, dated 06/02/11, documented the resident had six posts holding the halo frame, 2 posts above each ear and two in the forehead. The assessment also noted a vertical incision to the posterior neck. There was no assessment of the skin under the halo brace. An initial assessment, dated 06/08/11, documented the resident was independent in cognitive skills for daily decision-making, was at risk for a pressure ulcer, but had no pressure ulcers on admission. A care plan, developed on 06/22/11, documented, "...Problem: I am risk for impaired skin integrity R/T my incontinence at times.... Approach: ... Skin assessments provided weekly by the nurse..." The care plan did not include potential skin issues the resident could have with a halo device and a rigid, restrictive brace that could not be removed. It did not include interventions for assessing and caring for the resident's skin under the brace. A skin assessment, dated 06/30/11, did not include documentation of the resident's skin, other than the surgical sites. It did not address the skin condition under the halo brace. A skin assessment, dated 07/07/11, did not include documentation of the skin condition under the halo brace. A nurse's note, dated 07/08/11 at 3:40 p.m., documented, "Resident tearful. Reports halo 'causing me problems' c/o (left) shoulder blade tenderness. Unable to visualize any skin breakdown..." A nurse's note, dated 07/10/11 at 4:25 p.m., documented, "... Also cleaned pts trunk and back using warm, wet towel to exfoliate her back and trunk. Resident tolerated well. Located a dime sized ulcer on the top of her spine. It had an open, yellow center and it's very tender to touch. Large reddened area around open area, very tender and soft..." A fax communication sheet to the primary physician, dated 07/10/11, documented, "...When cleaning pt's skin under her cervical vest, it was discovered a dime-sized ulcer with a yellow center. The vest was stuck to her. The perimeters are deep red and very tender. No drainage when edges palpated, but drainage was dried on the vest, green color. Slight odor noted. I was unable to see any other ulcers, but she c/o pain up and down her spine. She also says the [MEDICATION NAME] does not work any more. Any suggestions?..." The physician responded by documenting on the form, "1.) Wound care eval 2.) Keflex 500 mg po x 7 days 3.) (Dr. name deleted) will eval..." There was no other documentation of assessment of the resident's wound or documentation of skin care after 07/10/11. A physician's telephone order, dated 07/14/11, documented, "Pad area to mid back under brace until seen by (physician)..." The resident was admitted to a local hospital on [DATE] for surgical removal of the halo device and treatment of [REDACTED]. The resident was hospitalized for [REDACTED]. There was no documentation of a skin assessment upon return to the facility on [DATE]. There was no documentation of the resident's wound, it's dressing, planned treatments or interventions to care for it. A skin assessment, dated 07/28/11, documented one statement: "...Comments: Wound to spine. Seeing (hospital name deleted) wound clinic for treatment..." A significant change assessment, dated 09/08/11, documented the resident was cognitively independent in skills for daily decision making and had constant, severe pain that was rated as a "10" on a 1-10 scale. The assessment also documented the resident had an unhealed stage 2 pressure ulcer. The resident continued to have weekly wound care outside of the facility for the next two months. On 11/08/11 at 2:00 p.m., the resident was asked about the wound on her upper spine. She stated, "I told the staff about a month before that my back hurt under the brace. At first it felt itchy, then like it was rubbing. I asked people to look at it, but they said they couldn't see under it (the brace)." She was asked what happened next. She stated, "Finally I asked a nurse to a get a flashlight to look. She saw it and started washing under the brace. A few days later I went to the hospital. They took off the halo and started wound care." On 11/09/11 at 8:40 a.m., the DON was asked if the resident complained about discomfort or pain under the brace. She stated, "I don't remember." She was asked if the resident had weekly skin assessments under the halo brace. She stated, "She should have." She was asked if the resident needed daily skin assessment, considering the high risk of breakdown under the brace, and the resident's frail condition. She stated, "Probably."

Based on clinical record review, staff and resident interview, it was determined the facility failed to provide physical therapy services as ordered by the physician resulting in actual harm for one (#2) of one sampled resident with orders for physical therapy. This had the potential to affect 11 residents identified by the facility who needed specialized services. Findings: Resident #2 was admitted to the facility with a history of a cervical spine fracture with surgical repair and placement of a halo device, [MEDICAL CONDITION] arthritis and [MEDICAL CONDITION]. A history and physical report, dated 05/19/11, documented, "...History: The patient is a... female who initially came to medical attention with progressive weakness and multiple falls... The patient... underwent a C1-C2 transarticular screw... The patient did very well from this procedure and was ambulatory and moving quite well. Several days prior to admission, she had a fall after which she began to have pain in the neck and head. She also reports that her legs 'got wobbly' making it difficult for her to walk... Review of Systems:... positive for recent falls, neck pain, frequency, joint swelling, contractures and generalized weakness... Physical Examination: The patient is a... female in moderate acute distress. She is very small and cachectic... Musculoskeletal: The patient is tender to palpation in the cervical spine. There is ulnar deviation of the fingers at the metacarpophalangeal joints and some boutonniere deformities... Neurologic: The patient is awake and oriented x 3. Speech is clear and appropriate. Motor examination reveals 4/5 strength in all muscle groups of bilateral upper extremities and 4+/5 strength in all muscle groups of bilateral lower extremities..." An admission nursing assessment, dated 05/26/11, documented the resident was a one person assist with transfers, had full weight-bearing, and was a one person assist with a walker. The assessment documented the resident had a halo device with a brace. An initial assessment, dated 06/08/11, documented the resident was independent in cognitive skills for daily decision-making, needed limited assistance of one person with transferring, dressing, toileting, hygiene and bathing. The assessment documented the resident was able to walk with a walker and needed assistance moving from a seated to a standing position. A telephone physician's orders [REDACTED]. A care plan, developed on 06/22/11, did not document the resident's halo brace, contractures of the hands, or any other limits on range of motion. There was no documentation of a plan for physical therapy or restorative nursing services. There was no documentation in the clinical record that physical therapy was provided by the facility. A consultation report from the neurosurgeon to the primary physician, dated 08/23/11, documented, "... (resident) is a cachectic ... female... She has approximately 3 to 4-/5 strength in the bilateral upper extremities and 4/5 strength in the bilateral lower extremities. This is an on-going problem. She appears to have intact sensation..." A significant change assessment, dated 09/08/11, documented the resident needed extensive assistance with transfers, assistance with ambulation, and extensive assistance with dressing, toileting, hygiene and bathing. A comprehensive monthly evaluation, dated 09/15/11, documented the resident needed extensive assistance with bed mobility, transfers, toileting, hygiene and bathing. It documented the resident was now totally dependent on staff for dressing. A comprehensive monthly evaluation, dated 10/17/11, documented the resident needed extensive assistance with bed mobility, transfers, toileting, hygiene and bathing. The assessment also documented the resident was no longer walking in the corridor and was totally dependent for dressing. On 11/08/11 at 2:00 p.m., the resident was asked if she received regular exercises and practice with walking. She stated she did receive exercises for two or three sessions until the aide was moved to another shift and couldn't do them anymore. She stated no one else provided any guided exercises or had helped improve her walking skills. She stated she never received physical therapy. On 11/09/11 at 8:40 a.m., the DON was asked if the resident was ever evaluated for physical therapy services. She stated the resident was not evaluated for physical therapy because the resident did not have Medicare coverage.

Based on observation, clinical record review, and staff and resident interview, it was determined the facility failed to: a. assess, monitor and intervene for pain for one (#2) of eight sampled residents with pain. This resulted in actual harm and had the potential to affect 17 residents identified by the facility with pain; and b. ensure restorative services were provided as ordered by the physician for one (#7) of five sampled residents who had restorative therapy ordered. The facility did not identify any residents who required restorative services. Findings: A facility policy, titled "Pain Assessment", documented, "Policy: Residents will be assessed for pain upon admission, readmission, quarterly, annually, upon significant change, when a resident experiences a new onset of pain or experiencing uncontrolled pain. Procedure: 1. The clinical nurse will perform a pain assessment prior to initiation of therapy... 2. For those residents that can be interviewed, the clinical nurse will read the questions to the resident and document his/her response... 3. A weekly review of pain will be completed on the Weekly Progress Note... 4. A Pain Flow Record will be maintained with the resident's Medication Administration Record. This is to be completed when the resident has identified they have pain. Record the following: a. Date and time b. Site / location c. Type of pain d. Intensity e. Precipitating / aggravating f. Interventions - non-med / medication g. Side effects h. Initials..." A Pain Assessment Tool documented, "... Describe pain: (Ache, burn, throb, pull, sharp, shooting, stabbing, pressing, dull, cramping, gnawing, heavy, tender, splitting, sore)... Onset, duration, variations, rhythm: (continuous, intermittent):... Manner of expressing pain:... What causes or increases the pain?... Effects of pain: (note decreased functioning or quality of life, nausea, sleep disruption, appetite decreases, weight loss, physical activity reduction, relationship with others - irritability, emotions - anger, suicidal, crying, change in gait - limping, change in skin color, change in vital signs - increased heart rate, increased blood pressure, lack of concentration)... Checklist of Pain Indicators Vocal complaints, Nonverbal expressions of pain, not in words, moans, groans, grunts, cries and sighs... Facial grimaces, winces, furrowed brow, narrowed eyes, lightened lips, dropped jaw, clenched teeth, distorted expressions... Bracing body language, clutching side rail, bed, table during movement... Restlessness, constant or intermittent shifting of position, rocking, inability to keep still... Rubbing or massaging an affected area... Breathing occasional labored, short periods of hyperventilation... Consolability - distracted or reassured by voice or touch, unable to console, distract or reassure... Vocal complaints, verbal words expressing discomfort of pain, ouch, that hurts, cursing, protesting care "stop that's enough"... 1. Resident #2 was admitted to the facility with a history of a cervical spine fracture with surgical repair and placement of a halo device, [MEDICAL CONDITION] arthritis, [MEDICAL CONDITIONS] and depression. A history and physical report, dated 05/19/11, documented, "...History: The patient is a... female who initially came to medical attention with progressive weakness and multiple falls... Imaging studies... demonstrated a pannus related to [MEDICAL CONDITION] arthritis with the destruction of the odontoid process. The patient... underwent a C1-C2 transarticular screw... The patient did very well from this procedure and was ambulatory and moving quite well. Several days prior to admission, she had a fall after which she began to have pain in the neck and head. She also reports that her legs 'got wobbly' making it difficult for her to walk. The patient was seen in my office where plain films demonstrated screws which did not appear to be in the correct position. I sent her... for a CT scan of the head which demonstrated a rotary subluxation of C1 on C2... Review of Systems:... positive for recent falls, neck pain, frequency, joint swelling, contractures and generalized weakness... Physical Examination: The patient is a... female in moderate acute distress. She is very small and cachectic... Musculoskeletal: The patient is tender to palpation in the cervical spine. There is ulnar deviation of the fingers at the metacarpophalangeal joints and some boutonniere deformities... Neurologic: The patient is awake and oriented x 3. Speech is clear and appropriate. Motor examination reveals 4/5 strength in all muscle groups of bilateral upper extremities and 4+/5 strength in all muscle groups of bilateral lower extremities... Imaging: A cervical CT scan of the cervical spine... demonstrates rotary subluxation of C1 and C2. This rotary subluxation appears to have forcibly ripped her screws from C1. This subluxation has created a rather marked stenosis of the spinal cord..." An Operative Report, dated 05/20/11, documented, "...Procedures: 1. Removal of posterior cervical hardware... 3. Closed reduction of C1-C2 subluxation. 4. Placement of halo vest..." An admission nursing assessment, dated 05/26/11, documented the resident had pain on admission to the facility, described as mild pain daily - but not constant. The form documented the resident's pain was located primarily in her head. An ongoing, detailed assessment of the resident's pain was not found in the clinical record. Admission physician's orders [REDACTED]. "[MEDICATION NAME] Forte 500 mg. (one) po q 6 (hours) prn muscle cramps... [MEDICATION NAME] 5/325 (one or two) po q 4 (hours) prn pain..." There were no nurse's notes found in the clinical record for the remainder of May 2011. An initial assessment, dated 06/08/11, documented the resident was cognitively independent in skills for daily decision-making and had constant, severe pain that was rated as a "10" on a 1 - 10 scale. A care plan, developed on 06/22/11, documented, "Category Problem: I have pain every day in my lower back area and generally all over at times... Category Goal: I will be kept as comfortable as possible on a daily basis over the next 90 days... Category Approach: Train staff to recognize non verbal signs of pain such as combative behavior, restlessness, moaning, grimacing, loss of appetite or lethargy. Assist/evaluate me in finding non-pharmacological methods to deal with pain such as exercise, distraction, or music therapy. Pain evaluation monthly by a licensed nurse. Provide pain medication as ordered by physician. Seek additional pain consult when pain is not controlled or new pain emerges..." A Medication Administration Record, 9" and a "12" on a 1-10 pain scale. The MAR indicated some help", "some relief", or "no further complaints." The MAR indicated [REDACTED]. The first nurse's note found in the clinical record was dated 06/30/11 at 12:15 a.m. It documented, "c/o back pain - rated 10/10. PRN [MEDICATION NAME] 5/325 (two) as requested..." There was no ongoing, detailed assessment of the resident's pain for the month of June 2011 found in the clinical record. There was no documentation the physician was notified about the resident's severe pain and the continuous need for prn pain medication throughout the day and nighttime hours. There was no documentation of alternative interventions for pain management. A nurse's note, dated 07/08/11 at 3:40 p.m., documented, "Resident tearful. Reports halo 'causing me problems' c/o (left) shoulder blade tenderness. Unable to visualize any skin breakdown. Pin sites x 2 on forehead red et crusty. States very painful c cleaning... reports (headache) developing behind R pin site on (forehead)... Call placed to (neurosurgeon). (Appointment) July 19 @ 3:30 p.m. - start Keflex 500 mg. pop TID x 7 days..." A fax communication sheet to the primary physician, dated 07/10/11, documented, "...When cleaning pt's skin under her cervical vest, it was discovered a dime-sized ulcer with a yellow center. The vest was stuck to her. The perimeters are deep red and very tender. No drainage when edges palpated, but drainage was dried on the vest, green color. Slight odor noted. I was unable to see any other ulcers, but she c/o pain up and down her spine. She also says the [MEDICATION NAME] does not work any more. Any suggestions?..." The physician responded by documenting on the form, "1.) Wound care eval 2.) Keflex 500 mg po x 7 days 3.) (Dr. name deleted) will eval..." There was no order for a change in pain medication documented on the form. A nurse's note, dated 07/11/11 at 9:30 a.m., documented, "Res c/o pain back 10/10 [MEDICATION NAME] 5/325 (one) @ this x... called to (neurosurgeon) office c/o open area to back under brace this nurse unable to see... Office will try to make arrangements to be seen. Will return call..." A nurse's note, dated 07/12/11 at 11:30 a.m., documented, "c/o pain all over. Requesting prn pain med. Given as ordered. States "pain is really, really bad..." A nurse's note, dated 07/14/11 at 9:00 a.m., documented, "(new order) pad mid back under brace until seen by (neurosurgeon)..." At 4:40 p.m., a nurse's note documented, "... res to go to (hospital name deleted) enter through ER to eval halo et pressure area..." A nurse's note, dated 07/15/11 at 1:40 a.m., documented, "Res c/o all over pain 10/10. Res. given [MEDICATION NAME] 5/325 (one) po @ this x..." The clinical record documented the resident was admitted to the hospital on [DATE] for removal of the halo device and treatment of [REDACTED]. She returned to the facility on [DATE]. There was no head to toe assessment documented in the clinical record. There was no re-admission pain assessment. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident rated her pain a "9" or a "10" on a 1-10 pain scale. The MAR indicated some better", "some relief", "no complaints voiced", and "in bed with eyes closed." The MAR indicated [REDACTED]. A nurse's note, dated 07/31/11 at 4:40 p.m., documented, "Pt. has refused [MEDICATION NAME] Forte today...states not working..." There was no documentation in the clinical record the physician was notified about the resident's complaint that the [MEDICATION NAME] Forte was not effective, or that the physician was notified about how much pain medication the resident required. Nurses' notes, dated 08/01/11 through 08/03/11, documented the resident complained of pain that was a "10/10" several times each day. A fax communication sheet to the physician, dated 08/03/11, documented, "... res upset, states pain isn't controlled c [MEDICATION NAME] 5/325 and is requesting something different, wants [MEDICATION NAME] or [MEDICATION NAME], please advise..." The physician responded by documenting on the form, "1.) DC [MEDICATION NAME] 2.) [MEDICATION NAME] 5/325 mg #60 (one) po q 12 hours prn severe pain..." Nurses' notes documented the resident continued to receive [MEDICATION NAME] 5/325 on 08/03/11, 08/04/11 and 08/05/11. The resident received her first dose of [MEDICATION NAME] on 08/06/11. A fax communication form to the physician, dated 08/08/11, documented, "... Can we (increase) [MEDICATION NAME] to TID or can she go back to [MEDICATION NAME] order since it was q 4 (hours). States [MEDICATION NAME] q 12 hours is not holding her pain. Please advise..." The physician responded by documenting on the form, "1.) OK to (change) [MEDICATION NAME] to TID..." A fax communication form to the physician, dated 08/08/11, documented, "... FYI - (resident) (states) (increase) in [MEDICATION NAME] doesn't help her pain. She wants [MEDICATION NAME] 5/325 mg (two) po q 4 (hours) prn as she had before AND she wants the [MEDICATION NAME] Forte 500 mg q 6 (hours) prn back or equivalent - sorry to bother you but she's insistent..." The physician responded by documenting on the form, "OK for changes as described..." There was no documentation of an ongoing, detailed assessment of the resident's pain. There was no documentation of any alternative interventions for pain management. A significant change assessment, dated 09/08/11, documented the resident was cognitively independent in skills for daily decision-making and had constant, severe pain that was rated as a "10" on a 1 - 10 scale. The assessment also documented the resident had an unhealed stage 2 pressure ulcer. The assessment also documented the resident had worsening depression symptoms, rejected care, and had declined in her ability to transfer, ambulate, dress, and bathe herself. A quarterly review of the care plan, dated 09/11/11, documented,"(Resident) is on [MEDICATION NAME] 5/325 mg two tabs q 4 (hours) et she takes them q 4 (hours). rates her pain @ a "10" all the time. She is also on muscle relaxer - [MEDICATION NAME] Forte q 6 (hours). Physician aware of pain status et states if she is having that much pain in her back et neck she should go to hospital to eval. (Resident) refuses to go, 'they would not do anything for me. (No change in plan of care) @ this x..." A Comprehensive Monthly Evaluation form, dated 09/15/11, documented the resident had moderate to severe pain daily. It also documented the resident's pain management program was "effective." A MAR, dated September 2011, documented the resident requested pain medication four to six times every day for the entire month for pain she rated at a 10 out 10. The facility did not assess the resident's pain after medication was administered. There was no ongoing, detailed assessment of the resident's pain done in September 2011. There were no alternative interventions for pain documented in the clinical record. There was no documentation a pain management specialist was consulted. A Comprehensive Monthly Evaluation form, dated 10/17/11, documented the resident had severe pain daily and that the pain management program was "effective." emergency room physician's orders [REDACTED].) [MEDICATION NAME] 5 mg (one or two) po q 6 (hours) prn... 2.) DC [MEDICATION NAME] 4.) [MEDICATION NAME] 10 mg (one) po q 6 (hours) prn... 5.) Follow up with (neurosurgeon and primary physician) in 2-3 days... 6.) Return (to ER) for worsening..." A fax communication sheet to the physician, dated 10/28/11, documented, "... Was seen in ER [DATE], orders received. [MEDICATION NAME] 10 mg. po q 6 (hours) et for [MEDICATION NAME] 5 mg 1-2 po q 6 (hours) et to DC order for [MEDICATION NAME] 5/325 2 po q 4 (hours) prn... Would you like to continue [MEDICATION NAME] as ordered?..." The physician responded by documenting on the form, "OK for [MEDICATION NAME]" There was no documentation in the nurse's notes of the resident leaving the facility and going to the emergency room . A MAR, dated October 2011, documented the resident received prn pain medication three to six times a day, every day in October for complaints of pain rated a "9" or "10." The facility did not document a pain scale after the pain medication was given. There was no ongoing, detailed assessment of the resident's pain. There was no documentation of alternative interventions for pain. A MAR, dated November 2011, documented the resident received prn pain medication three times a day from 11/01/11 through 11/07/11. On 11/08/11 at 2:00 p.m., the resident was asked about her pain symptoms. She stated she was not happy with her pain control. She stated her pain was usually a "10" and the medication she received provided relief at a level of an "8." She stated she would "settle for a pain level of 5 to 6." She was asked why she went to the hospital emergency room in October 2011. She stated she had requested an office appointment with her primary physician to discuss her pain medications. She stated after two weeks there was no response from the facility or the physician. She stated she then asked her son to take her to the emergency room because her pain was so severe. She stated the emergency room physician evaluated her pain, treated it, and recommended a change in medications. She stated he recommended she take [MEDICATION NAME] two tabs every six hours along with [MEDICATION NAME] 10 mg. every six hours. She stated he also recommended she consult with her neurosurgeon. She was asked if the facility had provided any other pain relieving measures, such as heat/cold treatments, warm baths, massage or non-narcotic pain medications. She stated they had not. She was asked if she was assisted with regular exercise as a way to relieve pain. She stated she had been assisted with exercises two or three times, but then the assistance stopped. On 11/09/11 at 8:40 a.m., the DON was asked if the nurses and CMAs documented the results of pain medication using a pain scale. She stated they did not. She was asked if a registered nurse performed monthly comprehensive pain assessments. She stated, "No." She was asked if a resident who uses multiple prn pain medications would benefit from a routine pain management program. She stated, "Yes. (The resident) should be on routine pain medicines but the physician doesn't want her on them." She was asked if the resident watched the clock for pain medicines. She stated,"Sometimes, but you can tell by looking at her that she hurts. There's no doubt about it." She was asked if the resident was ever over-sedated with her pain medications. She stated, "No. Never. She is always alert and oriented times four." 2. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 03/20/11, documented, "Problem I am at risk for falls/injury d/t unsteady gait and use of antidepressant medication. Goal I will have no falls and or injuries reported and or observed over the next 90 days. Approach I will have assistance with all transfers. Ensure that I wear comfortable properly fitting low-heeled shoes with non-skid soles. Quarterly Review #1 6/11: (Resident) does (not) ambulate but she will assist staff c transfers. She has had (no) falls or injuries observed et or reported over the last 90 days. (No) chg (change) in POC @ this x (time)." A quarterly assessment, dated 09/16/11, documented the resident was moderately impaired in cognitive skills for daily decision making and was totally dependent on others for bed mobility, dressing, eating, toilet use, personal hygiene and bathing. It documented the resident required extensive assistance with transfers and did not ambulate in the last seven days. The resident was totally dependent on others for mobility on the unit. The October 2011 monthly physician's orders [REDACTED]. 05/02/11: -Active ROM to upper and lower ext x20 rep (repetitions) 3x weekly." The October 2011 [DATE] form documented the resident received passive and active range of motion exercises on 10/05/11, 10/06/11, 10/11/11, 10/15/11 and 10/21/11. The November 2011 [DATE] form, documented the resident did not receive any restorative services from the beginning of the month until present. On 11/10/11 at 8:45 a.m., the restorative aide was asked why restorative services were not provided three times a week in September 2011 and October 2011. He stated he could not provide restorative services as he was pulled to the floor to work.