Every finding on record at Epworth Villa Health Services

Based on observation, record review, and interview, the facility failed to ensure two staff members were present when a mechanical lift was used for transfers to prevent a laceration for 1 (#53) of 3 sampled residents reviewed for lifts. The administrator identified 12 residents required the use of a mechanical lift for transfers. Findings: On 08/04/26 at 1:54 p.m., Resident #53 was observed setting in a wheelchair with a lift sling under them out in the common area in front of a television. There were two pillows observed under their feet. The bed in the room of Resident #53 was observed to have a draw sheet and a crocheted blanket. A sign beside the door, read in part,BEFORE YOU LEAVE Can I reach my call lightAm I refreshed?Is my room tidy?THANK YOU! On 08/04/26 at 2:00 p.m., Resident #53 was observed in the common area. Staff were observed to move Resident #53 to a long table with activities in front of the television. On 08/04/26 at 2:27 p.m. am unidentified CNA was observed to push Resident #53 to their room and left them there. On 08/04/26 at 2:31 p.m., two unidentified CNAs were observed to take a mechanical lift into Resident #53's room. On 08/04/26 at 2:41 p.m., the two unidentified CNAs exited the room and brought out the mechanical lift and placed it in the hall. One of the unidentified CNA's took the soiled linens to the utility room. A policy titled Lifting Machine, Using a Mechanical, dated 07/2017, read in part, General Guidelines 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. A physician's order for Resident #53, dated 01/06/26, showed all transfers were to be completed with a full body mechanical lift. A facility reported incident, dated 02/10/26, showed CNA #3 transferred Resident #53 by themself from the wheelchair to the bed. The resident was subsequently sent to the hospital where they received sutures to their lower right extremity calf. The incident showed CNA #3 was reported to their agency and was relieved of their work. An in-service record, dated 02/26/26, showed an in-service was held with all staff related to transfers residents being transferred with a mechanical lift. A care plan for Resident #53, dated 04/08/26, showed the resident was at risk for falls. Interventions showed toileting, incontinent needs and transfer needs to help to prevent any impulsive behaviors that my bring harm to themself. A quarterly assessment for Resident #53, dated 08/08/26, showed the resident's cognition was severely impaired. The assessment showed Resident #53 required substantial/maximal assistance with toileting. The assessment showed the resident was frequently incontinent of urine and occasionally incontinent of bowel. The assessment showed Resident #53 had a fall history in the last two to six months prior to admission. Four residents who required the use of a lift were observed and interviewed. They stated staff utilized a lift and two people were always in attendance. Staff interviewed stated all residents who required the assistance of a lift required two staff members. On 08/06/26 at 4:35 p.m., the administrator stated falls were placed on the facility performance improvement plan and monitored by the quality assurance team, and the information was verified.

On 05/08/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to protect residents with exit seeking behaviors. Resident #1 had exit seeking behaviors and exited the facility on 04/28/25. Resident #1 was located by security to be lying on the ground on the sidewalk outside of one of the exit doors from household #3. Resident #1's care plan did not address elopement. Based on observation, record review, and interview, the facility failed to provide supervision and interventions to prevent elopement for 1 (#1) of 3 sampled residents reviewed for wandering and elopement. The administrator identified 70 residents resided in the facility and Resident #1 was the only resident able to walk independently. Findings: On 05/08/25 at 1:15 p.m., the exit door from household #3's sunroom was observed to be unlocked. The sunroom door led to the courtyard which had a gate that kept residents from being able to exit the grounds of the courtyard. All other exit doors were secured with a 15 second egress release and a secondary alarm that sounded when the door handle was pushed. The sound was loud enough to be heard at the nurse's station. An undated policy titled Wandering and Elopement, read in part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. An undated Profile Face Sheet for Resident #1 showed they were admitted to the facility on [DATE] and had diagnoses of included dementia. Resident #1's elopement risk evaluation, dated 02/17/25, show the resident had an elopement risk evaluation of 14 indicating they were an elopement risk. A score of 10 or more indicated they were an elopement risk. Resident #1's care plan, created on 02/27/25, did not address the risk of elopement. Resident #1's admission Minimum Data Set assessment, with an assessment reference date of 02/24/25, showed they had a brief interview for mental status score of 8 indicating moderate cognitive impairment. The assessment showed Resident #1 was able to ambulate with a walker. A Final Incident Report Form, dated 04/28/25, showed Resident #1 was not in their room at 4:20 a.m., when staff made rounds. Resident #1 was found lying on the sidewalk outside of household #3's back door. The incident report showed Resident #1 had fallen and sustained a fracture of the right wrist. The incident report showed a power surge from recent storms had made the door alarm go offline, causing it to not alarm when opened. A review of in-service documentation showed the facility provided in-service on 04/28/25 related to the doors not locking or alarming. A review of a work order showed on 04/28/25 the electronic company replaced the battery for the maglocks on the doors of household #3 and #4. Doors were then tested to be good. A review of the text message sent to all employees on 04/29/25 at 1:32 p.m. showed all staff were made aware the power outage prevented the doors exiting outside to not lock or alarm. The message showed all staff were to check the doors throughout their shift, especially during power flickers. A review of a Safety Officer Shift Report, dated 04/29/25, showed patrol checked all doors, door alarmed pushed to verify at 2:00 a.m. A review of an undated Shift Checks form showed checking the doors to the outside to ensure they were secured was the first item listed. A review of a document titled Residents at Risk Meeting, dated 05/01/25, showed management had addressed Resident #1's elopement, insomnia, and mobility. On 05/08/25 at 12:44 p.m., RN #1 stated most of the residents had dementia. RN #1 stated Resident #1 was the only resident that was ambulatory on household #3. RN #1 stated staff were in-serviced about checking the alarms on the doors throughout their shift. On 05/08/25 at 1:00 p.m., CMA #1 stated they were in-serviced on checking to ensure the alarms were working on the exit doors. CMA #1 stated the night shift usually had three staff members working, and they stayed in the common area to supervise the residents. CMA #1 stated they usually kept the residents in the common area when they were awake. On 05/08/25 at 2:34 p.m., CNA #1 stated Resident #1 had been refusing care, saying no to everything, and stating they wanted to go to their own home throughout the evening of 04/28/25. CNA #1 stated they were checking on Resident #1 more often due to restlessness and behavioral issues. CNA #1 stated when they went to check on Resident #1 around 30-45 minutes after walking them back to their room from the common area, Resident #1 was not in their room or bathroom. CNA #1 stated they notified the nurse and started to look for Resident #1. Security was then notified. CNA #1 stated security found Resident #1 outside. On 05/08/25 at 3:54 p.m., the administrator stated the alarm company came the same morning as the incident to check the doors. The administrator stated security was usually the ones responsible for checking the exit doors. The administrator stated checking the doors was now added to the checklist for every shift. On 05/08/25 at 4:18 p.m., the DON stated the interventions put into place for wanderers was to keep them in a public area when they were awake and increased checks. The DON stated if they thought the resident would elope, then they were not admitted because it was not a locked facility. The DON stated Resident #1's family did not want Resident #1 placed in memory care because the family did not want to have to move Resident #1 again when they started to need more physical care than memory care could provide. The DON stated Resident #1 had never tried to elope before and did not have a history of elopement. The DON stated melatonin (sleep hormone) was added to Resident #1's medication profile to help them sleep, occupational therapy was going to evaluate Resident #1 again, and staff would monitor the doors to ensure alarms were working each shift.

Based on observation, record review, and interview, the facility failed to obtain an informed consent prior to the installation of bed rails for one (#39) of one sampled resident reviewed for bed rails. The DON identified 14 residents had bed rails in the facility. Findings: Resident #39 had diagnoses which included unspecified osteoarthritis and pain in unspecified joint. On 09/30/24 at 1:46 p.m., Resident #39's bed was observed with a bed rail on each side of the head of the bed. Resident #39 stated they used the rails to assist in positioning and getting out of bed. There was no documentation an informed consent for the use of the bed rails was obtained. On 10/02/24 at 1:08 p.m., the DON stated there was no consent for the use of the assistive bar.

Based on observation and interview, the facility failed to ensure snacks were offered to all residents in the facility for one of one snack observation. The DON identified 65 residents received meal services from the kitchen. Findings: An undated Frequency of Meals & Snacks policy, read in part, Evening snacks will be offered routinely to all residents. 1. On 10/01/24 at 2:14 p.m., the resident council group stated they had to ask for snacks to get them. They stated staff did not pass snacks at bedtime. On 10/02/24 at 6:02 p.m., a tour of household three was completed. There were apples, oranges, and eight bananas on the kitchenette counter. One resident was observed in the common area. On 10/02/24 at 6:06 p.m., a tour of household four was completed. There were apples, oranges, eight bananas, two cookies, and two fruit bars on the kitchenette counter. One resident was observed in the common area by the nurse's station. On 10/02/24 at 7:17 p.m., CNA #6 was observed cleaning dining tables and the kitchenette. On 10/02/24 at 7:29 p.m., CMA #4 informed CNA #6 a resident in room [ROOM NUMBER] wanted a PBJ sandwich and milk. On 10/02/24 at 7:44 p.m., CNA #7 warmed a resident's food and took it to them along with a drink. On 10/02/24 at 7:45 p.m., CNA #6 made the PBJ sandwich and took it to the resident in room [ROOM NUMBER]. They stayed in the room to assist the resident with feeding. Staff were not observed going room to room offering snacks to all residents in households three and four. On 10/02/24 at 8:13 p.m., CNA #5 stated CNAs were responsible for passing out snacks to residents. On 10/02/24 at 8:14 p.m., CNA #5 stated they did not pass snacks to any residents in household three. On 10/02/24 at 8:43 p.m., CNA #6 stated they only gave a snack to the resident in room [ROOM NUMBER]. On 10/02/24 at 8:50 p.m., CNA #7 stated they offered snacks to two residents in household four. 2. On 10/02/24 at 5:53 p.m., household one was observed for the passing of snacks. There was a large bowl of bananas and other fruit observed on the counter of the dining room kitchenette. There was also a brown tray with cookies, pastry desserts, and a pudding cup observed on the counter. On 10/02/24 at 5:59 p.m., CNA #11 was observed picking up dinner meal trays from resident rooms. On 10/02/24 from 6:08 p.m. through 6:43 p.m., there were no observations of snacks being passed on household one. On 10/02/24 at 6:44 p.m., CNA #12 was observed passing out meal tickets to residents for the 10/03/24 breakfast. On 10/02/24 from 6:58 p.m. through 7:12 p.m., CNA #1 was observed offering ice/water to residents in rooms 1807, 1809, 1811, 1813, 1816, 1818, 1820, and 1822 . No snacks were observed being offered to the residents. Household one continued to be observed for the passing of snacks through 8:01 p.m. There were no snacks observed being offered/passed to residents on household one. On 10/02/24 at 8:04 p.m., there were no residents observed in the halls or common areas on household one. On 10/02/24 at 8:14 p.m., CNA #1 was asked the process of offering a snack to residents at bedtime. They stated if a resident asked for a snack at night they would ask the nurse. If the nurse stated they could have one, they would give the resident a snack. They stated they believed the residents received food at 5:00 p.m., and the facility had snacks (they pointed to the snacks on the counter at the kitchenette) and stated the residents could get a snack there as long as they were allowed to have snacks. CNA #1 stated at night, they were already asleep. They stated they checked on residents to see if they needed a shower and if they needed something. On 10/02/24 at 8:27 p.m., CNA #5 exited room [ROOM NUMBER] and walked toward the dining room kitchenette on household three, obtained a cup, then walked onto household four. On 10/02/24 at 8:29 p.m., there were no observations of snacks being offered/passed to residents on household three. There was a bowl containing oranges, apples, and bananas observed on the counter in the kitchenette. There were no residents observed out of their room. On 10/02/24 at 8:30 p.m., CNA #5 returned to household three and carried a glass of clear liquid into room [ROOM NUMBER]. On 10/02/24 at 8:36 p.m., CNA #5 exited room [ROOM NUMBER], took a bag of items into the door labeled exit, then entered room [ROOM NUMBER], and asked if they could change the resident. CNA #5 did not offer the resident a snack. Continued observations were made of household three through 8:45 p.m. There were no observations of staff offering/passing snacks to the residents on the unit. 3. On 10/02/24 at 6:04 p.m., household two was observed for passing snacks. A large bowl of bananas, oranges, and apples were observed on the counter in the dining room kitchenette. On 10/02/24 at 6:54 p.m., CNA #4 was observed offering ice/water to the resident in room [ROOM NUMBER]. There were no snacks observed being offered/passed to the resident. On 10/02/24 from 7:49 p.m. through 8:10 p.m., CNA #3 was observed offering water/ice to residents in rooms 1830, 1831, 1833, 1834, 1835, and 1839. There were no snacks observed being offered to the residents. On 10/02/24 at 8:11 p.m., CNA #3 stated snacks were passed at the beginning of their shift when ice/water was passed. On 10/02/24 at 8:22 p.m., CMA #2 stated snacks were offered when ice was being offered. 46216 48344

Based on record review and interview, the facility failed to ensure a comprehensive care plan included a bed alarm for one (#69) of 17 sampled residents reviewed for comprehensive care plans. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 67 residents resided in the facility. Findings: A Care Plan policy, undated, documented the comprehensive care plan would describe the services furnished to attain or maintain the resdient's highest practicable well-being. Resident #69 had diagnoses which included acute respiratory failure and malignant neoplasm of the left upper lung. A Care Plan focus, dated 07/21/23, documented Resident #69 was a fall risk. There was no documentation an early bed alarm was in place. A Nurse's Note, dated 07/22/23 at 5:22 p.m., read in part, .resident is a high fall risk, has early bed alarm . A Resident Assessment, dated 07/28/23, documented Resident #69 required extensive assistance of one for bed mobility, transfers, and toileting. A Nurse's Note, dated 08/07/23 at 1:58 p.m., read in part, .has early bed alarm . On 08/11/23 at 10:54 a.m., the DON was asked how staff determined what information would be in the resident's care plan. They stated by interview and record review. The DON was asked if an early bed alarm would be on the resident's care plan. They stated, Yes. The DON was asked to review Resident #69's care plan. They stated, I don't see it on his care plan.

Based on observation, record review. and interview, the facility failed to ensure a resident's care plan was updated to reflect their current diet order for one (#54) of 17 sampled residents reviewed for revised care plans. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 67 residents resided in the facility. Findings: A Care Plan policy, undated, documented care plans are revised as information about the residents and the residents' conditions change. Resident #54 had diagnoses which included dysphagia. A Care Plan, dated 07/01/23, documented Resident #54's diet was regular, puree with extra gravy, and nectar thick liquids. A Physician's Order, dated 07/12/23, documented a regular, mechanical soft diet with ground meat, no bread. On 08/08/23 at 12:08 p.m., Resident #54 was observed with chopped/sliced white meat, okra and beans on their lunch meal tray. On 08/09/23 ar 12:14 p.m., Resident #54 was observed with pizza, macaroni, beans, and a strawberry [NAME] on their lunch meal tray. On 08/11/23 at 11:02 a.m., the DON was asked what the policy was for updating care plans. They stated they would be updated with any change in condition, new orders, or when an MDS was completed. The DON was shown Resident #54's care plan and was asked if it had been updated to reflect the current diet order. They stated the current diet should be on the care plan.

Based on record review and interview, the facility failed to ensure controlled medications were signed off on the MAR for one (#57) of six sampled residents reviewed for accurate records. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 67 residents resided in the facility. Findings: Resident #57 had diagnoses which included dementia and fractured humerus. A Physician's Order, dated 07/27/23, documented to administer Percocet 10 mg-325 mg, one tablet, by mouth, every six hours as needed for pain. A Controlled Drug Receipt/Record/Disposition sheet, documented one tablet of Percocet had been removed from the medication card on 07/29/23 at 8:40 p.m. A July 2023 MAR, contained no documentation Percocet had been administered at 8:40 p.m. A PRN Medication Record, dated 07/29/23, contained no documentation Percocet had been administered at 8:40 p.m. A Physician's Order, dated 07/30/23, documented to administer Percocet 10 mg-325 mg, one tablet, by mouth, every four hours as needed for pain. A Controlled Drug Receipt/Record/Disposition sheet, documented one tablet of Percocet had been removed from the medication card on 08/11/23 at 8:11 a.m., 08/04/23 at 1:18 p.m., 08/06/23 at 3:30 p.m., and on 08/09/23 at 10:55 a.m. An August 2023 MAR contained no documentation Percocet had been administered on those dates at those times. A PRN Medication Record, dated August 2023, contained no documentation Percocet had been administered on those dates at those times. An August 2023 MAR documented the resident had taken Percocet once daily. On 08/11/23 at 10:31 a.m., CMA #3 was asked what the policy was for documenting prn narcotics/controlled medications. They stated they would go in to the MAR, click on it, it would bring up the prn effectiveness, and then sign it out on the narcotic count sheet. CMA #3 was asked how they ensured medications had been administered if it wasn't signed out on the MAR, but was documented on the narcotic count sheet. They stated, You sign the MAR first. They stated, They shouldn't do that. The MAR is the only way to know for sure. On 08/11/23 at 10:42 a.m., the DON was asked how staff ensured controlled medications had been administered if they had not been signed out on the MAR, but were signed out on the narcotic/controlled count sheet. They stated staff should go back after administration and document effectiveness. The DON was asked how staff were instructed to document narcotic/controlled medications had been administered. They stated they were to sign in the Emar that they pulled it, administer it to the resident, and sign it out on the narcotic sheet. The DON was shown the July and August 2023 MARs, controlled drug receipts, and prn medication records for Resident #57. She acknowledged the findings.

Based on record review, observation and interview the facility failed to ensure a Resident was provided pain medication for complaints of pain during the provision of wound care for one (#28) of three sampled Residents who were reviewed for pain management. Resident #28 stated they were in pain before and during incontinent care and wound care, when asked by LPN #1 and CNA #1. Resident #28 moaned and cried out Oh and Ow several times during incontinent care and wound care and stated, Someone is hurting me. The staff did not stop the incontinent or wound care, asssess and intervene for Resident #28's pain. Resident #28 recieved pain medicaiton one hour and 29 minutes after the first complaint of pain. The Resident Census and Conditions of Residents, documented eight Residents had a pressure ulcer. The DON identified 15 Residents who were provided wound care. Findings: Resident #28 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 05/23/22, documented Resident # 28 had moderately impaired cognition, had not had behaviors of rejection of care, required extensive assistance with bed mobility, rarely had mild pain and received an opioid (pain medication) seven of the seven days in the look back period. The MDS assessment documented the Resident had two unhealed pressure ulcers. A care plan for Pain, dated 02/10/22, read in parts, .I am at risk for pain due to decreased mobility, right knee pain .Be sure to offer me pain medication as ordered by my physician . The following intervention, dated 06/17/22, read in part, .Monitor for signs and symptoms of PAIN Q SHIFT and INTERVENE AS INDICATED . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound evaluation and summary, dated 07/20/22, read in parts, .STAGE 4 PRESSURE WOUND OF THE LEFT ISCHIUM FULL THICKNESS .Etiology .Pressure .Duration .>105 days .Wound Size (L x W x D): 0.7 x 0.7 x 3.8 cm Undermining .3 cm .Primary Dressing .Gauze packing strips ([MEDICATION(S)]) 1/2 apply once daily .Secondary Dressing .Gauze island w/bdr [with border] apply once daily . A Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 07/21/22 at 11:21 a.m., LPN #1 and CNA #1 were observed to provide incontinent and wound care to Resident #28. Resident #28 cried out, Oh and Ow each time the CNA wiped the Resident's bottom. LPN #1 asked Resident #28 if the Resident was hurting. Resident #28 stated, Yes. LPN #1 began removing the packing from the left ischium pressure injury wound. Resident #28 moaned and said Ow. CNA #1 asked Resident #28 if the Resident's bottom was hurting. Resident #28 stated, Yes. LPN #1 continued with the dressing change. LPN #1 cleansed the area with the wound cleanser and the Resident started to have another bowel movement. The wound care was stopped and the staff began to clean the Resident. Resident #28 stated, Ow and Oh each time the staff wiped. LPN #1 stated, I am sorry. each time the Resident cried out or moaned. LPN #1 stated they were going to let the Resident finish having a bowel movement and they would come back and finish the dressing change. On 07/21/22 at 12:17 p.m., LPN #1 was applying the packing to Resident #28's wound. Resident #28 stated, Someone is hurting me. Resident #28 cried out, Ow and Oh. LPN #1 stated, Sorry each time Resident #28 moaned or cried out. On 07/21/22 at 12:24 p.m., after the wound care was completed, LPN #1 stated to Resident #28 they were going see if the Resident had something for pain. On 07/21/22 at 12:32 p.m., Resident # 28 was asked about the pain during the wound care. Resident #28 stated she was hurting when they were changing the dressing and cleaning her bottom. Resident #28 was asked to rate the pain. Resident #28 stated, It hurt pretty bad. Resident #28 was asked about pain medication. Resident #28 stated they gave them pain medication every afternoon. On 07/21/22 at 12:41 p.m., LPN #1 was asked if Resident #28 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated they had asked Resident #28 if they were in pain when they were turning them and Resident #28 indicated they were hurting all over. On 07/21/22 at 12:42 p.m., CMA #1 was asked if Resident #28's [MEDICATION(S)] had been administered at 12:00 p.m. CMA #1 stated no. CMA #1 stated they had signed it out to administer the [MEDICATION(S)] but when they went to the room to administer the medication the staff was changing Resident #28's dressing. CMA #1 stated they labeled the medication cup with the pain medication in it and put it in the medication cart. On 07/21/22 at 12:50 p.m., CMA #1 administered the [MEDICATION(S)] 5 mg -325 mg to Resident #28. The pain medication was administered 26 minutes after the nurse stated she would check on Resident #28 pain medication. On 07/21/22 at 3:10 p.m., LPN #1 was asked what they would normally do if a resident complained of pain during wound care. LPN #1 stated they would normally ask the Resident about their pain, check to see if the Resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 was asked if there was a reason they did not stop the wound care when Resident #28 complained of pain. LPN #1 stated they had not worked with Resident #28 before and stated she had no particular reason for not stopping. On 07/25/22 at 10:41 a.m., the DON was asked what they expected the staff to do if a resident complained of pain during a dressing change on a wound. The DON stated they would expect the staff to stop the wound care, assess the resident's pain, and administer pain medication before finishing the dressing change. The DON stated they would have to look to see if Resident #28 had orders for pain medication. On 07/26/22 at 9:34 a.m., RN #2 stated they had not experienced Resident #28 being in pain during the wound care. RN #2 stated they went slow and supported the leg and would stop often and check on the Resident. RN #2 stated the pain medication was timed so that the staff could do the dressing change after Resident #28 received pain medication.

Based on record review, observation , and interview the facility failed to ensure physician's orders were followed for treatments related to [CONDITION(S)] and pressure ulcer prevention for one (#28) of two sampled residents who had pressure ulcers and one sampled resident who had [CONDITION(S)]. The Resident Census and Conditions of Residents documented eight residents had pressure ulcers. The DON identified seven residents who had [CONDITION(S)]. Findings: Resident #28 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for [CONDITION(S)], dated 02/10/22, read in parts, .I will .have decrease in [CONDITION(S)] in the next 90 days . The following intervention, dated 06/17/22, read in parts, .Apply ace wraps to bilateral lower extremities .For gentle tissue support and/or [CONDITION(S)] mgmt . A care plan for Pressure Injury, dated 03/23/22, read in parts, .I have a Stage 4 PI to my left ischium . The following intervention, dated 04/12/22, read in parts, .MAX TIME UP IN CHAIR IS 1 HOUR; Four times daily . A physician's order, dated 03/24/22, documented to apply ace wraps to bilateral lower extremities daily starting at the ball of the foot with four inch wraps transitioning to six inch wraps to just below the knee for gentle tissue support and/or [CONDITION(S)] management. A physician's order, dated 04/03/22, read in parts, .FREQUENT REPOSITIONING- up for all meals: MAX TIME UP IN CHAIR IS 1 HOUR- Four times daily .Max time up in chair is 1 hour . A quarterly MDS assessment, dated 05/23/22, documented resident #28's cognition was moderately impaired, required extensive assistance for bed mobility, transfers, personal hygiene, and utilized a wheelchair for ambulation. The MDS assessment documented the resident was at risk for pressure ulcers, had one unhealed stage three pressure ulcer, and one unhealed stage four pressure ulcer. On 07/21/22 at 9:08 a.m., Resident #28 was observed in the dining room without ace wraps on their legs. On 07/21/22 at 11:21 a.m., Resident #28 was observed in bed during incontinent care. Resident #28 did not have the ace wraps on their legs. On 07/21/22 at 12:32 p.m., CNA # 1 stated they were going to get the mechanical lift and get resident #28 up for lunch. The ace wraps were not on resident #28's legs. On 07/21/22 at 2:29 p.m., Resident #28 was up in the wheelchair. On 07/21/22 at 2:33 p.m., Resident # 28 stated they had not been back to bed since the staff had gotten them up for lunch. On 07/21/22 at 3:07 p.m., Resident # 28 was up in the wheelchair participating in an activity. On 07/21/22 at 3:15 p.m., CNA #1 stated Resident #28 had been up in the wheelchair since lunch. On 07/21/22 at 4:26 p.m., Resident #28 was up in the wheelchair in the common area. On 07/21/22 at 4:36 p.m., CNA #1 was observed putting Resident #28 in bed. Resident #28 was observed up in the wheelchair, for over three and half hours. On 07/25/22 at 10:41 a.m., the DON stated the current physician's order was for Resident #28 to be up in the wheelchair for a max of one hour four times a day. The DON stated the staff did not follow the physician's orders by leaving Resident #28 up in the wheelchair for more than an hour. The DON was asked about the order for the wraps to Resident #28's lower extremities. The DON stated the staff were supposed to wrap Resident #28's lower legs daily between 7:00 a.m. and 11:00 a.m. and the wraps were to be removed at night. The DON stated it was a current order and the wraps should have been on Resident #28's legs. On 07/26/22 at 9:34 a.m., RN #2, the wound care nurse, stated Resident #28 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 stated the wraps were put on in the morning and were taken off at night. RN #2 stated resident #28 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, observation and interview, it was determined the facility failed to have system in place to ensure employees consistently screened for COVID-19 symptoms prior to starting their shift for five of five employees reviewed for COVID-19 screening. The Resident Census and Conditions of Residents documented 63 residents resided in the facility. Findings: An undated facility policy titled, COVID-19 Employee Protocols, pages 4 and 5, read in parts, .Screening .All employees, regardless of what area they work, must screen prior to working in the community .compliance with screening is monitored by the supervisor/leadership of each department with random audits by leadership Upon entrance to the facility on each day of the survey a screening station was observed at the front main entrance as well as the entrance near the skilled households. 1. A review of the employee screening printout for the activities assistant documented the last date the employee screened was on 04/14/22 at at 9:25 a.m. A review of the time punch details documented the activities assistant worked 45 days from 05/26 through 07/25/22 without being screened at the beginning of their shift for COVID-19 symptoms. On 07/26/22 at 11:10 a.m., the activities assistant stated they knew the screening process and where the screening station was located. The activities assistant then stated screening was located at the main entrance. 2. A review of the screening logs for CNA #3 contained no documentation of screening from 06/14/22 through 07/25/22. A review of the time punch details documented CNA #3 worked 31 days from 06/18/22 through 07/25/22 without being screened at the beginning of their shift for COVID-19 symptoms. On 07/26/22 at 11:10 a.m., with CNA #3 stated she was screened at the start of each shift for COVID-19 symptoms. 3. A review of the screening logs for HSKP #1 contained no documentation of screening from 05/26/22 through 07/25/22. A review of the time punch details documented HSKP #1 worked 38 days from 05/26/22 through 07/25/22 without being screened at the beginning of their shift for COVID-19 symptoms. On 07/26/22 at 10:35 a.m., HSKP #1 stated she had worked at the facility for the past six months. The housekeeper stated they were screened daily prior to starting work every day when they entered the facility 4. A review of the screening logs for HSKP #2 contained no documentation of screening from 05/26/22 through 07/25/22. A review of the time punch details documented HSKP #2 worked 37 days from 05/26/22 through 07/25/22 without being screened at the beginning of their shift for COVID-19 symptoms. On 07/26/22 at 11:46 a.m., HSKP #2 stated they had worked at the facility three years and was required to screen before every shift for COVID-19 symptoms and fever. 5. A review of the employee screening printout documented the only date CNA #4 screened between 05/26/22 through 07/25/22 was on 07/08/22 at 6:55 a.m. A review of the time punch details documented CNA #4 worked 44 days from 05/26/22 through 07/25/22 without being screened at the beginning of shift for COVID-19 symptoms. On 07/26/22 at 11:26 a.m., the facilities director stated all department heads were to pull reports to monitor if employees were screened for COVID-19 at the beginning of each shift. The facilities director stated they can look up and pull the reports from the facial recognition machine used for the screening process. On 07/26/22 at 12:20 p.m. the Chief Nursing Officer stated screening for COVID-19 symptoms were not being completed consistently for all the employees and HSKP #1, HSKP #2 and CNA #3 have not been screening at all. They then stated department heads were to pull reports to make sure screening was occuring however it appeared that was not happening.

Based on record reviews and interviews it was determined the facility failed to: a. monitor daily weights for three (#1, 8 and #9) of three sampled residents reviewed for daily weights. The DON (director of nurses) identified 13 residents who had physician's orders [REDACTED]. b. assess, monitor and intervene for a resident with symptoms of fluid overload for one (#1) of two sampled residents reviewed with [DIAGNOSES REDACTED]. The DON identified two residents with [DIAGNOSES REDACTED]. c. assess, monitor and intervene for a resident with symptoms of respiratory distress for one (#1) of six sampled residents reviewed who had changes in condition. Resident #1 had a [DIAGNOSES REDACTED]. The resident's [MEDICAL CONDITION] was not monitored consistently and thoroughly during his stay at the facility. Daily weights were not monitored as ordered by the physician. The resident experienced a 20 pound increase in weight from the time he admitted to the facility and his first ER (emergency room ) visit four days after admission. Following the emergency room visit, the resident was admitted to the hospital for seven days and was treated for [REDACTED]. When the resident returned to the facility, he weighed 21 lbs more than his weight at admission. The resident continued to have [MEDICAL CONDITION] in his bilateral lower extremities which was not monitored and thoroughly assessed. The resident returned from the hospital with a physician's orders [REDACTED]. Six days after the resident's return to the nursing home, the resident's family member made an appointment for the resident with his Nephrologist. The Nephrologist admitted the resident to the ER for signs/symptoms of fluid overload. ER records documented the resident's [MEDICAL CONDITION] had increased and extended from his bilateral feet to mid back/abdomen. He was diagnosed with [REDACTED]. The DON (director of nurses) identified 76 residents who resided in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Daily Weight for all SNF (skilled nursing facility) patients with a [DIAGNOSES REDACTED]. SNF Daily Assessment .Once Daily . [MEDICATION NAME] (a diuretic) 80 mg (milligrams) .Daily For .[MEDICAL CONDITION] . Daily Weight before breakfast; notify physician for weight gain of 2-3 lbs (pounds) overnight or greater than 5 lbs in one week .Once Daily . O2 (oxygen) sats (saturation) q (every) shift; Notify physician of O2 sats less than 90 % (percent) . A baseline care plan, dated 02/03/20, documented the resident was at risk for weight loss and his weights would be monitored daily. The care plan documented the resident was on continuous oxygen at 2l/min (two liters per minute). The resident had a behavior of taking his oxygen off. The resident had two to three plus [MEDICAL CONDITION] to both bilateral lower extremities. A weight log, dated 02/03/20, documented the resident's weight was 162.5 lbs. A daily skilled nurse assessment, dated 02/03/20 at 4:16 p.m., documented the resident had bilateral lower extremity [MEDICAL CONDITION] present. The assessment further documented the resident had shortness of breath on exertion and wheezing. There was no further assessment documented of the resident's lung sounds and [MEDICAL CONDITION]. There was no documentation the physician was notified the resident had shortness of breath on exertion and was wheezing. There was no documentation of interventions which were implemented for the resident's abnormal respiratory assessment findings. A daily charting record, dated 02/04/20, documented the resident's fluid intake with lunch and dinner included 3600 cc (cubic centimeters) at lunch and 3600 cc at dinner for a total of 7200 cc of fluid. There was no documentation of the resident's fluid intake at breakfast, with meals and between meals. There was no documentation the resident's respiratory system and [MEDICAL CONDITION] was assessed on 02/04/20. A physician's progress note, dated 02/04/20 and untimed, documented the resident admitted to the facility from the hospital with a history of volume overload and [MEDICAL CONDITION] exacerbation. He was treated with intravenous diuretics. The resident's [MEDICAL CONDITION] effort was normal, without the presence of wheezing or rhonchi. The resident had bilateral lower extremity [MEDICAL CONDITION]. There was no documentation of whether the [MEDICAL CONDITION] was pitting or not. A daily skilled nurse assessment, dated 02/05/20 at 4:42 p.m., documented the resident had [MEDICAL CONDITION] to his bilateral lower extremities. The resident's breathing was documented as normal. The nurse assessment was not completed until 48 hours after the most recent assessment on 02/03/20, which documented the resident had shortness of breath on exertion, wheezes and bilateral lower extremity [MEDICAL CONDITION]. The assessment did not document the resident's lungs sounds or the amount of [MEDICAL CONDITION] in the lower extremities. A nurse's progress note, dated 02/05/20 at 5:47 p.m., documented therapy was unable to work with the resident because he was extremely tired today. The note documented the resident did not have swelling in his bilateral lower extremities today. A physician's orders [REDACTED]. A vital signs log, dated 02/06/20 at 2:29 p.m., documented the resident's oxygen saturation was measured at 96 % on room air. A daily skilled nurse assessment, dated 02/06/20 at 2:59 p.m., documented the resident's breathing was normal. There was no information related to the resident's lower extremity [MEDICAL CONDITION]. There was no documentation of the resident's lung sounds. A nurse's progress note, dated 02/06/20 at 7:40 p.m., documented the resident started [MEDICATION NAME] for a cough and phlegm. The resident continued on oxygen at 2l/min. The resident called out and said he could not breath (breathe), O2 tubing on forehead. The note documented, .Explained that he was breathing, and replace O2 tube in correct placement . There was no documentation the resident's breathing and lung sounds were assessed and monitored. There was no documentation the resident's oxygen saturation was measured. There was no documentation the physician was notified the resident had complained he could not breathe. A nurse's progress note, dated 02/07/20 at 4:57 p.m., documented the next entry in the resident's clinical record following the entry on 02/06/20 when the resident stated he could not breathe. The note was documented 21 hours after the onset of the resident's respiratory complaints. The note documented, .Resident send to (Named hospital) d/t (due to) low BP (blood pressure), heart rate between 50-142, resident has a fib ([MEDICAL CONDITION]). non productive cough, wheezing noted, lung sounds wet. left pupil pinpoint, left hand weaker than right, resident lethargic and reporting weakness, (Named physician #1) notified orders to send pt (patient) to the hospital, resident left via emsa (emergency medical services) . A physician's orders [REDACTED].Send to ER . A nurse's task flow sheet, dated 02/03/20 through 02/07/20, documented the resident's oxygen saturation was not monitored during the specified dates on the 7:00 a.m. to 7:00 p.m. shift and the 7:00 p.m. to 7:00 a.m. shift. An emergency department record, dated 02/07/20 at 11:58 a.m., documented the resident was seen in the emergency department with chief complaint of generalized weakness. The physical exam documented tachypnea (abnormally rapid and shallow breathing), [MEDICAL CONDITION] to right and left lower leg. The emergency room records documented the resident's weight was 182.6 pounds on admission to the hospital on [DATE]. An emergency room history and physical record , dated 02/07/20 at 4:36 p.m., documented a chest x-ray report documented the resident had a right lower lobe pneumonia, acute kidney injury and dehydration. Resident reported increased shortness of breath. A hospital course of stay record documented the resident was admitted with a [DIAGNOSES REDACTED]. The resident's mental status improved on 02/08/20 and his renal function decreased. The records documented the resident was transferred to another hospital on [DATE] at the request of a family member. The resident's discharge [DIAGNOSES REDACTED]. A hospital record, dated 02/10/20, documented the resident was received at the second hospital. The record documented the resident was transferred for further evaluation of pneumonia and acute on chronic [MEDICAL CONDITION] exacerbation. The resident was treated with diuretics and antibiotics. The resident was discharged from the hospital and returned to the nursing home on 02/14/20. A baseline care plan, dated 02/14/20, documented the resident was admitted to the facility with [DIAGNOSES REDACTED]. A physicians order, dated 02/14/20, documented, .Fluid restriction of 2000 cc/24h- (2000 cc of fluids in 24 hour period) . Daily Assessment-Once Daily . [MEDICATION NAME] 0.63 mg (milligrams)/3 ml (milliliters) Neb (nebulizer) PRN (as needed) every 6 hrs (hours) . [MEDICATION NAME] (a diuretic) 100 mg .Twice a day For .Hypertension . Daily Weight before breakfast; notify physician for weight gain of 2-3 lbs overnight or greater than 5 lbs in one week . The resident's clinical record documented the resident did not return to the facility with an order for [REDACTED].>A nurse task flow sheet, dated 02/14/20 through 02/19/20, documented the physician's orders [REDACTED]. A nurse progress note, dated 02/14/20 at 2:56 p.m., documented a head to toe assessment was completed. The note documented the nurse was unable to obtain a weight at the time of the assessment due to the resident refused to get up. The resident had [MEDICAL CONDITION] to his bilateral lower extremities. The nurse did not document the depth of the [MEDICAL CONDITION]. The note documented the resident was admitted to skilled care for right lower lobe pneumonia and [MEDICAL CONDITION] with fluid overload. The note further documented the resident was provided water and seemed tired. There was no further documentation in the nurse's progress note, dated 02/14/20 at 2:56 p.m., of what the head to toe assessment included and the findings of the assessment. A daily skilled nurse assessment, dated 02/14/20 at 6:05 p.m., documented the resident had bilateral three plus [MEDICAL CONDITION] to his bilateral lower extremities. A nurse task flow sheet, dated February 2020, documented the following monitoring was conducted of the physician ordered fluid restriction: The resident had 80 cc of intake on the 7:00 p.m. to 7:00 a.m. shift on 02/14/20. The resident had 960 cc of intake on the 7:00 a.m. to 7:00 p.m. shift on 02/15/20. There was no further documentation of the resident's intake of fluids during his stay at the facility on the nurse task flow sheet. A weight log, dated 02/15/20, documented the resident's weight was measured three times on 02/15/20. The resident's weight was documented as 183.5 lbs for each of the three entries. This was a 21 pound increase from the resident's admission weight on 02/03/20. There was no documentation the resident's physician was notified of the resident's severe weight gain. A daily skilled nurse assessment, dated 02/15/20 at 11:25 a.m., documented the resident had labored breathing. There was no documentation of the resident's bilateral lower extremity [MEDICAL CONDITION]. The resident's oxygen saturation was measured at 94 % on a nurse task flow sheet once between 7:00 a.m. and 7:00 p.m. on 02/15/20. A nurse's progress note, dated 02/15/20 at 3:06 p.m., documented a nurse note entry for events which occurred during her entire shift. The note documented the resident remained in skilled nursing for right sided pneumonia and [MEDICAL CONDITION] with fluid overload. The note documented the resident was assisted with breakfast and ate about 75 % of his meal. The note documented the resident coughed a couple of times when eating and had labored breathing. The resident's physician was notified and stated just monitor for now. There was no documentation the resident's respiratory effort and lung sounds were assessed and monitored following the documentation of the resident's labored breathing after breakfast. A weight log, dated 02/16/20, documented the resident's weight was measured at 184 pounds. This was a .5 pound increase in the resident's weight from the previous day, 02/15/20. There was no documentation the physician was notified the resident was weighed again and he continued to have a severe weight gain. A daily charting record, dated 02/16/20, documented the resident's fluid intake with meals was 350 cc at breakfast, 350 cc at lunch and 200 cc at dinner for a total of 900 cc with his meal intake. There was no documentation of any fluid intake with medications or between meals. The resident's clinical record did not document any further fluid intake monitoring for the resident during his stay. A daily skilled nurse assessment, dated 02/16/20 at 6:52 p.m., documented the next entry in the resident's clinical record following documentation of the resident's labored breathing after breakfast on 02/15/20. The note was documented over 24 hours after the most recent assessment of the resident's respiratory changes. The note documented the resident's breathing was normal. There was no documentation of monitoring or assessment of the resident's bilateral lower extremity [MEDICAL CONDITION]. There was no documentation the resident's lung sounds were assessed and monitored. A daily skilled nurse assessment, dated 02/17/20 at 3:23 p.m., documented the resident had normal breathing. The resident needed continuous oxygen at two liters. The resident had bilateral lower extremity [MEDICAL CONDITION]. There was no documentation the resident's lung sounds were assessed. There was no documentation the depth of the resident's [MEDICAL CONDITION] was assessed and monitored. A nurse's progress note, dated 02/17/20 at 3:34 p.m., documented the resident had a 12 % weight gain. The note did not document in what period of time the weight gain occurred in. The note documented the resident's physician and the dietician were notified. A weight log, dated 02/17/20 through 02/19/20, documented the resident refused to have his weight measured on 02/17/20 and 02/19/20. There was no documentation the resident's weight was measured or he refused on 02/18/20. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. On 02/17/20 a chest x-ray, documented, .right lower lobe infiltrate . A nurse's progress note, dated 02/18/20 at 3:27 p.m., documented the resident's respirations were within normal limits. The resident had shortness of breath on exertion. A chest x-ray was ordered. The note documented, .Hob (head of bed) elevated to prevent aspiration pneumonia. Resident on fluid restriction, he will drink, but will only eat 2 or 3 bites . There was no documentation the resident's respiratory effort was monitored and his lung sounds were assessed and monitored following the entry on the nurse's progress note, dated 02/18/20 at 3:27 p.m. A nurse's progress note, documented a care plan meeting was held on 02/19/20, the note documented the resident's family member wanted to take the resident to the physician (Nephrologist) and planned to make an appointment after the meeting. A nurse's task flow sheet, dated 02/14/20 through 02/20/20, documented the resident's oxygen saturation was monitored and above 90 % on 02/14/20, 02/15/20, 02/18/20, and 02/19/20 during the 7:00 a.m. to 7:00 p.m. shift. The flow sheet was blank on 02/16/20 and 02/17/20. The nurse's task flow sheet documented the resident's oxygen saturation was monitored and above 90 % on 02/14/20, 02/15/20 and 02/18/20 during the 7:00 p.m. to 7:00 a.m. shift. The flow sheet was blank on 02/16/20 and 02/17/20 and 02/19/20. A physician's progress note, dated 02/19/20, documented the resident was sent back to the ER after being in the facility for a short period of time. The note documented the resident was found to have right sided pneumonia. He was treated with antibiotics and intravenous diuretics. The note documented the resident returned to the facility and was not eating well and his lower extremity swelling had increased in a very short time since re-admission. Hospital records, dated 02/19/20 at 3:26 p.m., documented the resident presented with a chief complaint of [MEDICAL CONDITION]. The records documented the resident was referred to the ER by (Named Nephrologist) due to fluid overload and the need for intravenous [MEDICATION NAME] (a diuretic.) The hospital records documented the resident presented with increased bilateral lower extremity [MEDICAL CONDITION] with onset the past month. The records documented the resident had [MEDICAL CONDITION] from his bilateral feet to mid abdomen and back. He had bilateral respiratory rales. His weight was measured at 185 lbs. The hospital records documented the resident's BNP (brain natriuretic peptide, a test to determine severity of [MEDICAL CONDITION]) was high at 2,036 with a normal range of 0-100. The hospital records documented the assessment and plan included: volume overload, refractory to oral diuresis, start intravenous and oral diuretics, and strict intake and output monitoring. On 02/25/20 at 9:35 a.m., the resident's family member stated she spoke with the resident's case manager asking her if (Named resident #1) could be seen by a Nephrologist. She was concerned with the amount of swelling. She stated she met with the facility staff the next day and was told if she wanted to take him to the Nephrologist she could take him. She stated she made him an appointment and he was seen by the Nephrologist on 02/19/20. She stated the resident was sent to the ER from the Nephrologist's office. At 9:45 a.m., LPN (licensed practical nurse) #2 was asked what she would do if a resident was complaining of being SOB (short of breath). She stated she would check vital signs, give a breathing treatment if ordered, assess lungs and contact the physician. LPN #2 was asked what type of monitoring should be completed daily if a resident had a [DIAGNOSES REDACTED]. She stated the resident's weight and lung sounds should be monitored. She stated if the resident had [MEDICAL CONDITION] present staff should document the amount of [MEDICAL CONDITION] and characteristics of [MEDICAL CONDITION]. LPN #2 was asked how the nursing staff monitored fluid intake of a resident on a fluid restriction. She stated the staff should measure the liquid given to the resident. She stated whichever staff member provided the fluids to the resident would report to the nurse the amount of fluid given to the resident. She stated the assigned nurse would document on the TAR (treatment administration record) the amount of fluid the resident had for the shift. At 10:26 a.m., RN (registered nurse) #2 was asked how she monitored fluid intake for a resident on a fluid restriction. She stated fluid intake was measured and tracked by the CNAs. She was asked where was fluid intake documented for a resident on a fluid restriction. She stated it was documented in the nursing charting daily. At 11:02 a.m., CMA (certified medication aide) #1 was asked how he monitored fluid intake for a resident on a fluid restriction. He stated cups were removed from the resident's room and the resident was only given the amount the physician ordered. He stated he would give 120 ml (milliliter) with the medications. At 11:03 a.m., CNA (certified nurse aide) #4 was asked who charted fluid intake if a resident was on a fluid restriction. She said, I have no clue. He was asked where he documented the fluids he provided with the resident's medications. He stated the CNAs or the RN/LPNs documented fluid intake daily in their charting for residents on fluid restrictions. At 11:13 a.m., CNA #2 was asked how she monitored fluid intake for a resident on a fluid restriction. She stated the resident would have a designated cup and they would not be given a water pitcher to keep at bedside. She stated the resident would be given drinks at meals and with medications. She was asked where do you document fluids for a resident on a fluid restriction. She said, I don't document fluids only meal percentages, I assume the nurse documents. At 11:28 a.m., CNA #3 was asked how she monitored fluid intake for a resident on a fluid restriction. She said, I would use different size cups like a 120 ml (milliliter), ask the med (medication) tech (technician) how much they gave, and document the intake with the meals. At 11:39 a.m., CNA #1 was asked where was fluid intake documented for a resident who was on a fluid restriction. She said, Documented in care tracking. The same area where meal percentage is. At 11:53 a.m., RN #1 was asked how she monitored fluid intake for a resident on a fluid restriction. She said, We do layout of how much fluids with meals and meds and we calculate from the physician orders. She stated all the nursing staff measured the amount of fluids ingested by residents on fluid restriction. She was unable to describe exactly how the staff measured the amount of fluid intake. She was asked where do you document fluids for a resident on a fluid restriction. She said, Nurses and CNAs documents in system I believe. At 2:27 p.m., LPN #3 was asked what to do if a resident was having respiratory issues or shortness of breath. She stated she would apply oxygen right away, check oxygen saturation and contact the physician. LPN #3 was asked how residents on a fluid restriction were monitored. She stated the physician provides an order. She stated the order was on the TAR with an area to put in the resident's fluid intake amount. She stated the nurse should be documenting the intake amount. She was asked if residents on a fluid restriction should be monitored for [MEDICAL CONDITION]. She said, Yes. LPN #3 was asked what assessment should be conducted for a resident with a history of [MEDICAL CONDITION]. She stated [MEDICAL CONDITION], coughing and upper respiratory issues. On 02/27/20 at 9:03 a.m., the Nephrologist was asked what was his evaluation of the resident was on 02/19/20. He stated when the resident was seen, he was swollen and confused. He stated the resident was weak. He stated he appeared very ill. He stated he immediately walked the resident over to the hospital emergency room for treatment and evaluation. At 10:38 a.m., the ADON (assistant director of nurses) was asked how staff were expected to monitor residents with [MEDICAL CONDITION]. She stated if the CNA noticed swelling the findings should be reported to the nurse. She stated the resident's daily weights should be charted on the nurse task sheet and in the nurse aides daily charting. The ADON was asked to review the resident's daily weight charting from 02/03/20 to 02/07/20. She was asked if daily weights were obtained and documented as ordered by the physician. She said, No. She was asked if the nurse could report a weight gain or loss to the physician if weights were not charted. She said, No. She was asked why it was important to monitor the weights of a resident with a [DIAGNOSES REDACTED]. The ADON was asked if a resident was on fluid restriction, should the fluid intake be documented. She stated the nursing staff should document the fluid intake daily on the TAR and the CNA's should document in the computer. The ADON was asked to review the CNA documentation and the TAR from 02/14/20 to 02/19/20. She was asked if the fluid intake had been documented for the resident. She stated it was documented. The ADON was asked how residents with breathing problems were monitored. She stated the staff should take vital signs, raise the head of the bed, give a breathing treatment if ordered by the physician and assess the lungs. At 12:32 p.m., the dietary manager was asked if there was a protocol the facility used for residents with physician's orders [REDACTED]. She said, No. She said, Nursing tracks intake of fluids, CNA enters in meal percentages and fluid intake. She was asked how did staff know if a resident was on a fluid restriction. She said, Dietary tickets says fluid restriction. She was asked how do nursing staff know the amount of fluids which could be provided to the resident each shift. She said, Charge nurse divides up the amount of fluids by three meals, the amount at medication pass and snacks. She stated there was no suggestion on the amount for each meal from the dietary department. At 1:11 p.m., CNA #5 was asked who was responsible to weigh the residents. She stated the CNA's weigh the residents and chart the weights in the computer. CNA #5 was asked how she would know if a resident was on a fluid restriction. She stated she would get the information from the nurse and off going staff report. She was asked how would you know the amount of the fluid to restrict the resident to. She said, I don't know that answer. At 1:30 p.m., LPN #1 was asked how she would know if a resident was on a fluid restriction. She stated it comes up on the resident's profile and on the TAR. She was asked how CNAs know if a resident was on a fluid restriction. She stated the nurses put signs up in the residents' rooms. She stated the former dietary manager made up signs to place in each room with a resident on a fluid restriction. She stated the signs have different amounts to give at lunch, breakfast, dinner and medication pass according to the amount of the fluid restriction. On 03/02/20 at 2:30 p.m., the DON was asked how staff members knew if a resident had physician's orders [REDACTED]. She stated the information could be found in the physician's orders [REDACTED]. She was asked how did the CMAs know how much fluid they were able to give a resident with their medications when a resident was on a fluid restriction. She stated the physician's orders [REDACTED]. She was asked if there was a protocol which identified how much fluid a resident on a fluid restriction could have during each shift, during each meal, and with their medications to aide in staff communication and avoid a resident being given too much fluid. She said, No, I don't think so. She stated whatever was remaining after the day shift could be given over the evening and night shift. She further stated there was no protocol which broke down each shift and how much fluid a resident on a fluid restriction could have. She was asked if a resident's fluid restriction was not monitored accurately or at all, how would the next shift know how much fluid a resident could have on their shift. She said, They won't know if it's not documented. She was asked if it was possible for a resident to be given too much fluid if the previous shift did not monitor the resident's intake. She said, Yes, there is a possibility for a resident to get too much fluid. At 2:40 p.m., the DON and the administrator were shown the fluid restriction breakdown information sheets provided by LPN #1. The sheets documented different fluid restrictions and how much intake a resident could have with breakfast, lunch, dinner, medications, snacks and for each shift. Both staff members stated they had never seen the fluid restriction information sheets. They both stated the facility did not use them. At 2:44 p.m., the DON was notified of the interviews with the licensed and certified staff who were uncertain of how to determine if a resident was on a fluid restriction, how to implement a fluid restriction, where to document and who was responsible for documenting intake of a resident on a fluid restriction. 2. Resident #8 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. [MEDICATION NAME] (a diuretic medication) 20 mg (milligrams) .By mouth Once Daily for [MEDICAL CONDITION] . A weight log, dated 02/20/20 through 03/01/20, documented the following weights were obtained: 02/20/20 214 lbs (pounds) and 02/20/20 214 lbs 02/21/20 212.5 lbs 02/22/20 212.50 lbs and 02/22/20 211.0 lbs 03/01/20 212.5 lbs There was no documentation in the resident's clinical record for daily weights on 02/23/20, 02/24/20, 02/25/20, 02/26/20, 02/27/20, 02/28/20 and 02/29/20. On 03/02/20 at 11:41 a.m., the DON was asked to review the physician's orders [REDACTED]. She was then asked to review the weights obtained by the facility for the resident. She was asked if the resident's weights were monitored as ordered by the physician. She stated they missed getting a weight on the resident from 02/23/20 through 02/29/20. She was asked why was it important to monitor the resident for weight changes. She stated the resident had a [DIAGNOSES REDACTED]. 3. Resident #9 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A weight log, dated 02/14/20 through 03/02/20, documented the following weights were obtained: 02/14/20 149.5 lbs 02/15/20 149.1 lbs 02/16/20 145.0 lbs 02/18/20 146.0 lbs 02/19/20 145.4 lbs 02/20/20 142.0 lbs 02/21/20 143.0 lbs 02/22/20 141.0 lbs 02/27/20 140 lbs 02/28/20 138 lbs 02/29/20 138.5 lbs 03/01/20 136.0 lbs 03/02/20 135.5 lbs There was no documentation in the resident's clinical record for daily weights obtained on 02/17/20, 02/23/20, 02/24/20, 02/25/20, and 02/26/20. On 03/02/20 at 11:08 a.m., the DON was asked to review the physician's orders [REDACTED]. She was asked if the physician's orders [REDACTED]. She said, Not on

Based on record reviews and interviews, it was determined the facility failed to ensure records were complete and accurate for three (#1, 8 and #9) of nine sampled residents whose records were reviewed. The DON (director of nurses) identified 76 residents who resided in the facility: Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Daily Weight for all SNF (skilled nursing facility) patients with a [DIAGNOSES REDACTED]. Daily Weight before breakfast; notify physician for weight gain of 2-3 lbs (pounds) overnight or greater than 5 lbs in one week .Once Daily . O2 (oxygen) sats (saturation) q (every) shift; Notify physician of O2 sats less than 90 % (percent) . A baseline care plan, dated 02/03/20, documented the resident was at risk for weight loss and his weights would be monitored daily. The care plan documented the resident was on continuous oxygen at 2l/min (two liters per minute). The resident had a behavior of taking his oxygen off. The resident had two to three plus [MEDICAL CONDITION] to both bilateral lower extremities. A weight log, dated 02/03/20, documented the resident's weight was measured at 162.5 lbs. A vital signs log, dated 02/06/20 at 2:29 p.m., documented the resident's oxygen saturation was measured at 96 % on room air. A nurse's progress note, dated 02/06/20 at 7:40 p.m., no documentation the resident's breathing and lung sounds were assessed and monitored. There was no documentation the resident's oxygen saturation was measured. A nurse's task flow sheet, dated 02/03/20 through 02/07/20, documented the resident's oxygen saturation was not monitored during the specified dates on the 7:00 a.m. to 7:00 p.m. shift and the 7:00 p.m. to 7:00 a.m. shift. The emergency room records documented the resident's weight was 182.6 pounds on admission to the hospital on [DATE]. A baseline care plan, dated 02/14/20, documented the resident was readmitted to the facility. A physicians order, dated 02/14/20, documented, .Fluid restriction of 2000 cc/24h- (2000 cc of fluids in 24 hour period) . Daily Weight before breakfast; notify physician for weight gain of 2-3 lbs overnight or greater than 5 lbs in one week . A nurse progress note, dated 02/14/20 at 2:56 p.m., documented a head to toe assessment was completed. The note documented the nurse was unable to obtain a weight at the time of the assessment due to the resident refused to get up. A nurse task flow sheet, dated February 2020, documented the following monitoring was conducted of the physician ordered fluid restriction: The resident had 80 cc of intake on the 7:00 p.m. to 7:00 a.m. shift on 02/14/20. The resident had 960 cc of intake on the 7:00 a.m. to 7:00 p.m. shift on 02/15/20. There was no further documentation of the resident's intake of fluids during his stay at the facility on the nurse task flow sheet. A weight log, dated 02/15/20, documented the resident's weight was measured three times on 02/15/20. The resident's weight was documented as 183.5 lbs for each of the three entries. This was a 21 pound increase from the resident's admission weight on 02/03/20. The resident's oxygen saturation was measured at 94 % on a nurse task flow sheet once between 7:00 a.m. and 7:00 p.m., on 02/15/20. A weight log, dated 02/16/20, documented the resident's weight was measured at 184 pounds. This was a .5 pound increase in the resident's weight from the previous day, 02/15/20. A daily charting record, dated 02/16/20, documented the resident's fluid intake with meals was 350 cc at breakfast, 350 cc at lunch and 200 cc at dinner for a total of 900 cc with his meal intake. There was no documentation of any fluid intake with medications or between meals. The resident's clinical record did not document any further fluid intake monitoring for the resident during his stay. A nurse's progress note, dated 02/17/20 at 3:34 p.m., documented the resident had a 12 % weight gain. The note did not document in what period of time the weight gain occurred in. The note documented the resident's physician and the dietician were notified. A weight log, dated 02/17/20 through 02/19/20, documented the resident refused to have his weight measured on 02/17/20 and 02/19/20. There was no documentation the resident's weight was measured or he refused on 02/18/20. A nurse's task flow sheet, dated 02/14/20 through 02/20/20, documented the resident's oxygen saturation was monitored and above 90 % on 02/14/20, 02/15/20, 02/18/20, and 02/19/20 during the 7:00 a.m. to 7:00 p.m. shift. The flow sheet was blank on 02/16/20 and 02/17/20. The nurse's task flow sheet documented the resident's oxygen saturation was monitored and above 90 % on 02/14/20, 02/15/20 and 02/18/20 during the 7:00 p.m. to 7:00 a.m. shift. The flow sheet was blank on 02/16/20 and 02/17/20 and 02/19/20. On 02/25/20 at 9:45 a.m., LPN (licensed practical nurse) #2 was asked what type of monitoring should be completed daily if a resident had a [DIAGNOSES REDACTED]. She stated the resident's weight should be monitored. At 10:26 a.m., RN (registered nurse) #2 was asked how she monitored fluid intake for a resident on a fluid restriction. She stated fluid intake was measured and tracked by the CNAs. She was asked where was fluid intake documented for a resident on a fluid restriction. She stated it was documented in the nursing charting daily. At 2:27 p.m., LPN #3 was asked how residents on a fluid restriction were monitored. She stated the physician provides an order. She stated the order was on the TAR with an area to put in the resident's fluid intake amount. She stated the nurse should be documenting the intake amount. She was asked if residents on a fluid restriction should be monitored for [MEDICAL CONDITION]. She said, Yes. At 10:38 a.m., the ADON (assistant director of nurses) was asked how staff were expected to monitor residents with [MEDICAL CONDITION]. She stated the resident's daily weights should be charted on the nurse task sheet and in the nurse aides daily charting. The ADON was asked to review the resident's daily weight charting from 02/03/20 to 02/07/20. She was asked if daily weights were obtained and documented as ordered by the physician. She said, No. She was asked if the nurse could report a weight gain or loss to the physician if weights were not charted. She said, No. She was asked why it was important to monitor the weights of a resident with a [DIAGNOSES REDACTED]. The ADON was asked if a resident was on fluid restriction, should the fluid intake be documented. She stated the nursing staff should document the fluid intake daily on the TAR and the CNA's should document in the computer. The ADON was asked to review the CNA documentation and the TAR from 02/14/20 to 02/19/20. She was asked if the fluid intake had been being documented for the resident. She stated it was documented. On 03/02/20 at 2:30 p.m., the DON was asked how staff members knew if a resident had physician's orders [REDACTED]. She stated the information could be found in the physician's orders [REDACTED]. She was asked how did the CMAs know how much fluid they were able to give a resident with their medications when a resident was on a fluid restriction. She stated the physician's orders [REDACTED]. She was asked if there was a protocol which identified how much fluid a resident on a fluid restriction could have during each shift, during each meal, and with their medications to aide in staff communication and avoid a resident being given too much fluid. She said, No, I don't think so. She stated whatever was remaining after the day shift could be given over the evening and night shift. She further stated there was no protocol which broke down each shift how much fluid a resident on a fluid restriction could have. She was asked if a resident's fluid restriction was not monitored accurately or at all how would the next shift know how much fluid a resident could have on their shift. She said, They won't know if it's not documented. She was asked if it was possible for a resident to be given too much fluids if the previous shift did not monitor the resident's intake. She said, Yes, there is a possibility for a resident to get too much fluid. 2. Resident #8 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. [MEDICATION NAME] (a diuretic medication) 20 mg (milligrams) .By mouth Once Daily for [MEDICAL CONDITION] . A weight log, dated 02/20/20 through 03/01/20, documented the following weights were obtained: 02/20/20 214 lbs (pounds) and 02/20/20 214 lbs 02/21/20 212.5 lbs 02/22/20 212.50 lbs and 02/22/20 211.0 lbs 03/01/20 212.5 lbs There was no documentation in the resident's clinical record for daily weights on 02/23/20, 02/24/20, 02/25/20, 02/26/20, 02/27/20, 02/28/20 and 02/29/20. On 03/02/20 at 11:41 a.m., the DON was asked to review the physician's orders [REDACTED]. She was then asked to review the weights obtained by the facility for the resident. She was asked if the resident's weights were completed for daily weights. She stated they were not. 3. Resident #9 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A weight log, dated 02/14/20 through 03/02/20, documented the following weights were obtained: 02/14/20 149.5 lbs 02/15/20 149.1 lbs 02/16/20 145.0 lbs 02/18/20 146.0 lbs 02/19/20 145.4 lbs 02/20/20 142.0 lbs 02/21/20 143.0 lbs 02/22/20 141.0 lbs 02/27/20 140 lbs 02/28/20 138 lbs 02/29/20 138.5 lbs 03/01/20 136.0 lbs 03/02/20 135.5 lbs There was no documentation in the resident's clinical record for daily weights obtained on 02/17/20, 02/23/20, 02/24/20, 02/25/20, and 02/26/20. On 03/02/20 at 11:08 a.m., the DON was asked to review the physician's orders [REDACTED]. She was asked if the resident's record had completed documentation for daily weights. She stated no.

Based on record reviews and interviews, it was determined the facility failed to notify the physician for a resident's changes in condition for one (#1) of six sampled residents reviewed who had changes in their condition. The DON (director of nurses) identified 76 residents who resided in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Daily Weight for all SNF (skilled nursing facility) patients with a [DIAGNOSES REDACTED]. [MEDICATION NAME] (a diuretic) 80 mg (milligrams) .Daily For .[MEDICAL CONDITION] . Daily Weight before breakfast; notify physician for weight gain of 2-3 lbs (pounds) overnight or greater than 5 lbs in one week .Once Daily . A weight log, dated 02/03/20, documented the resident's weight was measured at 162.5 lbs. A daily skilled nurse assessment, dated 02/03/20 at 4:16 p.m., documented the resident had bilateral lower extremity [MEDICAL CONDITION] present. The assessment further documented the resident had shortness of breath on exertion and wheezing. There was no documentation the physician was notified the resident had shortness of breath on exertion and was wheezing. A nurse's progress note, dated 02/06/20 at 7:40 p.m., documented the resident started [MEDICATION NAME] for a cough and phlegm. The resident continued on oxygen at 2l/min. The resident called out and said he could not breath (breathe), O2 tubing on forehead. The note documented, .Explained that he was breathing, and replace O2 tube in correct placement . There was no documentation the physician was notified the resident had complained he could not breathe. A nurse's progress note, dated 02/07/20 at 4:57 p.m., documented the next entry in the resident's clinical record following the entry on 02/06/20 when the resident stated he could not breathe. The note was documented 21 hours after the onset of the resident's respiratory complaints. The note documented, .Resident send to (Named hospital) d/t (due to) low BP (blood pressure), heart rate between 50-142, resident has a fib ([MEDICAL CONDITION]). non productive cough, wheezing noted, lung sounds wet. left pupil pinpoint, left hand weaker than right, resident lethargic and reporting weakness, (Named physician #1) notified orders to send pt (patient) to the hospital, resident left via emsa (emergency medical services) . A physician's orders [REDACTED].Send to ER . A baseline care plan, dated 02/14/20, documented the resident was admitted to the facility with [DIAGNOSES REDACTED]. A physicians order, dated 02/14/20, documented, .Daily Weight before breakfast; notify physician for weight gain of 2-3 lbs overnight or greater than 5 lbs in one week . A nurse progress note, dated 02/14/20 at 2:56 p.m., documented a head to toe assessment was completed. The note documented the nurse was unable to obtain a weight at the time of the assessment due to the resident refused to get up. A weight log, dated 02/15/20, documented the resident's weight was measured three times on 02/15/20. The resident's weight was documented as 183.5 lbs for each of the three entries. This was a 21 pound increase from the resident's admission weight on 02/03/20. There was no documentation the resident's physician was notified of the resident's severe weight gain. A weight log, dated 02/16/20, documented the resident's weight was measured at 184 pounds. This was a .5 pound increase in the resident's weight from the previous day, 02/15/20. There was no documentation the physician was notified the resident was weighed again and he continued to have a severe weight gain. A nurse's progress note, dated 02/17/20 at 3:34 p.m., documented the resident had a 12 % weight gain. The note did not document in what period of time the weight gain occurred in. The note documented the resident's physician and the dietician were notified. On 02/25/20 at 9:35 a.m., at 9:45 a.m., LPN (licensed practical nurse) #2 was asked what she would do if a resident was complaining of being SOB (short of breath). She stated she would check vital signs, give a breathing treatment if ordered, assess lungs and contact the physician. LPN #2 was asked what type of monitoring should be completed daily if a resident had a [DIAGNOSES REDACTED]. At 2:27 p.m., LPN #3 was asked what to do if a resident was having respiratory issues or shortness of breath. She stated she would apply oxygen right away, check oxygen saturation and contact the physician. On 02/27/20 at 10:38 a.m., the ADON (assistant director of nurses) was asked how staff were expected to monitor residents with [MEDICAL CONDITION]. She stated if the CNA noticed swelling the findings should be reported to the nurse. She stated the resident's daily weights should be charted on the nurse task sheet and in the nurse aides daily charting. The ADON was asked to review the resident's daily weight charting from 02/03/20 to 02/07/20. She was asked if daily weights were obtained and documented as ordered by the physician. She said, No. She was asked if the nurse could report a weight gain or loss to the physician if weights were not charted. She said, No. She was asked why it was important to monitor the weights of a resident with a [DIAGNOSES REDACTED]. She was asked to review the documentation of the resident's weights. She was asked if the physician should have been notified. She stated yes.

Based on record reviews and interviews, it was determined the facility failed to ensure staff were competent and knowledgeable of which residents were on fluid restrictions and how to implement and monitor residents on a fluid restriction for one (#1) of three sampled residents reviewed who had physician's orders [REDACTED]. The DON (director of nurses) identified three residents who were on a fluid restriction. Findings: Resident #1 had [DIAGNOSES REDACTED]. A baseline care plan, dated 02/14/20, documented the resident was admitted to the facility with [DIAGNOSES REDACTED]. A physicians order, dated 02/14/20, documented, .Fluid restriction of 2000 cc/24h- (2000 cc of fluids in 24 hour period) . A nurse task flowsheet, dated February 2020, documented the following monitoring was conducted of the physician ordered fluid restriction: The resident had 80 cc of intake on the 7:00 p.m. to 7:00 a.m. shift on 02/14/20. The resident had 960 cc of intake on the 7:00 a.m. to 7:00 p.m. shift on 02/15/20. There was no further documentation of the resident's intake of fluids during his stay at the facility on the nurse task flowsheet. A daily charting record, dated 02/16/20, documented the resident's fluid intake with meals was 350 cc at breakfast, 350 cc at lunch and 200 cc at dinner for a total of 900 cc with his meal intake. There was no documentation of any fluid intake with medications or between meals. The resident's clinical record did not document any further fluid intake monitoring for the resident during his stay. On 02/25/20 at 9:45 a.m., LPN (licensed practical nurse) #2 was asked how the nursing staff monitored fluid intake of a resident on a fluid restriction. She stated the staff should measure the liquid given to the resident. She stated whichever staff member provided the fluids to the resident would report to the nurse the amount of fluid given to the resident. She stated the assigned nurse would document on the TAR (treatment administration record) the amount of fluid the resident had for the shift. At 10:26 a.m., RN (registered nurse) #2 was asked how she monitored fluid intake for a resident on a fluid restriction. She stated fluid intake was measured and tracked by the CNAs. She was asked where was fluid intake documented for a resident on a fluid restriction. She stated it was documented in the nursing charting daily. At 11:02 a.m., CMA (certified medication aide) #1 was asked how he monitored fluid intake for a resident on a fluid restriction. He stated cups were removed from the resident's room and the resident was only given the amount the physician ordered. He stated he would give 120 ml (milliliter) with the medications. He was asked where he documented the fluids he provided with the resident's medications. He stated the CNAs or the RN/LPNs documented residents fluid intake daily in their charting for residents on fluid restrictions. At 11:03 a.m., CNA (certified nurse aide) #4 was asked who charted fluid intake if a resident was on a fluid restriction. She said, I have no clue. At 11:13 a.m., CNA #2 was asked how she monitored fluid intake for a resident on a fluid restriction. She stated the resident would have a designated cup and they would not be given a water pitcher to keep at bedside. She stated the resident would be given drinks at meals and with medications. She was asked where do you document fluids for a resident on a fluid restriction. She said, I don't document fluids only meal percentages, I assume the nurse documents. At 11:28 a.m., CNA #3 was asked how she monitored fluid intake for a resident on a fluid restriction. She said, I would use different size cups like a 120 ml (milliliter), ask the med (medication) tech (technician) how much they gave, and document the intake with the meals. At 11:39 a.m., CNA #1 was asked where was fluid intake documented for a resident who was on a fluid restriction. She said, Documented in care tracking. The same area where meal percentage is. At 11:53 a.m., RN #1 was asked how she monitored fluid intake for a resident on a fluid restriction. She said, We do layout of how much fluids with meals and meds and we calculate from the physician orders. She stated the all nursing staff measured the amount of fluids ingested by residents on fluid restriction. She was unable to describe exactly how the staff measured the amount of fluid intake a resident consumed. She was asked where do you document fluids for a resident on a fluid restriction. She said, Nurses and CNAs documents in system I believe. At 2:27 p.m., LPN #3 was asked how residents on a fluid restriction were monitored. She stated the physician provides an order. She stated the order was on the TAR with an area to put in the resident's fluid intake amount. She stated the nurse should be documenting the intake amount. She was asked if residents on a fluid restriction should be monitored for [MEDICAL CONDITION]. She said, Yes. On 02/27/20 at 9:03 a.m., the ADON (assistant director of nurses) was asked if a resident was on fluid restriction, should the fluid intake be documented. She stated the nursing staff should document the fluid intake daily on the TAR and the CNA's should document in the computer. The ADON was asked to review the CNA documentation and the TAR from 02/14/20 to 02/19/20. She was asked if the fluid intake had been being documented for the resident. She stated it was documented. At 12:32 p.m., the dietary manager was asked if there was a protocol the facility used for residents with physician's orders [REDACTED]. She said, No. She said, Nursing tracks intake of fluids, CNA enters in meal percentages and fluid intake. She was asked how did staff know if a resident was on a fluid restriction. She said, Dietary tickets says fluid restriction. She was asked how do nursing staff know the amount of fluids which could be provided to the resident each shift. She said, Charge nurse divides up the amount of fluids by three meals, the amount at medication pass and snacks. She stated there was no suggestion on the amount for each meal from dietary department. At 1:11 p.m., CNA #5 was asked how she would know if a resident was on a fluid restriction. She stated she would get the information from the nurse and off going staff report. She was asked how would you know the amount of the fluid to restrict the resident to. She said, I don't know that answer. At 1:30 p.m., LPN #1 was asked how she would know if a resident was on a fluid restriction. She stated it comes up on the resident's profile and on the TAR. She was asked CNAs know if a resident was on a fluid restriction. She stated the nurses put signs up in the residents' rooms. She stated the former dietary manager made up signs to place in each room with a resident on a fluid restriction. She stated the signs have different amounts to give at lunch, breakfast, dinner and medication pass according to the amount of the fluid restriction. On 03/02/20 at 2:30 p.m., the DON was asked how staff members knew if a resident had physician's orders [REDACTED]. She stated the information could be found in the physician's orders [REDACTED]. She was asked how did the CMAs know how much fluid they were able to give a resident with their medications when a resident was on a fluid restriction. She stated the physician's orders [REDACTED]. She was asked if there was a protocol which identified how much fluid a resident on a fluid restriction could have during each shift, during each meal, and with their medications to aide in staff communication and avoid a resident being given too much fluid. She said, No, I don't think so. She stated whatever was remaining after the day shift could be given over the evening and night shift. She further stated there was no protocol which broke down each shift how much fluid a resident on a fluid restriction could have. She was asked if a resident's fluid restriction was not monitored accurately or at all how would the next shift know how much fluid a resident could have on their shift. She said, They won't know if it's not documented. She was asked if it was possible for a resident to be given too much fluids if the previous shift did not monitor the resident's intake. She said, Yes, there is a possibility for a resident to get too much fluid. At 2:40 p.m., the DON and the administrator were shown the fluid restriction breakdown information sheets provided by LPN #1. The sheets documented different fluid restrictions and how much intake a resident could have with breakfast, lunch, dinner, medications, snacks and for each shift. Both staff members stated they had never seen the fluid restriction information sheets. They both stated the facility did not use them. At 2:44 p.m., the DON was asked to provide orientation and/or competency evaluations related to how to care for a resident on a fluid restriction including how to identify residents were on a fluid restriction and how to implement and document intake for a resident on a fluid restriction for licensed and certified staff. She was asked to provide the documentation for RN #1 and #2, the ADON, LPN #1, CMA #1, and CNA #1, 2, 3, 4, and #5. She stated there was no documentation of training or competency evaluation for staff members related to fluid restrictions. She stated the staff member responsible for training had a discussion with staff members when they were hired about the importance of documenting and where to document fluid intake for residents on a fluid restriction. She stated the discussion was not documented. She further stated there was no competency evaluation related to fluid restrictions. She was notified of the interviews with the licensed and certified staff who were uncertain of how to determined if a resident was on a fluid restriction, how to implement a fluid restriction, where to document and who was responsible for documenting intake of a resident on a fluid restriction.

Based on record reviews and interviews, it was determined the facility failed to ensure: ~ meal intake percentages were documented for the purpose of evaluation to ensure a resident's nutritional needs were met; ~ a resident was offered a meal replacement supplement for decreased meal intake or meal refusals; ~ a registered dietician was notified and responded timely following a resident's severe weight loss; and ~ resident's weight was retaken to verify accuracy following a 5 % (percent) or more change since the prior weight assessment for one (#1) of three sampled residents reviewed for weight loss. The DON (director of nurses) identified 61 residents who resided in the facility. Findings: A facility policy titled, Weight Assessment and Intervention, documented: .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents . The nursing staff will measure residents weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter .Any weight change of 5 % (percent) or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing .The Dietician will respond within 24 hours of receipt of written notification .The Dietician will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for 'significant' weight change has been met .If the weight change is desirable, this will be documented and no change in the care plan will be necessary . Analysis .Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the .Approximate calorie, protein, and other nutrient needs compared with the resident's current intake . Resident #1 was admitted to the skilled nursing facility on 08/21/19 with [DIAGNOSES REDACTED]. A baseline care plan, dated 08/21/19, documented the resident's weight upon admission was 133 lbs (pounds). The care plan documented the resident was at risk for weight loss. Dietary interventions included monitoring resident's dietary intake. The resident required assistance of one person with eating. physician's orders [REDACTED]. The physician's orders [REDACTED]. A nutritional assessment, dated 08/22/19, documented the resident had a fair appetite, she consumed 51 to 75 % of her meals. She received one can of Ensure twice daily. The resident's estimated nutritional needs included: 62 grams of protein and 1868 total calories each day. The note documented the resident had increased protein needs related to low [MEDICATION NAME] ([MEDICATION NAME] testing measures the amount of protein in your blood) levels at 12. The note documented to continue Ensure twice daily for added protein. The assessment was completed by the CDM (certified dietary manager) and the RD (registered dietician.) A nurse's progress note, dated 08/25/19, documented the resident seems to have a better apetite (sic) today. The note documented the resident consumed 100 % of her lunch. There was no documentation of the amount consumed for breakfast or dinner. A nurse's progress note, dated 08/26/19, documented the resident ate 100 % of her lunch and dinner. There was no documentation of the amount consumed at breakfast. A weight log, dated 08/27/19, documented the resident's weight was 134.0 lbs. A nurse's progress note, dated 08/28/19, documented the resident ate 100 % of her lunch. There was no documentation of the amount consumed at breakfast or dinner. A nurse's progress note, dated 08/29/19, documented the resident ate 100 % of meals offered. The progress note did not document if breakfast, lunch and dinner were offered to the resident. A meal intake percentage record, dated (MONTH) 2019, was blank for all meals including breakfast, lunch and dinner. There was no documentation the resident had refused meals. A MAR (medication administration record), dated (MONTH) 2019, documented the resident received Ensure supplements as ordered by the physician. The MAR indicated [REDACTED]. A meal intake percentage record, dated (MONTH) 2019, documented meal percentage information was obtained for ten meals out of 90 meal opportunities. The record documented the resident consumed 50-75 % for eight meals and 10 % for two meals. There was no documentation the resident had refused any meals she was offered. A MAR, dated (MONTH) 2019, documented the resident consumed 50-75 % of Ensure supplements twice daily. The MAR indicated [REDACTED]. Five opportunities for documentation of the supplement were blank. A weight log, dated 09/03/19, documented the resident's weight was 136.5 lbs. A weight log, dated 09/10/19, documented the resident's weight was 125.5 lbs. The resident's weight loss was 11 lbs, or an 8 % decrease over eight days. There was no documentation the resident's weight was retaken the following day to verify accuracy. A nutrition risk meeting report, dated 09/11/19, was signed by the CDM and the RD. The report documented the reason for monitoring was weight loss. The report documented the resident's weight was 137 lbs on 09/04/19. The report documented, 9/10 (09/10/19) 126 # (pounds) ? (question) reweigh . The report further documented the resident had experienced an 8 % weight loss. There was no time period specified for the weight loss. There was no documentation the resident's weight was rechecked the following day to verify accuracy and the RD was notified. A dietary progress note, dated 09/26/19, was the next documentation which addressed the resident's weight. The note documented the resident's weight was 125.5 lbs and her height was 60 inches. The note documented the resident's BMI (body mass index, a measure of body fat based on height and weight) was 24 normal. The progress note was signed by the CDM. There was no documentation the RD had been notified and responded to the resident's severe weight loss. There was no documentation the RD had reviewed the CDM progress note dated 09/26/19. A meal intake percentage record, dated 09/27/19, documented the resident only consumed 10 % of her breakfast and lunch meal. There was no documentation the resident was offered a meal replacement shake when she consumed less than 25 % of her meal on 09/27/19. A meal intake percentage record, dated (MONTH) 2019, was blank for all meals including breakfast, lunch and dinner. There was no documentation the resident had refused any meals. A weight log, dated 10/08/19, documented the resident's weight was 130.3 lbs. A MAR, dated (MONTH) 2019, documented the resident was provided Ensure supplements 55 times for 62 opportunities. The MAR indicated [REDACTED]. There was no other documentation during (MONTH) 2019 of the resident's intake to track total protein and calories ingested daily. A meal intake percentage record, dated (MONTH) 2019, was blank for all meals including breakfast, lunch and dinner. There was no documentation the resident had refused any meals. A MAR, dated (MONTH) 2019, documented the administration of the resident's Ensure supplement shakes. There was one blank on the MAR. The resident consumed an average of 50 % of all Ensure supplements offered. A weight log, dated 11/04/19, documented the resident's weight was 125.0 lbs. The weight loss was a 5.3 lbs loss/4.07 % decrease in one month. A care plan, initiated on 11/04/19, documented the resident had unplanned weight loss. The identified goal was for the resident to receive adequate nutrition and fluid intake and stabilize weight over the next 90 days. Interventions included: serve diet as ordered and offered meal replacement if the resident eats less than 50 %, weights every week until stable, report to physician if there was a 5 % loss, and RD to review the resident's medical records and make recommendations. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A weight log, dated 11/13/19 and 11/19/19, documented the resident's weight was 122.0 lbs. A weight log, dated 11/26/19, documented the resident's weight was 121.4 lbs. The weight loss was 12.6 lbs, or a 9.4 % decrease in three months. A MAR, dated 11/08/19 through 11/26/19, documented the administration of the Mighty Shake supplement twice daily. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A dietary note, dated 11/27/19, documented the resident's weight was 121.4 lbs. The note documented the resident's weight had decreased by 8.9 lbs in one month and had decreased by 12.6 lbs in three months. The note documented the following interventions were added on 11/07/19: medication pass 2.0 60 ml (milliliters) and a health shake twice daily. The progress note was signed by the RD. A significant change assessment, dated 11/28/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required extensive assistance of one staff member with eating. The assessment documented the resident's weight was 121 lbs and she had experienced weight loss. She had received hospice services. On 01/08/19 at 8:15 a.m., CNA #1 (certified nurse aide) stated the amount residents consumed during meals was documented as a percentage in the computer after meals. At 8:30 a.m., LPN #1 (licensed practical nurse) stated CNAs were required to document meal intake percentages after every meal. She stated documentation of meal percentages was important to monitor for weight loss. She further stated weight loss could be a sign of an illness. At 10:00 a.m., the CDM stated meal replacement shakes were offered to all residents when they consumed 25% or less of their meal. She was asked who attended the nutrition risk meetings. She stated herself (the CDM), the DON, the RD and the MDS (minimum data set) staff. She was asked to explain the weights and notations on the nutrition risk meeting report dated 09/11/19 for the resident. She stated the weight recorded for 09/04/19 was the weight obtained on 09/03/19 (136.5 lbs) and rounded up to 137 lbs. She stated the weight recorded on 09/10/19 was the weight obtained from 09/10/19 (125.5) and rounded up to 126 lbs. She was asked why ? reweigh was documented next to the 09/10/19 weight. She stated the RD had reviewed the weight and had requested a reweigh to check for accuracy. She acknowledged the report documented the resident had an 8% weight loss. At 12:00 p.m., the DON stated meal replacement shakes should be offered to all residents if they refused a meal or ate less than 25 % of their meal. She was asked if the resident had any documentation of meal replacements being offered when she ate less than 25 % of her meal. She stated there was no documentation the resident had been offered a meal replacement while she was a resident in the facility. She was asked to review the resident's meal intake percentages. She acknowledged the documentation was sparse for meal percentages. She was asked why it was important to track the percentage of meals consumed by residents. She stated to track for potential weight loss and to aide in deciding if interventions needed to be changed or added. She was asked if there was not an accurate accounting of meal intake percentages was it possible to determine if the resident's nutritional needs were being met. She said, No. She was asked if the resident should have been reweighed following the 11 lb/8 % weight loss documented on 09/10/19. She stated the nutrition risk meeting on 09/11/19 documented the resident needed a reweigh. She stated the resident was reweighed but she didn't know where the weight was documented. She further stated she did not remember what the resident's reweigh amount was. She was asked how the RD was involved in resident care to ensure the resident's nutritional needs were met. She stated the RD attended monthly nutritional risk meetings and resident's weights were discussed. She stated if a resident experienced a weight loss of 5 % or more the physician and the RD were notified. She stated the RD then reviewed the resident's chart to determine what interventions needed to be changed or added.

Based on record reviews and interviews, it was determined the facility failed to ensure residents' records were completed for: a. percentage of meal intake for three (#3, 18, and #19) of four sampled residents whose meal intake records were reviewed. The CDM (certified dietary manager) identified 23 who received meals from the kitchen. One resident was identified who received nutrition and hydration solely via a feeding tube; and b. personal hygiene care for three (#16, 18, and #19) of four sampled residents whose hygiene records were reviewed. The DON (director of nurses) identified 18 residents who required assistance with their personal hygiene needs. Findings: 1. Resident #3 had [DIAGNOSES REDACTED]. A significant change assessment, dated 12/07/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required total dependence from staff with eating. A meal percentage record, dated (MONTH) 2019, documented the percent of the resident's meal intake was recorded for seven meals out of 93 meals provided. A meal percentage record, dated (MONTH) 2019, documented the percent of the resident's meal intake was recorded for 11 meals out of 90 meals provided. A meal percentage record, dated (MONTH) 2019, documented the percent of the resident's meal intake was recorded for 35 meals out of 93 meals provided A meal percentage record, date (MONTH) 2020, documented the percent of the resident's meal intake was recorded for 11 meals out of 18 meals provided. 2. Resident #16 had [DIAGNOSES REDACTED]. A quarterly assessment, date 10/10/19, documented the resident was mildly impaired in cognitive skills of daily decision making. She did not exhibit episodes of refusal of care during the seven day look back period. She required extensive assistance of one staff member with her personal hygiene needs. An activity daily report, dated (MONTH) 2019, documented the resident received assistance with her personal hygiene care for two days out of 30 days. The facility provided additional ADL (activity of daily living) checklist for 11/25/19. The checklists documented the resident received assistance with her personal hygiene needs on the identified date. An activity daily report, dated (MONTH) 2019, documented the resident received assistance with her personal hygiene care for eight days out of 31 days. The facility provided additional ADL (activity of daily living) checklist for 12/23/19. The checklist documented the resident received assistance with her personal hygiene needs on the identified date. An activity daily report, dated (MONTH) 2020, documented the resident received assistance with her personal hygiene care for three days out of seven days. On 01/05/20 at 10:05 a.m., the resident was asked if she was provided routine assistance with her personal hygiene needs. She said, No they don't help me wash my face or brush my teeth. She stated her daughter visited daily and provided assistance with her personal hygiene. She said, If I could get my wheel chair into the bathroom I could do for my self. I hate to ask. 3. Resident #18 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/11/19, documented the resident was moderately impaired in cognitive skills for daily decision making. She did not exhibit episodes of refusal of care during the seven day look back period. She required limited assistance from staff with eating. She required extensive assistance of one staff member with her personal hygiene needs. A meal percentage record, dated (MONTH) 2019, documented the percent of the resident's meal intake was recorded for four meals out of 90 meals provided. An activity of daily living report, dated (MONTH) 2019, documented the resident received assistance with her personal hygiene care for two days out of 30 days. The facility provided additional ADL (activity of daily living) checklists for 11/25/19 and 11/28/19. The checklists documented the resident received assistance with her personal hygiene needs on the identified dates. A meal percentage record, dated (MONTH) 2019, documented the percent of the resident's meal intake was recorded for 37 meals out of 93 meals provided. An activity of daily living report, dated (MONTH) 2019, documented the resident received assistance with her personal hygiene care for nine days out of 31 days. The facility provided additional ADL checklists for 12/02/19, 12/04/19, and 12/09/19. The checklists documented the resident received assistance with her personal hygiene needs on the identified dates. A meal percentage record, dated (MONTH) 2020, documented the percent of the resident's meal intake was recorded for 12 meals out of 18 meals provided. An activity of daily living report, dated (MONTH) 2020, documented the resident received assistance with her personal hygiene care for four days out of seven. On 01/05/20 at 10:16 a.m., the resident was asked if she was provided routine assistance with her personal hygiene needs. She said, They don't volunteer to help me. She stated she was not able to wash her face on her own because she was unable to turn on the water faucet without assistance. She stated the last time her face was washed was a week ago. She stated her husband used to live in the same room with her and he was able to help her, but he recently passed away. She said, I would like to clean my face every day, but I can't. On 01/07/20 at 11:25 a.m., the DON was asked to review the resident's meal intake percentage documentation for (MONTH) and (MONTH) 2019 and (MONTH) 2020. She was asked if the documentation was complete. She stated she was aware there were blanks in meal percentage documentation for residents. She stated the facility had transitioned to a new ADL and meal intake charting system in (MONTH) 2019. She was asked if the documentation for meal intake documented the resident had refused meals. She stated there was no information charted. She was asked why it was important to track resident's meal intake amounts. She said, For weight loss. She then stated the dietician also reviewed residents' meal intake percentages to determine if interventions were required to prevent weight loss. She was asked if the documentation showed the resident was consuming three meals a day. She stated she was unable to determine from reviewing the documentation. At 11:56 a.m., the DON was asked how often residents were provided assistance with their personal hygiene needs. She stated residents were provided assistance with brushing their teeth, washing their face, combing their hair, and dressing every day. She was asked to review the resident's personal hygiene documentation for (MONTH) and (MONTH) 2019 and (MONTH) 2020. She stated there were blanks in the documentation. She was asked how did she know if a resident had been provided personal hygiene assistance daily. She stated the staff should document when they provide the care. 4. Resident #19 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/28/19, documented the resident was severely impaired in cognitive skills for daily decision making. She did not exhibit episodes of refusal of care during the seven day look back period. She required supervision from staff with eating. She required extensive assistance of one staff member with her personal hygiene needs. A meal percentage record, dated (MONTH) 2019, documented the percent of the resident's meal intake was not obtained of the 90 meals provided. An activity of daily living report, dated (MONTH) 2019, documented the resident had not received assistance with her personal hygiene care out of the 30 days reviewed. A meal percentage record, dated (MONTH) 2019, documented the percent of the resident's meal intake was not obtained for the 93 meals provided. An activity of daily living report, dated (MONTH) 2019, documented the resident had not received assistance with her personal hygiene care for 31 days reviewed. A meal percentage record, dated (MONTH) 2020, documented the percent of the resident's meal intake was recorded for five meals out of 18 meals provided. An activity of daily living report, dated (MONTH) 2020, documented the resident received assistance with her personal hygiene care for 2 days out of seven.

Based on record review and interviews, it was determined the facility failed to revise residents' care plans for fall incidents and interventions for two (#1 and #8) of three sampled residents whose care plans were reviewed for falls. The DON (director of nurses) identified 31 residents who were a high risk for falls. Findings: A facility policy titled, Care Plans, documented: .Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather then addressing only symptoms or triggers .Identifying problem area and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making . Assessments of residents are ongoing and care plans are revised as the resident's condition change .The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .When the resident has had a change of condition . A facility policy titled, Falls and Fall Risk, Managing, documented: .Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .staff will identify and implement relevant interventions .to try to minimize serious consequences of falling . 1. Resident #1 had [DIAGNOSES REDACTED]. An admission assessment, dated 06/20/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required extensive assistance from staff with transfers and ambulation. She utilized a walker and wheelchair for ambulation. She had one fall within the last month prior to the admission. A facility incident report, dated 07/19/19 at 7:45 a.m., documented the resident was found on the floor on her fall mat beside her bed. Interventions listed as a result of this fall included a fall mat, her call light at the bedside, and bedtime and hourly rounding (nursing staff members to check on the resident every hour). A care plan, dated 07/25/19, documented, .Falls .I would like to remain free from major injuries related to a fall .please complete a fall risk assessment on me quarterly. Keep my room clutter free and well lit; my call light within reach and My bed in a low, locked position .Please orient to my surroundings and to my call light frequently. Always place call light within reach. Please keep my room free from clutter. Remove any loose cords and mobility equipment out of the main pathway. Please keep my wheelchair and walker pushed against the wall .Please ensure my adaptive devices .are in good repair .Please assist me in applying non-skid footwear .remind me to lock my wheelchair brakes and to ring for assistance when I need to transfer .monitor me for signs of fatigue while I am ambulating .Please take me to the toilet before and after my meals as well as before and after my activities to prevent me from trying to get up without assistance .Falling star program in place to alert staff that I am a fall risk .PVT (private) sitter sometimes . The care plan developed on 07/25/19 did not include the fall interventions of a fall mat at bedside and hourly and bedtime checks by nursing staff identified following the fall which occurred on 07/19/19. A facility incident report, dated 08/02/19 at 9:10 a.m., documented the resident was found on the floor with her head leaning against her bed. The resident was assessed and no injuries were found. An intervention of a fall mat was placed at the resident's bedside. A facility incident report, dated 08/04/19, documented the resident slid out of her wheelchair and onto the floor. There were no injuries observed during an assessment. A facility incident report, dated 08/09/19 at 11:05 p.m., documented the resident was found on the floor. There were no injuries observed. An intervention identified was for to staff to anticipate resident's needs and offer a drink and a snack during hourly rounds. A facility incident report, dated 08/12/19, documented the resident slid from the side of her bed onto the floor mat. There were no injuries observed. An OSDH (Oklahoma State Department of Health) incident report, dated 08/21/19, documented the resident was found on the floor near her bed. She was observed with a knot to the back of her head. The resident was evaluated in an emergency room and then returned to the hospital with no new physician's orders [REDACTED]. A facility incident report, dated 08/22/19, documented the resident was found on the floor at 2:15 a.m. The resident stated she slipped on the floor. There were no new injuries observed. An intervention identified was to ensure the resident was in the middle of her bed during hourly rounds. A nurse's progress note, dated 08/25/19, documented the resident was found on the floor by two CNA (certified nurse aides). The resident's right hip was observed to be swollen. The family and physician were notified and an x-ray of the resident's hip was ordered. The results of the x-ray were normal. An intervention identified was to ensure the resident's oxygen was on due to observed agitation when her oxygen was off. A facility incident report, dated 08/28/19, documented the resident was found on the floor at 8:25 p.m. There were no new injuries observed. The resident stated she fell while attempting to get up out of her recliner. Interventions identified were to attempt to keep the resident busy with activities during the day time and up until 11:00 p.m. each night. A facility incident report, dated 09/09/19, documented the resident crawled out of bed onto the floor mat at 4:30 a.m. There were no new injuries observed. The report documented the resident stated she was going to make breakfast. Interventions identified were the resident was provided a snack and frequent checks were initiated. A facility incident report, dated 09/14/19, documented the resident was observed on the floor. The resident stated she was attempting to transfer herself to the bathroom when she fell . An intervention identified was a discussion was held with the nurse to implement a toileting training program. A facility incident report, dated 09/28/19, documented the resident was found on the floor. There were no injuries from the fall observed during an assessment. The report documented the resident had attempted to reach for a personal item when she fell . Staff were educated to ensure personal items were kept within the resident's reach. A nurse's progress note, dated 10/07/19, documented the resident was found by staff on the floor mat with her pillow under her head. She was assessed and was found to have no new injuries. On 10/16/19, the resident's care plan was reviewed. The resident's care plan did not include the incidents of falls which occurred since 08/02/19. The last time the resident's fall care plan had been updated was 07/25/19. There were no fall interventions added to the resident's care plan following multiple falls since 08/02/19. On 10/17/19 at 2:35 p.m., the DON (director of nurses) was asked if residents care plans were updated after falls with the fall incident and new interventions if identified. She stated the nurses and the MDS (minimum data set) office updated the care plans with all fall incidents and identified interventions. She was asked to review the resident's care plan and multiple falls since 08/02/19. She acknowledged the resident's care plan was not updated with falls or interventions to prevent further falls. 2. Resident #8 had [DIAGNOSES REDACTED]. A care plan, dated 02/11/19, documented .I have a history of falls . A facility incident report, dated 05/29/19, documented the resident was alert, oriented and required the assistance of one staff member for stand by assist with activities of daily living. The report documented she had been trying to help another resident with their wheelchair when she fell and struck her head on a door. The report documented she received a laceration on her head and was sent to the local emergency room for evaluation. A facility incident report, dated 07/08/19, documented the resident was oriented to person, place and time, ambulated with a walker and required the assistance of one staff member with activities of daily living. The report documented she was trying to get a box off her walker to go to the bathroom when she fell . The intervention associated with this fall was to remind the resident to call for assistance. A facility incident report, dated 09/23/19, documented the resident was found on the floor near her bed. The report documented she was transported by ambulance to a local emergency department. An significant change assessment, dated 09/30/19, documented the resident was cognitively alert in skills for daily decision making. She required extensive assistance of two staff members with transfers. She had not had a fall since her readmission on on 09/30/19. An orthopaedic prescription dated, 10/10/19, documented .Diagnosis .right distal femur fracture around total knee .May wear a brace on the outside of close .Increase from 0-90' (degrees) range of motion .assess skin under brace daily .continue with non-weightbearing right leg for 4 weeks .Send X-rays for review .X-rays in 4 weeks prior to next office visit . On 10/17/19 at 11:00 a.m., the resident's care plan was reviewed. The care plan was not updated with falls the dates of 05/29/19, 07/08/19 and 09/23/19 or new interventions to prevent further falls. At 11:15 a.m., RN #2 reviewed the resident's care plan and stated the care plan had not been updated in the electronic medical records. She stated each fall should have been entered on the care plan with a documented intervention. She stated the fall documentation for this resident was not according to the facility policy.

Based on observations, interviews and record reviews, it was determined the facility failed to provide supervision to prevent falls and implement new interventions to prevent further falls for two (#1 and #8) of three sampled residents who were reviewed for falls. The DON (director of nurses) identified 31 residents who were a high risk for falls. Findings: A facility policy titled, Falling Star Program documented: .This program is designed to identify residents at a high risk for falls .This intervention will cue staff to pay close attention to what the resident is doing in order to intervene and assist should the resident attempt to get up and walk .Staff will make observed rounds hourly .This will be monitored by a check sheet which will be initialed by staff during these rounds . 1. Resident #1 had [DIAGNOSES REDACTED]. An admission assessment, dated 06/20/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required extensive assistance from staff with transfers and ambulation. She utilized a walker and wheelchair for ambulation. She had one fall within the last month prior to the admission. A facility incident report, dated 07/19/19 at 7:45 a.m., documented the resident was found on the floor on her fall mat beside her bed. Interventions listed as a result of this fall included a fall mat, her call light at the bedside, discontinuing [MEDICATION NAME], an anti-psychotic medication, at bedtime and hourly rounding (nursing staff members to check on the resident every hour). A care plan, dated 07/25/19, documented, .Falls .I would like to remain free from major injuries related to a fall .please complete a fall risk assessment on me quarterly. Keep my room clutter free and well lit; my call light within reach and My bed in a low, locked position .Please orient to my surroundings and to my call light frequently. Always place call light within reach. Please keep my room free from clutter. Remove any loose cords and mobility equipment out of the main pathway. Please keep my wheelchair and walker pushed against the wall .Please ensure my adaptive devices .are in good repair .Please assist me in applying non-skid footwear .remind me to lock my wheelchair brakes and to ring for assistance when I need to transfer .monitor me for signs of fatigue while I am ambulating .Please take me to the toilet before and after my meals as well as before and after my activities to prevent me from trying to get up without assistance .Falling star program in place to alert staff that I am a fall risk .PVT (private) sitter sometimes . The care plan developed on 07/25/19 did not include interventions of a fall mat at bedside and hourly and bedtime checks by nursing staff which were identified after the fall which occurred on 07/19/19. A facility incident report, dated 08/02/19 at 9:10 a.m., documented the resident was found on the floor with her head leaning against her bed. Interventions listed as a result of this fall included a fall mat and neurological checks. A facility incident report, dated 08/04/19, documented the resident slid out of her wheelchair and onto the floor. There were no injuries observed during an assessment. Interventions listed as a result of this fall included giving the resident her call light and continuing neurological checks. A facility incident report, dated 08/09/19 at 11:05 p.m., documented the resident was found on the floor. There were no injuries observed. An intervention identified was for to staff to anticipate resident's needs and offer a drink and a snack during hourly rounds. A facility incident report, dated 08/12/19, documented the resident slid from the side of her bed onto the floor mat. There were no injuries observed. Interventions listed as a result of this fall included redirection and hourly rounds. The report stated the resident was alert and confused. The report stated she could not always make her needs known, and she forgot to use her call light. An OSDH (Oklahoma State Department of Health) incident report, dated 08/21/19, documented the resident was found on the floor near her bed. She was observed with a knot to the back of her head. The resident was evaluated in an emergency room and then returned to the hospital with no new physician's orders [REDACTED]. A facility incident report, dated 08/21/19, documented the resident was alert and confused and continued to get out of her bed without assistance. The note documented the writer, LPN #3 (licensed practical nurse) had spoken with the resident's POA (power of attorney) about having a sitter come in to assist with one on one care since (Named resident) has no safety awareness. A facility incident report, dated 08/22/19, documented the resident was found on the floor at 2:15 a.m. The resident stated she slipped on the floor. There were no new injuries observed. An intervention identified was to ensure the resident was in the middle of her bed during hourly rounds and keeping residents' belongings at her bedside. A nurse's progress note, dated 08/25/19, documented the resident was found on the floor by two CNA (certified nurse aides). The resident's right hip was observed to be swollen. The family and physician were notified and an x-ray of the resident's hip was ordered. The results of the x-ray were normal. An intervention identified was to ensure the resident's oxygen was on due to observed agitation when her oxygen was off. A facility incident report, dated 08/24/19, documented nursing staff was to make sure oxygen was on during rounding times. A facility incident report, dated 08/28/19, documented the resident was found on the floor at 8:25 p.m. There were no new injuries observed. The resident stated she fell while attempting to get up out of her recliner. Interventions identified were to attempt to keep the resident busy with activities during the day time and up until 11:00 p.m. each night. A facility incident report, dated 09/03/19, documented the resident continued to be confused, forget her surroundings and get up out of her bed, wheelchair and recliner without assistance. The note documented she required one on one observation and LPN #3 had contacted her daughter and POA about the need for a sitter who would provide one on one supervision. The note documented the staff would continue to make hourly rounds, as the resident had no safety awareness. A facility incident report, dated 09/09/19, documented the resident crawled out of bed onto the floor mat at 4:30 a.m. There were no new injuries observed. The report documented the resident stated she was going to make breakfast. Interventions identified were the resident was provided a snack and frequent checks were initiated. The report stated the resident continued to be alert and confused. A facility incident report, dated 09/14/19, documented the resident was observed on the floor. The resident stated she was attempting to transfer herself to the bathroom when she fell . An intervention identified was a discussion was held with the nurse to implement a toileting training program. A facility incident report, dated 09/28/19, documented the resident was found on the floor. There were no injuries from the fall observed during an assessment. The report documented the resident had attempted to reach for a personal item when she fell . Staff were educated to ensure personal items were kept within the resident's reach. A nurse's progress note, dated 10/07/19, documented the resident was found by staff on the floor mat with her pillow under her head. She was assessed and was found to have no new injuries. On 10/16/19, the resident's care plan was reviewed. The resident's care plan did not include the incidents of falls which occurred since 08/02/19. The last time the resident's fall care plan had been updated was 07/25/19. There were no fall interventions added to the resident's care plan following multiple falls since 08/02/19. On 10/17/19 at 8:29 a.m., the DON (director of nurses) was asked what the process was for monitoring a resident after a fall. She stated the resident would be monitored every shift and fall notes would be documented in the interdisciplinary notes. She was asked if she could provide documentation the resident had received monitoring and supervision after her fall on 10/07/19. After reviewing the resident's records she stated she could only find two notes. She was asked if the resident had been monitored. She stated the resident had not been not monitored. At 10:36 a.m., RN #1 (registered nurse) stated after a resident fall the nurse should chart in the interdisciplinary notes every shift for 72 hours and if applicable complete neurological checks. At 1:54 p.m., LPN #1 stated each household should have had an hourly rounding form listing the residents at high risk for falls. She stated these forms were used to document hourly monitoring of residents. She said, We have not been consistent with the forms and stated sometimes there are no hourly monitoring forms. She provided hourly rounding forms for the long term care households. Dated hourly rounding forms could only be found for twelve days from (MONTH) through (MONTH) 2019. The last date of a completed rounding form was 09/23/19. Resident #1's name was not listed on any of the provided rounding forms. At 2:35 p.m., the DON was asked if the facility's monitoring of high risk residents for falls had been effective. She did not answer the question but reviewed the copies of the hourly monitoring forms and stated an LPN had been in the process of auditing the forms for completion and household three and four had not been checked yet for completion. She was asked if residents care plans were updated after falls with the fall incident and new interventions if identified. She stated the nurses and the MDS (minimum data set) office updated the care plans with all fall incidents and identified interventions. She was asked to review the resident's care plan and multiple falls since 08/02/19. She acknowledged the resident's care plan was not updated with falls or interventions to prevent further falls. 2. Resident #8 had [DIAGNOSES REDACTED]. A care plan, dated 02/11/19, documented .I have a history of falls . A facility incident report, dated 05/29/19, documented the resident was alert and oriented and required the assistance of one staff member for stand by assist with activities of daily living. The report documented she had been trying to help another resident with their wheelchair when she fell and struck her head on a door. The report documented she received a laceration on her head and was sent to the local emergency room for evaluation. A facility incident report, dated 07/08/19 at 1:05 a.m., documented the resident was oriented to person, place and time, ambulated with a walker and required the assistance of one staff member with activities of daily living. The report documented she was trying to get a box off her walker to go to the bathroom when she fell . The intervention associated with this fall was to remind the resident to call for assistance. A fall risk assessment, dated 08/10/19, documented the resident was assessed at a high risk for falls. Hourly monitoring forms for the month of (MONTH) 2019 were reviewed. Hourly checks were documented as completed for the following dates: 08/16/19, 08/29/19, 08/30/19, and 08/31/19. There were no hourly checks documented between 1:00 a.m. and 6:00 p.m. on 08/28/19. There was no further documentation of hourly monitoring of the resident for the month of (MONTH) 2019. Hourly monitoring forms for the month of (MONTH) 2019 were reviewed. A form, dated 09/01/19, documented hourly checks were completed from 1:00 a.m. to 6:00 a.m. only. There was no further documentation of hourly monitoring of the resident for the month of (MONTH) 2019. A facility incident report, dated 09/23/19, documented the resident was found on the floor near her bed. The report documented she was transported by ambulance to a local emergency department. A fall assessment, dated 09/27/19, documented the resident was at a high risk for falls with a score of 12. An significant change assessment, dated 09/30/19, documented the resident was cognitively alert in skills for daily decision making. She required extensive assistance of two staff members with transfers. An orthopaedic prescription dated, 10/10/19, documented .Diagnosis .right distal femur fracture around total knee .May wear a brace on the outside of close .Increase from 0-90' range of motion .assess skin under brace daily .continue with non-weightbearing right leg for 4 weeks .Send X-rays for review .X-rays in 4 weeks prior to next office visit . Hourly monitoring forms for the month of (MONTH) 2019 were reviewed. There was no documentation of hourly monitoring of the resident for the month. On 10/17/19 at 11:15 a.m., RN #2 reviewed the resident's care plan and stated resident's care plan had not been updated in the electronic medical records. She stated each fall should have been entered on the care plan and also documented an intervention. She stated the fall documentation for this resident was not according to the facility protocol. At 1:54 p.m., LPN #1 confirmed there was no documentation the resident had been monitored hourly each day since she was identified as a high risk for falls on 08/10/19.

Based on observations, record reviews and interviews, it was determined the facility failed to provide sufficient staff to ensure residents received medications timely for ten (#2, 3, 4, 7, 10, 11, 12, 13, 14 and #15) of ten sampled residents who were reviewed for timely medication administration. The DON (director of nurses) identified 74 residents who resided in the facility who received medications. She identified 41 staff members who administered medications to residents, including eight staff members who administered medications to the long term care units in households three and four. Findings: A facility protocol titled, Medication Administration Times, documented daily medications were to be administered upon arising between the hours of 7:00 a.m. and 11:00 a.m., medications administered two times a day were to be given upon arising and at bedtime, medications given three times a day were to be administered upon arising, after lunch, at bedtime and medications to be administered four times a day were to be given upon arising, after lunch, after dinner and at bedtime. On 10/16/19 observations were made of the medication administration pass for the long term care units in households three and four. It was observed medication administration was being completed later than physician ordered medications were timed. At 9:41 a.m., CMA (certified medication aide) #1 was asked how many more residents he had left to administer morning medications to. He stated he still had 40 to 50 % (percent) of residents left to pass medications to. During medication pass he was observed to also take residents' blood pressure readings, cut up residents' food at the breakfast table, help with residents' transfers and ambulation, and he stepped into the satellite kitchen and cooked an egg for a resident at breakfast. At 10:00 a.m., CMA #1 was asked how many staff were passing medications on household three and four. He stated he was the only staff member passing medications. He stated he was passing medication to 31 residents. He stated sometimes medications were passed late because, there are too many residents. He stated he had asked for his co-workers' help. He stated he was overwhelmed. At 11:10 a.m., CMA #1 was asked how many more residents he had left to administer morning medications to, and he stated about 75% of the medications had been passed. He said, I am going non-stop. Please bear with me. He stated a nurse used to pass medications on household three, but now he did it alone. He said, I am overwhelmed. He was asked to provide a list of the residents that had not yet received their morning medications and he provided a list including residents #2, 3, 4, 7, 10, 11, 12, 13, 14 and #15. At 11:49 a.m., CNA #1 (certified nursing assistant) was asked if there was enough staff to take care of residents' needs, and she stated there was not. She stated nursing staff did everything including meal preparation, serving food and kitchen cleanup. She stated previously the facility frequently had agency (non-facility employees/temporary) help, but since the new administrator came, they did not have facility help. On 10/17/19 at 6:45 a.m., the DON was asked when did they implement the process of one CMA doing medication administration for both households three and four in the long term care unit. She stated beginning in the middle of (MONTH) (2019) one CMA had been assigned to complete the medication pass for both long term care units. She stated the pharmaceutical company completed a feasibility study prior to the change and determined the pass could be completed in two hours. On 10/21/19 at 9:20 a.m., CMA #2 stated it took a long time to pass medications to the residents in the long term care households as the residents were often confused about taking them. She stated the CMA's needed to have time to talk with long term care residents about their concerns during the medication pass. She stated those residents required more time than the CMAs had. She stated it was important to give medications on time so that medications could be effective. At 9:46 a.m., LPN #1 stated she had to come to work early to start blood pressure checks in order to have a timely medication administration pass. At 9:52 a.m., LPN #2 was asked if there was enough staff to pass medications timely, and she said, No. She stated it was nearly 10:00 a.m., and she still had about half of her unit to pass morning medications to. She stated the scheduled CMA had called in to say they would not be coming to work. She stated she had been pulled from her usual duties to pass the medications for the household. She stated she was frequently pulled from charge nurse duties to pass medications. She stated, with over 25 residents on her household, it took four hours to complete a medication pass. She stated, when all of those residents were scheduled to get medications before sleeping at night, it was impossible to administer medications to everyone on time. She stated when residents complained about their late medications, .I tell them, I am sorry, but someone has to be last, and someone will be late. At 10:30 a.m., the DON and administrator were made aware of these concerns.

Based on observations, record reviews and interviews, it was determined the facility failed to ensure nursing staff demonstrated competency in skills for medication administration for three staff members (CMA #1 (certified medication aide), CMA #2 and LPN #1 (licensed practical nurse)) who were observed during medication administration at the facility. The DON (director of nurses) identified 74 residents who resided in the facility and who were administered medications. She identified 41 staff members who administered medications to residents, including eight staff members who administered medications to the long term care units in households three and four. Findings: A facility policy titled, Med-Pass Procedure, documented: .After administering medications, sign off the medications on the MAR (medication administration record) . The employee personnel files were reviewed. The annual skills competency evaluations for CMA's #1 and #2, who had been employed greater than one year, did not address medication administration. The employee file for LPN #1 was reviewed and did not contain any record of competencies or in-services for medication administration. Resident #2 had [DIAGNOSES REDACTED]. She was scheduled to receive the following medications between 7:00 a.m. and 11:00 a.m.; [MEDICATION NAME], a medication for gastro-[MEDICAL CONDITION] reflux disease, Med Pass, a dietary supplement, and ClearLax powder, a medication for constipation. A physician's orders [REDACTED]. On 10/16/19, observations were made of the medication administration pass for the long term care units in households three and four. It was observed medication administration was being completed later than physician ordered medications were timed. From 7:38 a.m. through 11:12 a.m., resident #1 was observed not to receive her morning medications. At 9:45 a.m., LPN #1 (licensed practical nurse), the charge nurse, was asked if the medication pass had been done for household three. She stated she did not think so. At 9:50 a.m., the DON (director of nurses) was asked if the time indicated on the MAR indicated [REDACTED]. At 11:00 a.m., CMA #1 (certified medication aide) was asked for a list of residents who had not been administered their morning medications. He provided a list including residents #2 3, 4, 7, 10, 11, 12, 13, 14 and #15. At 11:12 a.m., a review of resident #2's MAR, dated 10/16/19, documented no times of administration had been entered for [MEDICATION NAME], ClearLax, Med Pass or [MEDICATION NAME]. From the MAR, it appeared these medications and supplements had not been administered. At 1:33 p.m., a review of resident #2's MAR, dated 10/16/19, documented times for medication administration had been entered. The MAR indicated [REDACTED] At 1:40 p.m., CMA #1 was asked when resident #2's medications had been administered. He stated he had administered her medications earlier, but did not have time to document the administration until later. He was asked when he administered the 8:00 a.m. [MEDICATION NAME], and he stated it had been administered when the resident returned to her room after the piano activity sometime after 11:00 (a.m.) He stated he had estimated when he had given the medications. At 2:35 p.m., CMA #1 stated he had a habit of not signing the MAR indicated [REDACTED]. He stated he should sign for medication administration right away. He was asked if medication administration times could be changed in the computer. He said, Yes. He further stated he often changed administration times on the residents' MARs. At 8:41 a.m., the DON was asked if medication administration documentation should be done at the time of administration. She said, Yes. She stated anytime a medication was given late a note should be written and the physician should be called. She stated she thought the MAR indicated [REDACTED]. She stated she did not know times for medication administration could be changed in the computer. She was asked if the physician had been called about the identified medications were administered late or if a note had been written to indicate these medications were given late. She said, No. On 10/17/19 at 6:45 a.m., the DON was asked when the facility started the process of one CMA doing medication administration for both households three and four in the long term care unit. She stated beginning in the middle of (MONTH) 2019 one CMA had been assigned to complete medication pass for both long term care units. She was asked if staff training had taken place when the change had been implemented. She stated in the past few months an in-service had been provided to staff related to medication pass. She was asked to provide documentation of the in-service. She was unable to do so by survey exit. At 9:46 a.m., LPN #1 (licensed practical nurse) demonstrated how medication administration times could be changed in the electronic record. She stated she could change the times for all medications except insulin. On 10/21/19 at 9:20 a.m., CMA #2 stated the PIG (punch, initial, give) method of medication administration was very important to observe so medication errors related to double dosing and missing doses were avoided. She stated it was important to give medications on time so medications could be effective. At 9:30 a.m., the DON was asked what steps were taken to ensure facility staff exhibited and maintained competence with medication pass. She stated nursing staff had an annual competency completed with their yearly evaluation. She was asked if this competency addressed medication administration. She said, No. She stated she saw the need for more competency in that area and was putting together a competency test. She was asked why was it important for staff to sign for a medication when it was given. She stated there were many reasons including medication interactions and some medications needed to be given with food. At 9:52 a.m., LPN #2 was asked when the last in-service was conducted over proper medication pass. She stated the last in-service she remembered about medication pass was when she was hired about three years ago. When asked, she stated if medications were not signed for when administered it could lead to many potential errors including forgetting which medications were given. She stated there was the potential to administer some medications back to back. She stated it would be especially problematic for narcotic administration, .because it would look like no one had initiated them and residents could be given double. At 10:00 a.m., when asked what potential errors might occur by not documenting medication administration immediately, CMA #1 stated a resident could potentially be given a double dose. At 10:30 a.m., the DON and administrator were informed of the issues, and the administrator stated her concerns.

Based on observations, record reviews, and interviews, it was determined the facility failed to assess a resident's risk for falls, identify and implement individualized interventions to prevent falls, and failed to provide supervision by staff members to prevent falls for one (#67) of five sampled residents reviewed for falls. The resident was admitted on [DATE] post [MEDICAL CONDITION] that had required surgery. The resident fell on [DATE] and sustained a fracture adjacent to the hip prosthesis, which required surgical intervention. The DON identified 27 residents who were at high risk for falls. Findings: A facility policy titled, Falls and Fall Risk, documented: .Managing .the staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls .if falling recurs despite initial interventions, staff will implement additional or different intervention, or indicate why the current approach remains relevant .the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling . A facility form titled, Fall Assessment Form, documented: .basic responsibility: licensed nurse, nursing assistant .purpose .to assist in prevention of further falls .policy It is the policy to complete a Fall Assessment Form on admission, quarterly and when a resident has sustained a fall .procedure .1. The designated staff person is responsible to complete the Fall Assessment Form on admission, quarterly and when there is a fall. 2. The assessment is reviewed by the Director of Nursing Services/designee. 3. Care/Service Plan is changed as directed by the Director of Nursing/designee . A facility policy titled, Fall Risk Assessment, documented: .nursing staff in conjunction with the Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls .nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days .assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls .will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition .will identify and address modifiable fall risk factors and interventions . A facility policy titled, Fall Prevention Protocol, documented: .all residents who are assessed as being high risk for falls will be identified and individualized fall precautions will be developed for that resident. Preventative measures shall be taken to decrease the number of falls whenever possible .general guidelines for assessment may include, but are not limited to .a) Residents that are new admissions. b) [MEDICAL CONDITION] drug use. c) Fall history. d) Appropriate clothing and footwear. e) Visual deficits. f) Impaired mobility/functional status. g) Incontinence. h) Changes in environment. i) Cognitive status. j) Mood or behavior indicators. k) Underlying illness or disease process. l) Sensory status m) Orthostatic [MEDICAL CONDITION]. 1. A fall risk assessment will be completed at the following times: a. Upon admission/readmission 2. If the assessment finds the resident at risk, implement appropriate interventions/precautions . Resident #67 was admitted on [DATE] with [DIAGNOSES REDACTED]. A hospital physical therapy note, dated 12/24/18 at 10:56 a.m., documented the resident's right lower extremity (right leg) was impaired, she had poor balance, she required maximum assistance with two staff for standing and transfers and was a high fall risk. An admission referral note, dated 12/27/18, documented, .(Named resident) is a 94 y/o (year old) widowed female who'll be admitting to us today from (Named hospital) .Pt (patient) admitting s/p (status [REDACTED]. from) mechanical fall .Pt is currently max assist . The resident's clinical record did not include a fall risk assessment completed at the time of admission to the facility on [DATE]. A daily skilled nursing assessment, dated 12/27/18, documented, .short term memory loss .long term memory loss .oriented only to current season, family's names and faces. An interdisciplinary progress note, dated 12/27/18, documented, .resident arrived .R. hip [MEDICAL CONDITION] hemiarthroplasty r/t closed fx of R. hip from mechanical fall .forgetfulness noted at times. A baseline care plan dated, 12/27/18 at 2:47 p.m., documented the resident had sustained a fall related injury in the last month, required extensive assistance with mobility including assistance to the toilet, woke three times at night to void and experienced short and long term memory loss. There were no fall interventions identified on the resident's care plan. A physician's admission note, dated 12/28/18, documented the resident had fallen at home and sustained a right [MEDICAL CONDITION] resulting in surgery. The physician's note documented the facility's plan of care would include fall precautions. The record documented the resident had a fall on 12/31/18 at 12:30 a.m. A facility incident report, dated 12/31/18, documented, .heard resident saying help me Jesus, help me God, nurse rushed to residents room and found resident sitting beside her bed saying help me please. Resident could move her extremities. complain of right hip pain. x2 (two) staff made resident comfortable. Pain pill [MEDICATION NAME] 50 mg (milligrams) administered. Called mobile x ray .Pre-incident ambulation status .extensive assistance .Notes .(Named resident) is independent but has both short and long term memory loss. The staff educated her to call for assistance. She could not tell us what she had been doing just that she was trying to assist herself at the time when she fell . After the fall she was assessed and transferred with 2 person assist. She c/o (complained of) so the nurse got her apin (sic, pain) medications and ordered an x ray. She notified family. Because the mobile x ray could not come until 0700 (7:00 a.m.) she called for (Named emergency transport) where they diagnosed a [MEDICAL CONDITION]. The nurse was instructed by the DON to contact the physician . A nurse progress note, dated 12/31/18, documented, .Called mobile x ray. After an hour this nurse called x ray again to check what time for sure x ray tech will be coming. Mobile x ray took facility number and called back after 15 minutes saying that the tech (technician) called in sick and they will send someone to do x ray at 0700 (7:00 a.m.). This nurse notified family members and called the ambulance. (Named emergency transport) in the building at (2:45 a.m.) . A form titled, EMSA (Emergency Medical Services Agency) patient care report, dated 12/31/18, documented the resident was transferred to a hospital for evaluation and treatment. An emergency room admission note, dated 12/31/18 at 3:20 a.m., documented, .The patient had an unwitnessed fall tonight from bed at her nursing home. The patient was found on the ground by nursing home staff. The patient reports since the fall she has had an onset of right upper leg and right hip pain. The patient reports she was trying to get out of bed when she fell .Upon arrival the patient has continued complaints of pain . A hospital radiology report, dated 12/31/18 at 4:10 a.m., documented, .Procedure .xr (x-ray) femur .Reason for study: Injury closed displaced intertrochanteric fracture of right femur, initial encounter .Findings: There is a right hip prosthesis in place. There is an oblique periprosthetic fracture adjacent to the long stem portion of the prosthesis . A hospital history and physical, dated 12/31/18 at 4:39 a.m., documented, .recent right hip replacement presents after a fall. The patient has dementia and is unable to give a history .Per report she was found down by nursing home staff. She had initially broken her hip around 21 (MONTH) and this was repaired on 23 December. She was just discharged to the nursing home on 27 December. She now presents with a right periprosthetic [MEDICAL CONDITION]. She is complaint of right hip pain . A hospital consult note, dated 12/31/18, documented, .complains of hip pain .inciting event: fell while getting out of bed. Current symptoms include worse with weight bearing .Aggravating symptoms: standing . A hospital operative note, dated, 01/01/19, documented the resident required surgical intervention of right hip arthroplasty total joint revision for a fractured periprosthetic. A state reported incident report, dated 01/04/19 at 5:16 p.m., documented, .the staff relate that she is very confused sometimes .may forget to ask for assistance. When she fell she was trying to get up by herself . A state reported incident report, dated 01/04/19 at 7:59 p.m., documented, .corrective measures implemented to prevent recurrence .when she returns we will add a falling star to her door, educate staff to anticipate her needs and if her confusion continues we will ask that a sitter be provided . An email titled admission on HH2 (house hold two) (resident room #), dated 01/07/19 at 5:15 p.m., documented, .family will be staying with her and/or providing companion for at least first 48 hours. On 01/28/19 at 1:01 p.m., the resident was observed asleep in bed with a family member at the bedside. There was not a falling star sign observed on her door or anywhere in the resident's room. The family member stated, the resident had entered the facility to recover from a hip surgery after falling at home and breaking her hip. He stated the facility had required the family stay with the resident continuously and the family had become exhausted. He stated the first night the family had been unable to stay with the resident, the resident fell and re-broke her right hip. He stated the facility did not immediately notify him of the fall because the charge nurse had been calling a wrong number despite his repeated previous attempts to provide the facility with a correct phone number. He stated he was frustrated the facility had not updated their system with his correct phone number. He stated when he arrived at the facility the resident was crying out in pain. He stated when he found out an x-ray for the resident was not scheduled until several hours later he asked for an ambulance to be called to take her to the hospital. He stated after the resident's surgery to repair her broken hip, the facility informed him they would not take the resident back unless the family again provided 24 hour supervision. He stated the facility told him the family would again be required to provide supervision. On 01/30/19 at 9:42 a.m., the resident was observed in her room with a family member at the bedside. The family member stated she arrived at the facility after the resident's fall on 12/31/18, only to find out there would be a delay in transporting the resident to the hospital until 7:00 a.m. She stated this was several hours later and unacceptable. She stated the facility did not offer to call an ambulance but insisted their policy was to use a medride transportation service. She stated the family insisted an ambulance be called. She stated, after the re-pair surgery on the resident's broken hip, the admission nurse/LPN #4, told the family the resident could not return to the facility without the family providing around the clock supervision. At 11:07 a.m., the resident was observed sitting by the fireplace in the main living area in her wheelchair, grasping the right side of her chair and attempting to stand up. No falling star sign was observed on the door of the resident's room or anywhere else in her room. LPN #5 was asked how she identified a resident was at risk for falls. She stated residents at risk for falls would have a star on their door. She was asked if resident #67 had a star on her door. She said, I don't think so. She stated the resident should have a falling star on her door. She stated when the resident first came to the facility she was constantly trying to get up and required constant supervision. She stated the office had spoken with the family about watching the resident. She stated there were no family members at the facility at this time, so she had placed the resident in the main area because the resident had attempted to get up. She was asked if the resident was trying to get up now, and she stated, Yes and directed CNA #2 to help the resident. She stated if a resident fell the physician and family should be notified. On 01/31/19 at 8:35 a.m., the DON was interviewed. She was asked when a fall assessment should be completed on residents. She stated fall assessments should be completed within 24 hours of admission, with every fall and quarterly. She was asked to provide the admission fall risk assessment for resident #67. She stated, It was done on 01/07/19. She was asked if a fall risk assessment should have been completed on the admission date of [DATE]. She stated, Yes. She was asked if the baseline care plan included fall interventions for the resident. She said,No. She was asked if interventions should have been on the care plan. She said,Yes. At 10:37 a.m., the admission nurse/LPN #4, was asked if the facility required families to provide sitters for residents at risk for falls. She stated if the resident was confused, had dementia, had benefited from a sitter previously or while in the hospital, did not have a support system, or the family was hard to contact, the facility would require the family to provide a sitter for at least 48 hours. She stated, if the family could not provide a companion, the family would be provided with a list of referral sitters. She stated, if a resident was too high of a fall risk and the family could not provide a sitter, the facility would decline admission. At 11:25 a.m., RN #2 was asked if the resident was a fall risk. She stated the resident had a lot of physical ability but was confused, and so she was a fall risk. She stated the resident would frequently try to stand up unassisted. She stated this morning the resident stood up unassisted, but the family was there. She stated she noticed when the family stepped out to get coffee the resident would scoot to the end of the bed in a short amount of time. She stated since the resident's readmission, after her surgery and fall on 12/31/18, she had called the family twice to tell them they needed to supervise the resident. She stated the family said they could not be at the facility all of the time. At 12:06 p.m., the resident's physician was asked if she had been notified by the facility when the resident fell on [DATE]. She stated she had not been notified the resident had fallen, but had learned about the fall when she logged into her computer the next morning. She said, I was on call all weekend and was not notified. She was asked, Do you have standing orders for x-rays if someone falls at the facility? She said, No, they have to call me for an order. She was asked if the facility required the family to provide 24 hour supervision for the resident. She said, Yes. She stated, for safety reasons, 24 hour care was part of the requirement for the resident returning to the facility. She was asked if the resident should have been sent to the hospital instead of ordering a mobile X-Ray. She stated she had not given an order for [REDACTED]. At 5:00 p.m., the DON stated the resident needed someone there to watch her at all times because recently when her family member left for a few minutes, staff stated the resident was up out of bed and nearly fell . She stated the use of family members for fall supervision was an ongoing practice the facility used and an acceptable intervention utilized to prevent falls.