Every finding on record at Fairview Fellowship Home For Senior Citizens, Inc

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were used during wound and catheter care for 2 (#18 and #34) of 2 sampled residents reviewed for enhanced barrier precautions practices by staff. The administrator identified six residents required enhanced barrier precautions during the provision of care. Findings: A facility policy titled Enhanced Barrier Precautions Policy and Procedure, last updated on 07/28/25, read in part, Enhanced barrier precautions expand the use of PPE and refer to the use of gowns and gloves during high-contact resident care activities.Examples of high-contact resident care activities requiring gown and glove use include dressing, providing hygiene, changing briefs, device care, urinary catheter care, feeding tube, wound care with any skin opening requiring a treatment order. 1. On 12/04/25 at 8:36 a.m., LPN #1 was observed performing donning gloves to provide wound care on Resident #34's left lower leg. After wound care LPN #1 took off the gloves, washed their hands and donned new gloves to preform incontinent care for Resident #34. Feces were observed to be on Resident #34's buttocks. After performing incontinent care, LPN #1 was observed using the soiled gloves to apply a cream temporarily to open wounds on bilateral buttocks. LPN #1 was observed to not be wearing a gown during wound care and incontinent care. Physician orders, dated November 2025, showed Resident #34 was admitted on [DATE] with diagnoses which included chronic venous hypertension with ulcer on bilateral lower legs, and stage 2 pressure ulcer of right and left buttocks. A care plan for Resident #34, dated 11/13/25, showed they had open wounds and required enhanced barrier precautions. On 12/04/25, immediately following wound care for Resident #34, LPN #1 was asked if they understood EBP and was the procedure done correctly for incontinent care and wound care for Resident #34. They stated everything was done right. 2. Resident #18's physician's order dated 11/26/25, showed they had an indwelling catheter for comfort measures. On 12/04/25 at 9:57 a.m., CNA #1 and CNA #2 was observed donning gloves performing catheter care for Resident #18. The aides did not wear a gown during the provision of care. Immediately following the catheter care, CNA #1 and CNA #2 were asked if they understood enhanced barrier precaution practices and protocol. They stated yes indicating they used correct procedures with enhanced barrier precautions during care. On 12/04/25 at 10:24 a.m., the ADON was asked how the staff were trained on enhanced barrier precautions during wound care and catheter care, The ADON stated, They have been educated often.

Based on observation, record review, and interview, the facility failed to ensure medication orders for a psychotropic medication were correct to prevent unnecessary medication administered after a gradual dose reduction for 1 (#8) of 3 sampled residents reviewed for unnecessary medications. The DON identified 72 residents were administered medications from the facility. Findings:A facility policy titled PCU059-Medication Discrepancies and Adverse Reactions, dated 03/2025, read in part, Medication Discrepancy: An inappropriate or incorrect medication prescribed for, dispensed for, or given to a resident. It is also an omission of an ordered medication due to a prescribing, dispensing, or administering error.On 10/13/25 at 1:36 p.m., Resident #8 was observed ambulating independently in the common area on the memory care unit. Resident #8's admission record, dated 08/30/24, showed they were admitted with diagnoses which included unspecified dementia and generalized anxiety disorder.Resident #8's quarterly MDS assessment, dated 09/11/25, showed their cognition was severely impaired with BIMS score of 04. The assessment showed Resident #8 was prescribed anti-anxiety medication during the look back period. Resident #8's Medication Regimen Review form, dated 09/23/25, showed the pharmacist consultant reviewed Resident #8's medications and requested the physician consider a GDR of the prescribed hydroxyzine 25 mg (anti-anxiety medication) for anxiety TID. The form showed the physician ordered to reduce the hydroxyzine 25 mg to BID on 09/24/25. Resident #8's physician recap order summary read in part, a. Hydroxyzine HCI oral tablet 25 mg (Hydroxyzine HCI) Give 25 mg by mouth three times a day for increase anxiety, agitation, and restlessness related to GENERALIZED ANXIETY DISORDER. Order date -09/02/24, Start date -09/02/24 - end date 09/25/25.b. Hydroxyzine HCI oral tablet 25 mg (Hydroxyzine HCI) Give 25 mg by mouth two times a day for increase anxiety, agitation, and restlessness related to GENERALIZED ANXIETY DISORDER. Order date- 09/25/25, Start date -09/25/25 - end date 09/25/25.c. Hydroxyzine HCI oral tablet 25 mg (Hydroxyzine HCI) Give 25 mg by mouth three times a day for increase anxiety, agitation, and restlessness related to GENERALIZED ANXIETY DISORDER. order date- 09/25/25, Start date -09/26/25 - end date 09/29/25.d. Hydroxyzine HCI oral tablet 25 mg (Hydroxyzine HCI) Give 25 mg by mouth three times a day for increase anxiety, agitation, and restlessness related to GENERALIZED ANXIETY DISORDER. order date- 09/25/25, Start date -09/30/25 - end date 10/08/25.Resident #8's medication administration record, dated 09/2025, showed Resident #8 received hydroxyzine 25 mg TID from 09/26/25 through 09/29/25. The medication administration record showed Resident #8 received 4 additional doses of hydroxyzine not ordered by the treating physician from 09/26/25 through 09/29/25. A facility form titled Employee Counseling Form, dated 10/01/25, showed LPN #1 put an order for hydroxyzine TID. The form read in part, Resident hydroxyzine decreased to BID. ask for clarify from PCP and Dr. Confirmed BID, order written TID. When questioned, said Dr. really meant TID despite Dr. confirming BID to decrease to assess need.Changed treatment and med orders without doctors' orders.On 10/09/25 at 12:05 p.m., the administrator stated LPN #1 put the wrong order in for Resident #8 on 09/25/25 for hydroxyzine 25 mg TID when the physician reduced the dose after a GDR review on 09/24/25 to hydroxyzine 25 mg BID. The administrator stated the order was put in on 09/25/25 for hydroxyzine 25 mg BID after the GDR request by the physician. The administrator stated LPN #1 called the physician and verified the order as BID but LPN #1 put the order in as TID which was not what the physician had ordered. The administrator stated LPN #1 was an agency staff and was not allowed to return to the facility due to the error. On 10/09/25 at 4:10 p.m., RN #1 stated there was an order to reduce Resident #8's hydroxyzine 25 mg TID to BID on 09/24/25. RN #1 stated the DON changed Resident #8's orders to hydroxyzine 25 mg BID on 09/25/25. RN #1 stated on 09/29/25, they checked Resident #8's orders and saw LPN #1 changed Resident #8's orders on 09/25/25 around 7:00 p.m., to hydroxyzine 25 mg TID after the DON had changed the order on 09/25/25 earlier in the day. RN #1 stated they had the medication aide hold the medication and verified with the physician the order for Resident #8's hydroxyzine was not correct and should have been hydroxyzine 25 mg BID. RN #1 stated LPN #1 told them they knew the doctor meant TID and not BID so that was why LPN #1 entered the order as TID. RN #1 stated Resident #8 received 4 additional doses of Hydroxyzine 25 mg from 09/25/25 through 09/29/25 due to LPN #1 putting in the wrong dose order in Resident #8's orders.On 10/13/25 at 3:35 p.m., LPN #1 stated there was a medication review for Resident #8 and the medication aides asked them to change the orders back to TID. LPN #1 stated they changed the order for hydroxyzine 25 mg BID to TID without verifying the order was correct. LPN #1 stated they put the order in as hydroxyzine 25 mg TID when it should have been BID.On 10/14/25 at 1:46 p.m., the DON stated Resident #8's medications were reviewed by the pharmacist on 09/23/25. The DON stated the pharmacist requested a gradual dose reduction of the hydroxyzine 25 mg TID on 09/23/25. The DON stated the primary care physician agreed and requested Resident #8's order for hydroxyzine 25 mg TID to be changed to BID on 09/24/25. The DON stated they entered a new order in Resident #8's chart to reflect hydroxyzine 25 mg BID on 09/25/25. The DON stated on 09/30/25, RN #1 made them aware of the order in Resident #8' health record for hydroxyzine 25 mg TID on 09/30/25. The DON stated LPN #1 changed Resident #8's order for hydroxyzine 25 mg back to TID on 09/25/25 at 7:11 p.m. The DON stated LPN #1 was placed on a do not return from the agency as a result of the medication order error. The DON stated Resident #8 received four extra doses of hydroxyzine 25 mg on 09/26/25 through 09/29/25.

Based on record review and interview, the facility failed to ensure professional accepted standards of quality were met related to a physician's order being entered accurately for 1 (#8) of 3 sampled residents reviewed for unnecessary medications.The DON identified 72 residents were administered medications from the facility. Findings:The facility's policy titled PCU059-Medication Discrepancies and Adverse Reactions, dated 03/2025, read in part, Medication Discrepancy: An inappropriate or incorrect medication prescribed for, dispensed for, or given to a resident. It is also an omission of an ordered medication due to a prescribing, dispensing, or administering error.On 10/13/25 at 1:36 p.m., Resident #8 was observed ambulating independently in the common area on the memory care unit. Resident #8's admission record, dated 08/30/24, showed they were admitted with diagnoses which included unspecified dementia and generalized anxiety disorder.Resident #8's quarterly MDS assessment, dated 09/11/25, showed their cognition was severely impaired with BIMS score of 04. The assessment showed Resident #8 was prescribed anti-anxiety medication during the look back period. Resident #8's medication administration record, dated 09/2025, showed Resident #8 received hydroxyzine 25 mg TID from 09/26/25 through 09/29/25. The medication administration record showed Resident #8 received four additional doses of hydroxyzine not ordered by the treating physician from 09/26/25 through 09/29/25. Resident #8's Medication Regimen Review form, dated 09/23/25, showed the pharmacist consultant reviewed Resident #8's medications and requested the physician consider a GDR of the prescribed hydroxyzine 25 mg (anti-anxiety medication) for anxiety TID. The form showed the physician ordered to reduce the hydroxyzine 25 mg to BID on 09/24/25. Resident #8's physician recap order summary, dated 10/13/25, read in part, a. Hydroxyzine HCI oral tablet 25 mg (Hydroxyzine HCI) Give 25 mg by mouth three times a day for increase anxiety, agitation, and restlessness related to GENERALIZED ANXIETY DISORDER. Order date -09/02/24, Start date -09/02/24 - end date 09/25/25.b. Hydroxyzine HCI oral tablet 25 mg (Hydroxyzine HCI) Give 25 mg by mouth two times a day for increase anxiety, agitation, and restlessness related to GENERALIZED ANXIETY DISORDER. Order date- 09/25/25, Start date -09/25/25 - end date 09/25/25.c. Hydroxyzine HCI oral tablet 25 mg (Hydroxyzine HCI) Give 25 mg by mouth three times a day for increase anxiety, agitation, and restlessness related to GENERALIZED ANXIETY DISORDER. order date- 09/25/25, Start date -09/26/25 - end date 09/29/25.d. Hydroxyzine HCI oral tablet 25 mg (Hydroxyzine HCI) Give 25 mg by mouth three times a day for increase anxiety, agitation, and restlessness related to GENERALIZED ANXIETY DISORDER. order date- 09/25/25, Start date -09/30/25 - end date 10/08/25.A facility form titled Employee Counseling Form, dated 10/01/25, showed LPN #1 put an order for hydroxyzine TID. The form read in part, Resident hydroxyzine decreased to BID. ask for clarify from PCP and Dr. Confirmed BID, order written TID. When questioned, said Dr. really meant TID despite Dr. confirming BID to decrease to assess need.Changed treatment and med orders without doctors' orders.On 10/09/25 at 12:05 p.m., the administrator stated LPN #1 put the wrong order in for Resident #8 on 09/25/25 for hydroxyzine 25 mg TID when the physician reduced the dose after a GDR review on 09/24/25 to hydroxyzine 25 mg BID. The administrator stated the order was put in on 09/25/25 for hydroxyzine 25 mg BID after the GDR request by the physician. The administrator stated LPN #1 called the physician and verified the order as BID but LPN #1 put the order in as TID which was not what the physician had ordered. The administrator stated LPN #1 was an agency staff and was not allowed to return to the facility due to the error. On 10/09/25 at 4:10 p.m., RN #1 stated there was an order to reduce Resident #8's hydroxyzine 25 mg TID to BID on 09/24/25. RN #1 stated the DON changed Resident #8's orders to hydroxyzine 25 mg BID on 09/25/25. RN #1 stated on 09/29/25, they checked Resident #8's orders and saw LPN #1 changed Resident #8's orders on 09/25/25 around 7:00 p.m. to hydroxyzine 25 mg TID after the DON had changed the order on 09/25/25 earlier in the day. RN #1 stated they had the med aide hold the medication and verified with the physician the order for Resident #8's hydroxyzine was not correct and should have been hydroxyzine 25 mg BID. RN #1 stated LPN #1 told them they knew the doctor meant TID and not BID so that was why LPN #1 entered the order as TID. RN #1 stated Resident #8 received 4 additional doses of Hydroxyzine 25 mg from 09/25/25 through 09/29/25 due to LPN #1 putting in the wrong dose order in Resident #8's orders.On 10/13/25 at 3:35 p.m., LPN #1 stated there was a medication review for Resident #8 and the medication aides asked them to change the orders back to TID. LPN #1 stated they changed the order for hydroxyzine 25 mg BID to TID without verifying the order was correct. LPN #1 stated they put the order in as hydroxyzine 25 mg TID when it should have been BID.On 10/14/25 at 1:46 p.m., the DON stated Resident #8's medications were reviewed by the pharmacist on 09/23/25. The DON stated the pharmacist requested a gradual dose reduction of the hydroxyzine 25 mg TID on 09/23/25. The DON stated the primary care physician agreed and requested Resident #8's order for hydroxyzine 25 mg TID to be changed to BID on 09/24/25. The DON stated they entered a new order in Resident #8's chart to reflect hydroxyzine 25 mg BID on 09/25/25. The DON stated on 09/30/25, RN #1 made them aware of the order in Resident #8' health record for hydroxyzine 25 mg TID on 09/30/25. The DON stated LPN #1 changed Resident #8's order for hydroxyzine 25 mg back to TID on 09/25/25 at 7:11 p.m. The DON stated LPN #1 was placed on a do not return from the agency as a result of the medication order error. The DON stated Resident #8 received 4 extra doses of hydroxyzine 25 mg on 09/26/25 through 09/29/25.

Based on observation, record review, and interview, the facility failed to ensure a medication order for an anti-anxiety medication was entered accurately and an anti-anxiety medication was administered following physician orders for 1 (#8) of 3 sampled residents reviewed for medication administration.The DON identified 72 residents received medications from the facility. Findings:On 10/13/25 at 1:36 p.m., Resident #8 was observed ambulating independently in the common area on the memory care unit. Resident #8's admission record, dated 08/30/24, showed they were admitted with diagnoses which included unspecified dementia and generalized anxiety disorder.Resident #8's quarterly MDS assessment, dated 09/11/25, showed their cognition was severely impaired with BIMS score of 04. The assessment showed Resident #8 was prescribed anti-anxiety medication during the look back period. A facility policy titled PCU059-Medication Discrepancies and Adverse Reactions, dated 03/2025, read in part, Medication Discrepancy: An inappropriate or incorrect medication prescribed for, dispensed for, or given to a resident. It is also an omission of an ordered medication due to a prescribing, dispensing, or administering error.Resident #8's medication administration record, dated 09/2025, showed Resident #8 received hydroxyzine 25 mg TID from 09/26/25 through 09/29/25. The medication administration record showed Resident #8 received 4 additional doses of hydroxyzine not ordered by the treating physician from 09/26/25 through 09/29/25. Resident #8's Medication Regimen Review form, dated 09/23/25, showed the pharmacist consultant reviewed Resident #8's medications and requested the physician consider a gradual dose reduction of the prescribed hydroxyzine 25 mg (anti-anxiety medication) for anxiety TID. The form showed the physician ordered to reduce the hydroxyzine 25 mg to BID on 09/24/25. Resident #8's physician recap order summary, dated 10/13/25, read in part, a. Hydroxyzine HCI oral tablet 25 mg (Hydroxyzine HCI) Give 25 mg by mouth three times a day for increase anxiety, agitation, and restlessness related to GENERALIZED ANXIETY DISORDER. Order date -09/02/24, Start date -09/02/24 - end date 09/25/25.b. Hydroxyzine HCI oral tablet 25 mg (Hydroxyzine HCI) Give 25 mg by mouth two times a day for increase anxiety, agitation, and restlessness related to GENERALIZED ANXIETY DISORDER. Order date- 09/25/25, Start date -09/25/25 - end date 09/25/25.; .c. Hydroxyzine HCI oral tablet 25 mg (Hydroxyzine HCI) Give 25 mg by mouth three times a day for increase anxiety, agitation, and restlessness related to GENERALIZED ANXIETY DISORDER. order date- 09/25/25, Start date -09/26/25 - end date 09/29/25.d. Hydroxyzine HCI oral tablet 25 mg (Hydroxyzine HCI) Give 25 mg by mouth three times a day for increase anxiety, agitation, and restlessness related to GENERALIZED ANXIETY DISORDER. order date- 09/25/25, Start date -09/30/25 - end date 10/08/25.The facility's form titled Employee Counseling Form, dated 10/01/25, showed LPN #1 put an order for hydroxyzine TID. The form read in part, Resident hydroxyzine decreased to BID. ask for clarify from PCP and Dr. Confirmed BID, order written TID. When questioned, said Dr. really meant TID despite Dr. confirming BID to decrease to assess need.Changed treatment and med orders without doctors' orders.On 10/09/25 at 12:05 p.m., the administrator stated LPN #1 put the wrong order in for Resident #8 on 09/25/25 for hydroxyzine 25 mg TID when the physician reduced the dose after a GDR review on 09/24/25 to hydroxyzine 25 mg BID. The administrator stated the order was put in on 09/25/25 for hydroxyzine 25 mg BID after the GDR request by the physician. The administrator stated LPN #1 called the physician and verified the order as BID but LPN #1 put the order in as TID which was not what the physician had ordered. The administrator stated LPN #1 was an agency staff and was not allowed to return to the facility due to the error. On 10/09/25 at 4:10 p.m., RN #1 stated there was an order to reduce Resident #8's hydroxyzine 25 mg TID to BID on 09/24/25. RN #1 stated the DON changed Resident #8's orders to hydroxyzine 25 mg BID on 09/25/25. RN #1 stated on 09/29/25, they checked Resident #8's orders and saw LPN #1 changed Resident #8's orders on 09/25/25 around 7:00 p.m., to hydroxyzine 25 mg TID after the DON had changed the order on 09/25/25 earlier in the day. RN #1 stated they had the medication aide hold the medication and verified with the physician the order for Resident #8's hydroxyzine was not correct and should have been hydroxyzine 25 mg BID. RN #1 stated LPN #1 told them they knew the doctor meant TID and not BID so that was why LPN #1 entered the order as TID. RN #1 stated Resident #8 received 4 additional doses of Hydroxyzine 25 mg from 09/25/25 through 09/29/25 due to LPN #1 putting in the wrong dose order in Resident #8's orders.On 10/13/25 at 3:35 p.m., LPN #1 stated there was a medication review for Resident #8 and the medication aides asked them to change the orders back to TID. LPN #1 stated they changed the order for hydroxyzine 25 mg BID to TID without verifying the order was correct. LPN #1 stated they put the order in as hydroxyzine 25 mg TID when it should have been BID.On 10/14/25 at 1:46 p.m., the DON stated Resident #8's medications were reviewed by the pharmacist on 09/23/25. The DON stated the pharmacist requested a gradual dose reduction of the hydroxyzine 25 mg TID on 09/23/25. The DON stated the primary care physician agreed and requested Resident #8's order for hydroxyzine 25 mg TID to be changed to BID on 09/24/25. The DON stated they entered a new order in Resident #8's chart to reflect hydroxyzine 25 mg BID on 09/25/25. The DON stated on 09/30/25, RN #1 made them aware of the order in Resident #8' health record for hydroxyzine 25 mg TID on 09/30/25. The DON stated LPN #1 changed Resident #8's order for hydroxyzine 25 mg back to TID on 09/25/25 at 7:11 p.m. The DON stated LPN #1 was placed on a do not return from the agency as a result of the medication order error. The DON stated Resident #8 received 4 extra doses of hydroxyzine 25 mg on 09/26/25 through 09/29/25.

On 05/22/25 at 1:40 p.m., the Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy (IJ) situation related to the facility's failure to provide adequate supervision to prevent elopement from the facility. 1. Resident #1's admission record, dated 11/01/24, showed the resident was admitted with diagnoses which included unspecified dementia and displaced intertrochanteric fracture of the left femur. A Wander risk assessment, dated 11/01/24, showed Resident #1 was a low risk for elopement with a score of 4. A care plan, last revised 05/08/25, showed the resident was exit seeking on the following dates; a. 03/19/25; b. 04/11/25; c. 04/15/25; d. 04/07/25; e. 04/08/25; and f. 05/03/25. The care plan, revised 05/08/25, showed Resident #1 was moved to the memory care unit on 05/08/25. There were no additional documented interventions to address the wandering and exit seeking other than redirection. Resident #1's progress notes showed exit seeking behaviors and attempts to redirect on the following dates: a. On 03/11/25, resident and spouse were exit seeking; b. on 03/19/25, resident and spouse found on hall 2 trying to exit. Redirection was unsuccessful; c. on 03/21/25, resident stated they were leaving and the staff tried to reorient the resident; d. on 04/07/25, resident and spouse successfully exited through the front doors and was brought back in. Redirection was ineffective and the resident continued to exit seek; e. on 04/22/25, resident wandering and concerned about their house; f. on 04/27/25, resident tried to leave through the door, intervention of taking resident for walk was ineffective; g. on 04/28/25, resident was exit seeking with spouse to find their children; h. on 05/02/25, resident stated they were leaving and packed personal items, resident was redirected; i. on 05/03/25 at 1:51 p.m., resident was exit seeking. The resident was redirected but immediately began to exit seek. The resident shook all the doors and stated they were going to kick the doors down; and j. on 05/03/25 at 3:56 p.m., the resident was found on the ground outside the laundry room and in front of the trash cans behind the building. They had an abrasion to their right eyebrow with bleeding noted. On 05/22/25 at 1:50 p.m., the administrator and DON were notified of the immediate jeopardy (IJ) situation and provided the IJ template. On 05/23/25 at 11:23 a.m., an amended plan of removal was accepted by the Oklahoma State Department of Health. The plan of removal read in part, 1:1 supervision; assign 1:1 staffing to the resident 24/7 until further evaluation is complete .Secure the environment; move the resident to a locked or secure unit if available and appropriate .Door alarms and monitoring; ensure all doors are alarmed and functional, check surveillance system .Place a WanderGuard on resident .All residents will have a wandering risk evaluation completed by 5/23/25 . .Wandering risk will be done on new admission, re-admission, significant change, quarterly, and annually. .Reassess wandering risk evaluations; conduct a full interdisciplinary team to review including: .Care plan update; modify the residents care plan immediately to reflect: Elopement interventions Environmental changes Staffing changes. .Emergency In-service training on 5/22/25: Provide all staff with immediate re-education on: .Elopement protocols .Door alarm response procedures .Missing resident protocols .Immediate jeopardy awareness and CMS requirements .Document training: record date/time, attendance, trainer and materials used .Door alarms (functioning logs) .The Elopement Book will be implemented using current resident picture, face sheet, and working interventions. .Signage will be placed on the front and back of any door that has a regress to outside. On 05/23/25, the facility staff were interviewed in person and by phone regarding in-services completed on elopement. Staff interviewed were able to communicate elopement prevention strategies, identify residents at risk for elopement, and elopement response policies and procedures. All residents' electronic health records were reviewed and verified they had current wandering risk assessments. Twenty-six residents were assessed as a wondering risk. Their care plans were reviewed and verified to have elopement interventions. All exterior egress doors with locks were observed and verified to be in working order. Signage on doors were verified in place. Staff were observed ensuring all doors with locks latch when going through them. An elopement book containing a comprehensive list of all residents at risk for wandering was observed at all nurse stations. The elopement book contained a list of all residents at risk for wandering, a picture of each resident at risk, and care plan interventions to protect at risk residents. On 05/23/25, after interviews with staff, review of resident elopement wander risk assessments and care plans, posted signage, and in-services, the administrator was notified the immediacy was lifted effective 05/23/25 at 1:00 p.m. The deficient practice remained at a pattern for more than minimal harm. Based on record review and interview, the facility failed to: a. provide adequate supervision to prevent elopement for 1 (#1) of 3 sampled residents reviewed for elopement; and b. failed to ensure residents were assessed for wandering for 2 (#1 and #6) of 3 sampled residents reviewed for wandering assessments. The DON identified 26 residents were at risk for elopement. Findings: The facility's policy titled Resident Safety- Wandering/Elopement, revised 10/2023, read in part, The director of nursing will evaluate each resident upon admission in every three months thereafter for need of the wonder dash guard system. The evaluation will utilize information input from the family or legal guardian of the resident, the resident physician, and when possible, the resident. Additionally, residents will be evaluated for the Wander-Guard System when they: Seem confused or disoriented Pack belongings Have a history of wondering Verbalize a desire to leave Attempt to leave the facility Residents who are mobile enough to wonder and exhibit one or more of the above behaviors will be recommended for wonder guard. 1. Resident #1's admission record, dated 11/01/24, showed the resident was admitted with diagnoses which included unspecified dementia and displaced intertrochanteric fracture of the left femur. Resident #1's significant change assessment, dated 02/13/25, showed they had severe cognitive impairment for decision making with a BIMS score of 7. The assessment showed Resident #1 used a wheelchair to ambulate and had no wandering behaviors. Resident #1's assessment titled Wandering Risk Survey, dated 11/01/24, showed they were a low risk for wandering with a score of 4. Resident #1's nurses notes showed exit seeking behaviors and redirection attempts on the following dates; a. on 03/11/25, the resident was exit seeking with their spouse (Resident #6) on hall 2 looking for their house keys; b. on 03/19/25, Resident #1 and Resident #6 were found on hall 2 at the exit. The residents were redirected and Resident #1 had increased confusion; c. on 03/21/25, Resident #1 stated they were leaving in the morning. They tried to reorient the resident, but the resident continued to say their truck was being pulled up by hall 2 door; d. on 04/07/25, Resident #1 and Resident #6 were exit seeking and successfully exited through the North doors. They were brought back in and continued to push on the doors looking for a way out. They tried redirection and it was ineffective; e. on 04/07/25, hourly location checks were initiated; f. on 04/08/25, Resident #1 remained on hourly location checks; g. on 04/22/25, Resident #1 had increased confusion and continued to wander the facility looking for their children and belongings. The resident was unable to be redirected. h. on 05/02/25, Resident #1 walked without their wheelchair stating they were leaving and had packed their personal items. The resident was redirected multiple times. i. on 05/03/25 at 1:51 p.m., Resident #1 was going up and down the halls shaking the doors and stating they were going to kick the doors down. The resident was redirected multiple times by staff. j. on 05/03/25 at 3:36 p.m., Resident #1 was found outside the laundry room and in front of the trash cans. The resident had an abrasion to their right eye with bleeding noted. The resident was taken to the emergency room. A facility form titled 1 hour Location check, dated 04/07/25, showed they placed Resident #1 and Resident #6 on one hour location checks from 04/07/25 at 6:00 p.m., through 04/09/25 at 4:00 p.m. The one hour location checks were not documented in the care plan. An Oklahoma State department of Health incident report, Form 283, dated 05/03/25, read in part, Nurse called at [2:00 p.m.] by CMA going to lunch that resident had fallen, upon arrival resident was found on the ground outside of the laundry door. [They] were assessed, and an abrasion is noted to rt(right) eyebrow with bleeding noted. taken to [name of hospital withheld] ER (emergency room. [They] have been exit seeking this shift and remains a high risk for falls. Resident #1's emergency room hospital record titled After Visit Summary, dated 05/03/24 showed they were treated at the emergency room and had a diagnosis of laceration of the right eyebrow due to a small right front scalp hematoma with intact skull. Resident #1's care plan for wandering, dated 03/11/25, read in part, I am redirected by staff frequently. Date initiated 05/03/25.Wander guard placed on right ankle, however when we checked on 05/05/25, it was found in resident's closet. Will attempt to place on wheelchair when [they] arrive back from hospital. Date initiated 05/03/25. Resident #1's care plan did not have any interventions to prevent elopement prior to 05/03/25. 2. Resident #6 's admission record, dated 11/01/24, showed they were admitted with diagnoses which included Alzheimer's disease and type 2 diabetes. Resident #6's quarterly assessment, dated 02/13/25, showed their cognition was severely impaired with a BIMS score of 3. The assessment showed they did not wander. Resident #6's assessment titled Wandering Risk Survey, dated 11/01/24, showed they were a moderate risk for wandering with a score of 10. There was no documentation Resident #6 was reassessed for wandering after 11/01/24. Resident #6's nurses notes showed exit seeking behaviors and wandering on the following dates; a. on 03/06/25; b. on 04/06/25; c. on 04/07/25; d. on 04/28/25; e. on 05/02/25; f. on 05/03/25; and g. on 05/04/25. Resident #6's care plan for wandering, revised 05/08/25, read in part, focus- I reside in the secure care unit due to being an elopement risk/wanderer. Date initiated 05/08/25.Interventions - Provide structured activities: toileting, walking inside and outside, reorientation strategies. Date Initiated: 05/22/2025.Wandering risk assessment per policy. Date Initiated: 05/22/2025. The care plan did not have a focus for elopement prevention in Resident #6's care plan prior to 05/08/25. On 05/21/25 at 1:10 p.m., CMA #1 stated Resident #1 and Resident #6 has been trying to leave the facility. CMA #1 stated they were redirected continuously but it was not effective. CMA #1 stated Resident #1 eloped from the facility and fell outside resulting in a cut to their right eye. The CMA stated they did not know how to identify residents at risk for wandering or elopement. On 05/21/25 at 1:36 p.m., CMA #2 stated Resident #1 and Resident #6 had been trying to elope from the facility since admission date of 11/01/24. CMA #2 stated the residents were placed on hourly checks for a while, but a nurse (name unknown) said the resident was fine and they did not have to do them anymore. The CMA stated redirection and hourly checks for a couple days were the only interventions they had in the care plan to prevent elopement for Resident #1 and Resident #6. CMA #2 stated Resident #1 eloped from the facility out a backdoor through the laundry room door and fell off a 12-inch-high concrete patio in their wheelchair and was found on the ground with a cut on their head. On 05/21/25 at 1:55 p.m., CMA #3 stated Resident #1 was trying to get out and ask to leave frequently. They stated Resident #1 and Resident #6 started exit seeking started a few months after admission on [DATE]. CMA #3 was asked what interventions were used to prevent Resident #1 and Resident #6 from eloping. CMA #3 stated, they did one hour location checks for a couple days but those were stopped. On 05/21/25 at 2:06 p.m., LPN #1 stated Resident #1 and Resident #6 started exit seeking, trying the doors, and looking for personal items. LPN #1 stated the residents would be redirected, would become more forceful, and then reattempted to exit the facility. LPN #1 stated there was not a new intervention added to the care plan until 05/03/25 when Resident #1 received a new order for a wander guard. LPN #1 was asked what other interventions were in place to prevent elopement. They stated Resident #1 and Resident #6 were placed on one hour location checks on 04/07/25 through 04/09/25. LPN #1 stated they were unsure why they were doing the checks and they would redirect the residents. LPN #1 stated there were no interventions in Resident #6's care plan to prevent elopement before 05/08/25 when the residents were moved to memory care. On 05/21/25 at 3:00 p.m., the DON stated Resident #1 and Resident #6 had been seeking exit for a couple months. The DON was asked what interventions were in place to prevent elopement. The DON stated they had redirection only and did not add any interventions to the care plan to prevent elopement prior to 05/03/25 for Resident #1 and never had elopement interventions for Resident #6. The DON stated they moved Resident #6 and Resident #1 to the memory care on 05/08/25 and updated the care plans. The DON stated Resident #1 eloped from the facility through a laundry room door that was supposed to be locked and fell from their wheelchair outside the facility resulting in a cut over their right eye. The DON stated Resident #1 and Resident #6 were not reassessed for wandering risk after 11/01/24 upon admission. The DON was asked if their system failure. The DON stated they did not care plan interventions to prevent the elopement after the facility identified exit seeking behaviors, they did not reassess the residents for wandering per their policy for the use of wander guard, and the staff could not identify residents at risk for elopement. The DON stated residents who elope could be seriously harmed or result in death. On 05/22/25 at 12:23 p.m., the administrator was asked about the incident involving Resident #1 on 05/03/25. The administrator stated Resident #1 was able to open a door in the laundry room that was supposed to be locked and exit out the back door where they fell off a 12-inch-high concrete patio in their wheelchair resulting in a cut over their right eye. The administrator was asked to identify the system failure involving the elopement on 05/03/25. They stated, We knew [they] were exit seeking and we did not assess, monitor and intervene timely. The family meeting we set up was too little too late, we failed to ensure the door was secured. On 05/22/25 at 1:00 p.m., maintenance #1 stated they were asked to evaluate the laundry room doors had a lock with a keypad. They stated they could not figure out how the resident got the door open to the laundry room.

Based on record review and interview, the facility failed to ensure careplan's were reviewed or revised for 2 (#1 and #6) of 3 sampled residents reviewed for care plan revisions. The DON identified 75 residents resided in the facility. Findings: The facility's policy titled Resident Safety- Wandering/Elopement, revised 10/2023, read in part, The director of nursing will evaluate each resident upon admission and every three months thereafter for need of the wonder dash guard system. The evaluation will utilize information input from the family or legal guardian of the resident, the resident physician, and when possible, the resident. Additionally, residents will be evaluated for the wonder guard system when they: Seem confused or disoriented Pack belongings Have a history of wondering Verbalize a desire to leave Attempt to leave the facility Residents who are mobile enough to wonder and exhibit one or more of the above behaviors will be recommended for wonder guard. The facility's policy titled MDS (minimum data set) and Care Plan Process, reviewed 02/18/25, read in part, Care plan schedule and requirements: A complete care review will identify any changes in care, or any goals met. It will identify any changes needed to help each resident obtain their goals. It is designed to help each staff member provide the assistance and care for each resident on an individual basis.The careplan will be reviewed and updated quarterly .each care plan is to be accurate in identifying individualized approaches from each discipline to assist in providing care to each resident. 1. Resident #1's admission record, dated 11/01/24, showed the resident was admitted with diagnoses which included unspecified dementia and displaced intertrochanteric fracture of the left femur. Resident #1's significant change assessment, dated 02/13/25, showed they had severe cognitive impairment for decision making with a BIMS score of 7. The assessment showed the resident used a wheelchair to ambulate and had no wandering behaviors. Resident #1's assessment titled Wandering Risk Survey, dated 11/01/24, showed they were a low risk for wandering with a score of 4. Resident #1's nurses notes showed exit seeking behaviors and redirection attempts on the following dates; a. On 03/11/25, the resident was exit seeking with their spouse (Resident #6) on hall 2 looking for their house keys; b. on 03/19/25, Resident #1 and Resident #6 were found on hall 2 at the exit. The residents were redirected and Resident #1 had increased confusion; c. on 03/21/25, Resident #1 stated they were leaving in the morning. They tried to reorient the resident, but the resident continued to say their truck was being pulled up by hall 2 door; d. on 04/07/25, Resident #1 and Resident #6 were exit seeking and successfully exited through the North doors. They were brought back in and continued to push on the doors looking for a way out. They tried redirection and it was ineffective; e. on 04/07/25, hourly location checks were initiated; f. on 04/08/25, Resident #1 remained on hourly location checks; g. on 04/22/25, Resident #1 had increased confusion and continued to wander the facility looking for their children and belongings. The resident was unable to be redirected. h. on 05/02/25, Resident #1 was walking without their wheelchair stating they were leaving and had packed their personal items. The resident was redirected multiple times. i. on 05/03/25 at 1:51 p.m., Resident #1 was going up and down the halls shaking the doors and stating they were going to kick the doors down. The resident was redirected multiple times by staff. j. on 05/03/25 at 3:36 p.m., Resident #1 was found outside the laundry room, behind the building where employees enter, and in front of the trash cans laying on the ground. The resident had an abrasion to their right eye with bleeding noted. The resident was taken to the emergency room. A facility form titled 1 hour Location check, dated 04/07/25, showed they placed Resident #1 and Resident #6 on one hour location checks from 04/07/25 at 6:00 p.m., through 04/09/25 at 4:00 p.m. The one hour location checks were not documented in the care plan. An Oklahoma State Department of Health incident report form 283, dated 05/03/25, read in part, Nurse called at [2:00 p.m.] by CMA going to lunch that resident had fallen, upon arrival resident was found on the ground outside of the laundry door. [They] were assessed, and an abrasion is noted to rt(right) eyebrow with bleeding noted. taken to [name of hospital withheld] ER (emergency room).[They] have been exit seeking this shift and remains a high risk for falls. Resident #1's emergency room hospital record titled After Visit Summary, dated 05/03/24, showed they were treated at the emergency room and had a diagnosis of laceration of the right eyebrow due to a small right front scalp hematoma with intact skull. Resident #1's care plan for wandering, dated 03/11/25, read in part, I am redirected by staff frequently. Date initiated 05/03/25.Wander guard placed on right ankle, however when we checked on 05/05/25, it was found in resident's closet. Will attempt to place on wheelchair when [they] arrive back from hospital. Date initiated 05/03/25. Resident #1's care plan did not have any interventions to prevent elopement prior to 05/03/25. 2. Resident #6 's admission record, dated 11/01/24, showed they were admitted with diagnoses which included Alzheimer's disease and type 2 diabetes. Resident #6's quarterly assessment, dated 02/13/25, showed their cognition was severely impaired and with a BIMS score of 3. The assessment showed they did not wander. Resident #6's assessment titled Wandering Risk Survey, dated 11/01/24, showed they were a moderate risk for wandering with a score of 10. Resident #6's nurses notes showed exit seeking behaviors and wandering on the following dates; a. on 03/06/25; b. on 04/06/25; c. on 04/07/25; d. on 04/28/25; e. on 05/02/25; f. on 05/03/25; and g. on 05/04/25. Resident #6 was not assessed for wandering or elopement after the above exit seeking dates. Resident #6's care plan, revised 05/08/25, read in part, focus- I reside in the secure care unit due to being an elopement risk/wanderer. Date initiated 05/08/25.Interventions - Provide structured activities: toileting, walking inside and outside, reorientation strategies. Date Initiated: 05/22/2025.Wandering risk assessment per policy. Date Initiated: 05/22/2025. The care plan did not have a focus for elopement prevention in Resident #6's care plan prior to 05/08/25. On 05/21/25 at 1:10 p.m., CMA #1 stated Resident #1 and Resident #6 had been trying to leave the facility. CMA #1 stated they were redirected continuously. CMA #1 stated Resident #1 eloped from the facility and fell outside resulting in a cut to their right eye. On 05/21/25 at 1:36 p.m., CMA #2 stated Resident #1 and Resident #6 had been trying to elope from the facility since admission date of 11/01/24. CMA #2 stated the residents were placed on hourly checks for a while, but a nurse stated the resident was fine and they did not have to do them anymore. The CMA stated redirection and hourly checks for a couple days were the only interventions they had in the care plan to prevent elopement for Resident #1 and Resident #6. CMA #2 stated Resident #1 eloped from the facility out a backdoor through the laundry room door and fell off a 12-inch-high concrete patio in their wheelchair and was found on the ground with a cut on their head. On 05/21/25 at 1:55 p.m., CMA #3 stated Resident #1 was trying to get out and asked to leave frequently. CMA #3 stated Resident #1 and Resident #6 started exit seeking a few months after admission on [DATE]. CMA #3 was asked what interventions were used to prevent Resident #1 and Resident #6 from eloping. CMA #3 stated, they did one hour location checks for a couple days but those were stopped. On 05/21/25 at 2:06 p.m., LPN #1 stated Resident #1 and Resident #6 started exit seeking, trying the doors, and looking for personal items. LPN #1 stated Resident #1 and Resident #6 would be redirected, would become more forceful, and then reattempted exiting the facility. LPN #1 stated there was not a new intervention added to the care plan until 05/03/25 when Resident #1 received a new order for a wander guard. LPN #1 was asked what other interventions were in place to prevent elopement. They stated Resident #1 and Resident #6 were placed on 1 hour location checks on 04/07/25 through 04/09/25. LPN #1 stated they were unsure why they were doing the checks and they would redirect the residents. LPN #1 stated there were no interventions in Resident #6's care plan to prevent elopement before 05/08/25 when the residents were moved to memory care. On 05/21/25 at 3:00 p.m., the DON stated Resident #1 and Resident #6 had been seeking exit for a couple months. The DON was asked what interventions were in place to prevent elopement. The DON stated they had redirection only and did not add any interventions to the care plan to prevent elopement prior to 05/03/25 for Resident #1 and never had elopement interventions for Resident #6. The DON stated they moved Resident #6 and Resident #1 to memory care on 05/08/25 and updated the care plans. The DON stated Resident #1 eloped from the facility through a laundry room door that was supposed to be locked and fell from their wheelchair outside the facility resulting in a cut over their right eye. The DON was asked if there was a system failure. The DON stated Resident #1 and Resident #6 were not reassessed for wandering risk after 11/01/24 upon admission. The DON stated they did not care plan interventions to prevent the elopement after the facility identified exit seeking behaviors. The DON stated, they did not reassess Resident #1 and Resident #6 for wandering per their policy for the use of wander guard and the staff could not identify which residents were at risk for elopement. The DON stated residents who elope could be seriously harmed or result in death. On 05/22/25 at 12:23 p.m., the administrator was asked about the incident involving Resident #1 on 05/03/25. The administrator stated Resident #1 was able to open a door in the laundry room that was supposed to be locked and exit out the back door where they fell off a 12-inch-high concrete patio in their wheelchair resulting in a cut over their right eye. The administrator was asked to identify the system failure involving the elopement on 05/03/25. They stated, We knew [they] were exit seeking and we did not assess, monitor and intervene timely. The family meeting we set up was too little too late, we failed to ensure the door was secured.

Based on observation, record review, and interview, the facility failed to ensure residents dependent for meal assistance were treated with dignity during the noon meal for five (#11, 12, 16, 36, 50, 57, and #58) of 13 dependent residents observed during meal assist The MDS coordinator stated 13 residents required assistance with meal intake Findings: 1. Resident #11 had a diagnosis of seizures. A Care Plan, dated 11/27/23, documented Resident #11 had a potential impaired nutritional status and required assistance with meals at times. A Quarterly Assessment, dated 02/29/24, documented Resident #11 was cognitively intact for decision making and independent with eating. 2. Resident #12 had a diagnosis of dementia. A Care Plan, dated 07/20/23, documented Resident #12 had a potential for impaired nutritional status and required assistance with meals at times. A Quarterly Assessment, dated 04/18/24, documented Resident #12 had severe cognitive impairment and required partial to moderate assistance with eating. 3. Resident #36 had a diagnosis of dementia. A Care Plan, dated 11/30/20, documented Resident #36 had a potential impaired nutritional status, could feed themselves if set up assistance was provided. A Significant Change of Status Assessment, dated 03/28/24, documented Resident #36 had severe cognitive impairment, and required substantial to maximum assistance with eating. 4. Resident #57 had diagnoses to include other symptoms and signs involving cognitive function and awareness. A Care Plan, dated 09/28/23, documented Resident #57 had a potential for impaired nutritional status, and an ADL self care performance deficit. The care plan documented Resident #57 was able to feed themselves. A Significant Change of Status Assessment, dated 03/07/24, documented Resident #57 had moderate cognitive impairment, and was independent in eating. 5. Resident #58 had a diagnosis of Parkinson's Disease. A Care Plan, dated 10/05/23, doucmented Resident #38 had a potential for impaired nutritional status and staff were to assist with eating as needed. A Significant Change of Condition Assessment, dated 04/11/24, documented Resident #38 had moderate cognitive impairment, and required substantial to maximum assistance with eating. On 05/20/24 at 11:19 a.m., CNA #4 enter the secure unit from an outside hall door. As they walked past residents, seated at the dining tables, CNA #4 stopped and provided a bite of food to #36, while standing next to the resident. On 05/20/24 at 11:21 a.m., the following were observed: a. CNA #4 donned gloves , returned to Resident #36, and while standing next to the resident, provided assistance with eating. b. CNA #4 walked way from Resident #36, to assist Resident #58. c. CNA #5 assisted Resident #57 to be seated at a table, and stood next to the resident while they provided assistance with eating. d. CNA #5 then walked away from Resident #35 to a separate table, and stood while they provided eating assistance with Resident #11. e. CNA #5 walked away from Resident #11 and provided eating assistance for Resident #36, and remained standing to turn as provide eating assistance to Resident #58. f. While still standing, CNA #5 returned to assist Resident #36, to wipe food from inside and around the resident's mouth. On 05/20/24 at 11:27 a.m., CNA #5 stood next to Resident #11 while the CNA provided eating assistance. When CNA #5 walked away from Resident #11, CMA #3 stood next to Resident #11 and provided eating assistance. The staff continued to walk from table to table and stand next to dependent residents to provide eating assistance throughout the meal. On 05/20/24 at 12:36 p.m., CNA #5 was asked what the facility policy was in regards to providing eating assistance for dependent residents. They stated, staff are not to walk away from the resident they are assisting. CNA #5 was asked what the policy stated regarding staff standing next to the resident while assisting with eating. They stated it is ok to sit or stand just not to move away from the resident. CNA #5 was asked if standing over a resident that is eating could be a dignity issue. They stated, Yes, but I did not think about that. 36191 6. Resident #16 had diagnoses which included Alzheimer's Disease. A Nutrition care plan, dated 08/29/19, documented Resident #16 had altered nutrition related to cognitive impairment and the need for mechanically altered diet. The care plan intervention, dated 06/21/21, documented Resident #16 ate their meals in the main dining room with staff assistance. Resident #16's significant change assessment, dated 03/07/24, documented they had severe cognitive impairment and required substantial/maximal assistance with eating. 7. Resident #50 had diagnoses which included cerebral infarction (stroke) with aphasia (Damage to specific brain regions causing impaired language.) and dementia. A nutrition care plan, dated 08/17/23, documented Resident #50 was at risk for altered nutritional status due to physical condition after a stroke. The care plan intervention, dated 03/14/24, documented Resident #50 ate their meals in the main dining room with staff assistance. Resident #50's quarterly assessment, dated 02/22/24, documented they had severe cognitive impairment and required substantial/maximal assistance with eating. On 05/20/24 at 12:00 p.m., CNA #3 was observed standing while they assisted Resident #16 and #50 with eating. On 05/20/24 at 12:02 p.m., CNA #3 remained standing with their back to Resident #50, and talking to another staff while they assisted Resident #16 with eating and turning back and forth to Resident #16 and Resident #50 while assisting them with eating. On 05/20/24 at 12:06 p.m., CNA #3 went to other side of the table to assist another resident out of the dining room. Resident #50 remained at the dining room table with food in front of them. There was no staff assisting the resident to eat. On 05/20/24 from 12:09 p.m. through 12:16 p.m., Resident #50 was sitting at the table not feeding themselves and there was no staff assisting the resident with eating. On 05/20/24 at 12:17 p.m., CNA #3 came back to the table to feed Resident #50. The resident ate the food offered by the CNA. CNA #3 remained standing while they assisted the resident with their meal. On 05/20/24 at 12:28 p.m., CNA #3 stated Resident #50 would feed themselves every once in a while. CNA #3 stated they knew they were not supposed to stand over the residents while they fed them. CNA #3 was asked why they left Resident #50 with food in front of them and went to care for another resident. They stated they had to assist the other resident back to their hall or they would try to get up on their own and fall.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours a day, seven days a week. Census: 65 The PBJ Staffing Data Report, for 10/01/23 thru 12/31/23, documented the facility did not identify RN hours for 10/1/23, 12/22/23, 12/25/23, and 12/30/23 On 05/21/24 at 9:15 a.m., requested HR to provide documentation an RN had worked eight consecutive hours, in the building on 10/1/23, 12/22/23, 12/25/23, and 12/30/23. On 05/21/24 at 1:40 p.m., HR reported the facility did not have RN coverage in the building on 10/01/23.

Based on observation and interview, the facility failed to provide a separately locked, permanently affixed compartment for storage of controlled drugs for one of two refrigerators utilized for storage of drugs. The DON identified 65 residents who resided in the facility. Findings: On 05/21/24 at 3:20 p.m., the medication mini refrigerator was observed at the nurse's station on hall five. The medication refrigerator was sitting on the counter not permanently affixed and there was a small metal lock box inside the refrigerator not affixed. The lock box was observed with LPN #2. The lock box contained two plastic bags with the following medication: Lorazepam 0. 5mg 30 syringes and Lorazepam 0. 5mg 22 syringes. The nurses' station where the mini refrigerator was observed had an open window area to the hall. On 05/22/24 at 10:02 a.m., the nurse's station on hall five was observed with the door propped open, the black mini fridge was observed on the counter not affixed. On 05/22/24 at 10:05 a.m., RN #2 stated the door was closed and locked most of the time. On 05/23/24 at 1:38 p.m., the DON was notified of the observation of the mini refrigerator containing controlled medication not being permanently affixed and the door to the nurses' station open and unlocked.

Based on record review and interview, the facility failed to ensure the Payroll Based Journal accurately reflected RN coverage. Census: 65 Findings: The PBJ Staffing Data Report, for 10/01/23 thru 12/31/23, documented the facility did not identify RN hours for 10/1/23, 12/22/23, 12/25/23, and 12/30/23 On 05/21/24 at 9:15 a.m., requested HR to provide documentation an RN had worked in the building on 10/1/23, 12/22/23, 12/25/23, and 12/30/23. On 05/21/24 at 1:40 p.m., HR provided documentation RN coverage for the facility on 12/22/23, 12/25/23 and 12/30/23. They stated the PBJ report not did not accurately reflect the RN coverage on three of the four days in question.

Based on observation, record review, and interviews, the facility failed to ensure: a. hand hygiene was maintained during eating assistance for seven (#11, 36, 55, 56, 57, 58, and #64) of 15 sampled residents observed during noon meal assistance on the secure unit; b. enhanced barrier precautions were implemented for a resident with an indwelling catheter and the urinary catheter bag was not on the floor for one (#12) of one sampled resident reviewed for infection control with a catheter; and c. oxygen tubing and humidification bottles were labeled for one (#34) of one sampled residents reviewed for the use of oxygen equipment. Census: 65 Findings: A Hand Washing Policy, updated on 03/15/11, read in parts, .Hands should be thoroughly washed before and after providing resident care .hand washing techniques must be followed at all times . The facilty's Evaluation for Justification of Indwelling Catheter Use policy, dated 10/2023, read in part, .STEPS TO PREVENT INFECTIONS IN CATHETER RESIDENTS .Catheter should never touch the floor, neither tubing or bag . 1. On 05/20/24 at 11:19 a.m., the following was observed in the dining area of the secured unit: a. CNA #4 enter the secure unit from an outside hall door, provided a bite of food to Resident #36, then went to the sink and washed their hands. b. CNA #4 donned gloves, and assisted Resident #36. c. With the same gloved hands, CNA #4, moved to next table to assist Resident #58. d. CNA #5, while wearing gloves, assisted Resident #57 to ambulate to a table, assisted to move a chair Resident #57 to be seated, removed the resident's walker, return to Resident #57, removed plate cover and placed on the tray cart, returned to Resident #57, to provide bites of food from the plate. e. With the same gloved hands, CNA #5 walked to Resident #36, and provided bites of food. f. With the same gloved hands, CNA #5 assisted Resident #11 with bites of food, returned to Resident #36 to provide a few bites of food, then assisted Resident #58 with bites of food. g. With the same gloved hands, CNA #5 picked up eating utensils to cut bread into bite sizes for Resident #58 and handed the utensils to Resident #58, then returned to Resident #36, wiped food from resident's mouth, placed napkin in trash, open a cabinet to obtain new napkin, returned Resident #36 to wipe the resident's mouth again and remove food particles. CNA #5 disposed of the napkins in trash, and returned to Resident #36 and continued to wipe the resident's mouth. h. With the same gloved hands, CNA #5 provided eating assistance for Resident #11 On 05/20/24 11:27 at a.m., CMA #3 was observed as follows: a. CMA #3 donned gloves and assisted Resident #11 with bites of food. b. With the same gloved hands, CMA #3 went to the food cart, obtained additional cake, opened a wrapper of cookies into their hand and handed the cookies to Resident #55. c. With the same gloved hands, CMA #3 then served cake to Residents #57, #56, and #64. d. With the same gloved hands, CMA #3 obtained dirty dishes from Resident #64, and without changing their gloves, served cake to Resident #11. Staff did not change gloves or sanitize hands when changing from one resident to another, when touching foods to be eaten, or after picking up dirty dishes from residents. On 05/20/24 at 12:30 p.m., CNA #5 what was the policy for when staff were to wash their hands. They stated hands were to be washed after they deal with resident, toileting, after meals, and after going to the bathroom. On 05/20/24 at 12:35 p.m., CNA #4 was asked if they had washed their hands during the time provided the entered the dining area and provided meal assistance to the residents. They stated, I washed my hands when I came in. I have on gloves. CNAs #4 and #5, were asked if staff had followed the policy to wash their hands after assistance with each resident. CNA #5 stated, No. 2. Resident #34 had diagnoses to include pneumonia and UTI. A Physician Order, dated 04/30/24, documented Resident #34 was to be administered oxygen at two to four liters per nasal cannula, continuously to maintain oxygen saturation at or above 90 percent, staff were to initial and date all oxygen equipment, and to change the tubing and humidification bottle every seven days. A Discharge -Return Anticipated Assessment, dated 04/30/24, documented resident #34 had a memory problem and required modified independence with cognitive skills for daily decision making, and did not indicate resident #34 had utilized oxygen supplement. A Care Plan, dated 04/30/24, documented Resident #34 has shortness of breath and lethargy, oxygen at 2 to 4 liters continuously to maintain sats above 90 percent. The interventions documented, an update on 05/01/24, to monitor for worsening of signs/symptoms; oxygen at 2 to 4 liter continuously to maintain oxygen saturations above 90%, and provide medications as ordered. An Entry Assessment, dated 05/03/24, documented Resident #34 had re-entered the facility from a critical access hospital. On 05/19/24 at 10:37 a.m., an oxygen concentrator was in the resident's room. There was no label on tubing or humidification bottle. The nasal cannula was draped over edge of recliner next to the resident's bed. On 05/22/24 at 12:40 p.m. Resident #34 stated have been sick and in the hospital, had used oxygen for a few days but had not used oxygen today. Resident #34 stated the staff moved the concentrator to the foot of the bed. The oxygen concentrator was positioned at the foot of the bed. There was no label or date on the oxygen tubing or the humidification bottle. The tubing was rolled and placed between the handle and the concentrator. The nasal cannula is not covered or protected. On 05/22/24 at 12:51 p.m., LPN #1 stated Resident #34 had been in the hospital a week or two ago for pneumonia and a UTI, and the resident had only recently been on oxygen. LPN #1 stated, I don't see a label on the tubing or the water bottle, and there should have been. 46702 3. Resident #12 was admitted with diagnoses which included unspecified fracture of shaft of humorous, cerebral infarction, and urinary tract infection. A comprehensive assessment, dated 07/24/23 documented Resident #12's cognition was severly impaired. A document titled, Facility Monthly Infection Control Report Infection Rate, dated 01/2024, documented one residents who had an indwelling catheter had a UTI. A document titled, Facility Monthly Infection Control Report Infection Rate, dated 02/2024, documented four residents with an indwelling catheter had a UTI. A document titled, Facility Monthly Infection Control Report Infection Rate, dated 03/2024, documented three residents who had an indwelling catheter had a UTI. A document titled, Facility Monthly Infection Control Report Infection Rate, dated 04/2024, documented two residents who had an indwelling catheter had a UTI. A document titled, Urinary Tract Infection, dated 05/15/24, documented Resident #12 met the criteria for antibiotic therapy for UTI. A physician's order, dated 05/20/24, documented to administer Augmentin 875 mg-125 mg one tablet two times a day for seven days for UTI. A Order Summary report, dated 5/23/24, read in part, .Foley Catheter to straight drainage as needed . On 05/22/24 at 10:09 a.m., RN #2 and CNA #1 were observed providing perineal care for Resident #12. RN #2 and CNA #1 did not don an isolation gown before providing perineal care. The catheter bag was placed on the bed during care and fell into the floor. The catheter bag remained on the floor while the care was provided and the bed was moved. The catheter bag was drug across the floor before being picked up and hooked to the bed frame by the RN. On 05/22/24 at 1:57 p.m., the DON was asked what was the policy when emptying a catheter bag for placement and infection control. The DON stated the bag goes to below the bladder hanging on the side of bed. The DON was asked would the bag be on the floor. The DON stated,No, it shouldn't be on the floor. The bag should be replaced or the spout cleaned if the bag was on the floor. On 05/23/24 at 8:51 a.m., the DON stated they had not implemented enhanced barrier precautions for every resident who had a wound or indwelling catheter. They stated they implemented enhanced barrier precaution if the resident was colonized with a multidrug resistant organism and had an indwelling catheter or open wound.

Based on record review and interview, the facility failed to ensure residents were administered the pneumonia vaccination for two (#12 and #49) of five sampled residents reviewed for immunizations. The administrator identified 65 residents who resided in the facility. Findings: The facility's undated Immunizations and Vaccinations policy, read in part, .Pneumonococcal [sic]vaccines will be offered between Oct and March each year The policy also documented, The puemonococcal [sic] vaccine will be offered every five .years unless otherwise specified by the primary physician. 1. Resident #12 had diagnoses which included dementia. A document titled, Vaccine Information, dated 07/19/23, documented the resident's representative gave permission for the resident to receive the pneumonia vaccine. There was no documentation in the resident's record the pneumococcal vaccine had been administered. 2. Resident #49 had diagnoses which included pneumonia and diabetes. A document titled, Vaccine Information, dated 09/29/23, documented the resident gave permission to receive the pneumonia vaccine. There was no documentation in the resident's record the pneumococcal vaccine had been administered. On 05/23/24 at 11:18 a.m., the MDS Coordinator stated the consents were signed to receive the pneumococcal vaccine. They stated there was no documentation the vaccines had been administered and there was not a record in the Oklahoma State Immunization Information System of the vaccine being previously administered.

Based on observation, record review, and interview, the facility failed to ensure bed rails were assessed for risk of entrapment, reviewed the risks and benefits of the bed rails with the resident or resident representative, or obtained informed consent prior to installation of the bedrail for two (#43 and #168) of two sampled residents assessed for accident hazards. The DON identified 23 residents who utilized bed rails. Findings: 1. Resident #43 had diagnoses which included dementia, history of right femur, and protein calorie malnutrition. Resident #43's significant change assessment, dated 03/19/24, documented they had severe cognitive impairment and required partial to substantial assistance with ADL care. An ADL care plan, dated 01/04/24, documented Resident #43 required extensive assistance with ADLs and utilized half bed rails. On 05/19/24 at 12:49 p.m., Resident # 43 had a half bedrail in place on their bed in the upright position. 2. Resident #168 had diagnoses which included heart failure, altered mental status, and non-displaced chip fracture of the right talus. (A small break in the ankle bone.) A document titled, Side Rail Review, dated 05/03/24, documented half side rails were indicated. The risks and benefits were not documented on the form. Resident #168's admission assessment, dated 05/10/24, documented they had severe cognitive impairment, required partial to moderate assistance with bed mobility and transfers, and had one fall prior to admission. There was no assessment for entrapment or consent for the bed rails in Resident #43's or Resident #168's record. On 05/22/24 at 12:54 p.m., Resident #168 was observed in bed, laying on side, bedrails observed in the upright position. On 05/22/24 at 2:07 p.m., the DON stated Resident #168 utilized half rails on their bed. They stated the bed rails were used for independence and repositioning. The DON was asked if they had tried an alternative prior to installing the bed rails, assessed the resident for entrapment with the bed rails, had informed the resident and/or resident representative of the risks and benefits of the bed rails and obtained a signed consent prior to the use. They stated, No. The DON stated they had not done an entrapment assessment for any of the residents who had bed rails. On 05/23/24 at 1:38 p.m., the DON stated they did not have a consent or entrapment assessment for Resident #43.

Based on observation, record review, and interview, the facility failed to ensure the care plan was updated with fall interventions after falls for two (#32 and #36) of four sampled residents reviewed for falls. The DON identified 50 residents had falls in the facility and 65 residents who resided in the facility. Findings: The facilty's Incident Reporting, Information Routing and Follow-Up policy, revised 03/2023, read in part, All incidents are to be reported .so that proper care , interventions, treatment is identified and performed. The policy also read, The Care Plan Coordinator will review for appropriate interventions listed, update the care plan. A MDS and Care Plan Process document, revised 07/2023 read in part, Each care plan is to be accurate in identifying individualized approaches from each discipline to assist in providing care to each resident. The facility's Policy #13 policy, revised 07/2023, read in part, .If a resident is identified at risk for falls the MDS/ Care Plan coordinator will be notified and it will be addressed in the care plan . 1. Resident #32 had diagnoses which included dementia. Resident #32's significant change assessment, dated 04/04/24, documented they had severe cognitive impairment, required partial to moderate assistance for transfers and ambulation, and had two or more falls with no injury and two or more falls with minor injury. The fall care plan for Resident #32 documented the following interventions: a. initiated on 10/10/22 ensure the resident is wearing appropriate footwear when ambulating and follow facility fall protocol; b. initiated on 10/15/22 continue interventions on the at-risk plan; c. initiated on 10/18/22 determine and address causative factors of the fall; d. initiated on 11/10/22 resident is on the bowel and bladder program; and e. initiated on 12/04/22 pharmacy consult to evaluate medications. The care plan documented the resident had been found on the floor and/or had a fall on the following dates: On 06/11/23 the resident had a fall in the hall 3 sitting area with no injuries; On 11/13/23 the resident was found on the floor with no injuries; On 12/02/23 the resident was found on the floor with skin tear to right elbow; On 12/06/23 the resident was found on the floor with no injuries; On 12/25/23 and 01/22/24 the resident was found sitting on the floor with no injuries; On 02/03/24 the resident had a witnessed fall resulting in a hematoma to the back of their head; On 02/03/24 the resident was found on the floor in the dining room, the resident had the hematoma to the back of the head from a previous fall and had hit their head again; On 02/06/24 the resident was found sitting on the floor in doorway of room with no injuries; On 02/14/24 the resident was found sitting on the floor on hall three with no injuries; On 02/15/24 the resident was found sitting on the floor beside the recliner with a skin tear to the front and back of the left lower leg; On 02/16/24 the resident was found sitting on the floor with no injuries; On 02/18/24 the resident was found laying on the floor in the bathroom with no injuries; On 02/26/22 the resident was found sitting on the floor inside doorway of the room with skin tear to right elbow; On 02/26/24 the resident had a fall in the dining room with no new noted injuries. The resident was sent to the emergency room for evaluation with no injuries; On 03/15/24 the resident was found lying on their back behind their door with a skin tear to jawline and a bump to the right side of their head; On 04/10/24 the resident was found lying on the floor inside the doorway of their room with an abrasion to their left knee; On 05/08/24 the resident was found sitting on the floor in the three/four sitting area with no injuries; On 05/18/24 the resident had attempted to self ambulate and had fallen with no injuries. There were no new interventions documented on the care plan for the above falls. The care plan had not been updated with interventions since 12/2022. On 05/19/24 at 9:28 a.m., Resident #32 was observed with a dressing to left wrist. On 05/19/24 at 10:08 a.m., RN #2 stated the dressing on Resident #32's left hand was from a fall. On 05/21/24 at 8:14 a.m., Resident # 32 was observed walking in the hall with a staff member next to them providing assistance using the gait belt. On 05/22/24 at 9:37 a.m., the MDS Coordinator stated they had documented a few interventions to prevent falls but had not updated the care plan with each fall. The MDS coordinator was asked about the falls Resident #32 had in February 2024. They stated Resident #32 had Covid-19 and was in and out of isolation. They were asked what interventions had been put in place to prevent falls. They stated they knew staff had increased supervision rounds and the staff would have Resident #32 sit in the common area to be supervised. They stated they had not documented the interventions on the care plan. 46702 2. Resident #36 was admitted with diagnoses which included dementia, psychotic disturbance, and anxiety. Internal Incident Reports documented Resident # 36 had falls on : a. 03/31/24 b. 04/04/24, c. 04/08/24,and d. 05/06/24. On 3/31/2024 at 6:58 p.m., a nurses note read in part, .resident was on floor .lowered bed to floor, placed fall mat . On 4/4/2024 at 4:30 a.m., a nurses note read in part, .Resident was found lying on [their] right side on fall mat at bed side .bed lowered, fall mat put back in place and call light put within reach . On 04/8/2024 at 04:10 a.m., a nurses note read in part, Resident was lying on her right side on fall matt at bedside . Placed wedge behind her left side to attempt to prevent her rolling off bed. Bed in low position with fall matt in place .call light in reach . A comprehensive care plan, intimated 03/28/24, to prevent falls intervention was last updated on 04/01/23 and did not document and new interventions since 11/03/2020. On 05/6/2024 at 04:00 a.m., a nurses note read in part, .Resident found lying on her right side on fall matt at bedside . On 05/19/24 at 01:22 p.m., Resident #36 was observed to have low bed and fall mat at bed side. The interventions were not in the care plan. On 05/21/24 at 09:06 a.m.,CMA #1 was asked what interventions are in place to prevent falls. CMA #1 stated Resident #36 had low bed and a fall mat on the floor. CMA #1 was asked if the low bed and fall mat was care planned. CMA#1 stated the fall mat and low bed was not in the care plan. On 05/21/24 at 09:20 a.m., LPN #2 was asked what interventions were in place to prevent falls. LPN #2 stated they do bed checks frequently, door cracked, and moved resident's room closer to nurse station, resident had a low bed, and a fall mat provided by hospice. LPN #2 stated there were no fall interventions in the care plan for the previous items. On 05/22/24 at 9:32 a.m., the DON was asked how many falls Resident #36 had. The DON stated Resident #36 had 4 falls. The DON was asked what the policy was after a resident falls. The DON stated they discuss new interventions and add them to the care plan. The DON stated the fall mat was not documented in the care plan and no new interventions after the above falls were added to the care plan. The DON stated all interventions after post fall should of been added as soon as possible and no later than 14 days.

Based on observation, record review, and interview, the facility failed to ensure residents were offered hydration for one (#44) of two sampled residents reviewed for hydration. The MDS coordinator identified 13 residents who required assisted with eating/drinking. Findings: Resident #44 had diagnoses which included dementia, urinary incontinence, and UTI. A dietary note, dated 3/11/24, documented annual nutrition assessment was completed and Resident #44 had the estimated need of 1802 milliliters of fluid, monitor, and to continue the plan of care. A physician's progress note, dated 05/08/24, documented Resident #44 had an abnormal CT which indicated possible old stroke, Resident #44 had a UTI and to continue antibiotics for five days, culture pending, push fluids, and monitor. Resident #44's electronic record documented the resident had 600 ml of fluid on 05/09/24, 720 ml on 05/10/24, 360 ml on 05/11/24 and 05/12/24, 600 ml on 05/13/24 and 05/14/24, 1190 ml on 05/15/24, 360 ml on 05/16/24 and 05/17/24, 480 ml on 05/18/24, and 680 ml on 05/19/24. On 05/19/24 at 10:35 a.m., Resident #44's family member stated they had a camera in the room and had not observed the staff offering the resident anything to drink while the resident was in the room. The resident's family member was observed assisting the resident with drinking water. On 05/21/24 at 8:14 a.m., Resident # 44 in bed asleep, note on door documents do not wake up until after 10:00 a.m. On 05/21/24 at 8:30 a.m., Resident # 44 was observed in bed. The resident's water was on the table at the bed not within reach. On 05/21/24 at 8:59 a.m., Resident # 44 remained in bed, lights off, cup in same position. On 05/21/24 at 9:25 a.m., a staff member walked in and out of the resident's room. On 05/21/24 at 9:31 a.m., CNA #2 was observed while they provided incontinent care to Resident #44. They did not offer the resident a drink. On 05/21/24 at 10:11 a.m., CNA #2 came in to assist Resident #44 out of bed. CNA #2 assisted the resident out of bed with CMA #4's assistance. The staff finished providing personal hygiene to the resident. The staff did not offer the resident a drink. On 05/21/24 at 10:38 a.m., the staff took Resident #44 to exercise room, they did not offer the resident a drink. On 05/21/24 at 11:25 a.m., staff were feeding Resident #44. On 05/21/24 at 11:48 a.m., CMA #4 stated Resident #44 drank 375 ml of water. On 05/21/24 at 1:46 p.m., the staff were observed transferring Resident #44 into their recliner. The staff did not offer the resident a drink. On 05/21/24 at 1:48 p.m., Resident #44 was asked if they were thirsty. The resident did not answer. On 05/22/24 at 7:49 a.m., CNA #2 and CNA #7 were observed repositioning Resident #44. The staff did not offer the resident a drink. On 05/22/24 at 7:52 a.m., CNA #2 stated they checked the resident at 6:00 a.m. They stated we made sure Resident #44 was dry and repositioned the resident on their back. On 05/22/24 at 7:53 a.m., CNA #2 placed a water cup at the end of the resident's bed on the over bed table. The CNA did not offer the resident a drink. On 05/22/24 at 8:02 a.m., the MDS coordinator stated Resident #44 had a significant decline and was receiving hospice care. They stated the staff should check the resident for incontinence, change the resident if needed, reposition them, offer fluids, and make sure the resident's belongings and call light were within reach every two hours. They were made aware of the observations and stated the expectation was for the staff to offer fluids whenever they were in Resident #44's room. On 05/22/24 at 8:17 a.m., CNA #2 stated they had to assist Resident #44 with eating and drinking because they had a stroke. CNA #2 stated sometimes they offered Resident #44 a drink when the resident was awake and responsive. CNA #2 was asked if there was any reason they did not offer Resident #44 a drink while they were in the resident's room. They stated, No. They were asked what interventions they would do for a resident who had a UTI. They stated the CMA gave medications and they made sure the residents were offered plenty of fluid.

Based on interview and record review, the facility failed to ensure OHCA was notified after a resident received a significant mental health diagnosis for two (#12 and #30) of five residents reviewed for Pasarr. The DON identified 56 residents had mental health diagnosis. Findings: 1. Resident #12 was admitted on [DATE] with diagnosis which included vascular dementia with mood disturbance and anxiety. A comprehensive assessment dated [DATE] documented Resident #12's cognition was severly impaired and had Anxiety disorder in section I Active Diagnoses. A quarterly assessment, dated 10/19/23 documented anxiety,depression, and psychotic disorder in section I Active Diagnoses. A Order Summary Report, dated 5/23/24, read in part, .Celexa Oral Tablet 10 mg .related to depression .9/18/23 .Seroquel Oral Tablet 25 MG---related to unspecified psychosis not due to a substance or known physiological condition . 9/27/23 On 05/22/24 at 01:43 p.m., the DON Tell me about the Seroquel prescribed 9/28/23. The DON stated It was prescribed related to a new diagnosis of unspecified psychosis not due to a substance or known physiological condition. The DON was asked if a PASARR II was completed after a new diagnosis. The DON stated they did not complete A PASARR II. 2. Resident # 30 was admitted on [DATE] with diagnosis which included type 2 diabetes, unspecified intellectual disabilities and personal history of transient ischemic and cerebral infarction. A Oklahoma Health Care authority Nursing Facility Level of Care Assessment assessment, dated 05/04/20, read in part, .No Evidence of serious mental illness including possible disturbances in orientation or mood . A comprehensive assessment, dated 05/07/20, did not documented, Resident #30 had a diagnosis of psychotic disorders and anxiety. A comprehensive assessment, dated 7/13/23, documented, Resident #30 had a diagnosis of depression and anxiety disorder. A Order Summary Report document ,dated 5/21/24 , read in part, .Abilify Tablet 15 MG .related to delusional disorder .10/15/21 .buspirone HCI Tablet 15 MG .related to Anxiety Disorder .12/4/22. On 05/21/24 at 11:51 a.m., the DON stated the facility did not have a Passar policy. On 05/21/24 at 01:38 p.m., the DON was asked about the PASARR completed after diagnosis of delusional disorder on 10/15/21 and anxiety disorder on 12/05/22. The DON stated there was no PASARR completed after the new diagnosis.

Based on observation, record review, and interview, the facility failed to develop a care plan for the use of bed rails for one (#168) of two sampled residents who had bed rails. The DON identified 23 residents who had bed rails. Findings: The facility's MDS and Care Plan Process policy, revised 07/2023, read in part, The plan of care is a road map in how to best care for each resident and the needs each individual resident has. The policy also read, Each care plan is to be accurate in identifying individualized approaches .to assist in providing care to each resident. Resident #168's care plan was reviewed. The care plan did not document the use of bed rails. On 05/22/24 at 12:54 p.m., Resident #168 was observed laying on their side in bed with half bed rails observed in the upright position. On 05/22/24 at 1:53 p.m., Resident #168 observed in bed there were two half rails on bed in the upright position. On 05/22/24 at 2:07 p.m., the DON stated Resident #168 used bed rails for independence and repositioning. They stated they did not find the use of bed rails documented on the care plan.

Based on record review, interview, and observation the facility failed to ensure resident assessments were accurate for three (#11, 25, and #28 ) of 14 sampled residents reviewed for accuracy of assessments. The Resident Census and Condition of Residents form, dated 04/05/23, documented 59 residents resided in the facility. Findings: A Long-Term Care Facility Resident Assessment document, dated October 2019, read in part, .Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin) .Do not code antiplatelet medications such as aspirin . 1. Resident #25 had diagnoses which included hypertension and hyperlipidemia. A Physician Order, start date 10/14/20, documented the resident was to receive aspirin 81 mg once daily for heart health. A Quarterly Resident Assessment, dated 03/02/23, documented the resident received an anticoagulant seven of the last seven days (02/24/23, 02/25/23, 02/26/23, 02/27/23, 02/28/23, 03/01/23, and 03/02/23). On 04/06/23 at 1:53 p.m., MDS Coordinator #2 was asked to explain how they coded medications on the MDS Resident Assessments. They stated they had coded the anticoagulant medications incorrectly. They were asked to review Resident #25's 03/02/23 Quarterly Resident Assessment and explain the seven on the anticoagulant box. They stated the resident was on aspirin. They stated they had coded the aspirin incorrectly as an anticoagulant. They stated they did not realize aspirin should not have been coded as an anticoagulant. 41318 2. Resident #11 had diagnoses which included nondisplaced fracture of the right arm. A Resident Assessment, dated 03/02/23, documented Resident #11 received an anticoagulant seven of the last seven days (02/24/23, 02/25/23, 02/26/23, 02/27/23, 02/28/23, 03/01/23, and 03/02/23). There were no orders Resident #11 received an anticoagulant located in the residents clinical record. On 04/06/23 at 9:57 a.m., MDS Coordinator #1 and #2 were asked how they ensured the MDS was coded correctly. MDS Coordinator #1 stated they gathered information on the residents and inputted the information. They stated they referred to the RAI manual to clarify any questions they had. MDS Coordinator #1 and #2 were asked what medications Resident #11 was receiving that would be coded on the MDS. MDS Coordinator #2 stated Resident #11 was receiving aspirin and it was coded as an anticoagulant. MDS coordinator #1 and #2 were asked what was the classification of aspirin. MDS Coordinator #1 stated it was an NSAID. MDS coordinator #1 and #2 were notified what the Resident Assessment documented. They were asked based on the Long-Term Care Facility Resident Assessment document, was Resident #11's MDS coded accurately. MDS Coordinator #2 stated, No. 47453 3. Resident #28 had diagnoses of nontraumatic chronic subdural hemorrhage, dementia, osteoporosis, and incontinence of bladder and bowel. A Quarterly Resident Assessment, dated 03/16/23, documented the resident had an unstageable pressure area to the buttocks. A Nurses Note, dated 03/12/23 at 3:29 p.m., read in part, Resident has a small open area on .coccyx. It is only a slit within .buttocks crease. Area was cleaned and Calmoseptine applied. Will cont. to monitor area . On 04/06/23 at 9:51 a.m., CMA #2 and CNA #3 were observed assisting resident #28 with a sit to stand lift. The resident's buttocks was observed to have no open areas present. On 04/06/23 at 9:56 a.m., the DON was asked how staff determined resident #28 had an unstageable wound to their buttocks. The DON stated it was documented wrong on the quarterly resident assessment. The DON stated the MDS nurse who completed the assessment was new and had incorrectly documented the wound. The DON stated the resident never had an unstageable wound.

Based on record review and interview, the facility failed to ensure an RN worked a minimum of eight hours a day, seven days a week for eight of eight days reviewed. The Resident Census and Conditions of Residents report, dated 04/05/23, documented 59 residents resided in the facility. Findings: The fiscal year quarter one PBJ Staffing Data report, dated 04/03/23, documented no RN hours for the following dates: 10/12/22, 10/15/22, 10/16/22, 10/22/22, 11/05/22, 11/20/22, 12/13/22, and 12/26/22. On 04/05/23 at 9:04 a.m., during the Entrance Conference, the DON was provided a copy of the above PBJ Staffing report. The DON was asked to provide documentation an RN worked at least eight hours on 10/12/22, 10/15/22, 10/16/22, 10/22/22, 11/05/22, 11/20/22, 12/13/22, and 12/26/22. On 04/06/23 at 8:09 a.m., the DON stated We did not have RN coverage. She was asked the policy for RN coverage. She stated she was not sure the facility had a written policy, but they had to have RN coverage for Eight hours, seven days a week.

Based on observation, record review, and interview, the facility failed to: A. conduct an assessment of the resident for use of resident alarms, B. document the medical symptom being treated for the use of resident alarms, C. document ongoing re-evaluation for the need of resident alarms for three (#2, 53, and #109) and D. obtain a physician order for a floor pressure alarm for one (#109), E. obtain a physician order for a personal alarm for one (#2) and F. care plan the use of resident alarms for one (#109) of four sampled residents reviewed for resident alarms. The DON identified 13 residents with alarms resided in the facility. Findings: 1. Resident #109 had diagnoses which included dementia and mood disturbance. A Nurses note, dated 02/22/23 at 2:38 p.m., documented the resident had arrived at the facility and walked with a walker with the assistance of one staff member and gait belt short distances only. It documented otherwise the resident used a wheelchair. A Nurses note, dated 02/22/23 at 6:15 p.m., documented Resident #109 was confused , tried numerous times to stand alone and move about the room. It documented Resident #109 was really unsteady, needed one person and gait belt assistance, and a clip alarm was added at this time. There was no documentation of additional interventions attempted prior to staff applying the clip alarm to Resident #109 the same day they admitted to the facility. A Physician Order, dated 02/22/23, read in part, To help alert staff of resident exiting from the w/c and bed, use a clip on alarm to the resident while in the w/c and bed .every shift Check for placement . There was no order located for Resident #109's floor pressure alarm. Resident #109's Care Plan, initiated 02/24/23, did not address the use of the clip on alarm or the floor pressure alarm. An Order Summary report, dated 04/06/23, documented Resident #109's admitted was 02/22/23. On 04/05/23 at 9:34 a.m., Resident #109 was asked to explain the floor pressure alarm which was observed in front of the recliner they were seated in on the floor. Resident #109 stated the floor mat would sound an alarm if they got up. They stated they were not supposed to get up. They stated staff wanted them to use a call light when they needed to get up. Resident #109 was asked how they got around in the facility. They stated they used their wheelchair to ambulate to the dining room for meals. On 04/06/23 at 8:14 a.m., Resident #109 was observed sitting in their recliner with a floor mat alarm in place in front of the recliner. There was also a personal alarm observed clipped to Resident #109's shirt. The resident was asked to explain the alarm clipped to their shirt. They stated, That one, if I get up, it will go off. Resident #109 was asked how long they had been using the alarm on the floor and the alarm clipped to them. They stated, It's been since I've been here. They were asked to explain what happened when the alarms went off. They stated when the alarms went off, staff would come in and undo them. On 04/06/23 at 8:21 a.m., CNA #1 was asked what Resident #109's functional ability was. They stated the resident required one person physical assist with a walker for ambulation. They stated staff assisted the resident in walking to the dining room daily. CNA #1 was asked what the purpose of the floor alarm was in Resident #109's room. They stated the resident liked to get up on their own. They stated the resident's family wanted to ensure the resident did not fall. CNA #1 was asked if Resident #109 had fallen at the facility. They stated, No. CNA #1 was asked if they had noticed any impact on the resident with the use of the alarms. They stated Resident #109 did not get up as much. They stated the resident did not push their call light. They stated the resident just waited for staff to pass by and then would inform them they needed to use the rest room. CNA #1 was asked when Resident #109's alarm use started. They stated they were not sure of the exact start date. They were asked what interventions were attempted prior to the use of the alarms. They stated staff had placed notes in the resident's room to remind them to use the call light. They stated they were not aware of any other interventions. CNA #1 was asked how often the alarms were used. They stated the floor alarm was used anytime the resident was in bed or in the recliner. They stated the tab alarm was used when the resident was in bed, in the recliner, and when they were in the wheelchair. On 04/06/23 at 8:30 a.m., LPN #2 was asked the policy for using position change alarms. They stated they knew alarms could not be used to restrain a resident. They stated as long as the resident could freely move, they could be used. They stated Resident #109 had a family member visiting who requested signs be hung to remind the resident to use their call light. They stated the signs were placed in the resident's room. They stated staff also checked on the resident often. LPN #2 stated there was also an order for staff to check off each day the alarm was in place and working. LPN #2 was asked who evaluated residents for alarm use. They stated the MDS Coordinators. LPN #2 stated staff discussed residents in the morning meetings and then would ask the doctor if they thought and alarm would be appropriate. They stated staff would obtain an order from the physician for the alarm use. LPN #2 was asked if there was documentation of an assessment of the resident for position change alarm use. They stated MDS Coordinator #1 would know that information. LPN #2 was asked how often residents were re-evaluated for alarm use. They stated that would be a question for MDS Coordinator #1. LPN #2 was asked to explain the reason for Resident #109's floor and personal alarm. They stated the floor alarm was used for the bed and recliner. They stated if the resident would sit up or try to get out of bed, it would go off. LPN #2 stated the tab alarm was helpful when the resident was in their wheelchair, recliner, or in bed to catch Resident #109 before they got to the floor alarm. They were asked when the alarm use started. They stated both alarms started the same day the resident admitted to the facility. They stated the resident had experienced several falls at home, but had not fallen at the facility. On 04/06/23 at 8:39 a.m., LPN #2 was asked what interventions were tried prior to the alarm placements. They stated on admission, Resident #109 was confused and tried several times to stand alone and move around their room. They stated a clip alarm was needed. They stated prior to admission, the resident lived alone and kept falling. On 04/06/23 at 8:45 a.m., MDS Coordinator #1 was asked who was responsible for completing resident care plans. They stated MDS Coordinator #1 and #2 completed care plans. MDS Coordinator #1 was asked what types of things did they include in a care plan. They stated they started with the basics such as diagnoses, preferences, allergies, then developed more individualized care plans as they became more familiar with the resident. MDS Coordinator #1 was asked if position change alarms were something they would include on a resident's care plan. They stated, Yes. They were asked to review Resident #109's care plan and determine if their position change alarms were included. MDS Coordinator #1 stated under the fall risk care plan for Resident #109, the alarms were added. MDS Coordinator #1 was asked when the alarms were added to the resident's care plan. They stated, This morning. On 04/06/23 at 8:47 a.m., MDS Coordinator #1 was asked who evaluated residents for alarm use. They stated the facility generally did a team meeting three times a week where they discussed resident issues. MDS Coordinator #1 was asked if there was an evaluation completed before using alarms on residents. They stated they did not have a standardized form they used. MDS Coordinator #1 was asked how they determined alarms were appropriate for use. They stated staff would discuss each resident's fall risk. They stated the alarms were often used because a fall had happened or nearly happened. MDS Coordinator #1 was asked if Resident #109 had fallen at the facility. They stated they were not sure, but the resident had fallen prior to admission. On 04/06/23 at 8:49 a.m., MDS Coordinator #2 reviewed Resident #109's record and stated the resident had not fallen at the facility. MDS Coordinator #1 was asked when the alarm use for Resident #109 started. They stated the first note documented a clip alarm was added on 02/22/23 at 6:15 p.m. MDS Coordinator #1 was asked what day Resident #109 admitted to the facility. They stated the resident admitted that same day 02/22/23 early in the afternoon. MDS Coordinator #1 was asked what interventions were attempted prior to the use of the alarm. They stated the only comment in the note was the resident was unsteady, it did not mention interventions. MDS Coordinator #1 was asked if staff re-evaluate alarm use and if so how often. They stated Resident #109 was getting therapy. They stated a lot of times therapy or the nurses would bring it to the meetings that an alarm was no longer needed. They stated there was no specific timeframe for re-evaluating the alarm use. MDS Coordinator #1 was asked to verify if there was any documentation of evaluations for alarm use on residents. They stated, No. 2. Resident #2 had diagnoses which included dementia, neuropathy, and schizoaffective disorder. A Physician Order, dated 11/10/22, read in part, To help alert staff of resident exiting out of bed, use a pressure pad alarm while resident is in bed. Check function q week/prn . There was no order located for the resident's personal alarm. An Incident Report, dated 11/04/22, documented Resident #2 was found on the floor in the hallway yelling out. It documented there were no injuries noted and the alarm was not in use. There were no other incident reports related to falls for Resident #2 after this date. A Significant Change Resident Assessment, dated 03/09/23, documented the Resident #2's cognition was severely impaired and a bed and chair alarm was used daily. A Fall Care Plan, target date 03/21/23, documented fall interventions for Resident #2 which included monitor that the resident's alarms were in place and working properly. The date the intervention was initiated was 11/07/22. On 04/05/23 at 11:57 a.m., Resident #2 was observed using their feet to propel themselves down Hall 100. On 04/05/23 at 12:01 p.m., Resident #2 was observed with an alarm attached to the wheelchair they were seated in. The alarm was clipped to the resident's pink sweatshirt. An interview was attempted with the resident, however the resident refused the interview. On 04/06/23 at 10:06 a.m., Resident #2 was observed in an exercise activity located in the chapel room. A personal alarm was observed hanging from the right handle of the resident's wheelchair. The alarm was clipped to the upper back area of Resident #2's peach shirt. On 04/06/23 at 10:18 a.m., LPN #2 was asked if Resident #2 used any alarms. They stated the resident used a tab alarm and pressure alarm. They stated the pressure alarm was placed under the resident's bedding and the tab alarm was used when the resident was in bed or in their wheelchair. LPN #2 was asked the reason for the alarms. They stated the resident had neuropathy in their feet. They stated they did not always have feeling in their feet and could not stand alone. They stated the resident did not use the call light. LPN #2 stated the alarm in bed was used to alert staff when Resident #2 was getting up so they could assist them. They stated the tab alarm was used to help alert staff when the resident was trying to stand so they could assist them. They stated the resident leaned forward, and they didn't want the resident to fall as they had decreased safety awareness. On 04/06/23 at 10:21 a.m., LPN #2 was asked when the alarm use started. They stated 11/10/22 for the bed alarm and 06/27/22 for the tab alarm. They were asked what interventions were in place prior to the alarm use. They stated the resident was located close to the nurse's station, staff constantly educated the resident on call light use, and kept the call light close to the resident. They stated there were several notes of the resident taking the tab alarm off, which was why the pressure alarm was used for back up. On 04/06/23 at 10:30 a.m., LPN #2 was asked when Resident #2's last fall was. They stated the last fall was 11/04/22. On 04/06/23 at 10:32 a.m., CNA #2 was asked if Resident #2 used any alarms. They stated the resident had a tab alarm on them all the time. They stated a pad alarm was also used when the resident was in bed. CNA #2 was asked the reason for the alarms. They stated the alarms were ordered because the resident was a fall risk. They were asked when the alarm use started. They stated the pad alarm was started in the past year. They stated the tab alarm has been used about two years. On 04/06/23 at 10:34 a.m., the DON was asked if they were familiar with Resident #2. They stated they were. They were asked the reason for the resident's alarms. they stated the resident got up a lot and had experienced multiple falls due to incontinence. They stated the resident stumbled around in the dark. The DON was asked when the alarms were initiated. They stated it looked like 06/2022. The DON stated the resident's last fall was 11/04/22. The DON was asked how staff determined alarm use was an appropriate intervention for residents. They stated they held team meetings three times a week and discussed residents with the charge nurse. They stated it was a team decision, if they felt the resident was at risk for hurting themselves or were not cognitively intact. The DON was asked how they determined what type of alarm was appropriate. They stated through the team meetings. They stated they did not complete assessments. They stated if a resident was getting up and carrying their alarm, the facility would then use a pressure pad or floor alarm. The DON was asked if staff re-evaluated residents for the use of alarms. They stated they did not do an assessment, but if a resident had a decline and was no longer able to get up without staff assistance, they would discontinue the alarm. The DON was asked if they knew of any attempts to discontinue Resident #2's alarm since their last fall in November 2022. They stated, No. The DON was asked for a copy of their policy for alarms. On 04/06/23 at 2:14 p.m., the DON stated they did not have an alarm policy. 47453 3. Resident #53 had diagnoses which included dementia, depression, and anxiety. An Order Summary, dated 01/30/23, documented use of tab and motion alarm for elopement risk. A nurses note, dated 03/25/23, read in part, .[Resident #53] has tried to flop .leg over the side of the geri chair today was repositioned for comfort. This helped for a while. Alarms in place to help alert staff that resident is trying to exit .chair without assistance . There was no assessment located for the resident's alarm use. Resident #53's Care Plan, dated 04/05/23, read in parts, .Falls: high risk, multiple falls since admission. I use a clip on alarm while in my w/c. Check function q week/prn. replace batteries as needed. To help prevent independent exiting out of bed, use a pressure pad alarm while I am in my bed. Check function q week/prn. change batteries as needed . On 04/05/23 at 1:56 p.m., Resident #53 was observed to have a personal alarm clipped to their shirt and a sensor alarm located under them while seated in a geriatric chair. 04/06/23 at 12:50 p.m., the DON was asked the reason for alarm use on Resident #53. They stated the resident had numerous falls since their admission. The DON stated Resident #53 was very aggressive with staff and had tried to leave the facility. The DON stated the resident was sent for a psych evaluation. They stated the alarms were put in place because the resident was mostly confined to their geriatric chair. The DON was asked if Resident #53 had a medical condition where they needed the alarms. The DON stated not that she was aware of.

Based on observation, clinical record review and staff interview, it was determined the facility failed to prevent a decline in ambulation resulting in actual harm for one (#5) of one sampled resident with a decline in ambulation. This had the potential to affect 13 residents identified by the facility with a decline in ambulation. Findings: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An initial temporary care plan, dated 09/02/10, documented the resident required the assistance of one staff member for toileting, ambulating and transferring. The care plan also documented the resident had behavioral symptoms of anxiety and wandering. The care plan did not document interventions for anxiety and wandering. The care plan did not document the resident used a walker to assist with ambulation. The temporary care plan documented the resident did not use any restraint devices at the time of admission. A physical therapy plan of treatment form, dated 09/03/10, documented, "...Treatment DX: Difficulty Walking... Functional Goals: (increase) bed mobility, (increase) transfers, (increase) dynamic standing balance to fair, (increase) ambulation to 150 ft... Reason for Referrals: Acute hospitalization for UTI & depression c resulting decline in transfers & ambulation... Prior Level of Function: Lived in own home alone & ambulated (independently)... Outcome (Long Term Goal): Pt will perform transfers (independently) & will ambulate c (assistive devices)..." The medical record documented the resident received physical therapy five times a week for gait training, balance, and transferring skills beginning on 09/03/10. A physical therapy progress note, dated 09/03/10, documented the resident ambulated 50 feet with her walker. A skilled nurse's note, dated 09/06/10 at 8:50 a.m., documented, "...Resident found in hall opposite nurses' station sitting on buttocks. She had walker near her and set up....Moved to w/c (with) assist of 2 and gait belt. Will use a merrywalker to help facilitate walking and (decreased) chance of fall. Not wanting to place restraint to person in w/c (secondary to) cognition impact..." A physical therapy progress note, dated 09/06/10, documented the resident ambulated 100 feet in the merrywalker. A Resident Assessment Protocol (RAP) Summary, dated 09/08/10, documented, "...ADL Rehabilitation and Maintenance...(Resident name deleted) requires limited assistance of one staff of transferring between surfaces, walking in room, corridor and locomotion on and off the unit..." A skilled nurse's note, dated 09/09/10, documented the resident was restless and had an unsteady gait. An Assistive Device Assessment, dated 09/09/10, documented, "...Assistive Device: Merrywalker... 1. Define the reason for use of the device: Resident is extremely restless. Cannot be diverted to wait for assistance to ambulate. She wants to wander; 1 on 1 cannot be provided. She will not locomote in (wheelchair). Her advanced dementia is limiting safety awareness. 2. Determine the factors (symptoms) causing the need for device: Confusion (related to) dementia. Overwhelming urge to wander. Poor balance, poor safety awareness. We have tried alarms, but she is wanting up most of the time. 3. Determine the impact on the residents function: This device will help satisfy the desire to roam. It will help reduce fall risk. Allow for more independence. Does this item restrict freedom of movement? YES (check mark) Device is a restraint Physician order obtained for device. Restraint consent signed.... Define Residents current functional capacity: Due to cognitive ability she requires extensive to dependent help with ADLs. She cannot walk (without) the help of staff or some sort of device. She cannot open gate of merrywalker..." The resident's care plan was not modified to include the use of the merrywalker. A skilled nurse's note, dated 09/11/10, documented the resident was placed in a merrywalker. An ADL Flowsheet, dated September 2010, failed to document the resident was released, toileted, and repositioned every two hours on this date. A skilled nurse's note, dated 09/12/10, documented, "(2:00 P.M.) She is in the shower chair for her protection...(6:30 p.m.) Res in (wheelchair) c lap buddy on, tabs monitor in place..." The nurse's note did not document how long the resident was in the wheelchair with the lap buddy, or if the resident could remove the lap buddy. The September 2010 ADL Flowsheet failed to document the resident was released, exercised, toileted and repositioned every two hours on this date. A skilled nurse's note, dated 09/13/10 at 6:15 p.m., documented, "...Res. up in merrywalker...Able to ambulate self in walker..." A skilled nurse's note, dated 09/14/10 at 9:10 p.m., documented, "...Res. cont. to be restless assisted res. into (merrywalker)..." A skilled nurse's note, dated 09/19/10 at 3:00 p.m., documented, "...She is able to stand some days and walk some. She was able to transfer from merrywalker to toilet for this nurse...Res. was (up) walking (after) lunch in her merrywalker..." A facility incident/accident report, dated 09/20/10, documented, "...res fell through bottom of merrywalker...3 areas of bruising on back and elbow..." A facility incident/accident report, 09/21/10, documented, "...res fell through merrywalker, strained arm..." A skilled nurses note, dated 09/22/10, documented, "...walks c contact assist to toilet...Res sits in merrywalker (and) ambulates. When she gets tired is able to sit..." A facility incident/accident report, dated 09/22/10, documented, "...res caught leg in strap of merrywalker attempting to crawl out...4 skin tears...smaller merrywalker obtained..." An Assistive Device Assessment, dated 09/23/10, documented: "...Assistive Device: Velcro alarmed seat belt to (wheelchair)... 1. Define the reason for the use of the device: (Resident) is becoming increasingly unsafe in merrywalker (due to) endurance / fatigue. Will use this belt in (wheelchair) to help her rest and stay safer in her (wheelchair). The belt will alert staff with more time to respond to solo attempts to exit. We have tried clip on alarms which have showed little benefit. 2. Determine the factors (symptoms) causing the need for the device: (increased) fatigue in merrywalker, (increased) problems (with) coordination and balance problems. Multiple falls continue to occur. Confusion persists. 3. Determine the impact on the resident's function: This will help her to remain safer and allow for rest. She demonstrates the ability to locomote and does not have any agitation noted in (wheelchair). She is able to remove velcro belt... Does this item restrict freedom of movement? NO (check mark) Define Residents current functional capacity: Cognitive deficits (no) safety awareness. Relies on staff to complete ADLs. Not restricted (due to) level of cognition. Able to remove belt. Does this item assist in improvement of resident's functional status? YES (check mark) This is not a restraint..." There was no physician's order with documentation of a medical symptom for use of the lap belt. A RAP Summary, dated 09/24/10, documented, "...ADL Rehabilitation and Maintenance...She requires extensive assist of two staff members for her transferring, walking in room and corridor using her walker. She is limited assistance of one staff member for locomotion on and off the unit. (Resident name deleted) does move independently at times in her merrywalker, however she will move into a corner or in a doorway and can't get herself out..." The RAP Summary did not document the use of the wheelchair and lap belt alarm. Skilled nurses' notes, dated 09/24/10, 09/25/10, 09/26/10, 09/27/10, and 09/28/10 documented the resident was in a wheelchair with the lap belt alarm and was non-ambulatory. There was no documentation to indicate how long the resident was in the wheelchair each day, or to indicate the resident had the lap belt alarm released for exercise, toileting, repositioning or eating. There was no documentation to indicate the resident was ambulated with assistance on these dates. A significant change assessment, dated 09/28/10, documented the resident had deteriorated in the areas of cognition, ADL function, urinary continence, and overall care needs. There was no documentation to indicate the care plan had been modified in response to the significant change. This was the first comprehensive assessment documented for the resident. An admission comprehensive assessment that was due on 09/16/10 was not completed. A physician's telephone order, dated 09/29/10, documented, "...Make merrywalker PRN. (Continue as a restraint)..." Physical therapy progress notes documented the resident received balance and gait training and practice with transferring skills five times a week for the entire month of September. A skilled nurse's note, dated 10/01/10, documented, "...Res isn't ambulating...is able to move w/c...isn't ambulating much..." A skilled nurse's note, dated 10/02/10, documented, "...has had decrease in ambulation. Takes 2 person to assist to transfer...She has had (decrease) in movement...up in wheelchair, alarm in place...Res is alert but c decreased activity...total care..." There was no documentation to indicate how long the resident was in the wheelchair each day, or if she was assisted with ambulation. A skilled nurse's note, dated 10/22/10 at 2:00 p.m., documented, "...(Staff name deleted) here for PT. He suggests she have an alarm for her w/c seat that goes off when she stands in seat belt alarm." There was no documentation in the medical record to indicate the resident was evaluated for a seat alarm versus a seat belt alarm. The medical record documented physical therapy was provided five times a week for the entire month of October to improve balance, gait training and transferring skills. A physical therapy note, dated 10/31/10, documented the resident had full weight-bearing, had fair balance and used the merrywalker to ambulate 250 feet. A skilled nurse's note, dated 11/01/10, documented, "...9:00 a.m. PT here and walked her around the building hallway. She stops and tries to pick something up off the floor which causes her to be an (increased) fall risk...4:00 p.m. pacing the hall c her w/c. Lap belt for safety in place..." A skilled nurse's note, dated 11/02/10, documented, "...11:00 a.m. walked c PT in hall...4:00 p.m. pacing the hall c her w/c. Appears to be agitated...8:00 p.m. refused her meds this pm also refusing assist from CNA and taking seat belt off & walking about in her (room). CNA reminded res to be careful & res just says 'I can get (up) & walk if I want'..." A nurse's note, dated 11/05/10 at 1:00 p.m., documented, "...Assisted to walk at this time c this nurse & tolerated poorly..." A skilled nurse's note, dated 11/08/10, documented, "...Staff wheeled res in wheelchair to breakfast then took her back to her room. Explained to aides res is to walk to meals (and) in hallway when she is restless..." There was no documentation in the care plan to indicate the resident was to be ambulated with assistance everyday, or that a restorative plan including walk to dine was in place. The care plan did not indicate the resident should be ambulated with assistance during periods of anxiety or agitation. A skilled nurse's note, dated 11/10/10 at 6:45 p.m., documented, "...in w/c c seat belt on says 'this is garbage', she doesn't like seat belt at all..." The documentation did not indicate how long the resident was in the wheelchair. A skilled nurse's note, dated 11/18/10, documented, "...Res seat belt on intact working. Res plays with it @ times. Staff will walk res when she appears restless (and) she settles is calmer..." A physical therapy progress note, dated 12/08/10, documented the resident was ambulating with the merrywalker for 300 feet. A skilled nurse's note, dated 12/12/10, documented, "...D/C from skilled services to LTC at (midnight)..." A physical therapy progress note, dated 12/15/10, documented, "... Pt discharged from PT. No change from last note 12/08/11 (sic). Continue ambulation c assistance only..." There was no documentation of any further recommendations from physical therapy regarding a restorative program for the resident. A Restorative Flow Sheet, dated December 2010, failed to document the resident was assisted to walk to meals and as desired on 12/08/10, 12/09/10, 12/13/10, 12/15/10, 12/16/10, 12/18/10, 12/19/10, 12/22/10, 12/24/10, 12/27/10, 12/28/10, 12/29/10, 12/30/10 and 12/31/10. There were no other restorative flow sheets after December 2010. A Monthly Summary Progress Note, dated 12/17/10, documented the resident used a lap belt restraint and did not receive any therapies or restorative programs. A care plan, dated 12/21/10, documented, "...I need assistance to turn/reposition every two hours, more often as needed or requested...Please reposition me as needed..." There was no documentation of a plan for restorative services or a plan for assistance with ambulation. The care plan did not address nursing interventions to release the lap belt and toilet, exercise and reposition the resident at least every two hours. There was no documentation of a plan to attempt to reduce or eliminate the lap belt. For the month of December 2010, there was no documentation that indicated the resident was released from the lap belt every two hours for toileting, repositioning and exercise. The record did not document the resident's lap belt was released during meal times and during 1:1 interaction. A nurse's note, dated 01/24/11, documented, "...not amb. as usual. Requires 2 staff assist for transfers..." A nurse's note, dated 01/31/11, documented, "...Walking is unsteady. Leaning to the left. Takes 2 to walk when it only takes one usually..." There was no documentation that indicated how long the resident sat in her wheelchair each day. The record did not document the resident's lap belt was released during meal times and during 1:1 interaction. There was no documentation the resident was ambulated regularly with assistance during the months of January and February 2011. A monthly summary progress note, dated 02/21/11, documented the resident was not on a restorative program. A care plan, dated 03/04/11, did not address ambulation. It did not include restorative services to maintain strength and mobility. A physician's telephone order, dated 03/04/11, documented, "... DC merrywalker - non-use..." There was no documentation that indicated how long the resident sat in her wheelchair each day. The record did not document the resident's lap belt was released during meal times and during 1:1 interaction. There was no documentation the resident was ambulated regularly with assistance during the months of March and April 2011. A monthly summary progress note, dated 04/24/11, documented the resident was not on a restorative program. On 05/02/11 at 11:16 a.m., the resident was observed in the secure unit dining room as she ate lunch. She was sitting in a wheelchair at a table with a lap belt alarm secured across her lower abdomen. The lap belt was turned over so that the velcro release was on the under-side, and not easily accessible to the resident. The lap belt alarm remained in place throughout the meal. At 4:35 p.m., the resident was observed during the dinner meal seated at a table in a wheelchair. She had a lap belt alarm secured across her lower abdomen with the velcro release on the under-side, and not easily accessible to the resident. Staff did not release the lap belt at any time during the meal. On 05/03/11 at 8:55 a.m., the resident was observed in her wheelchair in the hallway of the secure unit. She had a lap belt alarm secured across her lower abdomen. The lap belt was secured with the release side turned under, inaccessible to the resident. At 1:30 p.m., the resident was observed in her wheelchair in the hallway of the secured unit. She had a lap belt alarm secured tightly across her lower abdomen. The resident's back was firmly against the back of the wheelchair. She was leaning her head against the handrail in the hallway. She was asked if she wanted to lie down. She did not answer. At 1:45 p.m., RN #1 was asked why the resident had a lap belt alarm. She stated, "She wears it because she tries to lean forward in her wheelchair to pick up imaginary things off the floor." She was asked if the resident could release the lap belt herself. She stated, "Yes." She was asked how long the resident had been using the lap belt alarm. She stated, "At least as long as I've been here. I came in December." At 4:30 p.m., the resident was observed at the dining table with the lap belt alarm tightly secured to her lower abdomen during the dinner meal. At 3:45 p.m., LPN #1 was asked if the resident could sit unsupported. She stated she could not. She was asked if the resident could walk at all with assistance. She stated, "No." On 05/05/11 at 8:20 a.m., the resident was observed in the main dining room sitting in her wheelchair at a table of four residents. She had been eating breakfast. The lap belt alarm was in place across her abdomen. At 9:50 a.m., the physical therapist was asked if he had completed a discharge summary with recommendations for follow-up care when the resident was discharged from physical therapy services in December 2010. He stated, "It should have been documented on the initial assessment form but it wasn't." He was asked if he made any recommendations for a restorative program for the resident. He stated he recommended a walk to dine program. He was asked if this was incorporated into the care plan. He stated he didn't know. He was asked if the facility employed restorative aides. He stated, "No. The CNAs perform that function." He was asked if the resident had retained her ability to walk 300 feet. He stated, "I don't think she can walk at all now. She has declined." He was asked if the resident could stand or move herself out of the wheelchair independently. He stated he didn't think so. He was asked if she needed the lap belt alarm. He stated, "I guess if you're saying if she can't walk, then why does she need a lap alarm. But she could get a burst of energy and try to stand, you never know. So the lap belt is needed because she can't handle another fall." At 10:10 a.m., CNA #5 was asked if the resident had recently walked with assistance to the dining room for meals. She stated, "I don't know." She was asked if the resident ever attempted to remove her lap belt and exit the wheelchair to try to walk. She stated, "No. She is a two person transfer. She's pretty weak." At 12:00 p.m., the ADON was asked if she could remember the last time the resident walked. She stated, "Maybe January." At 1:00 p.m., the DON was asked if there were any other facility records that documented restorative services for the resident, other than the December 2010 Flow Sheet. He stated there were not. He stated a restorative program would be starting the next day. At no time during the course of the survey was the resident observed out of the wheelchair, observed without the lap belt alarm, or ambulating with assistance.

Based on observations, review of clinical records, review of policies and procedures and staff interviews, it was determined the facility failed to prevent a severe weight loss of greater than 5% in 1 month and/or greater than 10% in six months resulting in actual harm for two (#5 and #13) of four sampled residents with a severe weight loss. This had the potential to affect 16 residents identified by the facility who experienced a severe weight loss in the last six months. Findings: A facility policy, titled, Weight Loss, documented, "1. All residents are to be weighed at least monthly. 2. When a resident is found to have lost a significant amount of weight; significant loss identified as: 5% of body weight in 30 days 7.5% of body weight in 90 days 10% of body weight in 180 days a. Re-weight taken immediately in case of error. b. Notify doctor of record (or doctor on call). c. Request: Complete Metabolic Profile now and thereafter protein monthly until WNL and weight is stable. CBC now. Other lab as Dr. orders. Weekly weight until stable for 4 weeks. Routine supplement orders. d. Consult with dietary manager. Request registered dietitian consult for re-evaluation. 3. ...5% or more of body weight is lost in one month doctor must be notified. We would not request lab unless the doctor suggested this, nor would we give supplements unless resident is below ideal body weight. When resident reaches IBW (ideal body weight), a maintenance diet should be ordered after consulting registered dietitian. 4. Document all of the above steps in nurses' notes. Document at least monthly on the progress (or lack of) that you see. 1. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. A facility weight record, titled Weights and Vitals Summary Report, documented the following weights: 10/05/10: 155.6 lbs 11/00/10: No weight recorded 12/10/10: 154.4 lbs 01/09/11: 148.5 lbs 02/21/11: 141.1 lbs 03/05/11: 133.0 lbs 04/00/11: No weight recorded 05/05/11: 131.8 lbs The resident had a 14.6% severe weight loss in the past five months. There was no weight recorded for the month of November 2010. The resident also had a 5.7% severe weight loss between 02/21/11 and 03/05/11, approximately a two week period. The resident's weight has continued to decline into May 2011. A care plan, dated 12/01/10, documented, "Focus: I am at risk for impaired nutrition status/weight. Goals: I will consume 75% of two or more meals daily and have no weight loss or skin breakdown by through review. Interventions: -Provide and serve diet as ordered. -Monitor/document/report to MD for s/sx of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. -Monitor % of meal consumed and offer a meal replacement if I consume less than 75% if (sic) each meal. -I am on nectar thickened liquids with a mechanical soft with gravy on meat diet. -I require total assistance with my meals. -Monitor and record weight per physician orders. -Braden scale, skin monitoring per facility policy." A dietary note, dated 01/30/11, written by the dietary manager, documented, "(Resident) diet is mechanical soft ground meat and nectar thickened liquids and gravy on meats when she returned from the hospital. She comes to the dining room fro (sic) meals and is assisted with her meals. She had a drop in her weight. She eats 63% of her meals. Labs: [MEDICATION NAME]-L-3.3, Potassium 2.8." The resident lost 5.9 lbs between December 2010 and January 2011. This was a 3.8 % weight loss in one month. No recommendations were made by the dietary manager. The February 2011 meal percentage sheet documented the resident took in less than 75% at 23 meals. She was offered a meal replacement at only six of these meals. A dietary note, dated 02/28/11, written by the dietary manager, documented, "(Resident) eats 71% of her meals and her weight is down 7.5% in 90 days. She has been moved to hall 5. We will monitor her weight and intakes." The resident lost 7.4 lbs between January 2011 and February 2011. This was a 4.9% weight loss in one month. No recommendations were made by the dietary manager. A quarterly assessment, dated 02/24/11, documented the resident was severely impaired in cognitive skills for daily decision making and required the total assist of one person to eat. The March 2011 meal percentage sheet, documented the resident took in less than 75% at 28 meals. She was offered a meal replacement at only four of these meals. A dietary note, dated 03/22/11, written by the dietician, documented, "133# March wt. Decrease of 5.7%/month, 14.4%/3 months, 12.5%/6 months. Notify doctor. Receives a mech (mechanical) soft diet with NTL (nectar thick liquids). PO intake avg is 73%. estimated calories is 1600 calories. Needs 1800 calories. 89% of needs met. Nursing indicates a notable decline. Currently on ATB for UTI. Fed by staff. March labs indicate: Glu (glucose) 86, K (potassium) 4.4, BUN (blood urea nitrogen) 20, Alb ([MEDICATION NAME]) 3.2. Meds (medications) include [MEDICATION NAME] and K. Consider shakes bid to increase caloric intake." The resident lost 8.1 lbs between February 2011 and March 2011. This was a 5.7% severe weight loss in one month. There was no documentation which indicated the physician was notified or that bid health shakes were initiated. The resident's March 2011 MARs were reviewed. There was no documentation to show the resident was offered or took a health shake bid. The April 2011 meal percentage sheet, documented the resident took in less than 75% at 11 meals. She was offered a meal replacement at six of these meals. A form titled, Dietary Recommendations, dated April 11, 2011, did not have the resident's name listed on it as being seen by the dietician. A dietary note, dated 04/29/11 and written by the dietary manager, documented, "(Resident) needs assistance with her meals and her diet is mechanical soft with ground meat and nectar thickened liquids. Her weight has declined in March. Will monitor her weight in April and meal intakes." There was no weight recorded for the resident for April 2011. The resident lost 1.2 lbs between March 2011 and May 2011. The resident's April 2011 MARs were reviewed. There was no documentation to show the resident was offered or took a health shake bid. A form titled, Dietary Recommendations, dated May 2, 2011, did not have the resident's name listed on it as being seen by the dietician. The May 2011 monthly physician's orders [REDACTED]. On 05/09/11 at 12:00 p.m., the ADON was asked if she was aware that the resident had a severe weight loss. She stated, "No. I wasn't. Maybe (the DON) is." She was asked if she knew whether or not the resident was supposed to get supplements. She stated she didn't know if she was supposed to get them. She also stated the DON was talking about fixing replacement documentation. At 12:18 p.m., the DON was asked if he was aware the resident had a severe weight loss. He stated, "We are having problems with residents being weighed." He was asked if he was aware the dietician had recommended health shakes for the resident in March 2011. He stated in the past, the dietician would give him forms each month with recommendations on them. He stated at some point this had stopped and he was unsure why. At 3:20 p.m., LPN #2 was asked if the resident received health shakes. She stated the resident received some health shakes but not routinely. She also stated the resident did not receive health shakes at meals. At 3:30 p.m., the ADON was asked where health shakes would be documented as being given. She stated, "On the meal percentage sheet if it's a meal replacement and the MAR indicated [REDACTED]." 2. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A temporary care plan, dated 09/02/10, documented the resident had anxiety and needed supervision with eating. An undated, admission nutritional status form, documented, "Weight via family is 123 lbs. Is on a regular diet. Likes sweets. Will need to monitor nutritional needs..." An admission weight, dated 09/03/10, documented the resident weighed 114.6 lbs. An undated, 5 day nutritional status form, documented, "Resident not eating well 70% of meals. Nursing is assisting resident but resident is figidy (sic). No diet change. Will monitor this resident's nutritional needs...." An undated, 14 day nutritional status form, documented, "Resident's weight is 113.7 (down) 9.3 lbs. in month. Resident eats very little... Resident is assisted to dining room in unit. Will monitor nutritional needs of resident..." A comprehensive care plan, dated 09/24/10, documented, "Nutritional Status: Problem: potential for impaired nutritional status due to significant weight loss, consuming less than 75% of most meals... Goals: Will consume 75% of 2 or more meals daily and have no weight loss by next review...nutritional status will remain stable...lab values WNL... Approaches: Provide total assistance with meals Monitor % of meal consumed and offer meal replacement if consumes less than 50% of each meal Diet as ordered: regular Notify doctor of 8.8% weight loss in 3 months Monitor and record weight per physician's orders [REDACTED]. Discuss food preferences with (resident) or family..." A significant change assessment, dated 09/28/10, documented the resident was severely impaired in cognitive skills for daily decision-making, had deteriorated in ADL function, had a 5% or more weight loss in the last 30 days, and left 25% or more of food uneaten at most meals. A nutrition risk assessment, dated 09/29/10, documented the resident was at moderate risk for a nutritional deficit. A Dietitian's Recommendations to Nursing/Dietary form, dated 09/29/10, documented, "...(resident) ...recommendations: offer fortified foods..." There was no doctor's order for fortified foods and the clinical records indicated the resident continued to receive a regular diet. An undated, 30 day nutritional status form, documented, "Weight loss of 9.3 lbs. since admit. Does not eat well...Monitoring resident's nutritional status. Not eating a concern..." On 10/08/10 the resident's weight was recorded as 107.9 lbs. This represented a severe weight loss of 6.7 pounds or 5.8% from the admission weight of 114.6 pounds on 09/03/10. There was no documentation that indicated the resident was weighed weekly, or that the physician was consulted as specified in the facility's policies. A dietary progress note, dated 10/17/10 and signed by the dietitian, documented, "107.9 Oct. wt.; Oct. 11th wt. 103.9 (down) 5.1% (in one month). Notify doctor. Intake has improved. Will monitor..." This note documented the resident lost an additional 4 pounds or 3.7% in three days. A dietitian's notification form, dated 10/17/10, documented, "...Wt. has (decreased) 5.1% (in a month) 113.7 - 107.9 (lbs) Staff indicates was not eating. Intake has improved over past few weeks..." No recommendations for further actions or interventions were documented on the form. There was no documentation on the form that indicated nursing staff reviewed the form, or that the physician was notified of the severe weight loss. An October 2010 monthly meal percentage record documented the resident consumed: 50% or less: 19 of 93 meals Refused: 10 of 93 meals No record: 16 of 93 meals The resident was offered one meal replacement during the month of October 2011. On 11/10/10, the resident's weight was recorded as 105.8 lbs. A dietary progress note, dated 11/22/10, and signed by the dietary manager, documented, "90 day assessment complete. Nov. weight 105.8 (down) 1.1 lb. Eats 79.5% of meals. No change in diet. No new labs. Will monitor weight and nutritional needs..." A Dietitian's Recommendations to Nursing/Dietary form, dated 11/24/10, did not list the resident's name as a person of concern to the dietitian. A November 2010 monthly meal percentage record documented the resident consumed: 50% or less: 10 of 90 meals Refused: 5 of 90 meals No record: 7 of 90 meals The resident was not offered a meal replacement for any meal in November 2010. On 12/10/10, the resident's weight was recorded as 104.5 lbs. This represented a severe weight loss of 10.1 pounds or 8.8% in three months from the admission weight of 114.6 pounds on 09/03/10. A dietary progress note, dated 12/13/10 and signed by the dietitian, documented, "104.5 Dec. wt. (down) 8.1% (in 3 months). Regular diet PO intake avg 82% provides 1968 cal needs 1280 cal. Notify doctor..." A dietitian's notification form, dated 12/13/10, documented, "Wt. (decreased) 8.1% (in 3 months) 113.7 - 104.5 (lbs) Regular diet. PO intake avg. 82% (estimate) calories 1968, needs 1280..." There was no recommendation for further actions or interventions documented on the form. There was no documentation on the form that indicated nursing staff reviewed the information or that the physician was notified of the severe weight loss. There was no documentation that indicated the resident was weighed weekly. A December 2010 monthly meal percentage record documented the resident consumed: 50% or less: 9 of 93 meals Refused: 7 of 93 meals No record: 15 of 93 meals The resident was offered only one meal replacement in December 2010. The resident refused it. On 01/07/11, the resident's weight was recorded as 101.7 lbs. This documented the resident lost an additional 2.8 pounds or 2.6%. A Dietitian's Recommendation to Nursing/Dietary form, dated 01/17/11, did not list the resident's name as a person of concern to the dietitian. A January 2011 monthly meal percentage record documented the resident consumed: 50% or less: 27 of 93 meals Refused: 3 of 93 meals No record: 17 of 93 meals The resident was offered and accepted two meal replacements. The resident refused two other meal replacements in January 2011. There was no documentation of any other nutritional supplements provided to the resident. There was no documentation of snacks between meals. On 02/14/11, the resident's weight was recorded as 104.8 lbs. A February 2011 monthly meal percentage record documented the resident consumed: 50% or less: 24 of 84 meals Refused: 5 of 84 meals No record: 8 of 84 meals The resident was offered and accepted three meal replacements. The resident refused three other meal replacements in February 2011. There was no documentation of any other nutritional supplements provided to the resident. There was no documentation of snacks between meals. A care plan, dated 03/04/11, documented, "I have a nutritional problem or potential nutritional problem r/t consuming less than 75% of meals... Goal: I will maintain adequate nutritional status as evidenced by no weight loss through review date... Interventions:...Provide and serve diet as ordered...Monitor intake and record q meal..." On 03/05/11, the resident's weight was recorded as 101.5 lbs. This represented a severe weight loss of 13.1 pounds or 11.43% in six months since the admission weight of 114.6 pounds on 09/03/10. There was no documentation that indicated the resident was placed on weekly weights, or that the physician was notified of the severe weight loss. A dietary document titled, Chart Review, dated 03/22/11, documented, "(Resident) wt. loss 10.7% in 6 months; notify doctor." There was no documentation that indicated the physician was notified of the severe weight loss. A March 2011 monthly meal percentage record documented the resident consumed: 50% or less: 24 of 93 meals Refused: 11 of 93 meals No record: 13 of 93 meals The resident was offered and accepted 13 meal replacements. The resident refused one other meal replacement in March 2011. On 04/03/11, the resident's weight was recorded as 102.2 lbs. An April 2011 monthly meal percentage record documented the resident consumed: 50% or less: 42 of 90 meals Refused: 12 of 90 meals No record: 15 of 90 meals The resident refused 21 meal replacements in April 2011. She was not offered 42 meal replacements. A dietary recommendations form, dated 05/02/11, did not include the resident's name as a person of concern for the dietary department. There was no documentation of any other nutritional supplements provided to the resident. There was no documentation of snacks between meals. On 05/03/11 at 11:16 a.m., the resident was observed sitting in a wheelchair at a table in the special care unit dining room. She had a small red drinking glass in front of her that was empty. It was not refilled by staff before the meal, or at any time during the meal. No staff sat at the table or assisted her during the meal. The resident ate approximately 75% of the lunch meal. At the end of the meal, an unidentified CNA began clearing away the trays. She picked up the juice glass and asked the resident if she wanted more to drink. She said, "No." The CNA walked away without asking the resident if she wanted anything else. At 4:35 p.m., the resident was observed in her wheelchair sitting at the table in the special care unit dining room. She drank all the juice in a small glass before the beginning of the dinner meal. The dinner meal was served. No staff sat at the table with the resident. No staff assisted her with her meal. She picked up her peaches and tried to drink them. A CNA walking by asked her if she wanted more juice. The resident did not respond. The resident ate 50% of the meal and then pushed herself away from the table. No other fluids were offered to the resident. No meal replacement was offered to the resident. At 4:45 p.m., RN #1 and the ADON were asked how the nurses kept track of meal percentages. They stated the CNAs document the meal percentages on a form every day and turn them in to dietary. They further stated the dietary department documents all the meal percentages for the month on a form, and then would give a monthly meal percentages report to the nurses. They stated the nurses get the data about one to two weeks into the next month. RN #1 stated, "Dietary lets us know if the resident begins to not eat well." She was asked how dietary communicated with the nursing staff. She stated the dietary manager came to talk to the nurses. She was asked if the dietary staff communicated in the progress notes. She said she didn't know. She was asked how the nurses monitored weight loss. She stated, "Dietary keeps on top of it. They are really good about tracking it." She was asked when the dietitian was to be consulted about a resident's weight loss. She stated, "The dietitian is here every so often. Dietary or the DON can contact her (the dietitian) if needed." On 05/04/11 at 11:30 a.m., the dietary manager was asked if she was aware of the resident's severe weight loss. She stated she had not reviewed the dietitian's most recent notes, written the day before. She stated she knew the resident had a small appetite. She was asked if the weight records for May were available. She stated she did not think so, but the CNAs could weigh the resident if the surveyor requested it. At 11:40 a.m., the dietitian was contacted by phone and asked if she had identified anyone with severe weight loss during her monthly visit the day before. She stated she did not think so. She was asked how the physician was notified about a resident's severe weight loss. She stated she would write an electronic progress note. She further stated, "The DON tells me I can trigger a notice to alert the nurses and the physician. I'm not sure how that works." At 12:00 p.m., the resident was observed in her wheelchair in the dining room. She had pushed herself away from the table. Her tray had already been removed. The resident had food stains on her shirt, crumbs on her shirt and pants, and juice stains around her lips. At 12:30 p.m., the DON was asked if the residents in the facility had been weighed for the month of May. He stated a very few of the residents were weighed, but not many. He was asked how the dietitian could assess the residents without the monthly weight records. He stated, "She can't. It's a problem." He was asked if the physician had been consulted about the resident's severe weight loss. He stated, "I know we don't have documentation on that, but I'm sure we did." At 1:15 p.m., the resident's weight was recorded as 100.8 lbs. At 4:30 p.m., the resident was observed in her wheelchair sitting at the table in the special care unit dining room. She drank all the juice in a small glass before the beginning of the meal. At 5:15 p.m., the resident was observed as she attempted to shred a tuna sandwich with a fork. She picked up a piece of the shredded sandwich, and using one hand, she would place it onto the fork. Balancing the piece of tuna sandwich on the fork, she tried to lift it to her mouth. Many times the sandwich fell off her fork before it got to her mouth. The plate also contained two large slices of tomato. The slices were not cut into bite-sized pieces. The resident tried twice to move the tomato around the plate in an attempt to eat it. She did not try to cut it with a knife. No staff person sat at the table with her. No staff person assisted her during the meal. At one point, the resident attempted to eat chicken noodle soup with her fork. She was not aware a spoon was on her tray. She finally stopped trying to eat her meal and pushed herself away from the table. Her juice glass remained empty for the entire meal. She was not offered any other fluids. She consumed 20-25% of her meal.

Based on clinical record review and staff interview, it was determined the facility failed to provide restorative services to maintain ambulation resulting in actual harm for one (#5) of one sampled resident who required restorative services to maintain ambulation. This had the potential to affect eight residents identified by the facility as needing restorative services. Findings: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An initial temporary care plan, dated 09/02/10, documented the resident required the assistance of one staff member for toileting, ambulating and transferring. A physical therapy plan of treatment form, dated 09/03/10, documented, "...Treatment DX: Difficulty Walking... Functional Goals: (increase) bed mobility, (increase) transfers, (increase) dynamic standing balance to fair, (increase) ambulation to 150 ft... Reason for Referrals: Acute hospitalization for UTI & depression c resulting decline in transfers & ambulation... Prior Level of Function: Lived in own home alone & ambulated (independently)... Outcome (Long Term Goal): Pt will perform transfers (independently) & will ambulate c (assistive devices)..." The medical record documented the resident received physical therapy five times a week for gait training, balance, and transferring skills beginning on 09/03/10. A physical therapy progress note, dated 09/03/10, documented the resident ambulated 50 feet with her walker. A physical therapy progress note, dated 09/06/10, documented the resident ambulated 100 feet in the merrywalker. A Resident Assessment Protocol (RAP) Summary, dated 09/08/10, documented, "...ADL Rehabilitation and Maintenance...(Resident name deleted) requires limited assistance of one staff of transferring between surfaces, walking in room, corridor and locomotion on and off the unit..." A significant change assessment, dated 09/28/10, documented the resident had deteriorated in the areas of cognition, ADL function, urinary continence, and overall care needs. There was no documentation to indicate the care plan had been modified in response to the significant change. This was the first comprehensive assessment documented for the resident. An admission comprehensive assessment that was due on 09/16/10 was not completed. A physical therapy note, dated 10/31/10, documented the resident had full weight-bearing, had fair balance and used the merrywalker to ambulate 250 feet. A skilled nurse's note, dated 11/08/10, documented, "...Staff wheeled res in w/c to breakfast then took her back to her room (and) walked her to breakfast per restorative orders she did well. Explained to aides res is to walk to meals (and) in hallway when she is restless ..." There was no documentation in the care plan to indicate the resident was to be ambulated with assistance everyday, or that a restorative plan including walk to dine was in place. The care plan did not indicate the resident should be ambulated with assistance during periods of anxiety or agitation. A physical therapy progress note, dated 12/08/10, documented the resident was ambulating with the merrywalker for 300 feet. A skilled nurses note, dated 12/12/10, documented, "...D/C from skilled services to LTC at (midnight)..." A physical therapy progress note, dated 12/15/10, documented, "... Pt discharged from PT. No change from last note 12/08/11 (sic). Continue ambulation c assistance only..." There was no documentation of any further recommendations from physical therapy regarding a restorative program for the resident. A Restorative Flow Sheet, dated December 2010, documented the resident was not assisted to walk to meals and as desired on 12/08/10, 12/09/10, 12/13/10, 12/15/10, 12/16/10, 12/18/10, 12/19/10, 12/22/10, 12/24/10, 12/27/10, 12/28/10, 12/29/10, 12/30/10 and 12/31/10. There were no other restorative flow sheets after December 2010. A Monthly Summary Progress Note, dated 12/17/10, documented the resident used a lap belt restraint and did not receive any therapies or restorative programs. A care plan, dated 12/21/10, documented, "...I need assistance to turn/reposition every two hours, more often as needed or requested...Please reposition me as needed..." There was no documentation of a plan for restorative services or a plan for assistance with ambulation. There was no documentation that indicated how long the resident sat in her wheelchair each day. There was no documentation the resident was ambulated regularly with assistance during the months of January and February 2011. A care plan, dated 03/04/11, did not address ambulation. It did not include restorative services to maintain strength and mobility. A physician's telephone order, dated 03/04/11, documented, "... DC merrywalker - non-use..." There was no documentation the resident was ambulated regularly with assistance during the months of March and April 2011. On 05/05/11 at 9:50 a.m., the physical therapist was asked if he had completed a discharge summary with recommendations for follow-up care when the resident was discharged from physical therapy services. He stated, "It should have been documented on the initial assessment form but it wasn't." He was asked if he made any recommendations for a restorative program for the resident. He stated he had recommended a walk to dine program. He was asked if the facility employed restorative aides. He stated, "No. The CNAs perform that function." He was asked if the resident had retained her ability to walk 300 feet. He stated, "I don't think she can walk at all now. She has declined." He was asked if the resident could stand or move herself out of the wheelchair independently. He stated he didn't think so. At 10:10 a.m., CNA #5 was asked if the resident had recently walked with assistance to the dining room for meals. She stated, "I don't know." She was asked if the resident ever attempted to remove her lap belt and exit the wheelchair to try to walk. She stated, "No. She is a two person transfer. She's pretty weak." At 1:00 p.m., the DON was asked if there were any other facility records that documented restorative services for the resident, other than the December 2010 Flow Sheet. He stated there were not. He stated a restorative program would be starting the next day.