Every finding on record at Forest Hills Care and Rehabilitation Center

Based on observation, record review and interview, the facility failed to ensure comprehensive care plans were developed for 2 (#80 and #108) of 20 sampled residents whose care plans were reviewed. The DON reported 140 residents resided in the facility. Findings: 1. On 04/29/25 at 2:37 p.m., Resident #80 was observed in bed. Resident #80's right hand was observed to be contracted. A facility policy titled Comprehensive Person-Centered Care Plan, reviewed 10/23/19, read in part, Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the facility will provide care. An admission record, dated 06/20/24, showed Resident #80 had diagnoses which included kidney failure and dementia. A care plan, initiated 06/20/24, did not show interventions for the resident's contracted right hand. A significant change assessment, dated 04/09/25, showed Resident #80 had a BIMS summary score of 13 which was indicative of intact cognition. The assessment also showed Resident #80 was totally dependent on staff for care and had a range of motion impairment to one side of their upper body. On 05/06/25 at 9:41 a.m., LPN #4 stated they sometimes put hand rolls in Resident #80's hand, but there were no formal interventions in place. On 05/06/25 at 4:45 p.m., the MDS coordinator stated interventions should be in place for Resident #80's contracted right hand and the care plan should include those interventions. 2. An admission record, dated 10/21/24, showed Resident #108 had diagnoses which included obstructive and reflux uropathy and retention of urine. A significant change assessment, dated 02/11/25, showed Resident #108 had a BIMS summary score of 12 which indicated the resident was moderately impaired in cognition for daily decision making. The assessment also showed Resident #108 had an indwelling urinary catheter. A care plan, revised 04/06/25, did not include the use of an indwelling urinary catheter. On 05/06/25 at 4:45 p.m., the MDS coordinator stated the use of a urinary catheter should be included on the resident's care plan.

Based on observation, record review, and interview, the facility failed to ensure: a. range of motion services were provided for 2 (#97 and #75); and b. provide contracture interventions for 1 (#80) of 3 sampled residents who were reviewed for range of motion. The DON identified 12 residents with contractures and 43 residents with limited range of motion. Findings: 1. A policy titled Establishment of an Individual Restorative Program, dated 01/02/24, read in part, To provide treatment and services to maintain and improve functional abilities per physician order. A policy titled Range of Motion, dated 01/24/24, read in part, To exercise the resident's joints and muscles as required and/or clinically indicated. A Restorative Nursing Care Plan, dated 03/28/25, showed Resident #75 was to receive restorative services two to three times a week for eight weeks. A PT [Physical Therapy] Evaluation and Plan of Treatment, dated 04/18/25, read in part, Patient educated on initiation of RNP to maintain currently [sic] functional status. RNP to be established on this date. An OT [Occupational Therapy] Evaluation and Plan of Treatment, dated 04/18/25, read in part, Pt is currently at [their] baseline in physical function. Pt to participate in restorative program. The quarterly assessment, dated 04/23/25, showed Resident #75 had a diagnosis of hemiplegia affecting left nondominant side, had a BIMS score of eight which indicated the resident was moderately impaired in cognition for daily decision making, upper extremity impairment on one side, lower extremity impairment on both sides, and had not received any restorative services during the look back period. A Restorative Delivery Documentation form, dated April 2025, showed Resident #75 had received restorative nursing services on 04/24/25 and 04/30/25. On 04/27/25 at 10:35 a.m., Resident #75 stated they were supposed to receive restorative services. They stated they only received restorative services one day in the past week. On 05/07/25 at 10:32 a.m., the DON stated the resident was evaluated for skilled nursing services, but it had been determined the resident was at their baseline functioning level. They stated the resident was to be on restorative services. The DON stated restorative services had not been being performed as indicated for the residents. 2. A Plan of Care Note, dated 07/15/24 at 11:20 a.m., showed during a care plan meeting a family member had verbalized they would like Resident #97 to be evaluated for restorative services. The quarterly assessment, dated 04/23/25, showed Resident #97 had a BIMS score of 08, which indicated the resident was moderately impaired in cognition for daily decision making, had impairment to one side of their upper body and impairment to both sides of the lower body, and no therapies or restorative nursing services had been received during the look back period. On 05/07/25 at 10:30 a.m. the DON stated they did not have documentation Resident #97 had been assessed for the restorative program. They stated they had instructed staff to perform range of motion exercises during ADL care. They stated they did not have any documentation range of motion had been provided for the resident. 42171 3. On 04/29/25 at 2:37 p.m., Resident #80 was observed in bed. Resident #80's right hand was observed to be contracted. An admission record, dated 06/20/24, showed Resident #80 had diagnoses which included kidney failure and dementia. A significant change assessment, dated 04/09/25, showed Resident #80 had a BIMS summary score of 13 which was indicative of intact cognition. The assessment also showed Resident #80 was totally dependent on staff for care and had a range of motion impairment to one side of their upper body. Review of the electronic health record did not show any interventions for the resident's contracted right hand. On 05/06/25 at 9:41 a.m., LPN #1 stated they sometimes put hand rolls in Resident #80's hand, but there were no formal interventions in place. On 05/06/25 at 4:45 p.m., the MDS coordinator stated interventions should be in place for Resident #80's contracted right hand and the care plan should include those interventions.

Based on observation, record review and interview, the facility failed to: a. follow EBP during the provision of care for 1 (#108) of 2 sampled residents reviewed for catheter care; and b. ensure clean laundry was transported appropriately. The DON reported 11 residents had urinary catheters and 110 residents' laundry was cleaned by the facility. Findings: 1. On 05/05/25 at 3:45 p.m., LPN #3 was observed providing catheter care to Resident #108. LPN #3 was not observed to wear a gown. A facility policy titled Enhanced Barrier Precautions, reviewed 05/15/24, read in part, The facility may expand the use of PPE [personal protective equipment] & refer to the use of gowns & gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to hands/clothing. The use of gown & gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for facility residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with colonization. An admission record, dated 10/21/24, showed Resident #108 had diagnoses which included obstructive and reflux uropathy and retention of urine. A significant change assessment, dated 02/11/25, showed Resident #108 had a BIMS summary score of 12 which indicated the resident was moderately impaired in cognition for daily decision making. The assessment also showed Resident #108 had an indwelling urinary catheter. On 05/05/25 at 3:55 p.m., LPN #3 stated they should have been wearing a gown while providing care to Resident #108. On 05/06/25 at 10:37 a.m., the DON stated the facility used EBP and a gown should be worn when providing direct care to a resident with an indwelling urinary catheter. 35474 2. On 05/06/25 at 4:58 p.m., laundry personnel #1 was observed to deliver clean personal laundry to residents on the 600 hall. The laundry cart/rack was observed to be uncovered when it was delivered to six rooms. On 05/06/25 at 5:07 p.m., laundry personnel #1 stated the cover for the laundry cart/rack was in the washing machine. They stated they should have waited to deliver the clean laundry until they had a cover to protect the clothing, but since they were delivering laundry to only five or six residents they delivered it without covering the clean laundry. On 05/07/25 at 11:25 a.m., the laundry supervisor stated laundry should be covered when it was delivered to the residents' rooms.

Based on record review and interview, the facility failed to ensure residents were offered the pneumococcal immunization for 3 (#28, 83, and #330) of 5 sampled residents reviewed for immunizations. The DON identified 140 residents resided in the facility. Findings: A policy titled Pneumococcal Vaccine, dated 12/05/24, read in part, The opportunity to receive the Pneumococcal Vaccine will be extended to all Residents. The facility will provide pertinent information regarding the Risks/Benefits of receiving the Vaccine. 1. An undated face sheet showed Resident #330 had a diagnosis of diabetes. Review of the immunization tab in the electronic clinical record did not show the resident had been offered the pneumococcal immunization. 2. A significant change assessment, dated 02/14/25, showed Resident #83 had a diagnosis of a stroke and the pneumococcal immunization was up to date. Review of the immunization tab in the electronic clinical record did not show when the resident had received the pneumococcal immunization or that the facility had offered the immunization. 3. A quarterly assessment, dated 04/30/25, showed Resident #28 had a diagnosis of heart failure, had a BIMS score of nine which indicated the resident was moderately impaired in cognition for daily decision making, and the pneumococcal immunization had been offered and declined. Review of the immunization tab in the electronic clinical record did not show when the resident had been provided education/offered the pneumococcal immunization. On 05/07/25 at 1:04 p.m., the DON stated pneumococcal immunization documentation should be under the immunization tab in the electronic clinical record. They stated they did not have information related to the pneumococcal immunization for Resident #330, 83, or Resident #28.

Based on record review and interview, the facility failed to ensure injuries of unknown origin were reported to the Oklahoma State Department of Health as required for 1 (#80) of 3 sampled residents reviewed for abuse. The DON reported 140 residents resided in the facility. Findings: A facility policy titled Abuse Prevention, revised 10/21/23, read in part, Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of a residents property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. If the events that cause the allegation do not involve abuse or result in serious bodily injury, are reported immediately, but not later than 24 hours after the allegation is made, to the administrator of the facility and to other officials (including State Survey Agency, and local law enforcement as required). An admission record, dated 06/20/24, showed Resident #80 had diagnoses which included kidney failure and dementia. A nurse note, dated 03/02/25 at 2:29 p.m., showed Resident #80's family informed the nurse the resident's shoulder was hurting. The note showed an assessment was completed with swelling and warmth being noted, and an x-ray of the left shoulder was ordered. A nurse note, dated 03/02/25 at 9:12 p.m., read in part, Results from shoulder x-ray received and are positive for left shoulder subluxation [partial dislocation]. A nurse note, dated 03/03/25 at 8:22 p.m., showed the resident was sent to the emergency room for evaluation of the left shoulder. A significant change assessment, dated 04/09/25, showed Resident #80 had a BIMS summary score of 13 which was indicative of intact cognition. The assessment also showed Resident #80 was totally dependent on staff for care. On 04/30/25 at 9:30 a.m., LPN #1 stated they were on duty when the resident's family complained their shoulder was hurting. LPN #1 also stated they were not sure what caused the injury. On 05/06/25 at 10:40 a.m., the DON stated that Resident #80's dislocated shoulder was not reported to the Oklahoma State Department of Health as an injury of unknown origin and that they had performed an internal investigation. The DON also stated the injury was unwitnessed and the resident was unable to explain what had happened.

Based on record review and interview, the facility failed to ensure injuries of unknown origin were thoroughly investigated for 1 (#80) of 3 sampled residents reviewed for abuse. The DON reported 140 residents resided in the facility. Findings: A facility policy titled Abuse Prevention, revised 10/21/23, read in part, The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and to provide protection to any alleged victims to prevent harm during the continuance of an investigation. An admission record, dated 06/20/24, showed Resident #80 had diagnoses which included kidney failure and dementia. A nurse note, dated 03/02/25 at 2:29 p.m., showed Resident #80's family informed the nurse that the resident's shoulder was hurting. The note showed an assessment was completed and that swelling and warmth to the left shoulder were noted, and an x-ray of the left shoulder was ordered. A nurse note, dated 03/02/25 at 9:12 p.m., read in part, Results from shoulder x-ray received and are positive for left shoulder subluxation [partial dislocation]. A nurse note, dated 03/03/25 at 8:22 p.m., showed the resident was sent to the emergency room for evaluation of the left shoulder. A significant change assessment, dated 04/09/25, showed Resident #80 had a BIMS summary score of 13 which was indicative of intact cognition. The assessment also showed Resident #80 was totally dependent on staff for care. On 04/30/25 at 9:30 a.m., LPN #1 stated they were on duty when the resident's family complained that their shoulder was hurting. LPN #1 also stated they were not sure what caused the injury or if an investigation was completed. On 05/06/25 at 10:40 a.m., the DON stated Resident #80's dislocated shoulder was investigated internally, but they did not document interviews with staff members or the physician, nor did they interview any additional residents regarding their treatment in the facility.

Based on observation, record review, and interview, the facility failed to provide ADL care for 1 (#3) of 3 sampled residents reviewed for ADL care. The DON identified 27 residents were dependent of staff for nail care. Findings: On 04/27/25 at 9:05 a.m., Resident #3 was observed lying in bed. The resident's toenails were observed to be long and unkempt. A facility policy titled Nail Care, reviewed 07/21/22, read in part, The purpose of nail care is to clean the nail bed, trim nails, and prevent infection. A significant change assessment, dated 03/06/25, showed Resident #3 had a BIMS summary score of 14 which was indicative of intact cognition, and they required substantial assistance from staff. A Skin Monitoring CNA Bathing Review form, dated 04/16/25, showed the resident's toenails needed to be trimmed. On 04/27/25 at 9:11 a.m., Resident #3 stated since they went off hospice no one was trimming their toenails. They also stated their toenails were so long they were uncomfortable. On 04/28/25 at 2:15 p.m., CNA #1 stated CNAs were supposed to provide nail care to residents on their hall on the resident's shower day unless the resident was diabetic, then they were supposed to inform the nurse. On 04/28/25 at 2:21 p.m., CNA #2 stated Resident #3's toenails were long and needed to be trimmed, but they were not sure if the resident was diabetic or not. On 04/28/25 at 2:28 p.m., LPN #1 stated charge nurses were responsible for ensuring residents received appropriate nail care.

Based on observation, record review, and interview, the facility failed to ensure medications were secure for 1 (500 hall medication/treatment cart) of 2 medication/treatment carts observed on the 500 hall. The DON identified 15 medication/treatment carts in the facility. Findings: On 04/29/25 at 11:50 a.m., the 500 hall medication/treatment cart was observed to be unlocked and unattended on the 500 hall across from the restrooms. On 04/29/25 at 11:54 a.m., the administrator locked the 500 hall medication/treatment cart as they walked by and stated they needed to find out who was assigned to the medication/treatment cart. On 04/29/25 at 11:57 a.m., LPN #5 stated they should have locked the cart, but had forgotten. On 05/07/25 at 10:38 a.m., the DON stated medication/treatment carts were to remain locked when left unattended. They stated they monitored medication/treatment carts to ensure they were locked when unattended. They stated it was a constant battle.

Based on record review and interview, the facility failed to ensure a resident was offered the COVID-19 vaccination for 1 (#83) of 5 sampled residents reviewed for the COVID-19 vaccination. The DON identified 140 residents resided in the facility. Findings: A policy titled Covid Vaccine, dated 09/04/24, read in part, The Facility will offer the COVID Vaccine to Employees/Residents to assist in mitigating the spreads [sic] of COVID-19. A significant change assessment, dated 02/14/25, showed Resident #83 had a diagnosis of a stroke and the COVID-19 vaccination was not up to date. Review of the immunization tab in the electronic clinical record did not show when the resident had been offered or received the COVID-19 vaccination. On 05/07/25 at 1:04 p.m., the DON stated Resident #83 must have been out of the facility when they had offered the COVID-19 vaccination during a COVID clinic. The DON stated, We must have missed it.

Based on observation and interview, the facility failed to ensure medications were labeled and not expired for three (200 hall treatment cart, 600 hall treatment cart, and 500 hall medication cart) of seven medication/treatment carts observed. The DON identified 13 medication/treatment carts in the facility. Findings: 1. On 02/05/24 at 7:38 a.m., the medication/treatment cart for 400 hall was observed to be unlocked and unattended. On 02/05/24 at 7:40 a.m., LPN #3 was observed to lock the medication/treatment cart. On 02/05/24 at 7:40 a.m., the medication/treatment cart for the 300 hall was observed to be unlocked and unattended. The cart was observed to have a bottle of wound cleanser sitting on the top. On 02/05/24 at 7:51 a.m., LPN #4 stated the medication/treatment cart did not belong to them and left without locking the cart. On 02/05/24 at 7:54 a.m., LPN #4 approached the medication/treatment cart, placed the bottle of wound cleanser inside, and left the cart unlocked and unattended. On 02/05/24 at 7:55 a.m., LPN #4 walked by the medication/treatment cart and locked it. On 02/08/24 at 12:02 p.m., CMA #1 stated when they had arrived on duty for their shift, the keys to the 500 hall medication cart were inside a three-ring binder on top of the unlocked cart. They stated they found the keys in the three-ring binder and the cart unlocked approximately once a week. 2. On 02/08/24 at 11:25 a.m., the 200 hall treatment cart was observed with LPN #1. LPN #1 stated they were not aware of the opened date or the expiration dates on the medications. The following medications were observed: a. One bottle of hydrogen peroxide expired 03/2022. b. One bottle of dakins solution expired 08/2022. c. One bottle of providine iodine expired 04/2023. d. Two, opened bottles of glucometer strips not dated. e. One bottle of sodium chloride one gram expired 01/2024. f. One bottle of vitamin B1 100 mg expired 10/2023. g. One bottle of senna plus expired 08/2022. h. One bottle of vitamin E tablets expired 09/2023. i. One bottle of bisacodyl 5mg tablets expired 12/2022. j. Two bottles of famotidine 10 mg. One expired 09/2022 and one expired 06/2023. k. Two bottles of cranberry 450 mg tablets. One expired 12/2023 and one expired 06/2022. l. One bottle of cetirizine 10 mg tablets expired 07/2021. m. One bottle of geri-cot 8.6 mg tablets expired 04/2023. n. One bottle of lactase supplement tablets expired 05/2023. o. Two bottles of docusate 100 mg. One expired 09/2022 and one expired 02/2023. p. Two bottles of probiotic tablets. One expired 12/2023 and one expired 09/2023. q. One bottle of magnesium oxide 400 mg expired 12/2023. r. One bottle of ibuprofen 200 mg expired 08/2023. s. One bottle of vitamin D 50000 iu expired 11/2022. t. One bottle of calcium carbonate chewable 500 mg expired 04/2023. u. One bottle of control solution for the glucometer expired 12/2023. v. Two derma-phor ointments opened but not dated. w. One tube of renew skin protectant opened but not dated. x. Two tubes of zinc oxide ointment opened but not dated. y. One tube of Voltaren gel opened but not dated. z. One tube of A and D ointment opened but not dated. aa. One tube of antifungal cream opened but not dated. bb. One tube of triad wound cream opened but not dated. cc. One tube of muscle rub cream expired 06/2023, opened but not dated dd. One unlabeled, unopened Novolog insulin pen. ee. One tube of arthritis relief cream opened but not dated. ff. One tube of triamcinolone cream opened but not dated. gg. One tube of lidocaine 2.5% cream opened but not dated. hh. One package of Promethegan 25 mg suppositories. The instructions document to store between 36 and 46 degrees Fahrenheit. ii. One Trelegy inhaler inhaler opened but not dated. On 02/08/24 at 11:39 a.m., the 600 hall treatment cart was observed with LPN #2. LPN #2 stated the DON and ADON monitored for labeling and expired medications. They stated medications should be labeled for the date the medication was opened. The following medications were observed: a. 18-lorazepam 2 mg/ml syringes for Resident #11, dated 03/06/23. The label documented the medication expired 30 days from the date of 03/06/23. b. 20-morphine 20 mg/ml syringes for Resident #4 expired 02/03/24. c. One Breo-Ellipta inhaler opened 01/02/24 for Resident #272. d. One albuterol inhaler for Resident #81 expired 12/2023. e. One albuterol inhaler for Resident #93 expired 06/2023. f. One albuterol inhaler for Resident #71 expired 06/2023. g. One albuterol inhaler for Resident #91 expired 01/2024. h. One tube of Voltaren gel, unlabeled and opened but not dated. LPN #2 stated it was a specific resident's medication but could not remember who it belonged to. i. One tube of arthritis relief opened but not dated. j. One tube of hydrocortisone cream opened but not dated. k. One bottle of control solution for the glucometer expired 12/31/23. l. One bottle of iodine mini caps expired 01/03/22. m. One bottle of iodine solution opened but not dated. n. One bottle of dakins solution expired 12/2023. o. One tube of Biofreeze opened but not dated. p. One bottle of glucometer test strips opened but not dated. On 02/08/24 at 12:02 p.m., the 500 hall medication cart was observed with CMA #1. The following medications were observed: a. One bottle of fluticasone nasal spray for Resident #31 and Resident #46 were opened, but not dated. b. One bottle of calcitonin nasal spray for Resident #75 opened, but not dated. c. One bottle of deep sea nasal spray for Resident #31 opened, but not dated. d. One bottle of artificial tears for Resident #66 dated 01/04/23 e. One bottle of artificial tears for Resident #34 opened, but not dated. f. One bottle of latanoprost eye drops for Resident #66 opened, but not dated. g. One bottle of latanoprost eye drops for Resident #47 opened, but not dated. h. One bottle of latanoprost eye drops for Resident #46 opened, but not dated. On 02/09/24, at 12:57 p.m., the DON stated the medication carts should always be locked when not attended by a nurse or a CMA. The DON stated expired medications should be removed from the cart.

Based on observation, interview and record review, the facility failed to ensure food was provided to residents in a manner required for their needs to prevent choking. Cook #1 stated five residents received pureed diets from the kitchen. Findings: On 02/05/24 at 10:51 a.m., cook #1 was observed to prepare pureed food. Cook #1 stated the facility had five residents who required pureed food. The cook had placed six to seven hamburger patties in the blender, along with water, thickener and a calorie/protein powder supplement. Upon completion of the puree, the puree was tasted. The food was grainy and without flavor. On 02/05/24 at 11:04 a.m., cook #1 was observed to pour peas and carrots, two scoops of thickener and one scoop of calorie/protein powder supplement into the bowl of the blender for puree. The skins of the peas were observed to be throughout the mixture and not smooth. A test sample was taken with a plastic spoon and provided to the surveyor. The puree was not smooth. Cook #1 was asked if there were anything that could cause a resident to choke. They stated no. On 02/05/24 at 11:10 a.m., the registered dietician was asked if the vegetables were of a pureed consistency. They stated no and suggested to the cook they use carrots only, due to the skin of the peas. On 02/05/24 at 11:12 a.m., the registered dietician was asked to taste test the pureed meat. The registered dietician began looking for a spoon and cook #1 removed the pureed meat from the line and discarded it. Cook #1 was asked if they were going to puree more meat. They stated yes. Cook #1 then placed five or six chicken fried steaks, hot water, thickener and a calorie protein powder supplement in the blender for puree. After multiple adds of water the meat was grainy and was without flavor. The registered dietician was asked why the original meat used was hamburger patties. They stated they had signed off on all of food substitutions. The registered dietician then asked for time with the cook and the puree was discarded. On 02/05/24 at 11:28 a.m., cook #1 placed five chicken fried steak patties and gravy in the blender for puree. When the puree was completed a taste sample was provided and observed to be smooth, hot, and full of flavor. On 02/05/24 at 11:58 a.m., cook #1 was observed to puree carrots using the broth from the carrots. When the puree was completed the carrots were tasted and observed to be smooth, hot, and full of flavor. The afternoon meal was scheduled to begin at 11:30 a.m. On 02/05/24 at 12:00 p.m., observations of plating food were conducted. The menu documented to use an ivory scoop to provide a 1/2 cup of vegetables. The scoop was available but not used to serve the vegetables. The portion sizes were observed to be inconsistent. The menu documented a gray scoop be used to provide a 1/2 cup portion of meat. A blue scoop was used to plate the ground meat. The US foods guide documented a blue scoop provided 1/4 cup. The menu documented to provide a 1/2 cup of mashed potatoes. Dietary aide #1 was observed to not fill the scoop entirely before plating the mashed potatoes. The US Foods guide documented a full gray scoop to provide 1/2 cup. The registered dietician was asked how they ensured staff used the correct size utensil to ensure the proper portion of food was provided for the nutritional requirements of the residents. No answer was provided. The dietician and the dietary manager then began replacing the utensils and instructing the staff on proper filling of the utensils to serve the remainder of the residents. The bread and desert were not provided in puree to the residents. On 02/07/24 at 12:46 p.m., the dietary manager stated the pureed beef was not pureed it was grainy. On 02/08/24 at 3:15 p.m., the registered dietician stated on Monday the puree was grainy and they did not provide an inservice with the cook, and there needed to be an inservice with all the cooks on how to properly puree food.

Based on record review and interview, the facility failed to ensure accurate code status for one (#55) of four sampled residents who were reviewed for advance directives. The administrator identified 127 residents who resided in the facility. Findings: Resident #55 had diagnoses which included chronic obstructive pulmonary disease. A signed DNR, dated 08/10/17, was in the scanned documents in the electronic clinical record. A signed DNR, dated 11/28/17, was in the scanned documents in the electronic clinical record. An Advance Directive Acknowledgement Form, dated 12/15/23, documented Resident #55 did not have an advanced directive. The Care Plan, dated 12/28/23, documented Resident #55 was a full code. The demographic banner, face sheet, and active physician orders in the electronic clinical record documented Resident #55 was a full code. On 02/07/24 at 1:01 p.m., the DON stated Resident #55 was a full code. They stated the signed DNR was from a previous admission to the facility but was still in the active electronic clinical record for Resident #55.

Based on record review and interview, the facility failed to ensure resident representatives were notified of changes in condition for one (#89) of one sampled resident who was reviewed for notification of change. The administrator identified 127 residents who resided in the facility. Findings: The Notification of a Change in Condition policy, dated 04/26/23, read in parts, .the Resident Representative will be notified of a Change in a Resident's Condition .Document in the Interdisciplinary Team [IDT] Notes .Resident Change in Condition . Resident #89 had diagnoses which included congestive heart failure. A facility incident report, dated 12/14/23, documented the resident fell . The incident report or nurse progress notes did not document the resident's POA had been notified. A nurse progress note, dated 12/29/23, documented the resident returned from a hospital visit. The note did not document the resident's POA had been notified of the resident's return. A nurse progress note, dated 01/10/24, documented the resident returned from a hospital visit. The note did not document the POA had been notified of the resident's return. A nurse progress note, dated 01/18/24, documented the resident returned from a hospital visit. The note did not document the POA had been notified of the resident's return. A nurse progress note, dated 01/19/24, documented Resident #89 was ordered an antibiotic. The note did not document the POA had been notified. A facility incident report, dated 02/05/24, documented the resident fell . The incident report or nurse progress notes did not document the resident's POA had been notified. On 02/06/24 at 10:13 a.m., the POA stated they had not been notified of changes in the status for Resident #89. They stated they were aware of returns from hospital visits if they called and asked the facility or inquired about their status when they visited. On 02/07/24 at 2:06 p.m., the DON reviewed the incident reports and nurse progress notes and stated there was no documentation the POA had been notified of the changes in condition for Resident #89. They stated they needed to educate the nurses to document resident representative notification of change for the residents.

Based on record review and interview, the facility failed to ensure medications and weights documented in the MDS were accurate for one (#68) of 25 sampled residents who were reviewed for MDS accuracy. The administrator identified 127 residents resided in the facility. Findings: A facility MDS 3.0 policy, dated 04/25/19, read in part .the MDS Coordinator, in conjunction with the Interdisciplinary Team (IDT), expected to complete assessments using the MDS 3.0 Resident Assessment Instrument (RAI) specified by the state in compliance with the MDS 3.0 RAI user's manual guidelines . Resident #68 had diagnoses which included psychotic disorder with hallucinations. a. An Order Summary report, dated 08/23/23, documented Resident #68 received Nuplazid (anti-psychotic medication) at bedtime. A MAR, dated November 2023, documented Resident #68 received Nuplazid. A Quarterly Assessment, dated 11/29/23, documented the resident did not receive antipsychotic medications since the prior assessment. On 02/29/24 at 12:24 p.m., the MDS coordinator stated medications were coded by drug classification. They reviewed Resident #68's quarterly assessment from 11/29/23 and stated it documented anti-psychotic medications were not received. The MDS Coordinator stated it was not accurate because Resident #68 received an anti-psychotic. b. A review of weights and vitals in the clinical of Resident #68, revealed the following weights: On 03/08/2023, Resident #68 weighed 204.6 lbs. On 09/06/2023, Resident #68 weighed 183 pounds, which was a 10.56 % Loss. On 06/07/2023, Resident #68 weighed 194 lbs. On 09/06/2023, Resident #68 weighed 183 pounds, which was a 5.67 % Loss. On 08/09/2023, Resident #68 weighed 191 lbs. On 09/06/2023, Resident #68 weighed 183 pounds, which was a 4.19 % Loss. On 10/15/2023, Resident #68 weighed 180 lbs. On 11/14/2023, Resident #68 weighed 174 pounds, which was a 3.33 % Loss. A Quarterly Assessment, dated 09/13/23 documented a weight of 205 lbs. This exact weight was not documented in the electronic medical record. On 02/08/24 at 3:23 p.m., the dietitian stated weight loss was addressed at the beginning of the month when monthly weights were obtained. They stated the weights were analyzed for weight loss or gain for one to six months along with other significant changes. The dietitian stated they look at the residents' orders, diagnoses, intake, skin, and clinical record and make recommendations based on the residents' needs. The dietitian stated Resident #68 had a significant loss of 11% for six months. They stated the weight loss was intentional and desired by Resident #68. On 02/09/24 at 9:30 a.m., the MDS coordinator stated they obtained the weights to code in the MDS from the weights and vitals in the electronic medical record. They stated the weights were automatically pulled into the MDS assessment. The MDS coordinator stated the weight of 205 lbs documented on the assessment was not accurate and was from the March weights in 2023.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed within 48 hours for one (#120) of one sampled resident reviewed for baseline care plan. The administrator identified 127 residents resided in the facility. Findings: A Comprehensive Person-Centered Care Plan policy, dated 01/23/19, read in part .POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . A Baseline Care Plan is to be developed within 48 hours. Develop initial goals based upon admission orders/resident's input and is recorded on the Baseline Care Plan . Resident #120 admitted with diagnoses which included muscle weakness, cognitive communication deficit, need for assistance with personal care, decreased white blood cell, soft tissue disorder, cellulitis to right upper limb, and encounter for other orthopedic aftercare. A Care Plan, dated 11/15/23, only documented an activity focus area. There was no other care plan located in the resident's clinical record. On 02/09/24 at 12:14 p.m., the DON stated baseline care plans were completed during the admission process, within the first 24-48 hours. She stated the nurse completing the admission completed the baseline care plan. The DON was asked to locate Resident #120's baseline care plan. She stated a care plan was initiated on 11/15/23 and only documented activities. She stated more interventions should be documented.

Based on record review and interview, the facility failed to ensure showers were provided for one (#172) of seven sampled residents reviewed for bathing. The administrator reported 127 residents resided in the facility. Findings: Resident #172 had diagnoses which included Parkinson's disease. Resident #172's shower documentation did not document the resident had been offered a shower between January 31, 2024 and February 09, 2024. On 02/09/24 at 1:45 p.m., Resident #172 stated they had not received a shower in several days, but would like to at least have a bed bath. On 02/09/24 at 2:00 p.m., CNA #1 stated they did not have time to give Resident #172 a shower on 02/06/24 or 02/09/24. They stated they reported it to the nurse and the oncoming shift to see if they had time to give showers.

Based on observation and interview, the facility failed to ensure chemicals were secured for one (300 hall) of five halls observed for storage of chemicals. The Resident Listing Report, dated 02/05/24, documented 14 residents resided on the 300 hall. Findings: On 02/05/24 at 8:26 a.m., an unlabeled closet was observed to be unlocked. The door was observed to have a key pad lock but the inside latch of the lock was taped so it remained unlocked. The following chemicals were observed unsecured in the unlocked closet: a. Three and one half-one quart bottles of floor cleaner. The label on the bottle documented the product caused serious burns. b. One-one quart bottle of spot shot professional stain remover. The label documented to keep out of reach of children. c. One-one quart bottle of red juice stain remover that was approximately half full. The label documented it may cause irritation to the mouth, throat, and stomach and to use splash goggles and gloves during use. d. One-one quart glass cleaner. The label documented to keep out of reach of children. On 02/05/24 at 8:49 a.m., the DON stated the room was a housekeeping closet that was to be kept locked with the key pad lock. They opened the door, removed the tape off the lock, and stated they did not know why the lock was taped, making it unsecured. They stated they did not have any residents who wandered.

Based on observation, record review, and interview, the facility failed to ensure controlled medications were reconciled for one (500 hall) medication cart of seven medication/treatment carts observed. The administrator identified 127 residents who resided in the facility. Findings: The Controlled Substances Count Shift Verification form, dated February 2024, documented a shift count verification of controlled substances had been completed 12 times out of 22 opportunities from 02/01/24 through 02/08/24 at 6:00 a.m. The form did not document any on-coming nurse/CMA signatures, no entries for 02/03/24 or 02/09/24 were documented, and no entries were documented for the 10:00 p.m. to 6:00 a.m. shift. On 02/08/24 at 12:02 p.m., the 500 hall medication cart was observed with CMA #1. The locked narcotic box was observed to contain a card of Cephalexin 500 mg for Resident #65. The card of Cephalexin was observed to have nine capsules remaining. The count sheet for the Cephalexin 500 mg documented CMA #1 administered one pill at 7:36 a.m. on 02/08/24 and there were ten capsules remaining. CMA #1 stated they had only administered one dose of Cephalexin to Resident #65 during their shift. They stated they had not counted the medication cart, including controlled medications, with the off-going nurse/CMA when they had arrived at 6:00 a.m. CMA #1 stated the medication cart was unlocked and the keys were in a three-ring binder on top of the cart when they arrived for their shift. On 02/08/24 at 12:15 p.m., CMA #2 asked for their medication cart keys from CMA #1. CMA #1 handed the keys to CMA #2 and stated they had them for the 300 hall medication cart while CMA #2 had been at lunch. CMA #1 stated they had not reconciled the 300 hall medication cart when they assumed possession of the cart's keys, including the keys for the controlled medications. On 02/09/24 at 12:57 p.m., the DON was informed of the observations and reviewed the Cephalexin count sheet for Resident #65. The DON stated due to the discrepancy with the Cephalexin they would question if the medications had been counted at shift change. They stated controlled medications on all medication/treatment carts were to be counted each shift. They stated they needed to provide education to the staff.

Based on observation, record review, and interview, the facility failed to ensure food contained nutritive value, was palatable, and served at preferred temperatures. The Resident Matrix provided by the facility on 02/05/24, documented 125 residents received food from the kitchen. Findings: On 02/05/24 at 9:51 a.m., Resident #83 stated the food was very cold. On 02/05/24 at 10:07 a.m., Resident #48 stated the food was not palatable. On 02/05/24 at 10:17 a.m., Resident #185 stated they wanted a decent breakfast. They stated staff bring eggs and oatmeal and they do not eat eggs, and oatmeal makes them gag. They stated this happened all weekend. Resident #185 stated lunch and dinner were usually good and if not, they requested a burger. On 02/05/24 at 10:39 a.m., Resident #55 stated the food temperature was inconsistent. They stated they ate in their room because it took too long to be served in the dining room. On 02/05/24 at 10:51 a.m., Cook #1 was observed to prepare pureed food. Cook #1 stated the facility had four or five residents who required pureed food. The cook had placed six to seven hamburger patties in the blender, along with water, thickener and a calorie/protein powder supplement. Upon completion of the puree, the puree was tasted. The puree was grainy and without flavor. On 02/05/24 at 11:04 a.m., Cook #1 was observed to pour peas and carrots, two scoops of thickener, and one scoop of calorie/protein powder supplement into the bowl of the blender for puree. The skins of the peas were observed to be throughout the mixture and not smooth. A test sample was taken with a plastic spoon and provided to the surveyor. The puree was not smooth. Cook #1 was asked if this was anything that could cause a resident to choke. They stated no. On 02/05/24 at 11:10 a.m., the registered dietitian was asked if the vegetables were of a pureed consistency. They stated no and suggested to the cook they use carrots only, due to the skin of the peas. On 02/05/24 at 11:12 a.m., the registered dietitian was asked to taste test the pureed meat. The registered dietitian began looking for a spoon and Cook #1 removed the pureed meat from the line and discarded it. Cook #1 was asked if they were going to puree more meat. They stated yes. Cook #1 then placed five or six chicken fried steaks, hot water, thickener and a calorie protein powder supplement in the blender for puree. After multiple additions of water, the meat was grainy and without flavor. The registered dietitian was asked why the original meat used was hamburger patties. They stated they had signed off on all of food substitutions. The registered dietitian then asked for time with the cook and the puree was discarded. On 02/05/24 at 11:19 a.m., the registered dietitian was asked how they ensured the nutritive value of food was maintained when using water to thin. They stated it was not. On 02/05/24 at 11:28 a.m., Cook #1 placed five chicken fried steak patties and gravy in the blender for puree. When the puree was completed a taste sample was provided and observed to be smooth, hot, and full of flavor. On 02/05/24 at 11:58 a.m., Cook #1 was observed to puree carrots using the broth from the carrots. When the puree was completed the carrots were tasted and observed to be smooth, hot, and full of flavor. The afternoon meal was scheduled to begin at 11:30 a.m. On 02/05/24 at 12:00 p.m., observations of plating food were conducted. The menu documented to use an ivory scoop to provide a 1/2 cup of vegetables. The scoop was available, but not used to serve the vegetables. The portion sizes were observed to be inconsistent. The menu documented a gray scoop was be used to provide a 1/2 cup portion of meat. A blue scoop was used to plate the ground meat. The food guide documented a blue scoop provided 1/4 cup. The menu documented to provide a 1/2 cup of mashed potatoes. Dietary aide #1 was observed to not fill the scoop entirely before plating the mashed potatoes. The food guide documented a full gray scoop to provide 1/2 cup. The registered dietitian was asked how they ensured staff used the correct size utensil to ensure the proper portion of food was provided for the nutritional requirements of the residents. No answer was provided. The dietitian and the dietary manager then began replacing the utensils and instructed the staff on proper filling of the utensils to serve the remainder of the residents. The bread and desert were not provided in puree to the residents. On 02/06/24 at 9:02 a.m., Resident #185 stated it looked like they ordered two pieces of bacon and four pieces of toast, but had ordered four pieces of bacon and two pieces of toast. They stated the food was not hot. On 02/06/24 at 9:10 a.m., Resident #3 stated the food was not good, it was always so cold, my daughter even asked the facility to serve me warm food, but it is still cold. The food would taste better if it were warmer. On 02/06/24 at 9:22 a.m., Resident #65 stated the food was always cold. On 02/07/24 at 9:38 a.m., Resident #48 stated they did not eat breakfast because the food was cold. On 02/07/24 at 11:30 p.m., the dietary manager was asked to debone one of the pork chops and weigh the meat. The dietary manager stated they did not have scales to weigh the food. On 02/07/24 at 12:00 p.m., test trays were requested from the 500 hall cart. The meal cart left the kitchen at 12:02 p.m., was parked in the hallway at 12:04 p.m. and the surveyor tray was obtained at 12:15 p.m. The following temperatures were taken: Pureed beef temp 113 degrees Fahrenheit (F), Pureed vegetable 106 degrees F, milk 58 degrees F, mixed vegetable 112 degrees F, and mechanical beef 97 degrees F. On 02/07/24 at 12:15 p.m., a surveyor tasted the three test plates. The regular tray pork chop was warm, not hot. The vegetables and milk were warm. The bread was room temperature. The mechanical tray ground beef was warm, not hot. The puree tray beef was very grainy, bland, and warm, not hot. The pureed vegetables tasted ok, but were not hot. On 02/07/24 at 12:46 p.m., the dietary manager looked at the pureed beef and stated the beef was not pureed, it was grainy. The manager was asked at what temperature milk should be served. They stated 40 degrees Fahrenheit. On 02/08/24 at 9:17 a.m., Resident #185 stated the bacon and toast were received as ordered, but the food was cold today. Resident #185 stated they just want hot food. On 02/08/24 at 9:45 a.m., Resident #103 stated they chose the alternative and ate in their room. They stated they had oats, cheerios, bacon, milk, and juice everyday, and the food was mostly cold when brought to their room.

Based on observation and interview, the facility failed to ensure a sanitary environment, provide food and drink at safe temperatures The Resident Matrix provided by the facility on 02/05/24, documented 125 residents received food from the kitchen. Findings: On 02/05/24 at 10:50 a.m., during the kitchen observation, several male staff members were observed to not wear beard nets or hair nets while preparing food. On 02/05/24 at 10:52 a.m, the dietitian was asked what length of hair growth would require a hair net. The dietitian stated they would expect the staff to wear hair nets at any stage of hair growth.

Based on observation, interview and record review, it was determined the facility failed to identify and provide treatment to prevent the development of an avoidable pressure ulcer for two (#375 and #385) of three sampled residents who were reviewed for pressure ulcers. The facility identified 12 residents who had pressure ulcers. Resident # 385 had multiple untreated unstageable pressure ulcers to his buttocks and penis. Findings: A facility policy, titled Skin Management Guidelines Practice Guidelines, dated February 2016, documented, .All caregivers are responsible for preventing, caring for, and providing treatment for [REDACTED].prevent breakdown of tissue or ulcerations .provide treatment that promotes prevention of ulceration and healing of existing ulcerations .Alterations or change(s) in skin integrity, any break in the resident's skin including skin tear, bruises, abrasions, ulcers .are to be recorded on the Weekly Skin Assessment form .Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes . 1. Resident #385 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Monthly physician's orders [REDACTED].post admit skin check to be performed and documented in PCC (electronic medical record) day after admit every day shift every Sat for 1 day .pressure injury risk assessment weekly x4 weeks then quarterly every day shift every 3 months starting on the 13th for 1 day .pressure injury risk assessment weekly x4 weeks then quarterly every day shift every Sat for 4 weeks .weekly skin check by licensed nurse every day shift every Tue . A nurse's note, dated 01/13/17 at 10:38 p.m., documented, 82 yr. old male admitted from hospital. Family at bedside. Has bruising noted on both sides of abdome (sic). of unknown origin. C/O pain in hip, back area and did have pain meds. Has foley catheter intact with clear yellow urine .no [MEDICAL CONDITION] noted . An admit/readmit assessment, dated 1/13/17, documented, .skin normal, warm, dry, bruising to L & R abdomen . An MDS kardex report, dated 01/13/17, documented, .Skin and Ulcer Treatment .bruising L/RT abd . A weekly skin check sheet, dated 1/14/17 at 8:34 p.m., documented, .skin intact, no open areas . A care plan, dated 01/15/17, documented, Focus: Skin: .at risk for pressure injury r/t need for assistance with bed mobility .skin is currently intact .Goal: .will have intact skin, free of redness, blisters or discoloration through the review date .Interventions: .weekly skin checks .administer treatments as ordered and monitor for effectiveness .change positions frequently. Alternate periods of rest with activity out of bed in order to prevent .dependent [MEDICAL CONDITION], flexion deformity and skin pressure areas .educate .as to causes of skin breakdown .transfers/positioning requirements .taking care during ambulating/mobility .frequent repositioning .follow facility protocol for the prevention/treatment of [REDACTED].family/caregivers of any new area of skin breakdown .monitor/document/report to MD prn changes in skin status .appearance, color . A pressure injury risk assessment, dated 1/15/17, documented, .Moderate Risk Score: 13.0 .bedfast .mobility .very limited .friction & shear .potential problem . A progress note, dated 01/17/17, documented, .Initial visit .Skin Exam .ulcer heel, bruising . A weekly skin check sheet, dated 1/17/17, documented, .skin intact, no open areas . A pressure injury risk assessment, dated 1/17/17, documented, .low risk, score 19 .chairfast .mobility .no limitation .friction & shear .no apparent problem . A five day assessment, dated 01/18/17, documented the resident had long and short term memory problems and was moderately impaired with cognitive skills for daily decision making. The assessment also documented the resident required extensive assistance of two or more persons with bed mobility, transfers, walking in room or corridor, locomotion on or off the unit, dressing, toileting, and bathing. An (ambulance) prehospital care report, dated 01/18/17 at 11:48 p.m., documented, per staff has decubitus ulcers to buttucks (sic), but these were not examined . A nurse's note, dated 01/19/17 at 12:28 a.m., documented, .res. was more alert today .would answer you back and follow your hand .pupils remain pinpoint .late in evening res. had very little urinary output spoke with dgtr. and D.O.N .sent res. out to (hospital name deleted) for evaluation. Res. left facility @ appr. 2330 (11:30 p.m.) . An emergency department note, dated 01/19/17 at 12:46 a.m., documented, .Pt with bunny boots to feet. Reported and charted several skin breakdown issues . A history and physical report from the hospital, dated 01/19/17 at 3:54 a.m., documented, .patient's nursing home staff noticed that his urine was darker than normal and they thought he might be getting dehydrated or have a urine infection so he was subsequently transferred to (hospital name deleted) for further evaluation and treatment .Skin: warm and dry color appropriate in all limbs. No [DIAGNOSES REDACTED], or induration on exposed observed areas of head, neck, and limbs . A case management discharge planning note from the hospital, dated 01/19/17 at 2:08 p.m., documented, .nursing staff informed that they are very concerned about possible abuse/neglect while at the nursing home .pt is very excoriated on his bottom and has an unstageable pressure ulcer on his bottom as well . pt's catheter does not appear to have been cared for .pt has a pressure ulcer on his penis . A hospital progress note, dated 01/19/17 at 4:36 p.m., documented, .Pt came from NH with unshakeable (sic) wound on sacrum, and one on tip of penis also has blister on left heel. His f/c very crusty and peri area red with blisters and dried bowel movement on skin .also has bruising around waist .Wound consult ordered . A hospital progress note, dated 01/20/17 at 11:14 a.m.,, documented, .wounds assessed and dressings applied .bilateral heels in boots from other facility . Pressure Injury .Buttocks Inner .right .left Staging: Deep Tissue Pressure Injury .non-healing, chronic .multiple scatterd (sic) small purple areas, 100% dark purple .peri-wound assessment .[DIAGNOSES REDACTED] . shape irregular .wound length 12cm wound width 6cm depth 0cm drainage amount scant drainage description serosanguineous . Pressure Injury .Penis .present on arrival?: Yes .Staging: Unstageable Pressure Injury Is this a Medical Device Related Injury?: Yes .non-healing/chronic Site Assessment Black;Red (50% black, 50% red) peri-wound assessment red .shape irregular wound length 1cm wound width 0.8cm depth 0cm .Drainage amount None . Pressure Injury .Heel Right Deep Tissue Pressure Injury .Present on arrival?: Yes .non-healing chronic .shape circular Wound Length 3.4cm Wound Width 2.4cm Depth 0cm . A hospital progress note, dated 01/20/17 at 3:58 p.m., documented: Assessment . 1- HCAP/Aspiration pneumonia . 2- multiple unstageable decubitus ulcers .continue daily dressing .wound/ostomy services following .High-risk of negligence at the nursing home, social worker following. 3-[MEDICAL CONDITION] present on admission secondary to the above . A hospital physician consult, dated 01/23/17 at 5:24 p.m., documented, .the pt is receiving Abx for PNA and multipe ulcers resulting [MEDICAL CONDITION] . A hospital medical discharge summary, dated 01/28/17, documented, .Discharge [DIAGNOSES REDACTED].sepsis present on admission secondary to the above .multiple unstageable decubitus ulcer . On 02/09/17 at 3:31 p.m., CNA #7 was asked if she had taken care of the resident. She stated she had taken care of the resident. She was asked if he had a foley catheter. She stated, Yes, I did catheter care on him. I would do catheter care with every brief change, about every one and a half hours. She was asked if the resident had any skin problems on his penis. She stated she hadn't noticed anything abnormal until the last day that he was at the facility. She stated, He had dried blood at the tip of his penis, almost like it had been tugged on, this was on the evening shift. I did not clean off the dried blood, I told the charge nurse. On 02/09/17 at 3:47 p.m., LPN #2 was asked if she had been on duty the night the resident had been transferred to the hospital. She stated she had been involved in his care and was off duty but stayed until he was actually transferred out. She was asked about the condition of the resident's penis and catheter before he was transferred to the hospital. She stated, There were no issues, no redness or swelling. She was asked if CNA #7 notified her that she had observed dried dark colored blood on his penis during catheter care. She stated, Oh yes, I remember there was dried blood on the tip of his penis. He pulled on the tubing a lot. His family even had mentioned that. I cleaned the blood off and nothing else was noted out of the ordinary. She was asked if there were any sores observed on his penis. She stated, No. She was asked who was responsible for completing the skin assessments. She stated, The day shift charge nurses do the skin assessments on Tuesdays. At 4:37 p.m., CNA #7 was asked if the resident had any pressure ulcers. She stated, I noticed the skin on his sacrum was red and peeling the last night before he was transferred to the hospital. She was asked if he had any sores on his penis. She stated, No. She was asked what she did when she had observed the red and peeling skin. She stated, I reported it to the charge nurse. At 4:45 p.m., LPN #2 was asked if the resident had any pressure ulcers. She stated, He had a butterfly shaped area on his coccyx that looked like bruising. He had open areas on his sacrum that looked like blisters had popped and the top skin had come off. She was asked if the resident had any skin breakdown on his heels. She stated, There was nothing on his heels. I admitted him from the hospital and he had nothing on his heels. She was asked where she had documented the pressure ulcers on his coccyx and sacrum. She stated, I documented in the nurse's notes and also notified (the emergency medical technicians on the ambulance). On 02/13/17 at 11:28 a.m., CNA #6 was asked if the resident had any pressure ulcers. She stated, His bottom was red. I think there was a bandage on his bottom, and there was red skin around the bandage. She was asked if there were any pressure ulcers on his penis. She stated, He had a little bit of blood on his penis, but no sores. She was asked about the condition of the resident's heels. She stated she wasn't sure about his heels. At 11:35 a.m., LPN #2 was asked when she was aware of the skin breakdown on the resident's sacrum and coccyx. She stated It was about nine p.m., on the evening he was transferred. She was asked if she had measured the area of the pressure ulcers. She stated, I didn't take any measurements, I was in the process of sending him out. She was asked if she had performed a skin assessment. She stated, I did not do a skin assessment. I was in the process of sending him out. She was asked for documentation of the skin breakdown. The nurse looked in the computer but was unable to find any documentation. She stated, Apparently I didn't document it. She was asked if it should have been documented. She stated, Yes. She was asked if she had ever observed a bandage over the resident's sacrum and coccyx area. She stated, When he came in from the hospital there was a dressing on [MEDICATION NAME]. I remember looking under the dressing and there was nothing there. She was asked if she had taken the dressing off. She stated, Once it came off I probably would have left it off. She was informed CNA#6 had stated she had seen a bandage on the resident's sacrum and coccyx area. She stated, If she (CNA#6) said there was a dressing there then I must have left it on. The day that he left there was no dressing on. At 1:48 p.m., LPN #2 was shown the initial progress note that had been completed by a nurse practitioner, and documented, ulcer heel bruising, in the skin assessment area. After she reviewed the nurse practitioner's documentation, she was asked if she had examined the resident to make sure no pressure ulcers had developed since her last assessment. She stated, Oh we don't look at that assessment. We check to see if there have been any orders written and we put them in the computer. We don't routinely look at the doctor or nurse practitioner assessments sheets. On 02/14/17 at 3:20 p.m., CNA #7 was asked if there were any interventions being used to relieve pressure on the resident's heels. She stated, He had booties and I also floated his heels when he was in bed. On 02/15/17 at 11:05 a.m., MDS coordinator #3 was asked if she was aware the resident had developed a pressure ulcer to his buttocks. She stated. I went by the skin assessment dated [DATE] that documented that his skin was intact. In order to know about a new pressure ulcer, someone would have to notify me directly or write a nurse's note about it. She was informed a CNA had stated he had heel boots that she applied for him and also floated his heels. She was asked why the interventions hadn't been listed on the resident's care plan. She stated, I go more in depth when I develop the comprehensive care plan. That would be something I would have added at that time. At 2:00 p.m., the DON was asked if the resident had any pressure ulcers. She stated, I was not aware of any skin breakdown at the time of his transfer to the hospital until the nurse had told me she thought he had a Kennedy ulcer. She was shown the nurse practitioner initial progress note. She was asked what the documentation of ulcer heel bruising, indicated to her. She stated, It would indicate there was a problem with the resident's heels. She was informed the nurse had stated the documentation was incorrect. She stated, I would expect the nurse to follow-up, especially if she thought the resident didn't have the documented ulcer to their heels. She should have clarified with the doctor or nurse practitioner. 2. Resident #375 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A care plan, dated 01/24/17, documented, Skin: .at risk for alteration in skin integrity and pressure injuries d/t extensive assist with bed mobility, incontinence, and dementia. She has an abrasion to her L hip that was present upon admission .Goals: . Resident will have intact skin, free of redness, blisters, discoloration through review date .Abrasion to L hip will resolve or move toward improvement by review date .Interventions: . Apply Pressure reduction mattress to bed .Weekly head to toe assessment by Licensed Nurse .Monitor skin with all cares .Report any changes to nurse . On 02/14/17 at 11:34 a.m., the resident was observed in the dining room. CNA #8 was asked to take the resident to her room to perform a skin check. The resident was observed to have a quarter sized open blister that was reddened around the open area on the lateral side of the left hip. The left leg below the knee had a foam dressing covering a skin tear. At 1:17 p.m., LPN #2 was asked if staff had reported any new open areas on the resident. She stated, No. At 1:33 p.m., the unit manager was shown the open area to the left hip. She stated, Looks like a blister. She was asked if it opened. She stated, Yes. The unit manager was asked about the treatment orders. She stated, I would have to check. It looks like a left thigh abrasion. They are doing dressing changes Monday, Wednesday, and Friday, but it's not really the thigh, its the hip. She was asked if it was a current treatment to the left thigh abrasion. She stated, Let me pull her TAR real quick. She stated, It looks like it healed on 02/02/17. She was asked when this open area developed. She stated, It looks like its new. She was asked if the CNA should have reported the open area to the nurse. She stated, Yes. On 02/15/17 at 2:19 p.m., RN #5 was asked what the process was for identifying and reporting open areas. She stated, Every Tuesday is skin check day. If we notice anything in between, we notify the physician and get orders and notify the family. She was asked how she received information of new skin issues. She stated, CNA shower sheet with new areas, verbal report from CNA, or report in TAR book. At 2:23 p.m., CNA #5 was asked what was the system or process for new skin issues identified. She stated, Anything new on the resident we notify the nurse. She was asked when she looked at the skin. She stated, When we shower or change them.

On 01/09/13, an Immediate Jeopardy (IJ) situation was determined to exist related to the failure of the facility to provide thickened liquids for residents who had physician ordered thickened liquids, and had a history of [REDACTED]. The Oklahoma State Department of Health verified the existence of the IJ related to thickened liquids. At 3:11 p.m., the administrator and Unit manager #1 were informed of the IJ related to thickened liquids. At 6:15 p.m., an acceptable plan of removal for the IJ situation was received from the facility. The plan of removal documented: "PLAN OF REMOVAL - IJ - Supervision to Prevent Accidents - January 9, 2013 Related To - Residents with orders for thickened liquids receiving thin liquids. 1:00 PM - Liquids removed from Dining Room Service Area by Nutritional Services Supervisor. 2:00 PM - Removed the coffee from the coffee machine in the Dining Room Service area to insure that coffee machine can not be turned back on by the Nutritional Services Supervisor. 3:11 PM - IJ received from the Survey Team informing management of the situation 3:35 PM - Administrator and Nurse Managers began plan for removal of jeopardy to residents. 3:40 PM - Administrator wrote an in-service for all staff members that will ensure that they understand all aspects of safety regarding thickened liquid IN-SERVICE includes: A. Management Personnel (see schedule) will be in the dining room for each meal service to monitor thickened liquids. They will monitor each tray and all liquids that are being served to residents against the thickened liquids list. B. Assignment of a CNA at the beginning of each shift to check each Resident's room who is on thickened liquids to ensure that they only have the appropriate fluids available to them. They will have a list of residents needing thickened liquids obtained from the nurse's station. C. Registered Dietitian will place an updated list of thickened liquid orders at the nurse's station each morning for staff availability. 1. The nurse will up date the list from any new doctor's order that occur during the day. 2. The nurse who updates the list will also provide a Communication of the order to the dietary department. D. Times for passing of ice are 6:30 A.M., 2:30 P.M., and 10:30 P.M. and a list will be taken with the water and ice to ensure that each resident has the appropriate thickening. Snacks will be passed at 10:00 A.M., 2:00 P.M., and 8:00 P.M. and a list will be included regarding the liquid thicknesses. 3:50 PM - Nursing Team began review of every resident's room to ensure that each resident has only the thickness of liquid ordered by their physician. 4:00 PM - Informal in-services have begun regarding thickened liquid safety. Each employee is being given lists of resident's who have thickened liquid orders. 4:30 PM - Staffing Coordinator has begun calling all staff to come to the building for in-services. 4:31 PM - The resident on thickened liquids rooms have been checked for water pitchers and ice. The water pitchers were removed from the rooms. 5:50 PM - Formal in-services have begun on full implementation of Accident Prevention regarding thickened liquids. All current staff will be in-serviced by 5:00 PM January 10, 2013. 6:10 PM - All resident rooms have been checked to ensure that they do not have straws." The IJ was removed on 01/11/13 at 9:50 a.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to ensure thickened liquids were provided for three (#15, #16, and #17) of three sampled residents who had physicians' orders to receive thickened liquids and had a history of [REDACTED]. This resulted in an Immediate Jeopardy Situation when three of three residents who had physicians' orders to receive thickened liquids received thin liquids. The facility identified 11 residents who had physicians' orders to receive thickened liquids. The facility also failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for three (#7, #14, and #20) of eight sampled residents who had experienced falls. The facility roster matrix identified 29 residents who were high risk for falls. Findings: A policy, dated 01/2008 and titled Accidents/Incidents, documented, "...The intent of this policy is that the center identifies each resident at risk for accidents and/or falls, and adequately plans care and implements procedures to prevent accidents...In the event an accident or incident occurs the Licensed Nurse: ...Initiates measure to prevent a re-occurrence. Updates the resident's care plan and nursing assistant care card...The DON/designee implements appropriate interventions to protect the resident(s) and prevent re-occurrence...The DON maintains records related to incident/accidents and reports regularly to the QM Committee..." A Falls Management Program, dated January 2008, documented, "...The program focuses on two areas: ...Prevention of falls through increased awareness. Managing falls that occur, including a root-cause analysis to determine how to minimize future risk...Since falls can occur for a multitude of reasons, it is important that the center's response to the potential and actual risks associated with falls is focused on the root cause(s)...The goal is to provide residents with an environment that promotes safety while minimizing the risk of injury..." 1. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. A dysphagia evaluation, dated 06/09/11, documented "...Pt received dysphagia eval (secondary) to recent CVA & (decreased) tolerance to P.O. intake...recommended...nectar c chin tuck...cont ...nectar c verbal cue to tuck chin. Pt, nursing & family notified...pt @ (increased) risk for aspiration. A care plan, dated 06/14/11, documented, "Focus: Potential alteration in Nutrition Status Diagnosis/disease condition/treatment dementia/CVA, Swallowing difficulty. Goals: ...Safe and comfortable ingestion of fluids...Interventions: ...Provide altered consistency meals/snacks...Meals in a supervised setting..." The nutritional care plan did not address the consistency of fluids the resident was to receive, how the resident was to be supervised during meal times, when fluids were provided, and if the resident should have a straw with liquids. A dysphagia clinical evaluation, dated 06/16/11, documented the resident had a history of [REDACTED]. A comprehensive assessment, dated 07/14/12, documented a BIMS score of 15 which indicated the resident was cognitively intact. The assessment documented the resident required set up help only with meals and did not receive a mechanically altered diet regarding consistency of fluids. The comprehensive assessment did not address the resident was to receive nectar thick liquids. A quarterly assessment, dated 10/08/12, documented a BIMS score of 6 which indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required set up help only with meals and did not receive a mechanically altered diet regarding consistency of fluids. The quarterly assessment did not address the resident was to receive nectar thick liquids. A dietician note, dated 10/05/12, documented, "...Diet/ Nutrient Plan...texture NTL (nectar thick liquids) continues on HCC c thickened liquids r/t medical hx (and) difficulty c swallowing liquids..." The care plan, last reviewed on 10/22/12, did not address the specific texture of nectar thick liquids. A nursing progress note, dated 10/25/12, documented "Res in dining room c nausea + vomiting. Another resident's family stated she gave her a cup of regular coffee not thickened..." A nurse's note, dated 12/29/12, documented, "Res has non productive hacky cough. Lung sounds - wheezes on exhalation in all lobes...Res states that she doesn't feel bad but cant (sic) stop coughing..." A dietician note, dated 12/31/12, documented "...Swallowing Ability: requires thickened liquids...remains on nectar thick liquids per ST documentation...Plan continue HCC/Regular diet c nectar thick liquids..." A current monthly physician's orders [REDACTED]. On 01/09/13 at 12:32 p.m., the resident was observed during the lunch meal. The resident was observed drinking regular coffee that was not thickened. The resident took a drink of the coffee and did not cough. At 12:40 p.m., CNA #2 delivered the resident's lunch tray. She placed the resident's plate and a glass of thickened water and thickened milk in front of the resident. She did not notice that the resident had a cup of regular coffee. At 12:50 p.m., the resident took a drink of the regular coffee and coughed once. The resident took another drink of the regular coffee and then coughed deeply two more times. The resident placed the coffee cup on the table. Unit manager #2 was asked who the dining room monitor was. He left the dining room to go check the list and find out for sure who the monitor was. LPN #3, who was walking through the dining room was asked if she was monitoring the dining room. She stated that LPN #4 was the monitor. Unit manager #2 returned and stated that LPN #4 was the dining room monitor. LPN #4 was shown the regular coffee and asked if the coffee was thickened to nectar thick consistency. She stated, "No." She was shown the resident's diet card on the table and asked if the resident was to receive nectar thick liquids only. She stated the resident had nectar thick orders, but the family has been made aware and said it was ok for her to have thin liquid. She stated the family had signed a paper about it because the resident went into the drink area and got her own coffee. She stated, "She goes in and gets her own all the time." Unit manager #2 stated the resident was on nectar thick liquids and there was no documentation the resident could have thin liquids. LPN #4 and unit manager #2 were asked if it could be considered a hazard for the resident to go and get her own thin liquid when she had a physician's orders [REDACTED]. They both stated, "Yes." On 01/15/13 at 1:57 p.m., the administrator, DON, and unit managers #1 and #2 were asked who checked the MDS for accuracy and made updates to the care plan. The DON and unit managers #1 and #2 stated they updated the care plans with handwritten updates in the morning meetings and then the MDS and care plan nurses did the MDS assessments and made updates to the care plans quarterly on the computer. They stated there had been an issue getting the handwritten updates on the care plan when it was updated in the computer and a new care plan was printed. At 2:40 p.m., MDS/CP #1 and #2 were asked if they checked the MDS for accuracy. They stated, "Yes." They were asked why the MDS dated [DATE] and 10/08/12 had not been updated to reflect the resident was on nectar thick liquids. They stated they would have to check and see why it was not done. They were asked why the resident's care plan was not updated to show she was to only receive nectar thick liquids and interventions added to address that she would go in and out of the drink station located next to the kitchen and get her own drinks. They stated the DON and unit managers put the updates on the care plan in the morning meetings they did add those updates and new interventions into the care plan. They stated they were unaware the resident was getting her own drinks and did not address that on the care plan. At 3:05 p.m., MDS/CP #1 stated she had checked the MDS dated [DATE] and was not sure why it was not updated. She stated she had completed the MDS assessment on 10/08/12 and had not realized the RD's note that documented "NTL" meant nectar thick liquid and therefore did not put it on the MDS. 2. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A nutritional care plan, dated 01/04/13, documented, "Focus: Potential alteration in nutrition status related to dx HTN, CVA with dysphagia requiring modified texture diet...Interventions: continue house/ground diet per speech therapy. monitor for S/sx aspiration..." An initial assessment, dated 01/07/13, documented the resident had a BIMS score of 14. This score indicated the resident was cognitively intact for daily decision making. The assessment documented the resident needed supervision while eating, did not have a swallowing disorder, and was on a mechanically altered diet which required a change in texture of food or liquids. A physician's orders [REDACTED]. Rec crush all crushable meds..." A dysphagia evaluation report, dated 01/09/13, documented, "...Recommendations: Diet: mech soft. Liquids: nectar. Medications: crushed...Other: Monitor lung sounds and temperature after meals due to risk of aspiration...Compensatory strategies/Swallow precautions: ..Pt @ high risk for silent aspiration c thin liquids & mixed consist..." An interdisciplinary progress note, dated 01/09/13, documented, "...Radiologic Dysphagia Eval obtained this am revealed...penetration c thin liquids s response..." An interdisciplinary communication to nutrition services, dated 01/09/13, documented, "...Diet order:..Thickened liquids - nectar..." On 01/09/13 at 1:29 p.m., the resident was observed to have a pitcher of ice water that was not thickened. At 3:12 p.m., the resident was observed in her room with a pitcher of ice water that was not thickened. The resident was asked if she drank the water in her pitcher. She stated, "I have been drinking water like this for a week." At 3:15 p.m., CNA #8, who worked on the hall where the resident resided, was asked how she knew what residents were to receive thickened liquids. She stated, "I look in the care chart and I ask in the change of shift report for any changes." She was asked if there were any changes with residents on the hall she was working. She stated, "No changes." She was asked if any resident had a change from thin liquids to thickened liquids or from thickened liquids to thin liquids. She stated, "No." At 5:30 p.m., the resident was observed in her room with a straw in a glass of thickened water that was approximately 3/4 full. On 01/15/13 at 2:50 p.m. the DON was asked for the procedure of relating a new physicians order. She stated, "The person who notes the physician's orders [REDACTED]." 3. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medical nutritional therapy assessment, dated 08/09/12, documented, "Diet Order: Regular..." A nutritional care plan, dated 08/09/12, documented, "Focus: Potential alteration in Nutrition Status related to hx dementia...Interventions: ...continue regular diet...adequate time for self-feeding..." An admission assessment, dated 08/10/12, documented the resident had a short/long term memory problem and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with eating and had no signs and symptoms of a swallowing disorder. An incident report, dated 12/27/12, documented, "...Observed resident choking, still coughing. Encouraged to continue to coughing, until pt went unresponsive. Staff performed heimlich maneuver until pt became responsive and food particles removed from mouth. Cyanois (sic) noted...Resident transferred to ER for eval..." The nutritional care plan was not updated to include the choking during a meal time. A physician's orders [REDACTED]. Diet...Puree...Fluid Consistency: Honey..." A dietary communication, dated 01/02/13, documented, "Diet order: Puree...Thickened liquids...Honey..." A nurse's note, dated 01/02/13, documented, "...Puree diet & nectar liquid..." The nutritional care plan documented an undated intervention that included a puree diet with honey consistency fluids. The care plan did not address the resident's choking/aspiration. The resident's room was observed at 2:30 p.m., on 01/09/13. The resident's water pitcher was observed on the bedside table. The pitcher contained thin water, ice, and a straw was observed next to the pitcher. At 3:15 p.m.,the resident's water pitcher was observed. The pitcher contained thin water and ice. At 3:15 p.m., CNA #3 was asked why the resident had thin ice and water in her room when she had an order for [REDACTED].#5) is new to this hall, he must have put that in here by mistake." 4. Resident #14 was admitted with [DIAGNOSES REDACTED]. A fall care plan, updated 02/14/12, documented, "Focus: Fall; has risk for falls as she has need for assist with care, has impaired balance and has orders for psychotropic meds...Goals: will have no falls/injuries as related to falls x 90 days...Interventions: administer medication...bed in low position...do not leave resident with bed control unattended...floor mats at side of bed when she is in bed...bed alarm secure whenever she is resting in bed...frequent rounding for repositioning and incontinent care...high back reclining wheelchair for positioning, proper positioning when she is in her bed or in her wheelchair, monitor her whereabouts frequently, personal alarm secure when she is in her wheelchair..." An incident report, dated 07/16/12, documented, "...Resident was in reclining back w/c sitting at dining room table during activitiy. Resident slid out of seat to floor hit her glasses on table edge and cut her eyebrow with glasses...Corrective measures implemented to prevent recurrence...Therapy to evaluated (sic) for beveled or tilt cushion to help keep resident positioned from sliding out of chair...Care Plan reviewed and updated..." A nurse's note, dated 07/16/12, documented, "...Resident slid out of G/C into floor. Eyeglasses cut area above L eye, L forearm skin tear...Yelling out before fall. Staff pulled resident (up) numerous times before fall..." A fall assessment, dated 07/16/12, documented, "...Fall...Interventions initiated immediately after fall: ...Placed in low bed with bed alarm in place and activated...Recommendations to prevent further falls...(This area was left blank)...Root Cause Conclusion: (this area was left blank)..." The fall care plan, updated 07/16/12, documented, "...Interventions: ...Reinforce need to call for assistance...Ensure seating in dining room is close to entrance/exit..." The fall care plan did not address the fall the resident had experienced on 07/16/12, the injury the resident had sustained, therapy to evaluate and the conclusion of the evaluation, and a beveled or tilt cushion to be placed in the wheelchair. A significant change assessment, dated 07/19/12, documented the resident had a short/long term memory problem and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required a two person extensive assistance with all transfers and toilet use, was always incontinent of bowel and bladder, and had experienced a fall with injury. A nurse's note, dated 07/19/12, documented, "...follow up from fall-looking into wedge cushion to help prevent her falling-on restorative program for maintenance..." An incident report, dated 07/26/12, documented, "...Staff notified this nurse that resident was on floor mat beside bed...no injuries noted...Placed back in low bed with bed alarm in place, also call light in reach. Redirected to use call light for assistance..." A fall assessment, dated 07/26/12, documented, "...Fall...Interventions initiated immediately after fall: ...(This area was left blank)...Recommendations to prevent further falls...(This area was left blank)...Root Cause Conclusion: (this area was left blank)..." A nurse's note, dated 07/26/12, documented, "...Staff notified this nurse resident was on floor matt (sic), ...Dr. notified...(no) new orders...cont. to monitor..." The fall care plan did not address the fall the resident had experienced on 07/26/12 and the resident's ability to use the call light to ask for assistance. A nurse's note, dated 08/23/12, documented, "...currently on Keflex for UTI enc PO fluids...has had several falls from w/c - wedge cushion in chair to help prevent sliding down & for positioning..." The fall care plan had not been updated to address the resident was currently on an antibiotic for a urinary tract infection, the resident had experienced several falls from the wheelchair and from the bed, a wedge cushion to be placed in the wheelchair to prevent sliding out of the chair, and the resident's ability to use the call light to ask for assistance. An incident report, dated 09/11/12, documented, "...resident found lying in (sic) floor on bedside mat, no injury, personal alarm working and in place, air mattress working and in place, both bedside mats by bed...dimmed room by turning off all lights except bedside lamp to help resident know it is dark and it is bedtime, continue using all safety features that are currently being used, increase frequency of nocturnal checks...resident is confused, history of falls, currently on antibiotics for uti, care plan includes bolsters, floor matts (sic), bed alarm..." A fall assessment, dated 09/11/12, documented, "...Fall...Interventions initiated immediately after fall: Rechecked all safety devices...dimmed room lights...adjusted HOB...asked resident to please call out if she needs to get up again...increased frequency of nocturnal checks...Recommendations to prevent further falls...continue using all current safety devices, keep roomlights low at night to help adjust to bedtime, and more frequent visual of resident...Root Cause Conclusion: Resident has Alzheimer's Dementia causing no impulse control and lack of safety awareness..." A change of condition documentation, dated 09/12/12, documented, "...Resident found on the mat in (sic) the floor...resident reeducated on calling out if she needs help or to get up..." A nurse's note, dated 09/12/12, documented, "...Resident found on bedside mat on floor...Dr. notified...says she hurts but cannot be specific about where stated her L shoulder neck area was hurting...continue to monitor..." The fall care plan, updated 09/12, documented, "...PT/OT fall screen...lighting-dimmed @ HS..." The fall care plan did not address the fall and pain the resident had experienced on 09/11/12, and what the frequency of nocturnal checks were to be. An incident report, dated 09/16/12, documented, "resident personal alarm answered...Found resident sliding off of bed...3x3 red area on left arm where arm fell on mat...alert with confusion, Alzheimer's Dementia, high fall risk related to cognition..." There was no fall assessment documented to determine the root cause of the fall the resident experienced on 09/16/12 and to determine the appropriate interventions to prevent further falls. An update to the care plan, dated 09/16, documented, "...med review-prophylactic ATB?..." The fall care plan did not address the fall the resident had experienced on 09/16/12. A nurse's note, dated 09/27/12, documented, "...res cont to be fall risk...unable to redirect at times...cont to monitor..." A significant change assessment, dated 09/28/12, documented the resident had a short/long term memory problem and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required two person extensive assistance with all transfers and toilet use, was always incontinent of bowel and bladder, had experienced pain, and had experienced two or more falls with no injuries and two or more falls with injury. An incident report, dated 11/07/12, documented, "...Resident seen sitting in (sic) floor with buttocks on wheel chair extended foot rest...no injuries found...Resident returned to w/c and placed in TV room with supervision...Resident had been observed pulling herself down in her wheelchair and repositioned multiple times...Dysum added to wheelchair and attempted to redirect resident's attention to engage in activity...Resident dementia results in her poor saftey (sic) judgment and forgets she is unable to stand/ambulate..." There was no fall assessment documented to determine the root cause of the fall the resident experienced on 11/07/12 and to determine the appropriate interventions to prevent further falls. The fall care plan did not address the fall the resident had experienced on 11/07/12, or that Dysum was to be added to the resident's wheelchair. An incident report, dated 12/09/12, documented, "...Resident sitting in WC in dining room and slid out of WC to floor on buttocks...No injury noted...Dementia, hx of falls..." A fall assessment, dated 12/09/12, documented, "...Fall...resident in w/c with wedge cushion and high back raised feet pedals reaching out of w/c and slid out to floor...Interventions initiated immediately after fall: ...assessed for injury and assisted back up to w/c...Recommendations to prevent further falls...monitor resident when up in w/c make sure all items needed are within reaching distance...Root Cause Conclusion: resident with poor safety awareness, with seating in w/c reaching will cause resident chair to potentially tip with resident sliding to floor..." The fall care plan did not address the fall the resident had experienced on 12/09/12, or to ensure all items the resident used or needed were within reach. The fall care plan did not address how many times the resident had fallen, where the resident had fallen, or why the resident had fallen, or what type of injuries the resident had sustained. The resident was observed on 01/09/13 at 12:20 p.m., in the small dining room. The resident was seated in a high back wheelchair with her back facing the window and her chair away from the entrance to the small dining room. The resident could not be seen from the entrance to the small dining room as staff walked by. No staff were observed in the dining room. The leg rests to the wheelchair were up and the resident was attempting to climb over the leg rests. The resident was yelling, "I can't get up." At 12:30 p.m., staff entered the small dining room and repositioned the resident. The staff left and the resident continued to push the table forward and move her drinks around. The resident continued to try to get out of the wheelchair. At 12:40 p.m., the resident's legs were off the leg rests. The nurse repositioned her legs back on the leg rests. No wedge cushion or slide mat were observed in the resident's chair. The resident was observed on 01/11/13 at 2:59 p.m., in bed. A mat was observed on the floor beside the bed and the call light was between the mattress and the rail. The call light was not within reach of the resident. The resident was observed on 01/15/13 at 9:30 a.m., sitting in her wheelchair at the dining room table. LPN #9 was observed raising the leg rests on the wheelchair. No wedge cushion or slide mat were observed in the resident's wheelchair. On 01/15/13 at 1:08 p.m., the administrator, DON, unit manager #1 and unit manager #2 were informed of the residents repeated falls since July 2012. They were asked if the resident could use the call light to ask for assistance. Unit manager #1 stated the resident was very inconsistent at times. She was asked if that would be an appropriate fall intervention for her. She stated, "No." They were asked if they had received a wedge cushion and Dysum for the resident's wheelchair. Unit manager #1 stated, "Yes." They were asked if they were using a wedge cushion or slide mat. She stated, "Obviously not." They were informed that during observations of the resident no wedge cushion or Dysum was observed in the resident's wheelchair. Unit manager #1 stated, "It did help. It may have become soiled and discarded." She was asked who was to monitor the resident and ensure the fall interventions were implemented. She stated, "Nurses and myself." They were asked if they were keeping the resident safe. The unit manager stated, "No she fell ." They were asked if the falls and interventions should have been addressed on the care plan. Unit manager #1 stated, "Yes." They were asked why the falls and new interventions to prevent further falls had not been addressed on the care plans. Unit manager #1 stated, "In morning meetings we addressed the falls and interventions. The handwritten updates are not added to the care plan." 5. Resident #7 had [DIAGNOSES REDACTED]. A nurse's note, dated 08/27/12 at 2:00 p.m., documented, "...Called into room by staff res observed on floor on left side of leg with head resting on bed...Redness on left side of face chin to ear...Observed redness to left outer leg..." A fall assessment, dated 08/27/12, documented, "...Describe the circumstances of the event and what actions, if any, have been taken currently: ...observed resident on floor on left side with head resting on bed. Redness noted to left face from chin to ear and left outer leg...Interventions initiated immediately after fall: assessed for injury and assisted to bed...Recommendations to prevent further falls: PT/OT screen look at possible tilt back w/c to prevent sliding forward out of chair...Root cause conclusion: cognitive status poor safety awareness weakness..." The fall care plan, dated 08/27/12, documented, "...Focus: Risk for falls related to: cognitive impairment, weakness, impaired balance and coordination...Uses a w/c. He is also on psychotropic medications putting him at further risk for falls...Interventions: ...8/28 assess for alternate w/c seating..." A change in condition document, dated 09/12/12 at 10:00 a.m., documented, "...Res observed sitting on floor in front of w/c @ 0630 (6:30 a.m.). Res assisted back in w/c x 2 person assist (sig)...scratch noted to R posterior thigh..." A fall assessment, dated 09/12/12, documented, "...Describe the circumstances of the event and what actions, if any, have been taken currently: Resident observed sitting on floor in front of w/c...Abrasion on right posterior thigh...Wheelchair legs elevated and legs supported with cushion...Interventions initiated immediately after fall: Notified doctor, family, hospice, and don, resident (sic) assisted to wheelchair x 2 assist. PT/OT fall screen...Recommendations to prevent further falls:

Based on observation, interview and record review, it was determined the facility failed to provide supervision to prevent accidents and failed to identify and implement interventions to prevent of falls for 1 (#2) of 2 sampled residents who were assessed to be at risk for falls. This resulted in actual harm for resident #2 when she suffered a fall resulting in a fracture to her left fibula that required surgical intervention. This had the potential to affect four residents, who the facility identified as being at high risk for falls. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A patient discharge record, dated 03/09/11, documented, "...Up with assist of 1-2 to sit pivot to wheelchair..." An admission assessment, dated 03/15/11, documented, "Bed mobility...extensive assistance - resident involved in activity; staff provide guided maneuvering of limbs or other non weight-bearing assistance...one person physical assist...Transfer-...2 person physical assist... Number of falls since admission...1...no injury - no evidence of any injury is noted on physical assessment...no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall..." A nurse's note, dated 03/15/11 at 6:30 a.m., documented, "Staff heard yelling from resident room, upon entering room, resident was found laying on floor in front of w/c, couldn't tell staff how she fell . CNAs stated they had just walked out of room and resident had been sitting up in w/c. Assisted up by staff. Denied hitting head, c/o pain to LLE. Ankle swelling with several small bruises. Dr. (name deleted) here for rounds N.O. xray (left) ankle...medicated for c/o pain..." A care plan, dated 03/15/11, documented, "Focus...Fall...res will remain free of injury r/t fall...keep (sic) within reach, call light use re-ed..." A nurse's note, dated 03/15/11 at 9:00 p.m., documented, "...x-ray results - no boney (sic) injury. Ice pack on (left) ankle for swelling. Pt anxious and tearful r/t ankle strain. A nurse's note, dated 03/26/11 at 4:30 a.m., documented, "Conducted head to toe skin assessment, findings as follows, 3 cm x 4 cm light purple bruise (with) yellowing borders on (left) shin. 4 cm x 2 cm deep purple area on (left) inner aspect of (left) foot. 2 (plus) edema to (left) foot. Top of foot is warm to touch...Ext. (extensive) A (assistance) (with) bed mobility..." A nurse's note, dated 03/27/11 at 9:00 p.m., documented, "Res in bed crying, repositioned, comforted, feet floated..." An untimed nurse's note, dated 03/27/11, documented, "late entry... while toileting res CNA reports that res (left) knee buckled slightly causing her to lose balance (and) bump head against wall. CNA states balance was quickly recovered (and) res was safely (transferred) back to w/c..." A nurse's note, dated 03/28/11 at 12:00 p.m., documented, "Unit supervisor approached this nurse (and) stated husband was concerned about pain and edema to (left) foot...N.O. x-ray of (left) ankle." An x-ray report, dated 03/28/11, documented, "...Findings...There is an acute to subacute nondisplaced fracture of the distal shaft of fibula...Mild lateral soft tissue swelling..." A nurse's note, dated 03/29/11 at 8:00 a.m., documented, "...medicated for c/o of (left) ankle pain..." A nurse's note, dated 03/29/11 at 3:00 p.m., documented, "(left) ankle x-ray results show acute/subacute fx of the distal shaft of fibula..." A nurse's note, dated 04/04/11 at 8:00 a.m., documented, "...NPO for procedure..." A nurse's note, dated 04/04/11 at 10:25 a.m., documented, "Out of facility for procedure..." A nurse's note, dated 04/26/11 at 9:30 p.m., documented, "...readmitted ...at 7:00 p.m.,...has cast to LLE. Able to wiggle toes to LLE..." A care plan update on 04/26/11, documented, "Focus...risk for falls, readmit (with) cast to LLE...P T to eval and tx..." An undated nursing assistant care card, documented, "ADL...support...assist x 2..." On 04/28/11 at 10:30 a.m., resident #2 was asked how she fell in the bathroom. She stated, "A guy was trying to help me on the pot and he slipped and I slipped and I wound up on the floor. I told him it took 2 but he said he could do it. He could pick me up but couldn't put me on the pot at the same time. I'm not going back to the bathroom. I don't care what they say. I don't want to fall again. It was an accident on his part but if there were 2, I wouldn't have fell ." At 1:02 p.m., the DON and the MDS care plan coordinator were asked why no new interventions had been implemented regarding the resident's falls. The administrator stated, "I don't know." The MDS care plan coordinator stated, "We review the care plans at the clinical meeting everyday." They were asked if anyone read the care plans in that meeting. She stated, "No." She was asked if new interventions were discussed during the meeting. She stated, "No, not set up in that meeting. They are done before the meeting." The MDS/care plan coordinator was asked if that would be a crucial time to address interventions. She said, "Yes." At 1:18 p.m., LPN #1 was asked if the resident was a 1 or 2 person transfer. He stated, "She's a two person now." He was asked why the physician's orders [REDACTED]. He stated, "I guess the nurse missed it."