Every finding on record at Fort Gibson Care & Rehab Center

Based on observation, record review, and interview, the facility failed to update and implement individualized fall interventions in the care plan for a resident who fell and sustained a head injury for one (#47) of one sampled resident reviewed for falls. The DON identified 17 residents who had fallen in the past three months. Findings: A policy titled FALL MANAGEMENT, read in parts, To provide an environment that remains as free of accident hazards as possible. The Facility will complete a Morse Fall Scale Evaluation on Residents to determine who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent to minimize further Falls and/or reduce injuries .Identified risk factors should be addressed in the Resident's Care-Plan to ensure individualized interventions to reduce the risk are implemented .The Care Plan should be reviewed after every fall and updated with a new intervention .Revise/Modify Care Plan/Kardex; Implement Interventions according to Treatment approach to minimize further Falls & reduce injury. Resident #47 had diagnoses which included psychosis, hallucinations, and dementia. A fall risk evaluation, dated 01/14/24, documented the resident was at risk for falls. A fall log for the resident documented the resident had three falls in February 2024, one fall in April 2024, one fall in May 2024, two falls in June 2024, one fall in July of 2024, two falls in August 2024, two falls in September 2024, and six falls in October of 2024. An incident report, dated 11/08/24, documented the resident was found sitting on the floor in their room by the bathroom. The report documented a moderate amount of blood was noted to the floor and on the resident's clothes. The report documented the resident had a vertical laceration to the forehead about 3.5 cm long. The report documented the resident was sent to the emergency room for treatment. The care plan intervention for fall risk, dated 11/08/24, documented to place the resident on every hour toileting program while awake. The care plan documented the resident had an injury fall on 11/08/24 sustaining a laceration with sutures to the forehead. An incident report, dated 11/14/24, documented the resident was on the floor in the lobby. The report documented the resident stated they were going to the bathroom. The care plan intervention for fall risk, dated 11/14/24, documented the pharmacist was to review the resident's medications. An incident report, dated 11/18/24, documented the resident was found in their room sitting on the floor in front of the toilet. The care plan intervention for fall risk, dated 11/18/24, documented the staff was to continue with the resident's plan of care. An incident report, dated 12/05/24, documented the resident was found in their room sitting on the floor by the bathroom door. The resident stated they had a nosebleed. The care plan intervention for fall risk, dated 12/05/24, documented the staff was to keep Kleenex within reach. The quarterly assessment, dated 12/12/24, documented the resident was severely impaired cognitively and had two or more non-injury/injury (not major) falls since admission. An incident report, dated 12/14/24, documented the resident was found in their room laying on the floor. The care plan intervention for fall risk, dated 12/14/24, documented neuro checks were initiated. An incident report, dated 12/16/24, documented the resident was found sitting on the floor in front of their recliner. The report documented the resident stated they were going to smoke a cigarette. The care plan did not document a new intervention for the incident which occurred on 12/16/24. An incident report, dated 12/17/24, documented the resident was found lying on the floor near the mens bathroom door with their wheelchair not locked. The care plan intervention for fall risk, dated 12/17/24, documented staff were to initiate neuro checks per protocol. A fall log for the resident documented the resident had falls on 12/19/24 and 12/20/24. There were no incident reports provided. The care plan intervention for fall risk did not document a new intervention for the fall which occurred on 12/19/24. The care plan intervention for fall risk, dated 12/20/24, documented visitors were to be educated on notification of staff if the alarm was sounding while the door was closed and visitor was caring for the roommate. An incident report, dated 12/22/24, documented the resident was found lying on the floor in their room with their brief saturated and complaining of being cold. The care plan intervention for fall risk, dated 12/22/24, documented staff were to do frequent checks at night due to the alarm not working correctly. An incident report, dated 12/24/24, documented the resident was assisted by staff to the bathroom per resident request. The report documented staff left the resident sitting on the toilet to obtain a new brief and clothing. The report documented the resident slid off the toilet to the floor. The care plan intervention for fall risk, dated 12/24/24, documented staff were not to leave the resident's side when they were not able to sit up straight on the toilet and to obtain assistance with dressing the resident. A fall log for the resident documented the resident had a fall on 12/26/24 and 12/30/24. There were no incident reports provided. The care plan did not document new interventions for the falls which occurred on 12/26/24 and 12/30/24. An incident report, dated 01/01/25 at 12:00 a.m., documented the resident was found lying on the floor in their room by the bed. The report documented incontinent care was provided and the resident was assisted back to bed. The care plan did not document an intervention for the fall which occurred on 01/01/25 at 12:00 a.m. An incident report, dated 01/01/25 at 1:55 a.m., documented the resident was found lying on the floor in their room. The report documented the resident had been incontinent of bowel and bladder and incontinent care was provided. The report documented the resident sustained a small abrasion to their left knee. The care plan intervention for fall risk, dated 01/01/25, documented the resident was to have wound care to the left knee abrasion until resolved. The care plan intervention for fall risk, dated 01/02/25, documented to change the resident's mattress to a wide mattress. On 01/12/25 at 4:16 p.m., the resident was in the dining room sitting in a wheelchair for the evening meal. The resident's wheelchair had a anti-tip back bar. No alarm was noted. The resident's room had floor mats covering the entire floor area of the resident's side of the room. On 01/14/25 at 4:06 p.m., the ADON reviewed the resident's plan of care and stated new interventions were no implemented with each fall occurrence. The ADON stated some interventions were repeat interventions or not appropriate fall interventions for the resident. On 01/15/25 at 8:14 a.m., the resident was sitting in the dining room in a wheelchair with their head down and their eyes closed. The wheelchair had a anti-tip back bar. The wheelchair did not have a chair alarm. The resident was wearing tennis shoes. On 01/15/25 at 8:28 a.m., CNA #4 stated the resident had a low bed, was observed every two hours, had a anti roll back attachment on their wheelchair, and was toileted every two hours. The CNA stated the resident was usually in common areas or near the nurse station during the day for visual site. The CNA stated the resident usually slept through the night, but was still checked on every two hours. On 01/15/25 at 10:54 a.m, the DON stated the staff were aware of resident's toileting program and documented in the task records. The DON reviewed the resident's plan of care and stated there were repeat interventions and not appropriate interventions for the resident. The DON stated the staff needed education regarding falls and fall interventions.

Based on observation, record review, and interview, the facility failed to ensure a resident received restorative services to maintain or improve their ability to carry out activities of daily living for one (#26) of one sampled resident reviewed for activities of daily living. The DON identified nine residents who were currently receiving restorative services. Findings: A document titled Policy and Procedure Range of Motion, read in parts, To exercise the resident's joints and muscles as required and/or clinically indicated .Verify exercise to be completed with physician's orders or treatment plan. Unless otherwise specified, repeat each exercise (3) times. There was no policy regarding restorative services provided. Resident #26 had diagnoses which included muscle weakness, lack of coordination, muscle wasting and atrophy, abnormalities of gait and mobility, and Parkinson's. The care plan, revised 08/07/23, documented the resident had muscle strength/muscle atrophy, weakness, and deconditioning. The care plan documented the staff were to encourage the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility. The care plan documented the staff were to refer the resident to PT/OT/restorative PRN indication/ordered. A physician order, dated 02/08/24, documented to discontinue part B physical therapy services and resident may have restorative nursing services. A physician order, dated 06/05/24, documented PT/OT/ST to evaluate and treat as indicated. A physical therapy discharge summary, dated 06/05/24 through 08/09/24, documented discharge recommendations for the restorative program. The summary documented range of motion program established with resident. The summary documented the resident was able to move their feet up and down, raise their arms above their head, chin to chest, and tier was functional and with restorative nursing program. The summary documented a transfer program was established with resident and they were currently able to perform stand pivot transfers, perform wheelchair transfers, and tier was functional with restorative nursing program. The annual assessment, dated 01/01/25, documented the resident was cognitively independent and was dependent assist with transfers and most ADLs. The assessment documented the resident had limited ROM with one side of the upper body. The assessment documented the resident was not receiving physical therapy, occupational therapy, or restorative services. On 01/12/25 at 2:36 p.m., the resident was observed lying in bed and was wearing an incontinent brief. The resident stated they just laid in bed because it took more than one staff member for transfers. The resident stated they had not received restorative services since their physical therapy had ended in August of last year. The resident stated they were walking in the hall with assistance when receiving physical therapy. On 01/14/25 at 2:47 p.m., the DON could not provide documentation the resident ever received restorative services. The DON stated they were responsible for ensuring restorative services were provided when therapy made a recommendation. The DON stated they were not aware of the recommendation for restorative services for the resident. On 01/14/25 at 3:10 p.m., the resident was observed for ROM and a transfer. The resident stated they were still able to complete ROM and transfers as when receiving physical therapy, but they were just weaker now.

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were utilized during resident care for one (#32) of one sampled resident observed during care. The administrator identified 11 residents that required enhanced barrier precautions. Findings: An Enhanced Barrier Precautions (EBP) policy, last reviewed on 05/15/24, read in part, enhanced barrier precautions refer to the use of gowns and gloves during high-contact resident care provides opportunities for transfer of multidrug resistant organisms to hands or clothing. EBP should be used during these high contact areas: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or toileting for people with central lines, urinary catheters, enteral tubes, tracheostomy/ventilator, and wound care for skin openings that require a dressing. On 01/13/25 at 8:02 a.m., Resident #32 had EBP signage on the door. CNA #1 was observed in Resident #32's room assisting with toileting and dressing. CNA #1 was observed wearing gloves and a mask, but no gown. Resident #32 had a dressing over their right foot. CNA #1 was observed placing a sock over the dressing and assisting resident to place a boot on the right foot. CNA #1 then assisted Resident #32 with applying deodorant. CNA #1 then proceeded to change the bed linen that had a yellow stain that was darker around the edges on the bottom sheet. On 01/13/25 at 4:07 p.m., CNA#3 was asked what EBP or enhanced barrier precautions meant. CNA #3 stated EBP was lantiseptic and you were supposed to use gloves at all times with all residents. On 01/13/25 at 4:13 p.m., CNA#2 stated they were not told about enhanced barrier precautions or what it meant. On 01/14/25 at 11:29 a.m., LPN #1 was observed providing wound care to Resident #32. LPN#1 cleaned the bed side table appropriately, applied clean gloves, removed Resident #32's boot, sock, and dressing from their left foot. On 01/14/25 at 11:34 a.m., LPN #1 donned clean gloves and washed wound, the wound was patted dry and measured. Santyl was applied followed by calcium alginate, 4x4 abdominal pad, stretch gauze, Kerlix, and secured with Coban. On 01/14/25 at 11:48 a.m., LPN #1 stated they provided wound care five days a week. LPN #1 stated EBP were to be used for wounds, urinary catheter care, peg tube care, and breathing treatments to prevent cross contamination. LPN #1 stated they were trained and magnets were placed on the side of the door to indicate EBP were to be used and the supplies were supposed to be on the back of the door inside the rooms. LPN #1 stated they used an app that reported what residents required EBP when providing high contact direct care. LPN#1 stated they were not wearing a gown and should have been. On 01/14/25 at 2:25 p.m., the ADON stated they had started re-educating staff when it was brought to their attention that some of the staff's understanding was incomplete or inaccurate.

Based on observation, record review, and interview, the facility failed to ensure: a. the ovens were clean; b. foods were labeled and dated in the refrigerator; and c. the ice scoop was maintained in a sanitary manner. The administrator identified 51 residents resided in the facility. Findings: A policy titled Ice Machine, read in parts, The ice machine, scoop, and storage container will be maintained in a clean and sanitary condition .The scoop and storage container will be cleaned once per day. A policy titled Refrigeration, read in part, Foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a leftover. All leftovers shall be labeled and dated with an expiration date of no more than three (3) days. On 01/12/25 at 11:55 a.m., a tour of the kitchen was conducted. The ice scoop was observed lying on top of the ice machine uncovered and not in a bag. Three ham sandwiches were in the refrigerator in sandwich bags unlabeled and undated. On 01/12/25 at 12:05 p.m., the ovens were observed to have a thick black substance on the bottom and sides of the oven. On 01/12/25 at 12:07 p.m., cook #1 stated the ovens needed to be cleaned. The cleaning schedule posted on the wall documented the oven had been cleaned a week ago. The cook stated the ovens did not look like they had been cleaned a week ago. The cook stated the ice scoop should be kept in a plastic bag and the bag changed daily. On 01/13/25 at 3:45 p.m., the DM stated the ovens had not been cleaned per the cleaning schedule and staff education had been provided.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for one (#21) of five sampled residents reviewed for unnecessary medications. The administrator identified 51 residents resided in the facility. Findings: The Medication Administration policy, dated 01/2024, read in part, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Resident #21 had diagnoses which include hypertension, hypothyroidism, and bipolar disorder. A November 2024 Medication Administration Record was blank on November 28th, 29th, and 30th for Resident #21's order for levothyroxine (thyroid hormone medication) 50 mcg to be given twice daily for hypothyroidism. A December 2024 Medication Administration Record was blank on December 7th, 8th, 11th, and 16th for Resident #21's order for levothyroxine 50 mcg to be given twice daily for hypothyroidism. A January 2025 Medication Administration Record was blank for the 2:00 p.m. dosage of metoprolol (beta blocker) 50 mg to be given three times daily for hypertension on January 4th and 9th. The MAR was also blank for the 2:00 p.m. dosage of protriptyline (antidepressant medication) 20 mg to be given three times a day for bipolar on January 4th and 9th. On 01/14/25 at 2:12 p.m., CMA #1 stated they were unable to verify if the medications were given if the medication administration was blank. On 01/14/25 at 2:25 p.m., the ADON stated the blanks meant the medication administration was not documented, so there would be no way to know it the medication was administered or not.

Based on observation, record review and interview, the facility failed to ensure a care plan was updated for one (#7) of thirteen resident care plans reviewed for accuracy. The administrator identified 51 residents resided in the facility. Findings: 1. Resident #7 had diagnoses which included surgical amputation of left lower leg. The resident's care plan was reviewed and did not document the amputation of the left lower leg. On 01/15/25 at 10:51 a.m., the MDS coordinator stated the care plan should have been updated to include the amputation and any other changes to their abilities that resulted from the amputation. On 01/15/25 at 11:00 a.m., the DON stated the care plan should have been updated.

Based on record review and interview, the facility failed to ensure a referral was made to the LOCEU for one (#3) of three sampled residents reviewed for PASSARs. The DON identified eight residents with a level II PASSAR. Findings: Resident #3 had diagnoses which included hypertension, dementia, and hallucination. A level I PASSAR, dated 08/30/18, documented the resident did not have a diagnosis of a serious mental illness. A level I PASARR, dated 06/10/19, documented the resident did not have a diagnosis of a serious mental illness. On 01/11/24 the resident received a diagnosis of psychosis not due to a substance or known physiological condition. The annual assessment, dated 08/28/24, documented the resident was not currently considered by the state level II PASSAR process to have serious mental illness and/or intellectual disability or a related condition. On 01/14/25 at 12:35 p.m., the ADON reviewed the resident's diagnoses and stated they were not aware of the diagnosis of psychosis for the resident. The ADON stated when the resident received the psychosis diagnosis a referral should have been made to the LOCEU for consultation.

Based on record review and interview, the facility failed to complete a significant change assessment for a resident with a decline in ADLs due to an above knee amputation for one (#7) of 13 sampled residents reviewed for assessments. The administrator identified 51 residents resided in the facility. Findings: An annual MDS assessment, dated 04/21/24, documented Res #7 had no functional impairments in range of motion. The MDS documented Res #48 required setup/cleanup assistance with upper body dressing. The MDS documented Res #7 used both a walker and a wheelchair for mobility, and required supervision with walking 10 feet. A quarterly MDS assessment, dated 09/18/24, documented Res #7 had declined in range of motion and had impairments of upper and lower extremities on both sides. The MDS documented Res #7 required supervision with walking 10 feet. A progress note, dated 11/25/24, documented Res #7 was being sent to the hospital due to possible gangrene to their left heel. The facility census report documented Res #7 went to the hospital on 11/25/24 and returned on 12/02/24. A progress note, dated 12/02/24, documented the nurse observed eight sutures and 20 staples to the left side above the knee amputation. A review of the record identified a significant change assessment had not been completed. On 01/15/25 at 10:51 a.m., the MDS coordinator stated a significant change should have been completed within 14 days of recognizing a significant change had taken place. On 01/15/25 at 11:00 a.m., the DON stated a significant change should have been completed.

Based on observation, record review, and interview, the facility failed to utilize their antibiotic stewardship policy to monitor antibiotic use for four (#11, 25, 32, and #36) of five residents reviewed for antibiotic use. 1. Res #11's physician order dated 08/18/23, documented the resident was to receive Zithromax 250 mg daily for four days for COVID-19. 2. Res #32's physician order, dated 08/22/23, documented the resident was to receive Zithromax 250 mg daily for four days for COVID-19. 3. Res #36's physician order, dated 04/17/23, documented the resident was to receive Cefdinir 300 mg twice a day for four days. 38495 4. Res #25 had diagnoses which included UTI and ESBL. A physician order, dated 06/15/23, amoxicillin/clavulanate, administer one tablet by mouth two times a day related to urinary tract infections for seven days. A physician order, dated 07/04/23, documented levofloxacin 750 mg, one time a day related to ESBL for 10 days. On 09/18/23 at 4:28 p.m., the IP was interviewed and reported the facility had implemented an antibiotic stewardship program utilizing the McGreer's criteria. The IP stated they would answer the questions to the McGreer's criteria in their head and then started antibiotics if the criteria was met, but we do not keep documentation of the McGreer's criteria. On 09/18/23 at 4:30 p.m., the corporate nurse presented a document of the McGreer's criteria for antibiotic stewardship program. They stated the IP nurse did answer the questions to the McGreer's criteria but did not keep documentation of the form utilized.

Based on observation and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. The Resident Census and Conditions of Residents form documented 45 residents resided at the facility. Findings: On 09/14/23 at 12:21 p.m., an initial tour of the kitchen and food storage areas was conducted. On 09/14/23 at 12:30 p.m., the ice machine in the kitchen was wiped from the ice drop with a clean white paper towel. The paper towel was observed with a black substance on it. At that time the DM observed the black substance. The DM stated the ice machine had been cleaned on 07/18/23. The DM stated the maintenance man and the DM cleaned the ice machine. On 09/14/23 at 12:37 a.m., a hand sanitizer dispenser was observed on the wall inside the kitchen door. The dietitian was observed to use the hand sanitizer when entering the kitchen. On 09/14/23 at 4:45 p.m., CNA #1 was observed to move a stool on wheels, touched their own glasses, then opened and removed the silverware out of the paper holder and handed it to a resident. The CNA was not observed to perform hand hygiene at that time. On 09/14/23 at 4:49 p.m. NA #1 had been assisting a resident in the dining room rubbing the residents back to help the resident stay calm and try to eat. NA #1 touched multiple items during the observation and then touched the resident's bread with bare hand. On 09/14/23 at 4:59 p.m., the staff serving the meals would step into the kitchen and use the hand sanitizer between resident meals. On 09/19/23 at 3:03 p.m., the DM stated hand hygiene should be used in between every resident when serving in the dining room. The DM stated the staff should use hand hygiene when they touched anything dirty and should never touch the resident's food with bare hand. On 09/19/23 at 10:31 a.m., during the second tour of the kitchen, the DM was observed to use a bottle of hand sanitizer in the kitchen. The DM was asked about using hand sanitizer in the kitchen. The DM stated the staff will use it between glove changes in the kitchen. On 09/19/23 at 10:35 a.m., observed DA #1 enter the kitchen and use the water dispenser they did not wash their hands first. On 09/19/23 at 10:40 a.m., DA #1 was observed to enter the kitchen and go to the office and then to the dish room before washing their hands. On 09/19/23 from 11:29 a.m. to 11:46 a.m., multiple staff members were in and out of the kitchen to the dining room with out washing their hands. On 09/19/23 at 12:13 p.m., the DM was observed to come into the kitchen, move a cart over and went to the office. There was no hand washing observed. On 09/19/23 at 12:15 p.m. DA #2 was observed to enter the kitchen and get the milk from the refrigerator and retrieve a throw away glass and pour a glass of milk. The DA then took the glass of milk to the dining room for a resident. DA #2 did not wash their hands when they entered the kitchen. At 12:19 p.m., DA #2 was observed to enter the kitchen with the hot box for the hall trays. They did not wash their hands when they entered the kitchen. The DA went to he dish room brought out more plates and placed them on the plate warmer for service, placed small containers of butter in a container, and returned to the dining room. At 12:23 DA #2 re-entered the kitchen did not wash their hands. On 09/19/23 at 3:06 p.m., the DM stated they were not aware hand sanitizer could not be used in the kitchen. The DM stated when entering the kitchen the staff were supposed to wash their hands.

Based on observation, record review, and interview the facility failed to provide food that was palatable and at an appetizing temperature for the residents. The Resident Census and Conditions of Residents report, documented 45 residents resided in the facility. Findings: 1. Res #20 had a diagnosis of diabetes mellitus. A quarterly assessment, dated 08/18/23, documented the resident was intact with cognition and was independent with eating. On 09/14/23 at 1:47 p.m., Res #20 stated the food had gone down hill lately, it was either bland or to salty. Res #20 stated the milk was warm this morning and tasted spoiled they could not drink it. Res #20 stated the drinks were brought out in the warmer with the food. The resident stated they preferred to eat in their room. On 09/19/23 at 10:22 p.m., Res #20 stated they keep sending orange juice with breakfast and they did not like orange juice. The resident stated the drinks are not cold when they get them but the food is cold. Res #20 stated the oatmeal was hard on top by the time it got to them. 2. Res #25's Medicare five day assessment, dated 09/04/23, documented the resident was intact with cognition and was independent with eating. On 09/14/23 at 2:07 p.m., Res #25 stated the food was bland / or to salty. The resident stated it was much better when they first came to the facility. The food had gotten worse in the last two or three weeks. The resident stated they did not know what had changed in the kitchen. On 09/19/23 at 2:35 p.m., Res #25 stated they liked coffee with breakfast and they hardly ever get coffee with their breakfast. Res #25 stated they received coffee one time last week with her breakfast. 3. On 09/19/23 at 11:09 a.m., the food temperature was obtained when it was cooking and getting ready to be placed on the steam table. On 09/19/23 at 11: 14 a.m., A food temperature log was observed for both the regular and puree food. The log was kept on the side of the refrigerator. On 09/19/23 at 11:54 a.m., the plate warmer was observed to get plugged into an outlet. On 09/19/23 at 11:54 a.m., the food was not observed to be tempted on the steam table before service started. On 09/19/23 at 12:31 p.m., the hall trays went out of the kitchen. The test tray arrived at the room at 12:54 p.m., and the temperature of the food was taken. The roast was 127.7 degrees F, potatoes were 114.3 degrees F, green peas were 120.2 degrees F, Roll was 117.6 degrees F, bread pudding was 76.8 degrees F, and the yellow drink was 70.8 degrees F. The food was palatable with the gravy being a little salty. The bread pudding was difficult to cut. The drink was to warm, not palatable, and did not contain any ice. On 09/19/23 at 3:06 p.m., The DM stated she had received some complaints of cold food but never of the drinks being to warm. The DM stated they had just received the steam table over the week end and the staff should have got the holding temperatures of the food on the steam table before serving the meal. The DM stated they knew the food was hot because we temp it when cooking. The DM stated the residents should get coffee when they want it and if they don't like orange juice they should get something they like to drink.

Based on observation, record review,and interview, the facility failed to follow the menu and provide pureed foods listed on the menu for the puree diets from the kitchen. The Resident Census and Conditions of Residents form documented 11 residents resided at the facility who had mechanically altered diets including pureed and all chopped food. Findings: The menu for week three, regular puree meal, documented puree pot roast, puree new potatoes, puree green peas, puree dinner roll, puree bread pudding, margarine, salt/pepper, milk, and water. On 09/19/23 at 11:36 a.m., the bread was not observed to be pureed for the noon meal. On 09/19/23 at 11:54 a.m., a puree meal was observed to be served roast with gravy, potatoes, green peas, and bread pudding were observed to be served. Pureed bread was not served with the puree meal. On 09/19/23 at 3:06 p.m., the DM stated the puree meals should have received what ever was on the menu.

Based on record review and interview, the facility failed to ensure labs were obtained per physician order for one (#20) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, documented 45 residents resided in the facility. Findings: Res #20 admitted to the facility and had diagnoses which included heart failure, hypothyroidism, and diabetes mellitus. A physician order, dated 08/13/23, documented to perform a HgbA1c every three months in February, May, August, and November. A quarterly assessment, dated 08/18/23, documented the resident was intact with cognition and required limited assistance with most ADLs. The assessment documented the resident received insulin seven days during the assessment period. A care plan, last revised 08/19/23, documented the resident has unstable blood glucose levels related to hyperglycemia. The care plan documented to obtain an HgbA1c on admit and every three months. On 09/18/23 at 1:09 p.m., The DON could not provide the August HgbA1c. The DON stated the HgbA1c had been missed in August. The DON stated they had called the physician and were to obtain the lab now and then carry on with the way the order was written.

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors for one (#20) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, documented 45 residents resided in the facility. Findings: Res #20 admitted to the facility and had diagnoses which included heart failure, hypothyroidism, and diabetes mellitus. A physician order, dated 05/07/23, documented Novolog injection solution (insulin Aspart) inject as per sliding scale. A physician order, dated 05/11/23, documented Lantus subcutaneous solution (insulin Glargine) inject 50 units one time a day related to diabetes mellitus. A quarterly assessment, dated 08/18/23, documented the resident was intact with cognition and required limited assistance with most ADLs. The assessment documented the resident had received insulin the seven days prior to the assessment. A care plan, last reviewed 08/19/23, documented the resident had unstable blood glucose levels related to hyperglycemia. The care plan documented to administer insulin medications as prescribed. The August and September 2023 TARs were reviewed. The August TAR had one day which was blank for the Novolog insulin. The August TAR documented Lantus insulin had been held four days, the 6th, 12th, 26th, and 27th. The residents FSBS had not been documented two days, the 19th and 21st, when the insulin had been held. The TAR for September had three blanks for the Lantus Insulin. The dates were the 9th, 11th, and the 17th. On 09/18/23 at 2:23 p.m., the ADON stated if the TAR for insulin was not marked as given, they could not tell if the medication had been administered. The ADON stated the reason the insulin medication was held should have been documented on the treatment record. The ADON stated the nurse should have called the physician before holding the medication when the order did not have parameters. On 09/18/23 at 2:34 p.m., the ADON reviewed the resident's medical record and stated they were not able to find where the physician had been contacted regarding the holding of the resident's insulin.

Based on record review and interview, the facility failed to ensure behaviors and/or side effects were monitored for the use of psychotropic medications for two of (#20 and #25) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 45 residents who resided in the facility. Findings: 1. Res #20 had diagnoses which included insomnia and major depressive disorder recurrent. A physician order, dated 05/08/23, documented Wellbutrin SR (an antidepressant) 450 mg one time a day related to major depressive disorder. A physician order, dated 05/22/23, documented trazodone (an antidepressant) 150 mg at bedtime related to insomnia. A quarterly assessment, dated 08/18/23, documented the resident was intact with cognition and required limited assistance with most ADLs. The assessment documented the resident received antidepressant medication during the look back period. A care plan last revised 08/19/23, documented the resident received antidepressants. The care plan documented the resident had feelings of prolonged sadness, hopelessness, fatigue, low self-esteem associated with depression. The care plan documented to administer medications as prescribed and monitor for effectiveness, side effects and adverse drug reactions. The EHR did not contain documentation for side effect monitoring or behaviors notes or an AIMS for the resident. On 09/18/23 at 1:33 p.m., the DON stated they documented the behaviors under behavior notes and the AIMS but were not provided. 2. Res #25 had diagnoses which included insomnia, generalized anxiety disorder, and depression. A physician order, dated 06/06/23, documented to obtain an AIMS on admit and quarterly related to Abilify use. A care plan last reviewed 07/07/23, documented the resident received Abilify. The care plan documented the resident experienced self isolation associated with major depressive disorder and to administer medication as prescribed. The care plan documented to perform an AIMS quarterly. The care plan documented to report impaired vision, tremors, muscle twitching urinary retention to the physician promptly. The care plan documented to monitor for side effects of drowsiness, insomnia, agitation, anxiety, headache, seizures, neuroleptic malignant syndrome, light-headedness, akathisia, tremor, stroke, suicidal ideation, dystonia, cogwheel rigidity. The care plan documented the resident took a sedative medication and had sleep disturbance associated with insomnia. The care plan documented to administer medications as prescribed and monitor for side effects and toxicity. A physician order, dated 08/28/23, documented temazepam (a sedative medication) administer one every 24 hours as needed for insomnia. A physician order, dated 08/28/23, documented Lexapro (an antidepressant) administer 20 mg at bedtime related to major depressive disorder. A physician order, dated 08/29/23, documented Abilify (an antipsychotic) administer 10 mg one time a day related to major depressive disorder. A physician order, dated 08/29/23, documented Wellbutrin XL (an antidepressant) administer 450 mg one time a day related to major depressive disorder. A Medicare five day assessment, dated 09/04/23, documented the resident was intact with cognition and required limited assistance with ADLs. The assessment documented the resident had received an antipsychotic, antidepressant, and hypnotic medication during the seven day look back period. Behavior and side effects monitoring were not found in the EHR. On 09/18/23 at 1:38 p.m., the ADON stated they have behavior evaluations. The ADON stated they knew there was not a place to document daily monitoring of medications. The ADON stated they only documented when a resident had a problem. On 09/18/23 at 1: 50 p.m., Corporate RN #1 stated they did not have any batch orders for monitoring and normally it was on EMAR.

Based on record review and interview, the facility failed to ensure the physician was notified of a significant weight loss and residents received interventions to maintain nutritional status within acceptable parameters for one (#32) of two residents sampled for nutritional status. The Resident Census and Conditions of Residents form documented 45 residents who resided in the facility. Findings: 1. Res #32 had diagnoses which included Alzheimer's disease, encephalopathy, dementia, anxiety, and major depression. The weight record, dated 02/13/23, documented a weight of 155 lbs. The weight record, dated 03/6/23, documented a weight of 155 lbs. The weight record, dated 04/04/23, documented a weight of 144 lbs. A dietary note, dated 04/20/23, documented Res #32 had a significant weight loss of 7.1% in the last 30 days. The weight record, dated 05/05/23, documented a weight of 136 lbs. A dietary note, dated 05/31/23, documented Res #32 had a significant weight loss of 5.6% in the last 30 days and the dietician recommendation was to offer ice cream twice a day to the resident. There was no documentation ice cream was offered. The weight record, dated 06/06/23, documented a weight of 130 lbs. A quarterly assessment, dated 06/20/23, documented the resident had short and long term memory problems. The assessment also documented the resident had a weight loss of 5% or more in the last month or 10% in the last 6 months and the weight loss was not prescribed by a physician. A dietary note, dated 06/30/23, documented Res #32 had a significant weight loss of 15.6% in the last 90 days. The care plan, dated 08/08/23, documented to consult the physician about alternative methods of providing nutrition as indicated/prescribed. On 09/20/23 10:25 a.m., an interview was conducted with the ADON and they stated the physician was never notified of the weight loss and interventions had not been put in place.

Based on observation, record review, and interview, the facility failed to ensure residents received the supervision and assistance to prevent falls for one (#18) of three sampled residents reviewed for accidents hazards. The Resident Census and Conditions of Residents form, documented 45 residents resided at the facility. Findings: Res #18 had diagnoses which included COPD, dementia, and anxiety disorder. A care plan, dated 11/18/20, documented the resident was a high risk for falls. The care plan document the resident had altered sensory preception secondary to dementia. An incident report, dated 09/18/22, documented an unwitnessed fall for Res # 18. The resident was found on floor in their room on their knees with their hands and head resting in the seat of their wheelchair. The report documented the resident said they were trying to get out of bed and transfer to the wheelchair. The incident report documented there were no injuries. The incident report documented a fall alarm was placed on the bed. An incident report, dated 09/28/22, documented an unwitnessed fall. The incident report documented the nurse was called to resident's room because Res #18 was crawling to doorway. The report documented the resident said they were headed to get the baby. The report documented the resident had asmall amount of blood to the left eyebrow, blood to left forearm, left elbow, and left index finger at the knuckle. The incident report documented the trash can can had blood on it and the alarm did not sound due to a faulty alarm pad. The incident report documented the fall alarm was replaced on the bed, a fall mat added to bed side, and the trash can removed from area. A quarterly assessment, dated 12/12/22, documented the resident was severely impaired with cognition and required extensive assistance with most ADLs. The assessment documented the resident had two non-injury falls since prior assessment. An incident report, dated 12/23/22, documented an unwitnessed fall. The incident report documented Res #18 was found on fall mat beside the bed on their bottom with their legs in front of them. The report documented the bed was in the lowest position and the alarm on the resident's wheelchair was going off which lead the nurse to believe that Res #18 was attempting to self transfer. The incident report documented there were no visible injuries. The incident report documented there was not an alarm present on the bed. The incident report documented a bed alarm was placed on the resident bed. This intervention was already on the care plan. An incident report, dated 12/26/22, documented an unwitnessed fall. The incident report documented a noise was heard of a wheelchair hitting the wall and Res #18 was seen sitting on the floor in front of the wheelchair. The incident report documented there were no injuries observed and the resident denied pain. The incident report documented Res #18 was assisted back into the wheel chair and the safety alarm was in place and functioning. The incident report documented the resident had a pillow, blanket, stuffed animal, box of candy, two books, Christmas cards, and their water cup in their lap. The incident report documented Res #18 reported they just slipped out. The incident report documented the resident was assisted back into the wheel chair and the alarm was put in place. A non skid liner was placed in the resident's wheelchair. An incident report, dated 01/01/23, documented an unwitnessed fall. The incident report documented Res #18 was found by a CNA sitting on the floor on the fall mat in front of the bed. The incident report documented the resident reported they wanted to sit in their wheel chair. The incident report documented no injuries observed. The resident was assisted back to bed and the fall alarm was in the bed and the fall mat was in front of the resident's bed. There were no new interventions added to prevent reoccurrence. A quarterly assessment, dated 03/14/23, documentated the resident was severely impaired with cognition and required extensive assistance with most ADLs. The assessment documented the resident had two non-injury falls since prior assessment. An incident report, dated 03/31/23, documented an unwitnessed fall. The incident report documented the nurse was called to Res #18's room by a CNA. The resident was observed sitting on the floor beside their bed and the resident's wheelchair was behind the resident. The incident report documented the fall alarm was ringing at that time. The incident report documented there were no injuries observed and the resident denied pain. The report documented the Res #18 reported I thought I had enough get up and go to get in bed but I fell . A care plan intervention, dated 03/31/23, documented the resident was not to be left alone in their wheelchair in their room. An incident report, dated 04/12/23, documented an unwitnessed fall. The incident report documented Res #18 was found on the floor in front of their bed on their knees with alarm sounding and there were no injuries noted. The incident report documented it appeared as though Res #18 was trying to transfer to their bed. The report documented the resident reported when asked what they were doing when they fell the resident stated I'm tired, can I go to bed. The intervention after the previous fall of the resident not being alone in their room in their wheel chair was not carried out. A care plan intervention, dated 04/12/23, documented the staff were to perform hourly visual checks with CNA documentation. An annual assessment, dated 06/12/23, documentated the resident was severely impaired with cognition and required extensive assistance with most ADLs. The assessment documented the resident had two non-injury falls since prior assessment. An incident report, dated 08/15/23, documented an unwitnessed fall. The incident report documented the nurse was called to Res #18's room by the CNAs. The report documented the resident was observed on their buttocks on the fall mat beside their bed with their back against the bed. The incident report documented Res #18 stated, I don't know how I got here. The incident report documented there were no injuries observed. A care plan intervention, dated 08/15/23, documented the resident climbs out of bed and sits on the fall mat at will. A quarterly assessment, dated 09/12/23, documented the resident was severely impaired with cognition and required limited assistance with most ADLs. The assessment documented the resident had one non-injury fall since prior assessment. On 09/14/23 at 2:50 p.m., the resident's bed was observed in low position and a fall mat in place by the bed in the resident's room. The resident was not observed in the room at that time. On 09/20/23 at 12:27 p.m., the ADON stated the facility added a fall alarm to the bed after the 09/18/22 fall, and on 09/28/23 a fall mat was added. The ADON stated on 12/23/23 they repeated the intervention of the bed alarm. A non-skid liner to the wheel chair was added on 12/26/23. The ADON stated there was not a new intervention in January. The intervention in March was to not leave the resident alone in their room in the wheelchair and the 04/12/23 intervention was for hourly checks. The ADON stated there was not a new intervention for the fall on 08/15/23. ADON stated it was just a statement not an intervention. The ADON stated the CNAs find the fall interventions for the resident on the kardex.

Based on record review and interview, it was determined the facility failed to ensure a comprehensive care plan was developed for resident to resident interaction related to wandering for one (#11) of 12 sampled resident whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 45 residents resided in the facility. Findings: Res #11 was admitted to the facility on [DATE] with diagnoses of dementia and unspecified hallucinations. A care plan, dated 01/01/23, documented the resident was not a risk for wandering. An admission assessment, dated 01/12/23, documented the resident was severely impaired with cognition. An assessment for wandering, dated 04/09/23, documented the resident was moderate risk for wandering. An assessment for wandering, dated 07/10/23, documented the resident was moderate risk for wandering. A quarterly assessment, dated 07/15/23, documented the resident wanders daily. An incident report, dated 09/11/23, documented resident to resident altercation after Res #11 wandered into another resident's room. On 09/19/23 at 4:57 p.m., the MDS Coordinator stated there was no care plan for resident to resident altercation related to Res #11 wandering in the facility.

Based on interview and record review, the facility failed to ensure assessments were encoded and transmitted to CMS in the required time frame for two (#41 and #44) of twenty residents whose assessments were reviewed. The Resident Census and Conditions of Resident form documented 45 residents resided in the facility. Findings: 1. Res #44's five day Medicare assessment, dated 04/28/23 documented completed. A CMS Submission Report was not located by the facility. An admission assessment, dated 05/04/23, had been completed by the facility according to the EHR. The CMS Submission Report documented multiple warnings including information mismatch and the assessment had been submitted late. The resident's clinical records documented a discharge assessment, dated 06/08/23, documented completed. A CMS Submission Report was not located by the facility. 2. Res #41 had an entry dated 04/06/23, a discharge return not anticipated and a Medicare five day assessment dated [DATE]. CMS Submission Report for the assessments were not located by the facility. On 09/20/23 at 1:10 p.m., the ADON stated Res #41 was discharged on [DATE] and there was no record of the assessments being sent. The ADON stated Res #44 had two assessments a five day and a discharge which had not been transmitted.

Based on record review and interview, the facility failed to ensure a DNR was signed by the appropriate person for two (#7 and #3) of five residents reviewed for advance directives. The administrator identified 23 residents in the facility had a DNR. Findings: 1. Res #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A DURABLE POWER OF ATTORNEY FOR FINANCIAL MANAGEMENT form, dated [DATE], documented in parts .This document does not authorize anyone to make medical or other health care decisions. You may execute a health care proxy (also known as a health care or medical power of attorney) to do this . A DNR form, dated [DATE], was signed by the individual designated as the POA on the Durable Power of Attorney for Financial Management form. A quarterly resident assessment, dated [DATE], documented the resident was cognitively intact. On [DATE] at 10:29 a.m., Res #7 stated he did not want to be a DNR. He stated he did want CPR in the event he stopped breathing or his heart stopped. He stated that he did not have a medical POA or healthcare proxy. On [DATE] at 10:31 a.m., the DON was provided with the POA document and the DNR on file for Res #7. He stated the POA for financial management who signed the DNR did not have authority to sign for the resident in health care matters. 2. Res # 3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A comprehensive assessment, dated [DATE], documented Res #3 was severely impaired in cognition. On [DATE] at 5:24 p.m., an Oklahoma Do-Not-Resuscitate (DNR) Consent Form for Res #3 was reviewed. The form documented a signature of a family member who was not designated in the resident's Durable Power of Attorney form as the resident's health care proxy. On [DATE] at 12:25 p.m., the DON provided a DNR form signed on [DATE] by Res #3's health care proxy. The DON stated the previous signer of Res #3's DNR form had no authority to sign for Res #3.

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident remained as free of accident hazards as possible for four (#1, #2, #4, and #5) of six sampled residents reviewed for accidents. The facility failed to thoroughly investigate the accidents and implement measures to prevent avoidable accidents. Resident #4 sustained an amputation of the finger tip. Residents #1 and #2 fell and sustained fractures. Resident #5 fell and had a raised area on her head. The facility identified 18 residents that had fallen and sustained injuries during the first quarter of this year. Findings: The facility policy for investigating unexplained injuries documented all unexplained injuries would be investigated to ensure resident safety was not jeopardized. The policy documented the protocols for abuse investigation should be followed. The abuse investigation protocol documented staff members on all shifts, family members, and other residents who had contact with the resident during the 48 hours prior to the incident would be interviewed. The protocol documented other employees should be interviewed to determine if they had witnessed incidents of mistreatment by the accused employee. The protocol documented all events preceding the alleged incident should be reviewed. The protocol documented the local police department would be notified by the administrator if it was determined abuse had occurred. The policy and procedure for routine laboratory testing purpose was to obtain baseline laboratory data upon the admission of a resident, monitor laboratory data on a periodic basis to assure maintenance of health status, and to assist with the adjustment of medications as needed. The policy and procedure for routine laboratory testing documented if no specific orders were provided when a resident was admitted , orders would be written and followed pertinent to the resident's [DIAGNOSES REDACTED]. 1. Resident #4 was admitted to the facility on [DATE]. The resident's current [DIAGNOSES REDACTED]. The annual assessment, dated 12/16/10, documented the resident's cognition was severely impaired with short and long term memory problems and rarely understood. The assessment documented the resident was not ambulatory and was dependent on staff for activities of daily living (ADLs). The assessment documented the resident used a wheelchair for mobility. The assessment documented the resident had functional limitations in range of motion for the upper and lower extremities. The care plan, dated 12/17/10, documented the resident was at risk for falls related to impaired mobility and muscle weakness. Interventions included to keep the bed at the lowest level, to position the resident in a Geri-chair when out of bed, and to observe the resident frequently. A nurse's note, dated 02/09/11 at 12:30 p.m., documented the resident had been found in her bed in her room with blood on her gown, neck, and hands. The note documented the resident had a moderate amount of blood on the finger tip of the right middle finger and approximately 1/2 inch of the finger was missing. The note documented the edge of the finger was smooth with no loose skin. The note documented the nurse observed the sheets, floor mat, and floor around the bed, but no additional blood was noted. The note documented at 12:45 p.m. the resident's finger tip was found by the foot of the bed on the floor. The note documented the nurse practitioner was notified and orders for treatment were received. The note documented the resident was non-verbal but did not have signs and symptoms of pain. The note documented the family was notified. A nurse's note, dated 02/09/11 at 1:40 p.m., documented the resident's family was at the bedside. The note documented the facility staff and the resident's family made observations of the resident's surroundings including the bed, the Geri-chair, and other areas of the room to determine how the injury had occurred. The note documented the cause was unknown at that time. An incident report, dated 02/09/11, documented the resident had a laceration to the middle finger of the right hand. The incident report did not include corrective or preventive measures. A nurse's note, dated 02/09/11 at 5:20 p.m., documented the family had notified the facility requesting the resident to be sent to the hospital. The note documented the nurse practitioner was contacted and an order was received to transport the resident to the hospital by ambulance. The note documented the resident was admitted to the hospital for observation. A nurse's note, dated 02/14/11, documented the resident was discharged from the facility and was admitted to another facility. The note documented the cause of the injury was unknown and the investigation continued. The note documented two aides involved with the resident's care on the day of the incident had quit. The note documented the local police department had been contacted. On 03/14/11 at 3:23 p.m., the director of nurses (DON) was interviewed regarding the investigation of accidents with injuries. The DON stated she did tracking and trending of falls and other injuries. The DON stated the investigation of the amputated finger tip was still ongoing and at that time the cause of the amputation was unknown. On 03/15/11 at 5:00 p.m., the DON and administrator were interviewed regarding the investigation of the incident of the amputated finger tip. The administrator and DON stated they had reviewed the facility security cameras on the day of the incident and interviewed the staff that had been involved in the resident's care. The administrator and DON stated they had searched the resident's room and surroundings trying to determine how the incident had occurred but had not been able to determine the cause of the injury. The administrator stated the local police department had been contacted per the facility policy and their investigation continued at that time. The DON was asked if she had investigated other incidents to determine if other resident injuries had occurred during the provision of care by certified nurse aides (CNAs) #2 and #3. She stated she had not looked to see if any other incidents had occurred while the CNAs were providing care. The DON was asked if she had interviewed other staff members from other shifts. She stated she had only talked to the staff members that had been responsible for providing care for the resident at that time. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital history and physical, dated 02/08/11 (one week before admission to the facility), documented the resident was admitted to the hospital on [DATE] due to an exacerbation of her seizure disorder. The report documented the resident's phenytoin level was checked while the resident was in the emergency room . The report documented the phenytoin level (Dilantin) was low at 5.5 micrograms/milliliters (mcg/ml), normal range is 10.0-20.0 mcg/ml. The report documented the resident's medications were adjusted. The report documented a recommendation for the resident to live in a structured environment for assistance with activities of daily living and medication management. An admission assessment, dated 02/22/11, documented the resident was severely impaired related to cognitive skills for daily decision making and required supervision with transfers, ambulation, and toileting. A Care Area Assessment (CAA) for Activities of Daily Living (ADLs) - Functional Status Worksheet, dated 02/22/11, documented the resident did not have abnormal laboratory values. The worksheet documented the resident was at risk for falls and identified contributing factors which included a recent admission to the facility and cognitive impairment. The worksheet documented the resident required supervision and cues for ADLs related to [DIAGNOSES REDACTED]. The worksheet documented the resident's risk for falls would be added to the care plan. A CAA worksheet for Falls, dated 02/22/11, documented the resident had no history of falling prior to admission. The worksheet indicated the resident had physical performance limitations which included the resident's need to rock her body or push on the arms of the chair to stand up from the chair. The worksheet documented the resident had gait problems, had decreased safety awareness, and her balance was impaired. The worksheet documented the resident took medications that could cause confusion. The worksheet did not identify internal risk factors which included circulatory/heart problems, transient ischemic attacks, and/or and cerebral vascular accidents but documented the resident's seizure disorder. The worksheet documented the resident's fall risk would be added to the care plan. The resident's care plan, dated 02/24/11, documented that the resident was at high risk for falls related to use of psychoactive drugs and anticonvulsants. The interventions included observe for the side effects/toxic symptoms of psychoactive drugs being given. The interventions did not include monitoring for side effects of anticonvulsant medications. The interventions included to monitor for changes in the resident's gait, provide assistance as needed, keep the bed in the lowest position, and obtain labs as ordered. The facility did not provide a fall risk assessment for the resident. An incident report, dated 02/24/11 at 4:50 p.m., documented the resident had fallen while ambulating. The fall resulted in a 1 inch laceration above the resident's right eye. The resident was treated at the facility. The physician and the family were notified. The care plan was not updated with new interventions to prevent recurrence. An incident report, dated 03/04/11 at 8:20 p.m., documented the resident had rolled out of bed. The report documented the resident sustained [REDACTED]. The physician and the family were notified. The care plan was updated on 03/04/11 to include the resident had rolled out of bed. The goal for the new problem was for the resident to remain free from falls through nursing intervention and prevention as evidenced by no further falls. The interventions included to: a) review medication record to assess the drug relationship to the resident's fall potential, b) encourage the resident to ask staff for assistance with transfers and ambulation, c) frequently observe the resident's room to give immediate response as needed, d) respond to call light promptly, keep the call bell within the resident's reach and encourage the use of the call light, e) assist with transfers and ambulation as needed, f) keep the adjustable bed in a low position for safe transfers, and g) assess the cause and pattern of falls and act upon resolvable factors. An incident report, dated 03/07/11 at 10:30 a.m., documented the resident had fallen while ambulating in the lobby area of the facility. The report documented the fall resulted in the resident sustaining an abrasion above the right eye. First aid was administered to the resident, neurological checks were initiated, and the physician and the family were notified. The report documented the nurse added a chair and bed alarm for preventive and corrective measures to prevent recurrence. An incident report, dated 03/07/11 at 3:10 p.m., documented the resident had fallen while coming out of her room. The report documented the fall resulted in the resident hitting her head. The resident reopened the abrasion over the right eye from the fall earlier in the day, caused swelling over the left eye, an abrasion across the bridge of the nose, a cut above the lip, and bleeding was noted to the resident's nose, mouth and to the abrasion above the resident's right eye. The resident complained of pain to her head and to her right knee. The physician and the family were notified. Orders were received to send the resident to the emergency room for evaluation and treatment. The resident was hospitalized from [DATE] through 03/14/11. The History and Physical from the hospital, dated 03/07/11, documented that the resident was admitted with exacerbation of seizure disorder. The report documented the resident presented to the hospital with traumatic bruising on face and ribs. The hospital laboratory report documented the resident had Dilantin toxicity with the phenytoin level being 35.9 micrograms/milliliters (mcg/ml) (normal range for Dilantin level is 10.0-20.0 mcg/ml). A Computerized Axial Tomography (CAT) scan of the resident's head and chest documented a fracture of the nasal bone and ribs. On 03/15/11 at 10:20 a.m., the resident was observed lying in her bed. The resident was observed with multiple discolored areas to her face and neck. The resident was asked about the fall that sent her to the hospital. The resident stated she did not remember falling. The resident's bed was in the lowest position with a bed alarm in place. A wheelchair was at the bedside. On 03/15/11 at 10:27 a.m., the director of nurses (DON) was asked what kinds of laboratory values were obtained when a resident was admitted to the facility. The DON stated the facility had a policy and procedure for routine laboratory testing. The DON stated newly admitted residents should have a complete blood count (CBC), a comprehensive metabolic panel (CMP), a thyroid stimulating hormone (TSH), a prealbumin, and a lipid panel. The DON was asked if medications requiring monitoring such as Digoxin and Dilantin were obtained on new admissions. The DON stated those were also documented on the policy and procedure for routine laboratory testing, but were not routinely done on admission. The DON was asked about resident #1's admission orders [REDACTED]. The DON stated the resident had received all the laboratory testings required. The DON was asked if the resident should have had a Dilation level done on admission. The DON stated the physician was made aware of the resident's orders from the hospital. The DON was asked when the Dilantin level would have been obtained if the resident had not gone to the hospital. The DON stated she understood why a baseline was necessary on admission. The DON stated they would not know when to begin the monthly order if a baseline lab had not been obtained or a specific start time was ordered. On 03/15/11 at 10:52 a.m., the DON was asked if she was aware of the resident's history and physical (H&P) when readmitted from the hospital on [DATE]. The DON was shown the H&P which documented the resident had presented to the hospital on [DATE] due to an exacerbation of seizures. The H & P documented the resident's Dilantin level was toxic due to the level being greater than 35 mcg/ml. The DON was asked what the signs and symptoms might be if a resident had Dilantin toxicity. The DON stated slurred speech, confusion, unsteady gait, and falls. On 03/15/11 at 11:47 a.m., the DON was asked about fall risk assessments for the resident. The DON stated the fall risk assessment should have been in the resident's chart. On 03/15/11 at 1:15 p.m., the DON reported she had looked everywhere and was unable to locate the resident's admission fall risk assessment. The DON stated the fall risk assessment should be done on admission, after each fall, and with any readmission. On 03/15/11 at 3:15 p.m., the physician was interviewed regarding the resident's falls. The physician replied there could have been several factors that contributed to the resident's falls. The physician was asked if a Dilantin toxicity could have contributed to the falls. The physician replied it could have been the Dilantin toxicity as well as other factors. The physician stated he attended the facility's quality assurance meetings and worked with the facility staff to implement measures to prevent accident hazards. 3. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/25/11, documented the resident was moderately impaired with decision making and required assistance for ADLs. The assessment documented the resident had fallen since the last assessment had been completed. The resident's care plan, updated on 01/26/11, documented the resident had a potential for falls related to use of medications, history of cerebral vascular accident, and poor safety awareness. The interventions included to keep the bed at the lowest position, encourage the resident to request assistance with ambulating or transfers, keep the environment free from obstruction, and monitor the resident for appropriate footwear. The interventions included to assess the resident for changes in cognition and/or muscle strength, administer medications to the resident as prescribed by the physician, use a pressure sensitive alarm on the bed and chair, observe the resident frequently related to the need for assistance, and encourage the resident to use the call light. The facility did not provide a fall risk assessment for the resident. An incident report, dated 01/10/11 at 7:15 a.m., documented the resident slid out of the wheelchair and sustained no injuries. The physician and the family were notified. The care plan was updated to include the fall but no new interventions were put into place to prevent recurrence. An incident report, dated 01/11/11 at 4:10 a.m., documented the resident was discovered lying on the floor beside the bed with her pillow under her head. No injuries were documented. The report documented the alarm to the bed did not sound. The physician and the family were notified. The care plan was not updated. An incident report, dated 01/16/11 at 11:10 a.m., documented the resident had fallen from the wheelchair. No injuries were documented. The report documented the chair alarm did not sound. The physician and family were notified. Steps to prevent recurrence included to replace the batteries and the cord to the alarm. The care plan was not updated. An incident report, dated 01/19/11 at 7:30 p.m., documented the resident had fallen while trying to transfer herself unassisted. The incident report documented the chair alarm sounded when the resident attempted to transfer from her rocking chair to the wheelchair unassisted. The incident report documented the resident sustained [REDACTED]. The care plan was not updated with new interventions to prevent recurrence. An incident report, dated 01/25/11 at 6:20 a.m., documented the resident had fallen from bed and did not have injuries. The care plan was not updated with new interventions to prevent recurrence. An incident report, dated 02/28/11 at 2:50 a.m., documented the resident had fallen when she attempted to get up from the bed and did not have injuries. The care plan was not updated with new interventions to prevent recurrence. On 03/15/11 at 10:27 a.m., the DON was interviewed regarding the process for investigating accidents or incidents and implementing measures to prevent recurrence. The DON stated measures should be implemented to prevent recurrence with each fall or incident. The DON looked at the current incident report and stated at the present time there was no place to document that information. The DON was asked about updating the information to the care plan. The DON stated the care plan should be updated with each fall. On 03/15/11 at 11:47 a.m., the DON was asked about fall risk assessments for the resident. The DON stated the fall risk assessment should have been on the chart. On 03/15/11 at 1:15 p.m., the DON reported that she had looked everywhere and was unable to locate the resident's admission fall risk assessment. The DON stated the fall risk assessment should be done on admission, after each fall, and with any readmission. 4. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, updated 10/24/10, documented the resident was found on the floor. Interventions included to encourage the resident to use the walker when he was ambulating, to request assistance when ambulating and to assess the cause and pattern of previous falls, and act on the resolvable factors. An incident report, dated 01/07/11, documented the resident was found on the floor in his room. The care plan was not updated with new interventions to prevent recurrence. The care plan, updated 01/20/11, documented the resident was at risk for falls. Interventions included to ensure the call light was available and use the bed and chair alarm. The quarterly assessment, dated 02/03/11, documented the resident was severely cognitively impaired, had memory problems, and needed assistance with activities of daily living (ADLs). An incident report, dated 02/12/11, documented the resident was found on the floor sitting beside the bed. The incident report documented the resident had sustained a skin tear to the left arm. The care plan was updated to include the use of a bed/chair alarm. An incident report, dated 02/13/11, documented the resident slid out of his wheelchair to the floor and did not have injuries. The care plan was not updated. An incident report, dated 02/20/11, documented the resident was ambulating in the hall with his walker and fell backwards to the floor. The incident report documented the resident had sustained a fracture to the fifth finger of the left hand. The care plan was not updated. An incident report, dated 02/24/11, documented the resident was found laying on the floor beside the Geri-chair. The report documented the resident had sustained four skin tears to left hand and wrist. The report documented the chair alarm sounded. The care plan was not updated with new interventions to prevent recurrence. On 03/15/11 at 10:10 a.m., the resident was sleeping in the Geri- chair in the TV area of the central room. The resident's left wrist was wrapped with a gauze bandage. On 03/15/11 at 5:35 p.m., the DON was asked if the care plans should be updated after a resident had a fall. She stated the care plans should be updated after each fall.