Every finding on record at Glenhaven Retirement Village

Based on record review and interview, the facility failed to provide CPR for 1 (#1) of 3 sampled residents reviewed for code status.The administrator identified 75 residents resided in the facility.Findings: An Oklahoma State Department of Health Combined Initial and Final incident report, dated [DATE], read in part, [Resident #1] was lying in bed supine with eyes closed. No spontaneous respirations noted. No apical pulse on auscultation. [Resident #1] was unresponsive to verbal or tactile stimuli. [LPN #1] acted under the belief that [Resident #1] had a valid DNR order in place and the understanding that [their] care was focused on comfort measures; subsequently CPR was not initiated.after a chart review it was found that a valid DNR order was not present in [Resident #1's] medical record. An undated policy titled Death Procedure, read in part, When someone is on Hospice, death is an expected outcome. Be sure to check code status. An unlabeled and undated facility document showed a green dot indicated a resident was a full code. A Record of admission for Resident #1, dated [DATE], showed the resident was a full code. Physician orders for Resident #1, dated 07/2026, showed the resident was a full code. There was no DNR found in Resident #1's clinical record. On [DATE] at 2:51 p.m., CNA #1 stated there was no dot on Resident #1's door. On [DATE] at 3:00 p.m., CNA #2 stated after LPN #1 checked the resident's vitals they had stayed behind with CNA #1 and performed postmortem care. On [DATE] at 11:29 a.m., LPN #1 stated when they entered Resident #1's room the resident was not breathing. They stated they checked Resident #1's vital signs, and the resident was not breathing and had no heart rate or respirations. They stated they immediately notified hospice. They stated they should have checked Resident #1's chart. On [DATE] at 11:33 a.m., LPN #1 stated Resident #1 did not have a dot on their door or in their chart.

Based on observation, record review, and interview, the facility failed to maintain an effective pest control program. The DON identified 52 residents resided in the facility. Findings: An undated facility Pest policy, read in part, [name of facility withheld] will have monthly pest services to ensure that the facility remains pest free. On 01/16/24 at 8:32 a.m., the DON stated they had reports of spiders, roaches, and mice at least four times a week. On 01/16/25 at 8:46 a.m. an initial tour of the building was conducted. The following observations were made, a. in room C16 there were 14 dead roaches on the floor and roach egg sacks were visible, b. in room C16 there was one live roach located inside the dresser drawer next to the bed with roach eggs and dead baby roaches, and c. dead roaches were located behind the juice machine in the kitchen. On 01/16/25 at 8:47 a.m., the DON was present in room C16. They stated they saw one live roach and all the dead roaches above during the intital tour. On 01/16/25 at 9:35 a.m., Resident #5 was asked about pest concerns. They stated they saw a roach last night on the wall next to their bed and this morning. On 01/16/25 at 9:39 a.m., three dead roaches were observed behind the refrigerator in room [ROOM NUMBER]B. On 01/16/25 at 9:42 a.m., one dead roach was observed in the hall on the floor outside of room [ROOM NUMBER]B. On 01/16/24 at 9:45 a.m., one dead roach and one live roach was observed under the bed in room C17. On 01/16/25 at 9:45 a.m., Resident #4 stated they saw a live roach this morning in their room. On 1/16/24 at 9:00 a.m., the dietary manager was asked to discuss concerns related to pests. They stated the facility was having problems with roaches in the kitchen when they turned the lights on in the morning. On 01/16/25 at 9:12 a.m. the administrator in training was asked about the pest management. They stated they did not did not feel the previous company was effective because they still had a roach problem. They stated they hired a new company who came out on 01/13/25. They stated roaches were identified in room C16. On 1/16/25 at 9:17 a.m., the administrator stated the company they had used for pest management was not effective. They stated roaches were on B hall, in the kitchen, and in three resident rooms. On 01/16/25 at 9:51 a.m., CNA #1 was asked to discuss the pests at the facility. They stated the facility had a roach problem and they treated on 01/13/25. On 01/16/25 at 10:09 a.m., CMA# 1 was asked about the pests in the facility. They stated, They have been here for a hot minute. They stated the roaches seemed to be present and they were an ongoing problem for quite a few years. On 01/16/24 at 10:15 a.m., Resident #6 was asked about concerns related to pests. They stated they saw a live roach on 01/15/24 in their room.

Based on observation, record review and interview, the facility failed to ensure: a. a diuretic was included on the care plan for one (#23) of five sampled residents reviewed for unnecessary meds; and b. assist rails were included on the care plan for one (#43) of two sampled residents reviewed for restraints. The administrator in training identified 51 residents resided in the facility and 15 residents received diuretics. MDS Coordinator #1 identified three residents had assist rails. Findings: 1. Resident #23 had diagnoses which included hypertensive heart disease with heart failure. A physician order, dated 05/10/24, documented to administer hydrochlorothiazide (diuretic medication) 25 mg in the morning for hypertensive heart disease with heart failure. A physician order, dated 06/22/24, documented to administer furosemide (diuretic medication) 40 mg in the morning for hypertensive heart disease with heart failure. The resident's care plan was reviewed and did not document the use of diuretics. On 12/19/24 at 10:22 a.m., MDS Coordinator #1 stated they did not see diuretics on the care plan. They stated it should have been included. 2. Resident #43 had diagnoses which included arthritis and obesity. A physician order, dated 10/30/24, documented transfer bars in place at all times. A record review did not document a U-rail or positioning bar on the care plan. On 12/17/24 at 9:05 a.m., a U-rail was observed attached to the middle of the bed on the side of the bed touching the wall. On 12/19/24 at 2:03 p.m., MDS Coordinator #1 stated the U-rail/positioning bar was not on the care plan. They stated it should have been included.

On 10/07/24 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff followed proper procedure for the use of a mechanical lift to prevent accidents. The failure resulted in a fractured hip for Res #1. An undated facility Hydraulic Lift policy documented to check to be sure hooks are secure. A care plan intervention, dated 11/03/23, documented Res #1 required two staff assistance with a Hoyer (full body mechanical lift) for transfers. On 09/08/24, Res #1 had a fall due to the strap on the transfer sling failing to remain attached to the Hoyer lift. The resident was sent to the hospital and diagnosed with a closed hip fracture. Staff were in-serviced on 09/08/24 regarding lift safety and operation, but no ongoing monitoring was completed to ensure staff compliance with safe utilization of mechanical lifts. During interviews with staff conducted on 10/07/24, the staff stated lift sling straps were to be checked to ensure placement prior to lifting a resident. On 10/07/24 an observation was made of Res #3 being transferred from the wheelchair to the bed. The middle strap on the left side of the resident did not remain secured to the hook on the lift. A loud pop was heard, and the middle strap could be seen hanging below the resident. On 10/07/24 at 2:10 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 10/07/24 at 2:21 p.m., the administrator was notified of the IJ situation. On 10/07/24 at 5:40 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: [Name withheld] CC2606 PTAN 375359 NPI 1740313048 On October 7, 2024, we immediately inserviced nursing staff that was present on 7-3 and 3-11 shifts with demonstration and return demonstration of newly rented lift, with option to buy. New lift arrived by 3:30 pm by local DME company. All other nursing staff are projected to be inserviced by 9 am on October 8, 2024. If staff is not inserviced they cannot clock in to work until they have been inserviced. Root cause analysis is unknown. Therefore, it was agreed that due to age of current Hoyer lift and recent events a new lift would be obtained and all nursing staff inserviced on the proper use of lift and slings to ensure safety. The IJ was lifted, effective 10/08/24 at 9:00 a.m., when all components of the plan of removal had been completed. The deficient practice remained at an isolated with a potential for harm. Based on observation, record review, and interview, the facility failed to ensure staff followed proper procedure for the use of a Hoyer (full body mechanical lift) to prevent accidents for two (#1 and #3) of three sampled residents reviewed for mechanical lift safety. The failure resulted in a fractured hip for Res #1. The DON identified 52 residents resided in the facility. Eight residents required use of a mechanical lift for transfers. Findings: An undated facility Hydraulic Lift policy, read in part, Attach S hooks of the chain to the loops on the seat hanger. BE SURE TO INSERT THE OPEN END OF THE HOOKS AWAY FROM RESIDENT TO THE OUTSIDE OF THE SLING FOR SAFETY .Attach S hooks of the back rest if seat has a back rest. NOTE: AT THIS POINT, CHECK TO BE SURE THAT ALL HOOKS ARE SECURE AND EVENLY PLACED SO RESIDENT IS BALANCED. 1. Res #1 had diagnoses which included muscle weakness and history of stroke. A care plan intervention, dated 11/03/23, documented Res #1 required two staff assistance with a Hoyer for transfers. A progress note, dated 09/08/24 at 6:21 p.m., documented Res #1 had fallen out of the lift sling. It read in part, Upon further investigation it is apparent that one of the hooks on the sling was not seated properly, therefore allowing that side to slip off when maneuvering the resident from above the bed to above the wheelchair, and ultimately causing the resident to fall out of the sling. Res #1 was sent to the hospital for evaluation due to complaints of pain to their hip. A hospital record dated 09/08/24, documented Res #1 sustained a closed fracture of the left hip. An annual MDS, dated [DATE], documented Res #1 was totally dependent on staff for transfers and severely cognitively impaired. On 10/07/24 at 11:32 a.m., Res #1 was observed resting in their bed. The resident was unable to participate in an interview. Their representative did not return contact attempts for interview. On 10/07/24 at 12:05 p.m., RN #1 stated the DON had completed an inservice with the staff to address Res #1's fall. On 10/07/24 at 12:13 p.m., the DON stated there was no documented monitoring for effectiveness of training or ongoing compliance regarding lift safety. 2. Res #3 had diagnoses which included dementia, weakness, and cognitive deficits. A car plan intervention, dated 01/09/23, documented Res #3 required two people assist with transfers using a Hoyer lift. A quarterly MDS, dated [DATE], documented Res #3 was severely cognitively impaired and was totally dependent on staff for transfers. On 10/07/24 at 11:27 a.m., CNA #3 stated straps on lift slings were to be double checked to ensure the strap was on the hook prior to transferring the resident. On 10/07/24 at 11:35 a.m., CNA #1 stated staff were to ensure the sling was properly secured on the lift prior to a transfer. On 10/07/24 at 12:08 p.m., Res #3 was observed being assisted from the wheelchair to the bed using a Hoyer lift. The lift was operated by CNA #1 and CNA #2. The CNAs were observed placing three straps on each side of the resident onto the hooks of the lift. When the resident's body was approximately six inches in the air above the wheelchair a loud pop was heard. The middle strap on the left side of Res #3 was observed hanging below them and no longer was attached to the lift. CNA #2 was heard stating, You're ok, it sounds scarier than it is. The CNAs continued to transfer the resident from the wheelchair to the bed using the lift with one of the sling straps not attached. While lowering the resident onto the bed CNA #2 was heard stating this came off, that's my fault. On 10/07/24 at 12:17 p.m., CNA #2 stated they were unsure how the strap to the sling came off of the lift.

Based on record review and interview, the facility failed to submit PBJ data to CMS for the third quarter of the fiscal year for 2023. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings The PBJ Staffing Data Report documented the facility failed to submit data for the third quarter of 2023 (April 1 - June 30). On 10/10/23 at 9:43 a.m., the BOM was asked how often the facility submitted staffing data to CMS. They stated quarterly. They were asked if they had submitted data for the third quarter of 2023. 10/10/23 at 11:18 a.m., the BOM stated they did not submit the data for the quarter and should have.

Based on observation, record review, and interview, the facility failed to: a. attempt appropriate alternatives prior to installing bed or side rails; b. perform an entrapment risk assessment; c. review the risks or benefits with the resident and/or their representative; d. obtain an informed consent; and e. develop a care plan for side rail use for one (#39) of three sampled residents reviewed for accident hazards. The DON identified 16 residents whose beds were equipped with a bed rail of any type. Findings: A Bed Rail policy, undated, read in parts, .A duo-faceted approach will be used to achieve sustainable quality outcomes, including 1) bed maintenance as needed and 2) individual bed rail evaluations. In response to the requirement of providing for a safe, clean, comfortable, and homelike environment .No matter the purpose for use, bed rails and other bed accessories, although prescribed to improve functional independence with bed mobility and transfers, can increase resident safety risk. Thus, weighting the risks and benefits of devices (including bed rails) is integral to achieving positive resident outcomes . Res #39 was admitted with diagnoses which included diabetes mellitus, overactive bladder, and dementia. An admission assessment, dated 04/24/23, documented the resident was moderately cognitively impaired, required supervision with bed mobility, and required extensive one person assistance with transfer. A care plan, dated 04/26/23, documented the resident was at risk for completing daily ADLs due to decreased strength, balance, endurance, and safe mobility with an intervention of extensive weight bearing assist of one person to help with transfer. The care plan documented an intervention of the staff to assist with turning and repositioning every two hours. There was no documentation of side rail use in the care plan. There was no documentation of an entrapment risk assessment, alternatives prior to the use of side rails, physician consultation, or resident and/or representative informed consent for side rails found in the clinical record. On 10/09/23 at 12:46 p.m., Res #39 was observed lying on their left side in bed. The bed was observed up against a wall on one side and a half side rail was observed in the up position on the outer side of the bed. An attempted interview with the resident was unsuccessful due to resident's cognition. Res #39's spouse was observed seated in a recliner beside the bed. The spouse stated the bed rail was used to prevent falls and to assist with transfers. The spouse stated the staff would raise and lower the bed rail, but did not think Res #39 could manipulate the rail independently. On 10/10/23 at 2:19 p.m., Res #39 was observed lying in bed. A half side rail was observed in the up position on the outer side of the bed. Res #39 stated they were unable to put the side rail down independently. Res #39 stated their spouse or the staff would have to put the rail down for them. Res #39 stated they would crawl around the rail to get out of the bed most of the time. On 10/10/23 at 3:00 p.m., the DON was asked to provide documentation of an entrapment risk assessment and informed consent of side rail use with explanation of alternatives for the resident. On 10/11/23 at 3:21 p.m., the DON stated no entrapment risk assessment for the use of side rails, documentation of alternatives, or informed consent of the use of side rails for the resident had been completed. They stated the facility's bed rail policy had not been followed.

Based on observation, record review, and interview, the facility failed to ensure a resident received adequate supervision and assistance to prevent falls for one (#39) of three sampled residents reviewed for accidents. The facility failed to consistently implement interventions to prevent recurrence and evaluate interventions for effectiveness for a resident who had frequent falls. The Resident Census and Conditions of Resident report documented 46 residents resided in the facility. Findings: A Fall Focus Program policy, revised 04/23/07, read in parts, .Fall risk factor evaluation: Review any health problems or conditions that could contribute to a fall .Review the medications that could contribute to a fall .Review environmental hazards such as poor lighting, carpet, poorly arrange furniture .Review previous falls to determine patterns .Incident of fall: Consider and evaluate factors regarding fall and develop care plan using appropriate interventions .Review the fall at next safety committee meeting and gain input for interdisciplinary team members for other possible interventions to prevent falls. Make sure to update and revise plan of care as indicated .Schedule care plan meetings as indicated for review and revision . Res #39 was admitted with diagnoses which included diabetes mellitus, overactive bladder, and dementia. An incident report, dated 04/20/23, documented the resident was found in the floor of their room. The resident stated they had attempted to go to the bathroom and had slipped. The report documented the resident received a laceration above the left eye brow. The incident report documented an intervention to encourage use of call light. An admission assessment, dated 04/24/23, documented the resident was moderately cognitively impaired, required supervision with bed mobility, and required extensive one person assistance with transfer and toileting. The assessment documented the resident had one fall with injury during the review period. A care plan, with initiation date of 04/26/23, documented the resident was at risk for falls and had numerous falls at home prior to admit to facility. The care plan documented the resident had one fall since admit on 04/20/23 while trying to transfer self to toilet. The resident presented on the floor with an open area to left brow. The following interventions were included: a. keep my call light within reach at all times and encourage it's use, b. keep my environment consistent and pathways free from clutter, c. encourage me to wear sturdy well fitted, low healed shoes with non-slip soles (including house shoes) for all transfers and ambulation, and d. remind/allow me to take time when transferring or ambulating and to sit up on the side of the bed for a short time prior to standing and to pause when I first get up to get my balance. An incident report, dated 08/20/23, documented the resident had an unwitnessed fall in the bathroom with no injury. The incident report documented an intervention to encourage use of the call light, have shoes on, and use walker. The interventions were a repeat from the previous fall. The care plan was not updated to reflect any new interventions to prevent falls. An incident report, dated 08/23/23, documented the resident fell in the floor beside the recliner and received two skin tears to the left elbow. The incident report documented an intervention to wear non-skid socks. The intervention was a repeat intervention. The care plan was not updated to reflect any new interventions to prevent falls. An incident report, dated 08/25/23, documented the resident fell in the bathroom and received two skin tears to the right elbow. The incident report documented an intervention that the staff will continue frequent checks and offer/assist with toileting every two hours and as needed. The intervention was a repeat intervention. The care plan documented the same repeat intervention. The care plan was not updated to reflect any new interventions to prevent falls. An incident report, dated 09/04/23, documented the resident fell outside on the facility's front porch and received no physical injury but was sluggish in responsiveness. The report documented the resident was transported to the emergency room and admitted to the hospital with diagnoses which included altered mental status, urinary tract infection, dehydration, and heat exhaustion. The incident report documented an intervention of an in-service for all staff related to provision of increased visual checks of the front porch every hour and as needed during days with extreme temperatures. The care plan was not updated to reflect any new interventions to prevent falls. On 10/09/23 at 12:37 p.m., Res #39 was observed lying on their left side in bed. An attempted interview with the resident was unsuccessful due to resident's cognition. Res #39's spouse was observed seated in a recliner beside the bed. The spouse stated they were sitting with Res #39 outside the facility on the covered front porch on 09/04/23. The spouse stated they left the facility some time around 2:00 p.m. and thought the resident would go back inside or the staff would come and check on them soon. The spouse stated the staff called them around 5:00 p.m. that evening and stated the resident was found on the ground beside their wheelchair underneath the covered porch and had been transferred to the emergency room for evaluation due to their altered mental status. On 10/12/23 at 11:19 a.m., MDS Coordinator #1 stated they documented the interventions specified on Res #39's incident reports on the care plan. They stated they didn't feel the interventions were appropriate because they were repeat interventions, but felt it was the DON's responsibility to evaluate interventions already in use and update the care plan with new appropriate interventions. MDS Coordinator #1 stated the fall policy was not followed, but should have been. On 10/12/23 at 11:49 a.m., the DON stated Res #39 is somewhat independent, but does not always use call light for assistance depending on their cognition. The DON stated the repeat fall prevention interventions documented on Res #39's care plan was appropriate due to the resident's need for frequent reminders of safety. They stated all falls for Res #39 were reviewed and evaluated. The DON stated the care plan should have been updated by the MDS coordinator. The DON stated they felt the fall policy had been followed, but the care plan had not been reviewed and revised appropriately.

Based on observation, record review, and interview, the facility failed to turn and reposition a resident with limited range of motion (ROM) in order to increase ROM and/or prevent further decline for one (#1) of three residents reviewed for mobility. The Resident Census and Conditions of Residents report, documented 44 residents who required assistance with mobility. Findings: A Nursing Assistant Duties general guideline, undated, documented to turn and reposition all bed and chair residents every two hours and all wheelchair residents are to be checked frequently and taken to the bathroom at least every two hours as requested or per individual schedule. Res #1 was admitted with diagnoses which included restless leg syndrome, muscle spasms, and colon cancer. A care plan, dated 01/31/23, documented the resident required total assistance with most ADLs with an intervention of assistance and/or reminders to turn and reposition every two hours. A quarterly assessment, dated 07/11/23, documented the resident was cognitively intact, required extensive one person assistance with mobility, and was totally dependent with most ADLs. The assessment documented the resident had impaired ROM on one side in the upper extremities and on both sides in the lower extremities. On 10/09/23 at 2:45 p.m., Res #1 was observed lying supine in bed with their left leg bent at the knee and contracted up towards their neck. Res #1's neck was observed as bent downward towards their left side. Res #1 stated they relied on staff for repositioning due to their decreased mobility. They stated the staff did not attempt or offer to turn or reposition them very often. Res #1 stated they felt uncomfortable often from the lack of repositioning. On 10/09/23 at 5:10 p.m., Res #1 observed lying in the same position as described above. Res #1 stated staff had not offered or attempted to reposition them since the previous interview. On 10/10/23 at 8:20 a.m., Res #1 observed lying supine in bed with their left leg bent at the knee and contracted up towards their neck. Res #1's neck was observed as bent downward towards their left side. The right leg was observed elevated on a pillow. On 10/10/23 at 11:48 a.m., Res #1 observed lying in the same position as described above. Res #1 stated staff had not offered or attempted to reposition them in several hours. On 10/10/23 at 1:00 p.m., CNA #1 stated Res #1 had not been out of bed in several months due to refusal of most attempts at activity or repositioning. CNA #1 stated the resident refused to be repositioned often but stated they did not document the refusals in the clinical record. They stated there is no specific area in the clinical record to document the resident's refusal of care. On 10/10/23 at 1:35 p.m., RN #2 stated Res #1 received restorative care twice weekly. They stated the resident refused most attempts at activity or repositioning. RN #2 stated the resident's refusals in this care area should be documented in the plan of care. There was no documentation found in the clinical record that turning and repositioning had been offered or attempted every two hours for Res #1. There was no documentation of resident refusals of positioning found in the clinical record. On 10/10/23 at 3:15 p.m., the DON was asked how the facility ensured Res #1 was turned and/or repositioned every two hours. The DON stated all staff know that dependent residents have to be turned and repositioned every 2 hours. The DON could not specify where completion of this task or a resident's refusal was documented in the clinical record. On 10/11/23 at 3:35 p.m., the DON stated the facility was unable to produce documentation that Res #1 was turned and/or repositioned every two hours per their plan of care. The DON stated refusals were not documented in the clinical record but should have been.

Based on observation, record review, and interview, the facility failed to provide nail care for one (#34) of two sampled residents reviewed for activities of daily living. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings: Res #44 had diagnoses which included ventricular tachycardia, hypokalemia, chronic ischemic heart disease, unspecified diastolic congestive heart failure, hypotension, GERD, muscle weakness, and acute respiratory failure. A quarterly resident assessment, dated 09/08/23, documented their cognition was intact and they required extensive assistance with personal hygiene. On 10/09/23 at 11:58 a.m., the resident was observed in their bed with their left foot exposed. Their toenails were excessively long. The resident was asked when was the last time their toenails had been trimmed. They stated they did not know. They stated their toenails were extremely long and it caused pain to their left foot. On 10/10/23 at 1:04 p.m., CNA #2 was asked how often nail care was provided. They stated on Sundays. They stated the nurses performed nail care if the resident was diabetic. She was asked if Resident #44 was diabetic. They stated they were not. They were asked where it was documented when nail care was provided. They stated they did not know. CNA #2 was asked to observe the resident's toenails. They were asked if it looked like nail care was being provided. They stated they were long and needed to be clipped.

Based on observation, record review, and interview, the facility failed to review and/or revise the care plan related to: a. a decrease in mobility for one (#3) of 13 residents whose care plans were reviewed, and b. fall prevention interventions for one (#28) of 13 residents who were reviewed for accidents. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings: A Fall Focus Program policy, revised 04/23/07, read in parts, .Incident of fall: Consider and evaluate factors regarding fall and develop care plan using appropriate interventions .Review the fall at next safety committee meeting and gain input for interdisciplinary team members for other possible interventions to prevent falls. Make sure to update and revise plan of care as indicated .Schedule care plan meetings as indicated for review and revision . 1. Res #3 had diagnoses which included intellectual disabilities, convulsions, and thyrotoxicosis. An annual assessment, dated 06/20/23, documented the resident was severely cognitively impaired and required supervision with bed mobility, locomotion, and eating. The assessment documented the resident ambulated with supervision and required limited assistance with transfer. A significant change assessment, dated 07/27/23, documented the resident was severely cognitively impaired and required extensive assistance with bed mobility and eating. The assessment documented the resident did not ambulate and was totally dependent with transfer and locomotion. A care plan, dated 09/10/23, documented a decline in physical health with an inability to ambulate, transfer, or reposition without staff assistance. On 10/12/23 at 4:00 p.m., MDS Coordinator #1 stated the care plan had not been updated in a timely manner after the significant change assessment was completed. 2. Res #28 had diagnoses which included epilepsy, anxiety, and major depressive disorder. A care plan, dated 02/12/23, documented the resident had no falls during the quarter and the plan of care was to be continued. There was no documentation in the clinical record the care plan had been reviewed or revised after this date. An annual assessment, dated 04/18/23, documented the resident was cognitively intact, required supervision with most mobility and ADLs, and had one fall with no injury. A quarterly assessment, dated 07/11/23, documented the resident was cognitively intact, required supervision with most mobility and ADLs, and had one fall with no injury. An incident report, dated 09/27/23, documented Res #28 fell in the shower room and received a raised area to the right side of the head. The report documented the resident was transported to the hospital and later diagnosed with basal ganglia hemorrhage and stroke affecting the left side. On 10/09/23 at 1:10 p.m., Res #28 was observed sitting in a recliner with a mesh lift sling noted under the resident. The resident stated they had a fell a while ago in the shower and had to go to the hospital. Res #28 stated the staff do not allow them to get up on their own anymore and that they needed assistance with all transfers. Res #28 stated they could no longer ambulate independently. On 10/12/23 at 9:34 a.m., MDS Coordinator #1 stated the care plan should have been reviewed and revised after each comprehensive assessment or after each fall but hadn't been because they had been behind with their work due to having multiple work responsibilities.

Based on record review and interview, the facility failed to fully develop comprehensive care plans for four (#6, 8, 44, and #47) of 13 sampled residents reviewed for care plans. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings: 1. Res #6 had diagnoses which included depression, insomnia, heart failure, and chronic kidney disease. A comprehensive resident assessment, dated 05/05/23, documented activities was a care planning decision on the CAA summary. There was no documentation activities was developed on the care plan. On 10/11/23 at 4:40 p.m., MDS Coordinator #1 was shown the resident's assessment where activities was a care planning decision. They were asked if the resident's care plan was developed to include activities. They reviewed the resident's care plan and stated it was not on the care plan and should have been. 2. Res #44 had diagnoses which included a pressure ulcer to the sacrum. An admission assessment, dated 07/09/23, documented the resident had an indwelling catheter. It was documented urinary incontinence/indwelling catheter was a care planning decision on the CAA summary. There was no documentation the use of an indwelling catheter was developed on the care plan. On 10/11/23 at 10:51 a.m., MDS Coordinator #1 was shown the resident's assessment where urinary incontinence/indwelling catheter was a care planning decision. They were asked if the resident's care plan was developed to include the resident had an indwelling catheter. They reviewed the resident's care plan and stated it was not on the care plan and should have been. 46582 3. Res #8 was admitted [DATE] with diagnoses which included hypothyroidism, cardiac arrhythmia, diabetes mellitus, and insomnia. An admission assessment, dated 03/22/23, documented the resident was cognitively intact, required extensive assistance with most ADLs, and received psychoactive medications during the review period. A care plan, dated 04/11/23, was reviewed. The care plan was documented as initial care plan by the MDS coordinator. 4. Res #47 was admitted [DATE] with diagnoses which included atrial fibrillation, recurrent depressive disorders, anxiety, and dysphagia. An admission assessment, dated 08/08/23, documented the resident was severely cognitively impaired, required extensive assistance with most ADLs, and received psychoactive medications during the review period. A care plan, dated 09/20/23, was reviewed. The care plan was documented as initial care plan by the MDS coordinator. On 10/11/23 at 8:22 a.m., MDS Coordinator #1 stated the care plan for Res #8 and Res #47 did not get developed or initiated in the required time frame after completion of the comprehensive assessment but should have. They stated having been behind on the completion of several resident's care plans.

Based on record review and interview, the facility failed to ensure quarterly assessments were completed once every three months and/or no later than 14 days after the ARD for two (#6 and #36) of 13 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings: 1. Res #6 had diagnoses which included depression, insomnia, heart failure, and chronic kidney disease. A quarterly resident assessment, dated 07/28/23, documented on 09/09/23 the RN assessment coordinator signed the assessment as completed. On 10/11/23 at 2:49 p.m., MDS Coordinator #1 was made aware the resident had a quarterly assessment completed on 09/09/23 when the ARD was 07/28/23. They stated they knew the assessment had not been completed within 14 days of the ARD. 2. Res #36 had diagnoses which included abdominal aortic aneurysm without rupture, COPD, disorder of kidney and ureter, cerebral infarction, pure hypercholesterolemia, unspecified osteoarthritis, generalized anxiety disorder, chronic pain syndrome, diabetes, senile degeneration of the brain, vascular dementia without behavioral disturbance, recurrent depressive disorders, hereditary and idiopathic neuropathy, HTN, GERD, muscle weakness, and cognitive communication deficit. A quarterly resident assessment, dated 04/17/23, documented on 06/08/23 the RN assessment coordinator signed the assessment as completed. There was no documentation a quarterly assessment had been completed in July 2023. On 10/12/23 at 11:11 a.m., MDS Coordinator #1 was made aware the resident had a quarterly assessment completed on 06/08/23 when the ARD was 04/17/23. They stated they were aware. They stated they had an illness during that time. They were asked if there was a quarterly assessment completed in July 2023. They stated they needed look. On 10/12/23 at 11:14 a.m., MDS Coordinator #1 stated they missed it. They stated it should have been done on 07/10/23.

Based on record review and interview, the facility failed to ensure comprehensive assessment were accurate and/or completed timely for two (#6 and #44) of 13 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings: 1. Res #6 was admitted to the facility on [DATE] with diagnoses which included depression, insomnia, heart failure, and chronic kidney disease. An admission assessment, dated 05/03/23, documented on 06/15/23 the RN assessment coordinator signed the assessment as completed. On 10/11/23 at 2:49 p.m., MDS Coordinator #1 was asked about the type of assessment they had completed for the resident. They stated they would have to look. They stated the assessment should have been an annual assessment. They stated they marked the assessment incorrectly. MDS Coordinator #1 was made aware the assessment was completed on 06/15/23 when the ARD was 05/03/23. She stated they knew it was not completed within 14 days of the ARD. 2. Res #44 had diagnoses which include pressure ulcer to sacrum, HTN, hyperlipidemia. pain, depression, cerebral infarction, GERD, anemia, hypothyroidism, and protein calorie malnutrition, An admission assessment, dated 07/09/23, documented on 08/28/23 the RN assessment coordinator signed the assessment as completed. On 10/11/23 at 10:51 a.m., MDS Coordinator #1 was made aware the assessment was completed on 08/28/23 when the ARD was 07/09/23. They stated they knew it was not completed within 14 days of the ARD.

Based on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one (#39) of three residents reviewed for accident hazards. The DON identified 16 residents whose beds were equipped with a bed rail of any type. Findings: A Bed Rail policy, undated, read in parts, .A duo-faceted approach will be used to achieve sustainable quality outcomes, including 1) bed maintenance as needed and 2) individual bed rail evaluations. In response to the requirement of providing for a safe, clean, comfortable, and homelike environment .No matter the purpose for use, bed rails and other bed accessories, although prescribed to improve functional independence with bed mobility and transfers, can increase resident safety risk. Thus, weighting the risks and benefits of devices (including bed rails) is integral to achieving positive resident outcomes . Res #39 was admitted with diagnoses which included diabetes mellitus, overactive bladder, and dementia. An admission assessment, dated 04/24/23, documented the resident was moderately cognitively impaired, required supervision with bed mobility, and required extensive one person assistance with transfer. A care plan, dated 04/26/23, documented the resident was at risk for completing daily ADLs due to decreased strength, balance, endurance, and safe mobility with an intervention of extensive weight bearing assist of one person to help with transfer. The care plan documented an intervention of the staff to assist with turning and repositioning every two hours. There was no documentation of side rail use in the care plan. There was no documentation of regular bed rail inspections or maintenance found in the clinical record. On 10/09/23 at 12:46 p.m., Res #39 was observed lying on their left side in bed. The bed was observed up against a wall on one side and a half side rail was observed in the up position on the outer side of the bed. An attempted interview with the resident was unsuccessful due to resident's cognition. Res #39's spouse was observed seated in a recliner beside the bed. The spouse stated the bed rail was used to prevent falls and to assist with transfers. The spouse stated the staff could raise and lower the rail but did not think Res #39 could manipulate the rail independently. On 10/10/23 at 2:19 p.m., Res #39 was observed lying in bed. A half side rail was observed in the up position on the outer side of the bed. Res #39 stated they were unable to put the side rail down independently. Res #39 stated their spouse or the staff would have to put the rail down for them. Res #39 stated they would crawl around the rail to get out of the bed most of the time. On 10/10/23 at 3:00 p.m., the DON was asked to provide documentation of regular bed rail inspections for the resident. On 10/12/23 at 12:59 p.m., the DON stated the facility had not completed regular bed rail inspections, but should have per policy. They stated the bed rails for Res #39 would be removed.

Based on record review and interview, the facility failed to ensure a significant change in status MDS was completed timely by the 14th calendar day after the determination the significant changes has occurred for one (#26) of 13 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 10/10/23, docuented 46 residents resided in the facility. Findings: Res #26 had diagnoses which include chronic kidney disease. A significant change assessment, dated 08/08/23, documented on 09/12/23 the RN assessment coordinator signed the assessment as completed. On 10/10/23 at 4:27 p.m., MDS Coordinator #1 was asked the reason a significant change assessment had been completed. They stated the resident started on dialysis. They were made aware the assessment was completed on 09/12/23 when the ARD was 08/08/23. They stated the assessment should have been completed within 14 days of the ARD.

Based on record review and interview, the facility failed to ensure physician orders were obtained for code status for two (#26 and #1) of 13 sampled residents reviewed for code status. The DON identified 23 residents who were DNR's. Findings: 1. Res #26 was had diagnoses which included chronic kidney disease, HTN, atrial fibrillation, and pain. A DNR consent form, dated 04/17/23, was located in the resident's medical chart. There was no physician order for the resident's code status. On 10/11/23 at 8:53 a.m., the DON was asked what was the resident's code status. They stated they were a DNR. They were asked if there was a physician order for the resident's code status. They stated there was not. 46582 2. Res #1 had diagnoses which included asthma, restless leg syndrome, and muscle spasms. A DNR consent form, dated 08/16/06, was located in the resident's medical chart. There was no physician order for the resident's code status. On 10/12/23 at 11:40 a.m., the DON stated Res #1 had a documented DNR consent form but there was no physician order for the resident's code status.

Based on record review, observation, and interview, the facility failed to notify the physician of an unstageable pressure ulcer, provide appropriate treatment, and provide wound care in a way to help prevent infection for one (#33) of two residents reviewed for pressure ulcers. The facility documented an unstageable ulcer on 11/04/22 and the physician was not notified. On 12/07/22, during an observation of wound care, an additional pressure ulcer was observed. The Resident Census and Conditions of Residents report, dated 12/06/22, documented two residents resided in the facility who had pressure ulcers. Findings: A Risk Assessment and Pressure Ulcer Policy revised 06/24/08, read in parts, .3. Residents with pressure ulcers will be reassessed on a daily basis to help identify any new impairment of skin integrity .8. Pressure Ulcer Weekly Summary .will be completed and forwarded to DON and Administrator for weekly review for QA purposes .10. All pressure ulcers will be staged according to MDS Assessment definitions. 11. Weekly Pressure ulcer documentation will include site, size (use measurement tool in cm), odor, drainage, periulcer skin, stage and treatment and effectiveness of treatment. 12. Residents Physician and representative will be notified of new skin breakdown, significant change in a wound, or when current treatment to a wound is ineffective . Res #33 had diagnoses which included osteomyelitis, depressive disorder, and Alzheimer's disease. A physician order, dated 09/24/21, documented to clean buttocks with soap and water, pat dry, and apply Calmoseptine twice daily. A physician order, dated 11/29/21, documented to clean coccyx with wound spray, pat dry, skin prep per wound, and cover with Opifoam dressing daily. A quarterly assessment, dated 09/10/22, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident did not have any pressure ulcers but did have MASD. A care plan, last revised 09/16/22, documented no skin issues on the care plan. A Wound Care Status Report dated 11/04/22, documented the resident had a 1.0 x 1.0 cm pressure ulcer with epithelial and slough. The report documented a treatment of betadine and Optifoam dressing. The report did not document where the ulcer was located. There was not a physician order for betadine. On 12/05/22 at 5:25 a.m., Res #33 reported he had a wound to his bottom. He stated the facility was providing care and he was told it was getting better. On 12/07/22 at 7:43 a.m., Res #33 was observed laying flat of his back in the bed. He spoke good morning and stated he was doing okay. On 12/07/22 at 1:11 p.m., Res #33 was observed in the bed on his back. Wound care was observed performed by LPN #1 at this time. LPN #1 had already placed gloves on her hands before observation. The LPN entered the resident's room with gloves on with supplies in hand. LPN #1 laid the supplies on the resident's overbed table without a barrier or cleaning the table. The old dressing was observed and dated 12/06. The LPN removed the old dressing and placed it in the trash. An unstageable pressure ulcer and a stage II pressure ulcer were observed near the resident's coccyx. She then cleaned the wound with wound wash and patted dry with 4x4 gauze. LPN #1 then applied a barrier cream to the pressure ulcers wearing the same gloves. The LPN stated she should have brought more gloves in the room with her but she didn't. LPN #1 then placed the new dressing on the resident wearing the same gloves. The LPN left the room to the cart to obtain more supplies. She did not remove her gloves before leaving the room or returning to the room after getting supplies from the cart. LPN #1 then borrowed a sharpie pen from the CNA, who was helping with positioning the resident, and dated the dressing. She then applied lotion to the resident's back in the same gloves. Res #33 was positioned for comfort on his left side. LPN #1 removed the gloves and used hand sanitizer in the hall. The CNA washed her hands in the resident's room before leaving. During record review, on 12/07/22, there was no documentation the physician was notified of the resident's pressure ulcer on 11/04/22 and no new orders for the pressure ulcer. On 12/07/22 at 2:46 p.m., LPN #1 stated she performed the treatment order which was dated 11/29/21, the order for skin prep. She was asked to show what she used and she showed the surveyor the Calmoseptine cream. LPN #1 stated that was what she was instructed to use. On 12/07/22 at 2:53 p.m., RN #1 stated she wound get the wound nurse to come into the facility and clarify what treatment was being done for Res #33. A nurse note, dated 12/07/22 at 3:11 p.m., documented the following: Removed previous dressing from coccyx area, cleaned area with normal saline and patted dry. Applied barrier ointment and Optifoam dressing. The resident tolerated dressing change well. Upon reassessing, noted a small superficial open area to the left above the medial area. Both open areas were covered by the foam dressing. On 12/07/22 at 3:44 p.m., the wound RN stated she mostly worked the weekends. She stated the doctor should have been notified by fax of the resident's wound by the floor nurse. She stated the nurses do all the faxing to the doctor. On 12/07/22 at 3:50 p.m., the MDS coordinator measured the pressure ulcers. She documented the measurements as a 0.5 x 0.3 cm stage I pressure ulcer on the coccyx and a 1.0 x 0.5 cm unstageable pressure ulcer with yellow slough on the left side of coccyx. On 12/07/22 at 3:53 p.m., the wound RN stated Res #33's treatment for his pressure ulcer was betadine and Optifoam dressing. She stated she did the measurements and the orders but had not performed any wound care for the resident. She stated the floor nurses do the wound care, unless she worked the floor. She stated there was not an order for betadine after being asked to look to see if there was an order for the resident. The wound RN stated she had only been tracking the one pressure ulcer to the left of his coccyx. She stated she did not know the resident had two pressure ulcers. On 12/07/22 at 4:25 p.m., physician #1 was interviewed. The physician looked at the communications from the nursing home for November 2022 and stated several things have come in for November. He stated he could not find any communication regarding a wound for Res #33 in November. On 12/08/22 at 8:30 a.m., RN #1 stated she was not the one that followed the wounds but if the resident had an order for a preventative treatment and then had a wound open up, then the resident would need a more aggressive treatment to treat an open wound. The RN stated when you have a change in condition the physician needs to be notified. On 12/08/22 at 10:19 a.m., the MDS coordinator stated after measuring the pressure ulcers yesterday she had not reported the resident's pressure ulcers to the physician. RN #1 stated it was the wound RN and the floor nurses job to report changes to the physician. RN #1 stated she was not aware the physician was not notified of the resident's pressure ulcers.

Based on record review, observation, and interview, the facility failed to notify the physician of a new pressure ulcer for one (#33) of two residents reviewed for pressure ulcers. The Resident Census and Condition of Residents report, dated 12/06/22, documented two residents had pressure ulcers in the facility. Findings: Res #33 had diagnoses which included osteomyelitis, depressive disorder, and Alzheimer's disease. A quarterly assessment, dated 09/10/22, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident did not have any pressure ulcers but did have MASD. A care plan, last revised 09/16/22, documented no skin issues on the care plan. A Wound Care Status Report dated 11/04/22, documented the resident had a 1 x 1cm stage I pressure ulcer with epithelial and slough. The report documented treatment of betadine and Optifoam dressing. A dietary note, dated 12/02/22, documented a pressure ulcer was present. On 12/05/22 at 5:25 a.m., Res #33 reported he had a wound to his bottom. He stated the facility was providing care and he was told it was getting better. On 12/07/22 at 1:11 p.m., during wound care two small open areas were observed. The resident had one pressure ulcer to the coccyx and another one higher and to the left. There was no documentation in the resident's record the physician had been notified of the new pressure ulcer on 11/04/22. On 12/07/22 at 4:25 p.m., physician #1 was interviewed. The physician looked at the communication from the nursing home for November 2022 and stated several things have come in for November. He stated he could not find any communication regarding a wound for Res #33 in November. On 12/08/22 at 10:19 a.m., the MDS coordinator stated after measuring the wounds yesterday she had not reported the resident's wounds to the physician. RN #1 stated it was the wound care nurse and the floor nurses' job to report changes to the physician. RN #1 stated she was not aware the physician was not notified.

Based on record review, observation, and interview, the facility failed to ensure assessments accurately reflected the residents status for three (#10, 29, and #32) of 14 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 12/06/22, documented 43 residents resided in the facility. Findings: 1. A physician order, dated 12/11/21, documented Res #10 was to receive methenamine hippurate (Hiprex) (anti-infective medication) 1gm tablet for UTI. A quarterly assessment, dated 03/07/22, documented the resident received an antibiotic for seven days during the last seven days or since admission/entry if less than seven days. The February and March 2022 MARs were reviewed and documented Hiprex was received. A quarterly assessment, dated 05/31/22, documented the resident received an antibiotic for seven days during the last seven days or since admission/entry if less than seven days. The May 2022 MARs were reviewed. It documented Hiprex was received. A quarterly assessment, dated 08/23/22, documented the resident received an antibiotic for seven days during the last seven days or since admission/entry if less than seven days. August 2022 MARs were reviewed. It documented Hiprex was received. On 12/08/22 at 10:00 a.m., the pharmacist was asked if Hiprex was classified as an antibiotic. He stated it was not classified as an antibiotic. He stated it was an urinary acidifier. He stated the medication was not an antibiotic at all and was used for other conditions such as kidney stones. On 12/08/22 at 11:15 a.m., the MDS coordinator was asked what class of drugs Hiprex belonged to. She stated she would have to look. She stated an antibiotic. She was asked what source she used to determine drug classification. She stated she looked on Google. She stated doctors used the medication for maintenance. She was asked if there was a discrepancy with the drug classification what would she do. She stated she would call the pharmacist. She was made aware the facility's pharmacist did not classify the medication as an antibiotic. She was made aware Res #10's MDSs were coded as they received antibiotics. 2. A physician order, dated 03/03/22, documented Res #32 was to receive methenamine hippurate (Hiprex) 1gm tablet twice a day for prophylaxis. A quarterly assessment, dated 04/05/22, documented the resident received an antibiotic for seven days during the last seven days or since admission/entry if less than seven days. The March and April 2022 MARs were reviewed and documented Hiprex was received. A quarterly assessment, dated 06/27/22, documented the resident received an antibiotic for seven days during the last seven days or since admission/entry if less than seven days. The June 2022 MARs were reviewed and documented Hiprex was received. A quarterly assessment, dated 09/19/22, documented the received an antibiotic for seven days during the last seven days or since admission/entry if less than seven days. The September 2022 MARs were reviewed. It documented Hiprex was received. On 12/08/22 at 10:00 a.m., the pharmacist was asked if Hiprex was classified as an antibiotic. He stated it was not classified as an antibiotic. He stated it was an urinary acidifier. He stated the medication is not an antibiotic at all and was used for other conditions such as kidney stones. On 12/08/22 at 11:15 a.m., the MDS coordinator was asked what class of drugs Hiprex belonged to. She stated she would have to look. She stated an antibiotic. She was asked what source she used to determine drug classification. She stated she looked on Google. She stated doctors used the medication for maintenance. She was asked if there was a discrepancy with the drug classification what would she do. She stated she would call the pharmacist. She was made aware the facility's pharmacist did not classify the medication as an antibiotic. She was made aware Res #32's MDSs were coded as they received antibiotics. 38495 3. Res #29 had diagnoses which included muscle weakness, COPD, and diabetes mellitus. A therapy discharge note from PT, dated 02/10/21 documented RNP to facilitate patient maintaining their current level of performance in order to prevent decline. The note documented instruction in bed mobility, grooming, eating, and active and passive ROM. A quarterly MDS assessment, dated 08/15/22 documented the resident was severely impaired with cognition and required total assistance with activities of daily living. The assessment did not document the resident received restorative care during the look back period. Restorative nursing care plan flow sheets for August 2022 documented the resident received restorative care during the look back period. On 12/05/22 at 11:01 a.m., the resident was in the bed and contractures were observed to resident's left wrist and hand. On 12/08/22 at 3:42 p.m., the MDS coordinator stated she was not aware the resident had received ROM during the look back period for the quarterly August MDS. She stated the staff needed to let her know when the resident received services.

Based on record review, observation, and interview, the facility failed to ensure bathing was provided to dependent residents for one (#1) of one resident who was reviewed for ADLs. The Resident Census and Condition of Residents report, dated 12/06/22, documented 43 residents resided in the facility. Findings: Res #1 had diagnoses which included COPD, chronic pain, and traumatic brain injury. A quarterly assessment, dated 11/01/22, documented the resident was intact with cognition and required total assistance with bathing. A care plan, last reviewed 11/07/22, documented the resident required total to extensive assistance meeting ADL needs. Res #1 required staff to assist for showers. The resident's bathing schedule was documented as Monday, Wednesday, and Friday on the 7:00 a.m. to 3:00 p.m. shift. The resident was scheduled for 13 baths for November 2022. The POC bathing history report for November 2022 documented the resident received six baths out of 13 for the month. On 12/05/22 at 10:30 a.m., Res #1 stated he was supposed to get a bath every day and did not get them as scheduled. Res #1 was observed with a beard and longer hair which was disheveled. Res #1 stated he wanted to keep his beard and the staff did not comb his hair. The resident was observed moving his head back and forth against the mattress as he was setting up in the bed. On 12/06/22 at 3:38 p.m., CNA #3 stated Res #1 had never refused a bath for her. On 12/06/22 at 3:54 p.m., CNA #4 stated the bathing schedules were in a book on the halls and when a resident was bathed they would document in the POC system on the hall. CNA #4 stated if a resident refused a bath it would be charted 'refused' in the POC. She stated the resident would refuse at times during the day but would let a CNA on night shift give him bed baths. On 12/06/22 at 4:09 p.m., CNA #5 stated the bathing schedule was in the ADL book. Res #1 was scheduled for baths on M-W-F. CNA #5 stated when a bath was given it was charted in the POC. CNA #5 stated Res #1 was a bed bath most the time. CNA #5 stated the resident will refuse a bath at times and the documentation would say refused if the resident refused. CNA #5 stated two baths a week at the most was what the residents were getting. CNA #5 stated they had been trying to get the resident to shave but he did not want to. On 12/06/22 at 4:19 p.m., CMA #1 stated the CNA should tell the nurse when a resident was not getting their bathes as scheduled. CMA #1 stated she was not sure if the refusals were documented on the POC. CMA #1 stated the resident received bed baths by the night CNA because it was hard for Res #1 to get up in the shower.

Based on observation, record review, and interview it was determined the facility failed to: ~accurately assess a resident's condition after a fall, ~accurately inform the physician of a resident's change in condition, and ~obtain an electrocardiogram (EKG) that was physician ordered on [DATE], and not completed until 01/12/11, for one (#6) of one sampled resident who acquired a fracture while residing in the facility. Findings: Resident #6 had [DIAGNOSES REDACTED]. The resident annual assessment dated [DATE], documented the resident was cognitively intact and was totally independent with transfers. The care plan for activities of daily living (ADL's) dated 10/06/10, documented the resident was highly involved in her care, performed some activities on her own, and required only supervision to limited assistance with other activities. On 12/21/10 at 4:30 a.m., a nurse's note documented the resident was found sitting on the floor of her restroom. The resident stated my ankle was hurting, her feet got stuck, and she "melted onto the ground," hitting the back of her head. Neuro checks were initiated and an assessment was done which documented no injuries. The resident was assisted by two staff members onto the toilet. The on call physician was notified and no new orders were received. At 8:50 a.m., the Medication Administration Records (MARs) documented the resident was administered [MEDICATION NAME] 50 mg for leg pain. The resident rated her pain level a 9, on a scale of 1 to 10. (10 being the highest level of pain.) At 10:30 a.m., a nurse's note documented the resident was complaining of left leg and knee pain and pain when bearing weight. No discoloration or swelling was noted. A call was placed to the Primary Care Physician's (PCP's) office for an order to X-ray the resident's leg. At 11:40 a.m., a fax was sent to the PCP which documented, "Resident c/o (complains of ) (left) leg/knee pain. Able to move s (without) difficulty, however does hurt when bearing weight. fell early AM this morning. Going to get portable x-ray this afternoon. (No) swelling or discoloration noted." At 12:20 p.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg for leg pain. The resident rated her pain level an 8, on a scale of 1 to 10. At 6:50 p.m., a nurse's note documented the x-ray company arrived and obtained an x-ray of the resident's left leg and knee. At 9:45 p.m., a nurse's note documented the facility received an x-ray report, with no findings of acute injury. There was no documentation to show a registered nurse (RN) conducted a pain assessment after the resident's complaints of left ankle pain on 12/21/10. The X-ray obtained was only done of the left leg/knee, not of the ankle. On 12/22/10 at 8:15 a.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg before restorative therapy. The Restorative Care Flow Record dated 12/22/10, documented the resident ambulated 200 to 400 feet. By documentation, pain medication was given prior to ambulation. On 12/23/10 at 2:15 a.m., a nurse's note documented the resident was complaining of continued discomfort to her left leg. There was no documentation to show pain medication was given. At 8:00 a.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg for "body ache," pain. The resident rated her pain level a 7, on a scale of 1 to 10. On 12/24/10 at 12:00 a.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg for "general discomfort." The resident rated her pain level a 10, on a scale of 1 to 10. At 8:15 a.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg before restorative therapy. The resident ambulated 200 to 400 feet. At 10:00 a.m., a nurse's note documented the PCP saw the resident, but no new orders were written. On 12/26/10 at 7:35 a.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg for back pain. The resident rated her pain level a 6, on a scale of 1 to 10. 12/27/10 at 7:00 a.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg before restorative therapy. At 8:30 a.m., a nurse's note documented, "noted (left) leg/foot c (with) [MEDICAL CONDITION], toes to (left) foot discolored... Ambulated c restorative on 12/24/10, refuses to walk c restorative this AM due to c/o of pain to (left) leg and (left) foot..." Fax was sent to PCP. The fax to the PCP documented,"Resident fell [DATE] c/o of (left) leg/knee pain. X-ray done of left leg/knee (negative for fracture). Walked c restorative on 12/24/10, cont (continues) to c/o of pain to (left) leg. Do you wish to put restorative on hold @ (at) this time? Noted [MEDICAL CONDITION] to (left) leg/foot c discoloration to (left) toes this morning. Please advise." At 10:50 a.m., a nurse's note documented a return fax was received from the PCP with a new order to hold restorative therapy and elevate the resident's leg. At 11:00 a.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg for foot and ankle pain. The resident's pain level was rated an 8, on a scale of 1 to 10. At 6:00 p.m., a nurse's note documented the resident's left leg was swollen and her left foot and toes were discolored. Her leg was elevated. On 12/28/10 at 3:00 a.m., a nurse's note documented the resident's [MEDICAL CONDITION] and discoloration continued to her left foot and toes. At 7:10 a.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg for foot and ankle pain. The resident's pain level was rated a 7, on a scale of 1 to 10. At 3:00 p.m., a nurse's note documented the resident "cont c [MEDICAL CONDITION] to (left) leg/foot. Discoloration to (left) toes. Encouraged to keep elevated. Res (resident) request x-ray to (left) ankle. Unable to bear weight (and) stand on it. Fax sent to (Name deleted, PCP)." The fax to the PCP documented, "Resident cont to c/o (left) ankle/foot pain, swelling (and) discoloration remains. Res request x-ray, states I can't stand on it, Refusing to bear weight. May we have an order for [REDACTED]. At 6:00 p.m., a nurse's note documented, "Remains in bed. Unable to bear wt (weight) d/t (due to) (right) leg discomfort. (Right) ankle discoloration, +2cm. (at) bottom of foot (and) toes, ankle swelling c discomfort when palpated. Becoming more dependent for ADL skills. Wants to stay in bed." On 12/29/10 at 1:30 a.m., a nurse's note documented, "cont with discoloration to (left) foot (and) toes, resident now has discoloration to (left) ankle/(lower) leg. (Left) leg from knee down has 2+ [MEDICAL CONDITION]. C/o of pain when moved. Leg elevated." The clinical records contained no documentation the resident was administered pain medication. At 3:00 a.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg for back pain. The resident's pain level was rated an 8, on a scale of 1 to 10. At 7:30 a.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg for ankle pain. The resident's pain level was rated an 8, on a scale of 1 to 10. At 9:00 a.m., a nurse's note documented, "The resident cont c discoloration to (left) foot/toes, discoloration has moved (up) (left) leg as well. [MEDICAL CONDITION] 2+ to (left) (lower) leg/ankle area. C/o of pain, unable to bear weight (at) this x (time). Requires assist c transfers. Encouraged to keep (left) leg elevated.... Received order to get x-ray of (left) ankle/foot per (Name deleted, PCP). Mobile x-ray notified..." At 11:00 a.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg for ankle pain. The resident's pain level was rated a 10, on a scale of 1 to 10. At 4:25 p.m., a nurse's note documented, " (Name deleted) mobile x-ray here." At 4:40 p.m., a nurse's note documented the x-ray technician informed the facility of a possible fracture (fx). At 5:00 p.m., a nurse's note documented the on call physician was called and a message was left requesting a return call. At 5:10 p.m., a nurse's note documented the on call physician ordered the resident to be sent to the hospital emergency room for evaluation. At 5:41 p.m., a fax was received from (Name deleted) x-ray company. It contained a radiology report which documented,"... an oblique fracture through the distal fibula, as well as a [MEDICATION NAME] fracture through the medial malleolus. These fractures are mildly displaced by 6 and 4mm (millimeters). There is resulting mild subluxation of the talus laterally...." At 6:05 p.m., a nurse's note documented the ambulance transferred the resident to the hospital emergency room . At 8:35 p.m., a nurse's note documented,"Resident returned to facility via carrier per ambulance (and) attendants.... L foot (and) leg c splint immobilizer c ace wrap in place.... Order... for non weight bearing on L leg. F/U (Follow up) with orthopedic in 3-5 days or f/u c (Name deleted, PCP)." The resident's quarterly assessment dated [DATE], documented the resident was cognitively intact, had a fall, and required extensive assistance with the help of two staff members for transfers. On 12/30/10 at 7:30 a.m., the MARs documented the resident was administered [MEDICATION NAME] 50 mg for ankle pain. The resident's pain level was rated a 10, on a scale of 1 to 10. At 10:30 a.m., the PCP's nurse phoned with instructions for the resident to be seen that day at 1:00 p.m., by orthopedic physician #1. Orthopedic physician #1 referred the resident to orthopedic physician #2. While in his office the resident was scheduled to be seen on 01/05/11 at 9:00 a.m., by orthopedic physician #2. At 8:38 (blank) the MARs documented the resident was administered [MEDICATION NAME] 50 mg for ankle pain. The resident's pain level was rated an 8, on a scale of 1 to 10. The MARs for 12/31/10 documented: 7:30 a.m.: [MEDICATION NAME] 50 mg for foot pain. Pain level 8. 11:50 a.m.: [MEDICATION NAME] 50 mg for ankle pain. Pain level 8. 6 p.m.: [MEDICATION NAME] 50 mg for foot pain. Pain level 10. On 01/05/11 at 8:45 a.m., a nurse's note documented the resident was seen by orthopedic physician #2. The care plan for ADLs dated 01/06/10, documented the resident was not ambulatory. She required the assistance of two staff members for ADLs and transfers. On 01/07/11, a telephone order from orthopedic physician #2 documented: 1. complete blood count (CBC), basic metabolic profile (BMP), and electrocardiogram (EKG), 2. discontinue aspirin 5-7 days prior to surgery, 3. nothing by mouth after midnight prior to surgery, and 4. take only [MEDICATION NAME] and [MEDICATION NAME] the morning of surgery. On 01/11/11 at 9:55 a.m., after the team had been told the EKG had not yet been obtained, the DON was interviewed and asked if it was possible for them to obtain a mobile EKG. She stated she didn't know, but she did know the hospital would not come to the facility and perform them. At 10:00 a.m., a licensed practical nurse (LPN) was asked why the EKG was not scheduled until the 12th. She stated she had tried to schedule it two times the previous Friday on the 7th, but the hospital had not called her back. She stated she phoned the hospital on Monday (01/10/11) and the hospital stated they could perform the EKG anytime within the next couple of days. She stated that she had asked the social service director (SSD) on Monday the 10th, when she would be available to transport the resident for an EKG. The LPN stated the SSD said she was unavailable until Wednesday the 12th. At 10:05 a.m., the DON stated orthopedic surgeon #2 didn't want to operate until all of the swelling was gone in the resident's ankle. She was asked for the surgeon's notes with the documentation. The DON stated the family told her that, she did not have progress notes from the office visit. At 1:45 p.m., the resident was interviewed. She stated prior to the fall she could ambulate in her room independently; could go to the restroom by herself, and could use her wheelchair to go long distances. The resident was asked how she felt about having to ask for help. She stated it was a little embarrassing. She knew she needed help and that was their job. She was afraid to use her leg now. She stated she was concerned that it was taking so long to fix her leg. The resident stated, "I stay in my room. I would like to go to Bingo. I don't have to, I want to. I haven't told them. It's not that important now but no one has asked me about Bingo." The resident stated after the fall all of her leg hurt all the time. The resident was asked if she was administered pain medications when requested. She stated they did. She stated sometimes the staff asked her if she needed pain medicines. She stated if she didn't move, it didn't hurt. At 2:30 p.m., the LPN was asked what color the resident's foot was when she observed it on the 27th. She stated it was purple. She was asked why she described it as discolored in the notes and on the fax to the PCP. She stated she did not know. The clinical records did not document a full assessment completed by a nurse of the foot and ankle. There was no detailed description of the swelling and/or color of the resident's foot. At 4:20 p.m., the social services director was asked when she was made aware of the resident's need to have an EKG. She stated the LPN informed her after 3:00 p.m., on Monday the 10th. The SSD stated, "I told her the resident required the use of a van due to her broken leg. I told her I would be unavailable on Tuesday the 11th..." She was asked if other staff was available to transport the resident. She stated there was not. On 01/12/11 at 8:30 a.m., the administrator stated if she had known the resident needed an EKG, she would have arranged for another staff member to transport the resident sooner. At 8:35 a.m., the PCP was interviewed. He stated orthopedic physician #1 arranged an appointment with another orthopedic physician because physician #1 didn't feel comfortable doing the surgery. The physician's progress note from the resident's appointment with orthopedic physician #2 on 01/05/11, could not be found in the clinical records. They were requested by surveyors, on 01/11/11. They were received by fax to the facility on [DATE]. The progress notes documented the physician recommended the resident have an open reduction internal fixation (ORIF) surgery to maximize her activity level after this break. "We are going to get her scheduled and see her back after surgery." On 12/21/10, the resident had fallen and complained of ankle pain. An x-ray was taken of the knee and hip not the ankle, even though the resident had complained of ankle pain. An x-ray was not done on the ankle until 12/28/10, when the resident requested an x-ray of her ankle. An x-ray of the ankle was not obtained until 12/29/10 at 4:30 p.m. A fracture was found on the ankle x-ray. On 01/12/11 at 5:00 p.m., the facility informed surveyors the resident was now scheduled for surgery, on the 20th of January, 22 days following the initial fall.