Every finding on record at Glenwood Skilled Nursing and Therapy

Based on observation, interview, and record review, the facility failed to ensure baths were provided as scheduled for six (#6, 14, 65, 27, 33, and #42) of seven residents reviewed for activities of daily living. The DON identified 72 residents who resided at the facility. Findings: 1. Resident #6 admitted with diagnoses which included vascular dementia, cervical disc disorder, and barretts esophagus. Review of the task documentation for the previous 30 days revealed one documented shower on 03/01/24, and an order for a shower three times a week and as needed. Review of bath documentation, provided by the DON, revealed for the month of January three baths were provided out of 14 opportunities. The bath documentation for February revealed no baths were given with two refusals documented out of 12 opportunities. The bath documentation for March to the date of survey revealed one bath out of six opportunities. On 03/12/24 at 11:24 a.m., Resident #6 stated it had been two weeks since they had a bath, and it was a bed bath with cold water, not warm. They stated it takes staff 30 minutes to answer the call light and then the staff act like the resident was bothering them by putting on their light. Resident #6 stated staff do not assist them with putting in their hearing aide every day and since they are bed bound, they are unable to reach the bed side table were the hearing aid is kept. Resident #6 was observed to have oily hair that was uncombed. The Care Plan for Resident #6 documented a risk for changes in their ADL status. The care plan documented Resident #6 required total assist for locomotion and did not walk. The care plan documented Resident #6 required one staff participation to reposition and turn in bed and with bathing. 2. Resident #14 admitted with diagnoses which included parkinsonism, dementia, and morbid obesity. The Care Plan, dated 01/17/24, documented Resident #14 required assistance with bathing and to provide a sponge bath when a full bath or shower cannot be tolerated. The task section of the health record documented Resident #14 was to receive a shower every other day. Baths for February were documented as one bath completed out of nine opportunities with one refusal. The March baths were documented as three baths completed out of seven opportunities. 3. Resident #65 admitted with diagnoses which included heart failure, anxiety disorder, and schizophrenia. The Care Plan, dated 03/07/24, documented Resident #65 was dependent for bathing. The task section of the health record documented Resident #65 was to receive a bath three times a week and as needed. A 30 day look back in tasks revealed one bath given on 03/01/24. The bathing documentation provided by the DON documented in February two refusals and zero baths completed out of 12 opportunities. The documentation revealed one bath in March out of six opportunities. On 03/14/24 at 2:38 p.m., the DON stated residents did not receive showers due to staff were stretched thin, and since the facility no longer had a shower aide, staff did not make bathing a priority. The DON stated the expectation was that everyone received a shower three times a week. 42171 4. Resident #27 had diagnoses which included hypertension and osteoarthritis. A care plan, dated 05/05/22, documented the resident preferred showering daily in the morning or afternoon. A quarterly assessment, dated 1/10/24, indicated the resident was cognitively intact and required moderate assistance with bathing. The task section of the health record documented the resident is to receive a shower daily. A review of bathing documentation, dated 01/28/24 through 02/27/24, documented the resident received or refused 8 showers out of 32 opportunities. 5. Resident #33 had diagnoses which included diabetes mellitus and hypertension. A care plan, dated 12/21/20, documented the resident was dependent on staff for bathing. A quarterly assessment, dated 12/21/23, documented the resident was cognitively intact and required moderate assistance from staff for personal hygiene. The task section of the health record documented the resident is to receive a shower twice a week and as needed. A review of bathing documentation, dated 01/31/24 through 02/26/24, documented the resident received two showers out of six opportunities. On 03/13/24 at 9:45 a.m., CNA #1 reported there is not always enough staff to give showers as ordered. On 03/13/24 at 10:00 a.m., CNA #2 reported sometimes they are unable to finish all the showers they are supposed to. On 03/13/24 at 10:15 a.m., CNA #3 stated that sometimes they stay late to complete showers, but sometimes they cannot stay late, and showers were not done. On 03/14/24 at 1:54 p.m., LPN #1 stated they are having staffing issues and they do not always provide personal care as timely as they would like. On 03/14/24 at 2:37 p.m., the DON stated the ADON was responsible for ensuring that showers were being completed and that the nursing staff should ensure the residents personal needs were being met. 41809 6. Resident #42 admitted with diagnoses which included diabetes. Review of tasks for showers revealed Resident #42 was to receive two showers a week and as needed. The task documentation for showers documented Resident #42 had received no showers since admission. To date Resident #42 should have received four showers in February and four showers in March. On 03/14/24, the DON stated the showers were a daily task for the ADON to monitor by pulling the POC charting reports under tasks. The DON stated Resident #42 had one bath sheet for one bath completed. The DON stated they would have to investigate as to why Resident #42 had only received one shower. They stated the facility had recently lost their shower aide to another sister facility and the staff had put the showers on the back burner.

Based on observation, record review, and interview, the facility failed to ensure sufficient staffing to meet the needs of the residents for six (#6, 14, 65, 27, 33, and #42) of seven residents reviewed for sufficient staffing. The DON identified 72 residents resided at the facility. Findings: 1. Resident #6 admitted with diagnoses which included vascular dementia, cervical disc disorder, and barretts esophagus. Review of the task documentation for the previous 30 days revealed one documented shower on 03/01/24, and an order for a shower three times a week and as needed. Review of bath documentation, provided by the DON, revealed for the month of January three baths were provided out of 14 opportunities. The bath documentation for February revealed no baths were given with two refusals documented out of 12 opportunities. The bath documentation for March to the date of survey revealed one bath out of six opportunities. On 03/12/24 at 11:24 a.m., Resident #6 stated it had been two weeks since they had a bath, and it was a bed bath with cold water, not warm. They stated it takes staff 30 minutes to answer the call light and then the staff act like the resident was bothering them by putting on their light. Resident #6 stated staff do not assist them with putting in their hearing aide every day and since they are bed bound, they are unable to reach the bed side table were the hearing aid is kept. Resident #6 was observed to have oily hair that was uncombed. The Care Plan for Resident #6 documented a risk for changes in their ADL status. The care plan documented Resident #6 required total assist for locomotion and did not walk. The care plan documented Resident #6 required one staff participation to reposition and turn in bed and with bathing. 2. Resident #14 admitted with diagnoses which included parkinsonism, dementia, and morbid obesity. The Care Plan, dated 01/17/24, documented Resident #14 required assistance with bathing and to provide a sponge bath when a full bath or shower cannot be tolerated. The task section of the health record documented Resident #14 was to receive a shower every other day. Baths for February were documented as one bath completed out of nine opportunities with one refusal. The March baths were documented as three baths completed out of seven opportunities. 3. Resident #65 admitted with diagnoses which included heart failure, anxiety disorder, and schizophrenia. The Care Plan, dated 03/07/24, documented Resident #65 was dependent for bathing. The task section of the health record documented Resident #65 was to receive a bath three times a week and as needed. A 30 day look back in tasks revealed one bath given on 03/01/24. The bathing documentation provided by the DON documented in February two refusals and zero baths completed out of 12 opportunities. The documentation revealed one bath in March out of six opportunities. On 03/14/24 at 2:38 p.m., the DON stated residents did not receive showers due to staff were stretched thin, and since the facility no longer had a shower aide, staff did not make bathing a priority. The DON stated the expectation was that everyone received a shower three times a week. 4. Resident #27 had diagnoses which included hypertension and osteoarthritis. A care plan, dated 05/05/22, documented the resident preferred showering daily in the morning or afternoon. A quarterly assessment, dated 1/10/24, indicated the resident was cognitively intact and required moderate assistance with bathing. The task section of the health record documented the resident is to receive a shower daily. A review of bathing documentation, dated 01/28/24 through 02/27/24, documented the resident received or refused 8 showers out of 32 opportunities. 5. Resident #33 had diagnoses which included diabetes mellitus and hypertension. A care plan, dated 12/21/20, documented the resident was dependent on staff for bathing. A quarterly assessment, dated 12/21/23, documented the resident was cognitively intact and required moderate assistance from staff for personal hygiene. The task section of the health record documented the resident is to receive a shower twice a week and as needed. A review of bathing documentation, dated 01/31/24 through 02/26/24, documented the resident received two showers out of six opportunities. On 03/13/24 at 9:45 a.m., CNA #1 reported there is not always enough staff to give showers as ordered. On 03/13/24 at 10:00 a.m., CNA #2 reported sometimes they are unable to finish all the showers they are supposed to. On 03/13/24 at 10:15 a.m., CNA #3 stated that sometimes they stay late to complete showers, but sometimes they cannot stay late, and showers are not done. On 03/14/24 at 1:54 p.m., LPN #1 stated they are having staffing issues and they do not always provide personal care as timely as they would like. 6. Resident #42 admitted with diagnoses which included diabetes. Review of tasks for showers revealed Resident #42 was to receive two showers a week and as needed. The task documentation for showers documented Resident #42 had received no showers since admission. To date Resident #42 should have received four showers in February and four showers in March. On 03/14/24, the DON stated the showers were a daily task for the ADON to monitor by pulling the POC charting reports under tasks. The DON stated Resident #42 had one bath sheet for one bath completed. The DON stated they would have to investigate as to why Resident #42 had only received one shower. They stated the facility had recently lost their shower aide to another sister facility and the staff had put the showers on the back burner.

Based on observation, record review, and interview, the facility failed to ensure infection control measures were followed during meal pass and medication administration regarding hand sanitation. The MDS coordinator #2 identified # residents who received meals in the dining room and # residents who received medications. Findings: On 03/11/24 at 11:49 a.m., during the noon meal, CNA #3 was observed to deliver meals to tables. CNA #3 returned for another tray and was not observed to sanitize their hands. CNA #3 was observed to obtain another tray and delivered it to another resident. CNA #3 was observed to reuse the tray for each resident they delivered meals to. The tray was not observed to be cleaned or sanitized between residents. On 03/13/24 at 6:52 a.m., during the medication administration, CMA #1, was observed to check the blood pressure of a resident in the lobby while wearing gloves. CMA #1 then poured twocal (2.0) HN into a cup, and punched out medications into their gloved hand, then placed the medications into a medication cup for Resident #53. On 03/13/24 at 7:01 a.m., CMA #1 was observed to touch the table, blood pressure cuff machine, and a resident while wearing gloves, then punched out medications into their hand and place the medications into a medication cup before administering the medications to Resident #72. On 03/13/24 at 7:17 a.m., CMA #1 was observed to wear gloves while taking the blood pressure of Resident #22, then punched out medications into their hand then into the medication cup for Resident #22. On 03/14/24 at 2:43 p.m., the DON stated they expected staff to maintain infection control during medication administration and meal pass by hand washing or using hand sanitizer between each resident during medication administration or meal pass.

Based on record review, observation, and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. The MDS coordinator identified 71 residents who received food from the kitchen. Findings: On 03/11/24 at 9:29 a.m., the handwashing sink was observed to be out of soap. On 03/11/24 at 9:32 a.m., the dietary manager was observed entering the kitchen without washing their hands. On 03/11/24 at 9:38 a.m., the walk-in cooler and freezer temperature logs were observed, both logs did not document temperatures had been recorded on 03/07/24, 03/08/24, 03/10/24, and 03/11/24. On 03/13/24 at 11:19 a.m., the dietary manager was observed preparing the pureed diet. The dietary manager pulled down their mask with a bare hand and then pulled the mask back up. The dietary manager pureed spaghetti for the noon meal without performing hand hygiene. They donned gloves without performing hand hygiene and measured the temperature of the pureed spaghetti. The dietary manager then wiped off the thermometer with an alcohol pad and rinsed it off in the handwashing sink. They then removed their gloves and put on another pair without performing hand hygiene. On 03/13/24 at 11:38 a.m., DA #1 was observed preparing to serve the noon meal from a steamtable in the dining room. They were observed moving trays, organizing meal tickets, touching the counter and various other surfaces with their bare hands. At 11:50 a.m. they started serving the noon meal without performing hand hygiene. On 03/14/24 at 12:45 p.m., the walk-in cooler and temperature logs were observed, the entries for 03/07/24, 03/08/24, 03/10/24 and 03/11/24 were observed to be completed. On 03/14/24 at 12:48 p.m., the dietary manager stated they had filled in the missing entries based on what the temperature usually was. They stated that the hand washing sink should always have adequate supplies and should only be used for hand washing. The dietary manager stated anyone entering the kitchen should wash their hands.

Based on observation, record review, and interview, the facility failed to ensure a homelike environment by providing clean, unstained carpeting throughout the facility. The DON identified 72 residents who resided at the facility. Findings: A Service Summary & Invoice, dated 09/07/23, documented commercial carpert cleaning was completed. This was the only invoice provided by the facility. On 03/13/24 at 7:04 a.m., a female housekeeper was observed to clean/vaccuum the carpet, the carpet remained stained. On 03/14/24 at 11:20 a.m., the carpet in the entry way and halls was observed to with multiple stained areas. The stains were observed in all the hallways. The carpet was observed to be worn down in areas of high traffic. On 03/14/24 at 11:20 a.m., the administrator stated they wished the carpet could be replaced. They stated the carpet was professionally cleaned every 6 months, and the carpet is swept daily, but the stains just come right back. They stated the carpet does not look good, it looks dirty.

Based on observation and interview, the facility failed to ensure dignity for two (#33 and # 187) of three residents sampled for dignity. The DON identified 72 residents resided at the facility. Findings: 1. Resident #178 was admitted with diagnoses which included diarrhea. On 03/11/24 at 11:31 a.m., the call light for room [ROOM NUMBER] was sounding. On 03/11/24 at 11:36 a.m., the call light for room [ROOM NUMBER] was still sounding. On 03/11/24 at 11:38 a.m., a CNA from 400 hall went down 200 hall to the linen cart. The CNA was observed to not check on the call light. On 03/11/24 at 11:42 a.m., the call light for room [ROOM NUMBER] began sounding and room [ROOM NUMBER] call light continued to sound. Two nurses were observed to be at the nurse's station. One nurse left the station and walked down 400 hall, then walked down 600 hall. On 03/11/24 at 11:46 a.m., the wound nurse was observed on 200 hall at their cart. The call light for room [ROOM NUMBER] was observed to be sounding. On 03/11/24 at 11:48 a.m., the staffing board was observed to document CNA #4 was assigned to 200 hall. CNA #4 was observed to be serving in the dining room. The call lights on 200 hall were observed to be unanswered. On 03/11/24 at 1:39 p.m., Resident #178 stated their call had not been answered. The call light was observed to be lit up outside of their room. Resident #178 was observed to be wearing a hospital gown and bags of clothes were observed in the room. Resident #178 stated the bags had pajamas in them, and they did not want to wear pajamas all day, only at night. On 03/11/24 at 2:40 p.m., Resident #178 was observed to walk to the lobby with disheveled hair and wearing a hospital gown. The gown was observed to not be completely closed in the back. Multiple staff and residents were in the lobby. Resident #178 spoke with the nurse and requested pain medication. On 03/11/24 at 2:44 p.m., the nurse offered to tie their gown in the back. On 03/11/24 at 2:48 p.m., CNA #3 walked the resident to their room. On 03/14/24 at 2:46 p.m., the DON stated the personal needs of Resident #178 should be met by answering call lights and providing care needs. 42171 2. Resident #33 had diagnoses which included diabetes mellitus and hypertension. A quarterly assessment, dated 12/21/23, documented the resident was cognitively intact and required moderate assistance with personal hygiene. On 03/11/24 at 12:10 p.m., Resident #33 was observed in bed, the resident had several 1/2 inch diameter pieces of what appeared to be biscuits stuck in their beard. They also had small white flakes in their hair which appeared greasy. Resident #33 had food debris on their shirt and reported they seldom got to take a shower and often had to wait long periods of time for assistance. The resident also reported they had not been provided incontinent care since 7:00 p.m. last night. On 03/13/24 at 09:24 a.m., Resident #33 was observed in the hallway, they had small crumbs in their beard and food debris in their lap. The resident's shirt was soiled. On 03/13/24 at 9:45 a.m., CNA #1 reported there were not always enough staff to give showers as ordered. On 03/13/24 at 10:00 a.m., CNA #2 reported sometimes they were unable to finish all the showers they were supposed to. On 03/13/24 at 10:15 a.m., CNA #3 stated that sometimes they stayed late to complete showers, but sometimes they cannot stay late, and showers were not completed. On 03/14/24 at 09:20 a.m., Resident #33 was observed in bed. The resident appeared to be wearing the same soiled shirt from yesterday, the resident also had food debris in their beard on their bed. The resident's wheelchair cushion was covered with food debris. On 03/14/24 at 1:24 p.m., the resident stated they did not feel like they were treated with dignity by the facility staff. On 03/14/24 at 1:54 p.m., LPN #1 stated they are having staffing issues and they do not always have time to provide personal care as timely as they would like. On 03/14/24 at 2:37 p.m., the DON stated the ADON was responsible for ensuring that showers were being completed and that the nursing staff should ensure the residents personal needs were being met.

Based on observation, record review, and interview, the facility failed to ensure the Resident was included in the development of the care plan for one (#37) of one reviewed for care planning. The DON identified 72 residents who resided at the facility. Findings: Resident #37 admitted with diagnoses which included cerebral vascular accident. Review of Progress Notes, revealed documentation that the resident agreed with the plan of care but no documentation Resident #37 was involved in a meeting regarding the total overall plan of care during the resident's stay with expectation of outcomes or discharge expectations. On 03/11/24 at 10:55 a.m., Resident #37 stated the facility did not have a care plan meeting with the resident, but they may have with their representative. On 03/13/24 at 9:07 a.m., the representative of Resident #37 was contact. The representative stated they had received a booklet and a tour before Resident #37 was admitted but no meeting had taken place after Resident #37 was admitted to the facility. On 03/13/24 at 11:15 a.m., the MDS coordinator #1 stated they had completed the care plan for Resident #37. They stated they talked to the family/resident representative within a week after the admission. The MDS coordinator #1 stated they did not document the conversation or the day and time of the conversation. They left to find documentation of the conversation. On 03/13/24 at 12:09 p.m., the MDS coordinator #1 returned with a copy of their checklist, written on the checklist were the words representative/res. They stated they spoke with Resident #37 when they had completed the admission assessment. The MDS coordinator #1 stated a meeting had not been conducted to discuss the expectations of the resident and staff, or the expected outcome of the care provided by the end of Resident #37's skilled stay. They stated there was not signature page for everyone involved in the care plan.

Based on record review and interview, the facility failed to ensure a resident's family was notified of a change in condition/transfer to the hospital for one (#9) of three sampled residents who were reviewed for notification of change. The administrator identified 71 residents who resided in the facility. Findings: The Resident's Family or Physician Notification of Change Guideline policy, dated 12/01/09, read in parts, .The facility will .notify the resident's legal representative or interested family member of the following events .An accident involving the resident, that results in injury and has the potential for requiring physician intervention .A decision to transfer or discharge the resident from the facility . Resident #9 had diagnoses which included hypertension. The face sheet in the electronic health record identified three emergency contacts and phone numbers. A nurse progress note, dated 01/14/24 at 2:30 p.m., documented the resident had fallen and orders were received to transfer the resident to the emergency room . The note documented the nurse had notified the resident they were going to call their family but the resident asked them not to because they were going to notify their family themselves. The Form ODH 283, dated 01/14/24, documented the resident spoke for themself and did not want staff to contact family members. The state report documented the physician, ADON, DON, and administrator were notified of the incident. On 01/18/24 at 11:11 a.m., family member #1, for Resident #9, stated the facility had not notified the family of the fall or transfer to the hospital. On 01/18/24 at 11:21 a.m., the administrator stated they would have notified the family of the transfer to the hospital related to the fall but understood why the nurse had not made the notification since the resident was cognitively intact for daily decision making. On 01/18/24 at 3:22 p.m., the ADON stated staff were to notify the family/emergency contacts of hospitalization s even if the resident stated they would notify family members themselves.

Based on record review and interview, the facility failed to ensure allegations of resident to resident abuse were reported to the state agency within two hours for one (#4) of three sampled residents who were reviewed for abuse. The administrator identified 71 residents who resided in the facility. Findings: The Resident Abuse, Neglect and Misappropriation of Property policy, dated 11/01/22, read in parts, .Director of Nursing/Administrator do initial state report .Immediately but not later than 2 hours if the alleged violation involves abuse . Resident #4 had diagnoses which included vascular dementia. A facility incident report, dated 11/27/23 at 10:08 p.m., documented Resident #4 stated Resident #10 had struck them in the chest. The facility incident report documented the ADON had been notified of the incident on 11/27/23 at 10:49 p.m. The ODH Form 283, read in parts, .Incident date 11/27/23 .Allegations of Abuse/Mistreatment . The ODH Form 283 documented Resident #10 had struck Resident #4 in the chest with no injuries noted and was signed by the ADON. The attached fax transmission confirmation was dated 11/28/23 at 11:51 a.m. On 01/18/24 at 3:53 p.m., the ADON stated they were made aware of the resident to resident abuse allegation via text message on 11/27/23 at 11:15 p.m. but they had not seen the text until the morning of 11/28/23 and submitted the initial report to OSDH on 11/28/23 at 11:51 a.m. They stated the incident should have been reported to OSDH within 2 hours of the incident. On 01/18/24 at 4:00 p.m., the administrator stated they were to report allegations of resident to resident abuse within two hours of the incident.

Based on observation and interview, the facility failed to ensure treatment carts were secure for four of four treatment carts observed. The DON identified there were four treatment carts in the facility. Findings: On 10/09/23 at 12:32 p.m., treatment carts at the end of 500 hall and at the end of 600 hall were observed unlocked. On 10/09/23 at 12:50 p.m., the treatment cart on 200 hall was observed unlocked. On 10/09/23 at 3:05 p.m., the treatment cart on Main Street hall was observed unlocked. Residents were observed to wander up and down Main Street hall. On 10/10/23 at 8:13 a.m., treatment carts at the end of 500 hall and at the end of 600 hall were observed unlocked. On 10/10/23 at 4:00 p.m., the treatment cart located by room [ROOM NUMBER] was observed unlocked. The second drawer was opened and bottles of hydrogen peroxide and iodine were observed. Other drawers were observed to contain dressing materials and medicated creams. On 10/10/23 at 4:10 p.m., LPN #1 stated they were to keep treatment carts locked. The LPN stated they did not know why the cart was unlocked unless it was when they were handling an emergency. On 10/10/3 at 4:15 p.m., LPN #2 stated they were to keep treatment carts locked. The LPN stated they did not know why the cart was unlocked. On 10/10/23 at 4:20 p.m., LPN #3 stated they had to keep the carts locked because there were residents who would rummage through stuff. The LPN stated the cart was left unlocked while they were moving back and forth between bedside care and obtaining supplies from the wound cart. LPN #3 stated they should have locked the cart when it was left unattended. On 10/10/23 at 4:25 p.m., the DON stated the carts were to remain locked when unattended. The DON stated they needed to educate the staff.

Based on observation, record review, and interview, the facility failed to provide incontinent care in a manner to prevent urinary tract infections and cross contamination for two (#11 and #12) of three sampled residents observed during incontinent care. The DON identified 16 residents who were incontinent of urine and four residents with urinary tract infections. Findings: 1. Resident #12 had diagnoses which included stroke, dementia, and diabetes. The care plan, revised 07/21/23, documented the resident was incontinent of bowel and bladder. The antibiotic/infection progress note, dated 10/08/23, documented the resident complained of burning with urination and was to receive Levaquin 500 mg daily for a urinary tract infection. On 10/10/23 at 9:16 a.m., CNA #1 was observed to provide incontinent care to Resident #12. Without performing hand hygiene, CNA #1 donned gloves and cleansed BM from the vaginal opening/groin with multiple disposable wipes fanned out across their hand. CNA #1 turned the resident and cleansed the resident's buttocks. CNA #1 was observed to lay the soiled disposable wipe on top of the packaging for wipes, fold the soiled wipe in half, pick up the soiled wipe, and cleanse the resident's buttocks. Without changing gloves, CNA #1 applied the resident's brief and bed pad, touched/handled the resident's call light, bed controller, pillows, beside table, and personal belongings. Then, without changing gloves, CNA #1 gathered the soiled linen and trash, exited the room, and entered a locked hopper room. 2. Resident #11 had diagnoses which included retention of urine, neuromuscular dysfunction of bladder, and obstructive and reflux uropathy. The care plan, revised 02/15/23, documented the resident had an indwelling catheter, was to remain free from catheter related trauma, and to monitor for signs of a urinary tract infection. On 10/10/23 at 9:27 a.m., CNA #1 was observed to provided incontinent care to Resident #11. Without performing hand hygiene, CNA #1 donned gloves and cleaned BM from the inner thighs with disposable wipes, turned the resident, and cleansed their buttocks. Holding the resident on their side with one hand and the soiled wipe in the other, CNA #1 flipped their wrist to fold the far edge of the disposable wipe to expose half of the underside and then cleansed the resident's buttocks with the folded wipe. Without changing gloves, CNA #1 positioned a brief and bed pad, positioned the resident, touched/handled the resident's pillows, linens/blankets, overbed table, and personal belongings. Then, without changing gloves, CNA #1 retrieved a graduated cylinder from the bathroom and drained the resident's urinary catheter bag. No catheter care was observed. On 10/10/23 at 3:20 p.m., CNA #1 stated they did not change gloves after providing incontinent care to resident #12 until after disposing of the soiled linen in the hopper. CNA #1 stated they were to change gloves after handling the soiled linen and trash and before placing the clean brief and linen. CNA #1 stated the CNAs were to perform catheter care for incontinent residents with catheters. The CNA stated they were to use clean gloves when handling any part of the urinary catheter and bag. On 10/10/23 at 3:25 p.m., CNA #2 stated to decrease the risk of infection, they changed gloves after incontinent care and before taking the soiled linen to the hopper room. CNA #2 stated CNAs were to perform catheter care for incontinent resident's with catheters. CNA #2 stated they performed catheter care by donning clean gloves and wiping the catheter tubing between the catheter anchor and the urine storage bag. On 10/11/23 at 2:35 p.m., the DON was informed of the observations above. The DON stated the staff were to perform hand hygiene and change gloves when moving from the dirty portion of a task to the clean portions.

Based on record review and interview, the facility failed to provide supervision to prevent accident hazards related to the weather for one (#1) of three sampled residents. Resident #1 refused to return indoors from 11:00 p.m. until 3:30 p.m. and remained in the sun outside. This resulted in actual harm when Resident #1 was transferred to the emergency room and was diagnosed with heat stroke/heat exhaustion and sunburns. The Residents Census and Condition of Residents report documented 75 residents resided in the facility. Findings: Resident #1 had diagnoses which included vascular dementia. An admit MDS assessment, dated 04/20/23, documented the resident utilized a wheelchair, was incontinent, and was severely impaired in cognition. A care plan, dated 04/20/23, documented the resident used a wheelchair, required assistance with ADLs, and was assessed for smoking. A skin assessment, dated 05/30/23 documented the resident had intact skin. A progress note, dated 06/01/23, at 3:45 p.m. documented Resident #1 was found unresponsive in the smoking area. The resident had rapid respirations, skin warm to the touch, and staff were unable to obtain vital signs. The resident was sent to the hospital for evaluation and treatment. The hospital record for Resident #1, dated 06/01/23, documented diagnoses which included sunburn and respiratory distress. An emergency department note, dated 06/01/23, read in part .[patient] remains unresponsive to painful stimuli with an upward left gaze and grunting.,,. An Incident Report Form read in part .on 06/01/23, [Resident #1] was observed to be unresponsive in the smoking area. [The] resident was assisted inside and assessed, [Resident #1] had rapid respirations, skin warm to touch and periods of syncope. Unable to obtain vitals. 911 activated and EMSA arrived transporting resident to [area hospital] for evaluation and treatment. Son (POA) and [physician of record] notified. On 06/02/23 [the hospital] reported an allegation of neglect regarding blisters noted to BLE and possible heat exhaustion. Investigation initiated and ongoing . A facility Quality Tip report, dated 06/02/23, documented a heat related event had been identified. The suggested solutions were: 1. In-service staff on signs and symptoms of heat exhaustion and smoking policy. 2. Review/assess all residents who smoke to ensure appropriate supervision is in place. 3. Update smoking contracts as appropriate. 4. Continue staff checks on resident who are outside. 5. Continue supervised smoking schedule every other hour. 6. Continue preventive measure, hydration, sunscreen, supervised as indicated and scheduled assessments. 7. Update care plans as appropriate. 8. Complete compliance rounds daily x 5 days, then weekly x 2 months. 9. Monitor in QA to ensure effectiveness of the plan. In-services dated 06/02/23 and 06/08/23 documented education was provided to all staff regarding supervision of residents while outside, smoking safety, Weekly compliance rounds started on 06/02/23 (daily for one week) then and continued through 07/26/23 at a weekly basis for monitoring of residents who are outside. The hospital Discharge Summary, dated 06/20/23, read in part, .Discharge diagnoses: *--Focal right hemispheric seizures likely due to heat stroke . *--Acute metabolic encephalopathy secondary to seizures, poetical state and heatstroke. *--Heatstroke/heat exhaustion. *--Skin damage, superficial burns . Physician orders, dated 06/22/23 documented burn wound treatments to upper right arm, and right and left thighs. A progress note, dated 06/29/23, read in part Focused assessment related to readmission resident has .wounds to . R upper arm, R and L thighs above the knees . A care plan revision, dated 06/29/23, documented wound care to right and left thighs. On 07/31/23 CNAs, CMAs, and charge nurses were interviewed about resident safety while outside. They were all knowledgeable of the protocol and the in-services which had been provided in June 2023. On 07/31/23, at 4:00 p.m., the DON was asked what the protocol was if residents were outside and refused to return inside related to the weather. The DON stated several staff had attempted different ways to get Resident #1 to return inside, the nurses had known the resident was outside, and had checked on the resident. The DON stated when the resident refused to come inside, staff should have told them so they could have made a judgement call on if they should have the resident come inside. On 07/31/23, at 4:25 p.m., the administrator was asked how they ensured residents who were cognitively impaired had adequate supervision to prevent injury. The administrator stated the nursing department assessed the resident as to the level of supervision needed. The administrator was asked who monitored to ensure supervision was provided to prevent accident hazards and/or injuries. They stated the DON and ADON. They were asked what had been implemented to prevent weather related injury if a resident refused to return indoors. The administrator stated they added a hydration station, increased the availability of shade, and increased supervision of residents by staff when residents were outdoors.

41318 Based on observation and interview, the facility failed to ensure palatable meals were provided to residents for one of one meal services observed. The DON identified 71 residents received food from the kitchen. Findings: On 02/16/23 at 9:53 a.m., Resident #47 stated the food was cold. On 02/16/23 at 11:24 a.m., Resident #49 stated the food was cold. On 02/16/23 at 11:42 a.m., Resident #46 stated the food was bad. They stated it was never really hot. On 02/16/23 at 1:46 p.m., Resident #24 stated the food was cold. On 02/16/23 at 2:28 p.m., Resident #44 stated the food was not good. On 02/16/23 at 2:47 p.m., Resident #125 stated the food was not usually hot at all. On 02/17/23 at 10:09 a.m., Resident #20 stated the food was cold. On 02/22/23 at 12:50 p.m., Resident #46 stated the food was warm but should be hot. On 02/22/23 at 1:11 p.m., the last hall cart was zipped up in a clear plastic cover and pushed out of the dining room. On 02/22/23 at 1:25 p.m., the last hall tray was served to a resident and the test tray was removed from the cart. The temperature of the meatloaf was 117 degrees F and tasted cool. The temperature of the macaroni and cheese was 99 degrees F. It was observed to look dry, tasted cold and had no flavor. The temperature of the green beans were 96 degrees F. They tasted cold and had no seasoning. On 02/22/23 at 2:35 p.m., the DM was asked how they ensured foods were served at an appetizing temperature. They stated they checked the temperature of the food prior to serving. The DM was asked if the plates were heated. They stated no. The DM was asked if they used insulated bottoms for under the plates. They stated no. The DM was asked how they ensured food was hot when delivered to the residents on the hall. The DM stated, That is a good question. The DM was asked how they ensured food was palatable. They stated they taste it. The DM stated the macaroni and cheese was awful today. The DM was asked how the green beans tasted. They stated the first batch was seasoned but could not say the second batch was seasoned.

Based on record review, observation, and interview, the facility failed to ensure staff administered medications through the peg tube for one (#2) of six sampled residents observed during medication pass. The DON identified one resident received medications via peg tube. Findings: Resident #2 had diagnoses which included age-related osteoporosis and iron deficiency anemia. An Order Summary Report documented Resident #2 was to receive the following medication via peg tube: a. Multivitamin tablet daily, b. Probiotic capsule daily, and c. Vitamin D tablet daily. On 02/22/23 at 9:14 a.m., CMA #2 was observed to punch out, crush, and place multivitamin tablet and vitamin D tablet into individual medication cups. CMA #2 was observed to open the probiotic capsule and place the contents into a medication cup. On 02/22/23 at 9:18 a.m., CMA #2 took the medication cups into Resident #2's room and placed them on a bedside table. CMA #2 mixed water with the medications. One cup was observed to turn a white color and another cup was observed to turn an orange color. CMA #2 placed a towel under the resident's peg tube. CMA #2 was observed to connect a syringe to Resident #2's peg tube and poured the white colored medication water into the syringe. Liquid was observed running down CMA #2's hand and arm that was holding the syringe and peg tube together. CMA #2 poured the orange color cup into the syringe. Orange color liquid was observed to run down CMA #2's hand, arm and drip on the towel under the resident's peg tube. CMA #2 disconnected, reconnected, and adjusted the peg tube to the syringe and poured the last of the medication into the peg tube. There was no observation of the medication liquid leaking after CMA #2 reconnected the peg tube. On 02/22/23 at 9:24 a.m., CMA #2 was asked how staff ensured medications went into the peg tube. They stated they poured the medication down the syringe that was connected to the peg tube. CMA #2 was asked if Resident #2 received all the medication. They stated they had felt wetness on the side of the tube while they were pouring the medication in. They stated the small opening on the side of the peg tube connector had opened. They stated they saw the colored liquid running out. On 02/22/23 at 9:28 a.m., the DON and ADON were asked how staff ensured medications were administered through the peg tube. The ADON stated the staff connected a syringe to the peg tube and let the medication flow to gravity. They were asked what staff were to do if they felt wetness on the outside of the peg tube while administering medications. The DON stated the medication wasn't going in the peg tube and the staff should stop, clamp the peg tube and go tell the nurse.

Based on record review, observation, and interview, the facility failed to ensure staff wore gloves while administering medications through the peg tube and did not touch medications with bare hands for one (#2) of six sampled residents observed during medication pass. The Resident Census and Conditions report, dated 02/23/23 documented 72 residents resided in the facility. The DON identified one resident received medications via peg tube. Findings: A Preparation and General Guidelines policy, dated January 2022, read in part, .Hands are washed before putting on examination gloves and upon removal for administration of .enteral .medications. Resident #2 had diagnoses which included age-related osteoporosis and iron deficiency anemia. An Order Summary Report documented Resident #2 was to receive the following medication via peg tube: a. Cyanocobalamin tablet daily, b. Multivitamin tablet daily, c. Probiotic capsule daily, and d. Vitamin D tablet daily. On 02/22/23 at 9:14 a.m., CMA #2 was observed to punch out and place cyanocobalamin tablet, multivitamin tablet, probiotic capsule, and vitamin D tablet into individual medication cups. CMA #2 was observed punch out each medication into their bare hand then placed into the medication cups. On 02/22/23 at 9:18 a.m., CMA #2 was observed to connect a syringe to Resident #2's peg tube and poured the medication liquids into the peg tube. Some of the medication liquid was observed to run out the side of the peg tube and the CMA had to adjust the connection of the syringe and peg tube. CMA #2 was not observed to wear gloves during the administration. On 02/22/23 at 9:24 a.m., CMA #2 was asked when staff wore gloves during medication administration. They stated they normally did. They were asked if gloves were worn during the peg tube administration. They stated they didn't think they had to wear gloves. On 02/22/23 at 10:55 a.m., the DON was asked when staff were to wear gloves when administering medications. She stated she would need to look at the policy. The DON was asked if staff were to handle medications with their bare hands. She stated, No.

Based on record review and interview, the facility failed to ensure one (#1) of three sampled residents was free from abuse. The Resident Census and Conditions of Residents report, dated 06/08/22, documented 77 residents resided at the facility. Findings: A facility policy titled, Resident Abuse, Neglect and Misappropriation of Property, revised 12/28/17, read in parts, .Abuse means 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish' .Misappropriation of resident property is defined as the patterned or deliberate misplacement .of a resident's belongings or money without the resident's consent . Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual resident assessment, dated 03/15/22, documented Resident #1's cognition was intact for daily decision making. Resident #1's care plan, revised 04/23/22, documented a goal of resident #1 was to cooperate with care through the next review date. Interventions included if the resident refused care, the staff were to provide reassurance and return in five to ten minutes to try again. A facility report titled, Documentation Survey Report v2, dated May 2022, documented Resident #1 received nine baths out of 13 opportunities. A facility document titled, Family/Resident Grievance Log, dated 05/20/22, read in part, .[Resident #1 representative name] 5/20/2022 purse . The area on the form to document who the grievance had been assigned to and the area for follow up information was left blank. On 06/08/22 at 11:11 a.m., Resident #1 stated CNA #4 took their purse multiple times to get them to shower. They stated CNA #4 ripped it from their grip and stated to them they could have it back after they showered. The resident stated they did not want to take a shower and when the staff would take their purse it made them feel useless and angry. Resident #1 stated on 05/20/22 their representative had attempted to reach them by phone, however, CNA #4 had taken the resident's purse which had the phone in it. They stated their representative was angry staff had taken their purse. On 06/08/22 at 1:30 p.m., CNA #2 stated they had witnessed CNA #4 take Resident #1's purse on multiple occasions to get them to shower and returned it after they showered. The CNA was asked how long CNA #4 had been taking the resident's purse. They stated approximately three months but had stopped when Resident #1's representative came to the facility on [DATE] and the administrator sent out a message to staff stating to stop taking the resident's purse. CNA #2 stated they thought it was abusive and reported it to the charge nurse who told CNA #2 it was the only way to get the resident in the shower. On 06/08/22 at 2:01 p.m., LPN #2 stated they were aware staff were taking Resident #1's purse to get them to shower. LPN #2 was asked if they had reported that information to anyone. They stated, They [administration] wouldn't let anyone change her till she showered. On 06/08/22 at 2:17 p.m., CNA #4 was asked if it was appropriate to take Resident #1's purse to get her to shower when she refused. They stated, No, that's wrong. On 06/08/22 at 4:25 p.m., the administrator was asked about the incident on 05/20/22. The administrator stated the resident's representative was in the lobby yelling at CNA #4. The administrator stated from what had been explained to them, Resident #1's purse was taken by staff but they had observed the resident with their purse. The administrator was asked if they investigated for further details for why the resident's purse had been taken. The administrator stated they had not understood the allegation that staff were taking their purse to get the resident in the shower. The administrator stated, No, the statement from the resident was that nothing was taken, so I didn't do a state reportable, it didn't feel like abuse.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for one (#1) of three sampled residents for abuse. The Resident Census and Conditions of Residents report, dated 06/08/22, documented 77 residents resided at the facility. Findings: A facility policy titled, Resident Abuse, Neglect and Misappropriation of Property, revised 12/28/17, read in parts, .A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283 .If an employee is alleged to have abused a resident, the administrator shall then suspend the accused employee until the allegations are thoroughly investigated . Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A facility document titled, Family/Resident Grievance Log, dated 05/20/22, read in part, .[Resident #1 representative name] 5/20/2022 purse . The area on the form to document who the grievance had been assigned to and the area for follow up information was left blank. On 06/08/22 at 11:11 a.m., Resident #1 stated CNA #4 took their purse multiple times to get them to shower. They stated CNA #4 ripped it from their grip and stated to them they could have it back after they showered. The resident stated they did not want to take a shower and when the staff would take their purse it made them feel useless and angry. Resident #1 stated on 05/20/22 their representative had attempted to reach them by phone, however, CNA #4 had taken the resident's purse which had the phone in it. They stated their representative was angry staff had taken their purse. On 06/08/22 at 1:30 p.m., CNA #2 stated they had witnessed CNA #4 take Resident #1's purse on multiple occasions to get them to shower and returned it after they showered. The CNA was asked how long CNA #4 had been taking the resident's purse. They stated approximately three months but had stopped when Resident #1's representative came to the facility on [DATE] and the administrator sent out a message to staff stating to stop taking the resident's purse. CNA #2 stated they thought it was abusive and reported it to the charge nurse who told CNA #2 it was the only way to get the resident in the shower. On 06/08/22 at 2:01 p.m., LPN #2 stated they were aware staff were taking Resident #1's purse to get them to shower. LPN #2 was asked if they had reported that information to anyone. They stated, They [administration] wouldn't let anyone change her till she showered. On 06/08/22 at 2:17 p.m., CNA #4 was asked if it was appropriate to take Resident #1's purse to get her to shower when she refused. They stated, No, that's wrong. On 06/08/22 at 4:25 p.m., the administrator was asked about the incident on 05/20/22. The administrator stated the resident's representative was in the lobby yelling at CNA #4. The administrator stated from what had been explained to them, Resident #1's purse was taken by staff but they had observed the resident with their purse. The administrator was asked if they investigated for further details for why the resident's purse had been taken. The administrator stated they had not understood the allegation that staff were taking their purse to get the resident in the shower. The administrator was asked if an investigation had been completed. The administrator stated they had interviewed CNA #4 who denied the allegation that they had taken Resident #1's purse. The administrator stated they had asked other residents about concerns about personal items being taken from them and the residents had not reported concerns to them. The administrator was asked if other staff had been interviewed. The administrator stated yes but staff stated they knew nothing about the resident's purse being taken. The administrator was asked for the documentation of the investigation. The administrator stated they would have to look for it. No further documentation was provided the allegation had been thoroughly investigated.

Based on record review and interview, the facility failed to report allegations of abuse for one (#1) of three sampled residents. The Resident Census and Conditions of Residents report, dated 06/08/22, documented 77 residents resided at the facility. Findings: A facility policy titled, Resident Abuse, Neglect and Misappropriation of Property, revised 12/28/17, read in parts, All employees of a nursing facility are mandated reporters of resident abuse, to appropriate personnel, neglect or misappropriation of property and must report any and all incidents. All employees shall report any reasonable suspicion of a crime against any individual who is a resident of the facility .Report the incident to the highest-ranking person working in the facility at the immediate time of the allegation .All allegations and incidents of abuse, neglect or misappropriation of resident's property, must be reported to appropriate Federal and State Agencies including OSDH and investigated to establish a reasonable conclusion about the validity of the allegation . Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility document titled, Family/Resident Grievance Log, dated 05/20/22, read in part, .[Resident #1 representative name] 5/20/2022 purse . The area on the form to document who the grievance had been assigned to and the area for follow up information was left blank. On 06/08/22 at 11:11 a.m., Resident #1 stated CNA #4 took their purse multiple times to get them to shower. They stated CNA #4 ripped it from their grip and stated to them they could have it back after they showered. The resident stated they did not want to take a shower and when the staff would take their purse it made them feel useless and angry. Resident #1 stated on 05/20/22 their representative had attempted to reach them by phone, however, CNA #4 had taken the resident's purse which had the phone in it. They stated their representative was angry staff had taken their purse. On 06/08/22 at 1:30 p.m., CNA #2 stated they had witnessed CNA #4 take Resident #1's purse on multiple occasions to get them to shower and returned it after they showered. The CNA was asked how long CNA #4 had been taking the resident's purse. They stated approximately three months but had stopped when Resident #1's representative came to the facility on [DATE] and the administrator sent out a message to staff stating to stop taking the resident's purse. CNA #2 stated they thought it was abusive and reported it to the charge nurse who told CNA #2 it was the only way to get the resident in the shower. On 06/08/22 at 2:01 p.m., LPN #2 stated they were aware staff were taking Resident #1's purse to get them to shower. LPN #2 was asked if they had reported that information to anyone. They stated, They [administration] wouldn't let anyone change her till she showered. On 06/08/22 at 2:17 p.m., CNA #4 was asked if it was appropriate to take Resident #1's purse to get her to shower when she refused. They stated, No, that's wrong. On 06/08/22 at 4:25 p.m., the administrator was asked about the incident on 05/20/22. The administrator stated the resident's representative was in the lobby yelling at CNA #4. The administrator stated from what had been explained to them, Resident #1's purse was taken by staff but they had observed the resident with their purse. The administrator was asked if they investigated for further details for why the resident's purse had been taken. The administrator stated they had not understood the allegation that staff were taking their purse to get the resident in the shower. The administrator was asked if a state report had been submitted. The administrator stated, No, the statement from the resident was that nothing was taken, so I didn't do a state reportable, it didn't feel like abuse.

Based on observations, interviews, and record review, the facility failed to implement CDC/CMS guidelines for infection control procedures to prevent the transmission of COVID-19 for one (#3) of three residents reviewed for Covid-19 infection control. The facility identified 67 residents lived in the facility, six residents were on quarantine precautions, and three residents received [MEDICAL TREATMENT]. Findings: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A annual assessment, dated 07/14/20, documented the resident was independent for daily decision-making, required extensive assistance with activities of daily living, and received [MEDICAL TREATMENT]. The care plan, dated 07/27/20, documented the resident received [MEDICAL TREATMENT] and was on Covid-19 precautions. On 09/11/20 at 9:30 a.m., the administrator and director of nurses (DON) stated Black Gold hall (200 hall) was designated the hall for residents on quarantine precautions or who were Covid-19 positive. The DON stated two residents received [MEDICAL TREATMENT] and were living on the quarantine hall. On 09/11/20 at 12:00 p.m., the resident was in her room watching television. A sign for transmission based precautions was not posted on the resident's door. Personal protective equipment (PPE) was not outside the resident's room. On 09/11/20 at 12:00 p.m., certified nurse aide (CNA) #1 was observed serving meals to the residents. The CNA came out of room [ROOM NUMBER] and without washing or sanitizing her hands she picked up a meal and delivered the meal to resident #3. The CNA did not don gloves or a gown before entering the resident's room. The CNA touched and moved items on the bedside table. Then she placed the meal on the table. The CNA took hold of the bedside table and moved it into place for the resident. The CNA did not wash or sanitize her hands before leaving the room. The CNA picked up another meal from the meal cart and delivered the meal to the next resident. On 09/11/20 at 12:15 p.m., CNA #1 stated she washed her hands at the beginning and end of meal pass but not after each resident. The CNA did not know the resident was on precautions. On 09/11/20 at 1:35 p.m., the resident stated she went out of the facility for [MEDICAL TREATMENT]. The resident stated the staff had her wear a mask when she left the building. The resident stated some staff washed their hands before leaving her room and others did not. 2. On 09/11/20 at 10:45 a.m., certified medication aide (CMA) #2 was observed preparing a resident's medication. During the preparation the side shelf on the medication cart fell off and dumped the straws, spoons, cups and other supplies onto the floor. The CMA took the prepared medicine, picked up the plastic container off the floor, and went to the medication room. The CMA was observed restocking the plastic container. The CMA stated she had wiped the container. The CNA returned to the medication cart. The CNA picked up the items off the floor, placed them in a trash bag, and placed bag on the floor. Without washing or sanitizing her hands, she picked up the medicine cup and the water pitcher and went to the ice machine in the dining room. Without washing or sanitizing her hands, the CNA pressed the button on the ice machine and filled the water pitcher. The CMA returned to the medication cart. The CMA placed the water pitcher on the cart and picked up the trash bag. The CMA went to to soiled utility room opened the door and discarded the trash. The CMA returned returned to the medication cart and without washing or sanitizing her hands she, still holding the prepared medication cup, the CMA picked up multi-dose medication containers and went to a resident's room. Without washing or sanitizing her hands the CMA administered the oral medication. The CMA removed the cap on one of the multi-dose medication containers, handed it to the resident, and the resident administered the eye drop medication. On 09/11/20 at 11:00 a.m., CMA #2 stated hands were to be washed or sanitized before and after each medication pass, after handling dirty items like trash, or when hands were visibly soiled. The in-service records dated 03/19/20 documented the CMA was provided Covid-19 infection control training. The skills check-off in the CMA's employee record was blank. The PPE competency sheet, dated 08/05/20, was documented as completed. 3. On 09/11/20 at 11:35 a.m., a housekeeper was observed cleaning resident rooms. The housekeeper finished mopping the floor in room [ROOM NUMBER]. She returned the mop to the cart and without removing her gloves or performing hand hygiene, the housekeeper pushed the cart to room [ROOM NUMBER]. Without changing her gloves or performing hand hygiene, the housekeeper picked up cleaning spray and a clean rag, went into room [ROOM NUMBER], and started cleaning a bedside table. The housekeeper was not able to be interviewed.

Based on observation, interview, and record review, it was determined the facility failed to develop a comprehensive care plan for two (#49 and # 52) of 30 residents whose care plans were reviewed. The census and condition report documented 69 residents lived in the facility. Findings: 1. Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 12/19/19, documented the resident was cognitively independent and required supervision to limited assistance with most activities of daily living (ADLs). The assessment documented the resident did not currently use tobacco. The care plan, dated 12/19/19, did not document a care plan for smoking for the resident. On 01/29/20 at 8:10 AM, the director of nurses (DON) stated the resident was new to the facility and had not been identified as a smoker. On 01/29/20 at 9:44 AM, the resident was observed in the smoking area smoking. The resident stated the staff were aware he smoked because he needed assistance to enter and exit the smoking area. On 01/29/20 at 10:21 AM, the care plan staff stated the resident did not have a care plan for smoking. The care plan staff stated she was not aware the resident was a smoker. 2. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 10/04/19, documented the resident was cognitively independent and required supervision with activities of daily living. The assessment documented the resident did not use tobacco. The care plan, dated 12/16/19, did not have a care plan for smoking. On 01/29/20 at 3:05 PM, the resident was observed in the designated smoking area smoking. The resident stated the staff was aware he smoked because they assisted him to the smoking area. On 01/29/20 at 10:21 AM, the care plan staff stated the resident did not have a care plan for smoking. The care plan staff stated the resident's smoking should have been care planned.

Based on observation, record review, and interview, it was determined the facility failed to implement interventions to aid in the prevention of severe weight loss in a timely manner for one (#1) of five sampled residents who were reviewed for weight loss. This resulted in an actual harm when the resident had a severe weight loss of 15.6 pounds (7.3%) in one month, a severe weight loss of 20.8 pounds (9.7%) in three months, a 27 pound (12.6%) weight loss in six months, and developed three stage II pressure ulcers. Two residents were identified by the facility with weight loss within the last 180 days. Findings: A facility policy, titled Weight Program, documented, "New admits and re-admits will be weighed weekly x 4 weeks and then monthly, thereafter, unless otherwise indicated. If a suspected discrepancy exists in the weights assistant director of nursing will request a re-weight. Identified weight loss residents will be placed on weekly weights x 4 weeks. Weekly weight meeting/review: Currently weekly, weights will be compared to previous weekly to determine if intervention is effective. Interventions will be change/modified if goals are not met. Monthly weight meeting/review: Facility residents on monthly weights will be reviewed by comparing current monthly weight to previous month's weight...If a resident shows a significant loss then they shall be placed on weekly weights and a nutritional intervention will be implemented. If weight losses are identified a care plan will also be created and or updated, during weight meeting, to address weight loss. Weight loss interventions will be determined on a case-by-case basis...Changes will be written by nursing to dietary, meals and MARS will be updated if indicated. Nutritional assessments evaluations will be conducted monthly by registered dietician. Dietary recommendations will be given to director of nursing which will send to respective resident's physician..." 1. Resident #1 had [DIAGNOSES REDACTED]. A nutritional care plan, dated 01/31/14, documented, "Focus: ...pureed diet...double portion of meat and eggs...DX of dysphagia...have had a weight loss while I was in the hospital...I require assistance with my feeding at meal times D/T my stroke...Goals: ...will have assistance with my meal Q meal time...will not have further weight loss...Interventions: assist me with eating my meals...monitor my weight...provide me with supplements if indicated...assist me to the dining room for my meal. Ensure I am in the assisted dining area for my meals..." A 60-day assessment, dated 02/27/14, documented the resident experience a long/short term memory problem and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with her meals, had a [DIAGNOSES REDACTED]. An RD note, dated 02/28/14, documented, "Most current wt was 214.6# on 2/21/14, continues back up. Intake appears fair to good overall. [MEDICATION NAME] was checked per previous rec and was 12L on 1/30/14. Resident was started on double portion eggs or breakfast meats daily at breakfast. No skin breakdown reported at this time. Will f/u to rec re-checking [MEDICATION NAME] next mo." Facility weight records, dated 03/2014, documented the resident weighed 199 pounds. This was a severe weight loss of 15.6 pounds or 7.3% in one month. The nutritional care plan, updated 03/24/14, documented, "Diet changed to mechanical soft small bites..." The nurses' notes documented the resident had been transferred to the hospital on [DATE] regarding [MEDICAL CONDITION] activity and returned to the facility on [DATE]. An RD note, dated 03/31/14, documented, "Resident in hospital at this time." A 5-day assessment, dated 04/07/14, documented the resident experience a long/short term memory problem and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with her meals, had a weight of 199 pounds, had experienced a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months, was at risk for the development of pressure ulcers, did not have a pressure ulcer, and required nutrition or hydration interventions to manage skin problems. A significant weight change notification, dated 04/23/14, documented, "...Team recommends: House supplement BID & pre-[MEDICATION NAME]" The physician documented, "OK" and signed the notification on 04/29/14. The nutritional care plan, updated 04/23/14, documented, "House supplement r/t wieght (sic) loss." An RD note, dated 04/30/14, documented, "Wt. 197.2#?? was 212.6# last mo. Wts have been up and down the past few mo. Intake [MEDICATION NAME] 11L. Was started on house supplements bid 4/23 and then new order for diabetic Healthshakes 4/29 but now specific as to how many or when. Rec d/c house supplements and diabetic healthshakes and order 4oz house diabetic supplements tid between meals." Facility weight records, dated 05/2014, documented the resident weighed 193.8 pounds. This was a severe weight loss of 20.8 pounds or 9.7% in three months. A significant weight change notification, dated 05/14/14, documented, "...Team rec. assisted dining for all meals." The physician signed the notification on 05/20/14. The nutritional care plan, updated 05/14/14, documented, "Assisted dining room for all meals." A significant weight change notification, dated 05/30/14, documented, "...Team rec-add snack rotation between meals, divided plate, bigger spoon c bigger handle for use of feeding self. (check) pre-[MEDICATION NAME]." The physician signed the notification on 06/19/14. An RD note, dated 05/31/14, documented, "Wt 193.8#, down 3.4#. Intake inconsistent. Supplements were changed to house supplement with med pass. Was also started on snack rotation. No new labs or skin breakdown reported. Will continue to follow." A significant weight change notification, dated 06/11/14, documented, "...Team rec. Snack rotation between meals TID." The physician signed the notification on 06/19/14. A nurse's note, date 06/16/14, documented, "...Resident has recently had some breakdown on her coccyx, buttocks, and labia..." An RD note, dated 06/27/14, documented, "Wt.? 185# 6/26, wts have been up and down this mo. Wt last mo. 193.8# at time of eval. Intake inconsistent. Labs 6/4 [MEDICATION NAME] 11L. No skin breakdown reported. Is receiving house supplements and was started on snack rotation. Rec give double portion eggs at breakfast." The nutritional care plan, dated 06/27/14, "Weight loss noted. Supercereal with breakfast." A quarterly assessment, dated 07/08/14, documented the resident experience a long/short term memory problem and was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required supervision with her meals, had a weight of 188 pounds, had experienced a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months, was at risk for the development of pressure ulcers, and did not have a pressure ulcer. The nutritional care plan, updated 07/14/14, documented, "Diet changed to add double portion eggs with breakfast." A nurse's note, dated 07/19/14, documented, "...Resident has had some breakdown to her groin and buttocks area..." A skin/wound note, dated 07/26/14, documented, "Skin warm dry and intact. No new wounds, redness or bruises. Res has excoriation to inner buttocks. Zinc oxide applied. Redness has decreased. An RD note, dated 07/31/14, documented, "Wt. 187.6#, stable this mo after up and down labs mo. Intake inconsistent. No new labs or skin breakdown reported. No response noted to rec for double portion eggs @ breakfast d/t low [MEDICATION NAME]. Will re-rec." A monthly physician's orders [REDACTED]." Facility weight records, dated 08/2014, documented the resident weighed 187.6 pounds. This was a severe weight loss of 27 pounds or 12.6% in six months. A skin/wound note, dated 08/16/14, documented, "Resident skin intact at this time, no open areas noted at this time." An RD note, dated 08/30/14, documented, "Wt. 187.6#, remaining stable. Intake appears fair overall. Labs: 8/20 - HGBA1C 6.2H; 8/5 - CMP all WNL except TP low; H/H - WNL. No skin breakdown reported. No new order for double portion eggs at breakfast as previously rec. Rec re-checking [MEDICATION NAME] to see if additional protein needed at this time." A treatment sheet, dated September 2014, documented the resident's skin was observed on the 6th, 13th, and the 20th. There was no documentation in the skin/wound notes for the month of September regarding the resident's condition of her skin or if she had any skin breakdown. The nurses' notes documented the resident had been transported to the hospital on [DATE], regarding the resident having tremors, and had returned to the facility on [DATE]. The nutritional care plan, updated 09/26/14, documented, "Snack rotation between meals for weight loss...Interventions: Encourage me to consume all of my snacks between meals..." The nutritional care plan, updated 09/29/14, documented, "...eating with fingers. Staff to ensure resident(sic) hands are clean and encourage resident to eat with utensil...Interventions: ...Offer me finger foods...monitor my eating ability with my new divider plate...make sure my meals are not served in bowls..." An RD note, dated 09/30/14, documented, "Wt. 182.8#, down 4.8#. Was out to hospital. Labs 9/24 [MEDICATION NAME] 12 L. No skin breakdown reported. Rec double portion eggs daily at breakfast." A significant weight change, dated 09/27/14, documented, "...House supplement TID between meals added 9/26/14 continue current plan & moniter (sic)." There was no physician's signature. A monthly physician's orders [REDACTED]. A quarterly assessment, dated 10/09/14, documented the resident experience a long/short term memory problem and was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required supervision with her meals, had a [DIAGNOSES REDACTED]. Facility weight records, dated 10/2014, documented the resident weighed 179.8 pounds. This was a weight loss of 34.6 pounds or 16.1% in eight months. The nutritional care plan, updated 10/13/14, documented, "Interventions: Encourage me to eat all my eggs...Monitor my lab values..." On 10/13/14 at 12:18 p.m., the resident was observed during the lunch meal. The resident was served mixed vegetables, bread, ground pork chop, mashed potatoes with gravy, and spinach. The resident was observed eating her food with a butter knife. At 12:25 p.m., an aide gave the resident a fork. The resident's food had not been served in a divided plate but on a regular paper plate. The resident had not been given a larger spoon with a larger handle. The nutritional care plan, updated 10/14/14, documented, "Interventions: Give me my diet as ordered." On 10/14/14 at 11:30 a.m., the resident was observed during the lunch meal. The resident was served her meal at 12:08 p.m., she received fried okra, rice, cole slaw, bread, and fish. The resident was served her meal in a regular plate and with regular utensils. No staff was observed offering the resident assistance or encouragement with her meal. At 4:20 p.m., the resident was observed in the main dining room for her evening meal. Her meal was served at 4:48 p.m. The resident received ground meat, rice, fried okra, bread, and spice cake. The meal was served on a regular plate with regular utensils. A staff member was observed to butter the residents bread and then left. The resident ate 100% of the okra, a few bites of meat, and one bite of the cake. No staff were observed to offer encouragement to the resident to eat during the meal. On 10/15/14 at 10:25 a.m., the resident's breakfast meal was observed. The resident was served biscuits and gravy. No double portion of eggs or breakfast meats were observed. No staff were observed to encourage the resident with her meal. A skin/wound note, dated 10/15/14, documented, "Called to resident's room by CNA. 3 open areas approximately 1 to 2 mm in size noted on R side of anus. Cleansed with soap and water and zinc oxide applied. Will cont to observe." The nutritional care plan, updated 10/16/14, documented, "N/O for divided plate Q meal. No bowls. Resident continues to eat with fingers..." A pressure ulcer care plan, dated 10/16/14, documented, "Focus: I have three open areas noted to the right side of my anus...Interventions: Give me the medication my doctor has ordered. Monitor my skin. Keep me clean and dry. Give me good peri care after each incontinent eopisode(sic)...Monitor my healing progress..." An RD note, dated 10/18/14, documented, "Wt. 179.8#, down an additional 3#. Did receive increased [MEDICATION NAME] x 3 days and had episodes of n/v/d which appears to have resolved quickly. Intake ave 54-65% over the last 4 wks. Was started on double portion eggs at breakfast per previous rec. Labs 10/10: H/H high, Glu 130H, Alb 3.5 - WNL. As resident well above IBW range and desirable BMI range, gradual wt loss would be acceptable. Will f/u next mo to rec re-checking [MEDICATION NAME] at that time." On 10/16/14 at 4:25 p.m., the resident was observed during the evening meal. The resident was served her meal at 4:37 p.m., in the main dining room. The resident was served a glass of water, a glass of milk, a dinner salad, stew, and mixed fruit. Regular utensils were observed and the stew and fruit were served in bowls. The resident was observed attempting to eat her salad with her spoon and her fingers. The resident picked up the fruit out of the bowl with her fingers and then picked up her salad with her fingers. She then picked up the fruit bowl and began to drink the fruit and juice. The resident placed the bowl on the table and picked up the stew bowl and attempted to eat the stew. An aide walked over and placed a clothing protector on the resident. The aide assisted the resident, handed the resident a spoon, and left. The resident began eating the stew with the spoon. The resident left the table at 5:03 p.m. On 10/16/14 at 4:59 p.m., the DON was informed of the resident's meal observation in which the resident had not received encouragement and very limited assistance. She stated, "OK." The DON was asked why the resident had not been placed in the assisted dining room as documented on their care plan. She stated, "They found she eats better in the other dining room." The DON was asked if she had been aware of the resident's severe weight loss. She stated, "Yes." She was asked why there were no new interventions in place for the weight loss since July. She stated, "I don't know there should have been." The DON was asked why the resident had not been served the double portion of eggs. She stated, "I don't know why she should have been." She was asked if the resident had any new pressure ulcers. She stated, "Yes. They found three stage II's yesterday (10/15/14)." On 10/21/14 at 9:44 a.m., the ADON entered the surveyor's room and stated the order for the resident had been changed for the resident to receive healthy shot instead of the double portion of eggs. She stated, "She (the resident) doesn't even like eggs." On 10/22/14 at 5:38 p.m., the care plan coordinator was asked why the severe weight loss and the continued weight loss had not been addressed on the care plan. She stated, "I thought that I was." The DON and the care plan coordinator were asked if the resident used a divided plate and a larger spoon with her meals. The DON stated, "I don't know for sure if we have." They were asked if the resident was served finger foods. The DON stated, "No. I don't believe so."

On 09/30/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to assess, monitor and intervene for increased signs and symptoms of pain, coordinate care with hospice and follow physician's orders [REDACTED]. The IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 3:10 p.m., the Administrator, Regional Director and the DON were informed of the IJ situation. At 5:00 p.m., the Administrator presented an acceptable plan of removal which was dated 09/30/14. The plan of removal documented: "Glennwood Healthcare Plan of Removal 09/30/14 All residents have the potential to be affected. In order to better coordinate care between facility and hospice, all hospice providers will be required to have a signature from the charge nurse on duty to verify report. Completion by 10:00 a.m. on 10-1-14 All licensed nurses will be in-serviced on how to asses, monitor and intervene with significant changes in resident care, especially related to pain management. In-service will also include how to better communicate and coordinate care between facility and hospice. Completion by 10:00 a.m. on 10-1-2014 Further in-service will be done with licensed nurses to insure that readmission screenings are being completed, as well as properly notifying the physicians/family members upon any changes. Completion by 10:00 a.m. on 10-1-14 All CMA's will be in-serviced on how to identify and report changes in resident's condition. Completion by 10:00 a.m. on 10-1-14 On 10/01/14 at 10:00 a.m., the immediate jeopardy situation was removed after determining by interviews and record review all components of the plan of removal had been implemented, including in-service for all licensed staff on how to assess, monitor and intervene with significant changes in resident care when indicated. The deficient practice remained at a pattern with potential for more than minimal harm. Based on interview and record review, it was determined the facility failed to: ~ assess, monitor and intervene for a resident with increased signs and symptoms of pain, ~ failed to coordinate care with hospice, and ~ failed to follow physician's orders [REDACTED].#4) of five sampled residents whose clinical records were reviewed for pain. This had the potential to affect all 82 residents who resided in the facility. The facility also failed to monitor intake and output for one (#3) of one sampled resident with orders for intake and output monitoring. The facility identified seven residents who had orders for intake and output monitoring. Findings: A facility policy, titled Pain Management, documented, "Purpose It is the policy of this facility to provide effective and timely pain management via the collaborative efforts of resident, family/responsible parties, and nursing home staff... Procedure Initial Assessment. Residents are assessed for pain by nursing upon admission... Re-Assessment. Residents are re-assessed at least monthly for effectiveness of their pain management program. Other causes for re-assessment are, any order changes of pain medications, or on an as needed basis for effectiveness. Considerations during assessment and re-assessment include... Grimacing Restlessness... Pain Management Flow Sheet. The pain management effectiveness is recorded on the Pain Management Flow Sheet. Pain rating is obtained using the Pain Intensity Scales on the flow sheet. The resident's attending physician will be updated and notified of any changes in the effectiveness of the resident's pain management program." 1. Resident #4 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A MAR, dated August 2014, documented,"[MEDICATION NAME] Tablet 7.5 -325 MG...Give 1 tablet by mouth four times a day for pain...Order Date 08/25/14... Pain Assessment Q shift...D/C Date 08/18/14... Monitor pain Q shift...D/C date 08/01/14..." A hospice document, titled Pain Assessment: 08/26/14, documented, "...Primary Pain...Increased By: movement or turning/repositioning... Additional Comments Pt c/o pain when HOB was lowered for repositioning/turning, pt was crying out, 'my back, my back' once pt was settled into a position, pain was relieved..." A hospice document, titled Skilled Nursing Visit: 08/26/14, documented, "...Additional Comments Pt's bilateral lower extremities are very dry and flaky with purplish discoloration... Care Coordination/Comments...Pt had complaints of back and leg pain stating that they were aggravating..." A hospice document, titled Pain Assessment: 08/27/14, documented, "...Primary Pain...Increased By: rising from sit to stand... Additional Comments Upon using the sit to stand device, pt complained of increasing pain...Pt has purplish discoloration...to bilateral lower extremities... Care Coordination/Comments...Pt complains of back pain when using the sit to stand device..." A facility monthly pain review, dated 08/28/14, documented, "...Should Pain Assessment Interview be Conducted...Yes... Location of pain-back... "How much of the time have you experienced pain or hurting over the last 5 days?" Frequently... "Over the past 5 days, have you limited your day-to-day activities because of pain?" Yes... Numeric Rating Scale (00-10) 8..." A MAR, dated September 2014, documented,"[MEDICATION NAME] Tablet 7.5 -325 MG...Give 1 tablet by mouth four times a day for pain...Order Date 08/25/14..." A hospice document, titled Skilled Nursing visit: 09/02/14, documented, "...Pt stated that he frequently hurts on his backside, movement and dressing changes increase pain... Additional Comments Bilateral lower extremities, below the knee are purplish in color..." A significant change assessment, dated 09/03/14, documented the resident was severely impaired in cognitive skills for daily decision making. He required total assistance of two people with transfers, toileting and bathing; required extensive assistance of two people for dressing and used a wheelchair for primary mobility. The assessment documented the resident received a scheduled pain medication. A hospice document, titled Skilled Nursing Visit: 09/04/14, documented, "...Pain Assessment...Facial Grimaces/Winces... Management...Medication change required: Yes... Additional Comments Pt complains of pain with brief changes, wound dressings and changes. An (sic) change in medication was made, the dosage to current medication was increased... Right foot is cool to touch, it is cooler than left foot. Both feet are pale in color. Upper extremities are warm and pink in color... Physician contacted regarding: medications Order changes: Yes, see comments Comments [MEDICATION NAME] 7.5 mg, take 2 PO QID..." There was no documentation in the resident's clinical record the new [MEDICATION NAME] order was implemented. A facility care plan, dated 09/05/14, documented, "... I have generalized pain. I am at risk for uncontrolled pain... Goals...I will be pain free daily... Interventions... Monitor my pain..." A facility nurse's note, dated 09/10/14 at 5:30 p.m., documented, "...Resident left facility via EmSA (sic) via stretcher to (Hospital) for wound care..." A hospital physician progress notes [REDACTED]. and pain with dorsi flexion and point tenderness. Skin and deformity appears to be older than admission last night here. will need x-rays of extremity right lower if Fx likely ortho transfer..." A hospital x-ray, Date of Exam: 09/12/14... EXAM: RIGHT ANKLE - TWO VIEWS. FINDINGS: Distal right tibial and fibular oblique displaced fractures are noted... IMPRESSION: Right distal tibial and fibular displaced fractures..." A hospital CONSULTATION REPORT, documented, "...DATE OF CONSULT: 09/15/14 REASON FOR CONSULTATION: Bilateral distal tibia and fibula fractures. HISTORY OF PRESENT ILLNESS: The patient is an [AGE] year old male with history of dementia who was admitted to (Hospital) from a nursing home. Upon arrival, the patient was noted to have severe skin breakdown in bilateral lower extremities with deformity in his right lower extremity. Bilateral lower extremity x-rays revealed a distal fibula and tibia fracture present bilaterally..." On 09/30/14 at 8:05 a.m., LPN #2 was asked how the resident was assisted with transfers. She stated, "He used to have to use the sit to stand, but then changed to a hoyer lift. He couldn't bear weight and it was painful for him to stand." She was asked when he stopped using the sit to stand lift. She stated when he returned from the last hospital stay. She was asked if he complained of pain in his legs prior to the last hospital stay. She stated, "No. He was a lot worse off when he left to go to the hospital this time." She was asked what kind of pain he had before the last hospital stay. She stated, "When he came back from (Hospital), it was in his legs. It was generalized before." On 09/30/14 at 10:00 a.m., the DON was asked what kind of pain the resident experienced before he went to the hospital. She stated, "He has never complained of pain before he went to (Hospital). She was asked what complaints of pain he had after returning from the hospital. She stated, "He didn't, that I know of." She was asked how often residents' pain assessments were done by a registered nurse. She stated, "Monthly and at least quarterly." She was asked if a pain assessment would be done with any readmission to the facility. She stated, "Yes, with the readmission screener." She was asked if there was a readmission screener and a pain assessment for the resident's last readmission on 08/25/14. She stated that she would have to look for it. She was asked what type of assistive device the resident used for transfers. She stated, "I will have to look in the computer but I am sure he was using a sit to stand lift." She was asked what happened when a resident could not use the current assistive device and required something else. She stated, "He would be assessed by staff." On 09/30/14 at 10:15 a.m., LPN #3 was asked how often pain assessments were done. She stated, "Every shift by the CMA." She was asked what happened when a change in pain occurred. She stated, "The CMA or whoever will notify us and we will go and assess for any new interventions." She was asked if the residents were screened for pain every shift. She stated, "Yes." She was asked what occurred when a resident used an assistive device and needed more assistance. She stated, "They will tell us and we will go and do a new assessment or evaluation. The MDS person does the lift evals." On 09/30/14 at 10:30 a.m., CMA #1 was asked if the resident had complaints of pain. She stated that he would complain of pain during care, when he was being turned and changed. She stated once he was repositioned and left alone, he would be better and she would give him his routine pain medication as ordered. On 09/30/14 at 10:35 a.m., MDS Coordinator#1 was asked what occurred when a resident requires a different lift assistive device. She stated, "We do a lift assessment." She was asked if anyone told her the resident needed a different assistive device. She stated, "No." On 09/30/14 at 10:40 a.m., the DON was asked where pain screens performed every shift were documented. She stated, "On the MARS." She was asked who performed the screens. She stated, "The CMA or the nurses." She was asked what occurred when there was a change in resident pain. She stated, "We would get a physician's orders [REDACTED]." At 10:50 a.m., the hospice chart was reviewed. There were no physician' orders in the chart. The chart contained no nurse's notes since his readmission of 08/25/14. The DON was asked for any hospice records for the resident. She stated she would have to look for them. On 09/30/14 at 11:00 a.m., the DON was made aware of the Pain assessment dated [DATE]. She was asked if she could find any documentation or orders for the changes in pain documented on 08/28/14. She stated, "I will have to look for one." At 11:15 a.m., the DON notified the surveyor that there was no pain assessment upon the resident's readmit on 08/25/14, and there were no new orders and/or changes in pain medication related to the pain assessment preformed on 08/28/14. At 2:30 p.m., LPN #4 was asked if the resident had any complaints of pain. The LPN stated that he had just begun to take care of the resident one week prior to this last hospitalization but that the resident did have complaints of pain when changed or with movement. He stated the resident was combative with care. He was asked when there was a change in condition of a resident who was on hospice services, what occurred. He stated that changes were communicated person to person. At 2:35 p.m., the DON gave the surveyor numerous hospice notes written since the resident's return from the hospital on [DATE]. She was asked how she obtained those records. She stated, "They brought them, but I have computer access now and can print them off ." On 09/30/14 at 2:40 p.m., the DON was notified of the hospice order on 09/04/14, for a change in pain medication. She was asked if the order was implemented. She stated she would have to look for one. The DON stated after looking for the order, "I guess he didn't get the medication as ordered." There was no documentation provided to verify the order was acknowledged, noted or implemented. 2. Resident # 3 was admitted to the facility with [DIAGNOSES REDACTED]. A TAR, dated July 2014, documented, "...Intake Q shift every shift for 2 liter fluid restriction...order date 06/25/2014.... Output Q shift every shift for 2 liter fluid restriction...order date-06/25/2014..." There was no monitoring of the input for one of 60 shifts and no monitoring of the output for two of 60 shifts. A TAR, dated August 2014, documented, "...Intake Q shift every shift for 2 liter fluid restriction...order date 06/25/2014.... Output Q shift every shift for 2 liter fluid restriction...order date-06/25/2014..." There was no monitoring of the input for four of 62 shifts and no monitoring of the output for four of 62 shifts. A TAR, dated September 2014, documented, "...Intake Q shift every shift for 2 liter fluid restriction...order date 06/25/2014.... Output Q shift every shift for 2 liter fluid restriction...order date-06/25/2014..." There was no monitoring of the input for two of 58 shifts and no monitoring of the output for two of 58 shifts. A quarterly assessment, dated 09/02/14, documented the resident was independent in cognitive skills for daily decision making. She was always incontinent of bowel and bladder. On 09/30/14 at 5:40 p.m., the DON was asked who is responsible for the monitoring of the intake and output. She stated, "Charge nurses." She was then shown the TAR's and asked why there would be blanks. She stated, "The blanks should not be there, we look at them and audit." She then stated, "She's not really compliant with her restriction." On 10/01/15 at 10:15 a.m., the Director of Observations was asked if there was a policy for the monitoring of intake and output. He stated, "No we don't."

On 09/30/14 at 8:50 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to implement their abuse policy to complete a thorough investigation for allegations of abuse and ensure residents were protected until a thorough investigation was completed. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy Situation. At 9:00 a.m., the Director of Operations, Administrator and Director of Nursing were notified of the IJ situation. On 09/30/14 at 11:00 a.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "All residents have the potential to be affected. CNA implicated in the abuse related to the immediate jeopardy was terminated on 9-19-14 after a full investigation was completed. LPN in question will be suspended until proper education can be given. CNA in question by the survey team will be suspended immediately until further investigation into the allegations of abuse can be completed. All staff will be immediately in-serviced on what abuse is as well as the abuse policy for Glenwood Healthcare by ways of phone and in person. Completion by 5:00 p.m. on 9-30/2014. Focus will be put on specific policy for the seven steps of reporting abuse for a;; staff, especially LPN's. Completion by 5:00 p.m. on 9-30-2014. Department heads will immediately begin interviewing all alert and oriented residents to rule out any other allegations of abuse. Completion by 5:00 p.m., on 9-30-2014." On 09/30/14 at 5:30 p.m., thru 10:00 a.m., facility staff members from all shifts who attended the inservices were interviewed. They were knowledgeable in regard to abuse policy and procedures for investigating, reporting and protecting the residents. The Immediate Jeopardy was removed on 09/30/14 at 5:00 p.m., after all components of the plan of removal had been completed. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on clinical record review, review of policy and procedure and staff and resident interviews, it was determined the facility failed to implement their abuse policy to ensure an allegation of staff to resident abuse was investigated, and measures were put into place to ensure protection from further abuse for one (#1) of four sampled residents with allegations of abuse. This had the potential to affect all 82 residents who resided in the facility. Findings: A facility policy, titled MANAGEMENT OF SUSPECTED ABUSE/NEGLECT, documented, "...It is the policy of this facility, under the guidance of applicable laws, that any person having reasonable cause to believe that any person in a state of abuse, exploitation or neglect shall report the information to the appropriate regulatory agency... ISSUES RELATED TO REPORTING ...Any person who believes that a child, adolescent, disabled adult or elderly individual is being abused, neglected or exploited shall notify, orally or in writing the appropriate department providing regulatory services... REPORTABLE CONCERNS AND PROCEDURAL STEPS FOR SUSPECTED ABUSE/NEGLECT ...Case of suspected sexual assault, physical abuse or neglect should be given priority... ...Adversely affected abuse or neglect by any person shall as soon as possible report the information supporting the belief to the Department of Health, or the appropriate state health care regulatory agency, by telephone, in writing or by personal visit...A health care provider who fails to report shall be referred by the Department of Health to the individuals licensing board for appropriate disciplinary action... PROCEDURE FOR MANAGEMENT OF SUSPECTED ABUSE/NEGLECT In the event there is an allegation or incidents involving employee to resident, resident to resident abuse, visitor to resident abuse, or visitor to employee abuse, the following shall occur: 1. The individual involved in the abuse should be immediately separated by the staff. 2. A complete assessment of the resident and other parties should be done by the charge nurse. 3. Once safety is established, the Administrator and Director of Nursing should be notified immediately. 4. The charge nurse should complete an incident report, being very precise about the incident and obtain statements from any witness to the incident. 5. The incident report and statements must be completed before the end of shift. 6. Place the incident report on Q-Shift focused charting of any incidents or other behaviors. If there is an allegation of abuse against the employee: ...Re-assign the employee to another area separate from the resident who was involved in the abuse. The Administrator and Director of Nursing must address the employee situation immediately by placing the employee on unpaid leave of absence pending completion of the facility's investigation... INVESTIGATIONS: The facility shall ensure, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. depression disorder, generalized pain and acute venous embolism. An annual assessment, dated 06/27/14, documented the resident was independent in cognitive skills for daily decision making and she was understood and understood others. She exhibited no signs and symptoms of [MEDICAL CONDITION]. She rejected care by staff on one to three days in the look back period. A facility assignment sheet, dated 09/12/14, documented CNA #1 was assigned to the resident's Hall. A facility document, provided by a family member and verified as signed and transcribed by LPN #1, documented, "...9/13/14 -1310 (1:10 p.m.) Resident states '(CNA #1) was screaming at me more than once' on night shift 9/12/14 resident feels 'scared' of (CNA #1) worried that she will be mad and not take care of her resident states she 'pulled covers over head when (CNA #1) was yelling at her.' Resident asked aide to change bed resident states that aide did not change linens. Resident stated that she was trying to get attention of aide that her roommate was needing to be changed resident stated that aide walked past room without checking on roommate. Other resident stopped and this resident asked them to find an aide. Kitchen aide arrived to assist and located nurse to assist. Resident stated that (CNA #1) started screaming at me accusing me of touching roommate. Resident states that she did not touch roommate. This nurse advised resident that aide would be re-assigned and DON notified of situation..." This nurse note was signed by LPN #1. A nurse's note, dated 09/13/14 at 5:00 p.m., documented, "...Resident noted to have increased anxiety this am. Resident stated to this nurse that aide on previous shift was 'screaming' at her accusing her of ambulating roommate. Resident's ex-spouse at facility to discuss resident's concerns. This nurse advised family member that DON would be notified of concerns..." This note was transcribed by LPN #1. A facility assignment sheet, dated 09/15/14, documented CNA #1 continued to be assigned to work on the resident's Hall. A facility incident report, dated 09/18/14, documented, "...Resident involved: (resident #1, resident #2 and resident #3)... Incident type...x Allegations of neglect...x Allegations of Abuse/Mistreatment... Description of incident...All allegations were reported to DON on 09/18/14: Resident #6037 (resident #1) complained that staff member (CNA #1) was screaming at her on 9/12/2014 and reported she was scared of her..." There was no documentation of any interviews or further investigation with residents, staff or family members related to the allegations of abuse. On 09/29/14 at 4:00 p.m., the resident was asked if any staff had ever been abusive towards her. She stated, "Yes, yelling abusively. Yes, when I was in my room minding my own business." She was then asked what she was yelling. She screamed to not help my roommate. I was scared." She was asked if she reported it to anyone. She stated, "I talked to (LPN #1) I don't remember exactly, the next day." She was then asked if the aide had been abusive any other time. She stated, "Another time after that she took my curtain and pulled it shut without saying anything. She had an attitude instead of saying I'm fixing to provide care she just shut the curtain." She was asked if she had reported this to anyone. The resident stated she was not sure when; it was in her notebook, but she had gone and reported it to the nurses and the DON. The resident stated she kept a record of occurrences in the facility, but did not have the notebook with her at the time of the interview. She was then asked if there were any other incidents. She stated, "(CNA #2) pushed me to my room and said I didn't need help." She was asked if she had reported this to anyone. She stated, "I reported it to (DON), I think." She then stated, "I reported (CNA #2) to nurse (LPN #1). Her reply was she probably doesn't know any better. We will talk about it in the meeting." The resident was tearful during the interview, whenever she talked about CNA #1. On 09/29/14 at 5:05 p.m., an interview was conducted with the resident's family member. He was asked if he was aware of the allegations of abuse from the resident. He stated, "Yes, we had a meeting on the 13th with (LPN #1)." He was asked what type of meeting. He stated, "A meeting with (LPN #1), (resident#1) and me about (CNA #1). I provided a copy to the DON." He was asked what the copy given to the Don was and he stated it was the copy of the notes (LPN #1) had taken. He was then asked if he gave the DON a copy of the notes on the 13th. He stated, "No, I faxed it to her on the 15th. I believe the following Monday. She said she would look at it." At 5:30 p.m., LPN #1 was asked if she had a meeting with the resident. She stated, "Yes." She was asked what the meeting was about. She stated (resident #1) was scared of staff. LPN #1 stated, "It was my opinion she had never been scared before of this particular aide. She told me the aide would yell at her." She stated, "She appeared upset and crying." I asked if she reported this to anyone. She stated after the meeting she had placed the DON's name on top of a copy of the notes and placed them under the DON's door. She was then asked if she followed up on the allegation. She stated, "I did not. I noticed they did resolve it. That aide no longer works at facility. They took her off that floor. The next day I was off." She was then asked who was responsible for filling out the incident reports and the assessments with any allegation of abuse. She stated, "The charge nurse does it." She was asked if she had completed an incident report and/or assessment with this allegation of abuse." She stated, "No." On 09/29/14 at 6:00 p.m., the DON was asked when she became aware of the allegation of abuse. She stated, "When he called me." She was asked who "he" was. She stated, "(Resident's ex husband)." She was asked the date she was informed of the allegation of abuse. She stated, "The first day was the date of the incident report. She was terminated on the 19th." She was asked if CNA #1 was reassigned off the resident's hall at any time. She stated, "Not moved that I am aware of." The facility assignment sheet for 09/15/14, documented CNA #1 continued to be assigned to work the resident's hall. On 09/30/14 at 8:30 a.m., the DON was shown the nurse's notes describing the allegation of abuse transcribed by LPN #1 and asked if she had ever seen it. She stated, "No."

On 09/30/14 at 8:50 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to complete a thorough investigation for allegations of abuse, failure to report allegations of abuse, and failure to ensure residents were protected until a thorough investigation was completed. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy Situation. At 9:00 a.m., the Director of Operations, Administrator and Director of Nursing were notified of the IJ situation. At 11:00 a.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "All residents have the potential to be affected. CNA implicated in the abuse related to the immediate jeopardy was terminated on 9-19-14 after a full investigation was completed. LPN in question will be suspended until proper education can be given. CNA in question by the survey team will be suspended immediately until further investigation into the allegations of abuse can be completed. All staff will be immediately in-serviced on what abuse is as well as the abuse policy for Glenwood Healthcare by ways of phone and in person. Completion by 5:00 p.m. on 9-30-2014. Focus will be put on specific policy for the seven steps of reporting abuse for all staff, especially LPN's. Completion by 5:00 p.m. on 9-30-2014. Department heads will immediately begin interviewing all alert and oriented residents to rule out any other allegations of abuse. Completion by 5:00 p.m., on 9-30-2014." On 09/30/14 at 5:30 p.m., thru 10/01/14 at 10:00 a.m., facility staff members from all shifts who attended the inservices were interviewed. They were knowledgeable in regard to abuse policy and procedures for investigating, reporting and protecting the residents. The Immediate Jeopardy was removed on 09/30/14 at 5:00 p.m., after all components of the plan of removal had been completed. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on interviews and review of clinical records, policies and procedures, personnel records, and staff schedules, it was determined the facility failed to: ~ ensure residents were protected until a thorough investigation of an allegation of abuse was completed; ~ ensure a thorough investigation of allegations of abuse was completed for one (#1) of four sampled residents observed for allegations of abuse; and ~ ensure allegations of abuse were reported to the Oklahoma State Department of Health (OSDH) for one (#1) of three sampled residents with allegations of abuse by staff. This had the potential to affect all 82 residents who resided in the facility. Findings: A facility policy, titled MANAGEMENT OF SUSPECTED ABUSE/NEGLECT, documented, "...It is the policy of this facility, under the guidance of applicable laws, that any person having reasonable cause to believe that any person in a state of abuse, exploitation or neglect shall report the information to the appropriate regulatory agency... ISSUES RELATED TO REPORTING ...Any person who believes that a child, adolescent, disabled adult or elderly individual is being abused, neglected or exploited shall notify, orally or in writing the appropriate department providing regulatory services... REPORTABLE CONCERNS AND PROCEDURAL STEPS FOR SUSPECTED ABUSE/NEGLECT ...Case of suspected sexual assault, physical abuse or neglect should be given priority... ...Adversely affected abuse or neglect by any person shall as soon as possible report the information supporting the belief to the Department of Health, or the appropriate state health care regulatory agency, by telephone, in writing or by personal visit...A health care provider who fails to report shall be referred by the Department of Health to the individuals licensing board for appropriate disciplinary action... PROCEDURE FOR MANAGEMENT OF SUSPECTED ABUSE/NEGLECT In the event there is an allegation or incidents involving employee to resident, resident to resident abuse, visitor to resident abuse, or visitor to employee abuse, the following shall occur: 1. The individual involved in the abuse should be immediately separated by the staff. 2. A complete assessment of the resident and other parties should be done by the charge nurse. 3. Once safety is established, the Administrator and Director of Nursing should be notified immediately. 4. The charge nurse should complete an incident report, being very precise about the incident and obtain statements from any witness to the incident. 5. The incident report and statements must be completed before the end of shift. 6. Place the incident report on Q-Shift focused charting of any incidents or other behaviors. If there is an allegation of abuse against the employee: ...Re-assign the employee to another area separate from the resident who was involved in the abuse. The Administrator and Director of Nursing must address the employee situation immediately by placing the employee on unpaid leave of absence pending completion of the facility's investigation... INVESTIGATIONS: The facility shall ensure, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. depression disorder, generalized pain and acute venous embolism. An annual assessment, dated 06/27/14, documented the resident was independent in cognitive skills for daily decision making and she was understood and understood others. She exhibited no signs and symptoms of [MEDICAL CONDITION]. She rejected care by staff on one to three days in the look back period. A facility assignment sheet, dated 09/12/14, documented CNA #1 was assigned to the resident's Hall. A facility document, provided by a family member and verified as signed and transcribed by LPN #1, documented, "...9/13/14 -1310 (1:10 p.m.) Resident states '(CNA #1) was screaming at me more than once' on night shift 9/12/14 resident feels 'scared' of (CNA #1) worried that she will be mad and not take care of her resident states she 'pulled covers over head when (CNA #1) was yelling at her.' Resident asked aide to change bed resident states that aide did not change linens. Resident stated that she was trying to get attention of aide that her roommate was needing to be changed resident stated that aide walked past room without checking on roommate. Other resident stopped and this resident asked them to find an aide. Kitchen aide arrived to assist and located nurse to assist. Resident stated that (CNA #1) started screaming at me accusing me of touching roommate. Resident states that she did not touch roommate. This nurse advised resident that aide would be re-assigned and DON notified of situation..." This nurse note was signed by LPN #1. A nurse's note, dated 09/13/14 at 5:00 p.m., documented, "...Resident noted to have increased anxiety this am. Resident stated to this nurse that aide on previous shift was 'screaming' at her accusing her of ambulating roommate. Resident's ex-spouse at facility to discuss resident's concerns. This nurse advised family member that DON would be notified of concerns..." This note was transcribed by LPN #1. A facility assignment sheet, dated 09/15/14, documented CNA #1 continued to be assigned to work on the resident's Hall. A facility incident report, dated 09/18/14, documented, "...Resident involved: (resident #1, resident #2 and resident #3)... Incident type...x Allegations of neglect...x Allegations of Abuse/Mistreatment... Description of incident...All allegations were reported to DON on 09/18/14: Resident #6037 (resident #1) complained that staff member (CNA #1) was screaming at her on 9/12/2014 and reported she was scared of her..." There was no documentation of any interviews or further investigation with residents, staff or family members related to the allegations of abuse. On 09/29/14 at 4:00 p.m., the resident was asked if any staff had ever been abusive towards her. She stated, "Yes, yelling abusively. Yes, when I was in my room minding my own business." She was then asked what she was yelling. She screamed to not help my roommate. I was scared." She was asked if she reported it to anyone. She stated, "I talked to (LPN #1) I don't remember exactly, the next day." She was then asked if the aide had been abusive any other time. She stated, "Another time after that she took my curtain and pulled it shut without saying anything. She had an attitude. Instead of saying I'm fixing to provide care she just shut the curtain." She was asked if she had reported this to anyone. She stated she was not sure when; it was in her notebook, but she had gone and reported it to the nurses and the DON. The resident stated she kept a record of occurrences in the facility, but did not have the notebook with her at the time of the interview. She was then asked if there were any other incidents. She stated, "(CNA #2) pushed me to my room and said I didn't need help." She was asked if she had reported this to anyone. She stated, "I reported it to (DON), I think." She then stated, "I reported (CNA #2) to nurse (LPN #1). Her reply was she probably doesn't know any better. We will talk about it in the meeting." The resident was tearful during the interview, whenever she talked about CNA #1. On 09/29/14 at 5:05 p.m., an interview was conducted with the resident's family member. He was asked if he was aware of the allegations of abuse from the resident. He stated, "Yes, we had a meeting on the 13th with (LPN #1)." He was asked what type of meeting. He stated, "A meeting with (LPN #1), (resident#1) and me about (CNA #1). I provided a copy to the DON." He was asked what the copy given to the Don was and he stated it was the copy of the notes (LPN #1) had taken. He was then asked if he gave the DON a copy of the notes on the 13th. He stated, "No, I faxed it to her on the 15th. I believe the following Monday. She said she would look at it." At 5:30 p.m., LPN #1 was asked if she had a meeting with the resident. She stated, "Yes." She was asked what the meeting was about. She stated (resident #1) was scared of staff. LPN #1 stated, "It was my opinion she had never been scared before of this particular aide. She told me the aide would yell at her." She stated, "She appeared upset and crying." I asked if she reported this to anyone. She stated after the meeting she had placed the DON's name on top of a copy of the notes and placed them under the DON's door. She was then asked if she followed up on the allegation. She stated, "I did not. I noticed they did resolve it. That aide no longer works at facility. They took her off that floor. The next day I was off." She was then asked who was responsible for filling out the incident reports and the assessments with any allegation of abuse. She stated, "The charge nurse does it." She was asked if she had completed an incident report and/or assessment with this allegation of abuse." She stated, "No." On 09/29/14 at 6:00 p.m., the DON was asked when she became aware of the allegation of abuse. She stated, "When he called me." She was asked who "he" was. She stated, "(Resident's ex husband)." She was asked the date she was informed of the allegation of abuse. She stated, "The first day was the date of the incident report. She was terminated on the 19th." She was asked if CNA #1 was reassigned off the resident's hall at any time. She stated, "Not moved that I am aware of." The facility assignment sheet for 09/15/14, documented CNA #1 continued to be assigned to work the resident's hall. On 09/30/14 at 8:30 a.m., the DON was shown the nurse's notes describing the allegation of abuse transcribed by LPN #1 and asked if she had ever seen it. She stated, "No."

Based on observation, interview, and record review it was determined the facility failed to administer pain medication before a wound treatment of [REDACTED]. This caused the resident pain during a wound treatment. This had the potential to affect 5 residents who the facility identified as having pressure ulcers. Findings: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission nursing care plan, dated 06/06/11, did not address the resident's pain and pressure ulcer. A pain assessment monitor, dated 06/06/11, documented, "...pain location...back...What triggers pain? movement...pain intensity before PCT (Pain Control Therapies/Treatments) = 9...pain intensity after PCT =3...pain location...L arm...What triggers pain? touching, movement...pain intensity before PCT = 7-8...pain intensity after PCT = 2..." A 5-day assessment, dated 06/13/11, documented the resident had been on a scheduled pain medication regimen and received PRN medication. The pain assessment interview documented the resident had pain almost constantly and she rated her pain at a 10 on a 1 - 10 pain scale. The assessment documented the resident had a stage III pressure ulcer that was 10.5 cm in length, 2.0 cm in width, and 1.0 cm in depth. On 06/21/11 at 3:40 p.m., LPN #1 was observed as she changed the dressing on the resident's stage III pressure ulcer on her coccyx. The resident yelled out in pain twice when LPN #1 wiped the pressure ulcer with a wet gauze pad and dry gauze pads. The resident moaned when the LPN put medication on the ulcer. After the treatment was completed, the resident stated, "That hurts so bad." The LPN told the resident, "I'm going to let the med aide know to give you something, it should be almost time." LPN #1 was asked what medication the resident had ordered for pain. She stated, "Routine [MEDICATION NAME], I will have to check." She was asked if the resident was given pain medication before the treatment. She stated, "Sometimes we do, but it hurts her even when we roll her onto her side." She was asked if the pain medication would have helped the resident with her pain. She stated, "Yes." The MAR for June 2011, documented the resident was to receive, "[MEDICATION NAME] 5mg 1 po Q 4 (hours)" at 1 a.m., 5 a.m., 9 a.m., 1 p.m., 5 p.m. and 8 p.m. The MAR indicated [REDACTED]." The MAR indicated [REDACTED]. On 06/22/11 at 9:45 a.m. the DON was asked about the facility's process for premedicating a resident before a treatment. She stated, "The staff should check to see if the resident had been given pain medication before the treatment and if the resident was in pain." The DON was asked what staff should do if it was known that the procedure would cause the resident pain. She stated, "The staff should give the resident pain medication before the treatment."

Based on observation, record review, and interviews, it was determined the facility failed to have an effective quality assessment and assurance program in place to identify problems and/or develop and implement plans of action to correct quality deficiencies. The facility failed to identify and implement a plan of action to correct systems failures related to: a. The provision of water [MEDICATION NAME] and flushes to residents with feeding tubes, who were at risk of dehydration, for one (#1) of four sampled residents who received tube feedings. This resulted in actual harm to resident #1, who was admitted to the hospital with [REDACTED]. b. The management of anticipated pain during pressure ulcer care for one (#10) of five sampled residents with pressure ulcers. This caused the resident to suffer unnecessary pain during the provision of care. The facility's failure to have an effective quality assessment and assurance program had the potential to affect all 64 residents who resided in the facility. Findings: 1. The facility failed to ensure water [MEDICATION NAME] and flushes were administered as ordered by the physician, tube feeding bags were changed according to current standards of practice, and tube feedings were held and resumed only by facility staff trained to do so for 1 (#1) of 4 sampled residents who received tube feedings. This resulted in actual harm for resident #1 who was admitted to the hospital with [REDACTED]. Refer to F322. 2. The facility failed to administer pain medication before a wound treatment of [REDACTED]. This caused the resident pain during a wound treatment. This had the potential to affect 5 residents the facility identified as having pressure ulcers. Refer to F309. On 06/22/11 at 5:07 p.m., the administrator and the DON were asked how often the QA committee meets. The DON stated they meet monthly now since the new administrator came. The DON was asked if they had addressed pain in the last three months during the QA committee meetings. She stated, "No." The DON was asked what system was in place to address residents who experienced pain. She stated, "Monthly pain evaluations and quarterly pain assessments." She was asked how they identified and ensured residents do not experience pain during a treatment. She stated, "Part of the weekly assessment. They (staff) should be checking for pain during the treatment." The DON was asked if the systems in place were effective. She stated, "They failed. Some systems are effective and some staff just need educated." The administrator stated, "We are going to hold people accountable for their jobs."

Based on observation, interview, and record review, it was determined the facility failed to ensure water [MEDICATION NAME] and flushes were administered as ordered by the physician, tube feeding bags were changed according to current standards of practice, and tube feedings were held and resumed only by facility staff trained to do so for 1 (#1) of 4 sampled residents who received tube feedings. This resulted in actual harm for resident #1 who was admitted to the hospital with [REDACTED]. The facility's Census and Conditions report identified 4 residents as receiving tube feedings. Findings: The facility's policy on enteral nutrition, dated April 2007, documented, "...Fluids to be provided (beyond free fluid in product) will be calculated by the Dietitian and refered to the physician for an order...The Dietitian will recommend [MEDICATION NAME] fluid flushes, with consideration of fluid content of feeding product, resident weight, diagnosis, nutritional status, and any fluid restrictions..." The facility's policy on hydration and the prevention of deydration, dated April 2007, documented, "...Nursing will monitor and document fluid intake and the Dietitian will be kept informed of status..." "Management of Feeding Tube Complications in the Long-Term Care Resident", annals of long term care.com. September 5, 2008, http://www.annalsoflongtermcare.com, documented, "...Enteral feeds are an ideal culture medium and can become contaminated with bacteria during handling or if allowed to stand in a feeding bag for more than 12 hours...Therefore...feeding bags and tubing should be changed daily...In addition to gastrointestinal problems,[MEDICAL CONDITION] can occur..." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 02/19/11 at 12:35 p.m., documented, "...Rec'd T.O...Increase shift flushes to 350 cc q shift..." Physician orders, dated March 2011, documented, "...Water [MEDICATION NAME] via peg - TID everyday, 0600 (6:00 a.m.) 1200 (12:00 p.m.) 1800 (6:00 p.m.): 350 ml per peg tid...2/19/2011..." Physician orders, dated April 2011, documented, "...Water [MEDICATION NAME] via peg - TID everyday, (6:00 a.m.) (12:00 a.m.) (6:00 p.m.): 350 ml per peg tid...2/19/2011..." A quarterly assessment, dated 04/19/11, documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent on staff for nutrition and hydration, had a feeding tube, received 51% or more of the total calorie intake via tube feeding, and averaged 501 cc/day or more of average fluid intake by tube feeding. The care plan, last updated 04/20/11, documented a problem, "I receive my nutrition per peg tube. I am at risk for aspiration, weight loss and/or S/S of dehydration..." Goals were, "I will not have complications associated with receiving my nutrition via peg tube..." Interventions included, "...Monitor and record my I/O q shift...Flush my peg tube with H2O as ordered...Monitor me for S/S dehydration such as increase (sic) confusion, dry oral mucosa, poor skin tugor (sic) or decrease in my urine output..." Another problem was, "...I am having S/S UTI. I am at increased potential for dehydration..." The goal was, "I will have minimal - no further S/S UTI..." Interventions included, "...Administer fluids per my peg as ordered...Monitor my I/O q shift..." Physician orders, dated May 2011 and printed on 06/21/11 during the survey, documented, "...Water [MEDICATION NAME] via peg - TID everyday, (6:00 a.m.) (2:00 p.m.) (10:00 p.m.): 350 ml per peg every 8 hours...2/19/2011..." The resident was to receive a total of 1,050 ml of water per day in addition to any tube feeding formula or flushes. Medication administration records, dated May 2011 and received from the hospital on [DATE] during the survey, documented the resident received 350 ml water [MEDICATION NAME] three times daily on each day from 05/01/11 through 05/24/11. Intake and output sheets, dated 05/01/11 through 05/25/11, documented the resident received the following amounts of water on each day: 05/01/11 - 920 ml, 05/02/11 - none, 05/03/11 - none, 05/04/11 - 700 ml, 05/05/11 - 530 ml, 05/06/11 - 550 ml, 05/07/11 - 420 ml, 05/08/11 - 430 ml, 05/09/11 - 480 ml, 05/10/11 - 400 ml, and 05/11/11 through 05/24/11 - none. Nurses' notes, dated 05/21/11 through 05/23/11, documented the resident was diagnosed with [REDACTED]. It was documented the resident had an increased body temperature, greater than 100.0 degrees Farenheit, on 05/21/11, 05/22/11, and 05/23/11. There was no documentation to show the facility monitored the resident for signs and symptoms of dehydration during this period. A nurse's note, dated 05/25/11 at 2:10 a.m., documented, "...Dr instructed nurse to send res to hospital..." A hospital history and physical, dated 05/25/11 at 9:44 a.m., and documented as being received by the facility on 06/02/11, documented, "...Her sodium was noted to be 175...severe [MEDICAL CONDITION]" A hospital physician dictation, dated 05/25/11 at 7:51 a.m., and documented as being received by the facility on 06/02/11, documented, "...Apparently she had been fine earlier in the evening. She was recently diagnosed about 3 days ago with pneumonia and has been on [MEDICATION NAME] since then. No other clear alleviating or exacerbating factors or additional history obtainable...This patient was seen and evaluated by me for respiratory difficulty...Her chemistry is grossly abnormal, especially when compared to the most recent on file from December 2010. This patient is in acute [MEDICAL CONDITION] with a creatinine of 1.45 and a BUN of 57. Her blood sugar is mildly elevated at 159. Of greatest significance is a sodium of 175 with a chloride of 132. This is all likely secondary to overall severe dehydration...A urinalysis came back very grossly positive for a urinary tract infection...Impressions: Acute [MEDICAL CONDITION] severe [MEDICAL CONDITION]" Hospital discharge orders, dated 06/03/11, documented, "...250 ml water (down) peg every 8 hrs..." Physician orders, dated June 2011, documented, "...Glucerna 1.2 @ 65 cc/hr continuous per peg...flush peg with 60 ml water before and after medication administration...Water [MEDICATION NAME] via peg - TID everyday, (6:00 a.m.) (2:00 p.m.) (10:00 p.m.): 250 ml per PEG every 8 hours...2/19/2011..." Review of medication administration records, dated 06/04/11 through 06/19/11, revealed no documentation to show the resident received the water [MEDICATION NAME] at 2:00 p.m. on 06/14/11 or 06/19/11. There was no documentation to show the resident received the water [MEDICATION NAME] at 10:00 p.m. on 06/09/11 through 06/11/11, a total of three days, or on 06/15/11 or 06/17/11. There was no documentation to show the resident received 60 ml of water before and after medication administration on the 6:00 p.m. to 6:00 a.m. shifts on 06/08/11, 06/10/11, 06/13/11, 06/16/11, or 06/17/11. It was documented the resident received 3 medications on the 6:00 p.m. to 6:00 a.m. shift. Intake and output records, dated 06/04/11 through 06/20/11, documented the resident received the following amounts of water on each day: 06/04/11 through 06/06/11 - none, 06/07/11 - 806 ml, 06/08/11 through 06/10/11 - none, 06/11/11 - 420 ml, 06/12/11 through 06/14/11 - none, 06/15/11 - 420 ml, 06/16/11 - 400 ml, 06/17/11 - 300 ml, 06/18/11 through 06/19/11 - none,and 06/20/11 - 360 ml. On 06/20/11 at 2:45 p.m., the bag containing the resident's tube feeding was observed with a date of 06/18/11 at 5:00 a.m. An empty, undated syringe bag was noted hanging on the pole which held the tube feeding and the pump. At 3:05 p.m., the DON was asked how often tube feeding bags should be changed. She stated, "Should be every 24 hours." The DON was shown the resident's tube feeding bag and was asked why the resident's bag had not been changed since 06/18/11. She stated, "I will have to speak with the night nurse. It should have been." At 3:10 p.m., LPN #1 was asked if there was a syringe in the resident's room by which to administer medications and water [MEDICATION NAME]. LPN #1 stated, "She did earlier. I rinsed it out and put it back in its' bag." LPN #1 was asked why she did not identify the resident's tube feeding bag was out of date with a date of 06/18/11. She stated, "I did." When asked why she did not change the bag out when she identified it was out of date, LPN #1 stated, "I don't have a reason." At 3:15 p.m., LPN #1 was asked where the resident's syringe was to administer medications and water [MEDICATION NAME]. She stated, "It was in there this morning at 10 o'clock. I rinsed it out and put it back in its' bag." The LPN was asked to show the surveyor where the syringe was. LPN #1 looked in the room for the syringe. She picked up a syringe barrel off the floor across the room from the resident and stated, "Here's one." There was no syringe piston in the barrel. When informed there was no piston, LPN #1 stated, "I know. The aides must of knocked it out." On 06/21/11 at 10:00 a.m., the resident's intake and output record for 06/20/11 was reviewed. There was no documentation to show the resident received a water [MEDICATION NAME] at 10:00 p.m. on 06/20/11. At 2:45 p.m., review of the resident's clinical record revealed no signed physician orders [REDACTED]. The DON and LPN #3 were asked to provide the documentation. At 4:00 p.m., the DON stated the documentation could not be found. The DON obtained copies of the documentation from the hospital where the resident was last hospitalized . On 06/22/11 at 9:49 a.m., CNAs #1 and #2 were observed providing urinary catheter care for the resident. Before lowering the resident's bed, CNA #2 placed the resident's tube feeding on hold. The CNAs performed the catheter care and then resumed the tube feeding. At 10:07 a.m., CNA #2 was asked if CNAs at the facility were allowed to place tube feedings on hold during care and then resume them. She stated, "Yes. It's alright for us to do that here." CNA #2 was asked if that was the facility's policy. She stated, "I don't know about policy. I've just been told it's ok to do it." CNA #2 was asked who informed her CNAs could hold and resume tube feedings. She stated, "Other aides." When asked if she had been informed by a nurse it was policy for CNAs to hold and resume tube feedings, CNA #2 stated, "No." On 06/22/11 at 3:45 p.m., LPN #3 was asked who was responsible for completing intake and output records. She stated, "The charge nurses." When asked if the records were supposed to be completed every shift, LPN #3 stated, "Yes." LPN #3 was asked who was responsible for totaling the records. She stated, "The night shift." At 3:49 p.m., the DON was asked if the resident had been hospitalized recently. She stated, "Yes." When asked why, the DON stated, "She had pneumonia that worsened." The DON was asked if that was the only [DIAGNOSES REDACTED]. She stated, "I got the discharge summary this morning. It said acute renal and high salt. I saw that this morning." The DON was asked if she had been aware the resident was diagnosed with [REDACTED]. She stated, " I don't know if knew that before this morning. The daughter said she was dehydrated." The DON was asked if she was aware of the resident's sodium level. She stated, "Maybe 145." The DON was informed the resident's sodium level was 175, that it was listed on the hospital history and physical found in the resident's clinical record, and that it was documented the facility received the history and physical on 06/02/11, prior to the resident's return. The DON was asked who read the hospital information the facility received. She stated, "I do." The DON was asked when she read it. She stated, "Right then. More than likely I saw it on 6/2 but definitely on 6/3." The DON was asked why the resident's sodium level would have been so high and why the physician would have documented the resident's overall condition was likely due to being severely dehydrated. She stated, "She shouldn't have been, with the tube feeding and water [MEDICATION NAME]." The DON was asked if the resident was receiving the water [MEDICATION NAME]. She stated, "To my knowledge." When asked how she would know, the DON stated, "They were ordered. The expectation is to follow through." The DON was shown the May 2011 intake and output records and was asked if the documentation showed the resident received the ordered [MEDICATION NAME]. She stated, "Not according to this documentation." The DON was asked if she had been aware of the [DIAGNOSES REDACTED]. back at the facility on 06/03/11. She stated, "Yes." The DON was shown the intake and output records and medication administration records for June 2011. She was asked if the resident was receiving the water [MEDICATION NAME] and flushes as ordered. She stated, "No." The DON was asked why the staff was not administering the resident's [MEDICATION NAME] and flushes as ordered if they were aware she had been diagnosed with [REDACTED]. The DON stated, "I don't have an answer for that." The DON was asked if she was aware CNAs were placing tube feeding pumps on hold when performing care and then resuming the feeding when finished with care. She stated, "No." The DON was asked what she expected the CNAs to do if they were providing care for a resident receiving a tube feeding. She stated, "Get the nurse."