Every finding on record at Grace Skilled Nursing and Therapy Jenks

Based on record review and interview, the facility failed to ensure medications were administered according to physician orders for 2 (#11 and #14) of 6 sampled residents reviewed for timely administration of medications.The administrator identified 114 residents resided in the facility.Findings:An undated medication administration showed medication pass times were 7:00 a.m. to 11:00 a.m., 2:00 p.m., 4:00 p.m., 7:00 p.m. to 11:00 p.m., 10:00 p.m., and 12:00 a.m.A policy titled Medication Administration, dated 01/2022, read in part, Medications are administered within 60 minutes of scheduled time, except before, with or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication schedule for the facility. Some facilities may choose to implement a liberal time policy i.e. (7am to 11 am). The time allowed for that pass will be only between those hours listed (may start at 7am but must be finished by 11am).1. An order summary report for Resident #11, dated 08/2026, showed:a. carbamazepine (an anti-seizure), dated 10/09/24, 200 mg by mouth three times a day for epilepsy,b. famotidine (an H2-receptor), dated 06/10/26, 40 mg by mouth one time a day for GERD,c. fluticasone propionate nasal suspension (corticosteroids), dated 10/09/24, 50 mcg/act one spray in each nostril two times a day for allergies,d. fluvoxamine maleate (serotonin reuptake inhibitor), dated 10/09/24, 50 mg by mouth two times a day for obsessive-compulsive disorder,e. furosemide (diuretic), dated 10/09/24, 40 mg by mouth two times a day for edema,f. levothyroxine (a thyroid hormone), dated 05/12/25, 75 mcg by mouth in the morning for hypothyroidism,g. lidocaine external patch (local anesthetic), dated 07/15/26, 4% apply to left shoulder topically one time a day for pain,h. melatonin (sedative/hypnotic), dated 10/09/24, 5 mg by mouth at bedtime for insomnia,i. omeprazole (proton pump inhibitor) 40 mg by mouth two times a day for GERD,j. oxybutynin chloride ER (an anticholinergics) 5 mg by mouth one time a day for overactive bladder,k. potassium chloride ER (mineral and electrolyte replacement/supplement) 10 mEq by mouth one time daily for supplement,l. potassium chloride ER 20 mEq by mouth one time daily for supplement,m. pramipexole dihydrochloride (dopamine agonist) 0.125 mg by mouth at bedtime for restless legs syndrome,n. sertraline HCI (selective serotonin reuptake inhibitor) 100 mg one and one half tablet by mouth one time a day for major depressive disorder,o. topiramate (an anticonvulsant) 100 mg by mouth one time a day for epilepsy,p. topiramate 100 mg two tablets by mouth at bedtime for epilepsy,q. travoprost ophthalmic solution (prostaglandin analogs) 0.004% 1 drop in both eyes at bedtime, andr. xyzal allergy 24 hour (antihistamine) 5 mg one time a day for allergies,A Medication Administration Audit Report, dated 08/01/26 through 08/12/26, showed:a. carbamazepine, scheduled for 2:00 p.m., was administered on 08/07/26 at 3:26 p.m., andb. oxybutynin, potassium chloride, fluticasone, furosemide, sertraline, topiramate, fluvoxamine, omeprazole, levothyroxine, lidocaine patch, famotidine, and carbamazepine, scheduled for 7:00 a.m. to 11:00 a.m., were administered on 08/11/26 at 12:24 p.m.2. An order summary report Resident #14, dated 08/2026, showed:a. bimatoprost (prostaglandin analogs) ophthalmic solution 0.01%, Instill one drop in both eyes at bedtime for glaucoma,b. bupropion (antidepressant) ER 24 hour 150 mg, give one tablet by mouth one time a day for depression,c. calcium citrate (mineral and electrolyte replacement/supplement) oral tablet 950 mg, give one tablet by mouth one time a day for supplement,d. cyclobenzaprine hcl (muscle relaxant) oral tablet 10 mg, give one tablet by mouth every 12 hours for muscle spasms,e. Cymbalta (antidepressant) oral capsule delayed release 60 mg, give one tablet by mouth two times a day for depression,f. diclofenac sodium (non-steroid anti-inflammatory oral tablet delayed release 75 mg, give one tablet by mouth two times a day for pain,g. docusate sodium (laxative) oral capsule 100 mg, give one capsule by mouth two times a day for constipation,h. estradiol (estrogenic hormone) transdermal patch twice weekly, apply one patch trans dermally one time a day every Monday and Thursday for a supplement,i. fentanyl (narcotic) transdermal patch 72-hour 25 mcg/hr, apply one patch every 72 hours for pain and remove per schedule,j. Flonase (intranasal steroid) Allergy Relief nasal suspension 50 mcg/act, two sprays in both nostrils one time a day for allergies,k. folic acid (vitamin) oral tablet 1 mg, give one tablet by mouth one time a day for supplement,l. fosfomycin tromethamine (antibiotic) oral packet 3 gm, give one packet by mouth one time a day every Monday for UTI prevention,m. gabapentin (anticonvulsant) oral capsule 300 mg, give one capsule by mouth three times a day for nerve pain,n. guaifenesin (expectorant) ER oral tablet 600 mg, give two tablets by mouth two times a day for congestion,o. hydroxychloroquine sulfate (antimalarial) oral tablet 200 mg, give one tablet by mouth two times a day for arthritis,p. potassium (mineral and electrolyte supplement) 20 mEq, give one tablet by mouth one time a day for supplement,q. Lasix (diuretic) 40 mg, give 1 tablet by mouth one time a day for chronic congestive heart failure,r. lidocaine (anesthetics) external patch 4%, apply to effected area topically one time a day for pain,s. Lipitor (lipid lowering agent) oral tablet 20 mg, give one tablet by mouth at bedtime for hyperlipidemia,t. lubricant eye drops (ophthalmic lubricant and irrigation) ophthalmic solution 0.5 %, instill 2 drops in both eyes three times a day,u. metoprolol tartrate (beta blocker) oral tablet 25 mg, give 0.5 tablet by mouth two times a day for hypertension,v. multivitamin with minerals (vitamin and mineral), give one tablet by mouth one time a day for supplement,w. omeprazole (proton pump inhibitor) oral tablet delayed release 20 mg, give one tablet by mouth one time a day related to GERD,x. prednisone (corticosteroid) oral tablet 5 mg, give one tablet one time a day on odd days for inflammation,y. prednisone oral tablet 10 mg, give two tablets one time a day on even days for inflammation, andz. Restoril (benzodiazepine) oral capsule 15 mg, give one capsule by mouth at bedtime for insomnia.A Medication Administration Audit Report, dated 08/01/26 through 08/12/26, showed:a. Cymbalta, scheduled for 6:00 p.m., was administered on 08/01/26 at 9:46 p.m.,b. guaifenesin, docusate sodium, diclofenac sodium, and metoprolol, scheduled for 6:00 p.m., were administered on 08/01/26 at 9:47 p.m.,c. metoprolol, scheduled for 6:00 p.m., was administered at 9:58 p.m.,d. fosfomycin, estradiol, diclofenac, bupropion, prednisone, Lasix, potassium, Flonase, guaifenesin, Cymbalta, calcium, docusate sodium, folic acid, multivitamin, and metoprolol, scheduled for 7:00 a.m., were administered on 08/03/26 at 11:13 a.m.,e. hydroxychloroquine sulfate, diclofenac, guaifenesin, Cymbalta, docusate sodium, and metoprolol, scheduled for 6:00 p.m., were administered at 9:03 p.m.,f. fosfomycin, estradiol, diclofenac, bupropion, prednisone, Lasix, potassium, Flonase, guaifenesin, Cymbalta, calcium, docusate sodium, folic acid, multivitamin, and metoprolol, scheduled for 7:00 a.m., were administered on 08/04/26 at 11:04 a.m.,g. hydroxychloroquine sulfate, diclofenac, guaifenesin, Cymbalta, docusate sodium, and metoprolol, scheduled for 6:00 p.m., were administered on 08/04/26 at 8:17 p.m.,h. diclofenac, guaifenesin, Cymbalta, docusate sodium, and metoprolol, scheduled for 6:00 p.m., was administered on 08/05/26 at 9:06 p.m.,i. hydroxychloroquine sulfate, diclofenac, guaifenesin, Cymbalta, docusate sodium, and metoprolol, scheduled for 6:00 p.m., on 08/07/26 at 9:29 p.m.,j. fosfomycin, estradiol, diclofenac, bupropion, prednisone, Lasix, potassium, Flonase, guaifenesin, Cymbalta, calcium, docusate sodium, folic acid, multivitamin, and metoprolol were administered on 08/08/26 at 12:15 p.m.,k. hydroxychloroquine sulfate, diclofenac, guaifenesin, Cymbalta, docusate sodium, and metoprolol, scheduled for 6:00 p.m., on 08/08/26 at 7:32 p.m.,l. hydroxychloroquine sulfate, diclofenac, guaifenesin, Cymbalta, docusate sodium, and metoprolol, scheduled for 6:00 p.m., at 9:26 p.m.,m. fosfomycin, scheduled for 6:00 p.m., was administered on 08/10/26 at 11:02 a.m.,n. diclofenac, guaifenesin, Cymbalta, docusate sodium, and metoprolol, scheduled for 6:00 p.m., on 08/10/26 at 8:56 p.m.,o. diclofenac, guaifenesin, Cymbalta, docusate sodium, and metoprolol, scheduled for 6:00 p.m., on 08/11/26 were administered at 8:46 p.m., andp. estradiol transdermal patch, scheduled for 6:00 p.m., was administered on 08/10/26 at 11:17 a.m.On 08/19/26 at 7:00 a.m., CMA #1 stated the time frame for the 9:00 a.m. medication was an hour before and an hour after. CMA #1 stated they had from 6:00 a.m. to 12:00 p.m. to pass the medications scheduled for 7:00 a.m. to 11:00 a.m.On 08/19/26 at 7:04 a.m., the ADON stated the 9:00 a.m. medications could be administered an hour before and an hour after. The ADON stated the medications schedule for 7:00 a.m. to 11:00 a.m. could be administered anytime from 6:00 a.m. to 12:00 p.m.On 08/19/26 at 8:53 a.m., the DON stated they had an hour before and an hour after the scheduled medication time to administer the medication. The DON was made aware of the above findings. The DON stated they were not aware of the policy with the blocked administration times.

Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for 2 (#17 and #18) of 12 sampled residents reviewed for bathing.The administrator identified 114 residents resided in the facility.Findings:1. On 08/11/26 at 11:06 a.m., Resident #17 was observed sitting up in their wheelchair in their room. Resident #17 was observed to be odor free and clothes were wrinkled. Resident #17 stated they were not sure if they received their showers.An undated diagnoses list for Resident #17 showed the resident was admitted to the facility with diagnoses which included dementia and hemiplegia/hemiparesis following cerebral infarction.A quarterly assessment for Resident #17, dated 08/07/26, showed the resident's cognition was moderately impaired with a BIMS score of 8.A bathing schedule log, dated 07/2026 and 08/2026, showed Resident #17 was to receive showers on Tuesday and Thursdays.The 07/2026 shower log for Resident #17, dated 08/17/26, showed the resident missed seven 07/02/26, 07/09/26, 07/16/26, 07/21/26, 07/23/26, 07/28/26, and 07/30/26, of nine opportunities for a shower.The 08/2026 shower log for Resident #17, dated 08/17/26, showed the resident missed one of five opportunities for a shower. Resident #17 missed their shower on 08/06/26.2. On 08/17/26 at 1:25 p.m., Resident #18 was observed resting on their bed. Resident #18 was observed to be odor free, and clothes were observed to be a little dirty.An undated diagnoses list for Resident #18 showed the resident was admitted to the facility with diagnoses which included diffuse traumatic brain injury with loss of consciousness.An admission assessment for Resident #18, dated 07/31/26, showed the resident's cognition was intact with a BIMS score of 13.An undated bathing task log for Resident #18 showed the resident was to receive showers on Tuesdays and Fridays. The bathing task log showed from 07/21/26 through 08/17/26, Resident #18 missed seven of eight opportunities for a shower. Resident #18 missed showers on 07/24/26, 07/28/26, 07/31/26, 08/04/26, 08/07/26, 08/11/26, and 08/14/26.On 08/17/26 at 1:25 p.m., Resident #18 was asked if they received their showers. Resident #18 stated sure and then laughed.On 08/17/26 at 2:00 p.m., the DON stated they had paper bath sheets as well as computer charting.On 08/19/26 at 8:30 a.m., CNA #1 and CNA #2 stated showers were documented in the electronic medical record.On 08/19/26 at 8:41 a.m., CNA #3 stated showers were documented on the computer under tasks.On 08/19/26 at 7:41 a.m., the DON stated they were unable to find the bath sheet for Resident #17. The DON stated there was no documentation showing the residents received their showers if it was not documented.

Based on observation, record review, and interview, the facility failed to ensure staff followed the facility lift policy for 1 (#19) of 3 sampled residents reviewed for accident hazards. The DON identified 35 residents required the use of a lift with a transfer. Findings:On 08/13/26 at 12:33 p.m., CNA #1 was observed bringing the full body mechanical lift out of the room of Resident #19.An undated diagnoses list for Resident #19 showed the resident had diagnoses which included spondylosis of the cervical region, spinal stenosis of the lumbar region, and low back pain.A facility policy titled Full Body Mechanical Lift Guide, dated 02/2025, read in part, A full body mechanical lift provides a safe transfer for the resident who has partial to non-weight bearing capabilities. Equipment/personal: full body mechanical lift, two (2) or more caregivers.On 08/13/26 at 12:41 p.m., CNA #1 stated they were the only staff assigned to the hall and were the only one using the lift for Resident #19.On 08/13/26 at 12:41 p.m., CNA #1 stated a transfer with a lift required two people.On 08/17/26 at 2:00 p.m., the DON stated the mechanical lift required the use of two staff members.

Based on record review and interview, the facility failed to ensure wound care was documented for 2 (#2 and #5) of 3 sampled residents reviewed for pressure ulcers.The DON identified 10 residents had pressure ulcers.Findings: 1.A physician order, dated 07/29/25, showed to cleanse the stage 3 pressure ulcer to Resident #2's left lateral buttock with normal saline, pat dry, and paint with Betadine (antiseptic) every shift. A physician order, dated 09/09/25, showed to cleanse the abrasion to Resident #2's right lateral buttock with normal saline, pat dry, apply Xeroform (gauze dressing), and cover with bordered foam every Tuesday, Thursday, and Saturday. An annual assessment, dated 09/12/25, showed Resident #2 had a BIMS score of 00, which indicated the resident was severely impaired in cognition for daily decision making, had a diagnosis of dementia, and had pressure ulcers. A care plan, updated 09/25/25, showed Resident #2 had impaired skin integrity and required wound care. A physician order, dated 10/07/25, showed to cleanse the stage 3 pressure ulcer to Resident #2's right medial knee with normal saline, pat dry, apply Durafiber (wound dressing), and wrap with gauze. Review of the treatment administration record, dated 10/01/25 through 10/31/25, did not show documentation wound care had been completed on 10/09/25 or 10/30/25 to the right medial knee or right lateral buttock. The treatment administration record did not show documentation wound care had been completed on 10/01/25, 10/08/25, 10/09/25, 10/29/25, or 10/30/25 for the day shift. On 11/05/25 at 10:30 a.m., wound care nurse #1 stated wound care was completed by the wound care nurses Monday through Saturday and on Sunday the charge nurses completed wound care, and they were to document on the treatment administration record. On 11/05/25 at 11:39 a.m., wound care nurse #1 stated there had been a failure to document. On 11/05/25 at 3:41 p.m., the DON stated they performed daily audits with the wound care team, followed them daily, and monitored the treatment administration records weekly. On 11/06/25 at 8:27 a.m., wound care nurse #2 stated they needed to complete more thorough documentation when wound care was completed. They stated they had completed the wound care for Resident #2 on the scheduled days in October 2025, but had missed documenting on the treatment administration record. On 11/06/25 at 10:36 a.m., the DON stated they had reviewed the treatment administration record for October 2025 and the wound care nurses had completed the wound care but they had not documented on the treatment administration record. 2. An admission record, dated 09/01/25, showed Resident #5 had diagnoses which included a stage 3 pressure ulcer of the sacral region and schizophrenia. A significant change assessment, dated 09/13/25, showed Resident #5 had a BIMS score of 4 which was indicative of severe cognitive impairment. A physician's order, dated 10/12/25, showed to cleanse the stage 3 pressure ulcer to Resident #5's sacrum with normal saline, pat dry, apply Triad (wound dressing) and cover with bordered foam every Tuesday, Thursday and Saturday. Review of the treatment administration record from 10/12/25 through 11/01/25 did not show documentation wound care had been completed on 10/18/25, 10/25/25 or 11/01/25. On 11/06/25 at 8:30 a.m., wound care nurse #2 stated they had performed the wound care for Resident #5 on 11/01/25, but they had not documented it.

Based on record review and interview, the facility failed to ensure nutritional supplements were provided as ordered for 1 (#2) of 3 sampled residents reviewed for nutrition. The DON identified 48 residents were ordered supplements.Findings:A weight entry, dated 09/11/25, showed Resident #2 weighed 130.8 pounds.An annual assessment, dated 09/12/25, showed Resident #2 had a BIMS score of 00, which indicated the resident was severely impaired in cognition for daily decision making, had a diagnosis of dementia, and had a feeding tube.A care plan, updated 09/25/25, showed Resident #2 had a potential nutritional problem and was at risk for weight fluctuations.A nutrition note, dated 09/26/25, showed a recommendation from the dietician for 2.0 cal (a nutritional supplement) 30cc twice daily via feeding tube.A nurse note, dated 10/01/25, showed the facility had received a new order for 2.0 cal 30cc twice daily via feeding tube. The note was signed by the ADON. A physician order, dated 10/01/25, showed Resident #2 had been ordered 2.0 cal 30cc twice daily via feeding tube twice daily.A weight entry, dated 10/14/25, showed Resident #2 weighed 131.6 pounds.Review of the medication/treatment administration record, dated 10/01/25 through 10/31/25, did not show the order for 2.0 cal 30cc twice daily via feeding tube.Review of the medication/treatment administration record, dated 11/01/25 through 11/03/25, did not show the order for 2.0 cal 30cc twice daily via feeding tube.On 11/05/25 at 10:18 a.m., LPN #1 reviewed the medication/treatment record for Resident #2 and stated the only supplements they were ordered and received vitamin C, zinc, and a multivitamin. LPN #1 stated they or an ACMA were responsible to administer supplements via feeding tube to Resident #2.On 11/05/25 at 10:22 a.m., ACMA #1 reviewed the medication/treatment record for Resident #2 and stated they were currently ordered supplements to include vitamin C, iron, zinc, and a multivitamin.On 11/05/25 at 11:32 a.m., the ADON stated when the order was entered into the electronic clinical record for the 2.0 cal nutritional supplement it had not carried over onto the medication/treatment record for administration.On 11/05/25 at 3:50 p.m., the DON stated the order for 2.0 cal had not been placed on the medication/treatment record for administration for Resident #2. They stated they audited new orders daily, but they had not identified the nutritional supplement had not been placed on the medication/treatment record for administration by the charge nurse or the ACMA.

Based on observation and interview the facility failed to ensure a clean comfortable homelike environment for 1 (#4) of 3 sampled residents reviewed for environment.The administrator identified 100 residents resided in the facility. Findings: On 11/05/25 at 9:05 a.m., Resident #4's room was observed. Two slats on the mini blinds were broken off and were missing. A one foot by one foot area on the North wall was missing paint, and several other smaller areas along the North and East wall were observed to be missing paint.On 11/05/25 at 9:05 a.m., Resident #4 stated the blinds had been broken and the paint had been missing for the three years they had been at the facility.On 11/05/25 at 9:15 a.m., CNA #1 stated they were new and they were unsure who was responsible for painting the rooms and replacing the blinds.On 11/05/25 at 9:20 a.m., LPN #2 stated that maintenance was responsible for the blinds and paint. LPN #2 stated they were unaware if maintenance was aware of the condition of Resident #4's room.On 11/05/25 at 9:25 a.m., the maintenance supervisor stated they were responsible for repainting resident rooms and replacing broken mini blinds.On 11/06/25 at 10:55 a.m., the administrator stated issues with the rooms should be reported to maintenance so they can be addressed.

Based on record review and interview, the facility failed to ensure residents were assessed before and after dialysis for 2 (#8 and #4) of 2 sampled residents who were reviewed for dialysis.The DON identified three residents required dialysis.Findings: 1. A Dialysis Communication form for Resident #8, dated 07/08/25, read in part, Pre-Dialysis This section to be completed by nursing facility and sent with resident .Post Dialysis This section is to be completed by dialysis unit and returned with resident. The form showed the assessment before dialysis contained a weight and blood pressure obtained on 07/07/25 and the pulse, temperature, and respirations had been obtained on 07/05/25. The section for the post dialysis assessment had not been completed. A Dialysis Communication form for Resident #8, dated 07/19/25, read in part, Pre-Dialysis This section to be completed by nursing facility and sent with resident .Post Dialysis This section is to be completed by dialysis unit and returned with resident. The pre dialysis section of the form showed the thrill and bruit were present, the weight was obtained on 07/08/25 and the pulse, temperature, and respirations were obtained on 07/20/25. The post dialysis section of the form showed vital signs, a pre dialysis weight, and the time dialysis started and ended. The post dialysis section read in part, Signature: per dialysis nurse. A Dialysis Communication form for Resident #8, dated 07/22/25, read in part, Pre-Dialysis This section to be completed by nursing facility and sent with resident .Post Dialysis This section is to be completed by dialysis unit and returned with resident. The pre dialysis section of the form showed the thrill and bruit were present, the weight was obtained on 07/08/25, and the pulse, temperature, and respirations were obtained on 07/20/25. The post dialysis section of the form had not been completed. A Dialysis Communication form for Resident #8, dated 07/29/25, read in part, Pre-Dialysis This section to be completed by nursing facility and sent with resident .Post Dialysis This section is to be completed by dialysis unit and returned with resident. The pre dialysis section of the form showed the thrill and bruit were present, the weight was obtained on 07/08/25, and the pulse, temperature, and respirations were obtained on 07/20/25. The post dialysis section of the form had been completed by the nurse at the dialysis center. A Dialysis Communication form for Resident #8, dated 08/05/25, read in part, Pre-Dialysis This section to be completed by nursing facility and sent with resident .Post Dialysis This section is to be completed by dialysis unit and returned with resident. The pre dialysis section of the form showed the thrill and bruit were present, the weight was obtained on 07/08/25, and the pulse, temperature, and respirations were obtained on 07/20/25. The post dialysis section of the form had not been completed. A quarterly assessment, dated 08/08/25, showed Resident #8 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, had a diagnosis of end stage renal disease, and had received dialysis. A Dialysis Communication form for Resident #8, dated 08/09/25, read in part, Pre-Dialysis This section to be completed by nursing facility and sent with resident .Post Dialysis This section is to be completed by dialysis unit and returned with resident. The pre dialysis section of the form showed the thrill and bruit were present, and the weight was obtained on 07/08/25. The post dialysis section of the form had not been completed. A care plan, updated 08/13/25, showed Resident #8 was to receive dialysis every Tuesday, Thursday, and Saturday. A Dialysis Communication form for Resident #8, dated 08/14/25, read in part, Pre-Dialysis This section to be completed by nursing facility and sent with resident .Post Dialysis This section is to be completed by dialysis unit and returned with resident. The pre dialysis section of the form showed the thrill and bruit were present, the weight was obtained on 08/11/25, and the pulse, temperature, and respirations were obtained on 08/09/25. The post dialysis section of the form had not been completed. A Dialysis Communication form for Resident #8, dated 08/16/25, read in part, Pre-Dialysis This section to be completed by nursing facility and sent with resident .Post Dialysis This section is to be completed by dialysis unit and returned with resident. The pre dialysis section of the form showed the thrill and bruit were present, the weight was obtained on 08/11/25, and the pulse, temperature, and respirations were obtained on 08/09/25. The post dialysis section of the form had not been completed. A Dialysis Communication form for Resident #8, dated 08/21/25, read in part, Pre-Dialysis This section to be completed by nursing facility and sent with resident .Post Dialysis This section is to be completed by dialysis unit and returned with resident. The pre dialysis section of the form showed the thrill and bruit were present, the weight was obtained on 08/11/25, and the pulse, temperature, and respirations were obtained on 08/16/25. The post dialysis section of the form showed a pre and post dialysis weight and the time dialysis started and time of when dialysis ended. A Dialysis Communication form for Resident #8, dated 08/26/25, read in part, Pre-Dialysis This section to be completed by nursing facility and sent with resident .Post Dialysis This section is to be completed by dialysis unit and returned with resident. The pre dialysis section of the form showed the thrill and bruit were present, the weight was obtained on 08/11/25, the blood pressure and pulse had been obtained on 08/25/25, and the temperature and respirations had been obtained on 08/09/25. The post dialysis section of the form had not been completed. A Dialysis Communication form for Resident #8, dated 08/28/25, read in part, Pre-Dialysis This section to be completed by nursing facility and sent with resident .Post Dialysis This section is to be completed by dialysis unit and returned with resident. The pre dialysis section of the form showed the thrill and bruit were present, the weight was obtained on 08/11/25, the blood pressure and pulse had been obtained on 08/27/25, and the temperature and respirations had been obtained on 08/09/25. The post dialysis section of the form had not been completed. A Dialysis Communication form for Resident #8, dated 09/02/25, read in part, Pre-Dialysis This section to be completed by nursing facility and sent with resident .Post Dialysis This section is to be completed by dialysis unit and returned with resident. The pre dialysis section of the form showed the thrill and bruit were present, the weight was obtained on 08/11/25, the blood pressure and pulse had been obtained on 09/01/25, and the temperature and respirations had been obtained on 08/09/25. The post dialysis section of the form had been completed by the dialysis center nurse. On 08/26/25 at 10:44 a.m., Resident #8 stated the nursing staff at the facility did not check their dialysis port before or after dialysis. On 09/02/25 at 11:10 a.m., LPN #2 stated they listened to the port, checked the dressing at the dialysis access site, and obtained the resident's vital signs before and after dialysis. They stated they documented the assessments on the dialysis communication form. On 09/02/25 at 1:46 p.m., the ADON stated the facility's nurse was to document their assessment before dialysis, send the paper to the dialysis center, and document a progress note with the dialysis center's assessment. On 09/03/25 at 10:18 a.m., LPN #2 stated Resident #8 had a dialysis port to the right chest and assessed for thrill and bruit with their stethoscope at the port site before the resident went to dialysis. They stated they did not always receive the Dialysis Communication forms from the dialysis facility to document the post dialysis assessment. On 09/03/25 1:37 p.m., the ADON stated the pre dialysis assessments which documented a thrill and bruit had been present were not accurate because Resident #8 had a port. The ADON stated the vital signs on the pre dialysis assessment were automatically input onto the form from the last set of vital signs in the electronic clinical record. By the end of the survey progress notes containing pre/post dialysis assessments had not been provided. 2. A physician's order for Resident #4, dated 03/19/25, showed to monitor the arteriovenous fistula for signs and symptoms of trauma and/or infection every shift. The order showed to check for thrill and bruit every shift due to dependence on renal dialysis. A physician's order for Resident #4, dated 03/19/25, showed to schedule visits to dialysis center and coordinate care accordingly for Monday, Wednesday, and Friday with a chair time of 1:05 p.m. A review of the June, July, and August 2025 medication administration records for Resident #4 did not show the dialysis event on Monday, Wednesday, and Friday. A review of July and August 2025 progress notes showed no notes regarding dialysis or assessment/monitoring of the fistula site for Resident #4. By the end of the survey progress notes showing assessment/monitoring of the fistula site for Resident #4 were not provided. A dialysis communication form for Resident #4, dated 07/02/25, showed a pre dialysis assessment, completed LPN #5, but no post dialysis assessment. A dialysis communication form for Resident #4, dated 07/04/25, showed a pre dialysis assessment completed by LPN #6, but no post dialysis assessment. A dialysis communication form, dated 07/07/25, showed a pre dialysis assessment completed by LPN #5, but no post dialysis assessment. A dialysis communication form for Resident #4, dated 07/09/25, showed a pre dialysis assessment completed by LPN #5, but no post dialysis assessment. A dialysis communication form for Resident #4, dated 07/11/25, showed a pre dialysis assessment completed by the ADON, but no post dialysis assessment. A dialysis communication form for Resident #4, dated 07/14/25, showed a pre dialysis assessment was completed by LPN #5, but no post dialysis assessment. A quarterly assessment, dated 07/31/25, showed Resident #4 had a BIMS of 15 which indicated they were cognitively intact. The assessment showed diagnoses which included end stage renal disease, diabetes, and hypertension. A dialysis communication form for Resident #4, dated 08/27/25, showed a pre dialysis assessment was completed and a post dialysis assessment. The note showed vitals were not completed by dialysis and the post assessment was completed upon return, with complaints of weakness and pain reported by Resident #4 of nine out of 10 in their knees and back, with general malaise. On 09/02/25 at 1:46 p.m., the ADON stated the facility's nurse was to document their assessment before dialysis, send the paper to the dialysis center, and document a progress note with the dialysis center's assessment.

Based on record review and interview, the facility failed to ensure range of motion services were provided for 2 (#7 and #8) of 2 sampled residents who were reviewed for range of motion services.The ADON identified 49 residents had limited range of motion.Findings: 1. On 08/26/25 at 10:47 a.m., Resident #8 was observed to be unable to raise their bilateral arms past the level of their shoulders. A policy titled Restorative Nursing Program, dated 05/2025, read in part, Purpose: To maintain residents' highest practicable level of physical, mental, and psychosocial well-being .Restorative proms should be planned, monitored, evaluated, and documented. Including: Restorative assessment .Care plan .Flowsheet documentation .Weekly oversight by licensed nurse. A quarterly assessment, dated 08/08/25, showed Resident #8 had a BIMS score of 15, which indicated they were cognitively intact for daily decision making, had impairment in range of motion to one side of the upper extremity, both sides of the lower extremity, and had not received restorative services during the look back period. A care plan, updated 08/13/25, showed nursing rehab was to assist the resident with active and passive range of motion to the bilateral upper and lower extremities. Review of the electronic clinical record for August 2025 did not show the resident had received range of motion services. On 08/26/25 at 10:47 a.m., Resident #8 stated they had limited range of motion in both arms. They stated they had not received any range of motion services in the past several months. On 09/02/25 at 11:08 a.m., CNA #1 stated Resident #8 was unable to use their legs and had limited range of motion in their arms. They stated Resident #8 could not put their own hat on their head, so they had assisted them. They stated they had not been instructed to provide range of motion services or exercises for Resident #8. On 09/03/25 at 11:36 a.m., CMA #1 stated they were not aware of any services for limitation in range of motion for Resident #8. On 09/03/25 at 11:38 a.m., LPN #2 stated Resident #8 did not have any limitation in their range of motion. They stated the resident was able to utilize all of their extremities without issue. On 09/03/25 at 11:59 a.m., the care plan coordinator reviewed the care plan for Resident #8 and stated the restorative aide was to provide active and passive range of motion. On 09/03/25 at 12:38 p.m., the care plan coordinator stated they had added active and passive range of motion to the care plan because they had discussed restorative therapy for Resident #8 in May 2025. They stated they had not started restorative services for Resident #8 because the facility had not yet hired a restorative aide. On 09/03/25 at 1:21 p.m., the DON and ADON reviewed the clinical record for Resident #8. The DON stated the resident had limitation in their range of motion for the upper and lower extremities and was to receive active and passive range of motion. The ADON stated the CNAs were to perform range of motion exercises with activity of daily living care. The ADON stated the CNAs were to document range of motion services in the electronic clinical record. The ADON stated they did not know why range of motion services had not been documented by the CNAs. 2. A quarterly assessment, dated 07/23/25, showed Resident #7 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, had impairment in range of motion on one side of their upper and lower extremities, and had not received restorative services during the look back period. A care plan, dated 07/25/25, showed Resident #7 had a right-hand contracture and that nursing rehab was to provide active and passive range of motion to the right upper and right lower extremities. Review of the electronic clinical record did not show range of motion services had been provided in July or August 2025. On 09/03/25 at 5:46 p.m., the DON stated they did not have restorative program in place, but the CNAs were to complete range of motion.

Based on record review and interview, the facility failed to ensure a bed hold notification was provided for 1 (#36) of 1 sampled resident who was reviewed for hospitalization.The administrator identified 107 residents resided in the facility.Findings: The policy titled Bed Hold, dated 10/14/19, read in part, Resident shall be given notice of the bed hold option at the time of hospitalization or other leave. An undated face sheet showed Resident #36 had a power of attorney and their primary payer source was Medicaid. An annual assessment, dated 05/21/25, showed Resident #36 had a BIMS score of 00, which indicated the resident was severely impaired in cognition for daily decision making. A nurse note, dated 08/20/25, showed Resident #36 was sent to the hospital for altered mental status. The note did not show notification of a bed hold had been provided. A nurse note, dated 08/26/25, showed Resident #36 returned to the facility. On 08/29/25 at 3:54 p.m., LPN #1 stated the marketer, or administration provided the notice of bed hold to residents/resident representatives. On 09/02/25 at 9:47 a.m., the DON stated the admission coordinator provided the notice of bed hold to residents/resident representatives. On 09/02/25 at 9:52 a.m., the admission coordinator stated the nursing department provided the notice of bed hold at the time of transfer. On 09/02/25 at 10:08 a.m., the administrator stated the nursing department was to provide the resident/resident representative of the notice of bed hold upon transfer to the hospital. On 09/02/25 at 11:10 a.m., LPN #2 stated they had not provided the notice of bed hold to Resident #36 or the resident's representative for the hospitalization on 08/20/25 because it was an emergency transfer.

Based on observation, record review, and interview, the facility failed to ensure sufficient staff to meet the needs of 1 (#110) of 1 sampled resident who was reviewed for sufficient staffing.The administrator identified 107 residents resided in the facility. Findings: On 08/26/25 at 2:10 p.m., Resident #110 was observed to be calling out for help to the bathroom. CNA #2 came down the hall to get the dirty linen cart and did not check on Resident #110. Resident #110 continued to call out for help to the bathroom. A quarterly assessment, dated 06/05/25, showed Resident #110 had a BIMS of 06 which indicated severe cognitive impairment. The assessment showed Resident #110 required supervision for sitting to standing and partial to moderate assistance with toilet hygiene. On 08/26/25 at 2:15 p.m., LPN #3 stated CNA #2 monitored the hall for residents who required assistance. LPN #3 was informed staff were not on the hall to monitor, and Resident #110 was yelling out for help to the bathroom. LPN #3 went down the hall and entered the room of Resident #110. On 09/03/25 at 5:26 p.m., CNA #6 stated they should get to call lights in a minimum of five minutes. They stated they did not feel there was enough staff to answer call lights that fast.On 09/03/25 at 5:27 p.m., CNA #2 stated they had five minutes to answer a call light, and they did not have enough staff to answer them that fast.On 09/03/25 at 5:29 p.m., CNA #7 stated they had five minutes to answer call lights, and they did not have enough staff to answer them that fast.

Based on observation, record review, and interview, the facility failed to ensure infection control measures were implemented when providing peg tube treatments for 1 (#34) of 1 sampled resident who was reviewed for infection control.The DON identified three residents received peg tube care.Findings: On 08/28/25 at 1:29 p.m., LPN #3 was observed to administer PEG tube medications and provide a PEG tube dressing change for Resident #34. LPN #1 was not observed to don appropriate personal protective equipment, a gown, for enhanced barrier protocol. A quarterly assessment, dated 07/21/25, showed Resident #34 had a BIMS score of 2, which indicated they were severely impaired for daily decision making. The assessment showed diagnoses which included a traumatic brain injury and dysphagia. On 08/28/25 at 1:57 p.m., LPN #3 stated they should have followed enhanced barrier protocol, but had forgotten to put on the gown.

Based on record review and interview, the facility failed to ensure a resident's damaged personal property was replaced for 1 (#66) of 1 resident sampled who was reviewed for personal property.The administrator identified #107 residents resided in the facility. Findings: A quarterly assessment, dated 07/16/25, showed Resident #66 had a BIMS of 14 which indicated the resident's cognition was intact and diagnosis which included stroke. Review of the grievance log showed no grievance for Resident #66 regarding their television. On 09/02/25 at 9:49 a.m., Resident #66 stated after a power outage at the facility, their television would not come on. They stated he screen would stay black and they only had sound. Resident #66 stated the facility took their television and loaned them one of theirs to use, but did not replace their television. They stated the administrator told them the facility would not replace their television. On 09/02/25 at 10:41 a.m., the administrator stated they were not aware of an issue with the television for Resident #66. They stated if a power outage had fried their television the family would have to replace it because the facility did not replace personal property. The administrator stated it was in their admission agreement.

Based on observation and interview, the facility failed to clean the lint build-up from the compartment which housed the gas lines and burner assemblies for 4 of 4 gas dryers in the laundry room. The administrator identified 107 residents resided in the facility. Findings:On 09/03/25 at 11:05 a.m., Laundry aide #1 assisted with the observations of the four gas dryers in the laundry room. Laundry Aide #1 pulled open each of the lint trap doors housed under each dryer drum. All four lint trap screens were thickly covered with lint. The space behind the dryers was observed to have lint covering the ceiling, the fire sprinkler, and the mechanical space above each of the four dryer drums. The mechanical space above the dryer drums housed the gas lines and dryer burner tube assembly. The lint covered the ceiling, floor, walls, electrical conduit, wires, switches, gas lines, and air intakes/holes for the gas dryer burner tube assembly of the mechanical space. Pictures were taken of the observations described above. On 09/03/25 at 11:10 a.m., Laundry aide #1 stated they cleaned the lint screens once daily and swept the space behind the dryers once a week or so. Laundry Aide #1 stated they were usually the one assigned to sweep behind the dryers. Laundry Aide #1 stated they did not clean the mechanical space above the dryer drums because they were never instructed to do so.On 09/03/25 at 4:35 p.m., the laundry supervisor stated the laundry aides were to clean the lint traps multiple times a day. The laundry supervisor stated Laundry Aide #1 usually swept behind the dryers approximately once a week as the other laundry aides had difficulty accessing the area behind the dryers. The laundry supervisor stated the facility had a company that serviced the laundry area monthly to switch out the chemicals, check the traps, and make sure the mechanical system which delivered the chemicals worked properly. The laundry supervisor looked at pictures of the area behind the dryers and of the mechanical area above each of the four dryers and stated they did not realize there was so much lint build-up on the ceiling, water sprinkler, and walls. The laundry supervisor stated the lint build-up in the mechanical area above each of the four dryers was a fire hazard.

Based on observation, record review, and interview, the facility failed to ensure fall interventions were implemented for 2 (#3 and #48) of 2 sampled residents who were reviewed for falls.The administrator identified 107 residents resided in the facility. Findings: 1. On 09/02/25 at 9:45 a.m., a visitor was observed in the room of Resident #3. A floor fall mat was not observed on the floor next to the bed. An over the bed grab bar was observed to be hooked onto the boom of the grab bar. On 09/02/25 at 10:17 a.m., a fall mat was not observed on the floor next to the bed or under the bed of Resident #3. On 09/03/25 at 10:19 a.m., a fall mat was not observed on the floor next to the bed of Resident #3. On 09/03/25 at 2:05 p.m., a fall mat was not observed on the floor next to the bed of Resident #3. A care plan, dated 03/31/25, showed a focus for risk for falls related to decondition, gait/balance problems, psychotropic medications, psychoactive drug use and history of falls. The care plan showed interventions which included to ensure the call light was within reach, encourage to request assistance, falling star program, Hoyer lift for transfers, replace bolsters on bed to cue resident to the edge of bed, replace posey cover to mattress, and positioning bars. An unwitnessed fall report, dated 05/12/25 at 2:00 a.m., showed Resident #3 was on the floor and upon nurse assessment, Resident #3 kept yelling they wanted to go to the hospital and did not know how they fell. The nurse assessment showed no new injuries noted, vital signs normal, and Resident #3 denied pain with notifications made to all parties. The report showed the intervention was to place a floor mat at bedside.An incident note, dated 05/12/25 at 2:48 a.m., read in part, CNA notified nurse of resident on the floor .Resident kept yelling .to go to the hospital .Head to toe [assessment] preformed on resident. No new injuries notied [sic].An admission note, dated 05/14/25 at 4:39 p.m., showed, an incision site to left thigh with five staples noted. The note showed a bandage wrap to the left leg and immobilizer to the right leg. Review of a final state report, dated 05/16/25, showed Resident #3 sustained a closed fracture of the distal (a location farther away from the origin) end of the left femur and a tibial plateau fracture (a break in the shinbone (tibia) at the knee joint) of the right femur. An annual assessment, dated 06/12/25, showed Resident #3 had a BIMS of 13 which indicated the resident's cognition was intact and diagnoses which included arthritis, anxiety, bipolar, and respiratory failure. The assessment showed Resident #3 required supervision or touching assistance with bed mobility and transfers were not attempted due to medical condition or safety concerns. On 09/03/25 at 2:05 p.m., CMA #2 stated Resident #3 was on hospice and would normally require a fall mat, but Resident #3 did not move out of the bed. On 09/03/25 at 2:07 p.m., LPN #3 stated measures to prevent falls/injury for Resident #3 were to position them with pillows to prevent falling out of bed, keep the bed low, ensure frequent checks, and they were right by the nurse's station. LPN #3 was asked if Resident #3 required a fall mat. They stated Resident #3 could not get out of bed by themself or even turn themself. They stated the ADON or DON were responsible to ensure the care plan was updated. 2. On 08/29/25 at 2:34 p.m., Resident #48 was observed in bed with the fall mat under their bed. On 08/29/25 at 3:40 p.m., Resident #48 was observed in bed with the fall mat under their bed. On 09/02/25 at 9:32 a.m., Resident #48 was observed in bed with the bedside table near the head of the bed in front of their nightstand and the fall mat under their bed. An annual assessment, dated 05/21/25, showed a BIMS of 00 which indicated severely impaired for daily decision making. The assessment showed diagnoses which included chronic obstructive pulmonary disease, anxiety, and Bell's palsy. A fall risk assessment, dated 07/16/25, showed Resident #48 was a high fall risk. A progress note, dated 07/16/25 at 4:00 a.m., showed a focused assessment related to a fall on 07/16/25. The note showed Resident #48 had a laceration to the right side of the head with a hematoma (bruise) noted to the forehead. The note showed abrasions were noted to both knees with the fall mat in place. The note showed neurological checks were initiated, and Resident #48 had complained of generalized pain. The note showed an order was received to send Resident #48 to the hospital for evaluation and treatment. A care plan, revised 08/12/25, showed interventions for falls to include ensure a baby doll was in bed with Resident #48, assist with toileting at night, concave mattress while in bed, educate to not remove oxygen, fall mat at bedside, sign in room to ask for help, keep call light in reach, keep bed in lowest position, and nonskid footwear before transfers. On 09/02/25 at 11:09 a.m., CNA #1 stated the interventions for Resident #48 were a fall mat and to keep the bed low. On 09/03/25 at 2:03 p.m., CNA #4 stated interventions in place for Resident #48 were a fall mat and low bed. They stated they did not know why the fall mat was not there. On 09/03/25 at 2:20 p.m., the DON stated they provided in-service and education to the staff and observed to ensure the interventions were in place. On 09/03/25 at 5:29 p.m., LPN #4 stated Resident #48 was observed partially on the fall mat when they fell. They stated the event was so rushed they were trying to remember. LPN #4 stated they were not sure if Resident #48 hit their head on the nightstand, bed side table, or a clothes hamper that was close to them. They stated they did not see blood on anything, so they were not sure, but were sure Resident #48 had the fall mat because they used it anytime Resident #48 was in bed.

Based on observation, record review, and interview, the facility failed to ensure resident's right of choice regarding diet for 1 (#2) of 3 residents sampled reviewed for resident rights. The administrator identified 111 residents resided at the facility. Findings: On 05/28/25 at 8:23 a.m., Resident #2 was observed to be in their room drinking soda. An admission assessment, dated 07/25/23, showed Resident #2 had a brief interview for mental status score of 14 which indicated the resident's cognition was intact. The assessment showed the resident had diagnoses which included history of stroke and aphasia. A physician's order, dated 07/25/23, showed a regular diet of regular texture and thin liquids. A hospital discharge record, dated 01/11/24, showed a diet order for low cholesterol, low fat, and low sodium. A physician's order, dated 01/11/24, showed a regular diet, level 6-soft and bite-sized texture with honey thick liquids. On 05/28/25 at 8:23 a.m., Resident #2 stated they received a soft diet and did not want a soft diet and thickened liquids. They stated they had not ever choked on their food or drink. Resident #2 stated they were told by staff at the facility they would choke if they ate regular food. On 05/29/25 at 12:18 p.m., Resident #2 stated friends had brought them food from outside the facility like pizza, cake, candy chips, and soda pop. They stated the last swallow evaluation they had was while they were at home. Resident #2 stated they had not had a swallow evaluation while at the facility because the facility informed them their insurance would not cover it. Resident #2 stated they had been eating regular food while at home and when they first admitted to the facility. On 05/29/25 at 1:21 p.m., the ADON stated the nurses transcribed the orders from the hospital and entered them into the electronic clinical record. They stated Resident #2 had signed a waiver to eat regular food while on hospice after their hospitalization, but had since been discharged from hospice and the facility did not offer a waiver. The ADON stated they did not know where the soft diet order had originated from. They stated they did not remember if Resident #2 had a swallow study and were not aware if Resident #2 had any incidents of choking. The ADON stated the only thing they could think of was when Resident #2 returned from the hospital, they had requested over easy eggs instead of scrambled and maybe that was where the soft diet had originated. On 06/02/25 at 10:21 a.m., the social services director stated they did not know where the order had originated. They stated Resident #2 had been on hospice and had signed a waiver for a regular diet, but had since been discharged from hospice and the diet would have reverted back to a soft diet. On 06/02/25 at 10:39 a.m., the administrator stated they would not know why Resident #2 was ordered a soft diet and would need to get with nursing. The administrator stated the facility did not offer any waivers to any residents. They stated they did not tell Resident #2 they could not eat regular food, but they would not offer a waiver. On 06/02/25 at 11:08 a.m., the administrator and interim DON stated they had a physician's order and they were following it. The DON stated they would not question the physician for a justification for the order. On 06/02/25 at 11:14 a.m., the primary physician of Resident #2 was called and a voicemail was left for them to return the call. No return call was received. On 06/02/25 at 12:45 p.m., via phone call, LPN #1 stated after reviewing the hospital discharge orders for Resident #2 they could not trace the soft diet order to the discharge orders. They stated they believed the order on 01/11/25 was an error and the order was meant for another resident. LPN #1 stated they were not the nurse for Resident #2 on that day, but had been the admission nurse for the facility and had entered the orders from the hospital on that date. On 06/02/25 at 12:49 p.m., via phone call, the medical director stated they believed the soft diet order was due to a stroke and Resident #2 had a diagnosis of dysphasia. The medical director was informed the hospital discharge paperwork nor the facility had a diagnosis of dysphasia for Resident #2. The medical director was informed Resident #2 had no incident of choking. The medical director stated they were not the primary physician for Resident #2. On 06/02/25 at 12:51 p.m., via phone call, the office of the primary physician for Resident #2 was called and their office informed the primary physician was out of the office seeing patients and would return the call later in the afternoon. A return phone call was not received before the end of the survey.

Based on observation and interview, the facility failed to ensure food items were labeled and dated. The DON identified 122 residents received nourishment from the kitchen. Findings: On 09/16/24 at 8:50 a.m., two plastic containers with sliced cheese, one plastic container with diced onion, one plastic container with diced tomatoes, one plastic container with diced honey dew melon, one paper plate with sliced cheese, and one opened container of tuna salad were observed in refrigerator #1. The food products were not labled and dated. On 09/16/24 at 8:55 a.m., dietary manager #1 stated they do not know why the containers were not labeled or dated, but they should be.

Based on observation, record review, and interview, the facility failed to ensure chemicals were secured for three (100/200 hall, 700 hall, and 800 hall) of eight halls observed. The facility map identified eight halls in the facility. Findings: The Housekeeping policy, dated 06/29/12, read in part, .ALL HARMFUL CHEMICALS .MUST BE STORED IN A LOCKED STORAGE AT ALL TIMES, BEFORE AND AFTER USE . The Red Juice Stain Remover MSDS, dated 03/25/15, read in part, .KEEP OUT OF REACH OF CHILDREN . The Film Away MSDS, dated 04/16/15, read in parts, .Store locked up . The Shineline Emulsifier Plus MSDS, read in part, .Keep out of reach of children . The PRO-543 Universal Wallcovering Adhesive MSDS, dated 08/09/18, read in part, .Keep out of the reach of children . The FiberPRO TLC MSDS, dated 10/07/21, read in part, .Causes severe skin burns and eye damage .Store locked up . The [NAME] Clean + Protect or Advanced Clean + Protect MSDS, dated 06/20/23, read in part, .Store Out Of Reach Of Children . The Xcelente MSDS, dated 12/18/23, read in part, .Keep out of reach of children . The Heavy Duty Floor Stripper MSDS, dated 07/31/24, read in part, .Store locked up . On 09/16/24 at 12:26 p.m., the 800 hall linen closet was observed to be unlocked. The closet was observed to contain the following. a. six bottles of 7.5 fluid ounce periwash. The label documented to keep out of reach of children; and b. one, 11 ounce can of shaving cream. The label documented to keep out of reach of children. On 09/16/24 at 12:35 p.m., the 700 hall house keeping closet was observed to be unlocked. The closet was observed to contain the following. a. one box of multi-purpose floor finish. The label documented to keep out of reach of children; b. three, 32 ounce bottles of Betco spot cleaner. The label documented to keep out of reach of children; c. four, 946 ml bottles of red juice stain remover bottles. The label documented to keep out of reach of children; d. two, 32 ounce bottles of easy task cleaner. The label documented to keep out of reach of children; e. two, unlabeled bottles of blue liquid with approximately 11 ounces in one bottle and 32 ounces in the other one; f. one gallon of fiber pro tlc. The label documented to keep out of reach of children; g. one bottle of Xcelente multipurpose cleaner. The label documented to keep out of reach of children; h. three, five gallon buckets of hard as nails film floor finish. The label documented to keep out of reach of children; i. one bottle of film away with approximately 10 ounces of product in it. The label documented to keep out of reach of children; j. one gallon of heavy duty stripper floor stripper. The label documented to keep out of reach of children; k. one gallon of shine line emulsifier plus. The label documented to keep out of reach of children; l. one, 62 ounce bottle of [NAME] advanced clean and refresh approximately half full. The label documented to keep out of reach of children; m. one gallon of pro 543 universal wallpaper border adhesive. The label documented to keep out of reach of children; and n. one, 16.9 ounce bottle labeled as purified drinking water. The bottle was observed to contain a green liquid that foamed at the top when moved. On 09/16/24 at 12:37 p.m., the 100/200 hall central supply closet was observed to be unlocked. The latch on the door was observed to be taped open causing the door not to lock when shut. The closet was observed to contain iodine swab sticks. The label documented to keep out of reach of children. On 09/16/24 at 12:48 p.m., the DON stated the floor technician had been in the facility the previous night and must not have locked the door to the 700 hall housekeeping closet when they were finished. The DON stated the 800 hall linen closet did not lock, but the chemicals were to be stored in a locked cabinet. On 09/16/24 at 12:52 p.m., the administrator stated the green liquid in the purified drinking water bottle in the 700 hall housekeeping closet was not water and the door should have been locked. On 09/16/24 at 12:55 p.m., the DON observed the tape on the latch for the 100/200 hall central supply closet and stated nothing should be utilized to keep the door from locking. On 09/17/24 at 9:46 a.m., the 800 hall linen closet and the cabinet inside the closet were observed to be unlocked. The unlocked cabinet contained eight bottles of periwash and one bottle of shaving cream. The labels on the periwash and the shaving cream documented to keep out of reach of children. On 09/17/24 at 9:53 a.m., the DON stated they had placed a lock on the cabinet in the 800 hall linen closet yesterday. They stated central supply personnel were to monitor to ensure chemicals were secure when they stocked supplies daily.

Based on record review and interview, it was determined the facility failed to report an allegation of neglect to OSDH for one (#86) of one sampled resident reviewed for neglect. The DON identified 123 residents resided in the facility. Findings: The Resident Abuse, Neglect and Misappropriation of Property policy, revised 12/28/17, read in part, .neglect is defined as failure to provide good and services necessary to avoid physical harm, mental anguish or mental illness. Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas .Facility responsibility .All allegations and incidents of abuse, neglect .must be reported to appropriate Federal and State Agencies including OSDH and investigated . Resident #86's quarterly MDS assessment, dated 07/18/24 , documented their cognition was intact and they had no cognitive impairments. The facility form, Quality Assurance Patient Concern Form, dated 09/10/24, read in part, .Resident complained about nurse aide not providing good care. Nurse Aide was told to help change people but refused . There was no documentation the facility had reported the allegation of neglect to OSDH. On 09/17/24 at 8:28 a.m., Resident #86 stated they had turned on their call light and after several hours an aide shut it off without providing care to both their roommate and themselves. The resident stated the nurse aide, after shutting off the call light, stated they would come back and provide care to the roommate and never returned. The resident stated they had spoken with and filed a complaint of the care not being provided with the ADON about two weeks previously. They stated nothing was done about it. On 09/18/24 at 3:12 p.m., the ADON confirmed Resident #86 had complained about the lack of care and they stated they reported it to the administrator. The ADON stated a grievance form was filled out and the administrator completed everything after that. They stated they did not document the report from the resident and was not sure who it all was reported to. On 09/19/24 at 2:10 p.m., the administrator confirmed they had spoken with the ADON and a grievance form was filled out. They stated they only reported to OSDH if they felt abuse occurred and it was the opinion of Resident #86 care was not provided.

Based on record review and interview, it was determined the facility failed to thoroughly investigate an allegation of neglect for one (#86) of one sampled resident reviewed for neglect. The DON identified 123 residents resided in the facility. Findings: The Resident Abuse, Neglect and Misappropriation of Property policy, revised 12/28/17, read in part, .neglect is defined as failure to provide good and services necessary to avoid physical harm, mental anguish or mental illness. Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas .Facility responsibility .All allegations and incidents of abuse, neglect .must be .investigated . Resident #86's quarterly MDS assessment, dated 07/18/24 , documented their cognition was intact and they had no cognitive impairments. The facility form, Quality Assurance Patient Concern Form, dated 09/10/24, read in part, .Resident complained about nurse aide not providing good care. Nurse Aide was told to help change people but refused . There was no documentation the facility completed a thorough investigation into the allegation of neglect. On 09/17/24 at 8:28 a.m., Resident #86 stated they had turned on their call light and after several hours an aide shut it off without providing care to both their roommate and themselves. The resident stated that the nurse aide, after shutting off the call light, stated they would come back and provide care to the roommate and never returned. The resident stated they had spoken with and filed a complaint of the care not being provided with the ADON about two weeks previously. They stated nothing was done about it. On 09/18/24 at 3:12 p.m., the ADON confirmed Resident #86 had complained about the lack of care. They stated they reported it to the administrator. The ADON stated a grievance form was filled out and the administrator completed everything after that. They stated they did not document the report from the resident and was not sure who it all was reported to. The ADON stated they did not complete an investigation and only reported it to the administrator. On 09/19/24 at 2:10 p.m., the administrator confirmed they had spoken with the ADON and a grievance form was filled out. The administrator stated they only spoke to one aide that was working on the hall and did not speak with the roommate or take a full statement from Resident #86. The administrator stated they did not interview other residents, but completed a full investigation. The administrator then stated they did not have statements to provide for the one aide that was interviewed. They did not document anything due to Resident #86 always complaining about the aide.

Based on record review, and interview, the facility failed to ensure a resident who had not had a bowel movement for three more days had their attending physician notified for one (#16) of one sampled resident reviewed for constipation. The DON identified 70 residents who had a diagnosis of constipation. Findings: The facility policy, titled Nursing Policies and Procedures Constipation, dated 10/10/03, read in part, .It is the policy of the facility to identify bowel elimination problems and intervene to assist residents with optimal bowel elimination. Assessment for constipation is initiated from a resident complaint or observation that the resident has been 3 days without a bowel movement .procedure for identification .review the flow sheet documentation to determine frequency .assess for signs and symptoms of constipation .identify usual bowel elimination patterns .procedure for correction notify the attending physician . Resident #16 had diagnoses which included encounter for orthopedic aftercare following a surgical ambulation and constipation. Resident #16's quarterly assessment, dated 08/07/24, documented they had moderate impairment with cognition and was always continent of bowel and bladder. ADL documentation for 08/29/24 through 09/05/24 documented Resident #16 had a bowel movement on 08/30/24. The next documented bowel movement for Resident #16 was five days later on 09/05/24. Resident #16 had not had a bowel movement in five days and the documentation on 09/05/24 indicated the resident was constipated. There was no documentation Resident #16's physician had been notified of them not having a bowel movement for five days and being constipated. Resident #16's September 2024 MAR documented they received an as needed order of magnesium hydroxide oral suspension (laxative medication) 400 MG/5 ML (magnesium hydroxide) 30 ml for constipation on 09/05/24 at 10:50 p.m. Resident #16's ADL documentation for 09/06/24 documented they did not have a bowel movement. There was no documentation Resident #16's physician had been notified of no bowel movements on 09/06/24. Resident #16 ADL documentation for 09/07/24 documented the they did not have a bowel movement. Resident #16's progress note, dated 09/07/24 at 4:36 p.m., documented, Therapy here working with resident. [He/She] states that resident states that [he/she] is constipated. Abdomen soft, ABS x 4. [He/She] is complaining of [his/her] rectum hurting I checked it and a sm amt of runny BM at entrance. No impaction noted. Bedside commode has wipes in it with smears of BM. No noted BM in commode. Informed [Name withheld] and new order received for Miralax [laxative medication] 17GM daily and Dulcolax [laxative medication] 5mg 2 BID PRN. A progress note, dated 09/07/24 at 4:36 p.m., documented notification to Resident #16's physician. On 09/19/2024 at 9:53 a.m., RN # 1 stated they were not aware Resident #16 was constipated and went five days without a bowel movement. They stated they had never notified the physician. RN #1 stated the physician was not notified until 09/07/24 when the resident went out to the hospital. On 09/19/24 at 11:11 a.m., the DON stated they identified the resident had not had a bowel movement for more then three days when they came back from vacation. They stated they realized nothing had been addressed. They stated the physician had not been notified until 09/07/2024 when the resident went to the hospital.

On 09/05/24, a Past Noncompliance Immediate Jeopardy situation was determined to exist related to the facilities failure to ensure Resident #1 was supervised and not using oxygen while smoking. A plan of correction document, titled Smoking Incident, the facility documented the facility completed the following actions: - Designated the smoking area as the patio off the north unit. - Posted No Oxygen Beyond This Point signs on the smoking area doors. - Added No Smoking signs to the garden area and the south door. - In-serviced all staff on smoking policy/plan. - Held a resident council meeting to discuss changes with residents. - Reassessed all residents who smoke for safety. - Updated smoking contracts on residents who smoke. - Educated residents on smoking hazards, options for smoking cessation and vaping. - All smoking will now be supervised, all smoking material will be secured by staff. - Smoking will be from 8:00 am until 8:00 pm on even hours. - All units now have a red folder with a current list of residents who smoke. A Quality Assurance Committee meeting was held on 08/28/24 at 1:00pm. On 09/05/24 staff were interviewed regarding recent training related to smoking and safety. All components of the plan of correction were verified. It was determined that the facility was in substantial compliance. Based on record review and interview, the facility failed to ensure a resident who required supervision while smoking was supervised and did not wear oxygen while smoking for one (#1) of four residents reviewed for smoking. The Administrator reported the census was 120. Findings: A facility policy titled Smoking Policy and Procedure, revised 02/24/20, read in parts .Oxygen equipment is not permitted in smoking areas. Smoking is not permitted while in possession of or in the presence of oxygen equipment .If it is determined by the interdisciplinary team that the resident is unable to smoke without supervision, such team will develop a plan that will allow the resident to smoke with supervision . Resident #1 had diagnoses which included dementia and chronic obstructive pulmonary disease. A quarterly assessment, dated 06/05/24, documented Resident #1 was moderately impaired for daily decision making and could independently operate a manual wheelchair. A physician's order, dated 07/29/24, documented the resident was to receive oxygen at 2-4 liters per minute via a nasal cannula as needed to maintain an oxygen saturation above 90 percent. A Smoking/Vaping Supervision Checklist, dated 06/19/24, documented Resident #1 was to be supervised while smoking. A nurse note, dated 08/27/24 at 7:26 p.m., documented that at 4:00 pm the nurse was notified by a CMA that Resident #1 was on fire. The nurse accompanied the CMA outside where Resident #1 was sitting in a wheelchair that appeared burned or melted, Resident #1 was naked and appeared to have multiple areas of burned skin. The note further documented that it appeared Resident #1 had tried to smoke with their oxygen on. The note documented the resident was transported via EMS to a hospital burn center. On 09/09/24 at 10:03 am, a supervised smoke break was observed. Two staff members were present along with eight residents, two residents were observed to be wearing smoking aprons. RA #1 stated that each nurses desk has a red folder with a list of smokers and what interventions are required. They also stated that staff now secures everyones smoking material. On 09/05/24 at 12:10 p.m., LPN #1 stated that on 08/27/24 around 4:00 pm they were called to the courtyard area by a CMA. They stated Resident #1 was no longer on fire when they arrived outside, and several staff members were present trying to assist the resident. They stated that Resident #1 was conscious and complaining they could not breathe, Resident #1 was taken inside and placed on oxygen. LPN #1 stated they provided assistance to Resident #1 until EMS arrived. On 09/05/24 at 1:00 p.m., the ADON stated that on 08/27/24 around 4:00 pm they were in their office when they heard someone yelling fire, they went to investigate and located the resident outside with several staff members. They stated by the time they arrived the fire was out, and staff were assessing and rendering aid to the resident. They also stated that Resident #1 was alert when EMS took them out of the building and that they were told the next day by Resident #1's hospice provider that the resident had passed away at the hospital. On 09/05/24 at 1:27 p.m., CMA #1 stated that on 08/27/24 around 4:00 p.m. they had gone outside to administer medication to Resident #5 who was under the gazebo. They stated Resident #5 pointed at Resident #1 across the courtyard and yelled that Resident #1 was on fire. CMA #1 stated that they observed Resident #1 seated in their wheelchair burning. CMA #1 stated they did not have anything to put out the fire with, so they ran inside to get help. CMA #1 stated that no staff members had been supervising Resident #1. On 09/05/24 at 3:34 p.m., CNA #1 stated that on 08/27/24 around 4:00 p.m., they were in the dining room passing out drinks for dinner when they heard someone yelling about a fire. CNA #1 reported they observed Resident #1 seated in their wheelchair on fire in the courtyard. They also reported that they got a shower blanket and went outside and began smothering the flames with the blanket. CNA #1 reported that after the fire was out and Resident #1 was transferred to another wheelchair they were brought inside until paramedics arrived. CNA #1 stated Resident #1 was not being supervised while smoking. On 09/05/24 at 2:50 p.m., the administrator stated that their investigation did not indicate Resident #1 was being supervised while smoking on 08/27/24. The administrator also stated fire blankets had been ordered, but had not been received.

On 09/26/19 at 7:05 a.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) related to the failure to prevent accident hazards in a resident accessible area of the satellite kitchenette. At 7:08 a.m., the steam table in the south dining room satellite kitchen was observed with an ADON. Steam was visible from the steam table. The temperature of the top corner of the steam table was measured at 199.5 degrees F and she was informed of the I[NAME] Communication with the administrator was requested. At 7:15 a.m., the administrator was informed of the IJ related to the resident accessibility to the hot steam table. The temperature of the top corner of the steam table was measured in the presence of the administrator at 200 degrees F. The administrator was asked for a plan removal. At 7:16 a.m., the administrator secured the doors to the kitchenette and posted a staff member to remain in the kitchenette while the steam table was hot. An acceptable plan of removal was received from the administrator on 09/26/19 at 9:30 a.m. The plan of removal documented: Plan of removal (name deleted facility) 9/26/19 Area where steam table is located was secured immediately by administrator. 7:15 am 9/26/19(.) All staff will be inserviced. This will be completed by 9/26/19(.) In-service scope will include steam table area will be locked or attended by staff while steam table is on or temp above 115 degrees. The IJ was removed on 09/26/19 at 10:02 p.m., after all components of the plan of removal had been completed. The deficient practice remained at a pattern level with the potential for more than minimal harm. Based on observation and interview, it was determined the facility failed to provide a safe environment in the satellite kitchenette adjacent to the south dining room by failing to monitor, supervise, and/or secure the hot steam table. The kitchenette housed a refrigerator, microwave, commercial coffee and tea makers, and a steam table for meal service. The facility identified 25 residents utilized the kitchenette for coffee and/or tea and seven confused and wandering residents resided on the center or south halls adjacent to the south dining room and kitchenette. Findings: The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, dated revised on 11/22/17, documented the following related to hazardous hot water temperatures: .Many residents in long-term care facilities have conditions that may put them at increased risks [MEDICAL CONDITION] by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, [MEDICAL CONDITION], decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate . The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure . (A chart in the regulations documented that a water temperature of 155 degrees F. would result in a 3rd degree burn in one second) . Third-[MEDICAL CONDITION] the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-[MEDICAL CONDITION] third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black . On 09/25/19 at 3:10 p.m., an observation of the south dining room, situated between the center and south halls/nurses' station was conducted. On the south end of the dining room, there was an open entryway onto a short hall which ran parallel to a portion of the dining room and housed an ice machine, a small kitchenette with double doors, a dining table, and a small office. The hall exited at another entryway on the north end of the dining room. The doors to the kitchenette were open. Standing at the doorway, a commercial coffee maker/dispenser and commercial tea maker/dispenser were observed on the left, to either side of a large sink. A microwave, steam table, and refrigerator were observed to the right. The microwave was observed facing north on a small table in the south west corner of the kitchenette. Beside the microwave lay the steam table, its length running north to south for approximately eight feet, creating a walkway between the west wall of the kitchenette and the steam table. This walkway provided access to the microwave and the front of the steam table. Behind the steam table and in the south east corner of the kitchenette was the refrigerator. On 09/25/19 at 3:20 p.m., the steam table was observed to be on and hot. The temperature of the corner edge of the steam table was measured at 186 degrees F. On 09/25/19 at 4:15 p.m., resident #86 was propelling herself in a wheelchair in the south dining room. Resident #86 propelled herself into the hallway that led to kitchen. She propelled herself approximately three feet from the open door where the steam table was located. The surveyor brought it to the attention of the activities staff member #1 that a resident was entering the kitchenette. The activities staff member walked over to the resident and asked the resident if she needed help as she was assisted back into the south dining room. On 09/25/19 at 5:30 p.m., the steam table was observed off and only warm to the touch. On 09/26/19 at 6:10 a.m., the steam table in the kitchenette was observed to be on but not burning hot to the touch. There was no nursing or dietary staff present in the kitchenette. At 6:35 a.m., resident #114 was observed to enter the kitchenette and obtain a cup of coffee from the coffee dispenser. He then exited the kitchenette. The temperature of the corner of the steam table was measured at 171 degrees F. There was no facility staff present in or near the kitchenette. At 6:38 a.m., DA #3 was observed to enter the hall and continue to clear ice from the ice machine located just south and outside of the kitchenette. The DA remained at the ice machine, clearing the stored ice for the machine to be commercially cleaned, until just after 7:00 a.m. when she left the area. At 7:08 a.m., the steam table in the south dining room satellite kitchen was observed with an ADON/LPN #1. The temperature of the top corner of the steam table was measured at 199.5 degrees F and she was informed of the I[NAME] She stated she would monitor the steam table for resident safety and contact the administrator. At 7:12 a.m., resident #79 was observed to enter the kitchenette in her wheelchair with a coffee cup in her hand. The resident was observed beside the steam table when she was stopped by staff. The resident stated she wanted to use the microwave to heat up her coffee. At 7:15 a.m., the administrator was informed of the IJ related to accident hazards. He asked if he needed to close and secure the doors to the kitchenette. At 7:16 a.m., the administrator closed and secured the doors to the kitchenette. At 9:45 a.m., the administrator asked if any residents were observed in the kitchenette. Resident #79 was present and she was asked if she used the microwave located in the kitchenette. She stated, she often used it to heat up her coffee.

Based on observation, interview, and record review, it was determined the facility failed to follow the care plan for two (#2 and #4) of four sampled residents whose care plans were reviewed for transfers. Resident #4, who required extensive asistance of two persons for transfers per her care plan, sustained a fracture of her femur when she was transferred with only one staff member. The facility identified 50 residents who required a mechanical lift for transfers. Findings: 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 04/16/15, documented, Focus .has ADL self care deficit r/t [DIAGNOSES REDACTED]/[MEDICAL CONDITION] .Goal .will have assist with ADL's and mobility as needed through the review date .Interventions .non-ambulatory .Transfers .extensive assist x 2 .W/C mobility .supervision at times on and off unit via electric w/c . A quarterly assessment, dated 07/03/17, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident required extensive assistance with two plus persons physical assist for transfers, was not steady, only able to stabilize with staff assistance for surface-to-surface transfers, had functional limitation in range of motion for one side of upper extremities, impairment on both sides of lower extremities, and required a wheel chair for mobility. The assessment also documented the resident had active [DIAGNOSES REDACTED]. A state reportable incident report, dated 09/18/17, documented, .resident complained of right knee pain. Focused assessment completed. No swelling or bruising noted. Resident c/o pain upon ROM. Pain medication was administered. No other injuries noted with assessment. Dr. (name deleted) notified. POA (name deleted) notified. Resident interviewed and stated .'reposition of leg the cna heard a pop and then resi (sic) stated 'it does that all the time.' POA .expressed concern that the CNA (name deleted) had broke her sisters leg. CNA (name deleted) suspended pending further investigation .police department notified. Appropriate licensing board, Dr. (name deleted) notified. (Name deleted POA) notified. Appropriate staff members .interviewed. X-ray orders obtained per physician orders [REDACTED].uses a motorized wheel chair for mobility .requires assistance with transfers and ADL's .has [DIAGNOSES REDACTED] .paralyti[DIAGNOSES REDACTED] .chronic pain .upon completion of the investigation, the facility determined that the resident was injured during an assisted transfer .as resident transferred (sic) to chair from bed the footboard of the motorized wheelchair was pushed from an upright position to lower position by resident right leg causing pressure to right leg during the transfer to a seated position. Final xray results revealed a fracture to right distal femur .new order to send to ER for further evaluation and treatment .returned to facility with a leg brace .spoke with appropriate staff regarding safe transfers. Educated family and resident on benefits of a (mechanical) lift especially with the specific disease process that indicated resident is at a higher risk for fractures .(name deleted) has been reinstated. Appropriate staff members have been in-serviced on .transfers. Family, resident and physician agreeable with the poc .appropriate safety/fall precautions in place .Falling star updated and care plan updated to reflect (mechanical) lift for transfers . A significant change assessment, dated 10/02/17, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident required extensive assistance with two plus person physical assist for transfers, was not steady, only able to stabilize with staff assistance for surface-to-surface transfers, and had functional limitation in range of motion for one side of upper extremities, and impairment on both sides of lower extremities, and required a wheelchair for mobility. The assessment also documented the resident had active [DIAGNOSES REDACTED]. A care plan, revised on 10/04/17, documented, Focus .has ADL self care deficit r/t [DIAGNOSES REDACTED]/paralysis .Goal .will have assist with ADL's and mobility as needed through the review date .Interventions .non-ambulatory .Transfers .(mechanical) lift with purple pad x 2 staff .W/C mobility .supervision at times on and off unit via electric w/c . On 11/07/17 at 11:55 a.m., the resident was asked to describe what had occurred regarding the transfer and leg fracture on 09/17/17. She stated the CNA had been in a hurry and picked her up and pivoted her by himself without the use of a gait belt. The resident stated her leg slipped down when the CNA pivoted her and she heard a popping sound and then heard another popping sound when he sat her in the wheel chair. She stated, I didn't think about it because I don't have much feeling in it and I do pop and creak and I didn't tell the nurse. She stated the CNA told the nurse the next day and an xray was ordered. Documentation on the falling star sheet posted in the resident's room revealed she required a mechanical lift with two persons assist for transfers. At 1:23 p.m., CMA/CNA #1 was asked what had occurred on 09/17/17 when he had assisted the resident with a transfer. He stated, I was transferring her from her bed to the wheel chair and the foot rest was in the up position. At the time the resident was a two person assist and I didn't have any help on the floor. We were minimum staffed and the resident was impatient and wanted up to go to activities. When I went to put her in the chair her right leg impacted the foot rest and caused a fracture. I went to scoot her over and her left leg popped. I heard only one pop. He was asked how he had transferred her. He stated, I put my arms under her arms and I lifted her and put her over in the chair. He was asked if he had used a gait belt. He stated, No, the resident has no use of her legs. He was asked if he had looked at the falling star located in the resident's room to determine how the resident should have been transferred. He stated, I didn't take time to look at it before I transferred her. On 11/13/17 at 3:45 p.m., the DON was asked why the CNA had transferred the resident by himself when she was a two person assisted transfer. She stated she did not know why. She stated the CNA should have requested and waited for assistance before transferring the resident. 2. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, revised on 07/02/15, documented, Focus .ADL'S .requires vaired (sic) level of assist with ADL'S R/T impaired mobility with left sided [MEDICAL CONDITION] R/T Hx.[MEDICAL CONDITION].Goal .will be clean and well groomed daily with assist as needed through the review date .Interventions .Transfers .(total) Staff utilize the lift for transfers at this time . An update to the care plan, dated 01/03/17, documented, Falls: 2 person assist at all times . A quarterly assessment, dated 08/15/17, documented the resident had a BIMS score of five. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with two plus persons physical assist for transfers, was not steady, only able to stabilize with staff assistance for surface-to-surface transfers, had impairment on one side of upper and lower extremities, and had active [DIAGNOSES REDACTED]. An incident report, dated 10/18/17, documented, .CNA reports that when he went to raise (mechanical) lift, lift bump (sic) the trapeze bar and bar hit the resident over the left side of her eye. No bruising, or swelling, noted at this time .Immediate Action Taken .neuro checks started and staff education done . A care plan, revised 10/18/17, documented, Focus .is at risk for falls R/T Hx. of falls, impaired mobility, [MEDICAL CONDITION] drug use, and dx. [MEDICAL CONDITION] disorder .Goal .will minimize injury R/T falls daily through the review date .Interventions .2 person assist at all times .10/18/17-bumped head on trapeze bar during transfer .I-raise trapeze bar and staff education . On 11/08/17 at 11:15 a.m., CNA #1 was asked what had happened during the incident on 10/18/17 with the resident. He stated the lift bar bumped the trapeze bar above the resident's bed and the trapeze bar hit the resident over the left eye. He was asked if he had another staff person with him when using the mechanical lift for the transfer. He stated, No, it was a busy time of day and the other CNA was busy and I was trying to keep on schedule so I did the transfer by myself. At 2:39 p.m., a falling star was observed in the resident's room. Documentation on the back of the falling star revealed the resident required two person assist for transfers. On 11/13/17 at 3:56 p.m., the DON was asked if the CNA should have used the mechanical lift by himself to transfer the resident. She stated, No. She was asked why the CNA had transferred the resident by himself when she was a two person assisted transfer. She stated she did not know why, but the CNA should have requested and waited for assistance before transferring the resident. She was asked why the CNA had not followed the resident's care plan for transfers with a mechanical lift. She stated, He should have been.

Based on record review, observation, and interview, it was determined the facility failed to ensure adequate supervision was provided and/or mechanical lifts were utilized during transfers to prevent accidents for three (#2, #3, and #4) of four sampled residents who were reviewed for transfers. Resident #4, who required extensive asistance of two persons for transfers, sustained a fracture of her femur when she was transferred with only one staff member. The facility identified 50 residents who required the use of a mechanical lift for transfers. Findings: A facility policy regarding the use of a hydraulic lift, dated 01/02/07, documented, .It is Grace Living Centers policy to have two staff members present during transfer to stabilize and support the resident .check with a licensed nurse to make sure this resident should be transferred by hydraulic lift as reflected in his plan of care .if the resident has an altered center of gravity (caused by a halo vest or a lower-extremity cast, for example) obtain help from a licensed nurse before transferring him with a hydraulic lift . 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 04/16/15, documented, Focus .has ADL self care deficit r/t [DIAGNOSES REDACTED]/[DIAGNOSES REDACTED] .Goal .will have assist with ADL's and mobility as needed through the review date .Interventions .non-ambulatory .Transfers .extensive assist x 2 .W/C mobility .supervision at times on and off unit via electric w/c . A quarterly assessment, dated 07/03/17, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident required extensive assistance with two plus persons physical assist for transfers, was not steady, only able to stabilize with staff assistance for surface-to-surface transfers, had functional limitation in range of motion for one side of upper extremities, impairment on both sides of lower extremities, and required a wheel chair for mobility. The assessment also documented the resident had active [DIAGNOSES REDACTED]. A state reportable incident report, dated 09/18/17, documented, .resident complained of right knee pain. Focused assessment completed. No swelling or bruising noted. Resident c/o pain upon ROM. Pain medication was administered. No other injuries noted with assessment. Dr. (name deleted) notified. POA (name deleted) notified. Resident interviewed and stated .'reposition of leg the cna heard a pop and then resi (sic) stated 'it does that all the time.' POA .expressed concern that the CNA (name deleted) had broke her sisters leg. CNA (name deleted) suspended pending further investigation .police department notified. Appropriate licensing board, Dr. (name deleted) notified. (Name deleted POA) notified. Appropriate staff members .interviewed. X-ray orders obtained per physician orders [REDACTED].uses a motorized wheel chair for mobility .requires assistance with transfers and ADL's .has [DIAGNOSES REDACTED] .paralyti[DIAGNOSES REDACTED] .chronic pain .upon completion of the investigation, the facility determined that the resident was injured during an assisted transfer .as resident transferred (sic) to chair from bed the footboard of the motorized wheelchair was pushed from an upright position to lower position by resident right leg causing pressure to right leg during the transfer to a seated position. Final xray results revealed a fracture to right distal femur .new order to send to ER for further evaluation and treatment .returned to facility with a leg brace .spoke with appropriate staff regarding safe transfers. Educated family and resident on benefits of a (name deleted) lift especially with the specific disease process that indicated resident is at a higher risk for fractures .(name deleted) has been reinstated. Appropriate staff members have been in-serviced on .transfers. Family, resident and physician agreeable with the poc .appropriate safety/fall precautions in place .Falling star updated and care plan updated to reflect (name deleted) lift for transfers . A witness statement, dated 09/18/17 at 10:13 a.m., documented, .during reposition of .leg further onto the foot rest we heard a pop .I encouraged her to let nurse know if she has any issues from it (the pop) . A radiology report, dated 09/18/17 at 6:34 p.m., documented, .Impression .acute fracture of the distal femur . A nurse's note, dated 09/18/17 at 8:10 p.m., documented, .XRay results received .impacted fracture of the distal femur noted and chronic fracture of the proximal tibia .Dr .notified of XRay results .new orders received to send to emergency room .new transfer requirements (mechanical) lift . A significant change assessment, dated 10/02/17, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident required extensive assistance with two plus person physical assist for transfers, was not steady, only able to stabilize with staff assistance for surface-to-surface transfers, and had functional limitation in range of motion for one side of upper extremities, and impairment on both sides of lower extremities, and required a wheelchair for mobility. The assessment also documented the resident had active [DIAGNOSES REDACTED]. A care plan, revised on 10/04/17, documented, Focus .has ADL self care deficit r/t [DIAGNOSES REDACTED]/paralysis .Goal .will have assist with ADL's and mobility as needed through the review date .Interventions .non-ambulatory .Transfers .(mechanical) lift with purple pad x 2 staff .W/C mobility .supervision at times on and off unit via electric w/c . On 11/07/17 at 11:55 a.m., the resident was asked to describe what had occurred regarding the transfer and leg fracture on 09/17/17. She stated CMA/CNA #1 had been in a hurry and picked her up and pivoted her by himself without the use of a gait belt. The resident stated her leg slipped down when the CMA/CNA #1 pivoted her and she heard a popping sound and then heard another popping sound when he sat her in the wheel chair. She stated, I didn't think about it because I don't have much feeling in it and I do pop and creak and I didn't tell the nurse. She stated the CMA/CNA #1 told the nurse the next day and an xray was ordered. Documentation on the falling star sheet posted in the resident's room revealed she required a mechanical lift with two persons assist for transfers. At 1:23 p.m., CMA/CNA #1 was asked what had occurred on 09/17/17 when he had assisted the resident with a transfer. He stated, I was transferring her from her bed to the wheel chair and the foot rest was in the up position. At the time the resident was a two person assist and I didn't have any help on the floor. We were minimum staffed and the resident was impatient and wanted up to go to activities. When I went to put her in the chair her right leg impacted the foot rest and caused a fracture. I went to scoot her over and her left leg popped. I heard only one pop. He was asked if he had reported the incident to the nurse. He stated, No, I was falling behind and the resident said she would report it. He was asked when the incident had been reported. He stated, The next day the resident was complaining of pain so I reported it to the day shift nurse. He was asked how he had transferred her. He stated, I put my arms under her arms and I lifted her and put her over in the chair. He was asked if he had used a gait belt. He stated, No, the resident has no use of her legs. He was asked if he had looked at the falling star located in the resident's room to determine how the resident should have been transferred. He stated, I didn't take time to look at it before I transferred her. He was asked if he had received any training regarding transferring residents. He stated he had received training regarding transfers when he had been hired in September of 2016. CMA/CNA #1 was asked if he had received any training regarding transfers after the incident had occurred. He stated, Yes, the DON talked with me about the falling star program and the proper way to transfer and to wait for and ask for assistance. He was asked if he had received any specific information regarding transfers for the resident. He stated, She is a two person transfer, and also I was told not to provide any care for the resident, another CNA would provide her care. He stated, She is now a (mechanical) lift with two person assist. He was asked why he was told to not provide care for the resident. He stated he had been told the resident didn't want him to care for her anymore. He was asked why he had been doing patient care on the floor instead of passing medications. He stated, I was working on the med cart and was pulled to work the floor for forty minutes to one hour. He was asked why he had been pulled away from the med cart to work the floor as a CNA. He stated, We were working short staffed. On 11/08/17 at 11:45 a.m., the resident was observed being transferred by (mechanical) lift from her bed to her electric wheel chair by CNA #8 and CNA #4. No licensed nurse was observed in the room during the transfer. At 1:40 p.m., CNA#2 was asked how the resident was to be transferred. She stated the resident was a two person assist with a mechanical lift. She was asked how she knew what type of transfer a resident required. She stated it was written on the back of the falling star in each resident's room. She was asked if she had been trained on transfers. She stated, Staff are trained on that their first day of employment. At 2:36 p.m., a falling star was observed in the resident's room. Documentation on the back of the falling star revealed the resident was to be transferred with a mechanical lift with two person assist. On 11/09/17 at 2:10 p.m., CNA #3 was asked how she knew what type of transfer a resident required. She stated it depended on the resident's condition. She was asked if she had been educated on the falling star program. She stated, No. On 11/13/17 at 10:10 a.m., RN #2 was asked if she was aware of the mechanical lift policy for residents who had an altered center of gravity such as a cast or brace on the lower extremities which required a licensed nurse to be present during the transfer. She stated, I don't remember that. I didn't know. She was asked if that information had been brought to her attention at any in-services. She stated, No. At 10:15 a.m., RN #1 was asked if she was aware of the mechanical lift policy for residents who had an altered center of gravity such as a cast or brace on the lower extremities which required a licensed nurse to be present during the transfer. She stated, I am aware of the mechanical lift policy. She was asked if she realized that a licensed nurse was to be present during the transfer of a resident by mechanical lift for residents with an altered center of gravity caused by a cast or brace to the lower extremities. She stated, I missed it. She was asked if that information had been brought to her attention at any in-services. She stated, No. At 3:45 p.m., the DON was asked why the CNA had transferred the resident by himself when she was a two person assisted transfer. She stated she did not know why. She stated the CNA should have requested and waited for assistance before transferring the resident. She was informed of the observation of the resident being transferred from her bed to her wheel chair by two CNAs when she had a brace on her right leg. She was asked why a licensed nurse had not assisted with the transfer of the resident since she had a lower extremity brace on her right leg. She stated, It was a knowledge deficit on our part. It is not on our skills check list. She was asked if the nurses and aides should have been aware of the facility policy. She stated, Yes. 2. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, revised on 07/02/15, documented, Focus .ADL'S .requires vaired (sic) level of assist with ADL'S R/T impaired mobility with left sided hemiparesis R/T Hx. CVA .Goal .will be clean and well groomed daily with assist as needed through the review date .Interventions .Transfers .(total) Staff utilize the lift for transfers at this time . An update to the care plan, date 01/03/17, documented, .Falls: .2 person assist at all times . A quarterly assessment, dated 08/15/17, documented the resident had a BIMS score of five. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with two plus persons physical assist for transfers, was not steady, only able to stabilize with staff assistance for surface-to-surface transfers, had impairment on one side of upper and lower extremities, and had active [DIAGNOSES REDACTED]. A nurse's note, dated 10/18/17 at 8:47 a.m., documented, CNA reports that when he went to raise (mechanical) lift, lift bump (sic) the trapeze bar and bar hit the resident over the left eye. No bruising, or swelling, noted at this time .neuro checks started and staff education done . An incident report, dated 10/18/17, documented, .CNA reports that when he went to raise (mechanical) lift, lift bump (sic) the trapeze bar and bar hit the resident over the left side of her eye. No bruising, or swelling, noted at this time .Immediate Action Taken .neuro checks started and staff education done . A care plan, revised 10/18/17, documented, Focus .is at risk for falls R/T Hx. of falls, impaired mobility, psychotropic drug use, and dx. seizure disorder .Goal .will minimize injury R/T falls daily through the review date .Interventions .2 person assist at all times .10/18/17-bumped head on trapeze bar during transfer .I-raise trapeze bar and staff education . On 11/08/17 at 11:15 a.m., CNA #1 was asked what had happened during the incident on 10/18/17 with the resident. He stated the lift bar bumped the trapeze bar above the resident's bed and the trapeze bar hit the resident over the left eye. He was asked if he had another staff person with him when using the mechanical lift for the transfer. He stated, No, it was a busy time of day and the other CNA was busy and I was trying to keep on schedule so I did the transfer by myself. He was asked if he received any education regarding this incident. He stated no. He was asked if he received training on the use of mechanical lifts during new employee orientation. He stated he was trained to use two people with mechanical lifts. He was asked why he transferred the resident without the help of another staff member. He stated, I was so busy and I was running late for her schedule, so I didn't wait to have another person assist me. He was asked if he was following the facility's policy for the use of mechanical lifts when he transferred the resident with the lift by himself. He stated, No, whenever I am using the lift it is on a case by case basis, if there had been more staff it would have helped. At 2:39 p.m., a falling star was observed in the resident's room. Documentation on the back of the falling star revealed the resident required two person assist for transfers. On 11/13/17 at 3:56 p.m., the DON was asked if the CNA should have used the mechanical lift by himself to transfer the resident. She stated, No. She was asked why the CNA had transferred the resident by himself when she was a two person assisted transfer. She stated she did not know why, but the CNA should have requested and waited for assistance before transferring the resident. She was asked if the CNA had followed the facility's policy regarding the use of mechanical lifts for transfers. She stated, No, he was not following the policy. She was asked if the CNA had received any education or in-services after the incident. She stated, No. 3. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, revised 10/04/16, documented, Focus .has an ADL self care performance deficit r/t limited mobility due to recent hospitalization for sepsis with UTI/C Diff infections .Goal .will improve current level of function .through the review date .Interventions .Transfers .total assist . An annual assessment, dated 08/15/17, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident was totally dependent for transfers with two plus persons, was not steady, only able to stabilized with staff assistance for surface-to-surface transfers, had impairment on both sides of upper and lower extremities, and had active [DIAGNOSES REDACTED]. An incident report, dated 10/04/17 at 7:20 a.m., documented, .CNA reports that during transfer with (mechanical) lift the bar of the lift bumped the bridge of resident's nose. No bruising, swelling, or pain noted to nose. Resident said her nose was bumped during transfer. A nurse's note, dated 10/04/17 at 9:15 a.m., documented, CNA reports that during transfer with (mechanical) lift the bar of the lift bumped the bridge of resident's nose. No bruising, swelling, or pain noted to nose. Resident said her nose was bumped during transfer. Neuro checks started, staff education, and (mechanical) lift bar padded . A care plan, dated 10/04/17, documented, Focus .has a potential for injury during transfers .Goal .will remain free of injury during transfers .Interventions .staff education .two staff present during (mechanical) lift transfer .pad the .lift PRN . On 11/08/17 at 9:58 a.m., the resident was asked about the incident that had occurred on 10/04/17. She stated, CNA #1 was helping me get up and ready for the day. The bar on the lift swung back and bumped my nose. They only have one CNA at a time on this hall especially in the mornings. She was asked if she usually got up for breakfast. She stated, CNA #1 hasn't been able to get me up lately for breakfast because he's too busy. She was asked if another staff person got her up. She stated, No, I eat in bed. She was asked if she wanted to eat in bed. She stated, No. She was asked if they had started using padding on the lift bar since the incident. She stated, They had put rubber bumpers on, but they weren't on there yesterday when CNA #8 used the mechanical lift to weigh me. Documentation on the falling star observed in the resident's room revealed she required a mechanical lift with two persons assist. At 11:00 a.m., CNA # 8 was asked if he had used a mechanical lift with a padded lift bar when he weighed the resident on 11/07/17. He stated, No, I wasn't aware that I was supposed to. At 11:15 a.m., CNA #1 was asked how the resident bumped her nose on 10/04/17. He stated, She bumped her nose on the lift bar. I told the nurse immediately and we started using foam padding on the bar when we lift her with the Hoyer. She wasn't injured. He was asked to show the surveyor the mechanical lift with the padded lift bar he used to transfer the resident. We went into the hall. The mechanical lift he showed me had no foam padding on the lift bar. He stated he didn't know where the foam padding was. A second mechanical lift was located at the end of the hall. It had no foam padding on the lift bar. CNA #1 was asked if he had received any education or attended any in-services after the incident on 10/04/17. He stated, I was instructed on how to use the mechanical lift. He was asked who got the resident up for breakfast if he was busy with another resident. He stated, Sometimes she wants to get up and sometimes she doesn't. If I am busy with another resident she has to wait for me to get finished with the other resident before I can help her. He was asked if he was the only CNA for the 800 Hall on the day shift. He stated, Yes, I have 18 resident that I am responsible for. He was asked how residents get ready for the day and get to the dining room for meals or activities if he was busy with other residents. He stated, If am busy with another resident they have to wait for me to get finished with the other resident before I can help them. He was asked if there were enough staff on the day shift for him to get his work done and to make sure the residents are taken care of and receive the assistance they need. He stated, Honestly, I feel that I cannot accommodate the needs of all my residents. It's a lot for one person to do for 18 residents. At 11:40 a.m., RN #2 was asked if they were using padding on the lift bar for the resident during transfers. She stated they had been but she didn't know where the lift with the padding was now. She stated they use the lifts all over the building. RN #2 was asked what they did for the resident since she needed the padded lift for transfers. She stated, We would have to go and find it for her. At 1:45 p.m., CNA # 6 was asked how he knew what type of transfer each resident required. He stated the information was on the back of the star in the resident's room. At 2:43 p.m., CNA #5 was asked how she knew what type of transfer each resident required. She stated the falling star hung up in the resident's room contained information regarding transfers. She was asked how a mechanical lift was to be used. She stated a mechanical lift always required two persons to assist. At 3:10 p.m., CNA #7 was asked how she knew what type of transfer each resident required. She stated the information was on the star in the room or on the resident's wheel chair. On 11/09/17 at 10:30 a.m., CNA #1 was asked if he had another staff person with him when he attempted to transfer the resident with the mechanical lift on 10/04/17. He stated No, the other CNA for 700 Hall was busy with their residents. I was trying to keep the resident on her schedule. The mornings are a very busy time, and I didn't want to get behind. He was asked if he had received training on mechanical lifts during new employee orientation. He stated, Yes, we were trained to use two people for mechanical lifts. He was asked why he had not used the lift they way he had been trained. He stated, I was trying to stay on schedule and not get behind. He was asked if he was aware that the facility's policy for the use of a mechanical lift stated two people were required for use of a mechanical lift. He stated, I was so busy and I was kind of running late for her schedule so I didn't wait to have another person assist me. He was asked if he had followed the facility policy for the use of a mechanical lift. He stated, No, whenever I am using the lift it is on a case by case basis, if there had been more staff it would have helped. The falling star observed in the resident's room documented the resident required a mechanical lift with two person assist for transfers. At 3:56 p.m., the DON was asked why CNA #1 had transferred the resident with a mechanical lift without the assistance of a second staff person. She stated, I don't know, but he should have waited for a second staff person to assist him. She was asked if CNA #1 had followed the facility's policy for the use of a mechanical lift. She stated, No. She was asked if there had been an in-service after the incident on 10/04/17. She stated, No. She was informed the incident report, dated 10/04/17, documented the lift bar was to be padded and staff were to be educated. She was asked where the staff education had been documented. She stated, Staff education is the falling star placed in each resident's room. The staff are supposed to look at it every time they come into the room. The nurse should update it at the time they come up with new interventions. She was asked why staff had not used a mechanical lift with a padded lift bar when they transferred the resident according to the resident's care plan. She stated, It is documented on the falling star. They should be doing it. We did have one that was padded but it ended up on a different hall.

Based on observation, record review, and interview, it was determined the facility failed to ensure there were sufficient qualified nursing staff to provide supervision to prevent accidents and to use the mechanical lift for transfers for three (#2, #3, and #4) of four sampled residents who were reviewed for transfers. Resident #4, who required extensive asistance of two persons for transfers, sustained a fracture of her femur when she was transferred with only one staff member. The facility identified 50 residents resided in the facility who required assistance for transfers with a mechanical lift. Findings: A facility policy regarding the use of a hydraulic lift, dated 01/02/07, documented, .It is Grace Living Centers policy to have two staff members present during transfer to stabilize and support the resident .check with a licensed nurse to make sure this resident should be transferred by hydraulic lift as reflected in his plan of care .if the resident has an altered center of gravity (caused by a halo vest or a lower-extremity cast, for example) obtain help from a licensed nurse before transferring him with a hydraulic lift . 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 04/16/15, documented, Focus .has ADL self care deficit r/t [DIAGNOSES REDACTED]/[MEDICAL CONDITION] .Goal .will have assist with ADL's and mobility as needed through the review date .Interventions .non-ambulatory .Transfers .extensive assist x 2 .W/C mobility .supervision at times on and off unit via electric w/c . A quarterly assessment, dated 07/03/17, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident required extensive assistance with two plus persons physical assist for transfers, was not steady, only able to stabilize with staff assistance for surface-to-surface transfers, had functional limitation in range of motion for one side of upper extremities, impairment on both sides of lower extremities, and required a wheel chair for mobility. The assessment also documented the resident had active [DIAGNOSES REDACTED]. A state reportable incident report, dated 09/18/17, documented, .resident complained of right knee pain. Focused assessment completed. No swelling or bruising noted. Resident c/o pain upon ROM. Pain medication was administered. No other injuries noted with assessment. Dr. (name deleted) notified. POA (name deleted) notified. Resident interviewed and stated .'reposition of leg the cna heard a pop and then resi (sic) stated 'it does that all the time.' POA .expressed concern that the CNA (name deleted) had broke her sisters leg. CNA (name deleted) suspended pending further investigation .police department notified. Appropriate licensing board, Dr. (name deleted) notified. (Name deleted POA) notified. Appropriate staff members .interviewed. X-ray orders obtained per physician orders [REDACTED].uses a motorized wheel chair for mobility .requires assistance with transfers and ADL's .has [DIAGNOSES REDACTED] .paralyti[DIAGNOSES REDACTED] .chronic pain .upon completion of the investigation, the facility determined that the resident was injured during an assisted transfer .as resident transferred (sic) to chair from bed the footboard of the motorized wheelchair was pushed from an upright position to lower position by resident right leg causing pressure to right leg during the transfer to a seated position. Final xray results revealed a fracture to right distal femur .new order to send to ER for further evaluation and treatment .returned to facility with a leg brace .spoke with appropriate staff regarding safe transfers. Educated family and resident on benefits of a (name deleted) lift especially with the specific disease process that indicated resident is at a higher risk for fractures .(name deleted) has been reinstated. Appropriate staff members have been in-serviced on .transfers. Family, resident and physician agreeable with the poc .appropriate safety/fall precautions in place .Falling star updated and care plan updated to reflect (name deleted) lift for transfers . A witness statement, dated 09/18/17 at 10:13 a.m., documented, .during reposition of .leg further onto the foot rest we heard a pop .I encouraged her to let nurse know if she has any issues from it (the pop) . A radiology report, dated 09/18/17 at 6:34 p.m., documented, .Impression .acute [MEDICAL CONDITION] femur . A nurse's note, dated 09/18/17 at 8:10 p.m., documented, .XRay results received .impacted [MEDICAL CONDITION] femur noted and chronic [MEDICAL CONDITION] tibia .Dr .notified of XRay results .new orders received to send to emergency room .new transfer requirements (mechanical) lift . On 11/07/17 at 11:55 a.m., the resident was asked to describe what had occurred regarding the transfer and leg fracture on 09/17/17. She stated CMA/CNA #1 had been in a hurry and picked her up and pivoted her by himself without the use of a gait belt. The resident stated her leg slipped down when the CMA/CNA #1 pivoted her and she heard a popping sound and then heard another popping sound when he sat her in the wheel chair. She stated, I didn't think about it because I don't have much feeling in it and I do pop and creak and I didn't tell the nurse. She stated the CMA/CNA #1 told the nurse the next day and an xray was ordered. At 1:23 p.m., CMA/CNA #1 was asked what had occurred on 09/17/17 when he had assisted the resident with a transfer. He stated, I was transferring her from her bed to the wheel chair and the foot rest was in the up position. At the time the resident was a two person assist and I didn't have any help on the floor. We were minimum staffed and the resident was impatient and wanted up to go to activities. When I went to put her in the chair her right leg impacted the foot rest and caused a fracture. I went to scoot her over and her left leg popped. I heard only one pop. He was asked if he had reported the incident to the nurse. He stated, No, I was falling behind and the resident said she would report it. He was asked when the incident had been reported. He stated, The next day the resident was complaining of pain so I reported it to the day shift nurse. He was asked if he had looked at the falling star located in the resident's room to determine how the resident should have been transferred. He stated, I didn't take time to look at it before I transferred her. He was asked why he had been doing patient care on the floor instead of passing medications. He stated, I was working on the med cart and was pulled to work the floor for forty minutes to one hour. He was asked why he had been pulled away from the med cart to work the floor as a CNA. He stated, We were working short staffed. On 11/08/17 at 11:45 a.m., the resident was observed being transferred by (mechanical) lift from her bed to her electric wheel chair by CNA #8 and CNA #4. No licensed nurse was observed in the room during the transfer. On 11/09/17 at 2:10 p.m., CNA #3 was asked how she knew what type of transfer a resident required. She stated it depended on the resident's condition. She was asked if she had been educated on the falling star program. She stated, No. On 11/13/17 at 10:10 a.m., RN #2 was asked if she was aware of the mechanical lift policy for residents who had an altered center of gravity such as a cast or brace on the lower extremities which required a licensed nurse to be present during the transfer. She stated, I don't remember that. I didn't know. She was asked if that information had been brought to her attention at any in-services. She stated, No. At 10:15 a.m., RN #1 was asked if she was aware of the mechanical lift policy for residents who had an altered center of gravity such as a cast or brace on the lower extremities which required a licensed nurse to be present during the transfer. She stated, I am aware of the mechanical lift policy. She was asked if she realized that a licensed nurse was to be present during the transfer of a resident by mechanical lift for residents with an altered center of gravity caused by a cast or brace to the lower extremities. She stated, I missed it. She was asked if that information had been brought to her attention at any in-services. She stated, No. On 11/13/17 at 3:45 p.m., the DON was asked why the CNA had transferred the resident by himself when she was a two person assisted transfer. She stated she did not know why. She stated the CNA should have requested and waited for assistance before transferring the resident. She was informed of the observation of the resident being transferred from her bed to her wheel chair by two CNAs when she had a brace on her right leg. She was asked why a licensed nurse had not assisted with the transfer of the resident since she had a lower extremity brace on her right leg. She stated, It was a knowledge deficit on our part. It is not on our skills check list. She was asked if the nurses and aides should have been aware of the facility policy. She stated, Yes. 2. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, revised on 07/02/15, documented, Focus .ADL'S .requires vaired (sic) level of assist with ADL'S R/T impaired mobility with left sided [MEDICAL CONDITION] R/T Hx.[MEDICAL CONDITION].Goal .will be clean and well groomed daily with assist as needed through the review date .Interventions .Transfers .(total) Staff utilize the lift for transfers at this time . An update to the care plan, date 01/03/17, documented, .Falls: .2 person assist at all times . A quarterly assessment, dated 08/15/17, documented the resident had a BIMS score of five. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with two plus persons physical assist for transfers, was not steady, only able to stabilize with staff assistance for surface-to-surface transfers, had impairment on one side of upper and lower extremities, and had active [DIAGNOSES REDACTED]. An incident report, dated 10/18/17, documented, .CNA reports that when he went to raise (mechanical) lift, lift bump (sic) the trapeze bar and bar hit the resident over the left side of her eye. No bruising, or swelling, noted at this time .Immediate Action Taken .neuro checks started and staff education done . On 11/08/17 at 11:15 a.m., CNA #1 was asked what had happened during the incident on 10/18/17 with the resident. He stated the lift bar bumped the trapeze bar above the resident's bed and the trapeze bar hit the resident over the left eye. He was asked if he had another staff person with him when using the mechanical lift for the transfer. He stated, No, it was a busy time of day and the other CNA was busy and I was trying to keep on schedule so I did the transfer by myself. He was asked why he transferred the resident without the help of another staff member. He stated, I was so busy and I was running late for her schedule, so I didn't wait to have another person assist me. He was asked if he was following the facility's policy for the use of mechanical lifts when he transferred the resident with the lift by himself. He stated, No, whenever I am using the lift it is on a case by case basis, if there had been more staff it would have helped. 3. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 08/15/17, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident was totally dependent for transfers with two plus persons, was not steady, only able to stabilized with staff assistance for surface-to-surface transfers, had impairment on both sides of upper and lower extremities, and had active [DIAGNOSES REDACTED]. An incident report, dated 10/04/17 at 7:20 a.m., documented, .CNA reports that during transfer with (mechanical) lift the bar of the lift bumped the bridge of resident's nose. No bruising, swelling, or pain noted to nose. Resident said her nose was bumped during transfer. On 11/08/17 at 9:58 a.m., the resident was asked about the incident that had occurred on 10/04/17. She stated, CNA #1 was helping me get up and ready for the day. The bar on the lift swung back and bumped my nose. They only have one CNA at a time on this hall especially in the mornings. She was asked if she usually got up for breakfast. She stated, CNA #1 hasn't been able to get me up lately for breakfast because he's too busy. She was asked if another staff person got her up. She stated, No, I eat in bed. She was asked if she wanted to eat in bed. She stated, No. She was asked if she liked to stay in bed. She stated, No, but there aren't enough staff to get me up. I like to get up for meals and activities, but there aren't enough staff to get me up and take me where the activities are. She stated, I especially like the ice cream social and the popcorn, but I don't get them very often, unless I am able to go to the activity. She was asked if she could remember the last time she had attended an activity. She stated, The last activity I got to attend was the happy hour on 10/17/17. At 11:15 a.m., CNA #1 was asked how the resident bumped her nose on 10/04/17. He stated, She bumped her nose on the lift bar. I told the nurse immediately and we started using foam padding on the bar when we lift her with the Hoyer. She wasn't injured. He was asked if the resident liked to get up for meals and activities. He stated, Sometimes she wants to get up and sometimes she doesn't. If I am busy with another resident she has to wait for me to get finished with the other resident before I can help her. He was asked if he was the only CNA for the 800 Hall on the day shift. He stated, Yes, I have 18 resident that I am responsible for. He was asked how residents get ready for the day and get to the dining room for meals or activities if he was busy with other residents. He stated, If am busy with another resident they have to wait for me to get finished with the other resident before I can help them. He was asked if there were enough staff on the day shift for him to get his work done and to make sure the residents are taken care of and receive the assistance they need. He stated, Honestly, I feel that I cannot accommodate the needs of all my residents. It's a lot for one person to do for 18 residents. On 11/09/17 at 10:30 a.m., CNA #1 was asked if he had another staff person with him when he attempted to transfer the resident with the mechanical lift on 10/04/17. He stated No, the other CNA for 700 Hall was busy with their residents. I was trying to keep the resident on her schedule. The mornings are a very busy time, and I didn't want to get behind. He was asked if he had received training on mechanical lifts during new employee orientation. He stated, Yes, we were trained to use two people for mechanical lifts. He was asked why he had not used the lift they way he had been trained. He stated, I was trying to stay on schedule and not get behind. He was asked if he was aware that the facility's policy for the use of a mechanical lift stated two people were required for use of a mechanical lift. He stated, I was so busy and I was kind of running late for her schedule so I didn't wait to have another person assist me. He was asked if he had followed the facility policy for the use of a mechanical lift. He stated, No, whenever I am using the lift it is on a case by case basis, if there had been more staff it would have helped. On 11/13/17 at 2:03 p.m., resident #5 was asked if he required staff assistance for transfers and other ADL's. He stated, Yes. He was asked how many staff assisted him with transfers. He stated, Usually two, but not always. He was asked if he felt there were enough staff to enable him to get the assistance he needed in a timely manner. He stated, There are not enough CNAs for each hall. The falling star observed in the resident's room documented the resident required a mechanical lift with two person assist for transfers. At 2:20 p.m., resident #7 was asked if he required staff assistance for transfers and other ADL's. He stated, Yes. He was asked how many staff assisted him with transfers. He stated he had been transferred with one person and the lift at times. The falling star observed in the resident's room documented the resident required a mechanical lift with two person assist for transfers. At 3:56 p.m., the DON was asked why CNA #1 had transferred the resident with a mechanical lift without the assistance of a second staff person. She stated, I don't know, but he should have waited for a second staff person to assist him. On 11/13/17 at 4:00 p.m., the administrator and the DON were asked about the lack of sufficient staff to meet the needs of the residents who required two person assist with a mechanical lift. The DON stated she was aware there were issues regarding staff not waiting for assistance or obtaining other staff members to assist with ADL care. They were asked about the injury that occurred to one resident and the inappropriate transfers of two additional residents. The DON stated the CNAs should have requested and waited for assistance before transferring the residents. They were asked why the CMA/CNA #1 had been pulled from his duties as a CMA to work as a CNA. The DON stated that was the day several of our administrative team had to be pulled to provide resident care due to not enough staff.

Based on observation, record review, and interview it was determined the facility failed to ensure residents with feeding tubes did not have significant or severe weight loss for one (#2) of four sampled residents who were dependent on tube feedings for enteral nutrition. The facility identified twelve residents with feeding tubes. Findings: A tube feeding policy, dated 06/24/10, documented, .Feedings are initiated and monitored by licensed nursing staff who have been trained and approved by the long term care facility to perform tube feeding procedures .A physician order [REDACTED].document in Treatment Administration Record (TAR). Record any unusual response or symptoms in clinical notes weekly or until stable and then monthly, unless otherwise required. Inform physician of any adverse reaction .Record in Intake and Output (I &O) record .Update resident care plan and resident profile as needed . Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The facility weight record, dated 12/06/16, documented the resident weighed 137.5 pounds. A quarterly assessment, dated 01/03/17, documented the resident was in a persistent vegetative state, was totally dependent with eating and all activities of daily living, had no weight loss, required a feeding tube, and received 51% or more of total calories through tube feeding. The facility weight record, dated 01/10/17, documented the resident weighed 139.5 pounds. The facility weight record, dated 02/06/17, documented the resident weighed 138.6 pounds. A care plan, updated 02/10/17, documented, Focus: .nutritional problem or potential nutritional problem r/t diet restrictions - NPO and Peg tube .Interventions .2/8/17 - Wt 138.6#, no sig wt change, diet is npo, TF Fibersource HN at 55ml/hr cont, flush with 120ml water q 4hrs, vitD, vitC 500mg bid, multi-vit, [MEDICATION NAME], wt stable, no new labs or pressure areas noted, expect TF meets needs . The facility weight record, dated 02/14/17, documented the resident weighed 122.4 pounds. The resident had lost 16.2 pounds (11.69%) in one week from 02/06/17 through 02/14/17. The physician and dietitian consultant were not notified of the severe weight loss. The facility weight record, dated 02/21/17, documented the resident weighed 120.4 pounds. The resident had lost 18.2 pounds (13.13%) in two weeks from 02/06/17 through 02/21/17. The physician and dietitian consultant were not notified of the severe weight loss. The facility weight record, dated 02/28/17, documented the resident weighed 120.2 pounds. The resident had lost 18.4 pounds (13.13%) in three weeks from 02/06/17 through 02/28/17. The physician and dietitian consultant were not notified of the significant/severe weight loss. A nurse's note, dated 03/04/17, documented the resident was sent to the hospital due to her peg (feeding) tube being dislodged. A nurse's note, dated 03/06/17, documented the resident was readmitted to the facility from the hospital with a new feeding tube in place. The facility weight record, dated 03/07/17, documented the resident weighed 119.0 pounds. The resident had lost 19.6 pounds (14.14%) in one month from 02/06/17 through 03/07/17. A nutritional evaluation and risk management note, dated 03/08/17, documented, .Most recent weight 119.0 .Describe Kcal needs: 1350-1620kcals .Tube feeding orders: Fibersource HN cont at 55cc/hr from 7pm to 6am and 240ml tid .diet order: npo .Dietary supplements: multi-vit c min, vitD, [MEDICATION NAME] .Weight status; loss or gain: BMI 19-27 No weight change .Comments: -14.1% since 2/6, -13.8% since 12/13, -17.5% since 9/27 .Summary Notes: Wt. 119#, -14.1% since 2/6, -13.8% since 12/13, -17.5% since 9/27, BMI 23.8, prealb 17 on 3/4, resident recently readmitted from hospital, diet is NPO, TF Fibersource HN cont at 55cc/hr from 7pm to 6am and 240ml tid, multi-vit c min, vitD, [MEDICATION NAME], current TF provides 1626kcals and 73g pro which is expected to meet or exceed est needs, Rec flush with 120cc h2o q 6hrs to provide 1578cc fluid to meet fluid needs. Plan .notify Dr of wt loss . A notice of significant weight change, dated 03/09/17, documented, .Most recent weight 119.0 date: 03/07/17 .weight loss time span: 1 month .Amount of weight loss 14.1% .Previous interventions for wt loss/gain: multi-vit with min,vitD, [MEDICATION NAME] .Current diet: TF 240ml tid, fibersource HN 55ml/hr 7pm-6am .Date physician contacted 03/09/2017 .New orders/interventions: Clarify TF to fibersource, flush with 120cc h2o every 6hrs . The care plan was not updated to address the severe weight loss of 19.6 pounds (14.14%) in one month or new nutritional interventions to prevent further weight loss. A significant change assessment, dated 03/20/17, documented the resident was severely impaired with cognitive skills for daily decision making, totally dependent with eating, had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, required a feeding tube, and received 51% or more of total calories through tube feeding. A registered dietitian progress note, dated 04/10/17, documented, Wt 120#, -14.0% since 1/10, -17.8% since 10/11, Alb 2.9 on 4/7, diet is npo, TF Fibersource 240ml tid and Fibersource cont at 55cc/hr from 7pm to 6am, flush with 120cc free water q 6hrs, multi-vit c min, vitD, vitC 500mg bid, [MEDICATION NAME], current TF provides 1626kcals and 73g pro which is expected to meet or exceed est needs, expect some wt change r/t recent hospitalization , appropriate interventions in place; Rec to notify Dr. of wt loss . The facility weight record, dated 04/11/17, documented the resident weighed 119.5 pounds. A notice of significant weight change, dated 04/14/17, documented, .Most recent weight: 119.5 .amount of weight loss -14.0% .other time spans and weight loss/gain: -17.8% since 10/11 .Previous interventions for wt loss/gain: Fibersource 240ml TID Fibersource cont at 55ml/hr from 7pm to 6am flush with 120cc free water Q6H Multi-vit x/minerals vitD vitC 500mg BID .current diet: NPO .Date physician contacted 04/14/2017 .New orders/interventions: (blank) . The care plan was not updated to address the severe weight loss of 20 pounds (14.34%) in six months or new nutritional interventions to prevent further weight loss. A registered dietitian progress note, dated 05/04/17, documented, Wt 118.6#, -14.4% since 2/6, -20.2% since 11/8, Alb 2.9 on 4/7, diet is NPO, TF Fibersource at 55cc/hr form 7pm to 6am and Fibersource bolus 240ml tid, flush with 120cc free water q 6hrs, vitD, multi-vit c min, vit C 500mg bid, [MEDICATION NAME]; nurse states resident has had some recent medication changes and resident seems to be less bothered by peg tube with bolus feeds during the day, resident with a sig wt loss since Feb but no sig wt change since readmit in March, current TF provides 1626kcals and 73g pro which is expected to meet or exceed est needs, rec to check [MEDICATION NAME]. Plan .Notify Dr of wt loss, -14.4% since 2/6, -20.2% since 11/8 .[MEDICATION NAME] . The facility weight record, dated 05/09/17, documented the resident weighed 114.0 pounds. The care plan was not updated to address the severe weight loss of 24.6 pounds (17.7%) in three months or new nutritional interventions to prevent further weight loss. A nurse's note, dated 05/28/17, documented the resident's feeding tube was misplaced and after several unsuccessful attempts to replace, the resident was sent to the hospital. A nurse's note, dated 06/08/17, documented the resident was readmitted to the facility after her stay at the hospital. The resident's feeding tube was replaced while in the hospital. A physician's orders [REDACTED].continues feed order: Fibersource HN liquid 60ml/hr every shift . A registered dietitian progress note, dated 06/12/17, documented, Wt 116.6#, -15.5% since 12/13, diet is NPO, TF Fibersource HN at 60ml/hr cont, flush with 240cc H2O q shift, multi-vit c min, vitC 500mg bid, vitD, [MEDICATION NAME], current TF provides 1728kcals and 78g pro, TF with flush provides 1886cc fluid, expect some wt loss may be r/t recent hospitalization , nurse states resident tolerating TF since readmit, appropriate interventions in place. Plan .Notify Dr of wt loss, -15.5% since 12/13 .Clarify Fibersource as enteral order category in pcc . The facility weight record, dated 06/13/17, documented the resident weighed 116.0 pounds. A physician's orders [REDACTED]. The care plan, updated 06/15/17, documented, .6/12/17-Wt 116.6#, -15.5% since 12/13, diet is npo, TF Fibersource HN at 60ml/hr cont, flush with 240cc H2O q shift, multi-vit c min, vitC 500mg bid, vitD, [MEDICATION NAME], current TF provides 1728kcals and 78g pro, TF with flush provides 1886cc fluid, expect some wt loss may be r/t recent hospitalization , nurse states resident tolerating TF since readmit, appropriate interventions in place. Plan .Notify Dr of wt loss, -15.5% since 12/13 .Clarify Fibersource as enteral order category in pcc . On 06/21/17 at 11:23 a.m., the resident was observed lying in bed awake with Fibersource HN running at 60ml/hr to her feeding tube with no complications. At 1:35 p.m., the DON was asked what [DIAGNOSES REDACTED]. She was asked if any of those [DIAGNOSES REDACTED]. She stated, No. She was asked why the doctor was not notified immediately when the resident lost 16.2 pounds (11.69%) in the month of February. She stated, When the weight triggers in pcc for the monthly weights we notify the doctor. The weight loss happened the second week. I notified the doctor as soon as the report was generated. She stated they look at the 24 hour reports during their daily meetings, the dietitian rounds, and they have dietary meeting to discuss monthly weights and who qualifies for reweighs. She was asked if the 24 hour reports triggered the weight loss. She stated, No. She was asked if she knew why the resident had lost weight while being dependent on tube feedings. She stated, No. At 1:50 p.m., the care plan coordinator was asked why the weight loss was not addressed on the care plan from February through May. She stated, I don't know. She was asked if the weight loss should have been addressed on the care plan. She stated, Yes. At 2:13 p.m., the registered dietitian was asked why there were no new nutritional recommendations for the resident's weight loss. She stated, We did in June. We increased her caloric needs. She was asked why she didn't address the weight loss during the months of March, April, and May. She stated, We didn't change March through May. We were watching it. She was asked if she knew why the resident had lost weight while being dependent on tube feedings. She stated, No. I don't know why.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for two (#4 and #5) of three sampled residents who had a physical restraint and had experienced falls. Resident #4 experienced six falls in six months. The resident sustained [REDACTED]. The facility identified two residents with physical restraints who were at high risk for falls and 140 residents who were at high risk for falls. Findings: A fall awareness program policy documented, .Evaluate fall risk factors .Review appliances and devices for possible problems as well as the resident's use of the appliance or device. Review to determine whether restraints are currently in use. Review environment/situational hazards that may contribute to falls .Review and investigate previous falls if able .Reinforce use of assistive devices .Evaluate need for an adjustment in resident's daily activity schedule .Implement use of protective equipment (helmets, hip pads) as indicated .Assess resident for injuries, provide appropriate medical attention .Obtain orders for X-ray as indicated. Complete incident report .Consider factors regarding the fall. Develop care plan based on interventions used .Re-evaluate environment for contributing factors. Re-evaluate resident's use of adaptive equipment or the need for .Review and revise plan of care as needed .Make sure to update and revise plan of care as indicated . A restraint policy documented, .obtain informed consent from the resident (if possible) for the use of the restraint .orders for physical restraints must be exact and specific when received from the physician what type of restraint is to be used .when the restraint is to be used .why the restrain is needed .when the restrain is to be released and for how long (release during supervised activities, ADLs, every 2 hours for 10 minutes .use of the restraint must be documented in the resident's care plan . 1. Resident #4 had [DIAGNOSES REDACTED]. An undated fall care plan, documented, Focus: .at risk for falls r/t impaired balance, altered cognition and hx of falls. Goal: .will be free from major injury r/t fall through the next review date. Interventions: Falling star program .Frequent safety reminders .Frequent alarm checks .Appropriate footwear .Keep call light in reach .Keep frequently used items within reach .Bed in low position . A nurse's note, dated [DATE] at 3:10 p.m., documented, Aide pushed resident to nurses station while sitting in her w/c and reported to nurse that resident had fallen. It was reported resident got up out of her w/c when she lost her balance and fell and hit her head on the wall. Resident was unable to explain what had happened r/t a [DIAGNOSES REDACTED]. Assessed resident. Neuros started .Resident is alert and responds to commands. No bumps, scrapes, or bruising observed. Dr .notified, n/o to send to ER for evaluation .Resident left by (ambulance) with 2 attendants. A nurse's note, dated [DATE] at 10:10 p.m., documented, .return from hospital visit .All test ran at hospital were negative. All previous interventions in place and functional . A nurse's note, dated [DATE] documented, Alerted by CNA that resident was on floor. Found resident lying on floor on right side next to wheelchair. Lap buddy partially removed from wheelchair. Resident had been noted sliding down in wheelchair earlier. Noted bump on right side of head .Neuro checks initiated. Assisted resident to wheelchair. Noted resident's boots had slick bottoms causing her to slide. CNA assisted resident to bed. Notified Dr .unit manager, and daughter .daughter stated to put boots away and she would pick them up . A nurse's note, dated [DATE] documented, Nurse sitting at nurses station when heard a loud thud. Resident laying on floor beside her wheelchair with lap buddy removed .New bump to right side of head with some bleeding .Dr .notified. N/O to send to ER for evaluation. A final state reportable incident report, dated [DATE], documented, .Upon completion of the investigation the facility has determined that the resident attempted to self transfer causing a fall to floor hitting head resulting in an abrasion to right side of head .resident fell trying to transfer independently and appeared to have an incontinent episode of urine .Initiated intervention for Q1h toileting in an effort to prompt toileting. POC and falling star updated . An update to the care plan, dated [DATE], documented, .Concave mattress, Wedge, Highback W/C. A nurse's note, dated [DATE], documented, Nursing notified by CNA that Resident observed on the floor in north dining room. CNA reported resident took off lap buddy and slide (sic) from w/c to floor Resident observed hitting her head on dining room floor .Notified daughter .and Dr .Resident transferred .ER for eval/tx New intervention will be clip alarm when resident returns to facility. A nurse's note, dated [DATE], documented, Resident returned from hospital .No new orders received .Resting in bed with fall mat in place. A combined initial/final state reportable incident report, dated [DATE], documented, .Nurse heard bed alarm go off and ran to resident room to find her laying on the floor beside her bed. Resident alert and crying. She is unable to say what happened r/t medical [DIAGNOSES REDACTED]. Redness observed to back of head .Redness observed to her mid back .Notified Dr .and daughter .N/O to transport to .Hospital for evaluation .Upon completion of the investigation the facility has determined that the resident attempted to self transfer causing her to fall to the floor. Resident has very poor safety awareness. Intervention is geri chair that has been initiated and is safe and effective. POC updated and falling star updated. Hospice aware .No latent injuries obvious . A nurse's note, dated [DATE], documented, X-ray results show recent ununited fracture of the right humeral neck fracture with medial displacement. Notified Dr .received order to send to ER to eval and treat .Daughter notified. (Ambulance) in facility. Transferred without incident. A hospital history and physical report, dated [DATE], documented, .past medical history significant for dementia. CVA right sided weakness and aphasia, debility wheelchair bound .On Saturday ([DATE]) patient got up and fell on to the ground on her right side. Nursing staff did find her and placed her back in bed. Yesterday patient daughter was at the nursing home noticed right arm edema. Requested x-ray to be done .right humerus fracture .Patient was transferred to .hospital for higher level care. Radiological exams done here showed comminuted fracture of the right proximal humerus is present . A nurse's note, dated [DATE], documented, Resident admitted into SNF r/t right humeral head fracture .alert .wearing sling on right arm . A significant change assessment, dated [DATE], documented the resident had a short/long term memory problem and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance and two person physical assist with transfers, used a wheel chair for mobility, had not experienced any falls, and used a trunk restraint daily. A nurse's note, dated [DATE], documented, .Surgical incision to right shoulder/upper arm measures 11cm x 0.2cm x <0.11 cm. Edges are well approximated with staples . A physician's orders [REDACTED]. Release Q 2 hours for 10 minutes, during meals and ADL's. A restraint care plan, dated [DATE], documented, Focus: Lap Buddy when up in wheel chair to prevent unassisted ambulation, prevent unassisted transfer r/t unsteady gait, poor balance and decreased safety awareness R/T Alzheimer's Dementia. Release Q 2 hours for 10 minutes, during meals and ADL's .Goal: .will be free from serious injury R/T restraint use. Interventions: Attempted restraint reduction: removed restraint for extended periods of times while supervised .continues to have poor safety awareness. Continues to be impulsive and attempt unassisted transfers .Release Q 2 hours for 10 minutes, during meals, and ADL's every shift . A quarterly assessment, dated [DATE], documented the resident had a short/long term memory problem, inattention, and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required limited assistance and one person physical assist with transfers, used a wheel chair for mobility, had not experienced any falls, and used a trunk restraint daily. A nurse's note dated [DATE], documented, Resident in the assisted dining room LPN removed lap buddy to assist resident up to table resident leaned forward landing on floor Hit head on floor receiving laceration on right side of head DON/Unit Manager assessed resident pressure applied Laceration continue to bleed .(Ambulance here to assist resident to gurney Resident alert/oriented to name . An update to the care plan, dated [DATE], documented, Upon rtn from the hospital a helmet to be worn to help protect head. A follow up state reportable incident report, incident date [DATE], documented, Resident observed lying on back on the floor in dining room. Resident has a laceration to the right side of head approx 0.2x0.2 cm. Active bleed from laceration this nurse unable to effectively control bleeding secondary to resident is on a blood thinner. Pressure applied until (ambulance) arrived. Neuro initiated and WNL for the resident. AROM without limitation to extremities. C/O pain in head. Pain medication provided. No other obvious injury. Doctor .and Family .notified. Resident sent to ER for further eval and treatment .CT scan result shows a hemorrhage and resident was admitted to the hospital. Resident expired on [DATE]. A facility discharge summary, dated [DATE], documented, .Cause of Death: Head injury resulting from fall. A state death certificate, dated [DATE], documented, .Immediate Cause Final disease or condition resulting in death .Intracranial Hemorrhage Due To Blunt Force Trauma Of Head .Date of Injury XXX[DATE] .Place of Injury .Nursing Home .How injury occurred: Fall . On [DATE] at 12:12 p.m., CNA #4 was asked if she monitored and assisted residents in the restorative dining room during meal times. She stated, Yes. She was asked if she was aware of the fall the resident had experienced on [DATE]. She stated she was not present but had heard about the fall. She was asked if any new interventions had been put in place regarding what had occurred. She stated, No. She was asked if she had received any training or education regarding what had occurred. She stated, No. At 12:30 p.m., CNA #5 was asked if she monitored and assisted residents in the restorative dining room during meal times. She stated, Yes. She was asked if she was aware of the fall the resident had experienced on [DATE]. She stated she was not present but had heard about the fall. She was asked if any new interventions had been put in place regarding what had occurred. She stated, No. She was asked if she had received any training or education regarding what had occurred. She stated, No. She stated the routine was to not remove the lap buddy until the resident had food and could be monitored. She stated the nurse had been putting clothing protectors on other residents and the resident got up and fell after the lap buddy had been removed. At 3:05 p.m., the DON was asked what occurred when the resident fell in the dining room. She stated a nurse was with her and she had removed the lap buddy and was assisting other residents getting ready for the meal when the resident got up and fell . She stated the wheel chair brakes were not locked because that would be a restraint and the resident rolled the chair back and fell forward hitting her head. She stated she was at the North nurses' station and was called to the restorative dining room. She stated the resident's head was bleeding and she and other staff assisted the resident and she was sent out to the hospital. The DON was asked if any plans or new interventions had been put in place regarding what has occurred. She stated nothing was documented regarding training or education. She stated we were just doing what we do getting residents ready for meals and she fell . She stated staff were back and forth getting residents ready to eat and it just happened. At 4:45 p.m., the DON and the assistant administrator were asked about the resident's falls. The DON was asked how they kept the resident safe when they released the lap buddy. She stated they had a doctor's order to release it and that's what they did. She stated, I don't understand. She's going to fall. You can only put so many interventions in place until you have none. She's not going to stay seated, she's going to fall. She was asked if they had kept the resident safe. No comment was made. The DON was asked if they had put any plans in place to keep residents with restraints from falling when their restraint was released in the dining room after the incident had occurred. She stated, If I would have felt they did anything wrong I would have inserviced, but I didn't feel she did anything wrong. She was preparing other residents for the meals and that's just what we do. She stated if the resident returned she was going to put a helmet in place as the intervention. She was asked why a helmet had not been attempted earlier since the resident had several previous falls with injury to her head. No comment was made. She was asked if any other residents with restraints removed during the meal had falls in the dining room. She stated she would have to check. No information was provided. On [DATE] at 9:55 a.m., LPN #3 was asked if she was present in the restorative dining room when the resident fell . She stated, Yes. She was asked what had occurred. She stated she had removed the resident's lap buddy and was turned away from the resident putting a clothing protector on another resident when she heard her and she turned around and the resident was on the floor. She was asked if there were any other staff in the restorative dining room when the fall occurred. She stated, No. She was asked if there had been any new plans put in place regarding safety when a restraint was removed. She stated, I think we talked about having more than one person in there at all times to keep an eye on everyone. She was asked if there had been any training or an inservice done. She stated, No. On [DATE], the lunch meal was observed. Resident #6 was observed to have her lap buddy removed and her wheel chair unlocked. A staff member was seated next to her during the meal. The staff was observed to leave the resident's side twice during the meal for several seconds each time to assist other residents. There were two other staff in the room seated at the other end of the table which was approximately 12 feet in length. At 2:20 p.m., the DON was informed of the lunch observation where the resident, who had a history of [REDACTED]. No comment was made. 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A fall care plan, initiated [DATE], documented, Focus: .is at risk for injury r/t falls d/t actual fall with no injury, impaired mobility, poor vision, poor safety awareness .Goal: .will be free from serious injury r/t falls through the review date .Interventions: .assess/evaluate any patterns to falls .encourage to request assistance .encourage to use of appropriate assistive devices .keep call light within reach, encourage use for needs, and answer in a timely manner .pharmacy consult to evaluate medications . A 60 day assessment, dated [DATE], documented the resident had a BIMS score of two. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with one person for bed mobility, and transfers, and total assistance with one person for locomotion throughout the facility. The assessment documented the resident had two or more non-injury falls since admission or prior assessment, and did not have any restraints. A lap buddy and pummel cushion care plan, dated [DATE], documented, Focus: .uses a lap buddy and pummel cushion daily .Goal: .will have no injury RT use of lap buddy and pummel cushion through the review date .Interventions: .lap buddy and pummel cushion when up in wheelchair to prevent unassisted ambulation, prevent unassisted transfer r/t unsteady gait, poor balance and decreased safety awareness R/T Alzheimer's dementia .release Q 2 hours for 10 minutes, during meals and ADL's every shift .release every ,[DATE] hours and reposition .release lap buddy at activities and monitor for safety .release lap buddy at meals when staff is directly available and monitor for safety .offer bathroom privileges and provide incont care as needed . Monthly physician's orders [REDACTED].unsteady gait, poor balance and decreased safety awareness R/T Alzheimer's dementia .release Q 2 hours for 10 minutes, during meals and ADL's every shift . A quarterly assessment, dated [DATE], documented the resident had long and short term memory problems and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with one person for bed mobility, and transfers, and total assistance with one person for locomotion throughout the facility. The assessment documented the resident had one non-injury fall since admission or prior assessment, and did have a chair restraint that had been used daily. An incident report, dated [DATE] at 8:23 p.m., documented, .found lying on left side on the floor away from floor mat, bed was in low position .knot 3 cm in length noted to left side of head above eye brow .assisted into w/c with lab(sic) buddy and brought into lobby .resident may require bed alarm or a concave mattress to help prevent rolling . A revision to the fall care plan, dated [DATE] documented, .resident was on the floor .lying on her left side .away from floor mat .bed was in low position .assisted into w/c with lap buddy and brought into lobby .resident may require bed alarm or a concave mattress to help prevent rolling XXX[DATE] .intervention low bed initiated . No new interventions to prevent future falls were added to the fall care plan. An incident note, dated [DATE] at 8:21 p.m, documented, .observed resident sitting on her bottom on her fall mat next to her bed .no bruising or apparent injury noted .assisted resident back up to her bed and got her ready for dinner . A revision to the fall care plan, dated [DATE], documented, .observed resident sitting on her bottom on her fall mat next to her bed .assisted resident back up to her bed and got her ready for dinner . No new interventions to prevent future falls were added to the fall care plan. An incident note, dated [DATE] at 10:00 p.m., documented, .pt was observed on floor in room .half on the floor and half on her safety matt(sic) at her bedside .roommate stated that pt scooted out of bed .onto safety matt(sic) at bedside and continued to move around until she was partly on the floor and matt(sic) .assisted off of floor into her w/c .brought to common area by nurses station .monitored for any changed(sic) r/t fall . A revision to the fall care plan, dated [DATE], documented .observe pt sitting on her buttocks half on the floor and half on her safety matt(sic) at her bedside .assisted off of floor into her w/c .brought to common area by nurses station .pt monitored for any changed(sic) r/t fall XXX[DATE] intervention-fell on mat without injury per plan of care . No new interventions to prevent future falls were added to the fall care plan. On [DATE] at 10:40 a.m., the resident was observed in the common area near the nurses station, sitting in a wheelchair with a lap buddy in place. Staff were observed to take the resident to her room and transfer her to the bed. A fall mat was observed on the floor next to the resident's bed, and the resident's mattress appeared to be concave. At 2:30 p.m., CNA #7 was asked what interventions were in place for the resident to prevent falls. She stated the resident was checked every two hours, a fall mat was placed on the floor at the bedside, a foam wedge was used while the resident was in bed to help prevent her from rolling out of the bed, a lap buddy and pummel cushion were used when the resident was up in the wheelchair, and the resident was not to be left unattended in her wheelchair while in her room. She was asked what the procedure was for a resident with a lap buddy on their wheelchair at meal time. She stated, I have been doing this for years, and was taught to wait until the resident's food is at the table before bring the resident to the dining room, sit the resident at the restorative table and undo the lap buddy while the resident is eating. She stated, You have to have staff by them at all times when the lap buddy has been removed. She was asked if she locked the wheelchair brakes when she removed the lap buddy from a resident's wheelchair while at the dining room table. She stated, No, because locking brakes on a wheelchair is considered a restraint. At 3:50 p.m., the care plan coordinator was asked why new interventions to prevent falls had not been put into place after the falls on [DATE], [DATE], and [DATE]. She stated, I'm not sure about that.

On 09/26/14, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to assess a resident's feet, who had overlapping toes which put her at risk for skin breakdown; identify and provide interventions to prevent skin breakdown on her toes; and failed to identify pressure ulcers and intervene for one resident who was hospitalized and found to have one Stage III pressure ulcer to her toes, and two Stage IV pressure ulcers with bone exposed to her toes. At 12:15 p.m., The Oklahoma State Department of Health (OSDH) was called and verified the existence of the Immediate Jeopardy situation. At 12:21 p. m., the administrator and the DON were informed of the Immediate Jeopardy situation. They were also informed that this placed the facility in a partial extended survey. At 3:26 p.m., the facility submitted an acceptable plan of removal. The plan of removal documented, "...1. Inservice of all staff will be conducted by facility RNs...Inservice will include the wound care policy. CNAs, CMAs to include how to identify skin impairment/breakdown, assessment of resident, timely notification of physician, obtaining orders for treatment as indicated, weekly at risk skin checks per braden score, and documentation per policy and procedure. All inservices will be completed by 9-26-14 at 10:30pm. 2. Skin assessments for all residents will be completed by licensed nurses. Findings will be documented, physicians will be notified as indicated, and wound care policy will be followed. All assessments will be completed by 12pm on 9-26-14." Staff were interviewed on 10/01/14, in regard to their knowledge of the in-service, to ensure their understanding of skin assessments, identification, and reporting skin problems. They answered with understanding of skin assessments and the identification of skin problems. They answered with understanding of whom to report the identified skin issues to and treatments to be ordered. The skin assessments were reviewed and all residents in the facility had been assessed. The IJ was removed effective 09/27/14 at 10:55 a.m., when the last employee in-service was conducted. The deficient practice remained at a pattern level of actual harm that was not an immediate jeopardy. Based on observation, record review, and interview, it was determined the facility failed to to assess a resident's feet, who had overlapping toes which put her at risk for skin breakdown; identify and provide interventions to prevent skin breakdown on her toes; and failed to identify pressure ulcers and intervene for one (#9) of five sampled residents who were reviewed for pressure ulcers. This resulted in an Immediate Jeopardy situation. The resident was hospitalized and found to have one Stage III pressure ulcer to her toes, and two Stage IV pressure ulcers with bone exposed to her toes. The facility identified nine residents as having pressure ulcers. Findings: A facility policy titled, Skin and Wound Care Guidelines, documented, "...Skin Integrity/Wound Care Program...To provide a systematic approach and monitoring process for skin integrity/pressure ulcer care. To prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and developing interventions. To promote healing of pressure ulcers. OBJECTIVE To maintain an optimal level of skin integrity and to promote optimum healing of pressure ulcers using an individualized plan of care... Risk Assessment Policy ...All residents will be assessed to determine factors that predispose the individual to risk of pressure ulcer formation... Note: If resident develops skin breakdown, complete the wound care status report, weekly... A multidisciplinary plan of care will be implemented that reflects intervention strategies designed to alleviate, reduce, or minimize the negative effects of each resident's identified risk factors, and manage and treat existing pressure ulcers...The care plan serves as a vehicle to communicate, monitor and evaluate care based upon individual resident needs... If a resident is identified with a pressure ulcer, complete the wound care status report weekly. The Skin at Risk sheet...should continue to be completed...Residents who develop a wound are at high risk for developing another. Continue monitoring and implementation of interventions are necessary for prevention... Pressure Ulcer Policy... The staging, measurement, assessment and documentation of pressure ulcers will be predicated on accepted standards of wound care... All pressure ulcers will be staged according to the MDS Assessment definitions... Residents identified with pressure ulcers will be reassessed on a daily basis for additional areas of concern and assessment documented... A multidisciplinary plan of care will be implemented that reflects intervention strategies designed to manage and treat existing pressure ulcers... Pressure ulcers will be measured and recorded in centimeters... Measured dimensions will include - head to toe direction - length - side to side direction - 90 )(degrees) from length- depth - deepest area - description of location of undermining using positions of a clock face... A resident's pressure ulcer should be documented weekly on Wound Care Status Report... The Grace Living Centers' Skin Assessment Weekly Summary should be completed weekly... Care Interventions... Plan of care is updated to reflect new problems and interventions... Assess weekly and document progress. Note details of any pain related to the pressure ulcer... I.D. causative factors and seek to remove..." 1. Resident #9 had [DIAGNOSES REDACTED]. A nurse's note, dated 03/22/13, documented, "...Res update on wound care to L 3rd toe...Refusing tx. Explain (sic) to res. again why it was important to do tx to cleanse area & to place [MEDICATION NAME] Ag between toes. Res agreed to tx. but states "I don't like it when my toes are pulled apart it hurts..." A physician's note, dated 03/25/13, documented, "...pain...(left) great toe (with) pressure ulcer, redness..." A nurse's note, date 10/29/13, documented, "...overlapping toes..." Weekly skin at-risk evaluation records, dated 12/27/13, 01/03/14, 01/10/14, 01/17/14, and 01/24/14 did not document any description of the resident's skin, risk factors, or interventions. The records were blank. A physician's orders [REDACTED]. A skin care plan, updated 01/29/14, documented, "[MEDICATION NAME] oint-apply to hallux wound BID..." The care plan had not been updated to address the resident's toes overlapped, the pressure ulcer on the resident's toe, and interventions to prevent pressure ulcers. Weekly skin at-risk evaluation records, dated 02/07/14 and 02/14/14, did not document any description of the resident's skin, risk factors, or interventions. The records were blank. There was no documentation to indicate if the wound on 01/29/14 had resolved or to document the condition of the wound, the treatment that was currently implemented, or interventions to prevent further pressure ulcers. A physician's progress note, dated 02/18/14, documented, "[MEDICATION NAME] to Hallux BID... WoundTeam/Reposition/Nutrition/Documentation..." An annual assessment, dated 02/20/14, documented the resident had a BIMS score of 15. This score indicated the resident was independent in cognitive skills for daily decision making. The assessment documented the resident was independent with transfers and ambulation, required limited assistance with dressing and personal hygiene, experienced frequent pain, and did not have a pressure ulcer. Weekly skin at-risk evaluation records, dated 02/21/14 and 03/01/14, did not document any description of the resident's skin, risk factors, or interventions. The records were blank. There was no documentation to indicate if the wound on 01/29/14 had resolved or to indicate the condition of the wound, the treatment that was currently being provided, or interventions to prevent further pressure ulcers. A skin care plan, dated 03/03/14, documented, "...Skin: Potential for skin breakdown R/T incontinence and hx. of skin breakdown...Interventions: Consult with wound/tx nurse, physician, wound consultant or dietician as indicated...monitor skin per protocol and report abnormalities noted to TX. nurse and physician as indicated..." The care plan did not address the resident's toes overlapped, if a pressure ulcer existed, and interventions to prevent pressure ulcers. A physician's progress note, dated 03/06/14, documented, "...Pain...Wounds..." Weekly skin at-risk evaluation records, dated 03/07/14, 03/14/14, and 03/21/14, did not document any description of the resident's skin, risk factors, or interventions. The records were blank. A social service note, dated 03/31/14, documented, "...scheduled to receive a foot exam & footcare on 5-9-14..." There was no documentation of a foot exam or foot care found. A quarterly assessment, dated 05/20/14, documented the resident had a BIMS score of 15. This score indicated the resident was independent in cognitive skills for daily decision making. The assessment documented the resident was independent with transfers and ambulation, required limited assistance with dressing and personal hygiene, experienced no pain, and did not have a pressure ulcer. A Braden scale risk assessment, dated 05/22/14, documented the resident had a score of 21. This score indicated the resident was at low risk for a pressure ulcer. A physician's progress note, dated 06/11/14, documented, "...ambulatory without assistance...severe [MEDICAL CONDITION] arthritic changes in her hands and feet...Skin: no new...ulcers..." The nurses' notes were reviewed for the month of July 2014. There was no documentation regarding skin assessments or any interventions applied for the prevention of pressure ulcers regarding the resident's overlapping toes. A physician's progress note, dated 08/12/14, documented, "...Skin: ...warm, dry..." There was no documentation regarding the resident's toes or feet. The nurses' notes were reviewed for the month of August 2014. There was no documentation regarding skin assessments or any interventions applied for the prevention of pressure ulcers regarding the resident's overlapping toes. A nurse's note, dated 08/17/14, documented the resident had been sent to the hospital. An integrated progress note from the hospital, dated 08/18/14, documented, "WC (wound care) note...Pt. has multiple pressure ulcer POA (present on admission)...Stage IV to L 2nd toe medial (with) bone exposed & L 2nd lateral - full thickness & L 3rd toe Stage IV + bone...concerned for osteo[DIAGNOSES REDACTED]...pt c/o pain to L foot..." A pressure ulcer order sheet from the hospital, dated 08/18/14, documented the resident had a Stage III pressure ulcer to her left second toe, and a Stage IV pressure ulcer to her left second toe and her left third toe. On 09/26/14 at 10:35 a.m., physician #1 was asked about the resident's feet and toes. The physician reviewed his progress note for June 2014 and stated, "I typically always look at their feet. Yes, I looked at her feet." The physician was asked if he would have noticed open areas with bone exposed. He stated, "Yes. I'm very meticulous about skin. I would have noticed blackness of toes and bone exposed." The physician was asked if the resident had recently received any treatments for her toes. He stated, "No treatment as far as I know." The physician was asked how long it would take for a deep tissue injury to become a stage IV pressure ulcer. He stated, "At least several days." At 10:46 a.m., the wound treatment nurse was asked if the resident had any pressure ulcers. She stated, "Not to my knowledge. We do weekly skin assessments if they are at high risk for skin breakdown. She was at 20 on her Braden. She would not have been on weekly skin assessments." The wound treatment nurse was asked if the CNA's documented the resident's skin condition when they would observe the residents. She stated, "CNA's don't mark anything that I'm aware of." At 2:15 p.m., CNA #11 was asked if she had provided care to the resident. She stated, "Yes." She was asked about the condition of the resident's toes. She stated, "Her toes were bent." She was asked if she had observed any open areas on her toes. She stated, "Not that I ever seen." She was asked if the resident had experienced pain. She stated, "Yes, mainly her feet and her toes. She would say they hurt and hard for her to stand." The CNA was asked what the process was for reporting skin issues. She stated, "If they have a skin tear or something on their bottom I tell the nurse but never write it down." The CNA stated, "A couple of days before she went to the hospital she wouldn't get up or eat." She was asked if she observed her skin the day she went to the hospital. She stated, "No." On 09/29/14 at 2:21 p.m., the DON was asked if the resident was ambulatory. She stated, "She was up until she started using the wheelchair." The DON was asked when the resident stopped ambulating. She stated, "Not positive. About a month before she went to the hospital." The DON was asked for the foot examination that was scheduled on 05/09/14. She stated, "It should be in the record." The DON was informed that it had not be found in the clinical record and could she provide the examination. No examination was provided. The DON was asked why the care plan did not address the resident's overlapping toes. She stated, "I don't know." The DON was asked why they stopped doing weekly skin assessments after 03/21/14 and why they were not doing weekly skin assessments on the resident's toes. She stated, "If their Braden is 18 or below we would do a weekly assessment. But, her's was a 21. So we wouldn't be doing an assessment on her." At 2:35 p.m., RN #6 was asked what was the condition of the resident's toes and feet the last time they were observed. She stated, "They (toes) overlapped and her feet went inward." The RN was asked when she had done a skin assessment on the resident's feet and toes. She stated, "One week before she went out (hospital)." She was asked if there were any open areas. She stated, "I didn't see anything." The RN was asked if she had documented the skin assessment. She stated, "No. It was just a look." On 09/30/14 at 1:24 p.m., LPN #7 was asked about the condition of the resident's feet and toes the day she went to the hospital. She stated, "I told the aide to get her ready. She didn't put any socks on her. Her toes were curled, lapping over each other. They were arthritic. I didn't see any redness or drainage. I didn't pull her toes apart. That would have been painful." The LPN was asked if she had documented her assessment. She stated, "No I didn't. I should have." The LPN was asked when she had conducted the last skin observation on the resident. She stated, "I really don't know." She was asked when the resident had stopped ambulating. She stated, "About a month before she went to the hospital she stopped walking." At 2:20 p.m., LPN #10 was asked if she had provided care for the resident. She stated, "I've taken care of her." She was asked about her toes and feet. The LPN stated, "Her toes overlapped each other and it was arthritis." She was asked if any skin assessments had been conducted on the resident. She stated, "They have weekly, but I don't know who did them. I didn't do any." The LPN was asked if the resident had any open areas. She stated, "I don't know." On 10/01/14 at 3:54 p.m., care plan coordinator #1 was asked why the resident's toes that overlapped and her feet were not addressed on the care plan with interventions in place to prevent pressure ulcers. She stated, "She was independent with ADLs and her Braden scored high on the skin assessment. I knew they (toes) overlapped and were disfigured but I didn't think to proceed further with interventions for her toes." She was asked if the resident's toes and feet should have been care planned with interventions to prevent pressure ulcers. She stated, "Yes."

Based on observation, interview and record review, it was determined the facility failed to provide supervision to prevent accidents and failed to identify and implement interventions to prevent falls for 2 (#8 and #9) of 3 sampled residents who were assessed to be at high risk for falls. This resulted in actual harm for resident #8 when he suffered a fall resulting in lacerations to his scalp and face requiring sutures and a fall resulting in a fracture to his nose and jaw. Resident #9 suffered 23 falls with injuries occurring with 4 of the falls. The facility identified 4 residents as being at high risk for falls. Findings: The facility's fall awareness program, revised 07/07/09, documented, "...Consider adjusting bed to lowest position...Reassess for safe footwear...Institute bowel/bladder routine program, as appropriate...Develop care plan based on interventions used. Review quarterly and as needed...Initiate 1/2 hour to hourly checks and/or placement of resident at nursing station, as appropriate...Consider room change...Re-evaluate toileting rounds to reduce unassisted trips to the bathroom...Check the resident frequently; particularly at high-risk times...Re-evaluate the mental status of high-risk patients every shift..." Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall safety sheet, dated 10/01/10, documented, "...Encourage resident to request assist with mobility, transfers and ambulation as needed...keep call light in reach...keep pathways clear and free from clutter...keep area consistently clear and well lighted...observe for dizziness, excessive fatigue, and unsteady gait. Encourage to rest as needed...resident ed: observe 'wet floor' signs avoid wet floors...ed. resident (and) staff to help assist in getting dressed..." A bladder assessment for retraining and/or prompted toileting form, dated 10/01/10, documented, "...Able to participate in B/B program - will refer to Restorative for retraining or prompted voiding program..." A nurse's note, dated 10/01/10 at 8:00 p.m., documented, "...(increased) fall risk...needs assist to restroom does have a walker unable to use for long periods of time..." An initial plan of care, dated 10/02/10, documented, "...Fall score...75...score 25 or more indicates at risk...Assess resident's mobility and need for assist with transfers, toileting, ambulation...Encourage resident to request assist with mobility, transfers, ambulation as needed. Call light in reach. Keep pathways clear and free from clutter. Keep area consistently clear and well lighted. 1 person assist with transfers..." A nurse's note, dated 10/05/10 at 12:00 p.m., documented, "...n/o's ambulates c walker c standby assist x 1..." The summary score of the MDS Brief Interview for Mental Status (BIMS), dated 10/12/10, documented the resident was moderately impaired. The resident scored a 12. An admission assessment, dated 10/12/10, documented the resident required set-up help only for transfers and personal hygiene, was independent in toileting, was continent of bowel and bladder, had no range of motion limitations, and had fallen in the last month prior to admission and within the last 2 - 6 months prior to admission. A nurse's note, dated 10/13/10 at 7:10 p.m., documented, "...res found laying on floor in front of bathroom door..." The resident's care plan, dated 10/14/10, documented a problem, "...Potential for falls r/t hx of falls, unsteady gait, poor vision, and psychotropic med use..." The goal was, "...will be free from serious injury r/t falls over the next 90 days..." Approaches included, "...Keep call light within reach, encourage use for needs, and answer in a timely manner. Remind of use of call light as needed...Family has been made aware of fall potential and risk for injury from falls...Keep frequently used items within reach...Promote safe environment: Keep pathways well lit and free from clutter...Assess/evaluate any patterns to falls...Encourage use of visual appliance as needed...Encourage to take rest breaks as needed...Monitor for unsteady gait...Encourage appropriate footwear daily...redirect poor decision making as able that could bring harm to self or others...Encourage use of appropriate assistive devices...Administer medications per physician order [REDACTED]. A nurse's note, dated 10/15/10 at 2:45 p.m., documented, "...Resident was leaving north dining room and slipped on wet floor..." An incident report, dated 10/15/10, documented, "...Resident ed re: observe wet floor signs avoid wet floors..." A nurse's note, dated 11/21/10 at 7:45 p.m., documented, "Resident found in the floor of resident's room. Dr. (name deleted) notified. Dr. (name deleted) ordered resident be send (sic) to the hospital...resident and (family member) refused to go the (sic) hospital...@ 2100 (9:00 p.m.) resident complained of headache..." An incident report, dated 11/21/10, documented, "...Resident stated he was trying to get his pants out (and) fell , hit head on fall (and) elbows bruised...educate resident and staff to help assist in getting dressed..." A nurse's note, dated 11/25/10 at 3:20 p.m., documented, "...Resident (up) at nurse's station...He turned to sit down in w/c and landed on bottom...Adv to ask for help..." An incident report, dated 11/25/10 at 5:00 p.m., for the fall at 3:20 p.m., documented, "...adv resident to ask for help...resident ed - bed alarm (check)..." A nurse's note, dated 11/25/10 at 5:30 p.m., documented, "...Called to dining room, observed resident sitting on floor...Resident states he was trying to walk over to where his four wheel walker was parked and lost his balance. Encouraged use of w/c..." An incident report, dated 11/25/10 at 6:00 p.m., for the fall at 5:30 p.m., documented, "...Encouraged resident to use w/c...call for assist..." A nurse's note, dated 11/26/10 at 5:00 a.m., documented, "...Environmental modification of room prior to bed last night. 2 walkers (sic) moved out of center of the room. Unused w/c folded and put out of the way. Instructed resident to call for assistance..." A nurse's note, dated 11/26/10 at 7:30 a.m., documented, "...CNA notified nurse resident's tongue (right) side is bruised from resident biting tongue when he fell on ,[DATE]. Resident was questioned but does not remember biting his tongue but says he probably did..." A nurse's note, dated 11/27/10 and untimed, documented, "...Resident found on the floor of his room. Resident unable to state how he got to the floor. Res states 'I just found myself on the floor.'..." An incident report, dated 11/27/10, for an incident that occurred at 3:30 a.m., documented, "...environmental modification..." A nurse's note, dated 11/27/10 at 9:00 p.m., documented, "...Resident's (family member) called the nursing station to inform the nurse resident was on the floor. Res found on the floor of (sic) the bathroom door...resident alert and oriented...res advised (sic) to call for help when the need to use the bathroom arise (sic)..." An incident report, dated 11/27/10 for the 9:00 p.m. incident, documented, "...toileting prog q 2 ( hours..." A nurse's note, dated 12/02/10 at 4:15 p.m., documented, "...Res observed on floor in room just inside the door. He reports he was standing up from the electric wheelchair to shut the room door and slipped (and) fell ...Resident encouraged to use call light (and) ask for assistance. Resident stated "I'll be more careful.' Did not state willingness to comply..." An incident report, dated 12/02/10, documented, "...Res enc to use call light. family ed - safety..." A nurse's note, dated 12/07/10 at 8:30 p.m., documented, "...Resident's (family member) called to nurses station to report '(resident #8) is on the floor.' Staff entered room and observed resident flat on his back in front of his bathroom. No walker near resident. Spare wheelchair behind him...Reported trying to lift bed covers to look under bed when he lost his balance falling back hitting his head and (left) hip on impact. 'Forgot to use walker.' Inspection of room shows limited room for movement...Discussed removal of some items from the room for safety...Resident refuses to use bed/chair alarm. He states he wants to 'maintain my dignity' and keep doing as much as I can myself..." An incident report, dated 12/07/10, documented, "...Family to remove extra w/c and see if there are any other furniture items they can remove to create more room...Do resident round @ 7p. to assist c ADLS..." A nurse's note, dated 12/08/10 at 6:00 a.m., documented, "...Res needs assist but doesn't ask sometimes. He states 'I still want to be independent'..." A nurse's note, dated 12/24/10 at 9:00 p.m., documented, "...Resident's (family member) called nurses station via cell phone from resident's room to report that (resident #8) was sitting on the floor but couldn't get up. Found resident sitting on floor between the two beds...States 'I was getting up out of bed and slid on floor. I did not fall.'..." An incident report, dated 12/24/10, documented, "...res and fam ed on non-skid footwear @ all times..." A nurse's note, dated 12/28/10 at 2:45 p.m., documented, "...Called to resident's room, observed resident sitting on floor wedged between toilet and wall...Spoke c resident about the importance of using call light before he goes to the restroom..." An incident report, dated 12/28/10, documented, "...spoke c resident about importance of using call light before he goes to restroom, so that someone can help him and help prevent a fall...res ed: call light w/c alarm, bed alarm..." A nurse's note, dated 12/29/10 at 4:00 a.m., documented, "...Resistant to ADL assistance...Very unsteady. Had to catch himself from falling by holding on to furniture...Amb. with walker down hallway to nurses station x 1...continual reminders of safety measures..." A nurse's note, dated 12/30/10 at midnight, documented, "...non-compliant c safety instructions..." An incident report, dated 01/02/11, documented, "...Res's (family member) states, 'He slide (sic) from his recliner...cont c current interventions in place..." A nurse's note, dated 01/03/11 and untimed, documented, "...Res found on the floor by his recliner chair. Resident's (family member) states, 'He slide (sic) down from his recliner.'..." A nurse's note, dated 01/04/11 and untimed, documented, "...non-compliant c request to call for assistance...Unsteady gait. Staff attempts to anticipate resident's needs to decrease chances of accidents..." A nurse's note, dated 01/05/11 at 8:00 p.m., documented, "...(family member) alerted staff to come to room. (Resident #8) was observed in front of his recliner kneeling with his elbows and torso resting on recliner. C/o loosing his balance while attempting to plug in scooter...c/o hitting head. Scant amt. of blood observed on a skin tear to (left) front of head. Small amt of blood observed on wall to the left of the recliner...Reviewed c resident the safety precautions he has agreed to adhere to in the past...Resident has stated several times he wants to maintain his independence and knows that with Parkinson's he will continue to fall..." An incident report, dated 01/05/11, documented, "...call family about de-[DIAGNOSES REDACTED] room..." A nurse's note, dated 01/07/11 and untimed, documented, "...Resident continues to be non-compliant and ambulates with walker down hallway without assist. Walks very fast c unsteady gait..." A nurse's note, dated 01/08/11 at 4:00 p.m., documented, "...Resident was amb c walker (and) lost balance (and) fell ..." An incident report, dated 01/08/11, documented, "...bed alarm (and) w/c alarm in place...." The summary score of the MDS Brief Interview for Mental Status (BIMS), dated 01/10/11, documented the resident was moderately impaired. The resident scored an 8. A significant change assessment, dated 01/10/11, documented the resident required extensive assistance of one person for transfers, toileting, and personal hygiene, had upper and lower extremity limitations in range of motion, was frequently incontinent of bowel and bladder, and had suffered 2 or more falls with injuries and 2 or more falls with no injuries since the last assessment. A nurse's note, dated 01/10/11 at 12:25 p.m., documented, "...Rsd unsteady on feet et c elec wc, running into walls et carts..." A nurse's note, dated 03/06/11 and untimed, documented, "...Resident fell in room this HS..." An incident report, dated 03/06/11, documented, "...res non-compliant c safety interventions...res able to understand importance of using call light for ADL assist..." A nurse's note, dated 03/15/11 at 10:00 p.m., documented, "...I entered room and call out for (resident #8) after viewing his empty wheelchair. He called out 'I am in here. I need your help.' Resident observed in his bathroom on the floor in front of the toilet with his pants down, lying on his back. States he lost his balance and sat on the floor...Resident instructed not to attempt to use bathroom s assistance..." An incident report, dated 03/15/11, documented, "...encourage approp. footwear...ed (family member) to use call light for assistance c (resident #8)..." A nurse's note, dated 03/17/11 and untimed, documented, "...Family...into vist. Discussed resident's need for assistance c toileting even though he often tells staff he needs no help. Staff education re: this..." A nurse's note, dated 03/18/11 at 1:45 p.m., documented, "...Called to room observed resident on floor face down. Resident stated was walking unassisted across room to walker..." An incident report, dated 03/18/11, documented, "...med review...labs ordered..." A nurse's note, dated 03/25/11 and untimed, documented, "...Has been asking staff and residents if they know where he can get a 'left ladder.' Will not tell us what he needs it for. confused about something. Goes in and out of confusion..." A nurse's note, dated 03/26/11 and untimed, documented, "...Became aggressive c staff briefly this H.S. Refused going to bed at midnight. Stated he needed to work on his taxes. Pushed me aside when I attempted to get him to sit down in wheelchair (was leaning and almost fell )..." A nurse's note, dated 03/27/11 at 5:30 p.m., documented, "...Resident found on floor in bathroom. Resident stated was in bathroom with walker lost balance (and) fell ..." A nurse's note, dated 03/27/11, documented, "...freq rounds to assist c toileting needs or any other ADLs..." A nurse's note, dated 03/27/11 for the 6:00 p.m. to 6:00 a.m. shift, documented, "...Resident found on floor in bathroom at 0150 (1:50 a.m.). Observed knot on (left) occipital and scrape on (left) cheek. States he was going to the bathroom..." An incident report, dated 03/27/11, documented, "...PT to screen for gait strengthening..." A nurse's note, dated 03/28/11 at 12:30 p.m., documented, "...Spoke c (family member) about (resident #8) being noncompliant c safety interventions. She explained that she was aware of his non-compliance but she wanted him to be as independent as he could be even it if meant he falls..." A nurse's note, dated 03/28/11 at 7:30 p.m., documented, "...Res (family member) called nrs station states '(resident #8) is laying on the bathroom floor.' Observed res laying on back between toilet (and) wall leaning left on wall. S/T noted above (left) elbow unable to proximate edges..." An incident report, dated 03/28/11, documented, "...spoke c (family member) understands (increased) fall risk but wants him to be independent as possible even if he falls - (resident #8)'s wishes..." A nurse's note, dated 04/01/11 at 3:00 a.m., documented, "...Res (family member) called nurse station '(resident #8)'s on the floor.' Observed res sitting on floor @ foot of his bed c blood noted to (left) side of face. Blood on floor. Assisted res (up) into w/c. Res combative biting hitting kicking trying to get (up). Cleaned face, head, hands (and) arms...put 4x4's on 2 open areas to top of head applied pressure then ice applied. (Lower) (left) eye purple hematoma side of (left) eye cut (and) hematoma (left) ear 3 cuts (and) big purple bruise to (upper) (sic) of ear. Reopened old S/T to (left) (upper) elbow. Cuts to wrist from watch...Transferred to (hospital name withheld)..." An incident report, dated 04/01/11, documented, "...cont to encourage rsd to request assist c ADLs..." A nurse's note, dated 04/06/11 at 12:00 p.m., documented, "...Returned...has purple bruising under left eye. Suture (3) top of head 6 sutures left side of head. Left ear nearly all purple - Bruising both hands..." A physician's telephone order, dated 04/06/11 at 12:00 p.m., documented, "...PT to eval (and) tx if indicated..." The summary score of the MDS Brief Interview for Mental Status (BIMS), dated 04/07/11, documented the resident was severely impaired. The resident scored a 6. A quarterly assessment, dated 04/07/11, documented the resident required extensive assistance of one person for transfers, toileting, and personal hygiene, had upper and lower extremity limitations in range of motion, was continent of bowel, had a urinary catheter, and had no falls since admission or prior assessment. The re-entry date was documented as 04/06/11. A nurse's note, dated 04/14/11 and untimed, documented, "...Ambulates c walker. X 1 assist c transfers...Abrasion to (left) forehead. Scabbed approx 2.8cm x 0.1cm (from fall). Bruise noted to (left) cheek 7cm x 3cm..." A nurse's note, dated 04/22/11 at 3:00 a.m., documented, "...Resident's (family member) called nursing desk and reported resident on the floor. This nurse entered room to note resident prone @ bsd...Resident alert and talking...Turned to his side s assistance. 2 person assist into w/c. Pool of blood that was under resident face appears to have came from his nose. Hematoma and bruising to bridge of nose. Blood clots in both nostrils. Nose appears irregular/asymmetrical. Resident report attempting to go to bathroom and fall 'flat on my nose.' Pupils initially pinpoint and non-reactive. Pupils (increase) in size but continued to be non-reactive. Answers questions appropriately...6 cm half moon skin tear to (right)dorsal hand...0.5 cm skin tear (right) dorsal just below the above...transfer to ER r/o traumatic head injury..." Review of the resident's clinical record revealed no documentation to show the resident's care plan had been revised to include any new interventions. There was no documentation to show the resident had been on the facility's bowel and bladder retraining program, and there was no documentation to show the resident had received a physical therapy evaluation. A hospital computed tomography scan result, dated 04/22/11, documented, "...There is a fracture involving the right nasal bone and the frontal process of the right maxilla..." On 04/25/11 at 1:00 p.m., the resident's family member stated the resident was at the hospital because "he fell and hurt himself." The family member was asked if the resident fell often. She stated, "Yes, he falls all the time. He has Parkinson's and I think he has more dementia than he used to." The family member was asked what type of injuries the resident sustained [REDACTED]." At 5:03 p.m., RNs #1 and #3 and LPN #1 were interviewed. RN #3 was asked if the resident was a high fall risk. She stated, "Yes." When asked if the resident was ever placed on the bowel and bladder retraining program, RN #3 stated, "I don't recall that he was." RN #3 was asked when the resident received physical therapy. She stated, "I don't believe he did. He came in on hospice. They didn't want anything for him." RN #1 was asked what interventions were put into place to attempt to reduce falls for the resident. She stated, "We actually placed alarms but the daughter and the resident removed them. We provided education, reminding him and (the family member)." RN #1 was asked if the staff attempted to educate the daughter. She stated, "Yes." When asked for the documentation, RN #1 stated it was in the nurses' notes. RN #1 was informed it was documented the daughter was provided education but there was no information on the education provided. RN #1 stated that was not documented. LPN #1 was asked if the resident was alert and oriented to person, place, and time. She stated, "No, to person and place at the most on his really good days." LPN #1 was asked if the resident was alert and oriented to person, place, and time on admission to the facility. She stated, "No. He has advanced Parkinson's with dementia." A hospital consult, dated 04/25/11, documented, "...Pt is...with...history of chronic [DIAGNOSES REDACTED]who came in from the nursing home after he fell from trying to get up out of his wheelchair. His CT of the head revelaed (sic) a right nasal fracture, bilateral temporomandibular disloaction (sic), and an acute on chronic subdural hematoma..." A nurse's note, dated 04/25/11 @ 7:30 p.m., documented, "...arrived @ facility...Awake, alert, et oriented x 2...weak et fatigue unsteady gaits, need assistance unable to bear full wt to extremities. Resident on low bed et floor mat. Staff is providing 1 (on) 1 for safety observation...dx of UTI (and) fracture of mandible...bruises to face, nose, chin et lower face, multiple abrasion to face..." A nurse's note, dated 04/25/11 at 9:30 p.m., documented, "...(family member) advised of safety measures in place @ this time to minimize rsd injury. States agreement c plan @ this time. Hi/low bed in place in low position c fall mat, staff providing 1:1 for safety observation this p.m., non skid socks in place, environmental sweep done...bedside table et nightstand padded for rsd safety. Staff toileting rsd p meals. Staff inservice completed on providing safety for this rsd...staff member @ bedside..." On 04/26/11 at 10:00 a.m., the resident was observed seated in his recliner with his eyes closed. His forehead, nose, cheeks, and chin were observed to be bruised. A staff member was with the resident. On 04/26/11 at 10:10 a.m., the administrator, RN #1 and LPN #1 were interviewed. RN #1 was asked if there was documentation the resident had been toileted every 2 hours. She stated, "No." RN #1 was asked if any new interventions had been identified since admission to aid in the prevention of falls. LPN #1 stated, "No." LPN #1 was asked for the physical therapy evaluations from 03/27/11 and 04/06/11. She stated, "I cannot find any documentation." LPN #1 was asked if the resident used his call light. She stated, "Sometimes he does and sometimes he doesn't. RN #1 was asked how the facility identified residents at risk for falls. She stated a fall assessment was completed on admission and was updated with each fall. When asked if it was working effectively, the administrator stated, "It identified him as a fall risk. What we did after that was the problem." When asked if the system was working, the administrator stated, "I think it was broke." 2. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, dated, 07/29/10, documented a problem, "...potential for falls/injuries r/t hx of falls, ms dx, tremors, muscle spasm, osteoporosis, unsteady..." The goal was, "...will be free from serious injury over the next 90 days..." Approaches included, "...assess/evaluate any patterns ie: time of day, location, etc...monitor for unsteady gait. Provide assistance prn...fall risk assessment per facility protocol...sensor pads have been dc'd r/t noncompliance..." A nurse's note, dated 09/30/10 at 5:00 p.m., documented, "Called to outside smoking area, resident noted on the ground sitting in front of w/c, facing w/c...neuro (checks) restarted...assisted to bed...fall mat in place, low bed..." A nurse's note, dated 10/26/10 at 5:20 p.m., documented, "Called to desk, resident on ground in front of door, (smoking area) lying on (right) side...placed in low bed with fall mat..." An update to the resident's care plan, dated 11/09/10, documented, "Called to rm, resident noted on floor, face first (with) knees bent, w/c on top of resident, resident states, "I was trying to get in bed."...place sign in room to remind (name deleted) to call for assist." An incident report, dated 11/12/10, documented, "...transferring...hurt elbow...fall mat, low bed, med review..." A nurse's note, dated 12/18/10 at 12:30 p.m., documented, "...CNA found resident in floor @ bedside, resident stated was transferring self from w/c to bed (and) lost balance (and) fell , hit forehead on floor...neuro (checks) started...low bed (and) fall mat in place..." A nurse's note, dated 12/30/10 at 12:45 p.m., documented, "...Resident transferring self from w/c to bed, lost balance (and) fell , hit head on floor, neuro (checks) started, denies pain assisted to bed, bed alarm and w/c alarm in place..." An update to the resident's care plan, dated 12/30/10, documented, "Res. transferring self from w/c to bed, lost balance and fell hitting head on floor, Neuro (checks) initiated, denies pain, bed alarm, and w/c alarm in place." No new interventions for the prevention of falls were documented on the resident's care plan. A significant change assessment, dated 01/12/11, documented, "...Two or more falls...no injury since the prior assessment." An update to the resident's care plan, dated 01/24/11, documented, "(name deleted) has had a significant decline in his functional status. Continue care plan x 90 days." The care plan did not include any new interventions for the prevention of falls. An incident report, dated 02/12/11, documented, "...transferring...hit head...low bed, fall mat..." An incident report, dated 02/26/11, documented, "...transferring...hit head...educated to use call light (and) ask for assistance..." The resident's care plan, updated on 02/26/11, documented, "...Res has been notified and educated to use call light and ask for assistance. He refused to adhere to interventions..." A nurse's note, dated 03/6/11, documented, "Found resident outside smoke area on ground...has abrasion to lt (left) forehead (and) l (left) leg, both cleaned ..." An update to the resident's care plan on 03/12/11, documented, "...WC and bed alarm. Document q shift on w/c and bed alarm..." A nurse's note, dated 04/02/11 at 1:00 p.m., documented, "CNA observed resident on floor in room beside w/c...attempting to transfer from bed to w/c (and) fell ...neuro (checks) started..." A quarterly assessment, dated 04/11/11, documented, "...Two or more falls...no injury...since the prior assessment." Review of the clinical record documented the resident had 23 falls with 4 falls that resulted in injury to the resident from 10/30/10 through 04/02/11. On 04/26/11 at 12:25 p.m., RN #1 and RN #2 were asked what new interventions were being implemented to ensure resident #9 did not fall. RN #2 stated, "They are pending." When asked what else could be done to ensure he did not fall, RN #1 and RN #2 did not comment. The administrator stated, "He won't use call lights, we can reason with him but he won't use it." When asked if the care plan should have been updated to include new interventions to ensure the resident did not fall transferring to and from bed, RN #1 stated, "Yes." When asked if the interventions on the care plan to prevent falls were working, RN #2 stated, "Apparently not."