Every finding on record at Greenbrier Village Health and Rehabilitation

Based on observation and interview, the facility failed to ensure furniture in the memory care unit was kept clean, maintained in good repair, and reflected a home-like environment. The DON identified 17 residents resided in the memory care unit. Findings: On 07/20/26 at 6:13 a.m., eight recliners were observed in the common area of the memory care unit which had small tears and small cracks on each arm of each recliner. On 07/20/26 at 6:20 a.m., two couches in the dining area of the memory care unit were observed to have multiple dark stains. The couch on the right was observed to have a large slit in the upholstery exposing the cushion inside. On 07/27/26 at 12:21 p.m., CMA #1 stated the couches in the dining area were worn, stained, the one on the right had a large slit in the fabric, and they should be replaced. On 07/27/26 at 12:25 p.m., licensed practical nurse #3 stated the eight recliners were not in good condition. They stated it would be better if each arm of each chair did not have cracks in them. On 07/27/26 at 12:26 p.m., CMA #1 stated the eight recliners in the common area were worn, with tears in all arms of each chair. They stated they should at least be recovered. On 07/27/26 at 4:17 p.m., the infection preventionist stated the stained couches should be deep cleaned, covered, and attempt to repair the split fabric on the couch on the right.

Based on record review and interview, the facility failed to protect the resident's right to be free from sexual abuse for 1 (#2 and #3) of 3 sampled residents reviewed for sexual abuse. The DON identified 17 residents resided in the memory care unit. Findings: A policy titled Suspected or Allegation of Resident Abuse/Neglect/Misappropriation of Property and Involuntary Seclusion, dated 06/2019, read in part, All employees .and visitors by law are to report allegations of and/or abuse .Sexual Abuse/Sexual Assault .lewd and indecent acts. 1. A nurse's note for Resident #1, dated 05/01/26, showed the resident admitted to the memory care unit. An admission assessment for Resident #1, dated 05/01/26, showed the resident had a BIMS score of 1, which indicated severely impaired cognition. A care plan for Resident #1, dated 05/02/26, showed the resident needed cueing, reorientation, and supervision as needed. A care plan for Resident #1, dated 05/08/26, showed the resident had mood, behaviors, delusional disorder to include wandering the hall, hitting staff, and a history of inappropriate touch. Interventions listed included to intervene as necessary to protect the rights and safety of other residents, if reasonable, discuss the resident's behavior explaining why the behavior was inappropriate or unacceptable, and monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential issues. A care plan for Resident #1, dated 05/12/26, showed the resident was to be provided with line of sight during times of agitation. A care plan for Resident #1, dated 05/13/26, showed the resident was referred to geri psych as indicated for escalated behaviors and medication management. A care plan for Resident #1, dated 05/27/26, showed the resident returned from geri psych and to encourage a calm, quiet environment, redirect from common areas during agitation. Approach calmly, from the front, do not surprise the resident. A care plan for Resident #1, dated 07/02/26, showed the resident used psychotropic medications related to behavior management. Interventions included to monitor, record occurrence for target behavior symptoms, pacing, wandering, inappropriate response to verbal communication, violence/aggression toward staff/others, and document per facility protocol. A progress note for Resident #1, dated 07/14/26, showed RN #2 reported they witnessed Resident #1 sitting close to Resident #2 and touching them inappropriately. A hospice visit note for Resident #1, dated 07/14/26, showed Resident #1 was in the dining room standing over Resident #2 who was seated with their hands on their chest, abdomen, and groin area. RN #2 attempted to redirect Resident #1. Resident #1 grabbed the face of Resident #2 and began kissing them. Resident #1 was redirected. Resident #1 stood behind Resident #2 and placed their hands in their hair. The residents were separated and Resident #1 was redirected toward their room. A police report, dated 07/14/26, showed Resident #1 forcibly kissed Resident #2. Resident #1 was being really touchy and touched Resident #2 on the breast and all over their body. Staff told Resident #2 to get away from Resident #1, but they looked shocked and stuck. Until staff were called and went with them, Resident #1 was taken to their room and being watched. A progress note for Resident #1, dated 07/17/26, read in part, [Resident #1] was accepted to inpatient geri psych with a bed available today. 2. A census list for Resident #2, dated 04/03/26, showed the resident admitted to the memory care unit. A medical diagnoses tab in the EHR for Resident #2, dated 04/14/26, showed the resident had diagnoses which included Alzheimer's, dementia, disorientation, and psychosis. A medical diagnoses tab in the EHR for Resident #2, dated 05/08/26, showed Resident #2 had a diagnosis of altered mental status. A quarterly assessment for Resident #2, dated 07/17/26, showed the resident could ambulate independently without a device. The assessment showed Resident #2 had a BIMS score of 6 which indicated moderately impaired cognition. On 07/27/26 at 2:18 p.m., RN #2 stated they observed Resident #1 with their hands on Resident #2 over their clothing in the groin area. They stated the face of Resident #2 looked distraught. Resident #1 placed their hands on Resident #2 from the groin area, abdomen, chest. RN #2 stated When they tried to gain the attention of Resident #1, they grabbed the face of Resident #2 and kissed their face. On 07/27/26 at 4:05 p.m., the power of attorney for Resident #2 stated they had been notified and they were relieved Resident #1 was no longer at the facility. 3. A medical diagnoses tab in the EHR for Resident #3, dated 07/11/25, showed the resident had a diagnosis of dementia. A care plan for Resident #3, dated 07/28/25, showed the resident was at risk for altered cognition related to dementia, depression, infection, and multiple sclerosis. The care plan showed the resident has a BIMS score was 11 on admission which indicated moderate impaired cognition. The care plan showed the resident required curing for short term memory recall. A census list for Resident #3, dated 06/30/26, showed the resident transferred to the memory care unit. A wandering risk scale assessment for Resident #3, dated 06/30/26, showed the resident was a high risk to wander. A final incident report, dated 07/02/26, showed an allegation of abuse reported by Resident #3 about Resident #1 going into their room at night and grabbing their breast. A police report, dated 07/02/26, showed Resident #3 advised Resident #1 had entered their room late one night and Resident #1 put their hand near their breast on their shoulder. The report showed Resident #3 stated they told Resident #1 to leave, and Resident #1 muttered something to themself and left. The report showed Resident #3 advised they believed the incident was accidental and Resident #1 was confused. A progress note for Resident #3, dated 07/18/26, showed the resident was transferred to the hospital after a fall for evaluation and treatment. A progress note for Resident #3, dated 07/19/26, showed the resident had been admitted to the hospital for a right ankle fracture with the possibility of surgery same day. On 07/22/26 at 11:39 a.m., the DON stated they increased staff on the memory care unit from two staff to three staff to monitor resident behaviors. On 07/22/26 at 11:44 a.m., the DON stated resident behaviors were tracked by the IDT daily, but there was no documentation of the behavioral findings or tracking of the IDT. The DON stated it was necessary to discuss resident behaviors and updated their care plans.

Based on record review and interview, the facility failed to implement their legionella water management program to prevent waterborne contaminants. The DON identified 99 residents resided in the facility.Findings: A Legionella Water Management Program policy, dated 09/01/22, read in part, The water management program includes the following elements:a. A detailed description and diagram of the water system in the facility.b. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria.c. The identification of situations that can lead to Legionella growth.d. Specific measures used to control the introduction and/or spread of Legionella.e. A diagram of where control measures are applied.f. A system to monitor control limits and the effectiveness of control measures.g. Documentation of the program.The facility had no documentation to show measures were taken to prevent legionella.On 06/25/26 at 3:21 p.m., the administrator stated the facility did not have a water management program in place. The administrator stated maintenance was only checking water temperatures weekly to prevent burns. The administrator stated there was no diagram of the facility's water system, no testing of the water, and no flushing of the pipes being conducted by anyone in the facility.

Based on record review and interview, the facility failed to ensure the required PBJ staffing data was submitted to CMS within the mandated timeframe.The DON identified 99 residents resided in the facility.Findings:A PBJ Staffing Data Report, dated 01/01/26 through 03/31/26 (Fiscal Year quarter 2 2026), showed the facility had not provided the staffing data to CMS for the PBJ staffing data report for quarter two of federal fiscal year 2026.On 06/24/26 at 2:59 p.m., the administrator stated they could not locate documentation the PBJ staffing data was submitted to CMS for quarter two.

Based on observation, record review, and interview, the facility failed to ensure their ice machine was maintained in a sanitary condition. The DON identified 99 residents received food and drinks from the kitchen.Findings: On 06/21/26 at 10:53 a.m., the ice machine located in the dining room was observed to have a black substance inside the ice storage bin when wiped with a paper towel. The facility had no documentation to show the ice machine was cleaned and sanitized. An Ice Machines and Ice Storage Chests policy, dated 01/01/12, read in part, To help prevent contamination of ice machines, staff shall clean and sanitize the tray and ice scoop daily. On 06/21/26 at 10:54 a.m., dietary #1 stated the ice machine was cleaned by environmental staff. Dietary #1 stated the ice machine was dirty after they witnessed the paper towel used to wipe the inside of the ice machine had a black substance on it. On 06/21/26 at 11:30 p.m., the certified dietary manager stated dietary cleaned the ice machine weekly, and maintenance cleaned it quarterly. On 06/24/26 at 10:45 a.m., the certified dietary manager stated dietary staff had only been wiping down the outside of the ice machine. The certified dietary manager stated they thought maintenance had been cleaning the ice machine, but there was no log.

Based on observation, record review, and interview, the facility failed to ensure the interdisciplinary team determined a resident could safely self-administer oral medications for 2 (#22 and #75) of 2 sampled residents reviewed for self-medication administration.The DON identified 99 residents resided in the facility. Findings: 1. On 06/22/26 at 10:05 a.m., 15 medications of different colors were observed in a medication cup in Resident #75's room. There was no staff in the room. An admission assessment for Resident #75, dated 05/21/26, showed the resident had a BIMS score of 3, which indicated the resident was severely impaired in cognition for daily decision making.On 06/22/26 at 10:02 a.m., Resident #75 stated staff did not observe them take their medications. They stated staff usually set the medications in their room and leave.On 06/22/26 at 10:17 a.m., CMA #1 stated the medications in the cup were Resident #75's morning medications. CMA #1 stated the medications included an opioid pain medication.On 06/22/26 at 10:19 a.m., CMA #1 stated they did not observe the resident take their medication. They stated they were supposed to observe the resident take their medication.On 06/22/26 at 10:21 a.m., CMA #1 stated Resident #75 did not have an order for self-administration of medication.On 06/25/26 at 8:23 a.m., the DON stated residents could self-administer medications if the provider and the interdisciplinary team determined safe administration.On 06/25/26 at 8:27 a.m., the DON stated staff should observe residents take their medications. They stated Resident #75 did not have a self-administration of medication assessment and a physician order to self-administer medications.2. On 06/23/26 at 8:17 a.m., Resident #22 was observed to take two pills. There was a cup with medication pills in them. Resident #22 was seated in the center of the dining room with their back towards CMA #2. CMA #2 was at the medication cart across the dining room with their back turned to Resident #22.A policy titled Administering Medications, revised 04/2019, read in part, Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.An admission assessment for Resident #22, dated 04/14/26, showed the resident had a BIMS score of 13, which indicated the resident's cognition was intact for daily decision making.On 06/23/26 at 8:18 a.m., Resident #22 stated there were 11 medication pills left in the cup. They stated they took two pills. Resident #22 stated CMA #2 gave them their morning medications.On 06/23/26 at 8:41 a.m., CMA #2 stated they gave Resident #22 their morning medications. CMA #2 stated the medications included an opioid pain medication.On 06/23/26 at 8:42 a.m., CMA #2 stated they did not observe Resident #22 take their medications. They stated the resident should be observed to take their medication.On 06/25/26 at 8:30 a.m., the DON stated Resident #22 did not have a self-administration of medication assessment and a physician order to self-administer medications.

Based on observation, record review, and interview, the facility failed ensure 2 staff members were utilized to transfer a resident with a mechanical lift placing the resident at risk for falls for 1 (#65) of 5 sampled residents reviewed for falls. The DON identified 27 residents required the use of a mechanical lift for transfers.Findings: On 06/23/26 at 7:35 p.m., Resident #65 was observed sitting in a geriatric chair in the common area between the [NAME] and [NAME] halls. On 06/23/26 at 7:51 p.m., CNA #2 was observed to walk out of Resident #65's room with the mechanical lift. CNA #2 was observed to have been in the room alone and had transferred Resident #65 to the bed from their geriatric chair. A Using a Mechanical Lifting Machine policy, dated 07/01/17, read in part, At least two nursing assistants are needed to safely move a resident with a mechanical lift. A care plan intervention for Resident #65, dated 02/15/26, read in part, Per physical therapy for safety, the resident is only to be transferred using a mechanical full-body lift. A quarterly assessment for Resident #65, dated 04/01/26, showed the resident required substantial/maximal assistance from staff for transfers. The assessment showed the resident's cognition was severely impaired with a BIMS score of 2. The assessment showed the resident had a diagnosis of dementia and a history of falls. On 06/21/26 at 11:55 a.m., family member #1 stated on 06/17/26, one staff member attempted to transfer Resident #65 by themselves using a mechanical lift, while the family member and hospice nurse were in the room with the resident. Family Member #1 stated the hospice nurse intervened because they knew two staff members were supposed to use the mechanical lift for safety. Family Member #1 stated the facility did not have enough staff to safely transfer residents who required a mechanical lift. On 06/23/26 at 3:28 p.m., CNA #2 stated they were very short-staffed on the 2 p.m. to 10 p.m. shift, and that made it hard to transfer residents who required two staff members for assistance. CNA #2 stated they were not allowed to use a mechanical lift without two staff members. On 06/23/26 at 3:30 p.m., CNA #3 stated they had been told to transfer a resident using a mechanical lift by themselves because no other staff was available. CNA #2 stated they refused to transfer a resident who was a two-person assist alone because it was not safe. On 06/23/26 at 3:53 p.m., CNA #4 stated they previously had to transfer a resident alone using a mechanical lift because no other staff was available. On 06/23/26 at 7:52 p.m., CNA #2 stated they had transferred Resident #65 by themselves using the mechanical lift because the other aide had to take a phone call and no other staff was available to help. On 06/23/26 at 8:15 p.m., the DON was asked if a staff member should transfer a resident by themselves with a mechanical lift. The DON stated absolutely not. The DON stated two staff members were required when using a mechanical lift.

Based on observation, record review, and interview, the facility failed to assess and provide care for a resident with edema for 1 (#23) of 24 sampled residents reviewed for quality of care.The DON identified 99 residents resided in the facility.Findings:On 06/21/26 at 3:40 p.m., Resident #23 was observed sitting in the memory care common room with no socks on. Resident #23's feet were observed swollen.On 06/23/26 at 2:39 p.m., Resident #23 was observed sitting on a recliner with yellow socks on in the memory care common room. Resident 23's feet were observed slightly swollen. The full condition of their feet could not be determined due to the resident was wearing socks.A review of Resident #23's electronic health record did not show a baseline care plan had been completed. The record did no show Resident #23 had been completely assessed to determine potential existing health conditions on admission.A nursing admission screening/history for Resident #23, dated 05/01/26, showed the assessment did not have any documentation in the extremities/gait/mobility section.A nursing note for Resident #23, dated 05/07/26, showed edema was noted to upper and lower extremities.An admission MDS assessment for Resident #23, dated 05/14/26, showed the resident had a BIMS score of 1, which indicated severe cognitive impairment.A nursing note for Resident #23, dated 06/25/26 at 2:32 p.m., read in part, per exight [sic] foot 1+ am pedal edema to both feet. R foot 1+ left foot trace.On 06/25/26 at 12:08 p.m., CNA #5 stated they had noticed Resident #23's feet were purple but did not know much about them. CNA #5 stated they did not check Resident #23's feet or notice if the resident was wearing their socks that day.On 06/25/26 at 12:38 p.m., RN #1 stated they did not think Resident #23 had edema in their feet. They stated the condition of Resident #23's feet might have been something they were born with.On 06/25/26 at 2:47 p.m., RN #1 stated Resident #23's feet did have some swelling, and the measurements were 1+ edema on the right left and trace edema on the left leg. RN #1 stated they had not assessed the pedal areas of the feet. RN #1 stated a nursing aide would be the one to check the resident's feet. They stated Resident #23 was combative and they did not like checking their feet. On 06/25/26 at 4:00 p.m., the medical director stated they had seen Resident #23 plenty of times. They stated Resident #23 probably had edema, but everyone at the facility had swollen feet. The medical director stated they would have to check the Resident #23's healthcare notes to make sure.On 06/25/26 at 4:16 p.m., the DON stated if a resident had edema in their legs, then the legs would need to be elevated. The DON stated the provider would need to be notified, and the resident might would need Lasix (diuretic medication). They stated staff should have been checking the resident for edema every shift even if the resident was on hospice. The DON stated they would have to look at the facility's policies for assessments to see what the staff needed to document in regard to edema. They stated the staff should have been documenting their findings.

Based on observation, record review, and interview, the facility failed to implement comprehensive care plan interventions regarding falls for 1 (#84) of 24 sampled residents reviewed for care plans.The DON identified 99 residents resided in the facility.Findings: On 06/21/26 at 11:24 a.m, Resident #84 was observed in the dining room with purplish dark bruises on their cheeks, forehead, and around their neck. A knot was observed on the resident's left temporal region above the ear. Resident 84 was observed wearing fuzzy non-grip blue socks.On 06/23/26 at 2:46 p.m., Resident #84 was observed sitting in the memory care common room with fuzzy non-grip blue socks on.On 06/24/26 at 3:12 p.m., Resident #84 was observed sleeping alone in their room recliner. No floor grip tape or call light tape was observed.On 06/25/26 at 2:50 p.m., no sign hung on the wall by the bed, no call light tape, and no grip tape on the floor was observed in Resident #84's room.A facility policy titled Falls - Clinical Protocol, dated 2001, read in part, If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed.A quarterly MDS assessment for Resident #84, dated 05/11/26, showed a BIMS score of 1, which indicated severe cognitive impairment.A care plan for Resident #84, dated 05/12/26, showed the resident had a fall on 04/02/26, 04/08/26, 05/07/26, and 06/08/26. The care plan showed interventions for fall prevention which included stop no fall sign placed on wall close to bed, yellow tape on the call light, grip tape on the floor, maintain bed in low position, and encourage proper footwear.A Morse Fall Scale assessment for Resident #84, dated 06/08/26, showed a score of 55, which indicated a high risk for falling.On 06/25/26 at 2:27 p.m., the ADON stated Resident #84's fall interventions included to assist with transfers, frequent checks, bright colored tape on call light, and a call don't fall sign by their bed. The ADON stated Resident #84 had shoes they wore that helped prevent falls. The ADON stated Resident #84 had a therapy note, dated 06/10/26, in their electronic health record which suggested interventions post fall that were not added to the current care plan. The ADON stated they were not sure who therapy communicated those interventions with. The ADON stated MDS coordinators made changes to care plans and could see the progress notes.On 06/25/26 at 3:08 p.m., CNA #1 stated there was no sign by Resident #84's bed, no tape on the call light, and the bed was not lowered to the lowest position.

Based on record review and interview, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for 1 (#23) of 24 sampled residents reviewed for baseline care plans.The DON identified 99 residents resided in the facility.Findings:A review of Resident #23's electronic health record showed the resident had diagnoses which included delusional disorders, unspecified dementia, unspecified psychosis, hyperlipidemia, and generalized anxiety disorder.A review of Resident #23's electronic health record face sheet showed the resident was admitted to the facility on [DATE]. The facility had no documentation to show a baseline care plan was completed within 48 hours after admission.An admission MDS assessment for Resident #23, dated 05/14/26, showed the resident had a BIMS score of 1, which indicated severe cognitive impairment.On 06/25/26 at 2:40 p.m., the ADON stated the baseline care plan for Resident #23 had not been completed because it could not be found in their electronic health record.

Based on observation, record review, and interview, the facility failed to evaluate a resident for the need of a PASSAR level II referral when they received a new diagnosis of mental illness for 1 (#65) of 1 sampled resident reviewed for PASSAR screening. The DON identified 99 residents resided in the facility.Findings: On 06/24/26 at 11:54 a.m., Resident #65 was observed in the dining room for lunch and refused to eat when offered food by a staff member. A PASSAR level I screening for Resident #65, dated 11/12/12, showed the resident had no qualifying diagnosis or mental illness to require a referral for a level II screen. A physician's order for Resident #65, dated 10/20/20, read in part, Paxil [antidepressant] 30 mg give one tablet by mouth one time a day related to recurrent depressive disorder. A Behavioral Assessment, Intervention, and Monitoring policy, dated 02/01/25, read in part, New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder are referred for a PASSAR level II evaluation. An admission record for Resident #65, dated 06/25/26, showed the resident was diagnosed with recurrent mental disorder 10/20/16, violent behavior on 10/17/17, psychotic disorder with delusion due to a known physiological condition on 02/23/18, and unspecified dementia on 10/01/22. On 06/25/26 at 8:13 a.m., MDS Coordinator #1 stated when Resident #65 was diagnosed with psychotic disorder with delusions, violent behavior, and recurrent depressive disorder, a referral for a PASSAR level II screen should have been completed. MDS Coordinator #1 stated they were not aware why the resident had not been rescreened since the dementia diagnosis was not received until after the mental illness diagnoses.

Based on record review and interview, the facility failed to notify a family member of a resident's fall for 1 (#107) of 3 sampled residents reviewed for notification of falls. The DON identified 99 residents resided at the facility. Findings: A policy titled Change in a Resident's Condition or Status, dated 12/2025, read in part, A nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury. A comprehensive admission assessment for Resident #7, dated 02/03/26, showed the resident was admitted on [DATE] for therapy services. A facility incident report, dated 02/12/26, showed Resident #107 fell on [DATE] at 4:27 p.m., obtained a large bruise, and a laceration which measured 1.75 cm over their right eye. There was no documentation Resident #107's family was informed until 02/13/26. On 06/24/26 at 10:23 a.m., a family member of Resident #107 stated they came to the facility on [DATE] at approximately 1:00 p.m., to visit Resident #107 when they noticed bruising and a laceration to the resident's right eye. They stated they were not informed of the fall Resident #107 experienced the day before. On 06/25/26 at 9:59 a.m., the ADON stated a fall which resulted in a laceration would be considered an emergency if the injury required stitches. On 06/25/26 at 10:01 a.m., the clinical VP stated they would attempt to notify the family immediately. They agreed the family should have been notified on 02/12/26, when the fall occurred.

Based on record review and interview, the facility failed to inform a resident's representative on the risks of psychotropic medications for 1 (#34) of 5 sampled residents whose clinical records were reviewed for unnecessary medications. The DON identified 67 residents on psychotropic medications.Findings:A facility policy titled Psychotropic Medication Use, dated 2001, read in part, Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal:.c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings).A review of Resident #34's medication orders showed the resident had active orders for Risperdal oral tablet 1 MG, an antipsychotic medication, and risperidone (generic name of Risperdal) oral tablet 0.25 MG. The medication orders showed Resident #34 had initially received the order for risperidone oral tablet in 2025. There was no documentation to show Resident #34, or their family member were informed of the risk for taking the antipsychotic medication.A quarterly MDS assessment for Resident #34, dated 05/13/26, showed the resident had a BIMS score of 1, which indicated severe cognitive impairment.A MAR, dated 06/2026, showed Resident #34 had been given Risperdal as ordered.On 06/24/26 at 10:52 a.m., Resident #34's POA stated the facility contacted them to talk about the resident's medications but did not inform them of the risks associated with the antipsychotic medication that was being given. Resident #34's POA stated they were not asked to sign any antipsychotic consent forms on Resident #34's behalf.On 06/25/26 at 8:27 a.m., LPN #1 stated the risks and benefits of a new medication were discussed with a resident's family before it was administered.On 06/25/26 at 9:05 a.m., the facility provided a blank antipsychotic consent form for Resident #34. The consent form listed the risks and benefits associated with antipsychotics and did not contain the name of any antipsychotic medications.On 06/25/26 at 9:50 a.m., the DON stated they could not locate the antipsychotic consent form for Resident #34 for the initial order date for risperidone.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week.The administrator identified 81 residents resided in the facility.Findings:A PBJ [Payroll Based Journal] Staffing Data Report, dated 01/01/25 through 03/31/25, showed no RN hours on 03/30/25. A Timecard Report, dated 03/30/25, did not show RN coverage for eight consecutive hours.A Timecard Report, dated 06/01/25 through 06/30/25, did not show RN coverage for eight consecutive hours on 06/07/25.On 07/03/25 at 9:49 a.m., the administrator stated they had an RN scheduled for the dates above, but they called in. The administrator stated they replaced the RN with a license practical nurse.

Based on observation, record review, and interview, the facility failed to ensure:a. EBP was followed during wound care observation for 1 (#13) of 2 sampled residents reviewed for pressure ulcers; b. dryer lint compartments were clean and free of excess lint for potential prevention of thorough drying and fire hazard observed during infection control observation of laundry room; andc. contact isolation procedure was followed during the provision of incontinent care for 1 (#32) of 3 sampled residents reviewed for incontinent care.The administrator identified 81 residents resided in the facility.Findings:1. On 07/01/25 at 10:44 a.m., the wound care nurse entered Resident #13's room to perform sacrum wound care treatment. They donned gloves. CNA #1 was in the resident's room. They had on gloves. On 07/01/25 at 10:55 a.m., the wound care nurse completed Resident #13's sacrum wound care and skin treatment with the assistance of CNA #1. The wound care nurse and CNA #1 did not have on gowns during the wound care and skin treatment.An undated facility policy titled ENHANCED BARRIER PRECAUTIONS (EBP), read in part, EBP are indicated for residents with any of the following: wounds .For residents whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Wound care.A physician's order, dated 06/18/25, showed clean sacrum wound with normal saline and pat dry to mechanically debride wound to remove nonviable tissue. Apply Hydrafera Blue (foam dressing) over lightly packed iodoform (disinfectant) and collagen Ag (dressing), cover with 4x4 gauze, secure with border dressing. change daily and PRN. Apply nystatin crusting (skin-prep and nystatin powder) to wound edges with each dressing change. Apply triple paste (treats infections) and Calmoseptine (topical ointment) over nystatin crusting to periwound every day shift related to pressure ulcer of sacral region, stage 4.On 07/01/25 at 11:02 a.m., the wound care nurse stated they did not know what EBP was. They stated the precautions they took during routine wound care was the use of gloves, handwashing, and alcohol based hand rub. They stated they donned gowns if the resident was on contact precautions. On 07/01/25 at 11:38 a.m., the DON stated they were not sure what EBP was and the facility policy for EBP. 2. On 07/02/25 at 11:02 a.m., the laundry supervisor stated the lint traps for the three dryers were cleaned twice a day or as needed. There were two shifts. Observations made of the three dryers lint compartments with the laundry supervisor. They stated cleaning As needed was what was seen at the observation. All three compartment trays were full of lint and the first dryer had two balls of lint on the floor of the compartment where some had fallen off of the tray. On 07/02/25 at 11:05 a.m., laundry aide #1 observed the compartments and stated there was more than average on them and needed to be cleaned. 3. On 06/30/25 at 11:17 a.m., Resident #32 had PPE carts outside of their room and a sign posted next to their door which read, Contact Isolation.On 06/20/25 at 11:25 a.m., CNA #2 was observed inside of Resident #32's room wearing only gloves. On 07/02/25 at 1:34 p.m., CNAs #2 and #3 donned gowns and gloves and entered Resident #32's room for incontinent care. CNA #3 lowered Resident #32's head of bed and then unfastened Resident #32's brief. CNA #3 wiped the resident's peri area front to back three times with three different wipes. Both CNAs assisted to roll Resident #32 to their left side. CNA #3 wiped Resident #32's buttocks from front to back three times with three different wipes. CNA #3 removed the resident's urine soiled brief and threw it in the trash can. CNA #3 placed a new, clean brief under Resident #32 and both CNAs assisted to roll the resident to their back, then to their right side. CNA #3 pulled the remainder of the clean brief under the resident and then assisted the resident to roll onto their back. CNA #2 pulled the clean brief up between Resident #32's legs, fastened the brief and began removing trash. CNA #3 did not change gloves throughout the procedure. On 07/02/25 at 1:42 p.m., CNA #3 was observed to have the same pair of gloves on that they used for Resident #32's incontinent care. CNA #3 lifted Resident #32's head and adjusted their pillow then covered the resident with a blanket. CNA #3 moved the resident's bedside table closer to Resident #32 and touched the top of the resident's diet coke bottle to move it closer to the resident.On 06/20/25 at 11:28 a.m., CNA #2 was asked what PPE was supposed to be worn inside a contact isolation room. They stated, Gown and gloves. CNA #2 was asked if they had on a gown inside of Resident #32's room. They stated, No.On 06/30/25 at 12:05 p.m., LPN #1 was asked what PPE was required to be worn inside of a contact isolation room. They stated, Gloves and gown. On 07/02/25 at 1:45 p.m., CNA #3 doffed their PPE and was asked if they missed any opportunities for glove changes. They stated, When I put the new brief on. CNA #3 was asked if they had the same gloves on throughout entire procedure and they stated, Yes. CNA #3 was asked what all did they touch with their gloves on after providing incontinent care. They stated, Blankets, the resident's head, pillow, and bedside table. CNA #3 was asked if they touched the top of Resident #32's bottle of diet coke. They stated, Yes, and the bed control crank.An MDS, dated [DATE], showed Resident #32 was admitted on [DATE] with diagnoses to include non-traumatic brain dysfunction and Alzheimer's disease.

Based on record review and interview, the facility failed to ensure:a. ongoing side effects and behavior monitoring were completed for residents on psychotropic medications for 4 (#2, 9, 26, and #28); andb. a PRN order for psychotropic medication was limited to 14 days for 2 (#9 and #28) of 4 sampled residents reviewed for unnecessary medication review.The administrator identified 62 residents received psychotropic medications resided in the facility.Findings:An undated facility policy Behavior and Psychotropic Drug Use, read in part, Anytime PRN antianxiety medication is given, Nurses Note must be placed in [system name withheld] under behavior Note. Medication follow up. All behaviors will be documented in a behavior note .Behaviors will be monitored by charge nurse and documented in [system name withheld] by exception under behavior notes .Physician evaluation to be completed every 14 days for any PRN psychotropic medications .Ongoing monitoring is essential to evaluate the effectiveness of the medication, identify potential adverse reactions, and ensure patient safety.1. A care plan, dated 04/29/25, showed Resident #2 had diagnoses which included generalized anxiety disorder and unspecified depression. The care plan showed to monitor for non-verbal signs and symptoms of depression: sadness, anxiety, and distress. Administer medication as ordered, monitor for effectiveness/side effects.A physician's order, dated 06/02/25, showed buspirone HCl (antianxiety medication) 5 mg, give one tablet by mouth two times a day related to generalized anxiety disorder.A physician's order, dated 06/02/25, showed Duloxetine HCl (antidepressant medication) capsule delayed release particles 60 mg give one capsule by mouth at bedtime related to generalized anxiety disorder.Review of the June 2025 medication administration record showed Resident #2 received the above medications as ordered.There was no order for side effects monitoring for the use of psychotropics.There was no documentation behavior and side effects monitoring for the use of psychotropics was completed from 06/02/25 to 07/03/25.2. Resident #26's physician's order, dated 02/26/25, showed clonazepam (anticonvulsant medication) 0.5 mg, give 0.5 tablet by mouth at bedtime related to unspecified anxiety disorder.A physician's order, dated 02/26/25, showed Mirtazapine (antidepressant medication) 30 mg, give one tablet by mouth at bedtime related to unspecified insomnia.A physician's order, dated 03/20/25, showed Wellbutrin SR (sustained release) (antidepressant medication) extended release 12 hours 150 mg, give one tablet by mouth one time a day related to unspecified recurrent major depressive disorder.A physician's order, dated 06/07/25, showed Effexor (antidepressant medication) extended release 24 hours 150 mg, give one capsule by mouth one time a day related to unspecified recurrent major depressive disorder.A care plan, revised 06/10/25, showed Resident #26 had diagnoses which included personal history of other mental and behavioral disorders, unspecified recurrent major depressive disorder, unspecified anxiety disorder, and unspecified insomnia. The care plan showed Resident #26 was at risk for side effects related to daily use of psychotropic medications and to monitor and document side effects.A physician's order, dated 06/12/25, showed risperidone (antipsychotic) 0.5 mg, give one tablet by mouth two times a day related to personal history of other mental and behavioral disorders. A review of Resident #26's medication administration record for April, May, and June 2025 showed the resident received the above medications as ordered.There was no order for side effects monitoring for the use of psychotropics.There was no documentation ongoing side effects monitoring for the use of psychotropics was completed from 04/01/25 through 06/30/25.The behavior notes documented from 04/01/25 through 07/03/25 were on the following days:a. 04/28/25 at 21:13 [9:13 p.m.],b. 06/13/25 at 16:35 [4:35 p.m.], andc. 06/13/25 at 16:39 [4:39 p.m.].On 07/03/25 at 9:46 a.m., the DON stated they charted behaviors and side effects by exception and intervene as needed.3. A physician's order for Resident #28, dated 08/01/23, showed Eliquis (blood thinning medication) tablet 2.5 mg, give one tablet by mouth two times a day related to atherosclerotic heart disease. A physician's order, dated 02/26/25, showed Duloxetine HCL (antidepressant medication) capsule delayed release particles 30 mg, give one capsule by mouth two times a day related to depression.A physician's order, dated 02/26/25, showed Namenda (memory loss medication) tablet 10 mg, give one tablet by mouth two times a day related to unspecified dementia.A physician's order, dated 02/27/25, showed Risperdal (antipsychotic medication) tablet 1 mg, give one tablet by mouth two times a day related to delusional disorders. A physician's order, dated 03/14/25, showed Lorazepam Intensol (antianxiety medication) oral concentrate 2 mg/ml, give 0.25 ml by mouth every four hours as needed for anxiousness. A care plan dated, dated 06/03/25, showed Resident #28 had diagnosis which included Alzheimer's, delusional disorders, dementia, depression, atherosclerotic heart disease, and atrial fibrillation. It showed to monitor for impaired balance and cognitive function for Alzheimer's. It showed to monitor for effectiveness. It showed to monitor therapeutic effectiveness and side effects for atrial fibrillation. It showed to observe for signs and symptoms of delirium and to observe for side effects of medications.Review of the March through July 2025 medication administration and treatment administration records showed Resident #28 received the medications as ordered mentioned above.There was no order for side effect monitoring or documentation for behavior and side effect monitoring for the use of psychotropics, anticoagulant, and Alzheimer's medication was completed from 03/01/25 through 07/03/25.There was no stop date or re-evaluation following 14 days for the administration of Lorazepam ordered as needed.On 07/03/25 at 9:15 a.m., LPN #3 stated Resident # 28 received the order for the Lorazepam on 03/14/25, and stated is was for 2 mg every four hours as needed. They stated the order had not been discontinued or re-written. LPN #3 stated Resident #28 received the Lorazepam as needed on 03/27/25, 04/17/25, 05/07/25, 05/12/25, and on 06/09/25. LPN #3 stated there was not a stop date.On 07/03/25 at 9:20 a.m., LPN #3 stated they did not have documentation that was a yes or no for behaviors. They just document when behaviors occur, notify, and follow orders if received and make a note.4. A Physician's Order, dated 11/26/24, for Resident #9 read, Lorazepam Intensol Oral Concentration 2 MG/ML Give 0.25 ml by mouth every 4 hours as needed for anxiousness related to generalized anxiety disorder. The end date for the Lorazepam order, read in part, Indefinite.A review of Resident #9's MAR from November 2024 through June 2025 showed Resident #9 was administered PRN Lorazepam Intensol Oral Concentration 2 MG/ML on 2/25/25, 3/13/25, 3/25/25, 3/27/25, and 5/8/25. There was no documentation of side effect monitoring.A review of Resident #9's physician progress notes on 01/16/25, 01/30/25, 05/28/25, 06/19/25, and 06/26/25 did not show an evaluation related to PRN lorazepam need or use.A Nurse' Note, dated 5/28/25, for Resident #9, read in part, This nurse contacted [physician] office to see when [they] would be out to see res RT [related to] PRN antianxiety medication order and the need to be seen Q 14 days to continue order. [Physician] staff reported due to [their] family emergency [they] would be out to see res as soon as possible but did not want to DC [discontinue] PRN lorazepam order with the knowledge of the Q 14 day rule. A Quarterly Minimum Data Set, dated [DATE], showed Resident #9 admitted to the facility on [DATE] with diagnoses to include delusional disorders, psychotic disorder, anxiety, depression, pseudobulbar effect, and non-Alzheimer's dementia.On 07/01/25 at 10:09 a.m., LPN #3 was asked what behaviors Resident #9 exhibited. They stated, If there's new staff [Resident #9] doesn't like it, but [they're] mostly calm. LPN #3 was asked if Resident #9 had ever been administered Lorazepam and they stated, Yes, usually an hour before [their] shower. LPN #3 was asked if they have ever had to give PRN Lorazepam for any behaviors besides anxiousness for baths and they stated, No.On 07/02/25 at 12:41 p.m., LPN #2 was asked what Resident #9's mood and behavior was like. They stated, Mostly in a good mood, but sometimes gets upset with care. [They're] very cooperative and friendly. LPN #2 was asked how often Resident #9 was utilizing their PRN Lorazepam. They stated, Not very often. I don't think hardly ever.On 07/02/25 at 12:51 p.m., LPN #1 was asked who prescribed the PRN lorazepam for Resident #9. LPN #1 stated the name of the physician and said, To maintain it [the lorazepam] [the physician] sees [Resident #9] every 14 days.On 07/02/25 at 12:53 p.m., LPN #1was asked if there was an end date for Resident #9's PRN lorazepam. They stated, No.On 07/02/25 at 1:54 p.m., the DON was asked how the facility monitored residents for side effects of psychotropics. They stated, Quarterly on their MDS and the charge nurses and aides on the floor know who's on what. They were asked where side effect monitoring was documented and they stated, We document by exception on behavior and side effects. The DON was asked how the charge nurses and aides on the floor knew what side effects for which residents to look for. They stated, The aides don't have access to the med list, but the med aides give meds. The DON was again asked how the charge nurses and CMAs know what side effects in which residents to look for. They stated, They know what medications they're on.On 07/02/25 at 1:59 p.m., CMA #1 was asked what drugs were psychotropics. They stated, Lorazepam and I can't think of any more. CMA #1 was asked what are side effects of psychotropic drugs. They stated, They can make them [residents] sleepy. That's the one I know. CMA #1 was asked how they knew which residents took psychotropic drugs and they stated, It pops up on my computer. CMA #1 was asked where they document the monitoring for side effects of psychotropic drugs and they stated, If anything were to happen then we tell the nurse.On 07/02/25 at 2:02 p.m., LPN #2 was asked how they monitored residents for side effects of psychotropic drugs. They stated, We check and assess residents every day. They were asked where they document residents on psychotropic drugs were monitored. LPN #2 stated, In the progress note. They were asked how often they document on the monitoring of psychotropic side effects. LPN #2 stated, If it's a PRN then we document after we give it. They were asked what the facility's process was on routine psychotropic drug monitoring. They stated, If there's any side effects we see, we chart on it.

Based on observation and interview, the facility failed to ensure all components of the daily staffing information was posted and was readily accessible to residents and visitors for 1 of 1 observation. The administrator identified 81 residents resided in the facility. Findings: On 07/02/25 at 10:30 a.m., a staff roster with unit name, staff names, a date of 07/02/25, and shift schedule was on a clip board at the nurse's station on the skilled unit. There was no posted staffing with all required components on the skilled unit. On 07/02/25 at 10:49 a.m., there was a white board with the name [NAME] and [NAME] (halls) and it showed names of staff, and a date of 07/02/25. The whiteboard did not have all the required components of the posted staffing. On 07/02/25 at 10:54 a.m., the [NAME] hall had a whiteboard with staff names and titles. The whiteboard did not have all the required components of the posted staffing. On 07/02/25 at 11:16 a.m., the administrator and assistant administrator observed [NAME] hall, [NAME] and [NAME], and the skilled unit for posted staffing. On 07/02/25 at 10:29 a.m., LPN #4 stated they did not have any posted staffing on the skilled unit. They stated the staff roster was on a clip board at the nurse's station. On 07/02/25 at 10:46 a.m., CMA #2 stated what was posted on the whiteboard on [NAME] and [NAME] was to show who was working on those halls on that shift. On 07/02/25 at 11:34 a.m., the administrator stated the posted staffing did not meet the regulatory requirements.

Based on record review and interview, the facility failed to ensure a PASARR level 1 was completed after a new mental health diagnosis for 1 (#9) of 5 sampled residents reviewed for PASARRs.The administrator identified 81 residents resided in the facility.Findings:A PASSAR Level 1, dated 06/15/21, showed Resident #9 had a primary diagnosis of cerebrovascular accident due to thrombosis and a secondary diagnosis of dementia without behaviors. A Behavior Note, dated 08/31/21, read in part, CNA told this nurse that resident was not acting [their] usual self et attempting to get out of bed by [themselves]. This nurse went to resident to assess et speak with [them] on how [they] was feeling. Resident responding with verbal aggression, body language very tensed as if [they] was going to hit this nurse. Resident demanded to get up, explained the use of hoyer lift to [them] et asked if we could assist [them] with the hoyer lift. Resident agreed. Hoyer brought into room et when res saw sling [they] became very aggressive, refused to use hoyer with sling. Sit to stand used in place of hoyer. Resident then assisted to recliner where [they] threw call light et continued with verbal aggression towards this nurse. This nurse attempted to reorient resident, listen to res about what [they] had to say, et tried to understand what was upsetting [them]. Resident c/o being tied down to bed, sheets et comforter noted to be only thing in bed at this time, et that [they] would 'NOT STAND FOR THIS!!'. This nurse offered to call res's [family] in hopes it may calm [them] down, this mad resident even more upset, PRN xanax [benzodiazepine] also offered et resident refused immediately. This nurse excused [themself] from room as resident continued to get more et more verbally abusive towards this nurse. CNA asked to sit with resident 1:1 for safety at this time. Nurse leader notified via text at this time. Will continue to monitor for increased aggression.A Nurse Progress Note, dated 09/23/21, read in part, N.O. [new order] discontinue Celexa [an antidepressant] and start Seroquel [an antipsychotic] 25mg qhs [every bed time] Dx. [diagnosis] Delusions.A Quarterly Minimum Data Set, dated [DATE], showed Resident #9 admitted to the facility on [DATE] with diagnoses to include psychotic disorder, anxiety, depression, pseudobulbar effect, and non-Alzheimer's dementia.A review of Resident #9's June 2025 MAR showed Resident #9 was prescribed Seroquel for delusional disorders.On 07/01/25 at 11:25 a.m., the DON was asked what diagnoses were on Resident #9's PASARR. They stated, Dementia and stroke diagnoses. They were asked if the delusional disorder diagnosis was included on the PASARR level 1. They stated, Delusion is a new symptom of dementia, so no it's not on there. The DON was asked if question #2 on the PASARR level 1 was answered correctly. They stated, I feel the delusional disorder was related to dementia, so I did not complete a new PASARR. The DON was asked if a resident was identified as having a newly evident or possible mental diagnosis, such as delusional disorder, after they have been admitted , what was the facility's process for referring the resident to the appropriate state-designated authority. They stated, If doctors put a new diagnosis in, I don't complete a new PASARR.

Based on record review and interview, the facility failed to ensure accurate documentation of a diagnosis on a PASARR form for a mental health illness for 1 (#73) of 2 sampled residents reviewed for the need of a level II screening. The administrator identified 81 residents resided at the facility. Findings: An undated policy titled Policy for completion of PASRR's, read in part, Evaluate residents/patient prior to admission to facility. Attempt to get good history and physical, including mental health history as well as any intellectual disabilities.Contact OHCA (LOCEU) if person coming to your facility with known intellectual disabilities or evidence or diagnosis of severe mental illness. A review of Resident #73's PASARR, dated 06/06/25, showed question #2 marked No for diagnosis of a serious mental illness for schizophrenic, paranoid, panic, mood or other severe anxiety or depressive disorder, somatoform disorder, personality disorder, or other psychotic disorder, or other mental disorder that may lead to a chronic disability. A review of the diagnosis list per electronic medical record showed delusional disorder as an admitting diagnosis on 06/03/25. A care plan, dated 06/17/25, showed Resident #73 had diagnosis of delusional disorder. Resident #73's level one PASARR was not completed to include the delusional disorder diagnosis and the State office was not notified of the PASARR. On 07/01/25 at 10:33 a.m., the administrator provided the PASARR level 1. They stated delusional was the only mental health diagnosis they could see for a PASARR. They stated delusional disorder was a mental health disorder. On 07/01/25 at 11:15 a.m., the DON stated Resident #73's mental health diagnosis was metabolic, but felt like it was not. They stated the resident was never diagnosed with any schizophrenia or anything like that. The DON stated the diagnosis on the level 1 was marked correctly because it was caused by a known medical condition. The DON stated delusional disorder was a diagnosis for Resident #73 and it was a psychotic disorder. They stated they thought it was accurately coded at the time and stated the State office was not called about the PASARR.

Based on record review and interview, the facility failed to notify a resident's responsible party when the resident had a fall for one (#1) of three sampled resident reviewed for falls. The Administrator identified 80 residents resided in the facility. Findings: A Doctor Calls form, undated, read in part, Assess residents for change in condition, disease processes, notify physicians and family. Resident #1 had diagnosis which included arterial fibrillation, acute respiratory infection, congestive heart failure. A progress note, dated 06/02/24 at 1:30 p.m., documented Resident #1 was on the floor in room, on their side with a skin tear to right elbow. The note did not document if the resident's representative was notified of the fall. On 10/08/24 at 10:33 a.m. The DON stated They stated they had reviewed Resident #1's progress note from 06/02/24 and did not find documentation anyone at the facility had notified the emergency contacts listed in Resdient #1's chart. On 10/08/24 at 11:21 a.m., LPN #1 was asked the policy for contacting family and/or resident representative for change of condition and/or fall. They stated that family is to be notified of all incidents. They were then asked to review a progress note for a fall on 06/-2/24 for Resident #1, after review they were asked if family and/or resident representative was notified of the fall on 06/02/24, they stated the progress note does not state if family was notified of fall.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facilities failure to ensure Resident #100 received CPR; the facility failed to ensure a systemic approach was used to determine what a resident's code status was for four (#60, 75, 89 and #95) of four sampled residents. Resident #100 had a physician's order for CPR/full code on [DATE], no DNR was in place. On [DATE] at 9:48 p.m. Resident #100 presented with a cough. 22 minutes later at 10:10 p.m. per a late entry nurses note at 11:45p.m. Resident #100 was found with pupils fixed and dilated. The physician was notified at 10:15 p.m. and there was no documentation that CPR had been initiated. A physician's death note, dated [DATE] documented LPN #3 had seen Resident #100 approximately 30 minutes prior to 10:10 p.m. On [DATE] at 6:40 a.m., LPN #3 who found the resident at 10:10 p.m., stated CPR had not been provided. LPN #3 stated if CPR had been started it would have been documented. She stated there have been times when they had started CPR, called the doctor, and he told us to quit because we knew they were dead. On [DATE] at 9:25 a.m., the Medical Director was asked what their expectations were for a resident who was found unresponsive with a full code status. The Medical Director stated if they had rigor mortis, do not start CPR. The Medical Director continued that if nurse is in-experienced they can perform CPR, but I really don't like it, can be problematic. I don't want them coded. It may be against the law, but that's my policy. He stated he didn't need nurses to call prior to CPR. They know if these residents are dead. The facility's nursing staff did not know the policy and protocol when a resident is found unresponsive and there were residents charts found to not have the identifier to indicate code status. On [DATE] at 3:05 p.m., The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 3:15 p.m., the administrator and the DON were notified of the IJ situation. On [DATE] at 5:39 p.m., a plan of removal was submitted to The Oklahoma State Department of Health. The plan of removal was reviewed and given the acceptance to move forward with the plan of removal dated of [DATE] at 3:00 p.m. The plan of removal sent via email documented: 1. Policies and Procedures Updated: A. CPR Policy (updated [DATE]) B. CPR Procedure (updated [DATE]) C. CPR Determination of Code Status ([DATE]) CPR Policy - Updated [DATE] 1. If a resident is found non-responsive, not breathing, or has no heartbeat: - A nursing staff member or non-nursing CPR certified staff member will initiate CPR. - A staff member will announce on the PA system if necessary Code Blue and Location - A staff member will run the code. - A staff member will be sent for the resident chart immediately. - A staff member will check the DNR/Code status. - A staff member will get the crash cart. - A staff member will call 911. 2. If a resident has a DNR, DO NOT INITIATE CPR. If CPR was already initiated, nurse will stop the code. Contact the physician and family/emergency contact. 3. If no DNR is present, begin CPR and call EMS, if not already initiated. Continue until relief by paramedics or until further orders are received. 4. On the spine of the resident chart there will either be a Red DNR sticker or Green FULL CODE sticker to indicate the residents code status. THE DNR IS LOCATED IN THE CHART. Always confirm visually code status/living will instructions. CPR Procedure - [DATE] If a resident is found unresponsive, not breathing, or has no heartbeat, the following process will be immediately initiated: 1. Notification: When necessary, the PA system sill (sic) bee (sic) used to call Code Blue and location 2. All Greenbrier phones have PA capability. a. Locations of phones Dining - receptionist or new phone to be located in dining room, whichever is closest. Neighborhoods = all nurses stations and most offices have phones, will use whichever is closest. 3. Anyone certified in CPR may start immediately. 4. Once a resident is identified as DNR or Full code status, the following will take place: a. If DNR - do not initiate CPR. b. If the resident has DNR and CPR was started, the nurse will initiate the stop of CPR. c. If Full Code - the nurse will take over the CPR, if didn't initiate. d. Will continue with full code procedure. 2. New Policy and Procedure was reviewed with all staff. 3. CPR Determination of Code Status was reviewed by admissions directors and admissions nurses. 4. New CPR Policy and Procedure was added to orientation packets for new hire employees. 5. Charts updated with Green FULL CODE sticker or Red DNR stickers at 9:15 p.m. on [DATE] 6. Prevention of recurrence: a. Any employees on medical leave must sign and review the CPR policy prior to return to work. This will be done through the HR department. b. All new staff review and sign CPR Policy during the orientation prior to start date. In the orientation packet and HR education. c. Admission QA updated with Change to Admission Director QA checklist and Admissions Nurse Checklist QA. Reviewed [DATE] at 7:45 p.m. with Admission/Move in Director, the Skilled Admission and the Skilled Nurse leader at 7:59 p.m. d. Nurse Leader QA has been updated for the oversight of policy during afternoon stand up meeting. Each Nurse leader has the updated QA: 10:00 a.m. [DATE]. For Skilled Nurse leader, Murray [NAME] Nurse leader and [NAME] Nurse leader. e. Stand up meeting Agenda has been updated with a place to monitor and discuss admits: their code status and to monitor the charts. SNF: In place as of 6:00 a.m. [DATE]. f. Stand up meeting Agenda has been updated with a place to monitor and discuss admits: their code status and to monitor the charts. Homes in place as of 11:00 [DATE]. On [DATE], staff were interviewed regarding recent training/updates in regards to the CPR policy and protocol. Staff stated they had received text messages and/or phone calls from various members of administrative nursing employees and verbalized understanding of the information provided in the in-service pertaining to the plan of removal. On [DATE] at 4:40 p.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of [DATE] at 3:00 p.m. The deficiency remained at a level of actual harm at a pattern. Based on record review and interview, the facility failed to ensure: A. They followed their policy to ensure a resident who was a full code status was provided CPR for one (#100) of one resident who had a full code status and; B. A systematic approach was used to determine what a resident code status was for four (#60, 75, 89, and #95) of four sampled residents. The Resident Census and Conditions of Residents report, dated [DATE], documented 96 residents resided in the facility. Findings: A CPR policy, updated [DATE], read in parts, .If resident is non-responsive, has no heart beat and is not breathing .check DNR/Code status .If not(sic) DNR present or colored name tag on chart, begin CPR and call EMS. Continue until relief by paramedics . A cardiopulmonary Resuscitation (CPR) Policy and Procedure, undated, read in parts, .CPR will be performed on the resident UNLESS a DNR/Physician Order is filed in the clinical record .Staff will initiate CPR .absence of respiration .absence of blood pressure .absence of pulse .obtain crash cart as needed and call 911 .CPR will continue until EMS arrives and assumes care . Resident #100 had diagnoses which included unspecified combined systolic and diastolic heart failure, presence of cardiac pacemaker, and atherosclerotic heart disease of native coronary artery without angina pectoris. A Physician's order dated [DATE], documented, CPR (Full Code). No DNR was documented on file. A Nurses Note dated [DATE] at 9:48 p.m., read in part, .patient c/o cough PRN Tessalon [NAME](sic) 100mg given oral . A Nurses Note dated [DATE] at 11:45 p.m., read in part, .10:10 p.m. pupils fixed and dilated, no vital signs. Notified [named physician] 10:15 p.m./[named], Director. 10:30 p.m. call to the medical director returned call 10:40 p.m., [named physician], gave information, and may release body to funeral home of family choice .notified funeral home at 11:10 p.m. [named]Administrator was notified . A Physician's Death, note dated [DATE], documented LPN #3 had seen Resident #100, 30 minutes prior to 10:10 p.m. On [DATE] at 6:40 a.m., LPN #3 stated CPR had not been provided to Resident #100. LPN #3 stated that if a resident is unresponsive CPR was to be started right then if not a DNR. LPN #3 stated she went to check on resident, the resident was short of breath, LPN #3 stated they had gone to get oxygen. LPN #3 stated when they returned to the room the resident had died . 2. Resident #60 had diagnoses which included dementia and atrial fibrillation. A physician's order, dated [DATE], documented the resident's code status as a DNR. On [DATE], Resident #60's chart was observed with a signed DNR. There was no blue sticker on the chart to identify resident as a DNR. 3. Resident #75 had diagnoses which included parkinson's disease, bradycardia and coronary artery disease. A physician's order, dated [DATE], documented the resident's code status as a DNR. On [DATE], Resident #75's chart was observed with a signed DNR. There was no blue sticker on the chart to identify resident as a DNR. 4. Resident #89 had a diagnosis which included Alzheimer's disease. A physician's order, dated [DATE], documented the resident's code status as a DNR. On [DATE], Resident #60's chart was observed with a signed DNR. There was no blue sticker on the chart to identify resident as a DNR. 5. Resident #95 had diagnoses which included dementia and type two diabetes mellitus. A physician's order, dated [DATE], documented the resident's code status as a DNR. On [DATE], Resident #95 chart was observed with a signed DNR. There was no blue sticker on the chart to identify resident as a DNR. On [DATE] at 3:11p.m., the administrator and DON were asked if the facility had a policy that staff could follow. The DON stated that the policies were out dated. The DON stated the nursing staff had a nurse resource book that they used. On [DATE] at 3:47 p.m., the DON was asked what the blue circular sticker on the exterior of the resident's chart indicated. The DON stated resident's chart with blue sticker is a DNR. On [DATE] at 4:06 p.m., CNA #2 was asked what was the protocol when a resident is found unresponsive. They stated they would go and get the nurse. They were asked how they know if a resident was a full code or DNR. They stated there was a form in the chart. On [DATE] at 4:08 p.m., CNA #4 was asked what was the protocol when a resident is found unresponsive. They stated they would get the nurse, check pulse and would call 911. They were asked how did they know if a resident was a full code or DNR. They stated, I think there is stickers on the chart, but I don't know which color is for what code. On [DATE] at 4:10 p.m., LPN #11 was asked what was the facility's policy on code status. They stated, I don't know what the policy is. On [DATE] at 4:14 p.m., RN #2 was asked what would you do if a resident was found unresponsive. They stated they would get vitals, notify the doctor, call 911 and start CPR if necessary. They were asked what the facility's policy was for code status. They stated, common knowledge, I'm not sure how to answer let me get back to you. On [DATE] at 4:23 p.m., LPN #4 was asked what was the policy on code status. They stated, honestly I don't know I would have to go check. On [DATE] at 4:32 p.m., CNA #1 was asked what would you do if a resident was found unresponsive. They stated they would stay with the resident and call out for help. They were asked what was the facility's policy for code status. They stated, I am not sure what the policy is here they have not told me yet. They were asked how did they know if a resident was a full code or DNR. They stated, Honestly I am not sure what they do here I would need to ask the nurse. On [DATE] at 4:46 p.m., RN #1 was asked how did they know if a resident was a full code or DNR. They stated that a copy of a signed DNR would be in the chart. They stated, Supposedly a blue dot that states DNR but I still look in the chart. On [DATE] at 9:25 a.m., the Medical Director was asked what their expectations were for a resident who was found unresponsive with a full code status. The Medical Director stated if they had rigor mortis, do not start CPR. The Medical Director continued that if nurse is inexperienced, they can perform CPR, but they really do not like it, can be problematic. They stated they did not want them coded. It may be against the law, but that is my policy. They stated they did not need nurses to call prior to CPR. The nurses know if these residents are dead. 45583 46216

******PAST NON-COMPLIANCE****** On [DATE] at 4:23 p.m., a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist, The IJ was in regard to the facility's failure to comply with a resident's Do Not Resuscitate (DNR) decision for 1 (#1) of 11 sampled residents whose clinical records were reviewed for DNR orders. The resident had a signed DNR form and a physician's orders [REDACTED]. The Oklahoma State Department of Health was notified. The past non-compliance IJ was verified. On [DATE] at 12:05 p.m., the administrator and director of nurses (DON) were informed of the past non-compliance IJ situation in regard to the non-compliance with the resident's DNR decision. Based on record review and interview, it was determined the facility failed to ensure compliance with a resident's DNR decision. This affected 1 (#1) of 11 sampled residents whose clinical records were reviewed for non-compliance with DNRs. Once CPR was initiated, ambulance personnel continued resuscitative efforts and the resident was transported to the hospital. The resident was placed on life support and expired 5 days after the initial event. This had the potential to affect 120 residents who resided in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was cognitively intact and required limited to extensive assistance with most activities of daily living. The care plan dated [DATE] addressed DNR status as follows: [DATE], DNR [DATE], no longer DNR [DATE] DNR The clinical record contained an OKLAHOMA DO-NOT-RESUSCITATE (DNR) CONSENT FORM dated, signed, and witnessed [DATE]. Current physician's orders [REDACTED]. A nurse's note dated [DATE] at 19:30 (7:30 p.m.) documented the licensed practical nurse (LPN) was notified at 18:25 (6:25 p.m.) by an aide that the resident was not acting like her self. The note documented the LPN entered the resident's room within ,[DATE] seconds after speaking to the aide. The note documented the resident was cyanotic and unresponsive. The note documented the aide was sent for help and to call 911. The note documented a nurse came from another hall and CPR was initiated until the ambulance arrived and continued compressions and breaths. The note documented the resident was transported to the hospital and the family was notified. The emergency room note dated [DATE] documented the chief complaint as post [MEDICAL CONDITION]. The note documented the resuscitative efforts by the nursing home and the ambulance service. The note documented .the nursing home staff did apparently find DNR orders . A reportable incident to the Oklahoma State Department of Health documented the facility had self-reported the above stated incident regarding DNR. The incident report form documented the nurse was unaware of the DNR when she started CPR. The form documented facility corrective measures as: (Director of Nurses) and administrator will update CPR policy to include Always check the chart under advance directives prior to initiating CPR. The form documented All nurse meeting will be held on Friday (MONTH) 4th to inform all staff nurses of new policy. The DON was asked for and provided the updated CPR policy dated [DATE] and the inservice with staff signatures dated [DATE] for nursing staff regarding the new policy. The inservice documented, .VERY IMPORTANT!!!!!!!: CPR POLICY: I HAVE RE-WRITTEN OUR CPR POLICY TO INCLUDE NO BREATHS OR COMPRESSIONS WILL BE STARTED UNTIL ADVANCE DIRECTIVES ARE CONFIRMED IN PAPER CHART. I WANT THE NURSE TO LAY EYES ON THE PAPER THAT STATES I HAVE OR HAVE NOT EXECUTED AN ADVANCE DIRECTIVE. MUST VISUALIZE WHETHER THERE IS A DNR OR NOT. Licensed staff were interviewed regarding the new CPR policy. Each staff contacted stated they had received an inservice and were able to provide the information regarding the new policy.

Based on observation, interview and record review, it was determined the facility failed to: ~ Ensure the biohazard room, which contained chemicals and biohazard materials, on one (Rogers Hall , Memory Care Unit) of seven halls was locked to prevent residents from entering. Six ( #6, 12, 13, 14, 15 & 16) of 13 residents on the unit were identified as ambulatory. This deficient practice resulted in the determination of an immediate jeopardy situation. ~ Ensure chemical storage areas were not accessible to residents. The janitor closets and biohazard rooms on five (Autry, Guthrie, Rogers, Brooks and Murray) of seven halls had a key on a chain by the doors at a level by which residents could reach the keys to unlock the doors. The janitor closet on one (Guthrie Hall) of seven halls was observed with the key in the lock. ~Shower rooms and bathrooms were observed unlocked and unattended on six (Rogers, Brooks, Autry, Murray, Guthrie and the West skilled hall) of seven halls. The shower and bathrooms contained chemicals within reach of residents. ~ Ensure water temperatures were maintained at proper temperatures to prevent scalding or burning on five (Guthrie, Brooks, Rogers, Murray and Autry) of seven halls. ~ Ensure syringes and needles were not accessible to residents on two (Skilled Hall East and West) of seven halls. ~ Provide supervision and identify and implement interventions to aid in the prevention of falls for one (#8) of five sampled residents who required assistance with transfers and/or ambulation. This resulted in actual harm of two head injuries that required sutures for the resident. The facility identified 38 residents as being on the facility's Falling Star program. Findings: Immediate Jeopardy An Immediate Jeopardy situation related to chemical access by residents on the Memory Care Unit (Rogers Hall) was identified on 02/06/12 at 10:58 a.m. The Oklahoma State Department of Health verified the existence of the Immediate Jeopardy situation at 11:50 a.m., on 02/06/12. The facility administrator, operations manager and human resources director were notified of the immediate jeopardy situation at 2:25 p.m. on 02/06/12. Immediate Jeopardy Situation - Unsafe Chemical Storage 1. On 02/06/12 at 10:20 a.m., the biohazard room on the memory care unit (Rogers Hall) was unlocked. The biohazard room contained a five gallon container labeled Eco-Lyzer (a disinfectant). The container had a round opening on the top which was not covered. The contents appeared to be gray and white crystals. The biohazard box contained sharps containers and the box was not covered. There was a strong, foul odor in the room. An artificial Christmas tree and other decorations were stored next to the biohazard box. On 02/06/12 at 10:24 a.m., LPN #9 was asked for the names of residents on the Memory Care Unit (Rogers Hall), who ambulated independently. She identified residents #6, 12, 13, 14, 15 & 16. LPN #9 was also asked if she had ever observed the residents in the unit try to unlock the janitor and biohazard closets with the keys hanging within reach by each door. She stated she had not observed them trying to open the doors with the key, "but they do jiggle the door knobs." She further stated they don't leave anything out because the residents try to eat everything. Resident #6 had a [DIAGNOSES REDACTED]. She was able to understand and was able to be understood. She was independent with ambulation on and off the unit. Resident #12 had [DIAGNOSES REDACTED]. He was able to understand and was able to be understood. He required supervision for his ambulation on and off the unit. Resident #13 had [DIAGNOSES REDACTED]. She was able to understand and was able to be understood. She required supervision for ambulation in her room and was independent out of her room and on the unit. Resident #14 had [DIAGNOSES REDACTED]. The Summary Score of the MDS BIMS assessment, dated 12/05/11, documented the resident's cognitive status was severely impaired. He was sometimes able to understand and was sometimes able to be understood. He required supervision for ambulation on and off the unit. Resident #15 had a [DIAGNOSES REDACTED]. She was usually able to understand and was able to be understood. She was independent with ambulation on and off the unit. Resident #16 had a [DIAGNOSES REDACTED]. She was usually able to understand and was able to be understood. She was independent in ambulation on and off the unit. On 02/06/12 at 10:37 a.m., LPN #9 was asked to lock the door to the biohazard room. She stated, "It shouldn't be unlocked." She then locked the door. On 02/06/12, at 10:50 a.m., a surveyor found the door to the biohazard room unlocked. On 02/06/12, from 10:15 a.m. until 2:45 p.m., janitor and biohazard closets on five (Autry, Brooks, Guthrie, Rogers, and Murray halls) of seven halls were observed to have a key on a chain by each door within the residents' reach. On 02/06/12 at 10:40 a.m., the following was observed on the west hall of the skilled nursing unit: An unlocked wall cabinet in the shower room contained two quart size bottles of 'Cen Kleen IV', a one step disinfectant/viracide cleanser. The container label stated 'causes eye irritation' and 'keep out of reach of children'. On 02/06/12 at 10:45 a.m., a janitor closet was observed with a key in the lock of the door. Inside the room the surveyor observed an open one-gallon bottle of 'Eco-Lyzer' disinfectant solution and two, five-gallon containers of 'Eco-Lyzer'. One of the five-gallon containers was open and contained approximately three cups of solution. The second five-gallon container was attached to a hose. The hose could easily be pulled from the container. NABC (non-acid disinfectant bathroom cleaner), one-half gallon of concentrated surface and glass cleaner, one liter of deodorizer and a three liter bottle of glass cleaner were observed on a shelf approximately 4 1/2 feet from the floor. A one liter bottle of carpet cleaner and a liter bottle of NABC were observed on top of a five-gallon bucket of 'Eco-Lyzer' in a cabinet. At 11:30 a.m., the shower room was observed with an open pack of five razors. There was also a full spray bottle of non-acid bathroom cleaner observed on the shelf with the razors. On 02/07/12 at 9:55 a.m., the surveyor observed the unlocked wall cabinet in the unlocked shower room on the west hall of the skilled nursing unit. The chemicals observed on 02/06/12 were still in the cabinet. The surveyor asked LPN #10 how the facility ensured safety of the residents regarding various chemicals used by staff. She stated all chemicals and biohazard materials were to be kept in a locked area inaccessible to residents. The surveyor showed the LPN the containers of 'Cen Kleen IV' in the unlocked wall cabinet. She stated the wall cabinet should have been locked. Plan of removal for Immediate Jeopardy A plan of removal, written by the administrator, for the immediate jeopardy was received and approved at 3:45 p.m. on 02/06/12. The plan of removal stated: "All rooms in question have been checked for chemicals and have been removed from the rooms in questions. All Keys have been taken down and doors locked until the locks can be replaced. A sign has been placed that the key is with the CMA (certified medication aide) and housekeeper on each home. Maintenance staff is in route to Lowe's to purchase new locks for all doors; notes will remain permanently on doors. On the attached sheets you will see our plan to contact all CNA's (certified nurse aides), CMA's and nurses (in pink) will be notified before 6:00 am February 7, 2012. All those in orange will be notified by phone this evening. Housekeepers have all been notified by their supervisor as of February 6, 2012 3:30 PM. And a signed in-service sheet will be attached as soon as everyone has been notified." At 3:02 p.m., on 02/07/12, an addendum was added to the plan of removal by the human resources director, due to the inability to make contact with four staff members. The addendum stated: "Information on "locked doors in facility" (i.e.) chemicals are kept, bio Hazard & etc. The following employees/shifts on 6/2 - 2/10 & 10/6 will not work their assigned duties until they have had an orientation dealing with the above policy." Immediate Jeopardy Removed The Immediate Jeopardy was removed on 02/07/12, at 4:00 p.m. based on the installation of new door handles and locks on all chemical and biohazard rooms. New procedures were implemented regarding access to the keys and staff were trained on the new procedures. Staff were interviewed after their training was conducted and were able to report the new procedures. All doors to chemical storage areas remained locked except when in use as observed from 9:00 a.m. to 8:00 p.m. on 02/07/12. Signs were posted on all doors regarding procedures to obtain keys to unlock the doors. A facsimile was received on 02/08/12, from the facility verifying the completion of the training for the four staff members who were unable to receive training while the survey team was on site. The deficient practice remained at a pattern level of potential for more than minimal harm. Unsecured Syringes and Needles The facility also failed to store needles and syringes securely on the skilled nursing unit. 2. On 02/06/12 at 11:30 a.m., the following was observed on the emergency cart on the west hall of the skilled unit. There were 10 loose needles, and 12 needles with syringes attached. In the emergency cart in the skilled unit dining/activity room (near the East Hall) there were nine loose needles and 10 syringes with needles. On 02/07/12 at 3:30 p.m., the surveyor asked LPN #10 how the facility ensured safety of the residents regarding items in the emergency carts. She stated the carts should be locked at all times when not in use. Hot Water Temperatures 3. On 02/06/12 at 1:10 p.m., the following water temperatures were recorded: Rogers Hall (Memory Care Unit): Room 18 was 121 degrees Fahrenheit Room 25 was 124 degrees Fahrenheit Room 26 was 124 degrees Fahrenheit Room 31 was 120 degrees Fahrenheit The shower room was 120 degrees Fahrenheit. Brooks Hall: Room 68 was 120 degrees Fahrenheit Room 57 was 124 degrees Fahrenheit Room 58 was 122 degrees Fahrenheit The men's bathroom was 124 degrees Fahrenheit The shower room was 123 degrees Fahrenheit Murray Hall: Room 37 was 124 degrees Fahrenheit The shower room was 122 degrees Fahrenheit On 02/06/12, at 3:49 p.m., resident #7, who resided in room 37, was observed washing his hands at the sink in his room. He was interviewed regarding the water temperature. He was asked if the water was ever so hot that he had to pull his hands out from under the water. He replied, "Sometimes it is." He was asked if the water was frequently or occasionally too hot and he stated, "It's always too hot, it's always been that way." Autry Hall: On 02/06/12 at 10:45 a.m., the temperature of the water in room 77 was measured at 127.8 degrees Fahrenheit. On 02/06/12 at 2:45 p.m., the surveyor asked CNA #5 if either resident in the room was able to access the water faucet. She stated neither resident was able to gain access to the sink independently. Falls: 4. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Nurses' notes, dated 01/09/11 at 8:15 p.m., documented, "...Found resident on floor in hallway...Nose crooked (with) small superficial laceration on bridge of nose..." A mobile x-ray result, dated 01/10/11, documented, "There is a comminuted fracture through the distal 1/3 of the nasal bone with inferior angulation of the distal component. Portions of the fracture are ill-defined, suggesting that (unknown) may be a reinjury of an old fracture..." A care plan update, dated 01/10/11, documented, "...Has had 5 falls this qtr. Last fall occurred on 1/9/11...Assistance levels c transfers vary depending on mood. At times requires ext assist c transfers but is also able to transfer independently. At these times, balance unsteady. Uses w/c as...transportation, able to propel self but also pushed @ (times). Cont POC..." A family conference form, dated 01/13/11, documented the resident remained at risk for falls. Nurses' notes, dated 01/22/11 and 01/28/11, documented the resident suffered 2 falls without injury while in her room. A fall risk assessment, dated 01/31/11, documented the resident scored a 13. The form documented a total score above 10 represented high risk for falls. Nurses' notes, dated 02/20/11 at 8:45 p.m., documented the resident suffered a fall without injury while in her room. A significant change assessment, dated 03/03/11, documented the resident was rarely or never able to express ideas and wants, rarely or never able to understand verbal content, had long and short term memory loss, and was severely impaired in making decisions regarding tasks of daily life. It was also documented the resident required extensive assistance of one person for bed mobility and transfers, totally dependent for locomotion on and off the unit, and was only able to stabilize during transfers with assistance. It was documented the resident had falls since her prior assessment but no injuries. Review of the clinical record revealed no documentation to show any new interventions had been identified or implemented to aid in the prevention of falls from 01/09/11 through 03/07/11. A fall risk assessment, dated 03/08/11, documented the resident scored a 15. The form documented a total score above 10 represented high risk for falls. The resident's care plan, dated 03/08/11, documented the resident was at risk for falls related to the use of antidepressant and anti-anxiety medications, impaired mobility, history of falls, and cognitive impairment. The goal was the resident would be free of injury and falls for 90 days. Approaches were, "...Document s/sx of adverse effects of medication on resident...keep door open to facilitate frequent visual checks...frequently check on resident to prevent falls...keep bed in lowest position...keep bedroom well lit. Make sure pathways are free of obstacles...keep personal belongings within easy reach...keep call light within easy reach. Answer promptly...Monitor for and document perceptual changes...Observe for decrease or loss of functional status...observe for dizziness, weakness, excessive fatigue...administer medications as ordered...monitor for side effects q shift...assist as needed with transfers...provide assistance to meet needs..." Undated entries to the approaches included, "...personal alarm in place @ all (times)...review meds for s/e. Discuss c physician...Assess for pain (and) adminis (sic) med as ordered...assist to toilet q 2 (hours) (and) (prn)...offer fluids...assess for environmental factors contributing for fall..." Nurses' notes, dated 03/08/11 at 3:30 p.m., documented the resident was found on the floor of her room when CNAs were performing bedchecks. It was documented the resident suffered abrasions on each side of her spine. Nurses' notes, dated 03/09/11 at 8:50 p.m., documented, "...(At approximately) 8:10 p.m., (resident) found on buttocks in room on floor next to bed...(Due to) (continued) anxiety @ 8:25 Ativan Intensol 0.5 ml (1 mg) given..." A CAA narrative report, dated 03/11/11, documented, "...has a clear risk for falls due to her ADL function/mobility deficit, balance problems, dementia, use of psychoactive medications, cognitive loss, and incontinence...fell on [DATE] without injuries...expresses pain by crying, and mumbling in a more loud and fervent way than usual when she has pain. She also may express her pain with behaviors ocassionally (sic) (none recent). Pain does place this resident at risk for impaired mobility, falls..." Nurses' notes, dated 04/01/11 at 3:00 a.m., documented the resident was found on the floor by her bed with her chair alarm in her hand. It was documented the resident had no injuries. Nurses' notes, dated 04/01/11 at 1:30 p.m., documented, "...Nurse called to (dining room). Resident on floor on her back. Noted to have bump on the back of her head...Resident was sitting in (dining room) chair (and) had personal alarm in her hand so that alarm wouldn't sound. she was transferring herself to (wheelchair) (and) fell ..." Nurses' notes, dated 04/02/11 at 12:45 a.m., documented, "...found face down on floor (at bedside) in pool of blood - CNA heard personal alarm (and) found her - assessed...laceration over (right) eye (approximately) 1 (inch) pouring blood (and) hematoma area noted around laceration the size of a golf ball - superficial laceration (with) blue discoloration noted @ bridge of nose..." An incident report, dated 04/02/11 at 12:45 a.m., documented, "...Will speak c family (and) administrator about bed alarm..." A patient transfer form, dated 04/02/11, documented, "...Third fall in 24 hr - removes personal alarm. Fall 4-1-11 @ 3 am no injury fall 4-1-11 @ 1:30 p.m. in cafe c bump on back of head. Fall @ 1:45 a.m. fell face first to floor - laceration over (right) eye...does not speak jibberish only sight/hearing impaired - dementia..." Nurses' notes, dated 04/02/11 at 4:15 a.m., documented, "...sutures placed to laceration above (right) eye..." Nurses' notes, dated 04/02/11 at 4:40 a.m., documented, "...hematoma cont where sutures are above (right) eye - nose swollen and discolored - dark areas (under) both eyes..." Nurses' notes, dated 04/02/11 at 7:00 p.m., documented, "Resident lying on floor on back...(complaint of) pain to (right) hip when touched..." An incident report, dated 04/02/11 at 7:00 p.m., documented, "...PT notified, (Hospice) notified...(physician name withheld) faxed for lap belt, pressure alarm (and) (low) bed c mat..." Review of the clinical record revealed no documentation to show a low bed and mat or lap belt were obtained for the resident. Nurses' notes, dated 04/02/11 at 7:15 p.m., documented, "...New order to send to (hospital name withheld) for eval (and) tx of (right) hip pain when (right) hip touched..." Nurses' notes, dated 04/02/11 at 9:30 p.m., documented, "...Ret'd to facility...in stable condition..." Review of the clinical record revealed no documentation to show the facility was aware of any diagnostic testing results or physician opinions of the resident's right hip pain. Nurses' notes, dated 04/03/11 at 10:50 a.m., documented, "...(hospice employee) return call (and) stated she called about bed (and) chair alarm (and) we maybe get them sometime next (week)..." Nurses' notes, dated 04/03/11 at 11:00 p.m., documented, "...Resident up @ side of bed attempting to stand (up) on own. Bed alarm intact in resident's hand..." Nurses' notes, dated 04/04/11 at 10:45 p.m., documented, "...Resident (up) out of bed taking off personal alarm several times, crying (and) tearful. Tylenol...given po for pain @ this time..." Nurses' notes, dated 04/04/11 at 11:35 p.m., documented, "...Resident continues to get (up) without assistance, began becoming agitated c intervention of 1:1. Lorazepam...given SL @ this time..." Nurses' notes, dated 04/05/11 at 1:00 a.m., documented, "...Resident (up) without assistance. Attempting to remove personal alarm. Resident placed in w/c (and) given snack. 1:1 c nurse. When transferring to w/c resident unable to bear full weight on (right) leg. (No) bruising, rotation, or shortening noted..." Nurses' notes, dated 04/06/11 at 1:00 a.m., documented, "...During inc change client reacts as if in pain when (right) hip touched. Lying in bed rubbing (right) hip/femur area c pained look on face. Tylenol...given/ can't rate pain d/t dementia..." Nurses' notes, dated 04/06/11 at 11:15 a.m., documented, "...bed alarm sounded client found standing @ BS..." Nurses' notes, dated 04/18/11 at midnight, documented, "...Resident continues to be (up) (and) (down) by self initiation in bed (and) w/c. Bed pad alarm, chair alarm in place c each transfer..." A care plan update, dated 04/18/11, documented, "...bed (and) chair alarm also put in place..." A care plan update, dated 05/01/11, documented, "...was observed on floor x 4 during month of April. Sent to ER x 2 - for sutures to laceration (and) eval of hip pain. She had a personal alarm in place but would take off (and) stand s assist. A bed (and) chair alarm were also put in place. Staff instructed to toilet her (every) two (hours) (and) offer food/fluids frequently. Cont POC..." There was no documentation to show a low bed had been obtained for the resident or that any other interventions had been attempted to aid in the prevention of falls when the resident attempted to transfer from her wheelchair. Nurses' notes, dated 05/14/11 at 8:00 p.m., documented, "...Res agitated babbling and grabbing @ staff getting up and down from w/c to bed multiple times setting off (personal safety alarm). Ativan...gave @ this time..." Nurses' notes, dated 05/14/11 at 9:25 p.m., documented, "...Called to res room @ 815 p.m. to find CNA holding washcloth to resident's forehead and resident was laying on stomach c (right) shoulder behind her call placed to Dr (name deleted) and message left telling him this nurse was going to ship res to ER for possible stitches..." Nurses' notes, dated 05/14/11 at 11:00 p.m., documented, "...returned to nursing home...Follow head injury instructions...Remove sutures in 5-7 days...Resident moves all extremities as previous to fall. Stitches to R forehead...bed alarm in place..." Nurses' notes, dated 05/15/11 at 8:55 p.m., documented, "...slipped OOB onto floor onto buttocks..." Nurses' notes, dated 05/16/11 at 5:30 p.m. as a late entry for 4:30 p.m., documented, "...staff heard residents personal alarm from wheel chair sounding, upon entering residents bedroom she was found sitting on the floor on her buttocks..." A Falling Star care plan, dated 05/16/11, documented the resident had been identified as a "falling Star" due to having had falls with injury and two or more falls in 30 days. The goal was documented as the resident would have a reduction in the incidence of falls during the next 60 days and re-assessment if another fall occurred during the 60 day assessment period. The form documented, "...falls are out of bed. She has a personal alarm in place...continues to fall as she tries to stand but cannot stand (and) balance. I discussed c charge nurse, restorative aide (and) other staff (and) we agree a low bed will be an appropriate intervention to avoid injury..." No new interventions to aid in the prevention of falls when the resident was attempted to transfer herself from her wheelchair were identified. Nurses' notes, dated 05/17/11 and untimed, documented, "...Seen by (physician name withheldl). DC Ativan...low bed c floor mattress...notified (hospice employee) - will bring bed/mattress..." Nurses' notes, dated 05/17/11 at 11:00 p.m. as a late entry for 4:30 p.m., documented, "...Upon hearing alarm sound, staff entered residents room and found her on the floor on her buttocks...resident attempted to get out of wheel chair without assistance, educated on call light and waiting for assistance..." A care plan update, dated 05/17/11, documented, "...low bed c mat on floor..." A care plan update, dated 05/26/11, documented, "...has had four falls this month. Sent toER on ,[DATE] for sutures. Conts to attempt to stand/get out of w/c s assist. Low bed c mat put in place on 5/17/11. Has personal alrm in addition to bed (and) chair alarm in place. Has severe cognitive loss c poor safety awareness. (Physician name withheld) reviewed meds on 5/17/11 (and) made (changes). Discussed use of w/c lap belt c PT, fall committee (and) staff; however, @ this x, not good idea d/t res agitation, anxiety (and) behaviors. Staff fears more injuries c lap belt. Staff to toilet q 2 (hours) (and) prn (and) offer food/fluids more frequently. Cont POC..." An update to the falling star care plan, dated 05/26/11, documented, "...continue same interventions. w/c lap belt discussed but not approved due to agitation...5/17 Ativan d/c, Depakote added 5/17...5/17...fell on self exit from w/c..." No other interventions were identified or implemented to aid in the prevention of falls when the resident attempted to transfer herself from her wheelchair. A care plan conference form, dated 06/08/11, documented the resident had 8 falls in the previous quarter with one fall requiring sutures to her face. It was documented, "...Now has low bed (and) floor mat (with) bed (and) chair alarms..." A care plan update, dated 06/15/11, documented, "...Has had 11 falls this qtr - several c injuries (and) several s. Her last fall occurred on 5/17/11. On that date, she had med (changes) (and) low bed c mat put in place. She has had no falls since that time. Conts to have personal alarm (and) bed alarm in place...Cont POC..." The care plan update did not address falls when the resident attempted to transfer herself from her wheelchair. A fall risk assessment, dated 06/15/11, documented the resident scored a 17. The form documented a total score above 10 represented high risk for falls. Nurses' notes, dated 07/05/11 at 9:00 p.m., documented, "...This nurse called to room by CMA. CNA stated res alarm went off (and) she sprinted to res room (and) saw res try to stand (up) from w/c (and) fell to the side bumped head on dresser next to bed. Res has bump on back of head (and) abrasion to mid (upper) back..." An incident report, dated 07/05/11 at 9:00 p.m., documented, "...If res is OOB mat needs to be off floor. Res needs louder alarm..." An update to the falling star care plan, dated 07/07/11, documented, "...fell [DATE]...cont on low bed. Staff educated..." No new interventions were identified or implemented to aid in the prevention of falls when the resident attempted to transfer herself from her wheelchair. No further updates to the resident's falling star care plan were documented. Nurses' notes, dated 07/27/11 at 9:50 p.m., documented, "...(at) approx 9:15 p res alarm sounding observed res lying on back on floor. Unable to verbalize if she hit head. S/T noted to (right) elbow..." An incident report, dated 08/23/11 at 6:45 p.m., documented, "...Found sitting on floor by CNA. Unable to state why she was on floor...Educate staff in assisting patient to bed as soon as possible (after) meal c HOB (up)..." Nurses' notes, dated 08/25/11 at 5:00 p.m., documented, "...Resident found on floor..." An incident report, dated 08/25/11 at 5:00 p.m., documented, "...Encourage resident to not get up without assistance..." Nurses' notes, dated 09/02/11 at 1:40 p.m., documented, "...Res observed sitting on floor beside w/c..." An incident report, dated 09/02/11, documented, "...Staff reminded to answer alarm ASAP..." Nurses' notes, dated 09/03/11 at 8:30 (a.m. or p.m. unknown), documented, "...heard alarm on w/c go off (and) turn around...she was sitting in floor in front of w/c..." An incident report, dated 09/03/11, documented, "...When she is out of bed watch her close (and) watch for her to go to her room..." A care plan conference form, dated 09/07/11, documented the resident remained on hospice services, had 4 falls during the previous quarter and was at risk for falls. A care plan update, dated 09/07/11, documented, "...Has had six falls this qtr - two c injuries. conts to have personal, chair (and) bed alarm in place. Low bed c mat also remains in place. Cont POC..." No new interventions to aid in the prevention of falls were identified. A fall risk assessment, dated 09/07/11, documented the resident scored a 15. The form documented a total score above 10 represented high risk for falls. Nurses' notes, dated 09/25/11 at 6:20 p.m., documented, "...Resident attempted to place self in bed (and) landed on floor from w/c (after) dinner..." An incident report, dated 09/25/11, documented, "...Resident needs to be evaluated for (memory unit)..." Nurses' notes, dated 09/27/11 at 5:15 p.m., documented, "...Observed on floor, next to mat, (after) getting out of w/c. Sm hematoma to back of head..." An incident report, dated 09/27/11, documented, "...Keep resident close to staff's sight when (up) in w/c. also, may entertain idea to obtain lap buddy for safety..." On 02/07/12 at 11:35 a.m., the DON was asked if the resident had experienced multiple falls. He reviewed the medical record and stated, "I'd say yes." The DON was asked what new interventions had been identified and implemented after each fall to aid in prevention of future falls. The DON reviewed the resident's care plan and stated the resident had been placed on a low bed and mat following her falls in April, 2011. The DON was shown the documentation that showed the low bed and mat were not implemented until 05/7/11. He stated he did not know why the low bed and mat were not implemented immediately or why the care plan did not address any new interventions. The DON was asked how the facility's falling star program worked. He stated when a resident fell , an incident report was generated and the fall was documented on the fall log. He stated if the resident fell within 2 weeks of admission or re-admission or had 2 or more falls, the resident would be placed on the falling star program. The DON stated the falling star committee; which consisted of a group of nurses, a restorative aide, and physical therapy, would then develop a goal and approaches designed to help prevent falls, and that information was shared with the nurse and MDS Coordinator. He stated the information was then incorporated into the resident's care plan. The DON was asked why the resident was not placed on the facility's falling star program until 05/16/11 since she had experienced multiple falls, some with injuries before that date. He stated the resident should have been placed on the program before then. The DON was asked why the facility had not identified or implemented any new interventions to aid in the prevention of falls when the resident attempted to transfer herself from her wheelchair. He stated he did not know. The DON was asked whose responsibility it was to identify and implement interventions to aid in the prevention of falls. He stated, "Everyone." On 02/07/12 at 10:10 a.m., the director of nursing was asked if falls were monitored and interventions to prevent further falls were initiated. He stated every week the physical therapist and the restorative aide met and discussed all the falls that occurred during the past week. At 1:30 p.m., the physical therapist was asked if he was notified of residents who had fallen. He stated he met every Thursday with the restorative aide, who had a copy of each of the incident reports for each resident that had fallen in the past week. He stated he reviewed the information and initiated a falling leaves care plan with recommendations for prevention o

Based on observation, review of clinical records, review of policies and procedures, and staff and resident interviews, it was determined the facility failed to assess, monitor and intervene: a. when a resident with complaints of pain failed to receive pain medication for one (#3) of 15 sampled residents who received pain medication. This had the potential to affect 51 residents identified by the facility who had pain; b. to ensure a resident with constipation did not develop a fecal impaction for one (#2) of one sampled resident with a fecal impaction. This had the potential to affect 18 residents identified by the facility who were being treated for [REDACTED]. c. when a resident with behaviors failed to receive behavior medications for one (#10) of eight sampled residents with behaviors. This had the potential to affect 31 residents identified by the facility as having behaviors; d. to ensure residents with pain received appropriate pain management for two (#10 and #18) of 15 sampled residents who received pain medication. This had the potential to affect 51 residents identified by the facility who had pain; e. to ensure weekly weights were performed for one (#11) of five sampled residents with orders for weekly weights. This had the potential to affect 53 residents identified by the facility as requiring weekly weights; f. to ensure Peg Tube placement was checked before medications were given for one (#14) of two sampled residents with Peg Tubes. This had the potential to affect two residents identified by the facility has having Peg Tubes; g. to ensure pain assessments were conducted for one ( #7) of seventeen sampled residents who were required to have pain assessments completed. This had the potential to affect all the residents who required that pain assessments be conducted; and h. to ensure a DNR status was clarified for one (#2) of one sampled resident with an unknown code status. This had the potential to affect 48 residents identified by the facility as having a DNR order. Findings: A policy and procedure titled, Pain Management Program Overview and Principles, documented, "Each resident will have a comprehensive & interdisciplinary pain assessment upon admission to the facility. A pain management care plan will be developed and followed for appropriate residents based on the assessment process... Complaints, signs or symptoms of new or increased pain or discomfort will be assessed in a timely manner by the interdisciplinary team. Whenever possible the resident will have an active role in determining the pain management program and evaluation its effectiveness... Quarterly and annual reviews will be performed based on the resident's needs and length of stay. Optimum and effective pain management is only successful through a systematic and total team effort. Continual monitoring, assessment and evaluation, resident education and utilization of scheduled medications and other modalities is crucial to the success of each resident's pain management plan. Pain Management Principles Pain is whatever the resident says it is. All pain is real regardless of its cause and must be treated even when the cause remains unknown. Pain is a subjective and complex experience. 1. Ask the resident about pain regularly. 2. Assess pain systematically. 3. Believe the resident and family in their reports of pain and what relieves it. 4. Choose appropriate pain control options for the resident, family and setting. 5. Deliver interventions in a timely, logical and coordinated fashion. 6. Empower the resident and their families. 7. Enable residents to control the course of treatment to the greatest extent possible." A policy titled, General Reminders for Gastrostomy Feeding, documented, "...2. Check tube placement before each feeding or at least once daily. (Listen with stethoscope over left upper quadrant while injecting 20 ml air into tube, or aspirate back [MEDICAL CONDITION] contents.)..." 1. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. admission orders Tylenol Extra Strength 1000 mg po bid for pain..." An initial resident assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent for transfers, did not ambulate and was always incontinent of bowels and bladder. The assessment documented the resident had not had pain in the last five days. A care plan, dated [DATE], was reviewed. There was no care plan which addressed pain or pain management. The [DATE] MAR from Rogers Home, did not have the order for routine Tylenol transferred onto it from the admission orders [REDACTED]. The MAR documented, "...Tylenol 500 mg 2 tabs oral bid/prn pain/fever NTE (not to exceed) 4 gms in 24 hrs from all sources..." No routine or prn Tylenol was documented as being given since the resident's transfer to Rogers Home on [DATE]. A physician's progress note, dated [DATE], documented, "...S: (Resident) is kind of hurting all over still, but that has been her main complaint...A: 6) Chronic pain is mostly [MEDICAL CONDITION] and partially dementia, will hold the course with that..." A pain assessment, dated [DATE], documented, "...Pain Location: Everywhere Date of onset: Unable to state Cause of pain: Does not know... Non-verbal Indicators: Grimacing... readmitted from SNF. Asked how she is doing and she said, 'Not very good.' She has no idea what caused the pain, what makes it worse etc. Tried to get a level of pain et she said it was 'bad.'" On [DATE] at 4:45 p.m. the resident was observed as she sat in her wheelchair in her room. She was asked by the surveyor how she was feeling. She stated, "Hurts all over." The resident was noted to have a grimace on her face. LPN #2 was outside the resident's room. She was told the resident had complained that she hurt all over. LPN #2 stated, "Oh, she says that every five minutes." She went on to state the resident was probably having some pain as she had [MEDICAL CONDITION]. The LPN did not provide medication for the resident or assess the resident for pain. At 4:50 p.m., the resident received incontinent care as she stood with the sit to stand lift. The resident screamed repeatedly, "I can't do it." The surveyor asked during the procedure if she was in pain. The resident stated, "Yes. I can't stand it." When the incontinent care was completed, CNA #1 asked the resident, "Was that too bad?" The resident stated, "Yes." At 5:00 p.m., LPN #2 was asked if the resident could receive something for pain. She stated the resident had routine pain medication. The LPN was asked if the resident had prn pain medication. She stated she thought the resident had Tylenol ordered prn. She stated she knew when the resident was in pain, as the resident would scream, hit, throw things and swear. She was informed the resident had been screaming during incontinent care. No comment was made. The LPN was asked if she believed the resident when she said she was in pain. Again, no comment was made. At that time the LPN checked the resident's MAR. She stated the resident should be on routine Tylenol bid, but it was not documented on the MAR as one of the resident's medications. The resident had not received her routine Tylenol for two days. The LPN was asked if the resident could receive her prn Tylenol. She stated, "Yes, we will give her some." At 5:15 p.m., the DON was informed the LPN had been told of the resident's complaint of pain at 4:50 p.m., and that the resident had not been assessed for pain or medicated at that time. The DON stated, "She should have given her medication and assessed her." On [DATE] at 2:10 p.m., CNA #1 was asked if the resident was in pain during incontinent care the day before. She stated she might have been in a little bit of pain as she yells when she was in pain. The CNA acknowledged the resident had been yelling. 2. Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent for all ADLs and had a Peg Tube for nutrition. On [DATE] at 9:30 a.m., during the medication pass, LPN #1 was observed as she prepared the resident's medication to be given via Peg Tube (PT). The LPN disconnected the continuous PT feeding from the pump and inserted a syringe into the tubing leading into the resident's abdomen. She attempted to pull back on the syringe and obtained no residual. She removed the syringe from the tubing and proceeded to administer the resident's medication. The LPN did not check the PT for placement by inserting air into the tubing and listening to the resident's abdomen. At 4:15 p.m. the DON was asked what was the protocol of the nursing home for checking PT placement. He stated the nurse should have checked for placement of the Peg Tube by using her stethoscope and listening for air movement in her abdomen. The care plan, dated [DATE], documented, "Problem: Resident is at risk for aspiration/fluid overload/social isolation due to Peg Tube feedings. Goals: (Resident) will receive Peg Tube feedings to meet her/her nutrition/caloric/fluid needs with aspiration, fluid overload, skin breakdown, weight loss, or social isolation daily 90 days. Approach: ...(2) Check tube placement q 8 hrs if resident is receiving continuous tube feeding..." 3. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Upon review of the resident's clinical record, the resident's admission pain assessment was located. It was completely blank. On [DATE] at 9:00 a.m., RN #2 was asked why the resident's admission pain assessment was not completed. She stated LPNs did not do pain assessments and an LPN had admitted the resident. She stated either herself or the DON should have done the assessment. She stated, "It's not done." 4. Resident #18 was admitted to the facility with [DIAGNOSES REDACTED]. A nurse's note, dated [DATE] at 1:30 p.m., documented, "Staff reports R hip swollen. Upon assessment, R hip is swollen, non tender et firm upon palpation. (No) s/s bruising, pain or tenderness noted. (No) (change) in facial expression upon PROM. Call placed to (family). Notified of (change) in condition + that Dr to be paged. Ok c family to send to ER for eval et tx (evaluation and treatment)." A nurse's note, dated [DATE] at 2:15 p.m., documented, "Call rec'd from (physician). Notified of (change) in condition. PROM different from baseline to RLE + RLE appears shorter than left LE. N/O (New order) rec'd + noted. May send to ER for eval + tx." A nurse's note, dated [DATE] at 5:25 p.m., documented, "Call rec'd from (staff) (at) (hospital name deleted). admitted ...Dx fx femur 2 places." A Radiology Report, dated [DATE], documented, "History: Hip and leg pain There is a right knee prosthesis that is within normal limits. The right hip prosthesis is noted as a radiopaque femoral head and proximal intramedullary femoral component. Complex fractures of the proximal femoral diaphysis about the prosthetic are noted with butterfly fragment extending laterally and a smaller butterfly fragment proximally that extends medially. Impression: 1. Acute proximal femoral fractures about the pre-existing radiopaque prosthetic..." A nurse's note, dated [DATE] at 1:40 p.m., documented, "Resident returned to home via (ambulance service) and stretcher. Fx x 2 Rt femur. Comfort care only...Bruise to R inner thigh close to vagina...noted swelling and slight bruising around R (upper) leg (femur area)...Hospital states comfort care only. Not a good candidate for surgery. Will keep in bed the rest of today until eval can be done." A nurse's note, dated [DATE] at 4:00 p.m., documented, "VS (T) 97.3, (P) 90, (R) 19, (B/P) ,[DATE]. Res showing s/s of discomfort. Gave prn Tylenol 650 mg po @ this time." A nurse's note, dated [DATE] at 5:00 p.m., documented, "(No) noted relief yet from Tylenol dosing will recheck in 1 hour then try [MEDICATION NAME] 7XXX,[DATE] (mg) elixer." A nurse's note, dated [DATE] at 6:15 p.m., documented, "Noted resident facial grimacing upon movement. Gave prn [MEDICATION NAME] 7XXX,[DATE] mg 15 cc @ this time." A nurse's note, dated [DATE] at 7:15 p.m., documented, "Resident resting c eyes closed. Breaths are even and unlabored. (No) s/s of distress noted." An annual assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent on others for all ADLs and was bedfast all or most of the time. A care plan, dated [DATE], documented: "Problem: (Resident) has the potential for complaints of pain related to [MEDICAL CONDITIONS] right femur fractures. Goals: Will be comfortable and have no verbal complaints of s/s of pain x 90 days. Approach: 1) Administer pain medications (sic) as ordered. 2) Monitor effectiveness of pain medications... 5) Assess characteristics of pain: location, severity, type, frequency, precipitating factors. Relief factors. 6) Observe for nonverbal s/s of pain: grimacing, moaning, increase vital signs, guarding areas of body, diaphoresis, dilated pupils..." On [DATE] at 12:15 p.m., the DON reviewed the resident's record for pain management on her return from the hospital with a fractured femur. He stated, "Not good pain management." He stated a prudent nurse would have assessed the situation and made a better decision for pain management for the resident. 5. Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented, "Problem (Resident) is at risk for altered nutrition due to leaving 25% or more uneaten at meals and a mechanically altered therapeutic diet. Goal: will receive adequate nutrition to meet caloric needs and maintain stable weight x 90 days. Approach: ...12) Weigh monthly. Notify physician of significant loss/gain..." The following are the resident's weights: [DATE]: 88 lbs [DATE]: 88 lbs [DATE]: 87 lbs [DATE]: 85 lbs [DATE]: 85 lbs [DATE]: 80 lbs Between [DATE] and [DATE], there was a severe weight loss of 5.8% in one month. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making, required extensive assistance with eating and had no significant weight loss in the past six months. On [DATE], a fax was sent to the physician which requested the following: "Super donut, healthy shot c meals, weekly weights." This fax was signed by the physician. The weekly weight sheets for [DATE], [DATE] and [DATE] did not have the resident's name or weights listed. On [DATE] at 9:55 a.m., the DON was asked if the resident had been weighed weekly. He stated, "If it's not on the sheet, we don't have it." 6a. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated [DATE], documented the resident had long and short term memory problems and was severely impaired in her cognitive skills for daily decision making. She required extensive assistance with her ADLs and was incontinent of both bladder and bowel. An ADL flow sheet, dated [DATE], documented the resident did not have a bowel movement on [DATE], [DATE], [DATE], [DATE]; she had a small bowel movement on [DATE]; and no bowel movement on [DATE], [DATE], [DATE], and [DATE]. A nurse's note, dated [DATE] at 8:10 a.m., documented, "Resident in bed yelling, hurt. Aides changing her brief. She passed a hard softball size BM. I auscultated her abd (abdomen). Bowel sounds x4 active. Soft abdomen but tender to right lower quadrant. Gave [MEDICATION NAME] 15ml per pegtube at this time." An ADL flowsheet, dated February 2011, documented the resident did not have a bowel movement on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. A nurse's note, dated [DATE] at 10:10 a.m., documented, "[MEDICATION NAME] 15cc/peg given for distended abdomen and constipation. Res yelling as if uncomfortable. [MEDICATION NAME] routine given. Res beginning to have a liq (liquid) BM. [MEDICATION NAME] 10 mg suppository i given. Hard BM in rectal vault surrounded by liquid BM. Res still hollering as if uncomfortable. Abd (abdomen) distended." A telephone order, dated [DATE] at 11:30 a.m., documented, "[MEDICATION NAME] 10 mg supp (suppository) R (rectal) i qd prn for constipation." The February 2011 ADL sheet, documented the resident had a large BM on [DATE]. A nurse's note, dated [DATE] at 11:30 a.m., documented, "Abd distended at this time. Resident yelling out that her belly hurts. [MEDICATION NAME] supp (suppository) administered at this time. Will monitor for results." A nurse's note, dated [DATE] at 2:30 p.m., documented, "Resident had an XL BM formed." The February ADL sheet, documented the resident had no bowel movements [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. A monthly physician order, dated [DATE], with an original date of [DATE], documented, "[MEDICATION NAME] 10Gm/15ml syrup 15 ml enteral qd/prn constipation..." On [DATE] at 4:25 p.m., the ADON was asked if she was aware of the resident's problems with constipation. She stated, "No. Not aware of any that I know of." At 4:40 p.m., the DON was asked about the facility policy and procedure when to notify the physician in regards to constipation. He stated three days was their policy. He was shown the ADL flowsheets and nurses notes. He stated, "It is severe. They should have called the doctor before then." He stated, "I'll tell the nurses about it." 6b. A resident transfer form, dated [DATE], documented, "...Advance directives ...Code status FULL..." The resident's admission paperwork, on [DATE], documented the resident was a full code. There was no documentation on the resident's monthly orders which indicated the resident's DNR status. The resident's care plan, dated [DATE], documented at the top of each page, the resident was a full code. The resident's careplan, dated [DATE], also documented, "...Problem (11) [DATE] (Resident) has a DNR order ...Short-Term Goal Will respect resident's wishes and no CPR will be performed X 90 days. ...Approach (1) Communicate DNR status to staff. (2) DNR form signed by resident or legal representative, witness and placed in chart. (3) If [MEDICAL CONDITION] occurs, do not resuscitate. (4) If resident is hospitalized , send a copy of DNR order with other orders." The care plan was updated as follows: "[DATE] cont to have DNR status [DATE] cont to have DNR effective [DATE] cont to have DNR order." An Oklahoma Do-Not-Resuscitate (DNR) Consent form was located in the back of the resident's clinical record. The resident's name was documented at the top of the form. The form had not been executed by the resident, the resident's representative, or a witness. On [DATE] at 12:20 p.m. the DON was asked how staff determines if a resident is a DNR. He stated, "There are blue dots on the back of the clinical record." The resident did not have a blue dot on the back of her clinical record. The DON was shown the DNR that had not been executed. He stated, "This is a problem. It will be remedied soon." 7. Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. A telephone physician's orders [REDACTED]. A telephone physician's orders [REDACTED]." A nurse's note, dated [DATE] at 2:00 p.m., documented, "Res. walking in hallway. Walked passed (sic) another res & hit her in the head c her fist... Res son called & informed of behavior..." A nurse's note, dated [DATE] at 4:00 p.m., documented, "... repeating conversations she hears on TV..." A nurse's note, dated [DATE] at 6:00 p.m., documented, "... keeps jumping up from chair & sitting down again. (Not) eating. Pacing in dining room, then sits down on sofa..." A nurse's note, dated [DATE] at 9:00 p.m., documented, "... At 9:05 p.m. went into the resident's room (the one she hit), crawled into bed and sat on the resident..." The resident was not offered [MEDICATION NAME] for agitation at any time on [DATE]. A nurse's note, dated [DATE] at 4:30 a.m., documented, "... (up and down), wandering on unit until now - to bed and still not sleeping - (eyes) open & resident looking around." At 8:00 a.m., nurses' notes documented, "... [MEDICATION NAME] 5 mg po for (increased) agitation crying, yelling, roaming in dining room, going from table to couch & corner chair repeatedly... 9:00 a.m. (no) change in behaviors - fed breakfast by staff. Res won't feed herself...12 noon has not slept, refused to eat." The resident was not offered any further doses of [MEDICATION NAME] on [DATE] as ordered by the physician for agitation. A nurse's note, dated [DATE] at 11:45 p.m., documented, "Resident up in hall asking for water. Given 3 glasses. Demands more. Drank whole pitcher of fresh water CNA gave her & wanted more. Pitcher removed from room. Had about ,[DATE] gallon water. To bed x 4..." The resident remained awake until 2:00 a.m. She was not offered [MEDICATION NAME] as ordered for agitation and anxiety. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision-making. She was assessed as having frequent verbal and physical behavioral symptoms, and required extensive assistance with all activities of daily living. A nurse's note, dated [DATE] 6:00 a.m. - 6:00 p.m., documented, "... resident unable to sit. (up and down) constantly. Has to be fed by staff - won't sit down to eat..." The resident was not offered [MEDICATION NAME] as ordered by the physician for agitation. A care plan, last updated on [DATE], documented, "Problem:... has an alteration in her mood and behaviors as evidenced by asking repetitive questions, being verbally abusive, resisting care and exhibiting socially disruptive behaviors... Approach:... monitor and document behaviors q shift... notify physician of changes in mood and behavioral symptoms..." The care plan did not address pain. A nurse's note, dated [DATE] at 3:00 p.m., documented, " [MEDICATION NAME] 5 mg po for (increased) agitation/anxiety. Calling out, 'I don't know what to do with myself.' Tried to engage in activities but continued c anxiety..." At 4:40 p.m., nurses' notes documented, "By (4:00 p.m.) resident has less crying out and less worried behaviors. By (4:30 p.m.) able to join in for snack and no further calling out..." At 7:00 p.m., nurses' notes documented, "(Increased) anxiety/pacing. Telling staff she doesn't know what to do..." The resident was not offered any [MEDICATION NAME] for anxiety or agitation. A nurse's note, dated [DATE] at 10:00 a.m., documented, "Ambulating back and forth. Very anxious. PRN [MEDICATION NAME] 5 mg po..." At 2:00 p.m., nurse's notes documented, "Has been less anxious p AM [MEDICATION NAME]. Some anxiety still remains...." The resident was not offered any more [MEDICATION NAME] for anxiety on that date. A nurse's note, dated [DATE] at 12:00 a.m., documented, "Resident remains up pacing and sitting in w/c. Refuses to go to bed... Very confused. [MEDICATION NAME] ineffective for behavior. Grabs staff and has hit them. Went to bed about 2 AM..." At 8:25 p.m., nurses' notes documented, "Exhibiting s/s anxiety/agitation. Pacing, weeping. [MEDICATION NAME] 5 mg po usually ineffective for behavior..." At 9:30 p.m., nurses' notes documented, "In bed @ present. (no complaints)..." A nurses' monthly summary, dated February 2011, and signed as completed by LPN #2, documented the resident had the following indicators of depression and anxiety: "... makes negative statements, repetitive questions, repetitive calling out for help, expressing unrealistic fears, unpleasant mood in the mornings, crying and tearfulness, repetitive physical movements, repetitive anxious complaints/seeks attention, sad, pained, worried facial expression, reduced social interaction, withdrawal from activities of interest, wanders, verbally abusive, physically abusive, socially inappropriate/disruptive behavior, resists care... Comments: ... yelling more, pretend crying sounds, hitting has increased in the last month. Decline thought to be UTI - (antibiotic) given (no changes) in behaviors or decline..." There was no documentation in the clinical record that the physician was notified of the resident's anxiety and agitation requiring the use of prn medication. The February 2011 nurses' monthly summary also documented the resident experienced moderate pain daily. A nurses' note, dated [DATE] at 6:45 p.m., documented, "...Still c/o ankle pain..." The resident was not offered prn Tylenol as ordered for pain. A nurse's note, dated [DATE] at 8:05 a.m., documented, "Tylenol... c/o L ankle pain (no) relief voiced - cont to c/o discomfort throughout the day... Using w/c occas throughout the day, she goes & gets it..." A nurse's note, dated [DATE] at 7:35 p.m., documented, "Tylenol given for Lt ankle pain..." A nurse's note, dated [DATE] at 7:45 p.m., documented, "c/o Lt ankle pain. (Tylenol) given..." A nurse's note, dated [DATE] at 9:25 a.m., documented, "... c/o legs hurting this am. PRN Tylenol po..." A nurse's note, dated [DATE] at 7:00 a.m., documented, "Resident's gait has a limp and she is complaining of leg pain, administered Tylenol..." A nurse's note, dated [DATE] at 9:00 a.m., documented, "Resident is still complaining of pain... encouraged resident to recline in bed c feet and legs elevated..." A nurse's note, dated [DATE] at 2:30 p.m., documented, "Still c/o leg and ankle pain administered Tylenol..." A nurse's note, dated [DATE] at 5:00 p.m., documented, "Resident is still not receiving any relief from pain..." There was no documentation in the medical record the physician was notified about the resident's persistent pain and the frequent use of prn pain medication without relief. By [DATE], the resident had complained of worsening pain over a 15 day period. A nurse's note, dated [DATE] at 1:30 p.m., documented the resident was seen by the physician for c/o shoulder and ankle pain, and new pain medication orders were received. On [DATE] at 2:30 p.m., LPN #2 was asked why prn [MEDICATION NAME] was not offered to the resident when she experienced anxiety or agitation. She stated the [MEDICATION NAME] was for severe agitation and anxiety. She was asked if the resident had demonstrated severe agitation and anxiety. She stated, "I suppose so." She was asked why the [MEDICATION NAME] was not given. She stated the [MEDICATION NAME] really did not work. She was asked to review the nurses' notes that documented when [MEDICATION NAME] was given, it was effective. She made no comment. She was asked why [MEDICATION NAME] was not given up to three times a day as ordered. She stated she believed it would sedate the resident. She was asked if the resident had demonstrated sedation after receiving [MEDICATION NAME]. She made no comment. She was asked if the physician had been notified about the resident's agitation and anxiety. She stated, "I don't document everything I do." She was asked why, if the resident was experiencing almost daily pain that was not relieved by Tylenol, the physician was not notified until [DATE]. She stated she couldn't answer that.

Based on observation, review of clinical record, and staff and resident interviews, the facility failed to ensure a resident who complained of pain was assessed and medicated, and was not neglected when a complaint of pain was made for one (#3) of one resident who did not receive pain medication when a complaint of pain was made. This had the potential to affect 51 residents identified by the facility as having pain. Findings: Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. admission orders Tylenol Extra Strength 1000 mg po bid for pain..." An initial resident assessment, dated 02/16/11, documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent for transfers, did not ambulate and was always incontinent of bowels and bladder. The assessment documented the resident had not had pain in the last five days. A care plan, dated 02/16/11, was reviewed. There was no care plan which addressed pain or pain management. The March 2011 MAR from Rogers Home, did not have the order for routine Tylenol transferred onto it from the admission orders [REDACTED]. The MAR indicated No routine or prn Tylenol was documented as being given since the resident's transfer to Rogers Home on 03/21/11. A physician's progress note, dated 03/03/11, documented, "...S: (Resident) is kind of hurting all over still, but that has been her main complaint...A: 6) Chronic pain is mostly [MEDICAL CONDITION] and partially dementia, will hold the course with that..." A pain assessment, dated 03/21/11, documented, "...Pain Location: Everywhere Date of onset: Unable to state Cause of pain: Does not know... Non-verbal Indicators: Grimacing... readmitted from SNF. Asked how she is doing and she said, 'Not very good.' She has no idea what caused the pain, what makes it worse etc. Tried to get a level of pain et she said it was 'bad.'" On 03/22/11 at 4:45 p.m., the resident was observed as she sat in her wheelchair in her room. She was asked by the surveyor how she was feeling. She stated, "Hurts all over." The resident was noted to have a grimace on her face. LPN #2 was outside the resident's room. She was told the resident had complained that she hurt all over. LPN #2 stated, "Oh, she says that every five minutes." She went on to state the resident was probably having some pain as she had [MEDICAL CONDITION]. The LPN did not provide medication for the resident or assess the resident for pain. At 4:50 p.m., the resident received incontinent care as she stood with the sit to stand lift. The resident screamed repeatedly, "I can't do it." The surveyor asked during the procedure if she was in pain. The resident stated, "Yes. I can't stand it." When the incontinent care was completed, CNA #1 asked the resident, "Was that too bad?" The resident stated, "Yes." At 5:00 p.m., LPN #2 was asked if the resident could receive something for pain. She stated the resident had routine pain medication. The LPN was asked if the resident had prn pain medication. She stated she thought the resident had Tylenol ordered prn. She stated she knew when the resident was in pain, as the resident would scream, hit, throw things and swear. She was informed the resident had been screaming during incontinent care. No comment was made. The LPN was asked if she believed the resident when she said she was in pain. Again, no comment was made. At that time, the LPN checked the resident's MAR. She stated the resident should be on routine Tylenol bid, but it was not on the MAR indicated [REDACTED]. The resident had not received her routine Tylenol for two days. The LPN was asked if the resident could receive her prn Tylenol. She stated, "Yes, we will give her some." At 5:15 p.m., the DON was informed the LPN had been told of the resident's complaint of pain at 4:50 p.m., and that the resident had not been assessed for pain or medicated at that time. The DON stated, "She should have given her medication and assessed her." On 03/23/11 at 2:10 p.m., CNA #1 was asked if the resident was in pain during incontinent care the day before. She stated she might have been in a little bit of pain as she yelled when she was in pain. The CNA acknowledged the resident had been yelling.

Based on observation, review of clinical record, and staff and resident interviews, it was determined the facility failed to ensure residents were not left standing on the sit to stand lift while incontinence care was provided for one (#3) of three sampled residents who used the sit to stand lift for transfers. This had the potential to affect 19 residents identified by the facility who used the sit to stand lift for transfers. Findings: Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. An initial resident assessment, dated 02/16/11, documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent for transfers, did not ambulate and was always incontinent of bowels and bladder. A care plan, dated 02/16/11, documented: "Problem: (Resident) has altered ADL/mobility which places resident at risk for falls, skin breakdown, and contracture r/t [MEDICAL CONDITION] and general decline in physical ability. Goals: (Resident) will be assisted with ADL tasks, have reduced falls and injuries, develop no pressure ulcers and maintain present ROM and ability to ambulate and participate in ADL's daily x 90 days. Approach: 1. Encourage and assist (resident) to reposition in bed q 2 hrs and as needed. 2. Use siderails to assit (sic) with bed mobility. 3. Encourage (resident) to ask for help (use call light) for assist with transfers and ambulation...13. Assist with toileting hygiene and incontinence care as needed. 14. Assist with changing incontinence briefs as needed..." There was no care plan in place which documented the resident used a sit to stand lift for all transfers. On 03/22/11 at 4:45 p.m., the resident was observed as she sat in her wheelchair in her room. She was asked by the surveyor how she was feeling. She stated, "Hurts all over." The resident was noted to have a grimace on her face. LPN #2 was outside the resident's room. She was told the resident had complained that she hurt all over. LPN #2 stated, "Oh, she says that every five minutes." She went on to state the resident was probably having some pain as she had [MEDICAL CONDITION]. The LPN did not provide medication for the resident or assess the resident for pain. At 4:50 p.m., CNA #1 and CNA #2 were observed as they provided incontinent care for the resident. They entered the room with the sit to stand lift and placed the lift in position in front of the resident. After securing the lift straps around the resident's back and under her arms, the resident was lifted to a standing position. During this procedure the resident screamed, "Ouch" and "I can't do it." The resident was left in the sit to stand lift while the two CNAs proceeded to provide incontinent care for both bowels and bladder. The incontinent care took approximately ten minutes to perform. The resident was left in the sit to stand lift the entire time. Throughout the procedure the resident repeatedly screamed, "I can't do it." The surveyor asked the resident if she was in pain. The resident stated, "Yes. I can't stand it." The resident attempted to lower herself down onto her wheelchair, but was unable to due to the lift. When the resident's incontinent care was completed, CNA #1 asked the resident, "Was that too bad?" The resident stated, "Yes." At 5:15 p.m., the DON was informed of the observation. He stated, "My thought is the lift should be used for transfers only." He stated the facility had just recently had an inservice on lifts. He stated the CNAs should not have done pericare while the resident was on the lift and it should have been done in bed. On 03/23/11 at 2:10 p.m., CNA #1 was asked if the resident was in pain during the incontinent care. She stated the resident might have been in a little bit of pain as she yelled when she was in pain. She was asked if providing incontinent care in the lift was appropriate. She stated, "We probably should have put her in bed." She was asked if she provided other residents with incontinent care while in the sit to stand lift. She stated it was routine to change some residents in the lift as it was the easiest way to do it if they were just wet. She was asked if she had been inserviced on how to use the lift. She stated she learned while she was working on the floor and had received no formal training. CNA #1's and CNA #2's personnel files were reviewed. There were no skills check list located in the files which would show the CNAs were familiar and trained on the sit to stand lift. Inservice records were reviewed. An inservice on lifts was conducted on 08/05/10. CNA #2 had attended the inservice. CNA #1's name was not on the sign in sheets. On 03/25/11 at 2:15 p.m., the Human Resources Coordinator was asked if they had documentation of a skills checklist for CNA #1 and CNA #2. She stated they had just started doing the skills checklist this month on new employees.