Every finding on record at Harrah Nursing Center

Based on record review and interview, the facility failed to ensure medical records were provided to a resident's representative and legal representative within 48 hours of request for 1 (#1) of 3 sampled residents reviewed for release of medical records.The director of nursing identified 68 residents resided in the facility. Findings: A Release of Information policy, dated 11/01/09, read in part, All information contained in the resident's medical record is confidential and may only be released by the written consent of the resident or his/her legal representative, consistent with state laws and regulations.A resident may obtain photocopies of his or her records by providing the facility with at least forty-eight hours' advance notice of such request.A discharge summary for Resident #1, dated 11/16/26, showed the resident admitted to the facility on [DATE] with diagnosis of deep vein thrombosis. The discharge summary showed the resident discharged from the facility on 11/10/25.A release of confidential information consent form for Resident #1, dated 12/19/25, showed the form was signed by the resident's representative.A copy of Resident #1's medical records, provided by family member #1, showed the records were printed on 12/29/25.A fax coversheet, dated 01/12/26, showed a records request from a lawyer's office.A written note provided by the administrator, dated 03/31/26 at 8:53 p.m., showed a call from a lawyer's office reporting they had made a second request for medical records on 02/03/26. A facility letter to the lawyer's office, dated 03/31/26, showed medical records for Resident #1 were sent on 03/31/26.On 04/29/26 at 4:35 p.m., family member #1 stated the family had issues with getting copies of Resident #1's medical records. Family member #1 stated family member #2 had requested Resident #1's medical records on 12/19/25 and did not receive the records until 01/02/26. Family member #1 stated the lawyer's office requested the resident's medical records from the facility on 01/12/26, 02/02/26, and 03/31/26. Family member #1 stated the lawyer's office did not receive the medical records until after the third request on 03/31/26.On 05/01/26 at 10:31 a.m., the administrator stated medical records should be released twenty-four to forty-eight hours after the release of information is signed. The administrator stated they did not know when the records were requested or released. The administrator stated they were told by the resident's representative it was no hurry in getting the records to them. The administrator stated the medical records were sent to the lawyer's office on 03/31/26, and they believed it was the second request from the lawyer's office.On 05/01/26 at 11:04 a.m., the administrator stated they found the records release signed by the resident's representative dated 12/19/25. The administrator stated there was no documentation of when the records were picked up by the resident's representative or when the lawyer's office had first requested the medical records.On 05/01/26 at 1:30 p.m., family member #2 reported they did not tell the facility it was no hurry on getting the medical records.

Based on record review and interview, the facility failed to ensure a resident's representative was notified of a newly prescribed medication for 1 (#2) of 3 sampled residents reviewed for notification of changes. The administrator identified 65 residents resided at the facility. Findings: An undated admission record for Resident #2 showed the resident had a family member listed as the power of attorney, the responsible party, and emergency contact #1. An annual assessment for Resident #2, dated 10/18/25, showed the resident had diagnoses which included non-Alzheimer's dementia and senile degeneration of the brain. The assessment showed Resident #2 was dependent on the staff for all activities of daily living and was severely cognitively impaired. A nurse practitioner's progress note, dated 11/20/25, showed Resident #2 was prescribed sertraline (an anti-depressant) 25 milligrams once daily for mood. A nurse's progress note, dated 11/21/25, showed Resident #2 continued on sertraline with no adverse reactions noted. There was no documentation Resident #2's representative had been notified of the new medication. On 01/14/26 at 1:37 p.m., the director of nursing stated the nurse that had taken the new order for the sertraline had not reached out to Resident #2's representative to inform them of the new medication order, as it was not documented.

Based on record review and interview, the facility failed to ensure the fall policy was implemented for one (#37) of three sampled residents reviewed for accidents. The administrator identified 72 residents resided in the facility. Findings: A Fall policy, dated March 2018, documented the physician would identify medical conditions affecting the fall risk. It documented the staff and the physician would identify possible causes of falls within 24 hours. It documented the staff and the physician would identify pertinent interventions to try and prevent further falls. It documented the staff and the physician would monitor and document the individual's response to interventions. Resident #37 had diagnoses which included dementia, anxiety, and concussion. An Annual assessment, dated 05/29/24, documented Resident #37's cognition was severely impaired. It documented they were independent with bed mobility and ambulation. It documented the resident had two falls since the prior assessment. A Fall Risk assessment, dated 10/19/24, documented Resident #37 was at high risk for falls. A facility Incident Report, dated 10/30/24, documented the resident tripped over the base of a mechanical lift. It documented the intervention was for the equipment to be removed from the hallway. A Fall Risk assessment, dated 11/06/24, documented Resident #37 was at high risk for falls. A facility Incident Report, dated 11/06/24, documented the resident was observed laying on the floor in the hallway next to a mechanical lift. It documented to maintain a clear and clutter free pathway. A Fall Risk assessment, dated 11/16/24, documented Resident #37 was at high risk for falls. A facility Incident Report, dated 11/16/24, documented the resident was laying on the floor with a skin tear to their right forearm. An intervention was not documented. A Fall Risk assessment, dated 12/07/24, documented Resident #37 was at high risk for falls. A facility Incident Report, dated 12/07/24, documented the resident was laying on the floor with a laceration to the right side of their head. An intervention was not documented. On 01/28/25 at 1:46 p.m., Resident #37 was observed with an area to the right side of the head. The area was quarter sized, slightly raised, and had dry blood. The top of the resident's right hand had green and yellow bruising. On 01/28/25 at 3:06 p.m., the DON stated when a resident had a fall, the staff tried to figure out what happened. The DON stated they would implement interventions after a fall. The Incident Reports, dated 10/30/24 and 11/06/24, were reviewed with the DON. They stated they had repeated similar interventions. The DON was asked if the staff were to remove the equipment from the hallway on 10/30/24, and the resident was observed laying next to the lift on 11/06/24, was the intervention effective. They stated, No. The Incident Report, dated 11/16/24, was reviewed with the DON. They were asked what the intervention was for the fall. They stated there was not one documented. The Incident Report, dated 12/07/24, was reviewed with the DON. They stated the resident's medications were reviewed. The DON was asked where the intervention regarding the medication review was located. They stated they did not see it. They stated they just looked at the medication, but did not request any reduction. On 01/28/25 at 3:32 p.m., the DON was asked if they were familiar with the fall policy. They stated they were. The DON was asked if the physician identified any medical condition affecting Resident #37's fall risk. They stated the physician had not. The DON was asked if the staff and practitioner identified the possible cause of the fall within 24 hours of Resident #37's falls. They stated, No. The DON was asked if the staff and physician identified pertinent interventions to try and prevent further falls for Resident #37. They stated, No. The DON was asked if the staff and physician documented monitoring of the response to interventions related to Resident #37. They stated, No. They were asked if the fall policy had been followed. They stated, No.

Based on observation, record review, and interview, the facility failed to ensure residents were assisted with incontinent care for one (#19) of one sampled resident reviewed for ADL care. The administrator identified 72 residents resided in the facility. Findings: An ADL policy, dated March 2018, documented residents who were unable to carry out ADLs independently would receive services to maintain good personal hygiene. Resident #19 had diagnoses which included muscle weakness and need for assistance with personal care. A Care Plan, dated 10/31/24, documented to check Resident #19 every two hours and provide incontinent care as needed. An Admission assessment, dated 11/20/24, documented Resident #19 had moderate cognitive impairment. It documented they had impairments to both lower extremities, were frequently incontinent of urine, and was dependent on staff for toileting. On 01/28/25 at 8:14 a.m., Resident #19 was observed laying in their bed. They stated a staff member came in at 1:30 a.m., and stated they would be back to change them, but never came back. A strong urine odor was smelled in the resident's room. On 01/28/25 from 8:17 a.m. to 8:41 a.m., CNA #1 was observed to provide incontinent care to Resident #19. Resident #19's brief was observed saturated with urine. The resident's shirt, bed pad, and fitted sheet were observed wet. The pillow case and mattress under Resident #19 were observed wet. While CNA #1 was cleaning Resident #19, Resident #19 stated, I don't think I have ever been this wet. On 01/28/25 at 8:56 a.m., CNA #1 stated Resident #19 had never been that wet when they had changed them. CNA #1 stated Resident #19 should have been changed about 5:00 a.m. this morning, but Resident #19 stated they had not been changed all night. CNA #1 stated Resident #19 was incontinent, but could tell the staff when they needed to be changed. On 01/30/25 at 9:04 a.m., the DON stated staff were to check and change residents every two hours and as needed.

Based on record review and interview, the facility failed to notify a resident's representative of changes with medications for one (#38) of one sampled resident reviewed for notification of change. The administrator identified 72 residents resided in the facility. Findings: Resident #38 had diagnoses which included anxiety disorder and osteoarthritis. A Third Party Facility Communication Form, dated 01/20/25, documented Resident #38's morphine (a narcotic) and Ativan (a benzodiazepine) was discontinued. There was no documentation the resident's representative was notified of the changes. On 01/27/25 at 2:56 p.m., Resident #38's family member stated the facility staff never contacted them with changes. On 01/30/25 at 8:33 a.m., LPN #1 stated they were to notify the resident's representative when there were medication changes. They stated if they received a third part communication form, they were to input the orders and notify the resident's representative. On 01/30/25 at 8:36 a.m., LPN #1 was asked to review Resident #38's third part communication form and was asked if the resident's representative had been notified of the changes. They stated they did not locate where the resident's representative had been notified.

Based on record review and interview, the facility failed to ensure the resident's code status matched in the EHR and hard chart for one (#8) of 24 sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 10/16/23, documented 73 residents resided in the facility. Findings: Resident #8 had diagnoses which included personal history of transient ischemic attack. A DNR consent form, dated 08/22/22, was signed by Resident #8. A Physician's Order, dated 11/29/22, read in part, .Full Code . On 10/17/23 at 11:37 a.m., LPN #1 was asked how staff identified residents' code status. They stated the code status was in the hard chart and in the EHR. LPN #1 was asked what was Resident #8's code status. They were observed to look in the computer and stated the resident was a full code. LPN #1 was asked to look Resident #8's hard chart. They were observed to look in the resident's hard chart and stated the resident had a DNR. LPN #1 was asked if the code statuses matched. They stated No.

41318 Based on record review and interview, the facility failed to provide CPR for one (#69) of one sampled resident reviewed for death. The Resident Census and Conditions of Residents report, dated [DATE], documented 73 residents resided in the facility. Findings: A Do Not Resuscitate Order policy, revised [DATE], read in part, .Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect .Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record .Use only State approved DNR forms . Resident #69 had diagnoses which included dementia. A Physician's order, dated [DATE] at 3:27 p.m., documented Resident #69 was a Full Code. A Progress note, dated [DATE], documented the resident was admitted to hospice. A Progress note, dated [DATE], documented the resident had no apical pulse or respirations at 4:55 p.m. It documented the staff called hospice who contacted the family and the funeral home. There was no documentation of CPR was performed. On [DATE] at 12:39 p.m., the ADON stated she didn't see any documentation CPR had been performed on Resident #69. 46653

Based on record review and interview, the facility failed to refer a resident with a newly evident mental disorder to OHCA for a level II evaluation for one (#13) of one sampled resident reviewed for PASRR level II evaluations. The Resident Census and Conditions of Residents report, dated 10/26/23, documented 73 residents resided in the facility. Findings: The facility's Behavioral Assessment, Intervention and Monitoring policy, not dated, read in part, .new onset or changes in behavior that indicate newly evident or possible serious mental disorder .will be referred for a PASRR Level II evaluation . Res #13 was admitted with diagnoses of dementia. On 04/09/19 the resident was diagnosed with bipolar disorder. There was no documentation the OHCA had been notified of the resident's new diagnosis to see if a level II PASRR was required. On 10/19/23 at 1:52 p.m., the DON stated another PASRR should be completed when there was a change of diagnosis or a new diagnosis of a behavioral diagnosis. On 10/19/23 at 1:59 p.m., the DON stated the social worker would have been the first to review the readmission documentation. On 10/19/23 at 2:04 p.m., the DON stated social services would know from the diagnosis to contact the PASRR people (OHCA). The DON stated, With the bipolar [the resident] should have had another PASRR.

Based on record review, observation and interview, the facility failed to maintain safe water temperatures (less than 120 degrees) for: a. one (#25) of 57 sampled residents whose handwashing sink was checked for unsafe water temperatures, and b. one of three shower rooms checked for unsafe hot water temperatures. The DON identified 20 residents who used the shower on Hall A and 66 residents resided in the facility. Findings: A Water Temperatures policy, revised 2009, read in part, .Water heaters that service resident rooms, bathrooms, common areas, and tub/showers shall be set to temperatures of no more than 120 [degrees Fahrenheit] .If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor . Res #25 had diagnoses which included muscle weakness, high blood pressure and anxiety. A quarterly assessment, dated 11/02/22, documented Res #25 was cognitively intact. A Hot Water Temperatures-Weekly Test, dated July 11-15, 2022, documented Resident #25's hot water temperature was recorded at 127 degrees F. A Hot Water Temperatures-Weekly Test, dated September 5-8, 2022, documented Res #25's hot water temperature was recorded at 124 degrees F. A Hot Water Temperatures-Weekly Test, dated October 10-14, 2022, documented hall A shower room hot water temperature was at 122 degrees F. On 11/02/22 at 11:19 a.m., Res #25's handwashing sink hot water was temped at 124.7 degrees F. On 11/02/22 at 3:46 p.m., Res #25 was asked, does your water in the handsink get too hot. Res #25 stated, You bet it does. They were asked, do you recall who you have told. They stated, I don't use the hot water. I use the cold because I am afraid I am going to burn my self. They stated, You could burn yourself very easy. Res #25 was asked how often the water temperature was checked. Res #25 stated they come in and check the water about once a month. On 11/02/22 at 4:10 p.m., Maintenance #1 was asked what hot water temperatures should be. They stated they were unsure. They stated they had just started and had been told to check the temperatures and fill out the temperature logs. On 11/02/22 at 4:14 p.m., the Administrator was present when Res #25's handwashing sink was tested , it was 121-122 degrees F. On 11/03/22 at 8:18 a.m., hall A shower room temperatures were obtained. The handwashing sink temped at 128.9 degrees F and the shower temped at 124.0 degrees F. On 11/03/22 at 9:15 a.m., Maintenance #2 was observed to check the hot water temperature in hall A shower. The handsink temped at 127 degrees F and the shower temped at 124 degrees F. On 11/04/22 at 7:47 a.m., the DON was asked what was a safe hot water temperature. They stated, The policy says 120 for hot water. The July and September 2022 documentation of water temperature logs that were outside the recommended range were reviewed for Res #25's room and hall A shower. The DON was asked what should have been done at that time. They stated, whoever checked them should have reported it.

Based on record review and interview, the facility failed to ensure the DON did not work as a charge nurse when the facility census was more than 60 residents. The Resident Census and Conditions of Residents report, dated 11/01/22, documented 66 residents resided in the facility. Findings: A shift Center Deployment Projection Sheet documented the DON worked as a charge nurse on the following days: 08/14/22 Census 64 08/16/22 Census 64 08/20/22 Census 64 08/22/22 Census 65 09/03/22 Census 66 09/12/22 Census 64 09/14/22 Census 66 09/15/22 Census 67 On 11/04/22 at 2:28 p.m., the DON was asked when was the last time they had worked as a charge nurse. The DON stated in August or September.

Based on observation and interview, the facility failed to ensure staff used sanitary measures when assisting residents during meal service for three (#4, #45, and #11) of all residents observed during dining service. [NAME] and Kit-did we make anyone aware of staff touching foods? did you interview the staff that touched the food Findings: A DINING AND FOOD SERVICE policy, undated, read in parts, . Residents will be provided with nourishing, palatable, attractive meals that meet the residents daily nutritional and special dietary needs. Each resident will be provided with service to maintain or improve eating skills. The dining experience will enhance the residents quality of life and be supportive of residents needs during dining . On 11/01/22 at 12:11 p.m., CMA #1 was observed handling Res #4's roll with their bare hands. On 11/01/22 at 12:12 p.m., CMA #1 was observed holding Res #45's sandwich with their bare hands and cutting it with a knife. CMA #1 then began picking up pieces of the sandwich with their bare hands and putting them in Res #45's mouth. CMA #1 was observed touching their face mask while feeding Res #45. On 11/01/22 at 12:30 p.m., CMA #1 was observed to handle a roll without using gloves and began to feed Res #11. CMA #1 did not wash her hands or use sanitizer between residents. On 11/04/22 at 8:27 a.m. DON was asked what the policy was for assisting residents with meals. The DON stated, Clean hands. We don't wear gloves when feeding residents. The DON was asked the protocol for washing hands while assisting a resident to eat. The DON stated, Don't wear gloves when feeding, they wash their hands, and only handle food with utensils. On 11/04/22 at 8:40 a.m. CMA #1 was asked the protocol with washing hands or using gloves while assisting a resident to eat. CMA #1 stated, We use wipes and sanitize hands, only handle food with utensils. On 11/04/22 at 8:55 a.m. ADON was asked the policy for assisting residents with meals. The ADON stated, Do not touch food with bare hands.

Based on record review, observation, and interview, the facility failed to implement weight loss interventions for one (#55) of three sampled residents reviewed for weight loss. The Resident Census and Conditions of Residents report, dated 11/01/22, documented four residents with unplanned significant weight loss/gain. Findings: A Dietitian policy, revised October 2017, read in parts, .A qualified, competent, and skilled dietitian will help oversee the food and nutrition services in the facility . Res #55 had diagnoses which included, dysphagia and muscle weakness. A resident assessment, dated 07/07/22, documented Res #55 was cognitively intact. A Dietitian's Recommendations to Nursing and Dietary, dated 05/16/22, read in parts, .REC: house supplement TID d/t BMI 17 .notify PCP . A Post Radiologic Dysphagia Evaluation Orders, dated 05/25/22, read in parts, .noted: mild stasis, reverse peristalsis, and delayed emptying . Monthly Nutrition/Dietary Notes for June, August, and September 2022 were documented by the DM. There was no documentation Res #55 had been evaluated by the dietitian monthly from 05/16/22 until 10/10/2022. The clinical record had no documentation Res #55's weight had been assessed by the dietitian or the dietary manager in July. Res #55 had a 13.29 percent weight loss from 05/18/22 to 10/31/22. Resident #55's Weights and Vitals Summary report documented the following weights: 10/31/22 90.0 Lbs 10/28/22 90.0 Lbs 10/27/22 89.8 Lbs 10/18/22 91.4 Lbs 10/13/22 92.4 Lbs 10/7/22 92.8 Lbs 9/21/22 99.4 Lbs 8/15/22 99.4 Lbs 7/20/22 97.6 Lbs 6/8/22 105.8 Lbs 5/25/22 105.2 Lbs 5/19/22 104.0 Lbs 5/18/22 103.8 Lbs A Dietician Nutrition/Dietary Note, dated 10/10/22 at 10:37 a.m., read in parts, .92.8# Oct wt. Sig wt loss x 1 mo (6.6%). PCP aware. Mech soft/ground meat diet. The following started (10/7): house shake TID; Med Pass BID; HS snack of sandwich. PO Intake avg 50-75% x most meals .BMI: 15. Continue care . On 11/01/22 at 9:51 a.m., Res #55 was asked if they had any weight loss. They stated, Yes, I need to have my throat stretched. I can't swallow good, they grind my meat. On 11/03/22 at 1:43 p.m., the DON was asked when the order for Medpass and health shakes had been implemented. The DON stated Medpass was started on 10/07/22 and that the regular health shakes were stopped and changed to protein shakes on 10/07/22. The DON was asked was there any interventions implemented for August and September? The DON stated, If I didn't have that put into place at that time I probably should have done that. On 11/03/22 at 2:04 p.m., the DM was asked if Res #55 had been seen by the dietitian in July. The DM stated, The dietitian did it remotely instead of coming in and did not see the resident. On 11/04/22 at 8:26 a.m., the DM was asked how often the dietitian comes in. The DM stated one time a month. The DM was asked why Res #55 had not been seen by the dietitian in June, July, August or September 2022. The DM stated, I am not sure.

Based on record review, observation, and interview, the facility failed to ensure the physician order was followed when administering medications for one (#27) of one sampled resident reviewed for medication administration via the enteral route. The DON reported two residents had enteral tubes. Findings: Res. #27 had diagnoses which included, gastrostomy (feeding tube), and dysphagia (trouble swallowing) A physician order, dated 03/23/22, read in parts, .Jevity 1.0 60 ml/hr continuous for 20hrs, turn off feeding from 10:00 am [a.m.] to 2:00pm [p.m.]. 50 ml flush every 4 hours every shift for nutrional needs .FYI-- MAY COCKTAIL MEDICATIONS FYI-- MAY GIVE 120ML OF H20 BEFORE AND AFTER MEDS every shift . On 11/04/22 at 9:33 a.m., LPN #3 was observed to have a cup that contained about a half an inch of reddish liquid that they identified as Res #27's medications sitting on the medication cart. LPN #3 entered the room and was observed to fill two cups of water with 120 ml of water and add more water to the already diluted medication cup. LPN #3 auscultated the abdomen for tube placement, then began to administer the first cup of water flush, then the cup of diluted medications. Res #27 began to cough, clear fluid was observed to drip out of the resident's mouth, the resident was heard to clear their throat. The nurse stopped for a few seconds, then began to flush with the last cup of water. On 11/04/22 at 10:43 a.m., LPN #3 was asked how much water was given with the medications. LPN #3 stated, 140 ml's. On 11/04/22 2:41 p.m., the DON was informed the nurse was observed to give 120 ml water before, 140 ml with meds, and 120 ml's after the medications. The DON was asked if the physician order stated may cocktail medications, may give 120 ml before and 120 ml after meds, should the nurse have given 140 ml water mixed with the residents medications. The DON stated, No, but there needs to be enough water to mix the medications.

Based on record review, observation, and interview, the facility failed to ensure a. enteral nutrition equipment was labeled with information for one (#27) of one sampled resident reviewed for enteral nutrition. b. that an excessive amount of fluid was not administered when staff was observed administering bolus water. The DON reported two residents received enteral nutrition. Findings: A Gastrointestinal Conditions policy, revised November 2018, read in parts, .Initiate Feeding .On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order . Res. #27 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 03/23/22, read in parts, .[MEDICATION(S)] 1.0 60 ml/hr continuous for 20hrs, turn off feeding from 10:00 am [a.m.] to 2:00pm [p.m.]. 50 ml flush every 4 hours every shift for nutrional needs .03/23/22 FYI-- MAY COCKTAIL MEDICATIONS FYI-- MAY GIVE 120ML OF H20 BEFORE AND AFTER MEDS every shift . On 11/03/22 at 8:31 a.m., Resident #27's tube feeding was observed running at 60 ml/hr. There was no start date on the bag of [MEDICATION(S)] or the bag of water flush. On 11/03/22 at 2:51 p.m., Res #27's bag of [MEDICATION(S)] and water/flush had no documentation when the enteral feeding and water flush had been started. On 11/03/22 at 3:22 p.m., Res #27's enteral feeding was observed with the DON. The DON stated, The bags aren't marked. The DON was asked what the process was for administering the enteral feeding. They stated everything is new and the items should be dated, with the nurse initials. The DON was asked if the [MEDICATION(S)] hanging was new. They stated, I don't know, they start the [MEDICATION(S)] at 6 a.m. The DON was asked if this bag had been started this morning. They stated, I don't know. The DON was asked what should be on the bag of [MEDICATION(S)]. They stated, Should have a sticker with room number, formula, date, time and nurse initials. On 11/04/22 at 9:33 a.m., requested to observe the discontinuation of enteral feeding and ostomy site. LPN #3 was observed to have a cup that contained about a half an inch of reddish liquid that they identified as Res #27's medications sitting on the medication cart. LPN #3 entered the room and was observed to fill two cups of water with 120 ml of water and then add more water to the red liquid. LPN #3 auscultated the abdomen for tube placement, then began to administer the first cup of water flush, then the cup of red liquid. Res #27 began to cough, clear fluid was observed to drip out of the resident's mouth, the resident was heard to clear their throat. The nurse stopped for a few seconds, then began to flush with the last cup of water. On 11/04/22 at 10:43 a.m., LPN #3 was asked how much water was given with the reddish fluid. LPN #3 stated, 140 ml's. On 11/04/22 2:41 p.m., the DON was informed the nurse was observed to give 120 ml water before, 140 ml with the red liquid, followed by an additional 120 ml's of water. The DON was asked if the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Should the nurse have given 140 ml of fluid with the reddish liquid (medications). The DON stated, No, but there needs to be enough water to mix the medications. .

Based on record review and interview, the facility failed to assist the resident in making appointments for dental referrals for one (#42) of one sampled resident reviewed for dental services. The Resident Census and Condition of Residents report, dated 11/01/22, documented 66 residents resided in the facility. Findings: Res #42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #42 received eloquis and apixiban daily for anticoagulation therapy. Clinical Notes from dental visit, dated 03/10/22, read in part, .Reports pain in LR gingival tissue and UR teeth .states [res #42] has not been for a consult visit with [Facility Name] yet, but does wish to do so .RECOMMENDATIONS/ORDERS .please schedule patient for consult with [Facility Name] Oral Surgery .evaluation for extraction . There was no documentation in Res #42's clinical record of attempts to schedule consult with [Facility Name] Oral Surgery following dentist visit of 03/10/22. Clinical Notes from dental visit, dated 10/31/22, read in part, .Bedside Exam- Severe Decay: 3, 11-13, 14, 15, 30, 31- Broken: 28, 29, 4, 5, 7, 13, 14 .the left side of my jaw is hurting .has some swelling .posterior to where there are teeth .Pt needs to see an OR [unknown abbreviation] or a medical field to have a [NAME] completed to reveal any abcessed, or inflamed ect .Referral slip left at [SSD's] door . There was no documentation in Res #42's clinical record of attempts to schedule visit with OR or a medical field to have a [NAME] completed following dentist visit of 10/31/22. On 11/02/22 at 9:47 a.m., Res #42 reported having occassional mouth pain because of several broken and decaying teeth. When asked if this had been reported to nursing staff, Res #42 stated, I saw the dentist a while ago and [dentist] said they would get [SSD] to set up an appointment for me, but [SSD] never got back with me. I had another appointment the other day cause my mouth still hurts sometimes. Res #42 was asked if the SSD had spoken to them since their latest dentist appointment on 10/31/22. Res #42 stated, No, [SSD] just blows me off. On 11/03/22 at 2:45 p.m., the SSD was asked when Res #42 was last seen by the dentist. The SSD replied, I believe it was around 11/01/22. I was out that day. They were asked if Res #42 had received orders following visit. The SSD stated if the dentist had ordered nanything it would be in the visit note. They stated they had reviewed the note, but didn't see any orders. The SSD was asked if arrangements had been made for Res #42 to see an OR or a medical field to have a [NAME] completed as recommended by the dentist on 10/31/22. The SSD stated, No, I was out but I am working on it. On 11/03/22 at 3:20 p.m., the SSD was asked if an [Facility Name] Oral Surgery consult was completed as ordered following Res #42's annual dentist visit on 03/10/22. The SSD stated, No, because they require that resident's POAs accompany them and Res #42's POA is very incapacitated. When asked if any arrangements had been made with the POA to have the resident seen by [Facility Name] Oral Surgery as ordered, the SSD stated, no. When asked what other arrangements had been attempted to facilitate Res #42's consult with [Facility Name] Oral Surgery that was ordered 03/10/22, the SSD stated none. When asked why Res #42 was seen by the dentist again on 10/31/22, before their annual appointment date, SSD stated, [Resident #42] requested to see the dentist because of continued mouth pain.

Based on record review and interview, the facility failed to educate residents or their legal representatives regarding the risks, benefits, and potential side effects of vaccinations and obtain signed declinations: (1) for two (#34 and #55) of four sampled residents who declined the pneumococcal vaccine, and (2) for one (#55) of four sampled residents who declined the influenza vaccine. Resident Census and Condition of Residents documented 38 residents received the Influenza vaccine and 51 residents received the pneumococcal vaccine. There were 66 residents residing at the facility. Findings: An Influenza Vaccine policy, revised [DATE], read in part, .4. Prior to vaccination, the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine .Provision of such education shall be documented in the resident's/employee's medical record .6. A resident's refusal of the vaccine shall be documented .and placed in the resident's medical record . A Pneumococcal Vaccine policy, revised [DATE], read in part, .3. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine .Provision of such education shall be documented in the resident's medical record .5 .if refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal . Resident #34's immunization log documented they had refused the pneumococcal vaccine. There was no documentation that information and education regarding the risks, benefits, and potential side effects of the vaccination had been provided. There was no documentation a declination had been signed. Resident #55's immunization log documented they refused the pneumococcal and influenza vaccines. There was no documentation that information and education regarding the risks, benefits, and potential side effects of the vaccinations had been provided. There was no documentation declinations had been signed. On 11/02/22 at 1:20 p.m., DON was asked to provide documentation that resident #34 had been offered the pneumococcal vaccine and provided information and education regarding the risks, benefits, and potential side effects of the vaccine. The DON could not. The DON was asked if the resident or legal representative's refusal of the pneumococcal vaccine for resident #34 had been documented in the resident's medical record. After a review of the clinical record for resident #34, the DON acknowledged there was no education regarding the risks, benefits, and potential side effects of the pneumococcal vaccination nor a signed declination for this resident. On 11/02/22 at 1:30 p.m., DON was asked to provide documentation that resident #55 had been offered the pneumococcal and influenza vaccines and provided information and education regarding the risks, benefits, and potential side effects of the vaccines. The DON could not. The DON was asked if the resident or legal representative's refusal of the pneumococcal and influenza vaccines for resident #55 were documented in the resident's medical record. After a review of the clinical record for resident #55, the DON acknowledged there was no education regarding the risks, benefits, and potential side effects of the pneumococcal and influenza vaccinations nor signed declinations for this resident.

Based on record review and staff interview, it was determined the facility failed to ensure care plans were fully developed for: ~ hospice for one (#67) of one sampled resident reviewed for hospice and ~ psychoactive drug use for one (#17) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 04/29/19, documented six residents received hospice services and 34 residents received psychoactive medications. Findings: 1. Resident #67 was admitted to hospice services on 03/29/19. The care plan, last updated on 04/11/19, documented, .Focus: The resident has a [DIAGNOSES REDACTED]. Interventions: ~ Adjust provision of ADLS (activities of daily living) to compensate for the resident's changing abilities. ~ Assess resident coping strategies and respect resident wishes. ~ Encourage support system of family and friends, ~ Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. ~ Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. ~ Work with nursing staff to provide maximum comfort for the resident . On 05/02/19 at 7:17 a.m., the director of nursing (DON) was asked to review the care plan for the resident and locate the hospice care plan. She was asked if the hospice care plan reflected what services the facility and the hospice provider were providing the resident. The DON stated, No, it needs to be more specific. 2. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The care plan, last updated on 04/15/19, failed to address the resident's use of the above psychoactive medications. On 05/02/19 at 7:21 a.m., the DON was asked to review the care plan for the resident and locate the resident's psychoactive medications. She was asked if the above medications were high risk medications which should have been care planned. The DON stated, Yes.

Based on observation and staff interview, it was determined the facility failed to ensure: ~ staff had access to disposable towels for hand washing, ~ food products were dated, monitored and discarded at designated times, ~ soiled rags were properly stored, ~ equipment was kept clean and maintained in good repair, ~ the floor and the walls were kept clean and ~ dishes were properly stored. The facility identified 79 residents who received services from the kitchen. One resident received nutrition and hydration solely through a feeding tube. Findings: On 04/29/19 at 7:36 a.m., an initial tour of the kitchen was conducted. The following observations were made: ~ there were no paper towels at the hand sink. The dietary manager (DM) stated there were no paper towels at the hand sink when she arrived to work. She stated housekeeping arrived around 6:00 a.m. and she hadn't had a chance to ask for them, ~ there were soiled rags stored on the food preparation table near the toaster oven and on the metal rolling food cart near the stove, ~ there was a box of bananas on a shelf in the dry storage room. The bananas were black in color and there were gnats flying around in the box, ~ there was an undated container of vegetable soup in the Beverage Air reach-in produce cooler, ~ there was a metal container of chili with a prepared date of 03/31 and a use by date of 04/06 in the Beverage Air reach-in produce cooler. There was a white furry substance growing inside of the container, ~ there was a plastic container of chili in the Beverage Air reach-in produce cooler with a prepared date of 04/12 and ~ there were two plastic containers of cream of mushroom soup in the Beverage Air reach-in produce cooler with prepared dates of 03/20 and 04/12. At 7:55 a.m., the DM was asked what the dates on the food containers indicated. She stated it was the date the product was opened or cooked. She stated the soups and the chili were opened and put into containers and were not leftovers. She stated they rarely had leftovers. She stated food products such as soups or chili were discarded within five days from when they were opened. She was made aware of the dates on the soup and the chili in the reach-in cooler. She acknowledged the findings. On 04/30/19 at 7:30 a.m., a follow-up tour of the kitchen was conducted. The following observations were made: ~ there was an accumulation of black residue and dried food on the table mounted can opener, ~ there was an accumulation of brown residue in the inside area of the cabinet below the hand sink, ~ there was an accumulation of a white and brown slime like residue inside of the juice spray nozzle, ~ there was an accumulation of spilled food debris on the shelving in the spice cabinet, ~ there was spilled food debris on the bottom casing of the Beverage Air two door reach-in freezer, ~ there was an accumulation of black, brown and white residue on the dish washer, drain boards and shelving in the dish wash area, ~ there was an accumulation of black residue on the chemical bucket dollies below the drain boards in the dish wash area, ~ multiple plastic bus tubs were stacked wet and dirty with food debris during storage on a shelf below the food preparation table across from the dishwasher, ~ there was an accumulation of lint on the oven hood, ~ there was an oven hood light burned out, ~ there was white plastic material left on the door of the dishwasher to the dirty side of the dish wash area, ~ there was an accumulation of black residue and food debris on the floor along the baseboards and under equipment and ~ there was an accumulation of food debris and black residue on the wall below the dish wash area. On 04/30/19 at 1:10 p.m., the DM was asked what staff had available to them at the hand sink to dry their hands. She stated there should be paper towels. She was asked how food products were to be stored in the dry storage area. She stated foods should be closed, sealed and dated. She was asked how soiled rags were required to be stored. She stated soiled rags in use should be stored in a sanitizer solution. The DM was asked how equipment and the physical environment was kept clean and maintained in good repair. She stated equipment should be cleaned every shift and as needed. She stated the floors were to be swept and mopped between each meal and the walls were to be cleaned as staff saw they were dirty. She was asked how dishes were to be stored. She stated dishes should be air dried and stored clean and upside down. The DM was made aware of the above observations. She acknowledged the findings.

Based on record review and staff interview, it was determined the facility failed to ensure: ~ physician's orders were followed to obtain blood pressure and pulse prior to the administration of hypertension medications and ~ physician's orders were followed to hold blood pressure medications for one (#60) of five sampled residents reviewed for medications. The facility identified 49 residents who had physicians' orders for blood pressure parameters. Findings: Resident #60 had [DIAGNOSES REDACTED]. Physicians' orders, dated 03/29/19, documented the following: .Carvedilol Tablet 6.25 MG (milligrams) Give 1 tablet by mouth two times a day for hypertension Hold if < (less than) 110/60 or pulse is <60 .Losartan Potassium Tablet 100 MG Give 1 tablet by mouth one time a day for Hypertension Hold if <110/60 .[MEDICATION NAME] Tablet 160 MG Give 1 tablet by mouth one time a day for hypertension until supply is gone. Hold if <110/60 . The (MONTH) 2019 Medication Administration Record [REDACTED] ~ on 03/29 through 03/31/19 at 5:00 p.m. and on 03/30/19 through 03/31/19 at 8:00 a.m., there was no blood pressure or pulse recorded for the Carvedilol and ~ on 03/30 through 03/31/19 at 7:00 a.m., there was no blood pressure recorded for the Losartan and [MEDICATION NAME]. A physician's order, dated 04/01/19, documented, .[MEDICATION NAME] Tablet 160 MG Give 1 tablet by mouth one time a day for hypertension Hold if <110/60 . The (MONTH) 2019 MAR indicated [REDACTED] ~ on 04/01 through 04/30/19 at 8:00 a.m. and on 04/01 through 04/29/19 at 5:00 p.m., there was no pulse recorded for the Carvedilol, ~ on 04/04, 04/10, 04/19 and 04/22/19 at 5:00 p.m., there was no blood pressure recorded for the Carvedilol and ~ on 04/14/19 at 7:00 a.m., [MEDICATION NAME] was documented as administered. The resident's blood pressure was recorded as 106/88. On 04/30/19 at 12:55 p.m., licensed practical nurse #1 was asked what it meant when there were staff initials recorded for hypertension medications but there were no blood pressures or pulse documented. She stated it meant staff gave the medication but didn't write it down. She was asked to review the MARs for the above findings. She reviewed the MARs and stated the [MEDICATION NAME] should have been held. She acknowledged the findings.

Based on record reviews and interviews, it was determined the facility failed to ensure residents were not administered antibiotics without indications for use for three (#1, 7, and #8) of four sampled residents reviewed with physician's orders [REDACTED]. The DON (director of nurses) identified 15 residents who received antibiotics since 08/01/18. Findings: A facility protocol titled, Revised McGreer Criteria for Infection Surveillance Checklist, documented: .Urinary Tract Infection [MEDICAL CONDITION] Surveillance Definitions . UTI without indwelling catheter .Must fulfill both 1 and 2 . 1. At least one of the following sign or symptoms . Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate . Fever or leukocytosis, and (greater than or equal to) 1 of the following .acute costovertebral angle pain or tenderness .suprapubic pain .Gross hematuria .New or marked increase in incontinence .New or marked increase in urgency .New or marked increase in frequency . If no fever or leukocytosis, then (greater than or equal to) 2 of the following .Suprapubic pain .Gross hematuria .New or marked increase in incontinence .New or marked increase in urgency .New or marked increase in frequency . 2. At least one of the following microbiologic criteria .(greater than or equal to) (100,000) cfu/ml (colony forming units per milliliter) of no more than 2 species of organisms in a voided urine sample .(greater than or equal to) (50,000) cfu/ml of any organism(s) in a specimen collected by an in-and-out catheter . Respiratory Tract Infection (RTI) Surveillance Definitions . pharyngitis .Must fulfill at least 2 criteria .Runny nose or sneezing .Stuffy nose or nasal congestion .Sore throat, hoarseness, or difficulty in swallowing .dry cough .Swollen or tender glands in the neck . Influenza like illness .Must fulfill both 1 AND 2 . 1. Fever . 2. At least three of the following criteria .Chills .New headache or eye pain .Myagias or body aches .Malaise or loss of appetite .Sore throat .New or increased dry cough . [MEDICAL CONDITION] or [MEDICAL CONDITION] .Must fulfill 1, 2, AND 3 . 1. Chest X-ray not performed, or negative for pneumonia or a new infiltrate . 2. At least two of the following criteria .New or increased cough .New or increased sputum production .O2 (oxygen) sat (saturation) (less than) 94 (percent) on room air or (greater than) 3 (percent) decrease from baseline O2 sat .New or changed lung exam abnormalities .Pleuritic chest pain .Respiratory rate (greater than) 25 breaths/min (minute) . 3. At least one of the following criterias .Fever .Leukocytosis .Acute mental status change .Acute functional decline . 1. Resident #1 was admitted with [DIAGNOSES REDACTED]. Progress notes, dated (MONTH) (YEAR), were reviewed. There was no documentation of signs or symptoms of a urinary tract infection. Temperature logs, dated (MONTH) (YEAR), were reviewed. There was no documentation the resident exhibited a fever. A significant change assessment, dated 09/14/18, documented the resident was cognitively alert in skills for daily decision making. He was independent with his personal hygiene. He was always continent of bowel and bladder. Progress notes, dated (MONTH) (YEAR), were reviewed. There was no documentation the resident exhibited signs or symptoms of a urinary tract infection. Temperature logs, dated (MONTH) (YEAR), were reviewed. There was no documentation the resident exhibited a fever. A urinalysis laboratory report, dated 10/04/18, documented the resident had one plus leukocytes, white and red blood cells, and trace amounts of bacteria and mucus in his urine. A physician's orders [REDACTED].Give 1 tablet by mouth two times a day for UTI . A facility McGreer criteria UTI checklist, dated 10/04/18, [MEDICATION NAME](an antibiotic) was ordered twice daily. The form documented the resident did not exhibit a fever, leukocytosis, acute changes in mental status, or changes in the level of assistance he required for his activities of daily living. The form documented required criteria for an antibiotic for a UTI was not met. The form further documented the resident had returned from an appointment with his physician with an order for [REDACTED].>A care plan, dated 10/04/18, documented, .Focus .The resident is on antibiotics for abnormal labs .Interventions .Cipro 500 mg (milligrams) twice daily x (times) 7 days .Date Initiated: 10/04/2018 .Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness .[MEDICATION NAME] 100 mg by mouth twice daily x 14 days Dx (diagnosis) UTI .Date Initiated: 10/11/2018 . A culture and sensitivity laboratory report, dated 10/06/18, documented, .Culture results: [MEDICATION NAME] Faecalis .(greater than) 100,000 CFU/ML .Antibiotic susceptibility test results .[MEDICATION NAME] ([MEDICATION NAME], an antibiotic) .S (susceptible) . There was no documentation on the culture and sensitivity report whether the identified bacteria was susceptible or resistant to the [MEDICATION NAME] had been initiated and administered to the resident starting on 10/04/18. A physician's orders [REDACTED].[MEDICATION NAME] .Give 100 mg by mouth two times a day for uti for 14 days . Medication administration records, dated (MONTH) (YEAR), documented the resident was [MEDICATION NAME] as ordered by the physician. On 10/23/18 at 12:15 p.m., the DON was asked how did the facility determine if a resident required an antibiotic. She stated the facility utilized the McGreer's criteria in their decision making process. She stated nurses had completed training on signs and symptoms which were required prior to starting an antibiotic. She was asked what action was taken if a resident returned from the hospital or a physician's appointment with orders for an antibiotic. She stated the facility made attempt to obtain documentation of signs and symptoms which warranted the antibiotic from the ordering physician. She was then asked why the resident was started on the [MEDICATION NAME] he returned from a physician's appointment on 10/04/18 and why was the antibiotic changed to [MEDICATION NAME] on 10/11/18. She stated there was no documentation the resident had exhibited any signs or symptoms of a urinary tract infection at the facility or at the physician's office visit. She further said, But he had a positive culture so we [MEDICATION NAME] then changed to [MEDICATION NAME] ([MEDICATION NAME]) due to sensitivities. She was asked if it was acceptable to treat a resident with an antibiotic if the only sign/symptom was a positive culture. She said, Absolutely. She was then asked to describe her understanding of colonization. She then said, Yes, yes you are right. She stated it's not acceptable to administer an antibiotic with only a positive culture. She stated additional signs and symptoms were required. She was then asked if the antibiotics were warranted for the resident. She said, No. 2. Resident #7 had a [DIAGNOSES REDACTED]. An annual assessment, dated 09/07/18, documented the resident understood others, was cognitively intact for daily decision making, made herself understood, and was occasionally incontinent of bowel and bladder. A nurse's note, dated 08/23/18, documented the resident's urine was light yellow and the resident had no complaints of pain or discomfort. The note also documented the resident exhibited no signs and/or symptoms (s/s) of distress. The clinical record contained no additional documentation the resident had been fully assessed for s/s of a urinary tract infection prior to being administered an antibiotic. A physician's orders [REDACTED]. The treatment administration record documented the resident received the antibiotic from 08/23/18 through 08/30/18. On 10/23/18 at 2:00 p.m., the director of nurses was asked for the documentation of the signs and/or symptoms the resident exhibited that warranted the administration of an antibiotic. She was also asked if a culture and sensitivity (c&s) had been obtained when the urinalysis was obtained. She stated there was no documentation of s/s exhibited by the resident. She added the lab results had documented that no c&s was required, so we did not request one. She added that we would normally have a sensitivity result prior to administering an antibiotic. 3. Resident #8 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/26/18, documented the resident was cognitively alert in skills for daily decision making. A physician's orders [REDACTED].Z pack ([MEDICATION NAME], an antibiotic) 250 mg (2 tablets) .first dose then (one) daily x 5 days .[DIAGNOSES REDACTED].acute rhonci . A care plan, initiated on 09/12/18, documented, .Focus .The resident has acute [MEDICAL CONDITION] r/t (related to) sob (shortness of breath) .Interventions .Administer antibiotic as per MD orders .Z pack ([MEDICATION NAME], an antibiotic) 250 mg 2 tabs on initial dose then 1 tab (tablet) daily x 5 days, acute [MEDICAL CONDITION] . An facility infection report, dated 09/12/18, documented, .Symptoms present .(other checked) Acute [MEDICAL CONDITION] .Specify symptoms: cough, pain . The report further documented the antibiotic ([MEDICATION NAME], Z pack) was administered. A McGreer criteria form, dated 09/12/18, documented the antibiotic [MEDICATION NAME] had been ordered. The form documented the resident did not exhibit a fever, leukocytosis, acute changes in mental status, or changes in the level of assistance he required for his activities of daily living. The form documented the resident did not exhibit any influenza or pneumonia signs/symptoms. It was documented the resident had new or increased cough and new or increased sputum production. The criteria form documented, in conclusion the McGreer criteria had not been met and the resident did not have signs/symptoms which warranted the use of an antibiotic. A Medication Administration Record, [REDACTED]. The resident's clinical record was reviewed. There was no documentation the resident exhibited any signs/symptoms of a a respiratory infection. On 10/23/18 at 2:00 p.m., the DON was asked to review the resident's clinical record. She was asked if the resident had exhibited any signs/symptoms which warranted the physician's orders [REDACTED]. She said, No. She was asked if the facility required McGreer's criteria was met prior to the initiation of an antibiotic. She stated it was not.

Based on record review and staff interviews, it was determined the facility failed to notify the physician in a timely manner of a resident whose elevated finger stick blood sugar (FSBS) tests results continued to elevate further over a period of ten and a half hours for one (#100) of nine sampled residents reviewed for FSBS tests. This resulted in actual harm to the resident. The facility identified 17 residents with physicians' orders for FSBS tests. Findings: A Change in a Resident's Condition or Status policy, last revised November 2015), documented, Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition . Policy Interpretation and Implementation .The Nurse Supervisor/Charge Nurse will notify the resident's Attending physician or On-Call Physician when there has been: .A significant change in the resident's physical/emotional/mental condition .A need to alter the resident's medical treatment significantly . A significant change of condition is a decline or improvement in the resident's status that: .Will not normally resolve itself without intervention by staff .Impacts more than one area of the resident's health status . Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . Resident #100 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The readmission orders [REDACTED]. The s/s documented if the FSBS test results were 150 - 199, give 4 units of regular insulin and if the FSBS test results were 200 - 300, give 8 units of regular insulin. There were no orders documented to contact the physician if the FSBS test results were over 300, how much regular insulin to administer if the FSBS test results were over 300 or how long to wait after the administration of regular insulin to recheck the FSBS test. The July 2017 treatment administration records (TARs) documented the resident's FSBS test results were 477 at 6:00 p.m. on 07/12/17 and 8 units of regular insulin was administered without a physician's orders [REDACTED].#2. There was no documentation to show the physician was contacted with the elevated FSBS test results on the 2:00 p.m. to 10:00 p.m. shift on 07/12/17. The July 2017 TARs documented the resident's FSBS test results were 532 at 12:00 a.m., on 07/12/17 and 8 units of regular insulin was administered without a physician's orders [REDACTED]. A nurse's note, dated 07/13/17 at 2:30 a.m., documented, Took resident's ordered 2400 (12:00 a.m.) blood sugar which was 532. Gave coverage of 8 units. Rechecked at 230 (2:30 a.m.) and glucometer was reading 'HI'. Notified dr. (doctor) Was given order to do STAT (now) 13 units of [MEDICATION NAME]. At 4:30 a.m., Rechecked blood sugar after given STAT 13 units of [MEDICATION NAME]. Blood sugar was 582. Notified dr of blood sugar and that resident was starting to sweat and VS (vital signs) were not WNL (within normal limits). T (temperature) 96.4 F (Fahrenheit) BP (blood pressure) 106/45 P (pulse) 52 R (respirations) 44 O2 (oxygen saturation) 86% (percent). Ordered by Dr to send resident to (local hospital) for eval (evaluation). A nurse's note, dated 07/24/17 at 3:36 p.m., documented, Late entry for 7-12-17 2-10 evening shift. Notified on call physician of elevated blood sugar and VS. Physcian inquired if routine insulin had been administered and this nurse confirmed administration. FSBS rechecked. Results now 464. No further orders at this time. On 08/07/17 at 2:40 p.m., the director of nursing (DON) was asked about the lack of documentation on the evening of 07/12/17 in regards to the resident's elevated FSBS. The DON stated during her investigation of the situation she interviewed LPN #2 and had asked her if she had contacted the physician. LPN #2 had stated she contacted the on call physician and no new orders were given except to monitor the resident. On 08/16/17 at 10:30 a.m., the DON was asked if the s/s orders should have been clarified when the resident was readmitted on [DATE]. She stated they had clarified all s/s orders now and implemented the missing piece to call the physician when FSBS were over 400. The DON was asked should LPN #2 have notified the physician when the resident's FSBS test results were well over 300 and there were no orders to administer regular insulin when the results were over 300. She stated, Yes. The DON was asked if the physician was notified of the resident's FSBS test results of 477 at 6:00 p.m. on 07/12/17. She stated, Yes. She stated LPN #2 had contacted the on call physician. The DON was asked if the physician was contacted again when the FSBS test results were 464. She stated LPN #2 told her she had contacted the physician again with the FSBS results. She was asked if there was documentation to show when the physician had been contacted. She stated, No.

Based on record review and staff interviews, it was determined the facility failed to assess, monitor and intervene for a resident whose elevated finger stick blood sugar (FSBS) tests results continued to elevate further over a period of ten and a half hours for one (#100) of nine sampled residents reviewed for FSBS tests. This resulted in actual harm as the resident. The facility identified 17 residents with physicians' orders for FSBS tests. Findings: An Insulin Administration policy, last revised [DATE], documented, Purpose To provide guidelines for the safe administration of insulin to residents with diabetes. Preparation .The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's orders [REDACTED]. Glucose Monitoring .The management of individuals with diabetes mellitus should follow relevant protocols and guidelines .The physician will order the frequency of glucose monitoring .Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation . Documentation .The resident's blood glucose result, as ordered .the dose and concentration of the insulin injection . A care plan problem for resident #100, last reviewed [DATE], documented, (Resident) has Diabetes Mellitus . Goal: (Resident) will have no complications related to diabetes, hypo/[MEDICAL CONDITION] through the review date . Interventions: .Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness . The care plan did not address the resident's [DATE] readmission orders [REDACTED]. The resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The readmission orders [REDACTED]. The s/s documented if the FSBS test results were 150 - 199, give 4 units of regular insulin and if the FSBS test results were 200 - 300, give 8 units of regular insulin. There were no orders documented to contact the physician if the FSBS test results were over 300, how much regular insulin to administer if the FSBS test results were over 300 or how long to wait after the administration of regular insulin to recheck the FSBS test. A 5 day prospective payment system resident assessment, dated [DATE], documented the resident had severely impaired cognitive skills for daily decision making skills, required extensive to total assist with all activities of daily living, was totally incontinent of bowel, used an indwelling urinary catheter for bladder incontinence and required a feeding tube for all nutrition, hydration and medications. The [DATE] treatment administration records (TARs) documented the resident's FSBS test results were 477 at 6:00 p.m. on [DATE] and 8 units of regular insulin was administered without a physician's orders [REDACTED].#2. There was no documentation to show the physician was contacted with the elevated FSBS test results on the 2:00 p.m. to 10:00 p.m. shift on [DATE]. The [DATE] TARs documented the resident's FSBS test results were 532 at 12:00 a.m., on [DATE] and 8 units of regular insulin was administered without a physician's orders [REDACTED]. A nurse's note, dated [DATE] at 2:30 a.m., documented, Took resident's ordered 2400 (12:00 a.m.) blood sugar which was 532. Gave coverage of 8 units. Rechecked at 230 (2:30 a.m.) and glucometer was reading 'HI'. Notified dr. (doctor) Was given order to do STAT (now) 13 units of [MEDICATION NAME]. At 4:30 a.m., Rechecked blood sugar after given STAT 13 units of [MEDICATION NAME]. Blood sugar was 582. Notified dr of blood sugar and that resident was starting to sweat and VS (vital signs) were not WNL (within normal limits). T (temperature) 96.4 F (Fahrenheit) BP (blood pressure) ,[DATE] P (pulse) 52 R (respirations) 44 O2 (oxygen saturation) 86% (percent). Ordered by Dr to send resident to (local hospital) for eval (evaluation). A Patient Care Report, dated [DATE], documented the EMTs (emergency medical technicians) arrived at the facility at 4:42 a.m. The resident was unresponsive, had weak peripheral pulses and a blood glucose of over 500. Nurse's notes from the local hospital, dated [DATE] at 5:25 a.m., documented, .Diagnosis: [REDACTED].Presenting complaint: EMS (emergency medical services) states: Nursing home called EMS patient was non-responsive did have heart rate. EMS arrived patient was nonresponsive resp (respirations) 6, bp (blood pressure) ,[DATE], no CPR (cardiopulmonary resuscitation) was started just bagging .Care prior to arrival: Glucose check. EMS greater (than) 500. A nurse's note, dated [DATE] at 3:36 p.m., documented, Late entry for [DATE] ,[DATE] evening shift. Notified on call physician of elevated blood sugar and VS. Physcian inquired if routine insulin had been administered and this nurse confirmed administration. FSBS rechecked. Results now 464. No further orders at this time. The nurse's note was unclear as to when the physician was contacted or how many times the physician was contacted on the 2:00 p.m. to 10:00 p.m. on [DATE]. On [DATE] at 2:40 p.m., the director of nursing (DON) was asked about the lack of documentation on the evening of [DATE] in regards to the resident's elevated FSBS. The DON stated during her investigation of the situation she interviewed LPN #2 and had asked her if she had contacted the physician. LPN #2 had stated she contacted the on call physician and no new orders were given except to monitor the resident. On [DATE] at 10:30 a.m., the DON was asked if the s/s orders should have been clarified when the resident was readmitted on [DATE]. She stated they had clarified all s/s orders now and implemented the missing piece to call the physician when FSBS were over 400. She stated she had held an in-service on [DATE] for the nurses in regards to FSBS. The DON provided a copy of an in-service dated [DATE]. The Inservice and Training Sign In Sheet, documented, Topic: FSBS (unless otherwise specified in the Physician orders [REDACTED]. The DON was asked should LPN #2 have notified the physician when the resident's FSBS test results were well over 300 and there were no orders to administer regular insulin when the results were over 300. She stated, Yes. The DON was asked if the physician was notified of the resident's FSBS test results of 477 at 6:00 p.m. on [DATE]. She stated, Yes. She stated LPN #2 had contacted the on call physician. The DON was asked if the physician was contacted again when the FSBS test results were 464. She stated LPN #2 told her she had contacted the physician again with the FSBS results. She was asked if there was documentation to show when the physician had been contacted. She stated, No. The DON was asked to explain LPN #3 waiting until 2:30 a.m. to recheck the [DATE] midnight FSBS. She had no comment. The DON was asked what the policy was rechecking FSBS test results after regular insulin had been administered. She stated there was no policy for rechecks on FSBS. She stated FSBS were usually rechecked in two hours.

Based on observation, record review and resident and staff interviews, it was determined the facility failed to: ~ assess, monitor and intervene for a resident who experienced pain in association with a non-pressure wound the facility was not treating consistently, for one (#6) of one sampled residents reviewed for pain. This resulted in actual harm for the resident who experienced untreated pain and ~ provide wound care treatment as ordered for a resident who experienced a non-pressure wound for one (#60) of three sampled residents reviewed for wounds. The Resident Census and Conditions of Residents report, dated 01/10/17, documented all 64 residents were on a pain management program. The director of nursing (DON) identified 10 residents who received wound care and 50 residents who had orders for PRN (as needed) pain medication. Findings: A pain assessment and management policy, last revised 03/15, documented, .Purpose .The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . General Guidelines .The pain management program is based on facility-wide commitment to resident comfort .Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals . Pain management is a multidisciplinary care process that includes the following .assessing the potential for pain .Effectively recognizing the presence of pain .Identifying the characteristics of pain .Addressing the underlying causes of the pain .Developing and implementing approaches to pain management . Identifying and using specific strategies for different levels and sources of pain .Monitoring for the effectiveness of interventions .Modifying approaches as necessary . Recognizing Pain .Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain .Possible Behavioral Signs of Pain .Verbal expressions such as groaning, crying, screaming .Facial expressions such as grimacing, frowning, clenching of the jaw . Ask the resident if he/she is experiencing pain. Be aware that the resident may avoid the term pain and use other descriptors such as throbbing, aching, hurting, cramping, numbness or tingling .Review the Medication Administration Record [REDACTED]. A change in a resident's condition or status policy, last revised 11/15, documented, .Policy Statement .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . Policy Interpretation and Implementation .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been . A discovery of injuries of an unknown source .A significant change in the resident's physical/emotional /mental condition .Instructions to notify the Physician of changes in the resident's condition . A significant change of condition is a decline or improvement in the resident's status that .Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .Impacts more than one area of the resident's health status . Requires interdisciplinary review and/or revision to the care plan .Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when .There is a significant change in the resident's physical, mental, or psychosocial status . Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . Regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments . The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . A wound care policy, last revised 01/11/17, documented, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Verify that there is a physician's order for this procedure . Review the resident's care plan to assess for any special needs of the resident .For example, the resident may have PRN (as needed) orders for pain medication to be administered prior to wound care . The following equipment and supplies will be necessary when performing this procedure .Dressing material, as indicated (i.e.(for example), gauze, tape, scissors . Use disposable cloth/wax paper (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached . Position resident. Place disposable cloth/pad next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites . Apply treatment as indicated .Dress wound .Mark tape with initials, time, and date and apply to dressing . Be certain all clean items are on clean field .Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly . Use sani (sanitizing) wipes to disinfect overbed table .Wipe reusable supplies with alcohol/sani wipe as indicated (i.e., outsides of containers that were touched by unclean hands, scissor blades, etc.). Return reusable supplies to resident's drawer in treatment cart . 1. Resident #6 had [DIAGNOSES REDACTED]. A physician's order, dated 08/24/15, documented the resident was to receive 650 milligrams (mg) of Tylenol by mouth every six hours as needed for pain or an elevated temperature. A physician's order, dated 08/29/15, documented, .APPLY [MEDICATION NAME] TO AFFECTED AREA(S) THREE TIMES DAILY AS NEEDED . APPLY [MEDICATION NAME] POWDER TO SKIN FOLDS AND PERI AREA THREE TIMES DAILY AS NEEDED . A physician's order, dated 10/04/16, documented the resident was to receive [MEDICATION NAME] 50 mg one tablet by mouth every six hours as needed for pain. A care plan, last revised 12/01/16, documented, .(Resident) is at risk for uncontrolled pain r/t (related/to) impaired cognition and mobility, psychosocial issues, h/o (history/of) falls, [MEDICAL CONDITION],generalized pain and neuralgia . Interventions .Pain eval (evaluation) by licensed nurse to include:pain history and effective forms of relief, side effects of pain management, aggravating factors (remove, eliminate where possible), characteristics: quality .severity .anatomical location .duration . document findings/eval and contact physician as indicated . Staff to provide non pharmacological means of pain relief . A care plan, last revised 12/01/16, documented, .(Resident) has potential impairment to skin integrity r/t impaired mobility and cognition, intermittent incontinency, use of diuretic . Interventions .Skin eval routinely and prn by licensed nurse- to include hydration component and use of formal instrument .as indicated with findings . The care plan did not document the resident had a current skin condition. A quarterly resident assessment, dated 11/20/16, it documented the resident required extensive assistance of one person for bed mobility, transfers, walking in room, walking in corridor, locomotion on and off unit, dressing and toilet use. It documented the resident required one person physical assistance in part of bathing activity. It documented the resident received/or offered as needed pain medication in the past five days and had received non-medication intervention for pain. It documented the resident had experienced pain in the last fives days frequently rated at a four. It documented the resident was at risk for pressure ulcer development and had moisture associated skin damage. A nurse's note, dated 12/18/16, documented, .Pt (patient) continues [MEDICATION NAME] for rash, no outward signs/symptoms of outward reaction to medication at this time, will continue to monitor for any changes . A weekly skin assessment, dated 12/22/16, documented the resident's skin was intact. It documented the resident had redness present to her abdominal fold and bilateral breast. It documented there was an as needed treatment in place. A weekly skin assessment, dated 01/07/17, documented the resident had redness to her abdominal folds. The most recent weekly skin assessment, dated 01/08/17, documented her skin had dryness and bruises. It did not document where the conditions were located on the resident's body. A nurse's note, dated 01/10/17, documented the resident had experienced a fall. It documented upon examination, .observed no redness or skin tears . The January 2017 Medication Administration Record [REDACTED]. It documented blanks for the result of the 9:00 p.m. dose on 01/10/17. All other doses were documented as effective. It documented, 08/29/15 (order date) apply [MEDICATION NAME] to affected area(s) three times daily as needed. The administration section was blank for the entire month. The MAR indicated [REDACTED]. It was documented as being administered only one time for the month, on 01/11/17. The MAR indicated [REDACTED]. Each shift for the month documented the resident experienced no pain. On 01/09/17 at 10:37 a.m., the resident was asked if she had any discomfort now or had she been having discomfort such as pain, heaviness, burning or hurting with no relief. She stated yes, she had been having pain in her right and left breast area and her abdomen. She stated she had asked staff for the stuff the physician had ordered for her, but staff weren't doing it. On 01/11/17 at 10:07 a.m., the resident was asked if she was currently experiencing any pain. She stated, Right now I'm hurting real bad across abdomen under right breast. She was asked to describe her pain. She stated, It feels like the skin is broken apart in the crease. She was asked if she had reported her pain to staff. She stated she believed she reported it in the past but couldn't recall if she had reported it today. The resident was asked what interventions staff were doing to address her pain. She stated for awhile, staff were putting cream on it. She stated, then they switched to powder and then they switched to cream and powder. She was unable to identify what powder was used. She stated the staff had put powder on her yesterday and today. She was asked if the powder helped. She stated, I was so sleepy I went off to sleep I don't know. She was asked how often treatment was provided. She stated she did not know. At 10:19 a.m., the shower aide was asked if she was familiar with the resident. She stated she was. She was asked if the resident had any skin issues. She stated, Not that I'm aware of. She was asked who she would report changes in the skin to. She stated, Charge Nurse. She was asked who her charge nurse was. She stated licensed practical nurse (LPN) #3 was her charge nurse for the day. At 10:40 a.m., LPN #3 was asked if she was familiar with the resident. She stated, Yes. She was asked if the resident experienced any pain. She stated the resident did experience pain periodically in varying locations. LPN #3 was asked to whom was the pain reported to. She stated the CNAs reported pain to her or the medication aide if they were unable to locate her. She was asked what interventions were in place to treat the pain. She was observed reviewing the resident's medication record and stated the resident received [MEDICATION NAME] as needed and [MEDICATION NAME] routinely for arthritis. She was asked how often the resident's pain was assessed. She stated the resident's pain was assessed once a day on her shift. She stated if complaints/concerns were noted, more often as needed. LPN #3 was asked if the resident had any current skin issues. She stated, not that she was aware of. She stated the resident hadn't said anything to her. She was asked if the resident had any current skin care treatments. She stated the resident did not have any ordered treatments right now for her skin. She was asked how often the resident's skin was assessed by facility staff. She stated the resident's skin was assessed weekly. LPN #3 was asked if the resident was able to voice her needs to facility staff. She stated she was confused at times but was able to notify staff when she was hurting or needed something. At 10:47 a.m., the DON was asked if she was familiar with any current skin issues with the resident. She stated, right now, No. She stated on Monday the resident had pink discoloration on her left abdominal fold. She was asked if she was aware of any skin issues with the resident's breasts. She stated she had not looked at the resident's breasts. At 10:49 a.m., LPN #3 stated she knew the resident did not have any routine treatment orders. At 10:50 a.m., the DON and LPN #3 were observed assessing the resident's skin. LPN #3 was observed lifting the resident's right breast which revealed a bright red area approximately 2 1/2 inches long by approximately 1/4 inch wide. The resident verbalized discomfort while her breast was being lifted. Next, LPN #3 lifted the resident's left breast. No skin conditions were observed under her left breast. The resident's lower abdomen was observed to be slightly pink with no open areas observed. At 10:59 a.m., the DON was asked if the skin under the resident's right breast was open. The DON stated she would have to go back and look to see if it was open. LPN #3 and the DON were asked if they were aware of the resident's skin condition under her right breast prior to this observation. LPN #3 stated she was not aware of the area. The DON stated the area comes and goes, but no she was not aware. At 11:00 a.m., the DON reentered the resident's room, washed her hands, donned a pair of gloves and lifted the resident's right breast. The resident stated, That hurts. The DON was asked if the area was open. She stated, I'm gonna say yes. She stated she wanted to wipe the area to get a better look. The DON removed her gloves, washed her hands, donned a pair of gloves and obtained a disposable wipe located in the resident's room. At 11:03 a.m., LPN #3 returned to the resident's room with supplies. The DON was observed running the wipe under water to warm the wipe. LPN #3 was observed washing her hands. The DON was observed using the disposable wipe to clean the red area under the resident's right breast and stated, Looks like a lot of blisters with skin intact. The DON was asked to verify the size of the wound. She stated the wound was approximately 2 1/2 inches long by 1/4 inch wide. LPN #3 began providing treatment to the resident's right breast. The resident was observed moaning out while the care was provided. The DON was asked to confirm what treatment was provided to the resident. At 11:13 a.m., the DON stated [MEDICATION NAME] powder was used for wound care. On 01/12/17 at 9:53 a.m., the DON was asked what the facility policy was for when staff identified changes in a resident's skin. She stated if the nurse aide observed changes during personal care, they report it to the charge nurse. She stated when a nurse identified an issue, they would notify the physician, family and implement treatment if needed. She was asked if the resident was able to verbalize her needs. She stated, Yes basic needs definitely. She was asked what the facility policy was for assessing, monitoring, and intervening for a resident with skin issues and pain. The DON stated for the skin, staff completed head to toe assessments on a weekly basis and as needed. She stated the staff documented the assessment on a weekly skin assessment flow sheet. She stated, when a skin issue was determined on a day other than the weekly skin evaluation, staff would document the findings on a weekly skin sheet, in a nurse's note and would update the care plan. The DON stated staff assessed residents every shift for pain and as needed. She stated if a resident complained of pain, staff would intervene with either medications, repositioning, shoulder rubs and other various nonpharmacological interventions. She stated the staff would review the resident's MAR for the possible administration of routine or as needed medication. She stated if there was nothing in place, staff notified the physician. She was asked if staff were instructed to do anything prior to the administration of the medication. She stated, staff were instructed to assess the resident's pain prior to the administration of the medication, and after the administration to assess for the effectiveness. The DON was asked if the nurse's note, dated 01/10/17, documented on examination, no redness or skin tears were observed and the resident's physician and family were notified. She stated yes, this was related to an incident. She was asked if this was the most recent nurse's note for the resident. She stated, Yes it is. She was asked to review the resident's last skin assessment dated [DATE]. She was asked if the assessment documented the resident had dry skin with bruises present. She stated, Yes ma'am. She was asked if it documented the resident had any other skin issues. She stated, No ma'am. The DON was asked if on observation of the resident's skin on 01/11/17, was the resident observed to have a bright red blister type area under her right breast as well as pink discoloration across her lower abdomen. She stated, Yes. She was asked if resident #6 verbalized pain/discomfort when her right breast was lifted. She stated, Yes. The DON was asked if the resident had any orders to treat her pain. She stated, Yes. She stated the resident had an as needed order for Tylenol and [MEDICATION NAME]. The DON was asked to identify what pain medication, if any, was administered to the resident on 01/11/17. She reviewed the resident's medical record and stated the resident received Tylenol on the 11th at 5:30 a.m. She was asked if the resident received any other medications she stated, No. She was asked if the clinical record documented the resident was assessed for the effectiveness of her as needed Tylenol after it was administered. She stated, No ma'am. She was asked if the clinical record documented the resident experienced any pain on the 6:00 a.m. to 2:00 p.m. shift on 01/11/17. She stated, No, it doesn't. The DON was asked if staff should have administered the resident's as needed pain medication when the resident verbalized pain during her skin observation. She stated, Yes ma'am. The DON was asked to review the January 2017 MAR/TAR (treatment administration record). She was asked if it documented the resident still had an order for [REDACTED]. The DON was asked if the resident had received any skin care treatment to her right breast. She stated, I have [MEDICATION NAME] powder reads skin folds and peri area. She was asked to identify when this treatment had been administered to the resident in the month of January 2017. She stated, On the 11th. She was asked if there were any other days this treatment was documented as having occurred for the month. She stated, No. She was asked if staff should have assessed the resident and identified these skin issues. She stated, Yes. She was asked if the nurse's note, dated 01/10/17 was the latest note in the resident's clinical record. She stated, Yes. The DON was asked if LPN #3 should have documented the skin issues identified yesterday. She stated, Yes. The DON was asked to review the resident's clinical record and determine whether or not she could locate any documentation of the resident's change in skin condition which was observed by her and LPN #3 yesterday. She reviewed the record and stated, No ma'am. 2. Resident #60 had [DIAGNOSES REDACTED]. A wound care specialist's evaluation, dated 12/28/16, documented the resident had a post surgical wound of the right buttock. It documented, .DRESSING: Sterile packing gauze - Three times per week, Dry Protective Dressing - Three Times per Week, [MEDICATION NAME] - Three Times per Week .RECOMMENDATION: [MEDICATION NAME] powder to wound . POST-SURGICAL WOUND OF THE RIGHT BUTTOCK - IMPROVED EVIDENCED BY DECREASING SURFACE AREA, DECREASED UNDERMINING . Discontinue: Hydrogel - Twice Daily .Continue: Sterile packing gauze - Three Times per Week, Dry Protective Dressing - Three Times per Week Recommendation: [MEDICATION NAME] powder to wound . The evaluation was electronically signed by the wound care physician. The most current physician's order, dated 12/28/16 documented, .cleanse area On Right hip (with) Normal saline, sprinkle [MEDICATION NAME] powder over packing gauze. Pack abscess and cover with gauze three times a week on Tuesday, Thursday and Saturday . A non-pressure wound progress note, dated 12/28/16, documented the resident had a post surgical wound to the right buttock. A wound care specialist's evaluation, dated 01/06/17, documented the resident had a post-surgical wound of the right buttock. It documented, .DRESSING: Sterile packing gauze - Three Times per Week, Dry Protective Dressing - Three Times per Week, Leptospermum honey - Three Times per Week and PRN . RECOMMENDATION: put approximately 5 ml (milliliters) of leptospermum honey in wound cavity, then pack with gauze coated with honey and cover . Continue: Sterile packing gauze - Three Times per Week, Dry Protective Dressing - Three Times per Week . Add: Leptospermum honey - Three Times per Week and PRN . Recommendation: Put approximately 5 ml of leptospemum honey in wound cavity, then pack with gauze coated with honey and cover Non-adherence to plan of care - risks and benefits explained to the patient . The evaluation was electronically signed by the wound care physician. No documentation was located in the resident's clinical record that this recommendation was acted upon. A significant change resident assessment, dated 01/03/17, documented the resident was at risk for pressure ulcer development. Under the other ulcers, wounds and skin problems, it documented none of the above were present. It documented the skin ulcer treatments in place were a pressure reducing device for the bed and pressure ulcer care. A non-pressure wound progress note, dated 01/06/17, documented the resident had a post surgical wound to her right buttock. A care plan, last revised on 01/10/17, documented, .The resident has potential impairment to skin integrity of the (body) r/t (related/to) fragile skin . abscess to (right) buttock/sacral (another word crossed out).area . Encourage good nutrition and hydration in order to promote healthier skin .Follow facility protocols for treatment of [REDACTED]. Monitor/document location, size and treatment of [REDACTED]. 12/5/16 tx (treatment) to sacral/buttock areas ordered . 01/10/17 skin prep as ordered wound . The facility failed to provide consistent documentation as to what the resident's right hip wound was and whether the location was the right hip or the right buttocks. The documentation reflects both. On 01/17/17 at 12:04 p.m., the staffing coordinator stated she had medicated the resident for wound care and stated she would be ready in approximately 30 minutes. At 12:44 p.m., the staffing coordinator was observed providing wound care for the resident. She was asked to identify what medication she gave the resident prior to the wound care. She stated she had given the resident one milligram of [MEDICATION NAME] and 10 milligrams of [MEDICATION NAME]. She was observed removing one container of [MEDICATION NAME] powder (which was contained in a plastic bag), two skin barrier wipes (skin prep), a Smith and Nephew disposable ruler and a white cup from her treatment cart. She then entered the resident's room placed the items on the resident's bedside table and washed her hands with soap and water. She failed to wash her hands prior to obtaining the wound care supplies. She failed to clean the resident's bedside table or place a piece of wax paper on the bedside table prior to placing the wound care supplies on the table. The staffing coordinator was observed using the Smith and Nephew disposable ruler to measure two wounds on the resident's left foot and placed the ruler back on the bedside table. The staffing coordinator was observed removing her gloves and washed her hands with soap and water. She then exited the room, grabbed two white cups from the treatment cart and returned to the resident's room. She was observed removing dermacleanse body wash from a drawer located under the sink in the resident's room. She squeezed the dermacleanse into one of the white cups and added water from the resident's sink to the cup. She placed the cup on the bedside table. She washed her hands with soap and water. The staffing coordinator started to pick up a washcloth from the resident's bedside table. She was asked where she obtained the washcloth from. She stated she had obtained it prior to the wound care observation. She was observed leaving the resident's room and obtained a washcloth from a cabinet in the whirlpool room located on B Hall. The staffing coordinator returned to the resident's room, placed the washcloth on top of the white cup with dermacleanse and water located on the resident's bedside table, and washed her hands with soap and water. She donned a pair of gloves and rolled the resident onto her left side. She then opened the right side of the resident's disposable brief, placed the washcloth in the cup of dermacleanse and water, pulled the brief down, and cleaned the wound located on the resident's right hip in a circular motion with the soapy washcloth. She was observed taking the other end of the washcloth and used it to dry the area. The staffing coordinator was observed placing the soiled washcloth on the left side of the sink, removed her gloves and washed her hands with soap and water and donned a new pair of gloves. She then picked up the 5 gram container of [MEDICATION NAME] powder and the same Smith and Nephew disposable ruler. She was observed placing the ruler on the residents right hip wound and stated it measured 1.3 by 0.5. The wound tissue was observed to have purple discoloration present. She then squeezed the [MEDICATION NAME] powder into the wound and placed the container on the bedside table. The lid of the container was observed to be face down on the bedside table. She was observed positioning the resident in bed, removed her gloves, tore the disposable ruler in half, wrote on it with a pen and placed the half in her back scrub pocket and threw the other half away. The staffing coordinator was observed washing her hands, and recapped the [MEDICATION NAME] powder with the same lid which was face down on the bedside table. She was made aware of the lid being stored improperly/face down on the bedside table. She stated, Ok. She placed the bottle back into the plastic bag without the lid. The staffing coordinator walked over to the treatment cart located just outside the resident's room and obtained two trash bags, reentered the room and washed her hands. She obtained all of the trash in trash bag and tied it shut, washed her hands, and placed the trash in the grey trash barrel located in the hall. At 1:24 p.m., she was asked if she was complete with wound care. She stated she was finished with wound care. She was asked if she had washed/cleaned off the bedside table prior to placing supplies on it. She stated she had cleaned the table prior to being watched, but not while being watched. She was asked when the resident's right hip wound originated. She stated the wound was a blister that opened and she was not sure of the onset date. She was asked how she knew it was okay to use the dermacleanse body wash to clean the wound during wound care. She stated she used the same stuff they used during a shower to clean the wound. She was asked if the right hip wound was left open to air. She stated it was. The staffing coordinator was asked if she used the same disposable Smith and Nephew ruler to measure the two wounds on the resident's foot and the wound on her right hip. She stated, Yes I did. She was asked if the same ruler was now in her scrub pant pocket. She stated she ripped the side used for measuring off and took the other side to record her measurements. She was asked how often the resident was provided wound care to her right hip. She stated wound care was provided on Tuesday, Thursday and Saturday. At 3:15 p.m., the DON was asked to explain the resident's wound. She stated the resident's wound to her right hip was an abscess. She was asked how often the resident received wound care. She reviewed the resident's record and stated she received wound care three times a week for the abscess. The DON was asked to describe what role the wound care doctor played in the resident's care. She stated the wound care doctor usually came on Wednesdays. She stated she coordinated with him which residents he was going to see that day depending on their wound progress. She stated some residents were seen weekly and others it may be a couple weeks before their next visit. She stated after his visit, he always made recommendations. She stated the facility looked at each resident as a team including the residents primary physician and Medical Director #1, to determine the best course of treatment for [REDACTED]. The DON was asked if the abscess was facility acquired. She stated the nurse who originally identified the wound, identified it as a reddened area. She stated the nurse was utilizing a barrier cream to the resident's buttocks and discovered the abscess. She stated she believed it began more like a boil with drainage around it which spread to the resident's buttock. The DON was asked what treatment orders the resident currently had for the wound to her right hip. She reviewed the resident's current orders and stated the resident's current orders were to cleanse the area with normal saline, sprinkle [MEDICATION NAME] powder over packing gauze, pack abscess and cover with gauze three times a week on Tuesday, Thursday and Saturday. She was asked what staff should be using to clean the resident's wound. She was informed the resident's treatment administration record only documented [MEDICATION NAME] powder as the treatment for [REDACTED]. She stated the pharmacy had not typed that information specifica

Based on observation, record review and resident and staff interviews, it was determined the facility failed to: ~ assess, monitor and intervene for a resident who experienced pain for one (#5) of three sampled residents who were observed for pain and whose clinical records were reviewed for pain. This resulted in actual harm for the resident who continued to experience pain. ~ assess, monitor and intervene for a resident who experienced loose stools for one (#4) of one sampled resident who was observed with loose stools. The facility identified 74 residents resided in the facility, 65 residents with orders for as needed pain medications and 50 residents were incontinent. Findings: A facility's pharmacy services and procedure manual policy, dated 01/09, documented, .Procedure .New Order/New Admission: Facility will provide information regarding a new admission to the Pharmacy using a completed Physician/Prescriber Order Sheet (POS)/ Physician/Prescriber Order Form (POF) .Facility should ensure all resident information is complete and verified by physician/prescriber . Orders should be communicated to the Pharmacy as follows .Written Medication orders .Facility should ensure that medication orders are legible when sent to the Pharmacy .Verbal Medication Orders Telephoned Into the Pharmacy .If the medication is needed before the next scheduled delivery, Facility staff should phone orders into the Pharmacy to a licensed pharmacist. Facility should state the exact time by which the medication is needed Telephone orders should be followed by a faxed copy to the Pharmacy . A facility acute condition changes - clinical protocol policy, revised 12/15, documented, .Direct care staff, including Nursing Assistants will be trained in recognizing subtle but significant changes in the resident .and how to communicate these changes to the Nurse .addendum 9/6/16 .Report to charge nurse changes in residents (sic) daily practice, toileting frequency, and general concerns . 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission start up order sheet, dated 08/31/16, documented, .[MEDICATION NAME] 5/325 MG (milligrams) (one) PO (by mouth) Q (EVERY) 4 (HOURS) PRN (AS NEEDED) MILD PAIN .[MEDICATION NAME] 5/325 mg (TWO) PO Q 4 PRN SEVERE PAIN . A pain evaluation form, dated 08/31/16, documented the resident had experienced pain prior to arrival at the facility. The resident described the pain as aching and reported the pain increased with changes in position. The form documented the resident was not experiencing pain on admission to the facility. It documented the resident had received his last pain medication at 4:00 p.m. on 08/31/16. A hospital medical record, dated 08/31/16, documented the resident had received his last dose of [MEDICATION NAME] at 4:14 p.m. A nursing evaluation/data collection form, documented the resident was admitted to the facility from a hospital on [DATE] at 6:30 p.m. It documented the resident's active [DIAGNOSES REDACTED]. A skilled daily nurses note, dated 08/31/16 at 7:30 p.m., documented .new admit (admission) - meds (medications) clarified + (and) faxed to the Pharmacy . A skilled daily nurses note, dated 09/01/16 at 3:00 a.m., documented, .Resident admitted on [DATE]. Resident c/o (complains of) pain and was medicated (with) (two) tylenol (sic) 500 mg po for c/o Pain .@ (at) 0525 (5:25 a.m.) Resident rated pain from 1-10 - 2 on pain scale .0555 (5:55 a.m.) Res (resident) medicated c (with) (two) [MEDICATION NAME] 5mg/325 po for c/o pain . A fax transmission report, dated 09/01/16 at 3:02 a.m., documented the hard script copy for [MEDICATION NAME] 40 mg subcutaneous daily and the [MEDICATION NAME] 5/325 mg 1-2 by mouth every six hours as needed was successfully faxed to the pharmacy. A physician's orders [REDACTED]. The resident's Medication Administration Record [REDACTED]. A comprehensive care plan nor a comprehensive resident assessment had been developed for resident #5. On 09/01/16 at 3:50 a.m., resident #5 was observed lying in his bed with his left leg hanging off of the bed. Certified nurse aide (CNA) #3 assisted resident #5 with getting his left leg back on the bed. The resident was observed to be groaning in pain. Licensed practical nurse (LPN) #4 stated resident #5 was admitted at 7:30 p.m. last night. She stated the resident complained of back pain. CNA #3 stated, This is going to kill him with no pain med. CNA #3 stated resident #5 had a left hip repair and had no pain medication. LPN #4 stated it's on its way. LPN #4 and CNA #3 were observed turning resident #5 onto his right side. They were observed encouraging the resident by speaking calmly to him. They rolled the resident to his left side and removed a wet brief and incontinent pad. They were observed repositioning the resident in bed and propped his heels up off of the bed with pillows. At 4:05 a.m., resident #5 was interviewed and asked if he was hurting. He stated, Yes. He was asked when was the last time he was administered pain medication. He stated, Last night. He was asked to rate his pain. He stated his pain was a ten out of ten. He stated his pain was in his back and all over. At 4:15 a.m., LPN #4 was asked what the policy was for receiving medications for a new admission. She stated the orders should be STAT (immediately) ordered on all skilled residents. She stated it did not happen for this resident. She was asked what the receival time frame was when they ordered a STAT medication. She stated two hours. She was asked if the resident's pain medication had been ordered. She stated yes, she herself had ordered the medication at 2:15 a.m. She stated she had faxed the orders. She stated she was looking for the resident's medications and discovered his medications had not been ordered. She stated she left a message at that time. She stated she left the message with pharmacy at 3:00 a.m. She stated she had not received a response. She stated she faxed the script for the [MEDICATION NAME] 5/325 to the pharmacy at 3:02 a.m. LPN #4 was asked who was responsible for ordering medications for new admissions. She stated the person who admitted them was responsible. At 4:25 a.m., resident #5 was observed lying in his bed. He was observed attempting to get a drink of water from a cup which had a straw in it. He stated his back is hurting bad. At 4:45 a.m., LPN #4 was asked what time resident #5 had complained of pain. She stated he complained about pain around 2:30 a.m. She stated she did what she could do to take care of the resident she thought. At 4:47 a.m., CNA #3 was asked when she first observed resident #5. She stated during midnight rounds. She was asked if the resident complained of pain at that time. She stated, No. LPN #4 stated she had received a new order for Tylenol 500 mg two by mouth every four hours for pain. She stated the resident was administered the Tylenol at 4:30 a.m. At 5:00 a.m., resident #5 was observed lying in bed with his eyes open. He was asked how his pain was currently. He stated, Pretty bad. He was asked to rate his pain on a scale of one to ten. He stated his pain was, Nine or ten. He was asked if he had received any Tylenol. He stated, Yes. He stated, But that ain't no good. He was asked if he was able to rest. He stated, No. He stated it was too painful. He was asked if he told his nurse he was hurting. He stated, Yes. At 5:25 a.m., LPN #4 stated she had called the pharmacy and left a message to crash the medications. She was asked what crash meant. She stated the medications were to arrive within two hours. She stated STAT orders were to arrive in four hours. At 5:28 a.m., the director of nursing (DON) was asked what resident #5 rated his pain at. She stated the resident rated his pain at a two out of ten now. At 5:30 a.m., resident #5 was interviewed and asked how he was feeling right now. He stated, I'm hurting. He was asked to rate his pain. He stated, Nine or ten I guess. He was asked if he experienced any relief from the Tylenol. He stated, Not very much. At 5:50 a.m., the pharmacy was observed in the building to deliver resident #5's medications. At 5:55 a.m., LPN #4 was observed asking resident #5 how many pain pills he wanted. The resident stated he wanted two. LPN #4 was observed administering two [MEDICATION NAME] to the resident. At 6:20 a.m., resident #5 was observed lying in his bed with his left leg hanging off of the bed. He was asked how long he had been hurting. He stated, two to three days. He was asked to rate his pain. He stated, About a ten. At 7:10 a.m., resident #5 was observed lying in bed with his left leg hanging off of the side of the bed. He was asked to rate his pain. He stated his pain was about a nine. He stated he still hurt. At 8:40 a.m., resident #5 was observed being transported out of the facility by emergency transport staff. At 9:45 a.m., LPN #5 was asked the reason the resident was transferred out of the facility. She stated after the facility staff took the resident's vital signs, his oxygen saturation levels would not go above 80-82%. She stated the physician was contacted and gave orders to send the resident to the emergency room if he did not stabilize. She stated the resident was sent out because they were unable to stabilize him. At 10:07 a.m., the DON was asked to describe the procedure for obtaining medications in the facility for a new admission. She stated it depended on when the new resident admitted . She stated the staff tried to get the medications within four hours. She stated if the resident admitted in the evening around 10 p.m., it would be the next morning before staff would try and get the medications. She stated staff could also STAT order medications which would arrive within four hours. She was asked if the facility had an emergency pharmacy they used. She stated they did have two local pharmacies they could use but they did not have a 24 hour pharmacy. She was asked to explain what the facility policy was when they needed an emergent pain medication. She stated the staff could obtain an order for [REDACTED]. The DON stated staff could crash order a medication from pharmacy which would take 2-3 hours. At 10:15 a.m., the DON was asked if 2:30 a.m. when resident #5 complained of pain to 5:50 a.m. when the pharmacy delivered the resident's medication was an acceptable amount of time for a resident who was experiencing pain to wait for his pain medication. She stated, No. 2. Resident #4 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's progress note, dated 05/04/16, documented the resident was alert and oriented to person, place and time. A quarterly resident assessment, dated 05/28/16, documented the resident's cognition was severely impaired. It documented the resident required limited one person assistance with transfers and was occasionally incontinent of bowel and bladder. A physician's orders [REDACTED].questran (one) scoop/ 4 (four) gm (grams) PO BID (twice daily) x (times) 7 (seven) days . The July 2016 activities of daily living (ADL) record documented the resident had two to seven daily bowel movements ranging from small to extra extra large in size. A comprehensive resident assessment, dated 08/30/15, documented the resident's cognition was moderately impaired. It documented the resident required limited one person assistance with transfers and was occasionally incontinent of bowel and bladder. A care plan, last revised 08/30/16, documented resident #4 had an ADL self-care performance deficit related to conditions which included diarrhea, diuretic medication use and incontinency. The interventions identified included the staff were to provide resident #4 with the level and type of assistance needed including prompt toileting and thorough incontinent/peri care. The August 2016 ADL record documented the resident had two to six daily bowel movements ranging from small to extra extra extra large in size. The August 2016 medication administration/treatment record, documented the resident had received one dose of the [MEDICATION NAME] on 08/01, 08/06, 08/09, 08/14, and 08/19/16. A physician's progress note, dated 09/01/16, documented the resident was alert and oriented to person, place and time. On 09/01/16 at 4:51 a.m., the call light in resident #4's room was activated. CNA #1 was observed entering the resident's room. The resident was observed seated on the toilet with the bathroom door opened. Loose brown feces was observed on the resident's floor next to her bed and on the incontinent pad located on the resident's bed. CNA #1 was observed wheeling resident #4 into the shower room. She obtained a plastic bag and placed it onto the floor, washed her hands with soap and water and donned a pair of gloves. She was observed adjusting the water in the shower. She was asked to identify the brown substance located on the resident's left lower leg. She stated, That's poop. She stated that was why she decided to shower the resident. She stated the resident, has a real problem with having loose stools constantly. She pulled the shower chair over to the resident and the resident transferred herself into the chair. At 10:55 a.m., CNA #4 (the shower aide) was asked how often resident #4 experienced loose bowel movements. She stated the resident had loose bowel movements as often as every 20-30 minutes depending on what she drank. She was asked if she reported the loose bowel movements to anyone. She stated she would report them to the nurse if they occurred during the resident's shower. At 10:57 a.m., LPN #2 was asked how often resident #4 experienced loose bowel movements. She stated the resident had not complained of loose bowel movements to her. She stated LPN #3 would be more familiar with the resident. At 11:00 a.m., LPN #3 was asked how often resident #4 experienced loose bowel movements. She stated it depends. She stated here lately she had come the other day maybe one week ago she had 2-3 bowel movements. She was asked if the physician had been notified. She stated, I'd have to look in my charting. She was asked what the facility policy was for notifying the physician of bowel movements. She stated the staff would notify the physician when a resident hadn't had a bowel movement for three days. She stated there was no specific parameters. She stated if a pattern of loose bowel movements was identified on consecutive days she would notify the physician. She was asked to identify the resident's bowel pattern. She stated she would have to look at the resident's ADL record. She was given the resident's record and asked to identify the resident's bowel pattern and if the resident's physician was notified of any loose bowel movements. She stated she would have to look. At 11:02 a.m., CNA #5 was asked how often resident #4 experienced loose bowel movements. She stated during the day shift the resident had three to four loose bowel movements from morning to lunch. She stated the resident would have up to five loose bowel movements on her shift daily. She was asked if she reported the loose bowel movements to anyone. She stated she reported the loose bowel movements every time the resident experienced them. She stated she would report it to the nurse or the medication aide. She did not specify the name of the individual she reported the resident's loose bowels to. At 11:10 a.m., LPN #3 returned and stated she did not see where the resident's physician had been notified of loose bowels recently. She stated it looked like the resident had at least three bowel movements a day. She stated she was only aware of one day the resident experienced loose bowel movements recently. She stated she would review the resident's Medication Administration Record [REDACTED] At 11:14 a.m., CNA #2 was asked how often resident #4 experienced loose bowel movements. She stated, All the time. She was asked if she reported the loose bowel movements to anyone. She stated she reported them to the medication aide and identified CMA #1. At 11:16 a.m., LPN #3 returned and stated she did not see where the resident was administered her antidiarrheal medication on the day she was recalling. At 11:45 a.m., the DON was asked how often resident #4 experienced loose bowel movements. She stated the resident had loose bowel movements occasionally. She was shown the resident's bowel elimination record located on the ADL record. She stated she was unaware of the resident's bowel pattern. She was asked when staff notified the physician of bowel concerns. She stated there was no written policy she was aware of. She stated if a resident did not have a bowel movement for three days, the physician would be notified. She stated as a nurse, she would check for a as needed order to treat a resident's loose stools. She stated if the resident did not have an order, she would notify the physician. She stated it would depend on whether or not it was normal for the resident to experience frequent loose stools on whether or not she would notify the physician. She reviewed the resident's ADL record for July and August 2016 and stated the resident did seem to have several daily bowel movements. The DON was shown the seven day order for Questran 4 grams for loose stools dated 07/06/16. She was shown the ADL record for the seven days the medication was administered which did not document the resident experienced a decrease in bowel elimination during that time. She acknowledged the findings. She was asked to provide any documentation the resident's physician had been notified any time after 07/06/16 related to bowel elimination. On 09/06/16 at 8:00 a.m., the DON was asked to provide any information related to resident #4's bowels. She stated the resident's physician had seen the resident last week and did not want to collect a stool specimen related to the resident's frequent bowels. She was asked if the resident had any orders for medication to treat loose bowel movements. She stated, Yes, the resident did have an order for [REDACTED].>The DON was asked what the nurse aides, who provided care to resident #4, were instructed to do when they observed the resident having loose bowel movements. She stated the aides were to report the loose bowel movements to the charge nurse. She was informed of the interviews with the nurse aides and nurses. She was shown the medication administration for the as needed [MEDICATION NAME]. She stated, I'm trying to think why nurses wouldn't know. The DON was asked if the nurse aides should be communicating with the medication aides and nurses. She stated, Yes.

On [DATE], a past-noncompliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess and monitor a resident who was admitted post hospitalization for complications of diabetes including [MEDICAL CONDITION], ketoacidosis and also episodes of [DIAGNOSES REDACTED]. The resident also had [MEDICAL CONDITION]. The facility failed to ensure fingerstick blood sugars (FSBS) were obtained and as needed insulin was administered. The facility failed to ensure medication administration records (MARs) and treatment administration records (TARs) were developed and implemented. The resident was admitted on [DATE] at 6:00 p.m. and was found to be unresponsive with no vital signs on [DATE] at 3:00 p.m. At 3:35 p.m., the existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 4:10 p.m., the administrator and the regional clinical manager were notified of the existence of the past-noncompliance IJ. A plan developed by the facility on [DATE] documented: Plan for Admission Process with FSBS Monitoring 1. All resident [DIAGNOSES REDACTED]. 2. All identified residents have had orders reviewed for FSBS orders, sliding scale orders and if on TAR. 3. All nurses have been inserviced on Admission Process. Only facility nurses will do start up orders on new admissions and readmissions to include completion of MARS and TARS. 4. Two nurses will reconcile admission orders [REDACTED] 5. Nursing Management will review new and readmission charts daily to ensure orders are accurate and MARS and TARS have been completed. 6. Regional Clinical Manager or designee will audit all admissions x 1 month for accuracy and completeness. Any concerns will be taken to QA committee. The facility provided documentation to show all nurses had been inserviced and resident's records were reviewed on [DATE]. Nurses were interviewed and knowledgeable regarding the new process. Based on record review and interview, it was determined the facility failed to assess and monitor and ensure fingerstick blood sugars (FSBS) were obtained and as needed insulin and a potassium supplement were administered following the admission of a resident with known unstable blood sugars and low potassium for one (#1) of two sampled residents who were admitted with physician's orders [REDACTED]. The resident was admitted post hospitalization for complications of diabetes including [MEDICAL CONDITION], ketoacidosis and also episodes of [DIAGNOSES REDACTED]. The resident also had [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. The facility failed to ensure medication administration records (MARs) and treatment administration records (TARs) were developed and implemented. The resident was admitted on [DATE] at 6:00 p.m. and was found to be unresponsive with no vital signs on [DATE] at 3:00 p.m. The administrator identified 16 residents had FSBSs and 13 residents received sliding scale insulin. Findings: An undated 'Admissions Reminder List' documented, .The admitting nurse must complete the admit nurses note .complete start up for pharmacy, write out MARs and TARs . On [DATE] at 6:00 p.m., resident #1 was admitted to the facility. She had [DIAGNOSES REDACTED]. The hospital records documented the resident 's blood sugar was over 500 when admitted to the hopital and her blood sugar had been under 40 while hospitalized . (Fasting blood sugars should range from 70 to 100.) The admitting nurse was an agency licensed practical nurse (LPN), who upon reviewing the staffing sheets, had not worked between [DATE] and [DATE]. The admitting physician's orders [REDACTED]. The resident was to be administered insulin per a sliding scale according to the FSBS results four times a day with meals. She was also to receive a potassium [MEDICATION NAME] tablet four times a day with meals. The admitting nurse's note, dated [DATE] at 6:00 p.m., documented, the resident was offered a supper tray but had refused to eat. She voiced no complaints and stated she was 'OK'. The activities of daily living (ADL) sheets documented the resident was asleep when the bedtime snack was offered on [DATE]. A nurse's note, dated [DATE], untimed but signed by the 10 p.m. to 6 a.m. shift nurse, documented the resident's vital signs had been stable that shift and she had no complaints. The meal percentage record documented the resident had consumed 0% of her breakfast and was blank for the lunch meal on [DATE]. A social services note, dated [DATE] at 1:00 p.m., documented the resident had no complaints. A nurse's note, dated [DATE] at 3:00 p.m., documented the resident was unresponsive with no vital signs. Cardiopulmonary resuscitation (CPR) was initiated and the emergency medical system (EMS) was activated. The EMS pronounced the resident deceased shortly after arrival. No MARs and TARs were located. No documentation was located that a FSBS had been obtained since the resident had been admitted or that any insulin or potassium had been administered. On [DATE] at 10:20 a.m., the administrator was asked to locate the MARs and TARs for the resident. At 10:45 a.m., the medical records employee stated she could not locate the MARs and TARs. At 11:05 a.m., the pharmacist was asked if the pharmacuy had sent printed MARs and TARs to the facility for the resident. He stated the facility was responsible for handwriting the MARs and TARs for new admissions. The pharmacy only sends printed copies at the end of the month. At 11:20 a.m., the regional clinical manager was asked if she could locate the MARS and TARs. She stated they had been unable to locate them. She was asked if she could locate any documentation that FSBSs had been obtained from the resident. She stated she would look. She was asked if the facility had a policy or protocol for nurses to follow for admissions. She stated they did not have a policy but there was a list of what the admitting nurse was supposed to do. She was asked if agency nurses were oriented to the admission protocol. She stated, We don't let the agency nurses do admissions right now. She was asked if an agency nurse had admitted the resident. She stated an agency nurse had admitted the resident but they were not allowing them to conduct the admissions at present. At 11:35 a.m., CMA #1 was asked if she had given the resident any medications on [DATE]. She stated, I didn't. At 11:40 a.m., the discontinued medications were reviewed with the regional clinical manager. The resident's potassium card had two pills removed. She should have received three doses. The resident's insulin was not located. She was asked again if she had located the documentation for the FSBSs. She stated, We have no documentation, either way, about whether she got her meds (medications). At 12:00 p.m., the nurse reference manual was reveiwed. Numerous forms regarding admissions were located in the manual. The regional clinical manager was asked if any of the forms in the manual were new. She stated the forms had been there for quite awhile, but the nurses weren't using them. She stated the nurses had been reinserviced on how to use the forms. She was asked if they had conducted an investigation following the death of the resident. She stated they had. She stated that was why they had made some changes to the admission protocol. At 1:40 p.m., the social services director was asked if she had spoken to the resident at 1:00 p.m. on [DATE]. She stated she had. She was asked if she knew if the resident had been offered meal trays during her stay. She stated there were two meal trays on the bedside table when she visited with the resident at 1:00 p.m. She stated the trays had not been consumed.

On 04/28/14, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's neglect to protect a resident from, 'force-feedings' by family members. The facility failed to identify, monitor, reassess and intervene in the, 'force-feedings'. The administrator and the director of nursing (DON) neglected to investigate the family, 'force-feeding' the resident. At 5:18 p.m., the existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 5:35 p.m., the administrator and the DON were notified of the existence of the IJ. At 7:25 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: "Plan of Removal for immediate Jeopardy for on (sic) Neglect 1. All the staff will be immediately inserived (sic) on the Abuse and Neglect Policy with focus on possible family and or visitor abuse of the resident by 3 p.m. on 4/29/14. 2. The Inservice will include identification of Abuse and Reporting of Abuse. 3. During the Inservice they will be asked if they have witnessed or if it has been reported to them that a family member or visitor may have abused a resident. 4. The resident that the surveyors have identified as failure to supervise and prevent neglect of, no longer resides at the facility. 5. New employees will be inserviced on first orientation day of what Abuse and Neglect is with Reporting of Allegation of Abuse. 6. Staff will be able to verbalize back what Abuse and Neglect is with Reporting Process. 7. Any allegations of Abuse and/or Neglect will be fully Investigated (by the) Social Services Director and Administrator with appropriate interventions put in place. 8. Any family member or visitor that is suspected of Abuse or Neglect will not be allowed to be with the resident without continued staff observations. 9. Family members and/or visitors will be educated and monitored by staff for compliance of Abuse and Neglect Policy. 10. Any investigation that substantiates an allegation of abuse and neglect will be reported to appropriate agencies." On 04/29/14, the inservice documentation was reviewed. The abuse policy was re-inserviced. Examples of possibly abuse discussed were force-feeding, isolation, physically making a resident take a shower and withholding/forcing medications. Force-feeding was defined as "compel to take in nourishment, to make people or animals swallow food against their will, may be by funnel or tube down the throat." Twenty four staff members were interviewed. All stated they had been inserviced and were able to verbalize potential abuse and neglect, along with the reporting process. The IJ was removed on 04/29/14 at 3:00 p.m., when all components of the plan of removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on observation, record review and interview, it was determined the facility failed to intervene and protect one (#1) of five sampled residents from force-feedings. The facility failed to identify, monitor, reassess and intervene in the 'force-feedings'. The administrator and the DON neglected to investigate and stop the family from, 'force-feeding' the resident. The facility identified 9 residents were dependent with their eating needs. Findings: The facility's abuse policy documented, "POLICIES AND PROCEDURES Subject: Resident Abuse Effective Date: 09/12 POLICY: It is inherent in the nature and dignity of each resident at (corporate name) that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of [REDACTED]. PROCEDURE: I. Definition of Resident Abuse: A. An abusive act is any act or omission, which may cause or causes physical, psychological or emotional harm or injury to a resident or any act which willfully deprives a resident of his rights by law or as stated herein... D. Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action... E. Furthermore, the Facility Administration recognizes that the resident abuse can be committed by other residents, visitors, or volunteers... IV. Employee Obligation A. All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights... V. Prevention (corporate name) is committed to the prevention of abuse, neglect, or misappropriation of property. The following systems have been implemented:..4. Monitoring of residents who may be at risk... PROTECTING INDIVIDUALS FROM ABUSE Report all complaints and any suspected abuse. Abuse in improper treatment that affects a person physically or emotionally; it is your legal responsibility to respect people's rights and to protect them from physical or mental harm...Recognize various forms of abuse, and protect people from any physical or mental hard(sic)... Examples of abuse: ...forcing utensils into the resident's mouth..." Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 02/03/14, documented the resident had severely impaired cognitive skills and required extensive assistance of one person for most activities of daily living (ADLs). She was able to propel herself around the facility in a wheelchair and was able to feed herself with supervision. The care plan, dated 02/03/14, documented: " Problem: I receive a therapeutic diet... I am a diabetic... I have no natural teeth or dentures so I am at risk for mouth/gum pain... I am able to feed myself after set up assist - I am at risk for malnutrition and weight loss... Interventions: Diet as currently ordered with ground meat - monitor for acceptance - compliance and percentages... RD (registered dietician) to assure I am receiving adequate hydration and nutrition... Watch for excessive thirst and voiding - changes in LOC (level of consciousness)..." The monthly physician's orders [REDACTED]. A nurse's note, dated 04/04/14, documented, "...(primary physician's assistant's name) here to see resident. Resident has been leaning to Rt (right) side. (Decreased) fluid, solid intake..." A physician's progress note, dated 04/04/14, documented the resident was "leaning" and had decreased level of consciousness and decreased food and fluid intake. It also documented, "...Pt. (patient) started leaning to R approx (approximately) 2 days ago. R arm and R leg limp. Spoke to family @ (at) length re: (regarding) end of life...dementia = advanced - now has a decline over the last week - worse x (times) 2 days... Impression/Plan: prog. (progressive)[MEDICAL CONDITION]/ (decreased) LOC... Exam: Pt. not opening eyes, not following direction..." A nurse's note, dated 04/05/14 at 8:00 a.m., documented, "Resident assist up to w/c (wheelchair) - Appears very stiff. Eyes large - no reaction to tactile stimuli...Attempt to feed - letting food run from mouth..." The April 2014 MAR (medication administration record) documented, "4/5 8p Res unable to take 4pm meds" The April 2014 MAR indicated [REDACTED] A nurse's note, dated 04/08/14 at 12:00 noon, documented, "...nonresponsive to verbal stimuli. Keeps head bowed...appetite 50%..." A nurse's note, dated 04/11/14 at 8:30 a.m., documented, "Unable to swallow am (morning) meal - letting food run from mouth...unable to get to drink fluids. Family (and) (Physician's name) assist (assistant) to meet over resident condition this afternoon..." A nurse's note, dated 04/12/14 at 1:00 p.m., documented, "...Resident assisted to w/c in D/R (dining room) - daughter here to feed resident lunch - fair appetite c (with) extreme encouragement from daughter..." A nurse's note, dated 04/13/14, documented, "Family force feeds resident. Spoke c family risks for aspiration. Family stated they understand, yet continues to force feed solids and fluids..." A physician's orders [REDACTED]. [MEDICATION NAME] 0.5 give 1/2 PO (by mouth) BID (twice a day) - hold am dose if sedated. Hydro/acetamin ([MEDICATION NAME]/[MEDICATION NAME], a pain medication) 5mg/325 1 tab PO TID (three times a day) Hold if resident sedated. Check with nurse prior to giving [MEDICATION NAME] 0.5mg and Hydro/acetamin 5mg/325mg for sedation level..." A nurse's note, dated 04/16/14, documented, "Family continues to force feed solids and fluids. Sat close to resident if aspiration occurs. Will cont (continue) to monitor..." The April 2014 MAR indicated [REDACTED] The April 2014 MAR indicated [REDACTED] 8pm held [MEDICATION NAME] and klonopin res. sedated per charge nurse..." A nurse's note, dated 04/19/14 at 5:30 p.m., documented, "...This nurse noticed daughter forcing food into resident mouth. Explain to daughter that resident could aspirate. She stated my mom needs to eat. Family members force mouth apart to put food in. Daughter couldn't understand why we couldn't force fluids or food. Explained to her resident has the right to refuse to eat. She stated Well I can." The April 2014 MAR indicated [REDACTED] On 04/24/14 at 4:05 p.m., the resident was observed. She had just received incontinent care and was being repositioned in the bed. She was non-responsive to verbal or tactile stimuli. She did not open her eyes or respond in any way during the repositioning. Her feet and ankles were showing signs of mottling. The family members stated the resident had not been able to eat or drink in three days. A nurse's note, dated 04/25/14 at 5:45 a.m., documented, "...Report given to paramedics about (Resident Name) being @ end of life care. She has been unable to swallow any food or fluids since Tuesday per family statement about eating. Resident is unresponsive to verbal stimuli or sternal rub..." The resident was transported to the emergency room at this time. The hospital discharge summary, dated 04/26/14, documented the resident was admitted on [DATE] with "bilateral healthcare-associated pneumonia present on admission...Large left [MEDICAL CONDITION] with mass effect..." On 04/28/14 at 2:50 p.m., licensed practical nurse (LPN) #19 was asked if she had observed resident #1's family feeding her since the first part of April. She stated, "Yes." She was asked if she would describe her observations of how the family had fed the resident. She stated they would tilt and hold her head back, pry her mouth open and put food in." LPN #19 was asked if the resident was awake and alert. She stated, "No." She was asked if the resident ever coughed. She stated, "No." She was asked if she had told anyone of her observations. She stated she had told the DON and the administrator. She was asked if she knew what had been done after she reported to them. She stated she thought they had explained the risk of aspiration to the family. LPN #19 stated she had explained the risk of aspiration to the family a couple of times. The family verbalized understanding but, "would keep on doing it anyway." She was asked if she had documented any of the observations or instructions to the family regarding the aspiration risk. She looked through the nurse's notes and stated, "I didn't even document any of my observations." She stated none of the entries were hers. At 3:05 p.m., certified nurses aide (CNA) #5 was asked if she had observed resident #1's family feeding her. She stated, "Yes." She was asked to describe what she had observed. She stated they would pick her head up and give her a bite. She was asked if the resident would open her mouth for the bite. She stated, "Sometimes." She was asked if she had notified anyone of her observations. She stated, "My charge nurse." At 3:15 p.m., the DON was interviewed. She was asked if she had observed the family feeding resident #1. She stated, "No." She was asked if she had ever been told about the family feeding the resident. She stated she had heard some rumors from a couple of CNAs about them pushing her head back and giving her bites. She stated the feedings were discussed in standup one day, about making sure the family was aware of the aspiration risk. She was asked if she had ever considered the resident's rights or the possibility of abuse with the feedings. She stated she knew the administrator was aware of the situation and thought she was probably dealing with it. At 3:35 p.m., the administrator was interviewed. She was asked if she had observed the family feeding resident #1. She stated, "No." She was asked if anyone had reported any concerns about the way the family was feeding resident #1. She stated social services had gotten involved in that a little bit. She was asked if anyone had reported the family was 'force-feeding' the resident. She stated, "I don't know if it was actually force-feeding, but they told me the family was feeding her." She was asked if she had been told of the family pushing the resident's head back, forcing her mouth open and then placing food in her mouth. She stated, "No." She was asked if anyone had ever reported this was happening with the resident being non-responsive. She stated, "No." She was shown the nurse's notes and after reviewing them she stated what was documented had not been reported to her. She then stated, "That could be abuse." She stated she had been told they were lifting her head up and coaxing her to open her mouth with a spoon. At 3:45 p.m., social services joined the interview at the administrators request. She was asked if she had observed resident #1's family feeding her over the last couple of weeks. She stated, "I saw them force-feeding her." She was asked to explain what she had observed. She stated the resident had gotten to where she kept her head down and the family would pick it up, place the spoon to her mouth until she opened it and massage her cheeks until she would swallow. She was asked if the resident was awake or unresponsive. She stated, "Her eyes were open and she would swallow." Social services was asked if she had ever considered what she observed to be possible abuse. She stated, "I asked someone about it, but they told me it wasn't abuse because she was awake and swallowed." The administrator stated she had probably been the one to tell her this. Social services was asked, what if they forced her head back, pried her mouth open and put food in her mouth. She stated if the resident was awake and swallowed, it was not abuse. She was asked what if the resident was nonresponsive. She stated, "That could be abuse." Social services was asked if she could locate any of her documentation regarding the feedings. She stated she had not documented it. The administrator discussed with social services what could possibly be considered abuse. Social services then stated she didn't really mean 'force feeding', maybe she should have said 'strongly encouraged'. Social services was asked if she had not been concerned about her observations, why did she ask someone if this could possibly be abuse. She gave no reply. The administrator stated she thought the resident was surrounded by people who would be with her if she choked. She was asked if a staff member was with the resident during the feedings. She stated the family was with her and they could have gotten the attention of the nurse in the dining room. She stated, "That is why we have a nurse in the dining room, to watch those residents with an aspiration risk." Both the administrator and social services were asked if they had considered supervising the family while feeding the resident. Social services stated the family would often take the resident to the far corner of the lobby, away from the dining room, and turn the chair's back to the dining room where the nurse could not see her. She stated she would sometimes walk over to the table and tell the family about the aspiration risk. She stated one family member would tell her they understood but no one was going to tell them how to care for the resident. The administrator was asked if she had investigated the feedings. The administrator stated, "No."

On 04/28/14, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent 'force-feeding' of a resident with a known aspiration risk. The facility failed to identify, monitor, continue to monitor, reassess and intervene in force-feedings of a resident by the family members. At 5:18 p.m., the existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 5:35 p.m., the administrator and the DON were notified of the existence of the IJ. At 7:25 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: "Plan of Removal for Immediate Jeopardy for Supervision with Hazards 1. Residents that are identified as having a swallowing problem or at risk for aspiration of meals will be monitored in the main dining area by staff. 2. C.N.A.'s (certified nurse aide) and C.M.A.'s (certified medication aide) will report to Charge Nurse any resident that they observe having difficulty with swallowing. They will be inserviced on reporting these concerns to the Charge Nurse by 3 p.m. on 4/29/14. 3. The Charge Nurse will make the physician aware of any concerns with the residents identified of having swallowing or aspiration concerns. 4. Staff will observe families that chose (sic) to feed their loved ones at meal times to ensure that no resident is being force fed. Force feeding will be defined for staff. 5. If the staff observes a resident being force fed, they will immediately notify their Charge Nurse. The Charge Nurse will Immediately notify the Director of Nursing or Administrator and the attending physician. 6. Any reports of force feeding will be fully investigated by Social Services Director and Administrator. Those individuals will be reported to the appropriate agencies. 7. The family member and/or visitor that is suspected of force feeding a resident will be educated on aspiration concerns with that resident having to take their meals in the dining area for continued staff observation. This will ensure that they are not neglecting their loved one. 8. Speech therapy will screen any resident that is identified as having a swallowing or aspiration concern. A room roster will be utilized to initially identify those residents. 9. New employees will be educated on reporting of residents with swallowing or aspiration concerns." On 04/29/14, the inservice documentation was reviewed. Aspiration risk was discussed along with interventions to ensure supervision for those residents identified at risk. Force-feeding was defined as "compel to take in nourishment, to make people or animals swallow food against their will, may be by funnel or tube down the throat." Twenty four staff members were interviewed. All stated they had been inserviced and were able to verbalize potential aspiration risks along with the reporting process. The IJ was removed on 04/29/14 at 3:00 p.m., when all components of the plan of removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on observation, record review and interview, it was determined the facility failed to ensure residents with known aspiration risks were supervised. The facility failed to identify, monitor, continue to monitor, reassess and intervene in 'force- feedings' of a resident by the family members. The facility failed to ensure: ~ one (#1) of five sampled residents with an aspiration risk was not 'force-fed', ~ one (#3) of five sampled residents with an aspiration risk was not given fluids via a syringe without the facility's knowledge and ~ one (#4) of five sampled residents with an aspiration risk was supervised while consuming meals in her room. The facility identified 12 residents with an aspiration risk. Findings: 1. Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 02/03/14, documented the resident had severely impaired cognitive skills and required extensive assistance of one person for most ADLs (activities of daily living). She was able to propel herself around the facility in a wheelchair and was able to feed herself with supervision. The care plan, dated 02/03/14, documented: " Problem: I receive a therapeutic diet... I am a diabetic... I have no natural teeth or dentures so I am at risk for mouth/gum pain... I am able to feed myself after set up assist - I am at risk for malnutrition and weight loss... Interventions: Diet as currently ordered with ground meat - monitor for acceptance - compliance and percentages... RD (registered dietician) to assure I am receiving adequate hydration and nutrition... Watch for excessive thirst and voiding - changes in LOC (level of consciousness)..." The monthly physician's orders [REDACTED]. A nurse's note, dated 04/04/14, documented, "...(primary physician's assistant's name) here to see resident. Resident has been leaning to Rt (right) side. (Decreased) fluid, solid intake..." A physician's progress note, dated 04/04/14, documented the resident was "leaning" and had decreased level of consciousness and decreased food and fluid intake. It also documented, "...Pt. (patient) started leaning to R approx (approximately) 2 days ago. R arm and R leg limp. Spoke to family @ (at) length re: (regarding) end of life...dementia = advanced - now has a decline over the last week - worse x (times) 2 days... Impression/Plan: prog. (progressive) CVA (cerebrovascular accident)/ (decreased) LOC... Exam: Pt. not opening eyes, not following direction..." A nurse's note, dated 04/05/14 at 8:00 a.m., documented, "Resident assist up to w/c (wheelchair) - Appears very stiff. Eyes large - no reaction to tactile stimuli...Attempt to feed - letting food run from mouth..." The April 2014, medication administration record (MAR) documented, "4/5 8p Res unable to take 4pm meds" The April 2014, MAR documented, "4-6 4p Res unable to take 4p meds..." A nurse's note, dated 04/08/14 at 12:00 noon, documented, "...nonresponsive to verbal stimuli. Keeps head bowed...appetite 50%..." A nurse's note, dated 04/11/14 at 8:30 a.m., documented, "Unable to swallow am (morning) meal - letting food run from mouth...unable to get to drink fluids. Family (and) (Physician's name) assist (assistant) to meet over resident condition this afternoon..." A nurse's note, dated 04/12/14 at 1:00 p.m., documented, "...Resident assisted to w/c in D/R (dining room) - daughter here to feed resident lunch - fair appetite c (with) extreme encouragement from daughter..." A nurse's note, dated 04/13/14, documented, "Family force feeds resident. Spoke c family risks for aspiration. Family stated they understand, yet continues to force feed solids and fluids..." A physician's orders [REDACTED]. Clonazepam 0.5 give 1/2 PO (by mouth) BID (twice a day) - hold am dose if sedated. Hydro/acetamin (hydrocodone/acetaminophen, a pain medication) 5mg/325 1 tab PO TID (three times a day) Hold if resident sedated. Check with nurse prior to giving Clonazepam 0.5mg and Hydro/acetamin 5mg/325mg for sedation level..." A nurse's note, dated 04/16/14, documented, "Family continues to force feed solids and fluids. Sat close to resident if aspiration occurs. Will cont (continue) to monitor..." The April 2014, MAR documented, "8p held Klonopin and Norco for 8pm, per charge nurse..." The April 2014, MAR documented, "4-18 8a Held Norco res too sedated... 8pm held norco and klonopin res. sedated per charge nurse..." A nurse's note, dated 04/19/14 at 5:30 p.m., documented, "...This nurse noticed daughter forcing food into resident mouth. Explain to daughter that resident could aspirate. She stated my mom needs to eat. Family members force mouth apart to put food in. Daughter couldn't understand why we couldn't force fluids or food. Explained to her resident has the right to refuse to eat. She stated Well I can." The April 2014, MAR documented, "4-19 8a Held Norco and Klonopin..." On 04/24/14 at 4:05 p.m., the resident was observed. She had just received incontinent care and was being repositioned in the bed. She was non-responsive to verbal or tactile stimuli. She did not open her eyes or respond in any way during the repositioning. Her feet and ankles were showing signs of mottling. The family members stated the resident had not been able to eat or drink in three days. A nurse's note, dated 04/25/14 at 5:45 a.m., documented, "...Report given to paramedics about (Resident) being @ end of life care. She has been unable to swallow any food or fluids since Tuesday per family statement about eating. Resident is unresponsive to verbal stimuli or sternal rub..." The resident was transported to the emergency room at this time. On 04/28/14 at 2:50 p.m., licensed practical nurse (LPN) #19 was asked if she had observed resident #1's family feeding her since the first part of April. She stated, "Yes." She was asked if she would describe her observations of how the family had fed the resident. She stated they would tilt and hold her head back, pry her mouth open and put food in." LPN #19 was asked if the resident was awake and alert. She stated, "No." She was asked if the resident ever coughed. She stated, "No." She was asked if she had told anyone of her observations. She stated she had told the DON and the administrator. She was asked if she knew what had been done after she reported to them. She stated she thought they had explained the risk of aspiration to the family. LPN #19 stated she had explained the risk of aspiration to the family a couple of times. The family verbalized understanding, but, "would keep on doing it anyway." She was asked if she had documented any of the observations or instructions to the family regarding the aspiration risk. She looked through the nurse's notes and stated, "I didn't even document any of my observations." She stated none of the entries were hers. At 3:05 p.m., CNA #5 (certified nurses aide) was asked if she had observed resident #1's family feeding her. She stated, "Yes." She was asked to describe what she had observed. She stated they would pick her head up and give her a bite. She was asked if the resident would open her mouth for the bite. She stated, "Sometimes." She was asked if she had notified anyone of her observations. She stated, "My charge nurse." At 3:15 p.m., the DON was interviewed. She was asked if she had observed the family feeding resident #1. She stated, "No." She was asked if she had ever been told about the family feeding the resident. She stated she had heard some rumors from a couple of CNAs about them pushing her head back and giving her bites. She stated the feedings were discussed in standup one day, about making sure the family was aware of the aspiration risk. She was asked if she had ever considered the resident's rights or the possibility of abuse with the feedings. She stated she knew the administrator was aware of the situation and thought she was probably dealing with it. At 3:35 p.m., the administrator was interviewed. She was asked if anyone had reported any concerns about the way the family was feeding resident #1. She stated social services had gotten involved in that a little bit. She was asked if anyone had reported the family was 'force feeding' the resident. She stated, "I don't know if it was actually force feeding, but they told me the family was feeding her." She was asked if she had been told of the family pushing the resident's head back, forcing her mouth open and then placing food in her mouth. She stated, "No." She was asked if anyone had ever reported this was happening with the resident being non-responsive. She stated, "No." She was shown the nurse's notes and after reviewing them she stated what was documented had not been reported to her. She then stated, "That could be abuse." She stated she had been told they were lifting her head up and coaxing her to open her mouth with a spoon. At 3:45 p.m., social services joined the interview at the administrators request. She was asked if she had observed the resident's family feeding her over the last couple of weeks. She stated, "I saw them force feeding her." She was asked to explain what she had observed. She stated the resident had gotten to where she kept her head down and the family would pick it up, place the spoon to her mouth until she opened it and massage her cheeks until she would swallow. She was asked if the resident was awake or unresponsive. She stated, "Her eyes were open and she would swallow." Social services was asked if she had ever considered what she observed to be possible abuse. She stated, "I asked someone about it, but they told me it wasn't abuse because she was awake and swallowed." The administrator stated she had probably been the one to tell her this. Social services was asked, what if they forced her head back, pried her mouth open and put food in her mouth. She stated if the resident was awake and swallowed, it was not abuse. She was asked what if the resident was nonresponsive. She stated, "That could be abuse." Social services was asked if she could locate any of her documentation regarding the feedings. She stated she had not documented it. The administrator discussed with social services what could possibly be considered abuse. Social services then stated she didn't really mean 'force feeding', maybe she should have said 'strongly encouraged'. Social services was asked if she had not been concerned about her observations, why did she ask someone if this could possibly be abuse. She gave no reply. The administrator stated she thought the resident was surrounded by people who would be with her if she choked. She was asked if a staff member was with the resident during the feedings. She stated the family was with her and they could have gotten the attention of the nurse in the dining room. She stated, "That is why we have a nurse in the dining room, to watch those residents with an aspiration risk." Both the administrator and social services were asked if they had considered supervising the family while feeding the resident. Social services stated the family would often take the resident to the far corner of the lobby away from the dining room and turn the chair's back to the dining room where the nurse could not see her. She stated she would sometimes walk over to the table and tell the family about the aspiration risk. She stated one family member would tell her they understood, but no one was going to tell them how to care for the resident. The administrator was asked if she had investigated the feedings. The administrator stated, "No." 2. Resident #3 had [DIAGNOSES REDACTED]. The facility identified the resident at being at risk for aspiration. The comprehensive resident assessment, dated 01/24/14, documented the resident had severely impaired cognitive skills with delusions. She was totally dependent, requiring two person assist for her ADLs. She was totally dependent on one person assistance for eating. Her dental status documented she had obvious or likely cavities or broken natural teeth. She required a mechanically altered diet. The care plan, dated 01/25/14, documented, "Problem: I need a mechanically altered diet due to HTN (hypertension) and increased risk of choking and aspiration - I have a poor appetite and am at risk for malnurition and dehydration - I am spoon fed meals as I have forgotten how to use my eating utensils... Interventions:...encourage extra PO (by mouth) fluids during meals and from hydration cart... Spoonfed (sic) me my meals - enc (encourage) me to use my utensils with reminders and cues..." The April 2014, monthly physician's orders [REDACTED]. A nurse's note documented by a hospice nurse, dated 04/14/14, documented, "...(Son's name) also expressed to this nurse they were giving his mom fluids by syringe (the family) because the NH (nursing home) would not. I explained NH could not due to high risk of aspiration. Coordinated care c (LPN #19 name)." On 04/29/14 at 12:35 p.m., resident #3 was observed being fed the noon meal by staff. She was observed taking fluids from a glass. At 1:45 p.m., LPN #19 was asked if she knew of any resident who was given fluids by a syringe. She stated, "No." She was asked if a hospice nurse had told her about a family member giving fluids through a syringe. She stated, "No, I would have reported that." At 1:50 p.m., the administrator was asked if she was aware of any residents who received fluids by a syringe. She stated, "No." She was shown the hospice note and she stated that maybe the minimum data set (MDS) coordinator knew about the syringe. She called the MDS coordinator into the office and asked her if she knew of any residents who were given fluids by a syringe. The MDS coordinator stated, "No." The administrator stated she needed to talk to the hospice services. They were asked to locate any documentation in the record the facility was aware of the syringe feedings and any interventions regarding them. No documentation was presented prior to exit. 3. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility identified the resident as at risk for aspiration. A nurse's note, dated 03/09/14 at 9:00 p.m., documented, "...Resident c/o (complained of) not being able to swallow very well..." An admission assessment, dated 03/17/14, documented the resident had severely impaired cognitive skills for daily decision making and required setup help with eating. The assessment also documented the resident coughed or choked during meals or when swallowing medication and was edentulous. A care plan, dated 03/24/14, documented, "...Problem: I need a mechanically altered diet with each meal-I have dysphagia...I am at risk of aspiration and choking-I do not have natural teeth...I have an esophageal hernia Goal: I will be well hydrated and my nutritional needs will be adequate Interventions:...Assist me as needed with each meal and watch for choking and aspiration... Assure I am in an upright position with chin down to protect my airway... Check my temp (temperature) and lung sounds daily as I am high risk for aspiration... May crush all applicable meds (medications)..." A Dietary Review Recommendations form, dated 03/28/14, documented, "...c/o (complains of) difficulty swallowing puree. Would you want swallow study done?..." The physician signed the form on 04/14/14. A Dietary Progress Note, dated 04/14/14, documented, "ST (speech therapy) eval (evaluation) complete. Current thin liquid diet is appropriate...has esophageal hernia but is not a surgical candidate..." Thirty-seven days had elapsed since the resident's first complaint on 03/09/14, two days after admission, until the physician signed the Dietary Review Recommendations form, dated 03/28/14, on 04/14/14. On 04/29/14 at 12:12 p.m., the administrator was asked to locate documentation of when the physician was notified of the resident's complaints of not being able to swallow. She stated she would give the record to the nurses to find the information. At 12:42 p.m., the resident was observed in her room in a recliner with her feet elevated. The noon meal was being served in the dining room. A CNA was asked if the resident was going to the dining room for lunch. She stated the resident ate breakfast and lunch in her room. At 2:00 p.m., the DON stated there was no documentation the physician was notified of the resident's complaints of a swallowing problem on 03/09/14. At 4:30 p.m., CMA #10 was asked if the resident had problems swallowing. She stated, "Yes," but she had not seen her choking. She was asked if the resident ate her meals in her room. She stated, "Yes." She was asked if anyone supervised the resident while she ate. She stated, "No," because she ate in her room. At 4:50 p.m., CMA #6 was asked if the resident had problems swallowing. She stated, "Not that I know of." She was asked if the resident ate her meals in her room. She stated, "Yes." She was asked if anyone supervised the resident while she ate. She stated, "No, she eats with the door closed." On 04/29/14 at 4:00 p.m., the administrator was asked if she was aware of the resident eating unsupervised in her room when she had been assessed and care planned as having swallowing problems and being at risk for choking. She stated she was not aware of the issue.

Based on observation, record review and interview, it was determined the facility failed to ~ ensure a comprehensive wound/skin assessment was conducted for a resident upon readmission from the hospital, ~ obtain wound care and skin care orders for a resident with a pressure ulcer and extremely reddened and excoriated skin on the buttocks, ~ ensure CNAs (certified nurses aides) informed the nurses about a resident's deteriorating skin condition and ~ implement interventions to aide in the healing of the residents current skin condition for one (#2) of two sampled residents whose records were reviewed for pressure ulcers. This resulted in actual harm to the resident. The facility identified two residents with pressure ulcers. Findings: The policy, Skin Management, documented, "...Upon admission, all residents are assessed for skin.... Residents admitted with skin impairments will have: a. Appropriate interventions implemented to promote healing; b. A physician's orders [REDACTED]. c. Wound location and characteristics documented in the Nurse's Notes... A Care Plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and further breakdown. The Care Plan should address, but is not limited to: ? Hydration ? Nutrition ? Preventive devices ? Physical activity ? Positioning requirements ? Proper body alignment..." The policy, Skin Program, documented, "...A licensed nurse will complete a total body assessment on each resident on admission and weekly...C.N.A. will observe resident skin condition daily during care and report skin conditions to the Licensed Nurse..." Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive resident assessment, dated 05/31/13, documented the resident had moderately impaired cognition. He required extensive assist of one to two persons for his ADLs (activities of daily living), which included bed mobility, transfers, and hygiene. He had an indwelling catheter and was always incontinent of bowel. The resident was identified as being at risk for the development of pressure ulcers. The CAA (care area assessment) Summary triggered pressures ulcers for careplanning and the facility had checked the triggered pressure ulcers area would be addressed in the care plan. The care plan, dated 06/14/13, documented, "...Problem: I have a bladder outlet obstruction...I have an indwelling foley catheter - and I am incontinent of bowel and at risk for alteration in skin integrity... Goal: I will have no signs or symptoms of UTI (urinary tract infection) - no [MEDICAL CONDITION] Interventions: (undated and handwritten after five interventions for catheter care ) Skin assessment per facility protocol... Updates: (handwritten) 1-17-14 - Open area to R (right) buttock Stage 2 - Tx (treatment) as currently ordered... Problem: I am at risk for an increase in pain and muscle spasms - a [MEDICAL CONDITION] with left sided weakness - [MEDICAL CONDITION] and I have gout... Goal: My pain and muscle spasms will be relieved with current interventions and I will have no breakthrough pain... Interventions:...Pressure relieving mattress to my bed... " No interventions were located for the reddened, excoriated skin. A Weekly Wound Assessment Sheet, dated 01/11/14 - 01/17/14, documented the resident developed a Stage II pressure ulcer on 01/15/14. The pressure ulcer was located on the right buttocks and measured 1.3 cm (centimeter) X 0.7 cm. No measurement of the depth or description of the wound bed or perimeter was documented. A physician's orders [REDACTED]. A nurse's note, dated 01/22/14, documented the resident was transferred to the hospital. A nurse's note, dated 01/25/14, documented the resident was readmitted to the facility. No documentation of the resident's skin status was located in the nurse's notes since he had been readmiitted. An Admission - Data Collection Form, dated 01/25/14, documented the resident had a stage II pressure ulcer on the right buttock. No comprehensive wound assessment was documented on the form. No documentation of a comprehensive skin/wound assessment was located in the record since the resident had been readmitted on [DATE]. No documentation of the reddened, excoriated skin was located. The admission orders [REDACTED]. On 01/28/14 at 3:33 p.m., resident #2 was transferred from the bed to a shower chair and taken to the shower room. After the resident was taken to the shower room, a trail of dime to quarter-sized drops of fresh blood and two areas of smeared blood were observed on the floor in the area between the bed and where the shower chair had been. At 6:41 p.m., the resident was in his room awaiting transfer to bed. He was asked about the blood on the floor with the earlier transfer. He stated he had a sore on his bottom and he had been scratching it. He stated the wound had stuck to the sheet when he was transferred and had "ripped my skin off" and he had bled on the floor. He stated the area "hurts." At 6:49 p.m., the resident was transferred to bed by CNA #2 and CNA #3 with the use of a mechanical lift. When the resident's incontinent brief was removed, a large area of his buttocks, his scrotum and his inner thighs were observed to be extremely red and excoriated. They had the appearance of ground beef. A dime-sized wound on the right inner buttocks was also observed. No dressing was observed. The entire area was covered in a whitish ointment. CNA #2 removed the brief and reapplied the ointment. He was asked what he was applying and he stated, "[MEDICATION NAME]." When applying the ointment, the resident was heard to say, "Hey, be careful. That's really sore." Both CNAs were asked if the condition of the resident's buttocks was usual for him. CNA #2 stated "No," He stated the resident did not look like this when he went to the hospital, just when he came back. CNA #3 stated that was correct. They were asked if the nurses knew what his buttocks looked like. Both stated they didn't know for sure, but thought they did. They were asked if they had told a nurse about the resident's skin condition. Both stated, "No." On 01/29/14 at 3:05 p.m., the DON (director of nursing) was asked if she could locate a comprehensive skin assessment since returning from the hospital. After reviewing the records, she stated, "No." The wound care nurse walked up and the DON asked her if she had done a skin assessment on the resident since he had returned from the hospital. She stated, "No." The DON asked her if she was here when he returned. She stated, "Yes." The DON then asked her why she hadn't done an assessment then. She stated she thought the next shift was going to do it. The DON was asked if she could locate the physician's orders [REDACTED]. After reviewing the record, she stated, "It must have been overlooked. He was getting a dressing before going to the hospital." She was asked if the resident's pressure ulcer had been dressed or treated since returning from the hospital. She stated, "It doesn't appear so." The DON stated CNA #3 (certified nurses aide) had reported the resident's wound to her last night and CNA #2 had called her this morning and reported the resident's skin status. She stated she had left a note for the wound nurse to assess it today. She stated dressing change orders for the pressure ulcer had been received this a.m. The wound care nurse was asked if she had assessed the wound today. She stated, "No." The DON and the wound care nurse were asked if they had seen the resident's buttocks. Both stated, "No." They were asked to look at the resident at this time. The DON, an LPN and a CNA proceeded to the resident's room. Upon entering the room, the DON said, "I hear you have a sore bottom." The resident replied, "Oh yeah, it hurts." The resident was turned to his right side and two areas were observed where blood began seeping from the upper buttock area. One area was observed on the right upper buttock where blood began dripping down the buttock. The decubitus on the right buttock was covered with a bordered foam dressing. The DON removed the dressing and observed the wound. The DON was asked if this was the normal condition of the resident's skin. She stated, "No." She stated he had looked like this once before and it was a yeast infection. She would notify the physician. On 01/30/14 at 12:20 p.m., the DON presented wound sheets, dated 01/30/14, for resident #2. The right buttock wound was described as a stage II pressure ulcer which measured 1 cm X 0.7 cm X 0.1 cm. with 100% granulation. The buttocks area was documented as a non-pressure ulcer wound measuring 19 cm X 19 cm.

Based on observation, record review, and interview, it was determined the facility failed to: a. ensure residents were assessed, monitored, and treated for [REDACTED]. 4 residents triggered for pain recognition and management review. This resulted in an IJ situation for a resident who had untreated pain during pressure ulcer treatment. b. ensure residents were properly positioned during meals for 4 (#7, 42, 45 and #53) of 7 sampled residents who were observed for positioning during mealtime in the front dining room. This had the potential to affect 12 dependent residents in the front dining room. Findings: 1. Resident #76 was admitted on [DATE], with multiple [DIAGNOSES REDACTED]. A pain evaluation, dated 08/15/11, was completed by the ADON, an LPN. It documented, "Does the resident have any diagnosis(es) which would give reason to believe he/she would be in pain? Yes. If yes, describe cause, origin of pain, [MEDICAL CONDITION] of pain , and prior treatment: wounds to (lower) extremities. Ask resident: Have you had pain or hurting at any time in the last 5 days? YES. If yes, date of pain onset: 08/15/11. As patient describes it. What does the pain feel like: Exhausting, Throbbing, and Sharp. Additional symptoms associated with pain: anxious. Pain is increased by: moving around...Times when pain is worse: Early morning, Morning, Afternoon, Evening, and Night. Pain location/type/frequency/intensity/duration: ...At present Pain level 10 at site A (right heel) and Site B (left outer foot)...worse it gets: Site A all day, site B all day. Pain effect on function: Has the resident had any of the following changes in daily activities or habits? Participation in activities, Inability to perform ADL's, Loss of appetite/weight loss, Decreased ability to concentrate, Ability to focus, concentrate, Decrease/increase in physical/social activity, and Changes in mood, and emotions. Nonverbal/noncognitive signs of pain: grimacing/distorted face, clenched jaw/teeth, frowning/scowling, glazed eyes/tearing, wrinkled brow, turned down mouth, fright, moaning, grunting, gasping, cursing, pallor, altered gait/posture/limping, strenuous or altered breathing, and fidgeting/irritability. Relief of pain: Pain is relieved by: medication and deep relaxation. What is the acceptable pain level: 9-10. Is the resident on a scheduled pain regimen? NO. Does the resident receive a PRN medication? NO... Conclusion:...Pain management intervention is necessary, refer to resident plan of care...Interdisciplinary Team (IDT) progress note: Monitor pain BID (and) prn 0-10 scale. Resident is able to verbalize pain. Was started on [MEDICATION NAME] QID routine (and) daily prn." There was no physician's order for pain medication until 08/18/11. A physician's order, dated 08/18/11, documented the resident was to receive a routine order of [MEDICATION NAME]/[MEDICATION NAME] 5mg/325mg qid at 6:00 a.m., 12:00 p.m., 6:00 p.m., and at 12:00 a.m. He ordered 1 [MEDICATION NAME]/[MEDICATION NAME] 5mg/325mg to be given daily as needed for pain. According to the resident's narcotic record for [MEDICATION NAME] and the 08/20/11 MAR, the first dose of pain medication was administered on 08/19/11 at 6:00 a.m. The resident's comprehensive assessment, dated 08/26/11, documented the resident was able to be understood by others, and was able to understand others. His cognition was moderately impaired. It documented he required extensive assistance with transfers, walking, dressing, toilet use, personal hygiene, and bathing. He had lower extremity impairment on one side. He used a wheelchair for mobility. He was frequently incontinent of bowel and bladder. No pain was identified. He had been on a scheduled pain medication routinely. He was at risk for pressure ulcers. He had one stage IV pressure ulcer upon admission, and two unstageable, deep tissue pressure ulcers upon admission, with measurements of 5.7cm length, 3.0cm width, and 1.0cm depth The most severe pressure ulcer was necrotic tissue (eschar). The care plan, dated 08/26/11, documented, "Problem: I am at risk for pain due to the severity of the wounds on my feet and I have [MEDICAL CONDITION] and [MEDICAL CONDITION]. I receive a pain med routinely which is effective at this time. Goal: Pain will be relieved with no breakthrough pain. Interventions: 1. Pain meds as currently ordered and monitor for side effects and med effectiveness. 2. Monitor me for breakthrough pain with interventions as currently ordered. Notify MD if ineffective." The care plan, documented, "Problem: I receive added support with my care through (Name-deleted) Hospice Care. Goal: All my needs will be met - I will be kept comfortable and pain free. Interventions: 1. Notify hospice of any changes in my condition. 2. Notify my MD and hospice of any complaints of pain or discomfort not relieved by interventions in place..." The MAR, dated September 2011, documented the routine [MEDICATION NAME] had been discontinued on 09/01/11 after the 6:00 a.m. dose. A physician's order, dated 09/011, documented [MEDICATION NAME] 5mg/325mg could be administered every 4 hours as needed for pain. The MAR indicated [REDACTED]. There was no documentation to indicate the results of the narcotic medication. No additional [MEDICATION NAME] narcotic pain medication had been documented as given for September 2011. On 09/16/11 at 10:35 a.m., LPN #1 stated he was ready to perform wound care. He informed the resident he was going to do the treatment on his feet. At 10:45 a.m., LPN #1 pushed the bedside table with the supplies on it to the resident's bedside and then washed his hands. CNA #2 entered the room to assist with the procedure. The CNA picked up the resident's leg. The resident moaned. The LPN stated to the resident, "I know, I know it hurts." He told the CNA to hold the leg. The LPN again stated, "I know (resident #76) I am sorry." He proceeded to clean the right heel with normal saline soaked 4x4's. The LPN was asked what stage the pressure ulcer was. He stated it was a Stage IV. The resident began moaning and pulling away from the CNA. The LPN opened a sterile Q-tip and applied Santyl to the darkened areas around the edges of the heel ulcer. He then applied wound gel to cover the rest of the wound. He stated, "Hold still (resident #76) I know it hurts. I just need to be a little quicker." The CNA stated to the resident, "Hold on, it will be just a second longer." The resident pulled his foot away from the CNA. The LPN placed the Calcium Alginate to fit the size of the wound bed. The resident flinched. The LPN stated, "Try to be still, I know it hurts." As the LPN applied the pad and wrapped the foot with [MEDICATION NAME] gauze, the resident continued to moan and grimace. The LPN washed his hands and donned a new pair of gloves. He was asked the stage of the pressure ulcer on the resident's left foot. He stated the ulcer was unstageable and had a light yellow drainage most of the time. He instructed the CNA to pull off the resident's sock. The resident began moaning. The LPN washed the left foot with the normal saline soaked 4 x 4. He stated, "Easy (resident #76), bear with me," as he attempted to pull the existing calcium alginate off. The resident moaned and pulled back his foot. The LPN stated, "I'm sorry (resident #76), it is stuck to a piece of your skin." He then patted the wound dry with a 4 x 4. He obtained a sterile Q- tip and applied the Santyl to the wound bed. He stated, "Try to be still," as the resident pulled back his foot. He cut the calcium alginate to the size of the wound and applied it to the wound bed. The resident continued to moan. The LPN stated, "Almost done," and applied the pad and wrapped the foot with gauze. The LPN stated, "(resident #76) you've gotta be still. I know it hurts. I'm sorry." The resident moaned and pulled is foot back. As he completed his treatment, the LPN stated, "Thank you for your pain tolerance. I know it hurts." At 11:15 a.m., after the treatments were completed, the LPN was asked if he premedicated the resident before doing the treatments. He stated, "They did, but the doctor upped his medications so he gets it routine. He gets it at 8:00 a.m., so I try to perform the dressing change as close to that as I can get. But even with that, you just touch his foot and he does that." The MAR for September 2011, documented no pain medication had been administered since 09/07/11. On 09/16/11 at 1:25 p.m., CMA #1 was asked if resident #76 appeared to be in pain. He stated he didn't believe the resident was in pain, he was just restless. At 1:40 p.m., the DON was informed of the observation of wound care for resident #76. She stated the previous day that they noticed he was having more pain. She was asked if she knew if his pain medications had been changed. The DON stated she knew he went out to the hospital, but didn't know if it got dropped at that time. She stated she would have to look at his chart. The DON was shown the resident's clinical record. She stated she did not know why they discontinued his routine pain medication. The DON was informed of the pain evaluation upon admission by the ADON that documented the resident's pain was 9-10 and the descriptions indicated by a checkmark. She was informed that pain medication was not initiated until four days later. The DON was asked if the hospice nurse had been in the room when the dressing change was being performed to see the resident's response. She stated, "No. I don't think they've observed any of the wound treatments or how he's responding to the treatment. They used to perform the dressing changes themselves, but they don't do that now." The DON was asked how the facility communicated with the hospice team. She stated hospice always talked to the charge nurse. The DON stated, "The RNs and LPNs talk to me and tell me what they've found. There is usually good communication. We sit down at care plan meetings and go over medications, complaints and their diagnoses." The DON was asked if there had been a care plan meeting with hospice regarding resident #76. She stated, "No." At 2:10 p.m., the DON was asked if a pain assessment had been completed by an RN since admission. She stated, "If it's not in the chart, no" On 09/16/11 at 2:18 p.m., LPN #4 was asked why the routine [MEDICATION NAME] had been discontinued on 09/01/11 for resident #76. She stated she had talked to the brother who wanted it discontinued because the resident seemed more confused and he could not understand his speech. He thought the [MEDICATION NAME] might be the reason he was trying to get out of bed. The LPN was asked if an RN assessed the resident's pain prior to the discontinuation of the [MEDICATION NAME]. She stated, "No, I called (name-deleted physician)." She was asked if she usually took a family member's word for medication changes. She stated, "No, not without calling the physician." On 09/16/11 at 2:35 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health regarding the facility's failure to assess, monitor, and treat resident #76's pain. At 2:45 p.m., the administrator and DON were informed of an IJ in the failure to assess, monitor and treat resident #76's pain. On 09/16/11 at 4:25 p.m., the administrator provided the survey team with a written plan of removal which documented: "...1. The resident's (resident #76) physician has been called and an order obtained for pain management medicine; [MEDICATION NAME]/325mg tid and 30 minutes prior to dressing change. Resident will be reassessed by a facility RN for pain today, 9-16-11. 2. Effective 9-16-11, all pain assessments for current residents and future admissions will be done by a facility RN. 3 There are 63 residents in house today, 9/16/11. All 63 will be assessed for pain. Any residents currently on PRN pain medications will be assessed for routine pain management and if needed new orders obtained by 4:00 p.m. 9-17-11. 4. All charge nurses and other facility nurses as well as CMA's and CNA's and any other direct care personnel will be inserviced on pain assessment and management by 4:00 p.m., 9-17-11 or before they assume duties on their next shift. To be conducted by the Director of Nursing. 5. All licensed personnel will review any change in pain medications with facility RN or DON prior to calling Dr. for orders. Effective 9-16-11. 6. The Director of Nursing for the facility will in-service and coordinate with the resident's hospice. All hospice licensed personnel will coordinate with the Director of Nursing when they are in the facility. 7. The Director of Nursing and Administrator will monitor this POC to ensure that it is completed as stated, 4:00 pm., 9-17-11. 8. The Administrator and Director of Nursing will continue monitoring the assessment and management of pain for all current residents and future admissions. (weekly and random)." At 4:25 p.m., the plan of removal was accepted by the survey team. On 09/21/11 at 11:20 a.m., after reviewing the facility's inservice information, pain assessments, care plans, and interviews with the staff, the Administrator was informed the IJ had been removed effective 09/17/11 at 4:00 p.m., after the last inservice had been completed. The deficient practice remained at a scope of actual harm at a pattern. 2. Resident #7 had [DIAGNOSES REDACTED]. The annual assessment, dated 08/16/11, documented the resident had severe cognitive impairment; required extensive assistance with dressing and eating; was dependent upon staff for transfers, hygiene and bathing; and did not ambulate. The care plan, dated 09/07/10, and most recently reviewed/revised 08/16/11, documented the resident used a wheelchair. The care plan addressed problems related to the resident's mood/behavior and increased risk for pain due to [MEDICAL CONDITION] and chronic back pain. An intervention for both problems included to "assist with positioning for comfort." The care plan did not address the use of a geri-chair nor did it address positioning the resident for comfort and to enable her to perform activities of daily living to the highest degree possible. On 09/12/11 at 12:50 p.m., during observation of the noon meal in the front dining room, the resident was observed leaning forward in her geri-chair. Her personal alarm cord was pulled tight on her right shoulder. At 1:10 p.m., the resident continued to lean forward. The personal alarm cord remained tight, pulling on the right side of the resident's top. On 09/19/11 at 5:30 p.m., during dining observations in front dining room, resident #7 was observed sitting in her geri-chair and leaning to her right side against the arm of the geri-chair. She remained in that position throughout the meal. 3. Resident #53 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 08/19/11, documented the resident had severe cognitive impairment; required extensive assistance with transfers, dressing, eating, hygiene and bathing. The resident did not ambulate. The care plan, dated 05/24/11, documented the resident required extensive assistance or was dependent upon staff for activities of daily living and used a geri-chair for mobility around the facility by staff. An intervention related to the problem of pain was for staff to "provide assist with positioning for comfort." On 09/19/11 at 5:30 p.m., during dining observations in the front dining room, the resident was observed sitting in her geri-chair and leaning to her right side against the arm of the geri-chair. She remained in that position throughout the meal. 4. Resident #42 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly assessment, dated 08/25/11, documented the resident had severe cognitive impairment; required supervision with eating; required extensive assistance with transfers, dressing and hygiene; and did not ambulate. The care plan, dated 03/08/11, documented a geri-chair was used to transport the resident to activities. The care plan did not include an intervention to ensure the resident was properly positioned for comfort and to enable her to perform ADLs to the highest degree possible. On 09/12/11 at 12:50 p.m., during dining observations of the noon meal in the front dining room, the resident was observed leaning against the right side of her geri-chair. She remained in the same position throughout the meal. On 09/19/11 at 5:30 p.m., during dining observations in the front dining room, the resident was observed sitting in her geri-chair and leaning to her left side against the arm of the geri-chair. She remained in that position throughout the meal. 5. Resident #45 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 08/26/11, documented the resident had severe cognitive impairment and was dependent upon staff for transfers, dressing, eating, hygiene and bathing. The assessment documented the resident did not ambulate. The care plan, dated 03/08/11, did not address the use of a geri-chair. The care plan did not address positioning the resident for comfort and to enable her to perform activities of daily living to the highest degree possible. On 09/19/11 at 5:30 p.m., during dining observations in the front dining room, resident #45 was observed sitting in her geri-chair and leaning to her right side. Her right arm and elbow were hanging over the arm rest. She remained in that position throughout the meal. On 09/19/11 at 6:12 p.m., the surveyor asked the DON to observe residents #7, 53, 42 and #45 and asked if she noted any problem. The DON stated, "Positioning." The surveyor asked if the poor positioning would make it difficult for the residents to eat. She stated, "Yes."

Based on observation, record review, and interviews, it was determined the facility failed to ensure residents received supervision to prevent accidents for 1 (#12) of 1 sampled resident who smoked cigarettes. The facility failed to provide supervision to ensure safe smoking practices which resulted in an Immediate Jeopardy (IJ) situation. The facility failed to: ~ supervise resident #12 while she smoked inside and outside of the facility. Resident #12 experienced burns on her chest and fingers while smoking. ~ protect other residents who resided on Hall D from the likelihood of accidents related to resident #12 smoking in bed in her room. This had the likelihood to affect 16 other residents who resided behind the fire doors on D hall. The facility identified five resident who smoked cigarettes. ~ provide supervision for 2 (#20 and #58) of 3 sampled residents who were reviewed for falls. Eight residents who triggered for falls and/or fractures were identified by staff interviews. Findings: 1. Resident #12 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Upon admission, the resident signed her admission papers which documented she understood the smoking policy and procedures. The policy documented the facility was "smoke-free." A smoking assessment was conducted upon admission documented the resident was unsafe to smoke cigarettes unsupervised. A nurse's note, dated 07/29/11, documented, "1:15 a.m. - Resident was smoking in phone room. Did not deny, c/o civil rights - explained to resident (facility) was a non-smoking facility & confiscated lighter and placed in med cart." A physician's telephone order, dated 7/29/11, "Visual checks q 30 min, supervised smoking only." A nurse's note, dated 08/01/11, documented, "0600 (6:00 a.m.) Resident was complaining all night about everything. Caught her smoking in room @ 0230 (2:30 a.m.). Confiscated lighter and reminded her this was a non-smoking facility." The resident's care plan, dated 08/04/11, documented, "Manipulative behaviors/accuses staff of stealing her cig/lighters/personal belongings. Is a smoker & requires supervision at all times while smoking. Demanding to smoke all hours of day & night Noted smoking at night in her room-cigarettes removed from room taken to nurse's station. Interventions: 1. Review smoking P&P, fire code w/resident as needed. 2. Request that family members/visitors leave cig/lighters at home. 3. Monitor clothes for burn areas from cigarettes. 4. Strict supervision, smoke only in designated areas per P&P and fire code." A nurse's note, dated 08/06/11, documented, "0500 (5:00 a.m.) - ...DON stated she has to be staff supervised...She does smoke her cigarettes down and she burns her fingers..." A nurse's note, dated 08/07/11, documented, "0600 (6:00 a.m.) - Informed day charge nurse of all of this and was informed by another staff member that when she came in, this resident was outside smoking and she was alone." A nurse's note, documented, "2030 (8:30 p.m.)...Resident constantly attempting to be given extra cigarettes but explained I have to follow rules...This LPN asked resident why (she continued to break the facility's rules) after she was very aware of rules on this (smoking policy)...Yeah, I know I'm not supposed to do it but I'll probably keep on doing it because what more can be done to me? Continued verbalizing intentions on being non-compliant and doing whatever she's used to doing because I'm a grown woman and I'm used to doing whatever I want." A nurse's note, dated 08/09/11, documented, "0700 (7:00 a.m.) - Cigarette smoke smelled in room 45. This LPN asked resident if she was smoking. She stated, yes. But she had put it out. She was informed that she could burn the building down. That if this continued that her cigarettes could be kept @ nurse's station d/t her non-compliance (with) smoking rules." The resident's comprehensive assessment, dated 08/09/11, documented her cognition was independent. She was able to make her own decisions and was her own responsible party. The assessment, under behaviors documented, "Interferes with care of others, yells and screams at other residents, resists care at times." She required extensive assistance with all ADLs and transfers. She had an impairment on the upper and lower extremities on both sides. (She was a paraplegic)." Her assessment documented she had pain constantly every day on a pain scale of "8" (from 1-10). She was on Remeron and Cymbalta for depression, Valium for anxiety, Baclofen for muscle spasms, Oxycodone (narcotic for pain), and a Fentanyl patch (narcotic for pain). A social services progress note, dated 08/09/11, documented, "Spoke (with resident #12) about smoking in her room - counseled." A social services progress note, dated 08/16/11, documented, "CP meeting with DON/Administrator/APS/resident: Hiding meds under pillow/checking pills, confronted about breaking all the rules." A nurse's note, dated 08/16/11, documented, "...Resident's room cont to smell like smoke throughout the night..." A nurse's note, dated 08/20/11, documented, "At 0830 (8:30 a.m.) called to hallway by CMA. Could smell cigarette smoke in hallway and in resident's room..." A nurse's note, dated 08/21/11, documented, "1430 (2:30 p.m.) - Early AM smelled smoke in resident's room..." A nurse's note, documented, "1500 (3:00 p.m.)...Saw resident fumbling (with) cig butts that res was hoarding them..." A physician's progress note, dated 08/22/11, documented, "Wound to L SC, suspect it may be a possible cigarette burn." A physician's telephone order, dated 08/22/11, documented, "Wound care - possible burn, Clean L subclavian wound w/NS." A nurse's note, dated 08/24/11, documented, "0600 (6:00 a.m.)...Resident's room cont to smell of smoke periodically throughout the night. (Resident #44)complained of smelling cigarette smoke this morning." A social services note, dated 08/24/11, documented, "SSD/DON/Administrator spoke with (resident #12) about smoking in her room again. Continues to deny it. We will start checking every shift to make sure there is no smoking at all in the room." A nurse's note, dated 08/26/11, documented, "...Charge (nurse) smelled smoke in room..." A nurse's note, dated 08/27/11, documented, "0815 (8:15 a.m.) - Another res notified this nurse that she smelled smoke in hall...Res denied smoking or having cigarettes in room. Notified DON...Back to res's room. Res dropping something in bedside table drawer as I opened door. This nurse opened drawer pack of Prime time cigarettes lighter & some half smoked butts in drawer. Taken out of res room to nurse station. Res stated I wasn't smoking in my room." A nurse's note, dated 08/27/11, documented, "2155 (9:55 p.m.) - Resident has been up 1/2 the night. CNA came to desk & said she smelled smoke in resident's room, though she denies this. She was counseled about smoking in room...5:30 a.m. - CNA was by her room smelled smoke again. She had 1 pkg cigarettes and a lighter on her chest. She jerked them away & said that's tough! She was told about regarding smoking regulation & told her I was going to notify (DON). re: smoking in room. Refused to give up her lighter & cigarettes to nurse. Denied she has cigarettes in room." A nurse's note, dated 08/28/11, documented, "Res in bed. This nurse & CMA went in to find cigarettes that off-going nurse & CNA stated was in there. Res stated, knock yourself out, handing us 2 purses & stated, you can take the blankets off if you want...room smells of cigarettes." A nurse's note, dated 08/29/11, documented, (no time), "This nurse went to resident's room, could smell cigarette smoke in hallway before getting to her room. This nurse asked her if she was smoking. Had no verbal response." A nurse's note, dated 08/29/11, documented, "1430 (2:30 p.m.)...Could smell cigarette smoke in her room. Res denies smoking in room...Res down the hallway said she was smelling smoke daily and at night when she goes to bed." A social services progress note, dated 08/30/11, documented, "Meeting with APS, administrator, DON and resident. Spoke again about smoking in her room and not following rules and regulations and saying things that are not true. Stated she would start following rules & regulations." A social services progress note, dated 09/01/11, documented, "...Room was very smoky. It was cigarette smoke." A physician's telephone order, dated 09/01/11, documented, "Visual checks q 30 min." A nurse's note, dated 09/02/11, documented, "0500 (5:00 a.m.)...Room smells of cigarettes. Did not observe her (with) any cigarettes or smoking..." A nurse's note, dated 09/05/11, documented, "0530 (5:30 a.m.) - This nurse could smell cigarette smoke @ her door. I opened her door & she had a cigarette in her L hand that she was smoking. I stated to her, I caught you smoking. Are these cigarettes from her. I asked her for the lighter or matches or both. She wouldn't give me either of these items. Call placed to DON and informed her of resident's behavior. She stated to pass onto the next shift about not getting her lighter or matches." A nurse's note, dated 09/09/11, documented, "2200 (10:00 p.m.) - Res went outside this pm (without) staff supervision & smoked...Up & about via w/c. Went outside alone for a smoke. Came back in & asked med nurse to take a cig smoke (with) her...Resident was found smoking in her room (without) supervision." A nurse's note, dated 09/12/11, documented, "0330 (3:30 a.m.) - This nurse could smell cigarettes in hallway. On entering her room it had a strong cigarette odor. I asked her if she was smoking & she stated, No, I wouldn't do that. Informed her of the dangers of smoking in bed. She continued to deny smoking." A nurse's note, dated 09/14/11, documented, "3:00 a.m. - CNA & myself could smell strong odor, smoke in hall by this resident's door. I entered her room & stated to resident, you're smoking in here, give them to me. Resident denied. Informed of smoking policy AGAIN. Resident pulled a lighter out of covers and gave to LPN and also reached under the covers @ her chest area and gave her a smoked cigarette butt. Asked if she had been burned by the cigarette, she shook her head no. Assessed resident all over. No burns observed." The care plan had not been evaluated and revised to include new interventions to prevent the resident from smoking in bed in her room. At 5:05 a.m., LPN #2, the back hall charge nurse, was asked if the resident had been caught smoking in her room. She stated, "Yes." She was asked if the facility had developed a plan to monitor the resident. She stated, "The resident was to be observed every 30 minutes around the clock. This was started the 1st time the resident was caught smoking in her room." At 5:14 a.m., CNA #3 verified the resident had been caught smoking in her room. She was asked what measures had been implemented to monitor the resident during the night. She stated, "The resident is supervised when smoking outside. She is not to have any cigarettes in her possession and is checked every 2 hours." At 5:18 a.m., CNA #4 verified the resident had been caught smoking in her room. She was asked what measures had been implemented to monitor the resident during the night. She stated, "Just document it in the nurses' notes when she is caught smoking. The resident can't go outside to smoke after 9:00 p.m. and the resident is checked every 2 hours." At 5:27 a.m., LPN #3, the front hall charge nurse was asked about the resident smoking in her room and what measures had been put in place to monitor the resident. She stated, "It is written in her chart to monitor her behaviors. The resident was caught smoking in her room again last night." The LPN stated she took the resident's cigarettes and lighter from the resident. The LPN did not mention how often the resident was to be checked. At 5:54 a.m., CNA #5, working on the back hall, verified a strong smoke smell and smoke had been seen in the resident's room. She was asked what measures had been put into place to monitor the resident. She stated the staff were supposed to try to catch the resident smoking. She stated the charge nurse did everything else. At 7:30 a.m., LPN #2, the front hall charge nurse was asked if the resident had been smoking in her room during that shift. She stated the resident was caught smoking in her room. On 09/14/11 at 4:00 p.m., the administrator was asked about the resident and her smoking in her room. He stated, "We have confiscated her lighters and cigarettes numerous times. We don't know where she is getting them. We implemented a 30 minute watch a week ago and again yesterday. I have talked to her numerous times and she says she knows it's wrong but she is smoking anyways." At 5:00 p.m., the resident came to the conference room with the survey team. She was asked if she smoked in her room. She stated, "Yes, I did smoke in my room. I figured negative attention is better than no attention." On 09/14/11, an Immediate Jeopardy (IJ) situation was determined to exist in the failure to: a. supervise resident #12 to prevent her from smoking in her room. b. supervise resident #12 while she smoked outside of the facility. Resident #12 experienced burns on her chest and fingers while smoking. c. protect other residents who resided on Hall D from the likelihood of accidents related to resident #12 smoking in bed in her room. On 09/14/11 at 5:52 p.m., the administrator and DON were notified of the IJ situation regarding resident #12 lighting cigarettes and smoking in bed in her room. They were informed the night shift had been interviewed and only one of five staff were aware the resident was on 30 minute checks for smoking. The administrator was informed this IJ situation placed them in an extended survey. The administrator and DON were asked for a plan of removal for the IJ situation. The administrator stated, "We are already working on this. We have revoked all smoking privileges from her, no smoking at all. Someone gave her cigarettes and she is picking up cigarette butts out of the can and off the grounds. We will physically search her room and her person every shift. She could fall asleep smoking a cigarette...We have done a smoking assessment. I have seen burn holes on her chair. We will get to working on that and get it to you." On 09/14/11 at 6:50 p.m., the plan of removal was accepted by the survey team. The plan documented, "Smoking privileges are revoked immediately for the resident. Resident's room, clothing and personal items as well as her person will be searched for tobacco and/or tobacco paraphernalia upon resident's receipt of this notice. Resident will be subject to personal affects and body search per shift and prn. A private sitter has been hired by the facility to provide one on one care. The facility will provide one on one care 24 hours until resident is discharged from facility. A 30 day discharge notice for non-compliance will be issued to resident." On 09/15/11 at 4:40 p.m., the facility was notified the IJ had been removed on 09/14/11 at 7:10 p.m., when a one-on-one sitter from the facility had been hired to stay with the resident at all times. An agency nurse had been hired to continue the one-on-one through the night and agency and facility staff were with her at all times 24 hours a day. The resident's room had been searched as well as her personal belongings for smoking paraphernalia and the staff would do a room search daily. The deficient practice remained at a pattern level of actual harm with potential for more than minimal harm that was not an Immediate Jeopardy. 2. Resident #20 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's comprehensive assessment, dated 07/18/11, documented her cognition was independent. She made her own decisions and was able to make her needs known to the staff. The resident's care plan, dated 07/22/11, documented, "Falls - Increased potential for falls due to receiving anti-depressant & anti-anxiety meds. Fall risk score (16) A score of 10 or above is a high risk for falls. Intervention: Educate & encourage to use call light to summon assistance w/transfers/toileting. Falling star on door to alert staff; Fall risk assmt quarterly & prn." The resident's care plan for ADLs documented, "Required limited assist with ADLS. Staff report (resident) can ambulate short distance but unsteady. Intervention: Provide assist w/toilet & transfers, setup & assist w/oral hygiene daily." A nurse's note, dated 07/26/11, documented, "An ecchymotic area on the outer aspect of her arm from the mid-bicep down to her wrist, measuring 0.3cm x 0.1cm. A skin tear was noted on the resident's right forearm in the middle of the ecchymosis." A nurse's note, dated 08/09/11, documented, "(2:30 a.m.) Resident had a fall in room in bathroom. During head-to-toe assessment, resident c/o dizziness and nausea as well as R wrist pain. Resident did bump head on floor and has S/T on RFA and small S/T on R earlobe. BP 132/58...C/O HA, completed fall incident report, called primary contact & let them know we sent her to (Local hospital)...left on ambulance @ 0315 (3:15 a.m.)." The care plans for falls was updated on 08/09/11 after a fall. The new intervention was to place a pressure alarm on her bed and chair at all times and to perform neurological checks per facility policy. A nurse's note, dated 08/09/11, documented, "1400 (2:00 p.m.)...Res is unsteady when transferring. Went to therapy but returned shortly - therapist said she was not participating like she usually does." A physician's telephone order, dated 08/09/11, documented, "Resident fell in BR in room. EMS to (local hospital ER), Dx: fall." The resident had three falls on 08/09/11, with no injury, one fall on 08/26/11 with no injury and one fall on 08/30/11 which she sustained a skin tear to her right arm. The falls were not investigated to determine the cause of her falls. There were no new interventions to prevent further falls. A nurse's note, dated 08/24/11, documented, "1345 (1:45 p.m.) PT noticed that resident's right side was weak. She has poor hand & leg coordination. She is scissor walking. Weakness noted to R side. BP - 141/97." A physician's progress note, dated 08/24/11, documented, "Must walk w/assist or walker." The care plan updated on 08/30/11, after another fall, documented, "Low bed w/mat; Visual checks." A physician's telephone order, dated 08/24/11, documented, "Transport to (Local hospital)." A nurse's note, dated 08/24/11, documented, "2:45 p.m. - Ambulance here to transport to (Local Hospital)." A nurse's note, documented, "8:15 p.m. - Returned from ER N/O Meclizine - Needs neurology workup. CT Scan of head - Age related changes, to include old pontine stroke, w/o evidence of acute intracranial hemorrhage in this noncontrast head CT." A nurse's note, dated 08/26/11, documented, "0100 (1:00 p.m.) - Resident fell in room tonight, denies bumping head. BP 132/82 (everyone contacted)." A nurse's note, dated 08/30/11, documented, "7:30 a.m., Mobile medical notified for x-ray of R hip-femur knee. Results: No acute fx, slight lateral knee joint narrowing." A nurse's note, dated 08/30/11, documented, "4:00 p.m. - Unwitnessed fall. Resident stated she fell . Had bump on R side of head. Neuro checks WNL, MD & family notified. MD did not want resident sent out to ER for eval. Low bed w/mat placed and pressure alarm reapplied and visual checks q 30 min X 72hrs." A physician's telephone order, dated 08/30/11, documented, "Lowbed w/mat. Pressure alarm." A physician's telephone order, dated 09/02/11, documented, "discharged from skilled OT to RNA." A nurse's note, dated 09/04/11, documented, "2:30 p.m., Awake trying to ambulate per self sat on mattress on the floor. LE seems weak." A nurse's note, dated 09/07/11, documented, "7:35 p.m. - CNA reports she said she fell sitting on commode at this time. CNA denies seeing resident fall and denies helping her up from floor. Resident states didn't fall...Assessed for injuries. No injuries noted to head or body. Is on low bed for safety as she is unable to remember to call for assist. Requires mod assist of one for transfers. Balance poor. Bilat Upper & lower extremities uniform without deformities." A nurse's note, dated 09/14/11, documented, "2:35 p.m. - Called to room by RT, stated, she lost her balance in the BR. PT denies resident falling. (Not unusual for resident to be unsteady. That's why she requires mod assist of 1 staff for transfers.)...On low bed w/mattress near bed on floor. When asked, denies falling (has very poor short term memory) Assessment performed. Continues to have RUE bruising." On 09/19/11 at 4:14 p.m., CNA #10 was asked if she took care of the resident from 2:00 p.m. to 10:00 p.m. She stated, "Yes." She was asked if she put her to bed at night. She stated, "I help transfer her to bed." She was asked if she knew why she kept getting up by herself? CNA #10 stated, "I think she wants to go to the bathroom and forgets to use the call light. She uses it sometimes." CNA #10 was asked how often she took her to the bathroom? She stated, "Every 1 hr to every 2 hr but sometimes she needs to go in between." At 4:17 p.m., the MDS/Care Plan coordinator was asked about the resident's falls. She stated, "Our DON care plans the falls. She takes the incident reports and puts them on the care plan. She does the falls." At 4:20 p.m., the DON was asked about the resident's falls and what she had done to prevent further falls? She stated, "I update the CP if they have new falls from the incident reports. When they have a new fall, I look at the interventions and see if they need to be changed. Usually we implement: Personal body alarm, pressure alarm, low bed, neuro checks and the doc and pharmacist do med reviews. I believe she has had TIAs. (Medical Director) ordered a neuro evaluation." The DON was asked how she knew when the residents had falls? She stated, "From the incident reports." She was asked if she knew about all the falls? She stated, "Yes! They are very good about reporting falls and filling out incident reports and I review all of them." The pharmacy consultant medication reviews were conducted on 07/14/11 and 08/15/11. There was no documentation to indicate the medications were reviewed related to falls by the pharmacy consultant or the physician. On 09/20/11 at 9:40 a.m., the restorative aide was asked if the resident received restorative care. She stated, "No, I haven't received notice that she's supposed to be on restorative. (DON) usually notifies me if they need to be added." At 9:43 a.m., the DON was asked about the telephone order dated 09/02/11. She stated, "Let me look at the chart. The weekend RN noted that order. I don't know what's going on. Let me clarify that with PT/OT and I may need to write a clarification order." At 10:05 a.m., the DON stated, "I talked to PT. They don't feel she would benefit from further PT so when (Medical Director) comes in today, I'm going to get him to document something for her and what he wants to do further." The DON was asked if she thought the resident could be placed on restorative for ROM and strengthening/endurance to keep her ambulatory as long as possible. She stated, "Yes, we will do that." 3. Resident #58 had [DIAGNOSES REDACTED]. The significant change assessment, dated 08/01/11, documented the resident had severe cognitive impairment; required limited assistance with eating; required extensive assistance with transfers, dressing, toilet use, bathing and hygiene; did not ambulate in room or in corridor; did not have range of motion impairment; used a wheelchair for mobility in the facility, and had experienced 1 fall with minor injury since admission to the facility. The care plan, dated 06/29/11, documented the resident required extensive assistance with activities of daily living. The care plan documented the resident "has a history of falls. She attempts to transfer without assistance. She is on a low bed with mat on floor beside bed. She wears a personal alarm at all times. (Resident #58) will at times take alarm off. Fall risk assessment score of 21." Interventions included: "frequently observe room to give immediate response...low bed for safety with mat on floor beside bed, encourage (resident) to use call light to get assistance, pressure alarm at all times, visual alarm at all times, visual (checks every) 30 (minutes) on placement of alarms." On 08/02/11, an intervention was added for a nonrelease seat belt when the resident was in her wheelchair. She was to be checked every 30 minutes and the seatbelt released every 2 hours and at meal time. Fall risk evaluations, dated 06/09/11 through 08/25/11, documented the resident was at high risk for falls. A nurse's note, dated 06/10/11, at 4:10 p.m., documented the resident was noted lying on her right side on the floor. The resident was holding the fall alarm in her hand. A nurse's note, dated 06/11/11 at 1:40 p.m., documented the resident had fallen out of her wheelchair and bumped her head. She sustained an abrasion to the left upper forehead. The incident report for this incident documented steps taken to prevent recurrence were to do visual checks every 30 minutes for 72 hours and a new personal body alarm was applied. A nurse's note, dated 06/13/11 at 8:20 p.m., documented the resident was noted lying on right side on the mat beside the bed. The incident report for this incident documented steps taken to prevent recurrence were to do visual checks and reapply personal body alarm. A nurse's note, dated 06/22/11 at 7:50 p.m., documented the resident had leaned forward in her wheelchair trying to get into bed unassisted. The resident was holding the fall alarm in her hand. The incident report for this incident documented steps taken to prevent recurrence were to remind the resident to call for assistance when getting up and a pressure alarm was to be applied. A nurse's note, dated 06/28/11 at 9:10 p.m., documented the resident was lying on her right side on the mat beside the bed. The incident report for this incident documented steps taken to prevent recurrence were for staff to do visual checks and to reapply the personal body alarm. A nurse's note, dated 07/12/11 at 6:45 p.m., documented the resident was noted in her room sitting on her "bottom" on the floor in front of her wheelchair. The resident had "unclipped the fall alarm." The incident report for this incident documented steps taken to prevent recurrence were to monitor and to remind the resident to use the call light for assistance. A nurse's note, dated 07/23/11 at 3:15 p.m., documented the resident was trying to get out of bed and "fell on bottom." The incident report for this incident documented steps taken to prevent recurrence were to reapply the body alarm and the resident was reminded to use the call light for assistance. A nurse's note, dated 07/25/11 at 4:30 a.m., documented the resident had leaned forward/sideways in her wheelchair before staff could reach her and fell to the floor, bumping the left side of her head. The incident report for this incident documented steps taken to prevent recurrence were to do visual checks every 30 minutes for 72 hours and to use the pressure alarm at all times. A nurse's note, dated 07/25/11 at 7:30 p.m., documented the resident was found sitting on her buttocks on the floor in her room. The "fall alarm was sounding." The incident report for this incident documented steps taken to prevent recurrence were to do visual checks and to use the fall alarm and pressure alarm. A nurse's note, dated 07/26/11 at 1:00 p.m., documented the resident was found lying on her left side on the floor in her room. The personal alarm was on and in working order. The incident report for this incident documented steps taken to prevent recurrence were to do visual checks on the placement of alarms. A nurse's note, dated 07/27/11 at 3:20 p.m., documented the resident was "sitting on buttocks on floor." She had "unclipped the fall alarm." The incident report for this incident documented steps taken to prevent recurrence were to remind the resident to get assistance with transfers, to reapply alarms and visual checks by staff. A nurse's note, dated 07/29/11 at 7:40 p.m., documented the resident was observed by another resident "scooted out of her wheelchair onto the floor..." The incident report for this incident documented steps taken to prevent recurrence were to do visual checks and to apply the fall alarm and pressure alarm. A nurse's note, dated 07/30/11 at 7:30 p.m., documented the resident was found in the lobby lying on her right side on the floor. The incident report for this incident documented steps taken to prevent recurrence were to do visual checks every 30 minutes for placement of alarms "since resident takes off." A nurse's note, dated 08/02/11 at 4:35 p.m., documented the resident "fell out of w/c forward hitting front & top of head slight swelling on top of head. The incident report for this incident documented steps taken to prevent recurrence were to use a "nonrelease seatbelt when up in w/c due to poor trunk control." A fall investigation worksheet for this incident documented recommendations to prevent further falls were to get a new chair and a new bed from hospice. A nurse's note, dated 08/25/11 at 10:20 a.m., documented the resident was in the lobby and unfastened her seatbelt to transfer to the couch and "sat in floor." The pressure alarm was sounding. The incident report for this incident documented steps taken to prevent recurrence were to reapply the pressure alarm and staff were to monitor. On 09/22/11 at 9:00 a.m., during an interview with the DON and administrator, the surveyor reviewed findings regarding the resident's fall risk assessment which documented she was at high risk for falls and the resident's many falls. The surveyor asked if the facility had assessed the resident to determine the possible cause of the falls. The DON stated the resident was trying to get up and walk. She stated the resident had been placed on a bowel and bladder program. The surveyor reviewed the interventions of the low bed with the mat, the pressure alarm, the personal alarm and asked if the facility had re-assessed the interventions to determine if a different approach should be implemented. The DON stated the facility had evaluated the resident's pain and agitation status. The surveyor reviewed the steps to prevent recurrence as documented on the incident reports (visual checks every 30 minutes, personal body alarm, monitoring resident and reminding the resident to use the call light) and asked if those steps had been re-assessed when the resident kept falling after they were initiated. She stated the facility had talked to the resident's physician who wanted the consultation of a neurologist. The resident saw the neurologist who ordered a soft neck collar and fitted her for a hard collar. The surveyor confirmed with the DON that the resident was seen by the neurologist the end of June and the resident had several more falls after. The surveyor asked the DON why the resident continued to be left unsupervised while in her wheelchair in the lobby and in her room. The DON stated, "I don't have an answer." The surveyor asked if the resident's care plan had been reviewed and revised to reflect the current interventions for falls. She stated, "No." The surveyor asked if the facility had ensured the resident received adequate supervision to prevent accidents. The DON stated, "No."