Every finding on record at Heritage Manor

Based on observation, record review, and interview, the facility failed to ensure a medication cart was supervised and locked for 1 (medication cart #1) of 2 medication carts observed. The ADON identified 48 residents resided in the facility and there were two medication carts. Findings:On 05/19/26 at 4:43 p.m., medication cart #1 on the south hall by the nurse's station was observed to be unlocked and unattended. There was no staff in sight of the medication cart.On 05/19/26 at 4:44 p.m., the ADON was observed walking to the unlocked medication cart #1 on the south hall by the nurse's station and then left without locking the medication cart. On 05/19/26 at 4:45 p.m., CMA #1 was observed walking out of a resident's room on the north hall to medication cart #1 on the south hall. Medication cart #1 was unlocked and unattended. Medication cart #1 remained unlocked, out of sight and supervision, while CMA #1 was away from the medication cart. A facility policy titled Security of Medication Cart, revised April 2007, read in part, 4. Medication carts must be securely locked at all times when out of the nurse's view.On 05/19/26 at 4:47 p.m., CMA #1 stated medication carts should be locked and supervised at all times. CMA #1 stated they forgot to lock medication cart #1.05/19/26 at 4:48 p.m., CMA #1 stated they had medication cart #1. CMA #1 stated they went to help another resident and left medication cart #1 unlocked and unattended.On 05/19/26 at 4:49 p.m., the ADON stated anyone could have taken the medications from the cart and they were to be locked and supervised.

Based on record review and interview, the facility failed to ensure the arbitration agreement provided:the selection of a neutral arbitrator agreed upon by both parties; andfor the selection of a venue that is convenient to both parties.The administrator identified 51 residents resided in the facility.The social services director stated all 51 residents had entered into a binding arbitration agreement.Findings:An undated Dispute Resolution Plan, contained within the Admissions Agreement: Manor, read in part, The parties agree and acknowledge that the business relationship involves interstate commerce and that any such mediation or arbitration shall be governed by the Federal Arbitration Act (FAA) and conducted in accordance with the Rules of Mediation and Arbitration as then in effect and administered by Dispute Solutions, Inc.On 10/01/25 at 12:15 p.m., the social services director stated they went through each area of the admission packet separately, and they have not had a problem with people agreeing to sign the arbitration agreement.

Based on record review and interview, the facility failed to ensure residents or their representatives:Understood what an arbitration agreement was;Understood their right not to sign the agreement as a condition of admission, or as a requirement to continue to receive care at the facility; andWere explicitly granted the right to rescind the agreement within 30 calendar days of signing the document for 8 (#1, 2, 27, 38, 39, 42, 45, and #51) of 8 sampled residents reviewed for arbitration agreements.The administrator identified 51 residents resided in the facility.The social services director stated all 51 residents had entered into a binding arbitration agreement.Findings:On 09/30/25 at 12:15 p.m., the social services director was observed using Docusign to click through the sections of the admission agreement. Hitting the enter button would sign each section and move to the next, thereby agreeing to everything inside of the admission packet. The arbitration agreement was part of the admission packet and was agreed to upon admission for everyone admitted to the facility.An undated, Dispute Resolution Plan contained within the Admissions Agreement: Manor, read in part, It is hereby agreed and understood that any dispute, difference, and/or disagreement of any kind whatsoever, whether statutory or contractual, which arises from the services and/or products provided or relating in any way to the general business relationship of the parties to this agreement, shall be, as the sole available remedy, resolved through mandatory mediation and/or binding arbitration, rather than litigation. The parties agree and acknowledge that the business relationship involves interstate commerce and that any such mediation or arbitration shall be governed by the Federal Arbitration Act (FAA) and conducted in accordance with the Rules of Mediation and Arbitration as then in effect and administered by Dispute Solutions, Inc.On 09/30/25 at 1:15 p.m., during the resident council meeting, Residents #27, 38, 39, 45, and #51 stated they did not know what an arbitration agreement was or remember signing an agreement.On 10/01/25 at 1215 p.m., the social services director stated they went through each area of the admission packet separately, and they have not had a problem with people agreeing to sign the arbitration agreement.On 10/01/25 at 12:28 p.m., Resident #2 stated they did not know what an arbitration agreement was or remember signing one.On 10/01/25 at 12:28 p.m., Resident #33 stated they did not sign none of that stuff.On 10/01/25 at 12:29 p.m., Resident #3 denied signing an arbitration agreement. Resident #1 stated they did know what an arbitration agreement was but were unaware that not signing it would not affect their care or admission. On 10/01/25 at 12:30 p.m., Resident #51 did not remember signing the agreement.On 10/02/25 at 10:19 a.m., the DON and ADON were asked why all the residents agreed to give up their rights when they did not need to do that to receive care. The ADON stated Odds are, it doesn't sound like they all understood, but I wasn't there.

Based on record review and interview, the facility failed to complete the advance directive acknowledgement for 3 (#1, 2, and #42) of 13 sampled residents reviewed for advance directive acknowledgements.The administrator identified 51 residents resided in the facility.Findings:An Advance Directive policy, revised 2016, read in part, Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her representative, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.An Advance Directive Acknowledgement form, read in part, Please check ONE of the following statements: I HAVE executed and Advance Directive. I HAVE NOT executed an Advance Directive.Resident #1's Advance Directive Acknowledgement was docusigned on 09/17/25, but the question as to whether they had or had not executed an advance directive was not marked. Resident #1 was admitted on [DATE] and the admission assessment, dated 08/15/25, showed a BIMS score of 15 indicating they were cognitively intact.Resident #2's Advance Directive Acknowledgement was docusigned on 05/28/25, but the question as to whether they had or had not executed an advance directive was not marked. Resident #2 was admitted on [DATE] and the admission assessment, dated 05/20/25, showed a BIMS score of 15 indicating they were cognitively intact.Resident #42's Advance Directive Acknowledgement was docusigned on 05/28/25, but the question as to whether they had or had not executed an advance directive was not marked. Resident #42 was admitted [DATE] and the admission assessment, dated 05/20/25, showed a BIMS score of 14 indicating they were cognitively intact.On 09/30/25 at 12:15 p.m., the social services director stated, I assumed if nothing was marked it meant they did not have an advance directive.On 10/02/25 at 10:16 a.m., The ADON was asked if the signature on the advance directive with nothing marked regarding their choice, was a completed document. The ADON stated, Absolutely not, the advance directive acknowledgement is not completed.

Based on observation, record review, and interview, the facility failed to store and maintain food and ice in a safe manner for one ice machine and 2 of 3 freezers maintained in the dining room. The administrator identified 51 residents resided in the facility. Findings:On 09/29/25 at 11:30 a.m., an observation of the kitchen and dining room was completed. In the corner of the dining area were three freezers and an ice machine. Two of the three freezers and the ice machine were not locked. Residents were walking around in the dining area waiting for the noon meal. There was no signage for staff use only. A facility policy titled Ice Machines and Ice Storge Chests read in part, To help prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions .Limit access to ice machines or ice storage chests/containers to employees only.A facility policy titled PURCHASING, RECEIVING AND STORAGE, read in part, Food will be properly stored to preserve flavor, nutritive value, appearance, and safety. Only authorized personnel will have access to food preparation and storage areas. On 09/29/25 at 11:32 a.m., the DM stated they did not know the facility policy regarding the freezers and the ice machine being locked. The DM stated it was sufficient to dummy lock the freezers. On 09/30/25 at 11:15 a.m., the corporate DM stated the ice machine and the freezers in the resident dining area should always be locked due to area accessible to residents and visitors. On 10/02/25 at 10:10 a.m., the administrator stated the ice machine and the freezers in the resident dining area should be locked and with staff access only.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 (#59) of 1 sampled resident reviewed for abuse.The administrator identified 10 allegations of abuse in the last six months.Findings: An undated electronic clinical record for Resident #59, under the tab medical diagnosis, showed diagnoses of hemiplegia and hemiparesis following cerebral infarction, aphasia, and diabetes.A facility policy titled Abuse Investigation and Reporting, revised July 2017, read in part, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.The individual conducting the investigation, as a minimum.interview the person(s) reporting the incident,.interview the resident (as medically appropriate),.interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. An admission assessment, dated 03/31/25, showed Resident #59 had a BIMS of 15 and was cognitively intact. The assessment showed Resident #59 required substantial assistance from staff with most ADLs. An OSDH incident report, dated 04/17/25, showed an allegation of abuse. The report showed Resident #59 reported to LPN #1 during care that CNA #1 hit them. The investigative documentation did not show a statement from Resident #59 about the incident. The investigative documentation did not show a statement by LPN #1 who reported the incident to the administrator, or a statement from CNA #1 who was identified as the perpetrator.A progress note, dated 04/25/25, showed Resident #59 discharged from the facility with family. On 10/01/25 at 5:05 p.m., the administrator reviewed the investigative documentation. They stated statements from the reporter of the incident, the victim, the perpetrator, or other staff working at the time of the incident had not been completed. On 10/02/25 at 8:59 a.m., LPN #1 stated they spoke with Resident #59 and the resident reported CNA #1 had hit their right arm during care. The LPN stated they reported the incident immediately to the administrator. The LPN stated a written statement regarding the incident was not completed. On 10/02/25 at 10:12 a.m., CNA #1 stated they reported the incident on 04/17/25 regarding Resident #59 to the nurse and the administrator. CNA #1 stated they were not asked to document a statement regarding the incident.

Based on observation, record review, and interview, the facility failed to ensure two opened multidose vials of PPD solution were labeled with the date of the first usage for 1 of 1 refrigerators observed. Findings: A policy titled Dating and Discarding of Multidose Parenteral Vials, dated 06/21/17, read in part, If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days for the opened vial.On 09/30/25 at 9:53 a.m. an observation of the medication storage room was performed with LPN #3. Two multidose vials of Tuberculin PPD were opened and not dated. On 09/30/25 at 9:53 a.m., LPN #3 was asked what their policy on opened vials of medication was. LPN #3 stated the vials should have a date on them when they were opened.

On 03/19/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision for Resident #1 who wandered and experienced exit seeking behaviors. An undated elopement policy, read in part, It is the policy of this facility to provide a safe and comfortable environment to prevent resident elopements. Resident #1's Wandering Risk Assessment, dated 02/13/25, showed the resident was a high risk for wandering and was a known wanderer/history of wandering. A nurse note, dated 02/15/25 at 1:03 p.m., showed Resident #1 remains confused trying to exit pushing on north hall door. The note showed Resident #1 was wandering on other halls and went in other rooms. An admission resident assessment, dated 02/19/25, showed Resident #1's BIMS score was 00 (severe cognitive impairment) and the resident was independent for the task of sit to stand and walking 10 feet, 50 feet with two turns, and 150 feet. A nurse note, dated 02/19/25 at 8:35 p.m., read in part, At about [8:35 p.m.] this nurse was notified, by nurses aide, resident had wandered off, and was assisted back in by the neighbor. A State reportable incident, dated 02/19/25, showed staff responded to the alarm at the South door and could not find anyone there. The report showed staff began to perform an elopement drill, during the drill, neighbors brought Resident #1 to the front door. The report showed the neighbors witnessed Resident #1 leaving through the side door. The report showed Resident #1 was placed on every 15 minute observation for safety. On 03/19/25 at 10:42 a.m., Resident #1 was observed lying in bed with their eyes open. When the surveyor attempted to speak to the resident, Resident #1 just smiled and began to laugh. On 03/19/25 at 10:50 a.m., CNA #3 stated Resident #1 liked to walk around. They stated they tried to get the resident to walk toward the main part of the building to make sure the resident was not escaping. They stated the resident liked to go to the end of the hall and push on doors. They stated they tried to get them to watch TV. CNA #3 stated they could not answer whether or not Resident #1 had ever eloped. They stated not on their shift. On 03/19/25 at 10:57 a.m., CNA #2 stated they were not familiar with Resident #1, but they knew the facility completed 15 minute checks on the resident. They stated they did not know the reason for the 15 minute checks. On 03/19/25 11:02 a.m., CNA #1 stated elopement was when a resident ran off. They stated the facility completed 15 minute checks on certain residents and some were supervised at all times. They stated staff would search the premises if a resident had eloped. They stated staff would try redirecting the resident by offering them a drink to change their mood. CNA #1 stated Resident #1 liked to roam the building a lot. They stated staff completed 15 minute checks. CNA #1 stated from their understanding Resident #1 had not eloped. On 03/19/25 at 11:14 a.m., ACMA #2 stated the facility had codes on the doors so residents could not leave without the codes and they did not share codes with the residents. They stated if residents pushed on the door, after 15 seconds it would open and alarm. ACMA #2 stated elopement was when a resident ran away. They stated they would complete a head count, shut everything down, look around the building, look behind closet doors, and even have staff drive around a two mile radius looking if a resident eloped. They stated they did not know Resident #1. On 03/19/25 at 11:17 a.m., ACMA #1 stated staff checked on Resident #1 every 15 minutes. They stated everyone knew Resident #1 was at a high risk to leave. ACMA #1 stated Resident #1 liked to walk the halls and went to the door. They stated if they observed the resident walking the halls, they would sit them on the sofa because the resident would sit and watch TV. ACMA #1 stated they thought Resident #1 had eloped on a weekend because when they left, everything was fine, but when they came back to work, the nurse told them to keep an eye on the resident. ACMA #1 stated the nurse did not say why and so they did not know if Resident #1 had eloped or had tried to elope. On 03/19/25 at 11:28 a.m., LPN #2 stated the doors of the facility were coded and had alarms. They stated if they knew a resident was a wanderer, they would have someone always keeping an eye on them. They stated the policy for elopement was for everyone to come to the nurses' station, they would delegate where everyone was going to look for the resident inside and outside the building, and would complete a head count. They stated staff would place the residents on 15 minute checks and the nurses were responsible for completing them. LPN #2 stated they had redirected Resident #1 in the past by dancing with them down the hall. LPN #2 stated they knew Resident #1 was a wanderer, but they were not sure if the resident actually did elope. On 03/19/25 at 11:38 a.m., LPN #1 stated anyone who staff knew was an elopement risk, staff would keep an extra eye on. They stated the doors had to be pushed for 15 seconds before you could get out and the buzzer would sound. They stated there were codes for all of the doors. LPN #1 stated if staff noticed a resident was missing they would call everyone to the desk, staff would go to their specific hall, and complete a head count. They stated the nurse would assign who was responsible for searching inside the building, outside the building, and who would be responsible for driving the 2 mile radius from the building looking for the missing resident. They stated staff would continue searching until they were located. They stated the administrator would be called immediately. LPN #1 stated they were not aware of Resident #1 eloping from the facility. They stated the resident had not eloped on their shift and was on every 15 minute checks because the resident exit seeks. On 03/19/25 at 11:47 a.m., the DON stated Resident #1 got out. They stated they were not 100 percent, but the door was alarming and as they were doing the drill looking for the resident, the neighbor had seen Resident #1 go out the door and brought them back in the front door. The DON stated the administrator at the time came to the facility that night (02/19/25) and completed an elopement drill. On 03/19/25 at 1:02 p.m., the administrator stated they were new to the facility and was not aware of any resident in the facility that had eloped. They stated they knew Resident #1 was an elopement risk because they discussed it in their morning meetings, but they could not say whether or not it actually occurred because the administrator was not working at the facility at the time of the incident on 02/19/25. There was no documentation to show an elopement drill was conducted on 02/19/25. On 03/19/25 at 4:40 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 03/19/25 at 4:45 p.m., the administrator, DON, corporate nurse consultant #1, and corporate business office were notified of the IJ situation. On 03/20/25 at 4:46 p.m., the administrator, DON, corporate nurse consultant #1, corporate nurse consultant #2, and corporate business office were notified of the amended IJ template which contained the following additional information: On 02/19/25 between 7:52 p.m. and 8:52 p.m., the Oklahoma City outside temperature was 9 to 10 degrees Fahrenheit. There is a two lane residential road North [NAME] Avenue that sits west of the facility. Approximately half a block north of the facility is U.S. Route 66 which is a busy four lane road. On 03/21/25 at 12:57 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Heritage Manor Plan of Removal Immediate Jeopardy 3/19/25 The facility's response to the IJ called for the facility to implement a plan of removal to ensure there is a system in place to protect residents from elopement. The facility will be in compliance on 3/19/25 by 10pm. 1. All staff are educated on the Elopement Policy on hire and annually, as well as periodically as a reminder. An in-service had been completed with nursing staff following the attempted elopement by resident [Resident]. 2. In-service will be completed with all staff by 10 pm on 3/19/25 over the following: A. Elopement Policy to include the following interventions to prevent elopement: a. Any resident who is determined to be a wanderer on admission will be placed on Elopement Risk on their profile and frequent Q 15 minute visual checks to monitor for exit seeking behaviors for 4 weeks and then re-evaluated. If no exit seeking behaviors have been noted, they will no longer be considered an elopement risk. b. Institute 1:1 [one on one] monitoring or Frequent Visual Checks charting Q 15minutes or as indicated if a resident with Dementia is having any exit-seeking behaviors or attempts to go out without supervision, until no longer deemed at risk. c. Re-evaluate at least quarterly for wandering and exit seeking and revise plan for monitoring according to resident's risk. d. Institute other interventions as needed for residents with exit seeking behaviors to re-direct or distract resident from exit seeking behaviors such as: Camouflaging doors with wallpaper or curtains so they are not recognized as doors, Stop signs on exit doors, Encouraging family members to visit, Diversional activities during times of restlessness. B. Location of the Elopement Risk book that has a list and information for all residents on Elopement Risk. C. A list of Resident's at risk for elopement will continue to be posted in each charge nurses report book. 3. Agency will be provided with in-service materials as well. 4. Any staff on vacation or unable to reach will be in-serviced before working their next shift. 5. All residents considered high risk for elopement have an identifier on the residents profile to alert staff, Elopement Risk. The IJ was lifted, effective 03/19/25 at 10:00 p.m., when all components of the plan of removal had been verified as completed. This was verified by staff interviews, review of inservice information, and a review of resident records to ensure interventions were in place for residents who exhibited exit seeking behaviors and residents at risk for elopement. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to provide supervision for a resident who wandered and experienced exit seeking behaviors for 1 (#1) of 3 sampled residents reviewed for elopement. The administrator identified 11 residents at risk for elopement resided in the facility. Findings: On 03/17/25 at 1:55 p.m., no residents were observed exit seeking on the East Hall. On 03/17/25 at 2:17 p.m., no residents were observed exit seeking on the North Hall. On 03/17/25 at 2:57 p.m., Resident #1 was observed sitting on the couch in the tv area by the front door with their eyes closed. On 03/18/25 8:41 a.m., Resident #1 was observed lying in bed, eyes closed, with audible snoring heard. On 03/18/25 at 11:32 a.m. no residents were observed demonstrating exit seeking behaviors on the East, North, or South hall that were all observed from the nurses' station. On 03/18/25 at 12:26 p.m., Resident #1 was observed in the dining room being fed by ACMA #1 who was seated next to them. Resident #1 was observed using their left hand to take a drink from their cup while ACMA #1 gave the resident a bite of food in between drinks. Resident #1 did not speak during the observation. On 03/18/25 at 1:39 p.m., Resident #1 was observed seated on couch in the dining area, eyes closed, with staff present and the television on. An undated elopement policy, read in part, It is the policy of this facility to provide a safe and comfortable environment to prevent resident elopements .When the resident has been assessed to be a high elopement risk beyond he capability of the facility safeguards, the Administrator and Director of Nursing will ascertaine [sic] possible discharge of the resident to protect the safety of that resident .At any time during the course of the resident's stay, if the resident is assessed to be an elopement risk, the Administrator and Director of Nursing will confer with the resident's physician and family regarding the resident's admission status. If the determination is that the resident is appropriately placed in the facility, then the resident's care plan will address elopement risk and appropriate interventions tailored to the particular resident will be put into place to prevent any elopements .Also, residents who are determined to be at 'high risk for elopements' will have an identifier on the medical record. Resident #1 had diagnoses which included unspecified dementia unspecified severity, with other behavioral disturbance. Resident #1's Wandering Risk Assessment, dated 02/13/25, showed the resident was a high risk for wandering and was a known wanderer/history of wandering. A nurse note, dated 02/15/25 at 1:03 p.m., showed Resident #1 remains confused trying to exit pushing on north hall door. The note showed Resident #1 was wandering on other halls and went in other roomsand occasionally hard to re-direct attempts tohit [sic] staff but not successful. A nurse note, dated 02/16/25 at 3:42 p.m., read in part, Resident after lunch continues on observation r/t [related to] elopementbehavior[sic]/wandering with no incident of existing [sic] or trying to leave/push on doors. A nurse note, dated 02/17/25 at 9:41 p.m., read in part, Resident currently wandering through out facility, exit seekingthroughout [sic] shift, easily redirected. An admission resident assessment, dated 02/19/25, showed Resident #1's BIMS score was 00 (severe cognitive impairment) and the resident was independent for the task of sit to stand and walking 10 feet, 50 feet with two turns, and 150 feet. A nurse note, dated 02/19/25 at 8:35 p.m., read in part, At about [8:35 p.m.] this nurse was notified, by nurses aide, resident had wandered off, and was assisted back in by the neighbor. A State reportable incident, dated 02/19/25, showed staff responded to the alarm at the South door and could not find anyone there. The report showed staff began to perform an elopement drill, during the drill, neighbors brought Resident #1 to the front door. The report showed the neighbors witnessed Resident #1 leaving through the side door. The [NAME] showed Resident #1 was placed on every 15 minute observation for safety. On 02/19/25 between 7:52 p.m. and 8:52 p.m., the Oklahoma City outside temperature was 9 to 10 degrees Fahrenheit. There was a two lane residential road North [NAME] Avenue that sat [NAME] of the facility. Approximately half a block North of the facility was U.S. Route 66 which was a busy four lane road. There was no documentation to show an elopement drill was conducted on 02/19/25. A nurse note, dated 02/22/25 at 8:27 p.m., read in part, Resident wandering in hallway easily directed. A nurse note, dated 02/23/25 at 7:57 p.m., read in part, Resident wandering in hallway easily directed. A nurse note, dated 03/07/25 at 7:48 p.m., read in part, Resident assisted to bed at this time. Elopementmonitoring [sic] continues Given that, [they] tried to open front door threetime [sic]. A nurse note, dated 03/12/25 at 7:52 p.m., read in part, Resident continues on elopement risk precautions. This nurse had to redirect resident a few times. On 03/18/25 at 8:14 a.m., the host was observed seated at a table by the front door. They stated they were responsible for checking visitors in and answering phones. They stated their sign in was primarily for vendors. They stated when family members came in they would sign in and out at the nurses' station. The host stated just the staff members had the number to get out of the building. On 03/19/25 at 10:50 a.m., CNA #3 stated Resident #1 liked to walk around. They stated they tried to get the resident to walk toward the main part of the building to make sure the resident was not escaping. They stated the resident liked to go to the end of the hall and push on doors. They stated they tried to get them to watch TV. CNA #3 stated they could not answer whether or not Resident #1 had ever eloped. They stated not on their shift. On 03/19/25 at 10:57 a.m., CNA #2 stated they were not familiar with Resident #1, but they knew the facility completed 15 minute checks on the resident. They stated they did not know the reason for the 15 minute checks. On 03/19/25 11:02 a.m., CNA #1 stated elopement was when a resident ran off. They stated the facility completed 15 minute checks on certain residents and some were supervised at all times. They stated staff would search the premises if a resident had eloped. They stated staff would try redirecting resident by offering them a drink to change their mood. CNA #1 stated Resident #1 liked to roam the building a lot. They stated staff completed 15 minute checks. CNA #1 stated from their understanding Resident #1 had not eloped. On 03/19/25 at 11:14 a.m., ACMA #2 stated the facility had codes on the doors so residents could not leave without the codes and they did not share codes with the residents. They stated if residents pushed on the door, after 15 seconds it would open and alarm. ACMA #2 stated elopement was when a resident ran away. They stated they would complete a head count, shut everything down, look around the building, look behind closet doors, and even have staff drive around a two mile radius looking if a resident eloped. They stated they did not know Resident #1. On 03/19/25 at 11:17 a.m., ACMA #1 stated staff checked on Resident #1 every 15 minutes. They stated everyone knew Resident #1 was at a high risk to leave. ACMA #1 stated Resident #1 liked to walk the halls and went to the door. They stated if they observed the resident walking the halls, they would sit them on the sofa because the resident would sit and watch TV. ACMA #1 stated they thought Resident #1 had eloped on a weekend because when they left, everything was fine, but when they came back to work, the nurse told them to keep an eye on the resident. ACMA #1 stated the nurse did not say why and so they did not know if Resident #1 had eloped or had tried to elope. On 03/19/25 at 11:28 a.m., LPN #2 stated they knew Resident #1 was a wanderer, but they were not sure if the resident actually did elope. On 03/19/25 at 11:38 a.m., LPN #1 stated they were not aware of Resident #1 eloping from the facility. They stated the resident had not eloped on their shift and was on every 15 minute checks because the resident exit seeks. On 03/19/25 at 11:47 a.m., the DON stated the facility had doors that required a code to open and had alarms. They stated several residents were on frequent monitoring. They stated staff would redirect them if they were exhibiting exit seeking behaviors. They stated elopement was if a resident was outside the building without staff being aware. The DON stated the policy for elopement was if staff noticed someone was missing, they go to the nurses' station, the nurse calls the elopement drill, everyone checks halls and visually counts each resident. The DON stated if a resident was not found in the building, staff searched the perimeter and notified the administrator, police and family. The DON stated Resident #1 got out. They stated they were not 100 percent, but the door was alarming and as they were doing the drill looking for the resident, the neighbor had seen Resident #1 go out the door and brought them back in the front door. The DON stated the administrator at the time came to the facility that night (02/19/25) and completed an elopement drill. The DON stated the facility put every 15 minute monitoring in place, redirected the resident, used activities, and the mental health provider saw Resident #1 for interventions to prevent it from happening again. On 03/19/25 at 12:53 p.m., the DON was shown only 17 of their 49 staff signed the elopement drill on 03/13/25 and was asked to explain how the remaining staff were educated. The DON stated there had not been any additional elopement drills after Resident #1's elopement other than the one on 03/13/25. On 03/19/25 at 1:02 p.m., the administrator stated residents were to sign out in the book before they left the facility. They stated they had never been involved in an elopement. They stated the doors were always locked. They stated an alarm would sound if a resident pushed on the door and it opened. They stated they were new to the facility and was not aware of any resident in the facility that had eloped. They stated they knew Resident #1 was an elopement risk because they discussed it in their morning meetings, but they could not say whether or not it actually occurred because the administrator was not working at the facility at the time of the incident on 02/19/25. On 03/19/25 at 1:12 p.m., the DON stated the next quality assurance performance improvement meeting was scheduled on 03/28/25 and elopement would be discussed as well as any other concerns. On 03/19/25 at 3:12 p.m., the DON stated from what they understood everyone was looking for Resident #1 at the time of the elopement. The DON stated as they started looking for the resident, the neighbor saw Resident #1 go out. The DON stated from what they understood, it was minutes and the neighbor brought Resident #1 right back into the front door as they were still searching the building. On 03/19/25 at 3:52 p.m., LPN #1 stated they guess staff should not chart easily redirected. They stated they should say how they were redirecting. LPN #1 stated for instance when they came down the hall dancing with Resident #1, instead of putting easily redirected, they should have put dancing down the hall. They stated easily redirect could mean a lot.

Based on observation, record review, and interview, the facility failed to ensure thorough incontinent care was provided for one (#9) of three sampled residents observed receiving incontinent care. The AIT identified 44 residents resided in the facility. Findings: Resident #9 had diagnoses which included generalized muscle weakness and cerebral infarction. Resident #9's annual resident assessment, dated 09/17/24, documented they had severe cognitive impairment. Resident #9's care plan for ADL deficit, revised 10/10/24, documented they required total assist with toileting. On 10/22/24 at 2:59 p.m., CNA #1 entered Resident #9's room to provide incontinent care. They closed the door. On 10/22/24 at 3:00 p.m., CNA #1 told Resident #9 they would be providing care. CNA #1 had on gloves. They partly removed the resident's soiled brief, turned the resident on their side, and cleansed their buttocks. Fecal matter was observed during cleaning. CNA #1 removed the soiled brief and put it in a trash bag. They put the soiled pad on the floor mat. CNA #1 put a new brief on the resident and adjusted the resident in bed. Fecal matter was observed on Resident #9's labia. CNA #1 did not clean the resident's front peri-area. On 10/22/24 at 3:02 p.m., CNA #1 was asked to observe Resident #9's front peri-area. They stated they did not see the fecal matter in the peri-area. The new brief was observed to have fecal matter. CNA #1 stated they were supposed to clean the resident's front peri-area.

Based on observation, record review, and interview, the facility failed to ensure a privacy curtain was utilized during personal care for one (#9) of three sampled residents observed receiving incontinent care. The AIT identified 44 residents resided in the facility. Findings: An undated PERI CARE policy, read in part, Provide privacy, ensure door is closed, privacy curtain is pulled to provide full visual privacy and window blinds are closed. Resident #9 had diagnoses which included generalized muscle weakness and cerebral infarction. Resident #9's annual resident assessment, dated 09/17/24, documented they had severe cognitive impairment. Resident #9's care plan for ADL deficit, revised 10/10/24, documented they required total assist with toileting. On 10/22/24 at 2:59 p.m., CNA #1 entered Resident #9's room to provide incontinent care. CNA #1 closed the door. The resident's roommate was in the room in their wheelchair. On 10/22/24 at 3:00 p.m., CNA #1 told the resident they would be providing care. CNA #1 provided incontinent care to the resident. The privacy curtain was not utilized during the provision of care. On 10/22/24 at 3:11 p.m., CNA #1 stated the policy was to pull the privacy curtain during care. They stated they did not pull the privacy curtain during the provision of peri care.

Based on observation, record review, and interview, the facility failed to maintain infection control during the provision of incontinent care for one (#9) of three sampled residents observed receiving incontinent care. The AIT identified 44 residents resided in the facility. Findings: Resident #9 had diagnoses which included generalized muscle weakness and cerebral infarction. Resident #9's annual resident assessment, dated 09/17/24, documented they had severe cognitive impairment. Resident #9's care plan for ADL deficit, revised 10/10/24, documented they required total assist with toileting. On 10/22/24 at 2:59 p.m., CNA #1 entered Resident #9's room to provide incontinent care. They closed the door. On 10/22/24 at 3:00 p.m., CNA #1 told Resident #9 they would be providing care. CNA #1 had on gloves. They partly removed the resident's soiled brief, turned the resident on their side, and cleansed their buttocks. Fecal matter was observed during cleaning. CNA #1 removed the soiled brief and put it in a trash bag. They put the soiled pad on the floor mat. They put a new brief on the resident and adjusted the resident in bed. CNA #1 did not change their gloves. On 10/22/24 at 3:02 p.m., CNA #1 was asked to observe Resident #9's front peri-area. They stated they did not see the fecal matter in the peri-area. The new brief was observed to have fecal matter. On 10/22/24 at 3:03 p.m., CNA #1, with the same gloves they had on at the start of the incontinent care, opened Resident #9's drawers looking for wipes and a brief. They removed their gloves to go out of the room to locate wipes and a brief. On 10/22/24 at 3:06 p.m., CNA #1 came back with wipes. They donned gloves and cleansed the resident's peri-area. Another staff brought CNA #1 a brief. CNA #1 put the new brief on the resident and adjusted them in bed. CNA #1 did not change their gloves. On 10/22/24 at 3:08 p.m., CNA #1 with the same gloves, pinned the call light to the bed, and propped the resident with pillows. CNA #1 removed their gloves, took the trash out, and washed their hands. On 10/22/24 at 3:12 p.m., CNA #1 stated they were supposed to put the dirty pad in a plastic bag. They stated lately they were not provided with plastic bags. On 10/22/24 at 3:13 p.m., CNA #1 stated they were supposed to change their gloves three times, but changed them twice during the incontinent care.

Based on observation, record review, and interview, the facility failed to ensure: a. falls were evaluated for cause and interventions implemented to prevent falls with injuries for one (#48) of three sampled residents reviewed for accident hazards and falls. Resident #48 had a fall with a major injury in December 2023 which resulted in staples to the head. The facility did not assess the fall and implement changes in interventions to aide in the prevention of falls. Resident #48 had two additional falls one in March 2024 and one in April 2024 that also resulted in injuries without any implemented changes to interventions to aide in the prevention of falls. b. care plan interventions were implemented for one (#32) of three sampled residents reviewed for accident hazards and falls. The facility Centers for Medicaid and Medicare from 802 , documented 6 residents had falls with injuries and two had falls with major injuries. Findings: 1. Resident #48 had diagnosis that included Schizophrenia, dementia, unspecified psychosis, abnormal coagulation, and acute kidney failure. Residents #48 care plan, last revised on 05/18/23, read in part, .Focus .[Resident #48] is at risk for falls r/t history of falls, poor safety awareness, impaired cognition/dementia, confusion and delusional thought processes, amnesia, impaired balance, and medication use/side effects . .goal .will be free of minor injuries related to falls through the review date . .Interventions Administer medications as ordered by MD. Monitor/document/report PRN for side effects and effectiveness of medications Anticipate and meet [Resident #48] needs .At times, [Resident #48] uses a walker to assist with walking. Remind/encourage/cue him to use his walker when ambulating to reduce risk of falling .Be sure the resident's call light is within reach and encourage the resident to use it for assistance .Check on resident every 2 hours and .PRN .Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs .Encourage the resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility . Ensure the resident is wearing appropriate footwear when up and out of bed. (nonslip socks or shoes) .Fall Assessment quarterly and with each fall PRN .Falling Leaves Fall Prevention Program . Remind resident to ask for assistance with toileting, transfers and ADL's Resident needs a safe environment with even floors free from spills and/or clutter, .adequate, glare free light, a working call light, bed in lowest position, etc .The resident needs prompt response to all requests for assistance. A Morse Fall Scale, dated 10/31/23, documented the resident was a high risk for falls with a score of 55. A score of 45 or greater indicated a high risk for falls. A progress note, dated 12/02/23 at 1:39 a.m., read in part, .This nurse heard the CNA holler out for help to get res out of another res room. As I was walking down the hall I witnessed the res fall backwards into the hall hitting his head on the floor. Res began to bleed profusely. Pressure and ice applied immediately .sent to ER .for eval and treat . A progress note, dated 12/02/23 at 2:04 p.m., read in part, .Aide took report from the wife and left a note stating, He has staples in his head and has a brain bleed . The emergency department notes, dated 12/02/24, read in part, .assessment .subdural hematoma .CT 3mm acute subdural hematoma over right posterior parietal lobe .chef complaint .fall 5cm head lac .right scalp laceration, stapled . There was no documentation the facilty evaluated the fall for cause and potential ways to prevent further falls with injuries. Resident #48 care plan was not reviewed and there were no implemented changes in fall preventions after the fall that resulted in staples to the head and a brain bleed. The last documented update to fall interventions was dated 05/18/23. A quarterly assessment, dated on 01/24/24, documented the resident had two falls one with no injury and one with a major injury. A Morse Fall Scale, dated 01/24/24, documented the resident was a high risk for falls with a score of 55. A score of 45 or greater indicated a high risk for falls. An incident report, dated 03/03/24 at 8:45 a.m., read in part, .Resident was noted sitting in room floor on his bottom with his back facing the bed .unable to give description .injury type abrasion .left hand . A Morse Fall Scale, dated 03/03/24, documented the resident was a high risk for falls with a score of 80. A score of 45 or greater indicated a high risk for falls. There was no documentation the facilty evaluated the fall for cause and potential ways to prevent further falls with injuries. Resident #48 care plan was not reviewed and there were no implemented changes in fall preventions after the fall on 03/03/24 which resulted in an abrasion to the left pinky. The last documented update to fall interventions was dated 05/18/23. An incident report, dated 04/01/24 at 6:30 p.m., read in part, . This nurse was called to resident room by another nurse, upon entering the room resident was sitting on the floor, on buttocks. Upon body assessment noted blood flowing from the crown of resident's head .unable to give description .Upon assessment of resident's room, noted water on the floor, that resident had spilled .resident's assistive device a cane, in the bathroom . A Morse Fall Scale, dated 04/01/24, documented the resident was a high risk for falls with a score of 90. A score of 45 or greater indicated a high risk for falls. The emergency department notes, dated 04/01/24, read in part, .assessment closed head injury .reasons for visit .fall . There was no documentation the facilty evaluated the fall for cause and potential ways to prevent further falls with injuries. Resident #48 care plan was not reviewed and there were no implemented changes in fall preventions after the fall on 04/01/24 which resulted in a hematoma to the head. The last documented update to fall interventions was dated 05/18/23. A Therapy Screening Form , dated 04/12/24, read in part, .nursing referral .fall .pt evaluated today today for least restrictive device .is unstable with cane (sp) [secondary] to dragging .4ww recommended .left @ BS with resident .training today .notified staff . The wheeled walker was listed on Resident #48 as an intervention dated 05/18/23. An annual assessment, dated 04/23/24 documented Resident #48 had two falls with non major injuries since the last assessment that was completed on 01/24/24. On 05/22/24 12:45 a.m., Resident #48 was observed out of his ambulating from his room to the lobby. The resident was very unsteady and was not using a cane or a walker. On 05/23/24 at 9:45 a.m., Resident #48 was ambulating in the hall without the use of a cane, walker or any assistive devices. The resident was unsteady while ambulating. On 05/23/24 at 11:06 a.m., the regional MDS coordinator, stated the resident was a fall risk and had a fall with staples in December 2023. The regional MDS coordinator stated the resident had two additional falls after December that resulted in harm; one on 03/03/24 and 04/01/24. They stated the resident had a head injury with a hematoma to the head. The regional MDS coordinator then stated the other was an abrasion to his finger. They stated the facility did not evaluate the falls and no new interventions were implemented for falls. The regional MDS coordinator confirmed the last time Resident #58 care plan for falls was reviewed and revised was on 05/18/23. On 05/23/24 at 1:05 p.m., LPN #2 stated Resident #48 was a high risk for falls and was to use a cane for ambulating, but will forget to use the cane and walk without the assistive device. On 05/23/24 at 1:26 p.m., LPN #1 stated Resident #48 was a high risk for falls and was very unsteady on his feet. LPN #1 then stated the wife wanted a walker so therapy evaluated them for it. They then stated the resident does not use the walker or any assistive devices because they forget. On 05/23/24 at 9:59 a.m., Regional Nurse Consultant #2, the intern Director of nursing, stated they could not find any additional interventions changes between 12/02/24 and 04/01/24. The Regional Nurse Consultant #2, then stated there had been no changes and confirmed the resident had three injuries. 45462 2. Resident #32 had documented falls on 05/17/24 and on 05/19/24 with injury. Fall interventions on Resident #32's care plan included fall mat at bedside (dated 05/17/24) and environmental check and removal of rug (dated 05/19/24). On 05/21/24 at 9:50 a.m., Resident #32 was observed in bed asleep. Two throw rugs were observed on the floor in the path to the bathroom and no fall mat was at the bedside. On 05/21/24 at 9:58 a.m., Operations Manager was taken to Resident #32's room and was asked if fall precautions were being observed and if fall hazards had been removed from resident's room. They stated, There is so much wrong in here. [Resident #32] should have a fall mat. These rugs should not be here. On 05/21/24 at 12:20 p.m., Operations Manager acknowledged the accident hazards had not been removed from Resident 32's room and the care plan intervention had been implemented.

Based on record review and interview, the facility failed to submit accurate payroll based journal staffing data to CMS for FY quarter 1 2024. LPN #3 identified 51 residents resided in the facility. Findings: A PBJ Staffing Data Report dated 10/01/24 through 12/31/24, documented the facility did not have RN hours for 10/22, 10/23, 11/03, 11/10, 11/17, 11/30, 12/01, 12/04, 12/07, 12/08, 12/09, 12/10, 12/22, 12/23, 12/24, 12/25, and 12/30/24. The report documented the facility did not have licensed nursing coverage for 24 hours/day for 12/09, 12/10, 12/23, and 12/24/24. On 05/23/24 at 8:31 a.m., Corporate Nurse Consultant #1 stated we had the hours they just didn't get on the report. On 05/23/24 at 1:14 p.m., the Operations Manager provided documentation of coverage for the dates above.

Based on record review and interview, the facility failed to provide a SNF ABN to one of three residents reviewed for beneficiary notification. LPN #3 identified 51 residents resided in the facility. Findings: The Regional MDS Specialist identified 12 residents who had been discharged from a Medicare Part A covered stay with benefit days remaining in the past 6 months. Resident #206 admitted to Part A skilled services on 11/16/23 and discharged from Part A services on 12/05/24. There was no documentation a SNF ABN was provided to resident #25. On 05/20/24 at 2:23 p.m., the Regional MDS Specialist stated they had completed the SNF benefit review and Resident #206 did not have a notice issued. They stated there should have been a notice issued for Resident #206.

Based on record reciew and interview, the facility failed to ensure care plans were reviewed every three months for three (#12, #42, and #48) of 13 resident care plans reviewed. LPN #3 identified 51 residents resided in the home. Findings: 1. Resident #12 had diagnosis to include unspecified skin condition, peripheral vascular disease, and non-pressure ulcers. Resident #12 care plan was last reviewed on 03/11/23. 2. Resident # 42 had diagnosis to include schizophrenia, angina, cerebral infarction, restlessness and agitation, hypertension, acute kidney disease, psychosis and diabetes mellitus. Resident #42 care plan was last reviewed on 05/04/2023. 3. Resident #48 had diagnosis that included Schizophrenia, Diabetes Mellitus, unspecified psychosis, abnormal coagulation, and acute kidney failure. Resident #48 care plan was last reviewed on 08/14/23. On 05/23/24 at 11:06 a.m., the Regional MDS Coordinator was asked how often care plans were to be reviewed. They stated quarterly, every three months and a comprehensive care plan annually. The Regional MDS Coordinator reviewed the care plans for Resident #12, Resident #42 and Resident #48, and stated we have been doing the best we can and have been trying to fill this position. They then stated they had been doing the care plans for over a year because the facility did not have a full time care plan coordinator. When asked how many were not current or up dated, they stated just about all of them.

Based on observation, record review, and interview, the facility failed to: a. ensure a trauma wound to the left second toe was changed as needed when viably soiled and not intact for one (#12) of one sampled resident reviewed for trauma injury to the feet.; and b. accurately document behaviors to support the administration of as needed antianxiety medication for one (#29) of one sampled resident receiving as needed antianxiety medication. LPN #3 identified 51 residents resided in the facility. Findings: An Administering Medications policy, revised April 2019, read in parts, As required or indicated for a medication, the individual administering the medication records in the resident's medical record .any complaints or symptoms for which the drug was administered .any results achieved and when those results were observed . 1. Resident #12 had diagnosis to include unspecified skin condition, peripheral vascular disease, and non-pressure ulcers. The current physician orders for Resident #12 documented the following treatment order: cleanse left second toe area with non-saline, apply Medihoney and SilverAlg, cover with an ABD wrap with Kerlix every day shift on Monday, Wednesday, and Friday. A second order for Resident #12, read in part, .Observe dressing, if soiled or dislodged - Cleanse left second Toe with NS and pat dry, apply Medihoney and SilverAlg, cover with ABD (absorbent dressing) and wrap with Kerlix every shift . On 05/19/24 at 8:15 a.m., Resident #12 was observed up in his wheelchair in the hallway near the dining room. The resident did not have a show on the left foot. The resident had a soiled dressing wrapped around the ankle. The second toe had an absorbent dressing without any Kerlix over it. There was visible dried blood and drainage soaked through the absorbent pad. On 05/19/24 at 10:06 a.m., Resident #12 was observed in his room with his left shoe off. The The resident had a soiled dressing wrapped around the ankle. The second toe continued to have an absorbent dressing without any Kerlix over it. with visible dried blood and drainage soaked through the pad. On 05/19/24 at 10:15 a.m., two aides were observed transferring Resident #12 to bed and no one alerted a nurse to the condition of the dressing. On 05/19/24 at 11:25 a.m., Resident #12 was observed being transferred to the wheelchair and the dining room. Resident #12 continued to have no left shoe on and the dressing had not been changed. On 05/19/24 at 12:30 p.m., Resident #12 was again observed up in the dining room without the dressing being changed. On 05/19/24 at 1:30 p.m., Resdient #12 was observed up in his wheelchair with no changes to the left toe dressing. On 05/19/24 at 1:55 p.m., Resident #12 was observed in his wheelchair in his room. The left toe continued to have viable dried blood and drainage soaked through the pad without any Kerlix. On 05/19/24 at 2:30 p.m., LPN #4 was observed leaving the resident room. The resident was observed in bed with a new dressing on dated 05/19/24. The resident was observed for over six hours without the soiled dressing being changed. On 05/19/24 at 3:12 p.m., LPN #4 stated they had noticed while cleaning a urine mess under a dining room table that Resident #12 dressing was saturated and needed to be changed. The LPN stated the dressing was changed after 2:00 p.m., because they were not able to get to it sooner. LPN #4 than stated the dressing should have been changed earlier in the day but they did not know about it. 45462 2. Resident #29 had a physician's order, dated 05/17/24, to receive Vistaril Oral Capsule 25mg one capsule by mouth every eight hours as needed for anxiety for 14 Days. April 2024 MAR documented Resident #29 received PRN doses of Vistaril on 04/05/24 at 9:41 a.m. and 4:55 p.m.; 04/15/24 at 12:25 p.m.; 04/22/24 at 11:42 a.m.; and 04/25/24 at 11:02 a.m. April 2024 MAR documented Resident #29 had no behaviors warranting the administration of PRN Vistaril on any shift for the dates listed above. Progress Notes dated 04/01/24 through 05/22/24 documented no occurrences of behaviors on any shift warranting the administration of PRN Vistaril. On 05/22/24, at 10:55 a.m., PA, the assistant to Resident #29's Psych MD, was asked what the conditions should be for administering Resident #29's PRN Vistaril. They stated, It should be given for an episode of anxiety after attempts to redirect or calm resident have been unsuccessful. Episodes, measures attempted, and effectiveness should be documented to help us determine if the medication should be continued, adjusted, or stopped. On 05/22/24, at 10:57 a.m., Regional Nurse Consult. #1 stated a PRN anxiety medication would only be given after the resident was assessed by a nurse and acknowledged that behaviors warranting administration of the medication should have been documented on the MAR and in the progress notes. On 05/22/24, at 11:36 a.m., LPN #1 reported PRN anxiety medications would only be given by the CMA after the resident was examined by the nurse and that documentation would include why they needed the medication and what else was done to help them.

Based on observation, record review, and interview, the facility failed to implement a weight loss intervention of shakes three times a day timely for one (#48) of one resident reviewed for weight loss. The facility Centers for Medicaid and Medicare from 802 , documented 3 residents had excessive weight loss. Findings: Resident #48 had diagnosis that included Schizophrenia, Diabetes Mellitus, unspecified psychosis, abnormal coagulation, and acute kidney failure. A care plan last updated on 05/18/23, documented the resident was at risk for weight loss and had a history of severe weight loss. A documented intervention was to have the registered dietician to evaluate and make diet change recommendations. A review of Resident #48 weight record, dated 03/29/24, documented the resident weighed 158.2 pounds. The weight record also documented the resident had a severe weight loss of 32 pounds (16.8%) in 180 days from 10/25/23 to 03/29/24; and a severe weight loss of 11 pounds (6.5%) in 30 days from 02/23/24 to 03/29/24. A consulting dietician recommendation, dated 04/01/24, documented Resident #48 had a significant weight loss in one month and recommended an increase in the house shake from twice a day to three times a day. The consulting dietician recommendation, dated 04/01/24, was not signed by the facility director of nursing and physician until 05/14/24. A review of the Medication administration record and Treatment Administration record, documented the resident did not receive the shakes three times a day until 05/14/24. On 05/23/24 at 10:01 a.m., the dietary manager reviewed the consulting dieticans recommendations dated 04/01/24 and the implementation date of the recommendation. The dietary manager stated they facility did not act upon the recommendation timely. On 05/23/24 at 10:32 a.m., Regional Nurse Consultant #2, the intern director of nursing, stated the facility did not act upon the recommendations timely.

Based on observation, record review, and interview, the facility failed to ensure there was sufficient staff and supervison for the needs of the residents. LPN #3 identified 51 residents resided in the facility. Findings: 1. Resident #48 had diagnosis that included Schizophrenia, dementia, unspecified psychosis, abnormal coagulation, and acute kidney failure. Residents #48 care plan, last revised on 05/18/23, read in part, .Focus .[Resident #48] is at risk for falls r/t history of falls, poor safety awareness, impaired cognition/dementia, confusion and delusional thought processes .Interventions .Remind/encourage/cue him to use his walker when ambulating to reduce risk of falling .Check on resident every 2 hours and .PRN . A progress note, dated 12/02/23 at 1:39 a.m., read in part, .This nurse heard the CNA holler out for help to get res out of another res room. As I was walking down the hall I witnessed the res fall backwards into the hall hitting his head on the floor. Res began to bleed profusely. Pressure and ice applied immediately .sent to ER .for eval and treat . A progress note, dated 12/02/23 at 2:04 p.m., read in part, .Aide took report from the wife and left a note stating, He has staples in his head and has a brain bleed . The emergency department notes, dated 12/02/24, read in part, .assessment .subdural hematoma .CT 3mm acute subdural hematoma over right posterior parietal lobe .chef complaint .fall 5cm head lac .right scalp laceration, stapled . An incident report, dated 03/03/24 at 8:45 a.m., read in part, .Resident was noted sitting in room floor on his bottom with his back facing the bed .unable to give description .injury type abrasion .left hand . An incident report, dated 04/01/24 at 6:30 p.m., read in part, . This nurse was called to resident room by another nurse, upon entering the room resident was sitting on the floor, on buttocks. Upon body assessment noted blood flowing from the crown of resident's head .unable to give description .Upon assessment of resident's room, noted water on the floor, that resident had spilled .resident's assistive device a cane, in the bathroom . On 05/21/24 at 6:34 a.m., LPN #5 stated Resident #48 is a high risk for falls. They stated there are two aides and herself and it is hard to supervise all the residents and provide the care that is needed. LPN #5 stated Resident #48 does not use a walker or cane to ambulate when up because they forget about it. On 05/21/24 at 7:12 a.m., CNA #5, stated Resident #48 does not remember to ask for asssistance and was at risk for falls. They stated their are two aides and one nurse at night at they can not get their work done and monitor residents that need close supervison. On 05/21/24 at 7:37 a.m., CNA #6 stated they do not have enough staff to provide supervison to those needing supervison and provide the care. CNA #6 stated Resident #48 was at risk for falls and did not use a walker or cane to ambulate with. 2. Resident #12 had diagnosis to include unspecified skin condition, peripheral vascular disease, and non-pressure ulcers. A physician's order for Resident #12, read in part, .Observe dressing, if soiled or dislodged - Cleanse left second Toe with NS and pat dry, apply Medihoney and SilverAlg, cover with ABD (absorbant dressing) and wrap with Kerlix every shift . On 05/19/24 at 8:15 a.m., Resident #12 was observed up in his wheelchair in the hallway near the dining room. The resident did not have a shoe on the left foot. The resident had a soiled dressing wrapped around the ankle. The second toe had an absorbent dressing without any Kerlix over it. There was visible dried blood and drainage soaked through the absorbent pad. On 05/19/24 at 10:06 a.m., Resident #12 was observed in his room with his left shoe off. The The resident had a soiled dressing wrapped around the ankle. The second toe continued to have an absorbent dressing without any Kerlix over it. with visible dried blood and drainage soaked through the pad. On 05/19/24 at 10:15 a.m., two aides were observed transferring Resident #12 to bed and no one alerted a nurse to the condition of the dressing. On 05/19/24 at 11:25 a.m., Resident #12 was observed being transferred to the wheelchair and the dining room. Resident #12 continued to have no left shoe on and the dressing had not been changed. On 05/19/24 at 12:30 p.m., Resident #12 was again observed up in the dining room without the dressing being changed. On 05/19/24 at 1:30 p.m., Resident #12 was observed up in his wheelchair with no changes to the left toe dressing. The left toe continued to have visible dried blood and drainage soaked through the pad without any Kerlix. On 05/19/24 at 1:55 p.m., Resident #12 was observed in his wheelchair in his room. The left toe continued to have visible dried blood and drainage soaked through the pad without any Kerlix. The resident was observed for over six hours without the soiled dressing being changed. On 05/19/24 at 3:12 p.m., LPN #4 stated they had noticed while cleaning a urine mess under a dining room table that Resident #12 dressing was saturated and needed to be changed. The LPN stated the dressing was changed after 2:00 p.m., because they were not able to get to it sooner. On 05/21/24 during the resident council interview with five alert and oriented residents, all in attendance stated there were not enough staff to take care of the residents and care is not provided timely as a result. They stated the night time was the worse.

Based on record review and interview, the facility failed to ensure the cognitive pattern, section (C), of the minimum data set was coded for one (#42) of 13 sampled residents whose MDS were reviewed. LPN #3 identified 51 residents currently resided in the facility. Findings: Resident # 42 had diagnosis to include schizophrenia, angina, cerebral infarction, restlessness and agitation, hypertension, acute kidney disease, psychosis and diabetes mellitus. A quarterly assessment dated [DATE], under section C cognitive patterns had dashes located in every box. There were no documented answerers to any of the questions located in section C of the assessment. On 05/22/24 at 1:02 p.m., [NAME] Nurse Consultant #2, the intern DON, stated sections C should have been completed and the Regional MDS coordinator would be able to tell why it was not. He stated without it being filled out it was not accurate. On 05/23/2024 at 10:09 a.m., The Regional MDS coordinator stated section C had dashes which indicated the section was not coded and Resident #42 was not assessed for cognition. They then stated the assessment is not accurate when sections were left blank and not filled out.

Based on observation and interview, the facility failed to ensure room [ROOM NUMBER] was free of odors for one (#29) of 30 rooms observed for odors. The facility operations manager identified 30 rooms in the facility that were occupied by residents. Findings: On 05/19/24 from 8:30 a.m., through 1:15 p.m., there was a strong odor of urine coming from room [ROOM NUMBER]. When the rooms door was open it could be detected down the hall approximately six feet from the room. On 05/20/24, 05/21/24, 05/22/24 and 05/23/24, the same observations were made of the room. On 05/23/24 at 1:10 p.m., Housekeeper #1 stated room [ROOM NUMBER] has had a strong urine odor since they stated work at the facility the first of March, 2024. They stated the room is cleaned twice a day and the tile has been replaced and they still can not keep up with the urine odor in the room. On 05/23/24 at 1:18 p.m., the Housekeeping Supervisor stated they made rounds twice a day to ensure rooms were being cleaned. The supervisor stated they clean room [ROOM NUMBER] twice a day and smell of urine still remained. They stated they used chemicals in the room while cleaning to eliminated odors, changed the bathroom tile and the odors continued to strong. The housekeeping supervisor stated the issues had been going on for several months. On 05/23/24 at 1:47 p.m., the operations manger stated she was aware of the urine odor in the room and it had been an on going issues before they were at the facility.

Based on observation, record review, and interview, it was determined the facility failed to: ~ provide the necessary supervision to prevent falls and consistently identify and/or implement interventions to prevent falls for one (#51) of three sampled residents, whose records were reviewed for supervision/falls. This resulted in harm for resident #51. The resident had five falls from 09/03/16 through 12/17/16. The fall on 11/13/16 resulted in a right hip fracture, which required surgery. The facility identified an additional thirteen residents with falls. ~ ensure ordered therapeutic diets were followed for one (#23) of five residents on a pureed diet with nectar thickened liquids. This resulted in harm for resident #23 when facility staff provided the resident chocolate candy. This resident experienced an episode of choking and respiratory distress. The dietary manager provided documentation which identified there were five residents with physician ordered pureed diets with nectar thickened liquids. Findings: The facility transfer policy, effective 04/23/13, documented, All residents are two (2) person assist for any transfers. No exception. 1. Resident #51 had [DIAGNOSES REDACTED]. The resident's admission fall risk assessment, dated 08/24/16, documented the resident was assigned a fall risk score of 17. The assessment tool documented a total score of ten or above represented a high fall risk. The clinical record contained no documentation an admission care plan for falls had been developed for the resident after he had experienced a fall before admission to the facility and had been given a high fall risk status by the facility's assessment. A nurse's note, dated 08/25/16 at 4:00 a.m., documented the resident remained forgetful and confused. The note also documented the resident had been reminded to use the call light for assistance, but the resident had been unable to remember to use the call light. The note documented the resident had been observed walking behind his wheelchair in the hallway. A nurse's note, dated 09/03/16 at 10:30 a.m., documented the resident was found lying on his left side, on the floor of his room. The note documented the resident denied falling. The clinical record contained no documentation of an incident report or a care plan having been developed for falls, and no documentation of fall interventions having been initiated. The resident's admission assessment, dated 09/06/16, documented the resident understood others, made himself understood, was severely impaired in cognition, and had disorganized thinking. The assessment also documented the resident was independent with bed mobility, required limited assistance of two staff members for transfers, and required extensive assistance of two staff members for toileting. The resident was also coded as always incontinent of bowel and bladder. The resident's assessment documented the resident had one fall in the past month prior to admission. The resident's fall risk assessment, dated 09/30/16, documented the resident was assigned a high fall risk score of 17. The resident's fall risk assessment, dated 10/24/16, documented the resident was assigned a high fall risk score of 20. An incident report, dated 10/24/16 at 3:00 a.m., documented the resident was found sitting on the floor next to his bed. The report documented the resident had a bruise and skin tear to his elbow. The resident denied knowing when or how he fell . The interventions documented in the report were to encourage the resident to use the call light, wait for assistance, conduct safety checks, and to place the bed in the lowest position. The resident's care plan, dated 10/24/16, documented the resident had a fall in his room at 3:00 a.m. The fall resulted in a skin tear to his left elbow. The care plan for falls documented the interventions were to: ~ encourage the resident to use the call light and wait for assistance, ~ place bed at lowest level, and ~ safety checks every 30 minutes by staff. The resident had experienced two falls and the clinical record contained no documentation a care plan had been developed for falls prior to 10/24/16. A nurse's note, dated 10/25/16 on the 3 to 11 shift, documented the resident was status [REDACTED]. An incident report, dated 11/03/16, documented a new large dark purple bruise had been observed on the resident's right hip. The intervention was to continue with the safety checks. Attached to the incident report was a hand written note that documented on 11/04/16, the administrator interviewed the certified nurse aides (CNAs) who provided direct care to the resident. The note documented the findings were: ~ the resident did not understand to ask for assistance, ~ he transferred himself from his wheelchair to the toilet, and ~ he probably fell against the wall mounted safety bars on the bathroom wall. The care plan for falls, updated 11/03/16, documented: ~ the resident walked to the bathroom without assistance, ~ transferred self from wheelchair to toilet, and ~ the resident probably lost his balance and fell against the safety rails. The intervention on the care plan documented the resident understood to ask for help by using the call light. A nurse's note, dated 11/05/16 at 6:00 a.m., documented, to b/r (bathroom) byself, lg (large) bruise noted (L) (left) flank area, no pain or discomfort noted. The clinical record contained no additional documentation about the bruise to his left flank. No incident report had been completed. The resident's fall risk assessment, dated 11/13/16, documented the resident was assigned a high fall risk score of 20. A nurse's note, dated 11/13/16 at 6:00 a.m., documented the resident was found on the floor of his room with his pants around his ankles. The resident was holding the back of his head with both hands. The note documented the resident had stated he didn't know what happened. The note documented the resident had skin tears to his right outer elbow. The note also documented the resident denied pain during range of motion assessments. An incident report, dated 11/13/16, documented to continue with every 30 minute safety checks. The resident's care plan for falls, dated 11/13/16, documented the resident had a fall with a skin tear to his right outer elbow. The interventions documented the resident was to be placed in a low bed and safety checks every 30 minutes. A nurse's note, dated 11/16/16 at 4:00 p.m., documented the resident complained of pain in his right leg and refused to be transferred from his wheelchair to bed. The nurse's note documented a new order was obtained to get a portable x-ray. The x-ray report documented the resident had a questionable subcapital femoral neck fracture and recommended a repeat study. A nurse's note, at 5:00 p.m., documented the results were phoned to the physician and new orders were given to transport the resident to a local hospital for evaluation. A nurse's note, dated 11/16/16 at 9:00 p.m., documented a family member informed the facility the resident had been admitted to the hospital and was scheduled for surgery tomorrow. A hospital surgery operative report, dated 11/17/16, documented the resident had undergone a surgical repair of his fractured right hip. A nurse's note, dated 11/19/16 at 4:30 p.m., documented the resident was readmitted to the facility. The admission physician orders [REDACTED]. The clinical record contained no documentation a care plan had been developed for the resident's hip fracture. An incident report, dated 11/30/16, documented a CNA was transferring the resident from bed to his wheelchair. The bed was not locked and it begin to move. The resident became unstable and the resident was placed on the edge of the bed. The note documented the resident was sliding off the edge of the bed so, the bed was lowered and the resident was assisted to the floor. The intervention documented on the incident report was to use a two person assist at all times. A care plan for skilled services, dated 11/26/16, documented the resident had right hip surgery had weakness to lower extremities and at times became combative with staff. A care plan, dated 12/01/16, documented the resident was totally dependent on staff for all of his activities of daily living (ADLs). The resident was incontinent of bladder and bowel. The documented interventions were to do 30 minute checks and to toilet him every two hours, if able. The care plan for communication documented staff was to face him when speaking. The self-care deficit care plan documented the resident was totally dependent on staff for ADLs related to weakness from his recent hospital stay and surgery. The approaches were the resident was weight bearing and did pivot when assisted by two. The resident's high fall risk assessment, dated 12/13/16, documented the resident was assigned a fall risk score of 14. An incident report, dated 12/13/16, documented the resident was found sitting on the floor next to his bed at 3:05 a.m. The resident had an abrasion, with serous drainage to the back of his head. The resident was transported to a local emergency room . The resident was returned without new orders except neuro checks. The interventions documented on the report were to place a mat beside his bed and move the resident to a room closer to the nurses' station. The clinical record contained no documentation the resident had been moved closer to the nurse's station. The resident's high fall risk assessment, dated 12/15/16, documented the resident was assigned a fall risk score of 16. A care plan for falls, dated 12/16/16, documented: Falls Resident has had multiple falls within the last 3 months. Resident has been assessed and is at high risk for falls. Visual safety checks will be put into place. (Named resident) has recently returned from Hospital with a FX (fractured) right femoral neck w/ (with( cannulated screws. Goals Resident will have less falls from injury but be as independent as he wants to be Approaches 1. Assist with ambulation as needed. 2. Have resident stand up slowly from a sitting position for a few min. (minutes) before attempting to ambulate 3. Make sure path is well lit. 4. Resident to wear non skid shoes. 5. Keep area free of clutter 6. Show resident where call light is at and educate to use when getting up. 7. Remind resident they can still have independence. But staff can be there to observe just incase lose (sic) balance. 8. Staff will do safety checks on residents q 30 min for risky situations if resident needs any type of assistance bathroom needs or just getting up staff will stay with resident until they are ready to get in w/c (wheelchair) or bed. 9. Skill therapy to work with Resident PT/OT (physical therapy and occupational therapy). An incident report, dated 12/17/16 at 2:49 p.m., documented the resident was found on the floor in his room. The report documented the resident was unable to explain what happened. The report documented the interventions were to continue with previous safety and protective measures. The resident's fall risk assessment, dated 12/17/16, documented the resident was assigned a fall risk score of 18. A care plan for falls, dated 12/17/16 at 2:49 p.m., documented: Falls Res (resident) Has had a fall in room n--- ( sic, illegible word) injury. Charge nurse observed res. on floor in room Approaches 1. Assess cause, pattern of previous falls & (and) act on resolvable factors 5. Promote proper use of hand rails 9. Continue previous safety and protective measures, and 30 min safety checks. 10. Res up in w/c close to nursing station. On 03/13/17 at 10:43 a.m., the resident was in bed with the privacy curtains drawn around his bed. He was in bed B next to the window. The resident was not visible from the hall unless you entered the room and pulled the privacy curtains back. At 11:30 a.m., the resident was in bed with the privacy curtains drawn around his bed. The resident was not visible from the hall. At 3:00 p.m., the resident was in bed with the privacy curtains drawn around his bed. The resident was not visible from the hall. On 03/14/17 at 9:54 a.m., the resident was in bed with the privacy curtains drawn around his bed. The resident was not visible from the hall unless you entered the room and pulled the privacy curtains back. At 1:51 p.m., staff left the resident's room, pulled the privacy curtain closed around his bed, and closed the hall door. The resident was in bed B next to the window. The resident was not visible from the hall. At 4:03 p.m., certified medication aide (CMA) #1, transferred the resident from his bed to his wheelchair. With the assistance of the CMA the resident was able to stand and pivot. The resident remained calm during the transfer. The CMA was asked if the resident was able to use the call light. She stated the resident didn't know enough to use the call light. The CMA stated other people use two staff members to transfer him, but if you take your time with him and speak to him, he is not a problem. On 03/15/17 at 8:24 a.m., the resident was seated at the dining table when a staff member transferred him to the nurses' station, no nurses were seated at the station. At 8:47 a.m., the resident was still seated in the hall near the nurses' station. No nurses were seated at the station. At 8:48 a.m., the resident was transferred to his room. Certified nurse aides (CNAs) #2 and #3 were observed transferring the resident from his wheelchair to his bed. They lifted him by pulling up on his shoulders and the waist band of his pants (wedgie style). The resident was cussing and twisting the whole time. The resident was hard of hearing and staff had not faced him when they spoke to him. He was not given time to stand and pivot as he had on the previously observed transfer. They were asked about safe transfer techniques. They stated he was heavy so that was the only way they could lift him. They were asked if they had access to gait belts. They stated they were not issued gait belts. They were asked if the resident was able to stand and pivot. They stated he was not. They were asked if lifting him by the seat of his pants and pulling him by his shoulders was safe and comfortable for the resident. They again repeated his is too heavy to do it any other way. They were asked what the facility policy was for transfers. They responded by stating the policy was to use two people or a lift. They were asked if the resident was able to use the call light. They both stated he was not. They were asked how frequently the resident was toileted and/or checked on. They stated everyone was checked on every two hours. When the CNAs left the resident's room the privacy curtain was drawn around his bed and the door to the hallway was closed. The resident's bed was not visible from the hall. At 10:11 a.m., a staff member entered the room and asked both residents if they needed to use the restroom. She left and the privacy curtains remained drawn around the bed. The resident's bed was not visible from the hall. At 10:28 a.m., CNA #2 entered and left the room. She was overheard asking the resident in bed A if he wanted to use the toilet. She then left the room. She had not opened the curtains to check on resident #51. Privacy curtains were still drawn around the bed. At 11:27 a.m., a staff member entered the room to place a tray food at bed A. She did not open the privacy curtain to check on resident #51. At 11:40 a.m., staff entered the resident's room and began to transfer the resident to his wheelchair. The resident had not been checked on between 10:11 a.m. and 11:40 a.m. The care plan documented staff was to perform a visual check every 30 minutes on the resident. At 4:40 p.m., the director of nurses (DON) and administrator were asked if the staff was required to use gait belts when transferring a totally dependent resident. They stated they did not use gait belts, because all staff were required to do two person transfers or use a lift. They stated that was their policy. The DON was asked if the staff was conducting 30 minute visual checks. She stated they were. She was asked where the checks were documented. She stated it should be documented on the TARs (treatment administration record). The TARs was reviewed with the DON. There was no documentation of 30 minute safety checks. At 4:50 p.m., the DON was asked if it was a safe transfer when the resident was lifted by his arms and the seat of his pants. She stated she didn't think so. At 5:00 p.m., the administrator was asked if she had conducted an investigation concerning the bruises found on the residents flank and hip. She was also asked if she had investigated his falls to determine causes. The administrator stated she had conducted investigations and she had determined the resident self-transferred himself to the toilet, tried to ambulate, and had probably lost his balance and fallen against the wall mounted safety bars. She added the resident was not cognitive enough to use the call light and ask for assistance. The administrator was asked if she knew why the resident had not experienced a fall since 12/17/16. She said, He had experienced a decline and now he did not even try to self- transfer or ambulate. She added when he first arrived he was able to ambulate around the facility. The administrator was asked if the resident had been moved to a room closer to the nurses' station. She stated he had not been moved because she had not had a vacant room near the nurses' station. She said, Now he has declined there is no need to move him. 2. Resident #23 had [DIAGNOSES REDACTED]. The resident had originally been admitted to the facility on [DATE], on a pureed diet with nectar thickened liquids. The clinical record contained no documentation of a swallow study performed for the resident. A quarterly assessment, dated 01/01/17, documented the resident was moderately impaired in skills for daily decision making. The resident required extensive to total assistance from staff with ADL's (activity of daily living). The resident had a PEG (percutaneous esophagogastric) feeding tube in place which was used for fluid and supplement bolus. The resident was able to eat a pureed diet with nectar thickened liquids PO (per os, by mouth). A facility incident report, dated 02/14/17, documented, .Resident choked on chocolate candy, Initially unable to clear airway. Unable to effectively cough or breath .became cyanotic with SpO2 (peripheral capillary oxygen saturation) of 38-44% on RA (room air) EMSA (emergency service ambulance) initiated, resident returned to room and placed on O2 (oxygen) per PRN (as needed) order, airway cleared spontaneously during transfer to room. SpO2 95% on 3L/m (Liter/minute) via NC (nasal cannula). Lungs very course, EMSA Cx (cancelled). On call phoned (Named physician), N.O. (new order) CXR (chest x-ray) portable obtained and + (positive) for R (right) infrahilar infiltrate. Phoned on call once more. N.O. Levaquin 750 mg PO qd (every day) x (times) 10 days . A Final X-Ray Report, dated 02/14/17, documented, .The heart is somewhat enlarged. Vascular congestion is seen with a small right infrahilar infiltrate however there is no evidence for pleural effusions or pneumothoraces on either side .Small Right Infrahilar infiltrate . A facility form titled, One on One Inservice, dated 02/15/17, documented, .In-Service subject: Educated: Res (resident) on pureed food check with charge nurse before giving any food other then (sic) served with meal . The in-service was provided by the ADON to the administrator. A facility form titled, One on One Inservice, dated 02/15/17, documented, .In-service subject: Due to Residents reaction to the chocolate candy will not give to Resident again. Always check with nurse before giving any food other than what is served at meals or designated for residents . The in-service was provided by the DON and the administrator to the activity director. A nursing progress note, dated 02/15/17 at 2:30 a.m., documented, .Levaquin .given at 2355 (11:55 p.m.) upon arrival from pharmacy .Res resting in bed .Resp.(respiration) E+U (even and unlabored) with HOB (head of bed) elevated 30-45 degrees at all times + (and) O2 @ (at) 3L via NC bilat (bilateral) lung sounds remain course. Res denies SOB (shortness of breath)/cough . A nursing note, dated 02/15/17 at 9:00 a.m., documented, .Resident sitting in w/c (wheelchair) at nurses station. Resident is satting 93% on room air .course rhonci audible bilaterally upon expiration. Respiration is unlabored . On 03/14/17 at 4:00 p.m., LPN #1 was asked if she recalled the resident's choking incident on 02/14/17. She stated, Yes. I was called to the activity room overhead by the social services director. The resident was choking on a piece of candy. She was asked if she knew how the resident obtained a piece of candy. She stated, The activity director asked the administrator if the resident could have candy and she said yes. She was asked if EMSA had been called. She stated, EMSA was called first, then the doctor (Named physician) then the resident cleared her airway. The Nurse Practitioner (Named nurse practitioner) called back before EMSA's arrival, a portable chest x-ray was ordered, the ambulance was cancelled and I was told not to send her to the emergency room . She further stated, The chest x-ray was positive for lung infiltrates. An antibiotic, Levaquin, was ordered. She was asked if the resident's condition had gotten worse. She stated, It didn't get worse, but it didn't get better. She had course lung sounds that had been ongoing. On 03/15/17 at 8:42 a.m., the activity director was asked if she recalled a resident choking incident which occurred on 02/14/17. She stated yes, it was our Valentine's day social. The resident asked me for a piece of candy. I asked the administrator if the resident could have it and she said yes. The candy was soft like a pureed diet. I broke it in half, gave it to her and she started to choke on it. She was asked if she knew the resident was on a pureed diet with nectar thickened liquids. She stated, Yes She was asked if she could recall what happened after the resident received the candy. She stated the resident was choking and I told the administrator who ran over to the resident and raised her arms and patted her on the back. We called the nurse who was on duty. She was asked if the resident became unconscious or unresponsive. She stated, No. She was asked if an ambulance was called. She stated, No. She was asked if the resident remained in the activity room. She stated, The CNA (certified nursing assistant) and I took her back to her room and put her back in bed and raised up the head of the bed. She was asked if she had been In-serviced on resident diet's. She stated, After that I was. At 9:00 a.m., the administrator was asked if she recalled a resident choking incident on 02/14/17. She stated, That was the Valentines day social around 2:00 p.m., that's normally when the holiday parties are held. She was asked if the resident was present at the social. She stated, Yes. She was asked if the resident was served the same food and beverages as the other residents at the social. She stated, I came in later. She was asked what was the resident's diet. She stated, She was on a pureed diet with thickened liquids. She was asked if she was present during the resident choking incident. She stated, I walked in. The activity director asked if the resident could have a piece of chocolate that was pinched down because the resident had asked for it. I said it was okay. When the resident was chewing it, she was trying to cough up phlegm in her throat. She was asked what alerted you to call the nurse if the resident was coughing and not choking. She stated, I think when she swallowed that piece of candy it prompted her to cough up the phlegm. I know the nurses said she was choking but she never turned blue or anything. She was asked if EMSA was called. She stated, The nurse called an ambulance but after they put her back in bed and raised her up she was breathing normally and speaking to us. Her O2 sats went up. The ambulance was cancelled.

Based on observation, record review and interview, it was determined the facility failed to implement the care plan related to pain management with the treatment of [REDACTED].#22) of two sampled residents who were reviewed regarding pressure ulcer treatment. The resident was not administered pain medication prior to the treatments which resulted in severe pain. The facility's 'Resident Census and Conditions of Residents' form, dated 05/24/16, documented two residents had pressure ulcers. Findings: Resident #22 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan, dated 04/01/16, documented the resident had an alteration in pain and comfort related to ulcers and decubitus. The goal documented that pain would be relieved within 30 minutes of the intervention. Approaches included to assess the resident for pain management monthly and as needed by the director of nurses (DON) and/or registered nurse (RN), administer routine pain medication twice a day and every six hours prn (as needed), administer Tylenol 650 milligrams (mg) every six hours prn and apply a [MEDICATION NAME] 75 micrograms (mcg) every 72 hours. The annual assessment, dated 04/03/16, documented the resident required total assistance with bed mobility, toilet use, personal hygiene and bathing. The assessment documented the resident had limited range of motion to the upper and lower extremities on both sides, had an indwelling foley catheter and had four stage III pressure ulcers. The 05/2016 physician's orders [REDACTED]. every six hours prn. On 05/25/16 at 3:57 p.m., the resident was observed in bed with both legs elevated on pillows. The legs were wrapped in ace bandages and white bandages were observed on the calf areas. The resident was asked how she was feeling. She stated her legs were hurting a lot. She was asked if she needed something for pain. She stated, Yes. At 3:59 p.m., CMA #2 was asked if the resident had any prn medication. The CMA stated she did have pain medication, but she could only have it if she was in severe pain and was crying. The physician's prn pain medication order did not indicate her pain had to be severe in order to administer the medication. The CMA was informed the resident had asked for pain medication. The Medication Administration Record [REDACTED] The resident was medicated with a prn pain medication at 4:00 p.m. On 05/26/16 at 9:58 a.m., the DON was asked when she would perform the wound care on resident #22. She stated the physician was in that morning and took off all the dressings and was changing the orders. She stated she was going to do her wound care next, but had to call the physician and get the new wound care orders first. At 11:00 a.m., the DON performed wound care on the resident. When the staff assisted and pulled up the right leg for wound care, the resident immediately began to cry out in pain. The DON affirmed she knew it hurt, but she had different orders today and it would not be as long of a treatment as usual. The resident continued to cry out with the treatment. After the right leg treatment was completed, the staff member raised the left leg for wound care. Again, the resident cried out in pain and stated that the left heel was the one that hurt the worst. The DON assured her she would get the treatment done as quickly as possible. After the wound care was performed on the legs, the resident was rolled onto her right side for the wound care on her sacral area. The resident moaned during the wound care. At 3:03 p.m., certified medication aide (CMA) #1 was asked if she administered the morning medications to resident #22. She stated, Yes. She was asked when she had administered the routine pain medication to her. She stated she got down that hall to her around 7:30 a.m. At 3:09 p.m., the DON was asked if the resident was pre medicated before the wound care was performed that morning. She stated she had asked the CMA to medicate her 30 minutes prior to the treatment because she received routine medication as well. She stated the resident had severe arthritis in the right leg, so it was painful anyway. The DON stated she would ask the CMA when she medicated her. At 3:58 p.m., the DON stated there was a prn pain medication that could have been given, but the CMA stated she was waiting until 2:00 p.m. due to she could not give the medication until 6 hours after the routine. She further stated there was a miscommunication when she asked the CMA if she had given the requested prn pain medication. The physician's prn pain medication order did not indicate a time period to wait after the routine pain medication was administered. The DON was asked if the resident would have benefited from the prn pain medication prior to her wound care treatment. She stated, Yes. She was asked if the resident displayed any signs and symptoms of pain during the pressure ulcer treatment. She stated, Yes and the wound care physician had just debrided the left foot pressure ulcer that morning, so I am sure it was painful. The DON was asked if the care plan was followed related to administering pain medications for comfort prior to the treatment. She stated, No.

Based on observation, record review and interview, it was determined the facility failed to ensure a prn (as needed) pain medication was administered prior to pressure ulcer treatments for one (#22) of two sampled residents. This resulted in the resident being in severe pain during the treatments. The facility's 'Resident and Census of Conditions of Residents' form, dated 05/24/16, documented two residents who resided in the facility had pressure ulcers. Findings: Resident #22 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A resident data collection form (assessment), dated 03/10/16 and 03/21/16, documented the resident had one stage I ulcer to the left lower outer leg and one stage I ulcer to the left outer ankle. Two areas on the top of the left foot and one area on the top of the right foot were described as, .circular red areas stage I, darkened areas in center of 5 6 (top of the left foot) . The assessment documented wounds on both calfs were, .initial wounds that were healing prior to (hospital name deleted) 10 (posterior lower leg) new area stage 2/3 ulcer wound 11, 12, 13 (left buttock, coccyx and right buttock) stage 2 ulcerations .17 18 (right outer foot) stage 1/red circular areas pressure . The assessment was also checked Yes in the area titled 'Pain on admission' and documented, .Cried before and during any touch to person. The care plan, dated 04/01/16, documented the resident had an alteration in pain and comfort related to ulcers and decubitus. The goal documented that pain would be relieved within 30 minutes of intervention. Approaches included to assess the resident for pain management monthly and as needed by the director of nurses (DON) and/or registered nurse (RN), administer routine pain medication twice a day and every six hours as needed, administer Tylenol 650 milligrams (mg) every six hours as needed and apply a [MEDICATION NAME] 75 micrograms (mcg) every 72 hours. The annual assessment, dated 04/03/16, documented the resident required total assistance with bed mobility, toilet use, personal hygiene and bathing. The assessment documented the resident had limited range of motion to the upper and lower extremities on both sides, had an indwelling foley catheter and had four stage III pressure ulcers. The 05/2016 physician's orders [REDACTED]. every six hours prn. On 05/25/16 at 3:57 p.m., the resident was observed in bed with both legs elevated on pillows. The legs were wrapped in ace bandages and white bandages were observed on the calf areas. The resident was asked how she was feeling. She stated her legs were hurting a lot. She was asked if she needed something for pain. She stated, Yes. At 3:59 p.m., CMA #2 was asked if the resident had any prn medication. The CMA stated she did have pain medication, but she could only have it if she was in severe pain and was crying. The physician's prn pain medication order did not indicate her pain had to be severe in order to administer the medication. The CMA was informed the resident had asked for pain medication. The Medication Administration Record [REDACTED] The resident was medicated with a prn pain medication at 4:00 p.m. On 05/26/16 at 9:58 a.m., the DON was asked when she would perform the wound care on the resident. She stated the physician was in that morning and took off all the dressings and was changing the orders. She stated she was going to do her wound care next after she called the physician to get the new wound care orders. At 11:00 a.m., the DON performed wound care on resident #22. When the staff assisted and pulled up the right leg for wound care, the resident immediately began to cry out in pain. The DON affirmed she knew it hurt, but she had different orders today and it would not be as long of a treatment as usual. The resident continued to cry out with the treatment. After the right leg treatment was completed, the staff member raised the left leg for wound care. Again, the resident cried out in pain and stated that the left heel was the one that hurt the worst. The DON assured her she would get the treatment done as quickly as possible. After the wound care was performed on the legs, the resident was rolled onto her right side for the wound care on her sacral area. The resident continued to moan during the wound care. At 3:03 p.m., certified medication aide (CMA) #1 was asked if she administered the morning medications to the resident. She stated, Yes. She was asked when she had administered the routine pain medication to her. She stated, she got down the hall to her around 7:30 a.m. At 3:09 p.m., the DON was asked if the resident was pre medicated before the wound care was performed. She stated, she had asked the CMA to medicate her 30 minutes prior to the treatment because she received routine medication as well. She stated the resident had severe arthritis in her right leg, so it was painful anyway. The DON stated she would go ask the CMA when she medicated her. At 3:58 p.m., the DON stated there was a prn pain medication that could have been given, but the CMA stated she was waiting until 2:00 p.m. due to she could not give the medication until 6 hours after the routine medication. She further stated there was a miscommunication when she asked the CMA if she had given the requested prn pain medication. The physician's prn pain medication order did not indicate a time period to wait after the routine pain medication was administered. The DON was asked if the resident would have benefited from the prn pain medication prior to her wound care treatment. She stated, Yes. She was asked if the resident displayed any signs and symptoms of pain during the pressure ulcer treatment. She stated, Yes and the wound care physician had just debrided the left foot that morning, so I am sure it was painful.

Based on observation, record review and interviews, it was determined the facility failed to assess a resident's recurrence of falls and implement interventions to aide in the prevention of falls with injuries for one (#3) of two sampled residents who had multiple falls with injuries. This resulted in an actual harm. The director of nursing identified six residents who had three or more falls since 04/01/13. Findings: The "Fall Risk Assessment" policy documented, "Fall risk assessment will be completed upon admission, quarterly and following a fall or significant change of condition effecting balance to identify and, assess resident at risk for falls. Procedure...any resident identified as high risk will have fall prevention approaches initiated and documented on the care plan...the residents assessed as high risk for falls will be refereed to the interdisciplinary team for evaluation." Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan dated 09/13/12, and last up dated 09/09/13, documented, "Problem: Resident needs the following assistance with his ADL's (activities of daily living): X 1 staff for cueing. Resident is independent with most ADL's she will ask for help if needed...12/18/12 Res is indep (independent) /c ADL's will ask for help as she needs it. She is alert & has dementia..." A care plan dated 09/18/12, and last up dated 09/09/13, documented, "Problem: Cognitive deficits: Resident has cognitive deficits of forgetfulness...has DX of mild Dementia... Goals: Resident will respond to question or statement with appropriate response or with assistance through next review.... Approaches...provide assistance with decision making skills...reality orientation as needed...observe for changes in cognition... Problem: Psychosocial well-being resident has DX mild dementia and needs reminders and cueing of activity time, shower time. Resident is alert and orient will be reminded activities, meals and bath times..." A care plan dated 09/18/12, and last up dated 12/18/12, "Problem: At risk for falls. Resident is at risk for falls due to her age and meds (medication. Contributing [DIAGNOSES REDACTED]. Goal: Resident will have no falls with or without injuries through NRD (next review date).... Approach: place on the caution fall program..assist with transfers, ambulation, bed mobility, etc. call light within reach, assure proper footwear, observe for side effects from meds...remind her to utilize assistive devices, assure adequate lighting, keep pathway free and clear of any objects..." A quarterly assessment dated [DATE], documented the resident had short and long term memory problems and modified independence in cognitive skills for daily decision making. The resident required supervision during bed mobility, walking in the room, walking in the corridor toilet use and was able to stabilize self without staff assistance while walking and turning around. The resident had no documented falls. An incident report dated 04/14/13 at 8:50 p.m., documented,, "Resident notified nurse resident was lying in floor, nurse observed resident lying on back in floor next to night stand....additional comments or steps to prevent recurrence: re-educated res (resident) on safety risks and wearing shoes with socks." The "Heritage Manor Daily Assignment Sheet" dated 04/14/13, documented there were two certified nurse aides assigned to work on the south hall at the time of the fall. An incident report dated 05/04/13 at 2:20 a.m., documented, "Aide notified nurse res. was in the floor, res sitting on bottom in floor next to bed, res claimed she was reaching in the floor for blanket and slipped out of bed, res claims she hit her head....type of injury hematoma...other bruise...additional comments or steps to prevent recurrence: re-educated res of fall risks & encouraged res to use call light for assistance." The incident report noted a 4 cm (centimeter) X 4 cm knot with bruising to the left frontal part of the head and a 0.5 cm X 0.5 cm to the right shoulder. A report to the Oklahoma State Department of Health, dated 05/04/13, documented, "...On assessment by LPN (licensed practical nurse) there was a SM (small) bruise to RT (right) shoulder noted. Knot with bruising to left frontal top of head..." A nurse's note dated 05/04/13 at 2:30 a.m., documented, "Aide notified nurse res was in the floor, nurse observed res sitting in the floor on her bottom next to bed...nursing assessment completed, small bruise to (R) shoulder noted, lg (large knot /c bruising to (L) frontal top of head...educated res on safety risks and encouraged res to use call light for assistance..." There was no documentation the facility implemented additional interventions to aide in the prevention of recurrence of falls with injuries. The "Heritage Manor Daily Assignment Sheet" dated 05/03/13, documented there were two certified nurse aides assigned to work on the south and half of the east hall at the time of the fall. The aides were responsible for the care of 18 residents on the south hall and 10 on the east hall. A fall risk assessment dated [DATE], documented the resident was a high risk for falls with a score of 16. A score of 10 or above represented a high risk. An incident report dated 05/22/13 at 12:50 p.m., documented, "(Name deleted) standing in DR (door) of room 16 yelling (Resident) fell . Entered room resident on floor sitting upright @ (at) bedside...additional comments or steps to prevent recurrence: instructed resident to use call light for assistance..." The "Heritage Manor Daily Assignment Sheet" dated 05/22/13, documented there were two certified nurse aides assigned to work on the south and east hall at the time of the fall. The aides were responsible for all the resident's on both the south and east hall (38 residents). A quarterly assessment dated [DATE], documented the resident was severely impaired with cognitive skills for daily decision making, had two non-injury falls since the last assessment and the resident was not on a restorative program. The resident required supervision during bed mobility, walking in the room, walking in the corridor toiler use and was able to stabilize self without staff assistance while walking and turning around. A physician's progress note dated 06/26/13, documented, "...She has had some problems with arthritis...she has impairment in cognition and memory and is unable to offer any additional history or insight..." An incident report dated 07/05/13 at 8:30 p.m., documented, "...additional comments or steps to prevent recurrence: re-educated res on safety risks & skin care..." A nurse's note dated 07/05/13 at 8:30 p.m., documented, "Res has open area to (L) lateral calf 1.3 cm X 1.3 cm...." The cause was documented as unknown and suspected from a previous fall. A physician's telephone order dated 07/05/13 at 8:30 p.m., documented, "Cleanse (L) lateral open are to calf /c NSS (normal saline solution) pat dry, apply TAO and cover /c Band-Aid daily until healed." The "Heritage Manor Daily Assignment Sheet" dated 07/05/13, documented there were two certified nurse aides assigned to work on the south and half of the east hall at the time of the fall. The aides were responsible for the care of 18 residents on the south hall and 10 on the east hall. An incident report dated 07/06/13 at 2:22 a.m., documented, "Res. observed in floor sitting up on bottom in front of bed, res claims to have fallen while pulling pants up, res. denies injury or pain.....no call light on @ time res seen in floor...additional comments or steps to prevent recurrence: re-educated res on fall risk & using call light to ask for assistance..." The "Heritage Manor Daily Assignment Sheet" dated 07/05/13, documented there were two certified nurse aides assigned to work all halls of the facility. The quality of care report for July 2013, documented the census at the time of the fall was 49. A nurse's note dated 07/07/13 at 2:40 a.m., documented, "Continues on 72 (hour) obs (observation) R/T previous fall & new TX to open area on (L) leg..." An incident report dated 07/09/13 at 4:45 a.m., documented, "Resident on her way to restroom, did not make it before she urinated slipped in her own urine. remembers falling, denies hitting head, ROM (range of motion) good X 3. Unable to move left leg...type of injury: denies pain verbally Yet is grimacing VS (vital signs) ok for resident. O 2 (oxygen) 93% sent to nearest emergency room ......additional comments or steps to prevent recurrence: ask resident to use call light for assistance resident agreed..." The "Heritage Manor Daily Assignment Sheet" dated 07/08/13, documented there were two certified nurse aides assigned to work all halls of the facility. The quality of care report for July 2013, documented the census at the time of the fall was 49. A nurse's note dated 07/09/13 at 4:45 a.m., documented, "Resident heard yelling in room from nurses station. The nurse ran to residents room to inquire. Resident lying on floor in her urine. Says she slipped. Remembers falling...upon further assessment found 0 (no) raised areas on her head, ROM good X 3. (L) hip hurting. Unable to move. Res able to move toes. Denies pain yet resident groaning as she tries to move her leg. call 911 @ 0445 (4:45 a.m.)... 5:00 a.m., administrator notified... 5:40 a.m., notified Dr. (name deleted)." A physician's telephone order dated 07/09/13 at 5:00 a.m., documented, "Transfer res to nearest emergency room ." A nurse's note dated 07/09/13 at 10:00 a.m., documented, "DON (director of nursing) states daughter called to advise that res was admitted to (hospital) for hip fx (fracture)." The current physician's orders [REDACTED]." The [DIAGNOSES REDACTED]. A hospital consultation report dated 07/09/13, documented, "Reason for consultation: Evaluation of left intertrochanteric femur fracture...history...white female with history of hypertension and mild dementia...who fell on the morning of July 9, 2013. It was an unwitnessed fall; patient unable to ambulate. She was brought to the ER (emergency room ) where she was found to have externally rotated leg and pain in the left lower extremity. X-rays demonstrate a left intertrochanteric femur fracture...assessment left intertrochanteric femur fracture. I discussed with (Resident) at this point we would recommend surgery..." A "History and Physical" dated 07/09/13, documented, "...Impression: left intertrochanteric fracture..Plan: we will await orthopedic consult. Continue with pain management..." The last update to the resident's care plan for falls was on 12/18/12. The was no documentation the facility assessed the resident's falls and implemented interventions to aid in the prevention of the recurrence of falls with injury. A significant change assessment dated [DATE], documented was moderately impaired cognitive skills for daily decision making; inattention and disorganized thinking that comes and goes and changes in severity. The resident required extensive assistance with bed mobility, walking, locomotion, and dressing. Limited assistance was required with bed mobility and toilet use. The assessment further documented the resident had impairment on both sides of the lower extremity and required staff assistance with stabilizing while turning around, walking, surface to surface transfers, moving from a seated to standing position and moving on and off the toilet. The resident had one fall with a major injury since last assessment or reentry. An incident report dated 08/04/13 at 6:10 a.m., documented, "Res attempted to stand up from bed but doesn't remember what she was going to do, fell to the floor on mat @ bedside landing on bottom...skin tear to (R) (right) elbow....steri strips applied...type of injury: skin tear...additional comments or steps to prevent recurrence: Re-educated res on safety risks & importance of asking for assist, re-educated res on wearing skin sleeves for protection..." The report documented the measurements of the skin tear was 1.6 cm X 1.0 cm. The "Heritage Manor Daily Assignment Sheet" dated 08/03/13, documented there were two certified nurse aides assigned to work all halls of the facility. The quality of care report for August 2013, documented the census at the time of the fall was 53. A care plan dated 08/04/13, documented, "Problem: Resident had a fall with S (slight) injury attempted to stand @ 0610 (6:10 a.m.) from bed but does not remember she needs assistance. Has short and long term memory problems. Upon doing so caused a s/t to her right elbow.... Goals: level of independence will not be reduced related to fear of further trauma X 90 days. Will have less falls... Approaches...assess cause, pattern of previous falls & act upon resolvable factors...remind resident if feels different to turn call light on for assistance...if in activities inform act (cavities) personal that needs assistance back to room...keep environment free from obstructions...promote proper use of hand rails...will start neuros if needed...call MD and notify...." There was no documentation the facility assessed the resident's falls and implemented additional interventions to aid in the prevention of the recurrence of falls with injury. The interventions on the care plan dated 08/04/13, was the same as listed on the original care plan dated 09/18/12. An incident report dated 08/07/13 at 10:00 p.m., documented, "Res found sitting upright in front of toilet on bottom. Denies hitting head/necks, states just trying to go to toilet, full assessment completed, ROM WNL (range of motion within normal limits). S/T (skin tear) to (L) elbow approx (approximately) 2 x 2 cm discoloration around s/t noted...type of injury: other S/T...additional comments or steps to prevent recurrence: Re-educated res on safety, call light et (and) staff assistance. Fall precaution in place @ bedside..." The "Heritage Manor Daily Assignment Sheet" dated 08/07/13, documented there were two certified nurse aides assigned to work on the south and half of the east hall at the time of the fall. The aides were responsible for the care of 18 residents on the south hall and 10 on the east hall. An incident report dated 08/09/13 at 8:30 p.m., documented, "Res found sitting on floor, upright /c (with) walker in front of res. denies hitting head/neck...Res states attempting to ambulate to BR (bathroom), call light not used...additional comments or steps to prevent recurrence...Re education on safety, call light et staff assistance. Increase rounds /c more frequent check ins on resident by staff...." The "Heritage Manor Daily Assignment Sheet" dated 08/09/13, documented there were two certified nurse aides assigned to work on the south and half of the east hall at the time of the fall. The aides were responsible for the care of 18 residents on the south hall and 10 on the east hall. An incident report dated 08/27/13 at 7:10 a.m., documented, "Res sitting on floor, w/c (wheelchair) behind her, unable to state how/why.......additional comments or steps to prevent recurrence...will continue to check on res frequently & ask if needs to use restroom, lie down, change position etc..." A nurse's note dated 08/27/13 at 8:15 a.m., documented, "...unable to recall having sat in the floor five minutes later..." The "Heritage Manor Daily Assignment Sheet" dated 08/27/13, documented there were two certified nurse aides assigned to work on the south and half of the east hall at the time of the fall. The aides were responsible for the care of 18 residents on the south hall and 10 on the east hall. A care plan dated 08/27/13, documented, "Problem: Resident had a fall /s injury @ 710 am res was sitting on floor with w/c behind her. D/T (due to) resident mental status unable to explain what happened..." There were no updates to the resident's fall care plan interventions to include the frequent checks on the resident and/or how often the resident would be checked on. There was no documentation the facility assessed the resident's continued falls and/or implemented additional interventions to prevent the recurrence of falls with injuries. A 60 day assessment dated [DATE], documented the resident was severely impaired with cognitive skills for daily decision making, had hallucinations, delusions, occasionally incontinent of urine and bowels. The resident had two falls with no injury and one with a major injury since the last assessment or re-entry. A nurse's note dated 09/17/13 at 2:00 p.m., documented, "...Nsg conts to observe frequently for safety d/t res inability to remember to ask for /wait for assist /c transfers etc..." A nurse's note at 7:00 p.m., documented, "...Res has (arrow down) safety awareness continues to self ambulate et transfers, frequent checks made by staff..." An incident report dated 09/17/13 at 7:30 p.m., documented, "Res attempting to transfer self from w/c to bed /s (without) assistance. Res found sitting upright on floor between w/c et bed...additional comments or steps to prevent recurrence...Re education R/t safety, staff assistance, et call light use. Frequent checks made on res d/t decreased safety awareness..." The "Heritage Manor Daily Assignment Sheet" dated 09/17/13, documented there were two certified nurse aides assigned to work on the south and half of the east hall at the time of the fall. The aides were responsible for the care of 18 residents on the south hall and 10 on the east hall. A nurse's note at 7:30 p.m., documented, "Res found on floor upright between w/c et bed. States I tried to get to bed...res assisted back to bed, re-educated on safety, staff assistance et call light. Res has decreased safety awareness et does not understand education. Admin et Dr (name deleted) notified...staff continuing frequent checks on resident, call light in reach." An incident report dated 09/19/13 at 7:45 a.m., documented, "Sitting on edge of bed, attempted to transfer self /s assist to w/c that was too far away from her...additional comments or steps to prevent recurrence: Memory impaired d/t dementia, unable to remember that she needs assist, staff continue to (check) on res frequently..." A nurse's note dated 09/19/13 at 2:00 p.m., documented, "...At 0745 res sitting on side of bed, attempted to transfer self /s assist to w/c that was to far away from her...Admin (administrator) DON (director of nursing) et (name deleted) all aware. Nsg (nursing) conts (continues) to encourage res to ask for help et offers help frequently..." A fall risk assessment dated [DATE], 08/07/13, 08/27/13, 09/16/13, 09/17/13 and 09/19/13, documented the resident was a high risk for falls with a score of 19. A score of 10 or above represented a high risk. A care plan dated 09/19/13, documented, "Problem: Resident had a fall /s injury @ 0745 am resident is alert and confused. DX: Senile dementia. She is on a low bed, has a hx of falls mat removed from bedside to prevent res from loosing balance-Res is unable to remember that she needs help staff continue to (check) on res freq (frequently) /q (every) 2 (hours) for assistance to B/R b(bathroom) & dining room for meals.... Goals: level of independence will not be reduced relates to fear of further falls X 90 days. Will have less falls... Approaches.....assess cause, pattern of previous falls & act upon resolvable factors...remind resident if feels different to turn call light on for assistance...if in activities inform act personal that needs assistance back to room...keep environment free from obstructions...promote proper use of hand rails...neuro- none needed...call placed to (family)...will have walker by bed for res when attempts to get up." On 09/23/13 at 3:20 p.m., the resident was observed lying in bed with a wheel chair next to her bed. No walker was visible in the room. The resident's call light was on her bed under the blanket. An interview was conducted with the resident regarding her call light. She was asked where her call light was located. The resident pointed to her wheel chair and indicated it was the call light. She was asked again where the call was for to get help when she needed it. She once again pointed to the wheel chair. The resident's call light remained under the blanket and the resident had not been able to correctly locate it. At 3:45 p.m., 4:15 p.m., 4:30 p.m. and 4:45 p.m., the resident remained in bed with the call light under her blanket. No staff was observed entering the room and checking on the resident during this time frame. An interview was conducted on 09/23/13 at 4:50 p.m., with certified nurse aide #1 (CNA). She was asked what hall she normally was assigned to. She stated, "South and part of East." She also stated she worked with resident #3. The CNA was asked how many additional aides assisted with the same rooms. She stated, "One other certified nurse aide." The CNA was asked to describe the resident. She stated, "We try to keep her from getting up but it doesn't work." The CNA was asked if the resident had the ability to use her call light to ask for assistance. She stated, "She very rarely uses the call light we have to check on her." The CNA was asked how often residents were checked on. She stated, "Every two hours." The CNA was asked if there were residents who needed more frequent checks then every two hours. She stated, "Yes," and provided the name of three residents who were checked at least every hour. Resident #3 was not one of the residents checked every hour. The CNA was asked how often resident #3 was checked on. She stated, "We check on her every two hours." She then stated, "She doesn't remember one day from another." An interview was conducted on 09/23/13 at 5:00 p.m., with certified nurse aide #2 (CNA). She was asked what hall she was normally assigned to and she stated, 'South and Part of East." The CNA was asked to describe resident #3. She stated, "I don't know who (Resident) is." The CNA was asked how often residents were checked on. She stated, "Every two hours." The CNA was asked if there were any residents she worked with that needed to be checked on more frequently then two hours. She stated she had not been told of any residents who needed to be checked on more often. The CNA was asked if there were any residents she worked with that were a fall risk. She stated, "Not that I know. No one is a fall risk." An interview was conducted on 09/24/13 at 10:12 a.m., with certified nurse aide #3 (CNA). She was asked to describe the resident and stated, "Sweet lady, but very forgetful." The CNA then stated, "We try to explain to her (to call for assistance) but she never remembers." She then stated, "You have to watch her. She is very fast and sneaky." The CNA was asked how often residents were to be checked on and stated, "Every two hours." The CNA was asked to identify residents that needed more frequent checks. She identified two residents. Neither was resident #3. The CNA was asked how often resident #3 was checked on and stated, 'Every two hours." The CNA was asked if the resident was a fall risk. She stated, "She doesn't have a mat. A mat on the floor means the resident is a fall risk." The CNA was asked if the resident had many falls and stated none on the 7:00 a.m. through 3:00 p.m. shift. She stated all the falls happened on the 3:00 p.m. through 11:00 p.m., and 11:00 p.m. through 7:00 a.m. shift. An interview was conducted on 09/24/13 at 10:46 a.m., with licensed practical nurse #1 (LPN). She was asked to describe the level of assistance resident #3 required. She stated, "She needs more assistance then she gets. She has a memory impairment and can not remember to ask." The LPN was asked if the resident was incontinent. She stated, "Bladder incontinence, mostly continent of bowels." The LPN was asked how often residents were checked on and stated, 'Every two hours." The LPN was asked if there was any residents who needed to be checked on more frequently. She stated, "(Resident #3) at least every hour." She then stated, "The aides should know that too." The LPN was asked why the resident was checked on more frequently. She stated, "She tries to get up and falls." The LPN was asked if re-education for the resident, "to ask staff for assistance and use the call light," was an appropriate intervention on the care plan for this resident to aide in the prevention of recurrence of falls with injuries. She stated, "She does not have the ability to remember the education and to use the call light to ask for assist." The LPN then stated, "The resident had her greatest decline since her fall with the fracture." The LPN was shown the care plan for falls with frequent checks and made aware of the staff statements when interviewed. She looked at the care plan and stated, "Every two hours check is the standard. It's the minimum." An interview was conducted on 09/24/13 at 11:25 a.m., with the assistant director of nursing (ADON). She was asked if the care plan, fall intervention of resident re-educate on asking for assistance and use of a call light was appropriate. She stated, "No, because she doesn't remember. Her dementia has progressed since she broke her hip." The ADON was asked how often residents are checked on. She stated, "All resident's get checked every two hours." The ADON was asked if the resident's care plan addressed more frequent checks due to falls. She stated, 'The care plan does not address more frequent checks, just every two hours." The ADON was asked if there was documentation the facility had implemented additional interventions to aide in the prevention of recurrence of falls with injuries. No further documentation was provided. She was asked if all of the resident's current care plan was provided and she stated they had no additional care plans. An interview was conducted on 09/24/13 at 1:38 p.m., with the director of nursing (DON). She was asked to describe the resident and she stated, "Short and long term memory problems, delusional and hears voices coming out of her television." The DON was asked if the resident had the capacity to use the call light to call for assistance. She stated, "She never uses it." The DON was asked if re-education of the resident to use the call light and ask for assistance had been an appropriate intervention. She stated, "That's not an appropriate intervention." The DON was asked how often residents were checked on. She stated, "Every two hours." She was asked if there were any residents who were checked on more frequently then every two hours. She stated, "She (Resident #3) is checked on every hour." The DON was made aware of the staff interviews, observations and care plan for every two hours, not hourly. No comment was made. The DON was asked how she determined staffing on each hall. She stated the administrator did all the scheduling. An interview was conducted on 09/24/13 at 2:08 p.m., with the administrator (Adm.). She was asked if the facility assessed the resident's falls and discussed them during their quality assurance meetings. She stated, "We did discuss them." The Adm. was asked if the interventions of resident re-education and checks every two hours were effective. She stated, "The interventions are not working." The Adm. was asked how she determined staffing for each hall. She stated, "I don't go by the state. I determine based on the heavy care residents." She then stated, "I'm going to increase the staff on the 3 to 11 shift." The Adm. was asked about the 11:00 p.m. through 7:00 a.m. shift. She stated no changes were being made. The Adm. was asked if there was a trend of the resident's falls. She stated they had happened on the 3 to 11, and 11 to 7 shift.

Based on observation, record review, and interviews, it was determined the facility failed to have an effective quality assurance program to identify and implement corrective actions: a. for residents who had recurrence of falls with injuries and had no changes in interventions. The director of nursing identified six residents who had three or more falls with injuries since 04/01/13. b. a toileting program for residents who were good candidates for a program and had no program implemented. The director of nursing identified four residents who were a good candidate for a toileting program and did not have a program implemented. c. to ensure there was sufficient staff to meet the residents needs. The director of nursing identified all residents had the potential to be affected by this. This resulted in an actual harm to resident #3. Findings: The "Quality Assessment and Assurance" policy documented, "Facility maintains a quality assessment and assurance committee...The quality assessment and assurance committee...meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary...develops and implements appropriate plans of action to correct identified quality deficiencies...items that are monitored by the quality assessment and assurance committee include...incidents or accidents..." An interview was conducted on 09/24/13 at 2:08 p.m., with the administrator (Adm.) She was asked if the facility assessed the resident's falls and discussed them during their quality assurance meetings. She stated, "We did discuss them." The Adm. was asked if the interventions of resident re-education and checks every two hours were effective. She stated, "The interventions are not working." The Adm. was asked how she determined staffing for each hall. She stated, "I don't go by the state. I determine based on the heavy care residents." The Adm. then stated, "I'm going to increase the staff on the 3 to 11 shift." The Adm. was asked about the 11:00 p.m. through 7:00 a.m. shift. She stated no changes were being made. The Adm. was asked if there was a trend of the resident's falls. She stated they had happened on the 3 to 11 and 11 to 7 shift. The Adm. was asked how often the quality assurance committee meet. She stated, "Once a month." An interview was conducted on 09/24/13 at 3:45 p.m., with the administrator regarding the effectiveness of identifying the quality of care issues with falls, staffing and toileting programs. She stated, "Quality assurance was not effective for this resident. We had talked about the falls and nothing was done." a. Identify and implement interventions for residents who had recurrence of falls with injures. Refer to F-323. b. Identify and implement a toileting program for residents who were candidates for a program and/or had recurrence of falls with injuries well attempting to self toilet. Refer to F-315. c. Identify a deficient practice regarding sufficient staff to meet the residents needs. Refer to F-353

Based on record review and interviews, it was determined the facility failed to assess a resident's incontinence for a toileting program and/or a scheduled bladder program for one (#3) of two sampled residents with urinary incontinence who experienced reoccurring falls while attempting to self toilet. The director of nursing identified three residents who were currently on a toileting program. The resident census and condition report, dated 09/24/13, documented 28 residents were occasionally or frequently incontinent of urine. Findings: Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A "Bowel/Bladder Assessment for Retraining and/or scheduling Toileting" dated 09/05/12, 12/18/12, 03/19/13, 06/18/13 and 09/16/13 documented the resident was a good candidate for individualized training with scores between 16 and 20. A score of 21-15 indicated the resident was a good candidate. A care plan dated 09/18/12 and last up dated 09/09/13, documented, "Problem: Cognitive deficits: Resident has cognitive deficits of forgetfulness...has DX of mild Dementia... Goals: Resident will respond to question or statement with appropriate response or with assistance through next review.... Approaches...provide assistance with descension making skills...reality orientation as needed...observe for changes in cognition... Problem: Psychosocial well-being resident has DX mild dementia and needs reminders and cueing of activity time, shower time. Resident is alert and orient will be reminded activities, meals and bath times..." The care plan did not address the resident's incontinence of bladder. There was no documentation to indicate the facility placed the resident on a toileting program to improve her urinary continence. A quarterly assessment dated [DATE], documented the resident had short and long term memory problems and modified independence in cognitive skills for daily decision making. The resident required supervision during bed mobility, walking in the room, walking in the corridor toilet use and was able to stabilize self without staff assistance while walking and turning around. The resident had no documented falls. An incident report dated 07/09/13 at 4:45 a.m., documented, "Resident on her way to restroom, did not make it before she urinated slipped in her own urine. remembers falling, denies hitting head, ROM (range of motion) good X 3. Unable to move left leg...type of injury: denies pain verbally Yet is grimacing VS (vital signs) ok for resident. O2 (oxygen) 93% sent to nearest emergency room ......additional comments or steps to prevent recurrence: ask resident to use call light for assistance resident agreed..." A nurse's note dated 07/09/13 at 4:45 a.m., documented, "Resident heard yelling in room from nurses station. The nurse ran to resident's room to inquire. Resident lying on floor in her urine. Says she slipped. Remembers falling...upon further assessment found 0 (no) raised areas on her head, ROM good X 3. (L) hip hurting. Unable to move. Res able to move toes. Denies pain yet resident groaning as she tries to move her leg. call 911 @ 0445 (4:45 a.m.)... 5:00 a.m., administrator notified... 5:40 a.m., notified Dr. (name deleted)." A physician's telephone order dated 07/09/13 at 5:00 a.m., documented, "Transfer res to nearest emergency room ." A nurse's note dated 07/09/13 at 10:00 a.m., documented, "DON (director of nursing) states daughter called to advise that res was admitted to (hospital) for hip fx (fracture)." The current physician's orders [REDACTED]." The [DIAGNOSES REDACTED]. A hospital consultation report dated 07/09/13, documented, "Reason for consultation: Evaluation of left intertrochanteric femur fracture...history...white female with history of hypertension and mild dementia...who fell on the morning of July 9, 2013. It was an unwitnessed fall; patient unable to ambulate. She was brought to the ER (emergency room ) where she was found to have externally rotated leg and pain in the left lower extremity. X-rays demonstrate a left intertrochanteric femur fracture...assessment left intertrochanteric femur fracture. I discussed with (Resident) at this point we would recommend surgery..." A "History and Physical" dated 07/09/13, documented, "...Impression: left intertrochanteric fracture..Plan: we will await orthopedic consult. Continue with pain management..." An incident report dated 08/07/13 at 10:00 p.m., documented, "Res found sitting upright in front of toilet on bottom. Denies hitting head/necks, states just trying to go to toilet, full assessment completed, ROM WNL (range of motion within normal limits). S/T (skin tear) to (L) elbow approx (approximately) 2 x 2 cm discoloration around ds/t noted...type of injury: other S/T...additional comments or steps to prevent recurrence: Re-educated res on safety, call light et (and) staff assistance. Fall precaution in place @ bedside..." A 60 day assessment dated [DATE], documented the resident was severely impaired with cognitive skills for daily decision making, had hallucinations, [MEDICAL CONDITION], occasionally incontinent of urine and bowels. The resident had two falls with no injury and one with a major injury since the last assessment or re-entry. An interview was conducted on 09/24/13 at 10:46 a.m., with licensed practical nurse #1 (LPN). She was asked to describe the level of assistance resident #3 required. She stated, "She needs more assistance then she gets. She has a memory impairment and can not remember to ask." The LPN was asked if the resident was incontinent. She stated, "Bladder incontinence, mostly continent of bowels." The LPN was asked if the resident had been evaluated for and placed on a toileting program. She stated, "09/16/13 was the last assessment." The LPN was asked if the resident was on a toileting plan or scheduled program. She stated, "No, she is not on a program." The LPN was asked who was responsible for implementing a toileting program and or schedule. She stated, "The director of nursing is responsible for implementing a toileting program." An interview was conducted on 09/24/13 at 11:25 a.m., with the assistant director of nursing/care plan coordinator (ADON). She was asked if the resident's fall intervention of re-education on asking for assistance and use of call light was appropriate. She stated, "No, because she doesn't remember. Her dementia has progressed since she broke her hip." The ADON was asked how often residents were checked on. She stated, "All resident's get checked every two hours." The ADON was asked if the resident had been fully assessed and placed on a toileting program and or schedule. She indicated the resident was not. The ADON was asked if the resident's care plan addressed her urinary incontinence. She stated, "It's not care planned." The ADON was asked how long the resident had been occasionally incontinent of bladder. She stated, "As long as I can remember." An interview was conducted on 09/24/13 at 1:38 p.m., with the director of nursing. She was asked to describe the resident. She stated, "Short and long term memory problems, delusional and hears voices coming out of her television." She was asked if the resident, who had been assessed as a good candidate for a toileting program, had been placed on a program. She stated, "I didn't know to go further with the toileting program."