Every finding on record at Heritage Skilled Nursing and Therapy

Based on record review and interview, the facility failed to develop comprehensive care plans for 2 (#24 and #38 ) of 19 resident care plans reviewed. The administrator identified 65 residents resided in the facility. Findings: 1. Resident #24 was admitted to the facility on [DATE] with diagnosis of displaced fracture of upper end of left humerus. The admission (comprehensive) assessment was completed on 02/28/25. Care areas that were triggered (potential areas of concern) during the comprehensive assessment included: cognitive loss/dementia, ADL function, urinary incontinence, and psychoactive drug use. The care plan did not include cognitive loss, ADL function, urinary incontinence, or psychoactive drug use when reviewed on 03/25/25. The care plan should have been completed by 03/07/25. The Resident Assessment Instrument (RAI) guidelines state the comprehensive care plan should be completed by admission assessment completion plus seven days, and no later than the admitted plus 21 days. On 03/25/25 at 1:04 p.m., the MDS coordinator stated the comprehensive care plan was incomplete and should have addressed the triggered care areas. They stated it was their responsibility to make sure everything was in the care plan. 2. Resident #38 was admitted to the facility with diagnosis of displaced intertrochanteric fracture of the left femur. An admission (comprehensive) assessment, dated 02/22/25, showed the resident required assist of one with all ADL's. A care plan, dated 03/03/25, did not contain ADL documentation. The care plan should have been completed by 03/01/25. On 03/27/25 at 7:51 a.m., the MDS coordinator reported ADL's should have been care planned. On 03/27/25 at 8:30 a.m., the administrator stated they were unaware comprehensive care plans were not being completed. 49701

Based on observation, record review, and interview, the facility failed to ensure bottles containing tube feeding were labeled and dated for 2 (#30 and #215 ) of 2 sampled residents observed for tube feeding. The administrator identified three residents required tube feedings. 1. On 03/26/25 at 7:48 a.m., the tube feeding for Resident #30 was observed running at 60 ml/hr. The bottle was not labeled with the date or time opened, or who hung the bottle. A Tube Feeding policy, dated 06/24/10, read in part, Change and label (name of resident, date, and time) feeding set (tubing and appropriate syringe) every 24 hours. Resident #30 admitted to the facility with diagnoses which included dysphagia, diabetes mellitus, major depressive disorder, chronic pain, and cerebral infarction. A physician order, dated 10/14/24, read in part, one time a day Diabetisource AC 1250ml 60ml/hr x 21 hours flush at 35ml/hr over 21 hours AND one time a day turn feeding off at 9am on at noon AND every shift Diabetisource AC 60ml/hr x 21 hours document amount of formula only AND every shift flush 35ml/hr x 21 hours document amount of flush only. On 03/26/25 at 2:13 p.m., RN #1 was made aware of the observation this morning of the feeding tube bottle not having a date, time, or initials. RN #1 reported the bottle did not have any information on it. 2. On 03/26/25 at 8:10 a.m., the ADON stopped the tube feeding that was running at 60 ml/hr so wound care could be completed. The tube feeding was observed to have no label or date. Resident #215 was admitted to the facility with a diagnosis of cachexia (significant weight loss and muscle wasting). A physician order, dated 03/21/25, showed enteral feed order: every shift Diabetisource AC 60 ml/hr x 24 hours. On 03/26/25 at 8:21 a.m., the corporate nurse stated the tube feeding bottle should be labeled with the date and time it was opened and hung and by whom, but it was not. On 03/27/25 at 7:35 a.m., the administrator was made aware of the above observations. The administrator stated the tube feeding bottles should have been dated, timed, and initialed per facility policy. 49701

Based on observation, record review, and interview, the facility failed to monitor and intervene for a PICC line that required care for 1 (#215 ) of 2 sampled residents with PICC lines. The administrator identified 65 residents resided in the facility and two residents had PICC lines. Findings: On 03/26/25 at 12:18 p.m., a PICC line to Resident #215's left shoulder was observed with a dressing that had a date of 03/16/25 on it. There was brown drainage noted under the clear dressing. Resident #215 was admitted on [DATE] with a diagnosis of encephalopathy and severe sepsis with septic shock. An IV [intravenous therapy] Nursing Policies and Procedures policy, dated 06/01/11, read in part, Sterile dressing changes will be performed every 7 days and immediately if the integrity of the dressing is compromised. On 03/26/25 at 12:27 p.m., the ADON stated they were trying to get orders to discontinue the PICC line. They stated the policy was to change the dressing within 24 hours after being placed and then every 72 hours. They stated the dressing had not been changed. They stated, There is no excuse for it to go this long in all honesty. On 03/27/25 at 8:31 a.m., the RN/administrator stated they were unaware the PICC line had not been taken care of. They stated they received the order to discontinue this morning and removed the PICC line.

Based on observation, record review, and interview, the facility failed to ensure infection control practices were followed for glove usage. The administrator identified 65 residents resided at the facility. Findings: On 03/25/25 at 11:12 a.m., RN #1 was observed wearing gloves and getting a finger stick blood sugar of a resident. RN #1 then changed gloves and gave the resident their insulin. They did not sanitize their hands between glove changes. On 03/25/25 at 11:15 a.m., RN #1 was observed still wearing the same gloves out in the hall to get the sanitizing wipes from the nurses' cart. RN #1 cleaned the glucometer and then removed their gloves. A Personal Protective Equipment policy, dated 03/02/24, read in part, Gloves can protect both patients and healthcare personnel from exposure to infectious materials that may be carried on hands. During patient care, transmission of infectious organisms can be reduced by adhering to the principles of working from 'clean to dirty' and confining or limiting contamination to surfaces that are directly needed for patient care. On 03/25/25 at 11:18 a.m., RN #1 stated they should have sanitized their hands between glove changes, but they were unaware of the infection control issue when wearing gloves out in the hall after just giving insulin while wearing them. On 03/27/25 at 8:29 a.m., the administrator stated they do a lot of education on not wearing gloves in the halls.

Based on observation and interview, the facility failed to post nurse staffing in a prominent place accessible to residents and visitors. The administrator identified 65 residents who resided in the facility. Findings: On 03/25/25 at 8:00 a.m., no staffing board was observed in the facility. On 03/26/25 at 9:15 a.m., no staffing board was observed in the facility. On 03/26/25 at 10:58 a.m., the director of nursing pointed out a schedule on a cork board behind the nurses desk. Only half of the schedule was seen.

Based on observation, record review, and interview, the facility failed to ensure protected health information was secure for 1 (#66) of 65 residents receiving care in the facility. The administrator identified 65 residents resided in the facility. Findings: On 03/26/25 at 12:24 p.m., a computer on a cart by the nurses station for the North and Northeast halls was observed to be open and showed protected health information for Resident #66. There were no residents or staff around at that time. A Resident's Records policy in the admission agreement, dated 10/14/19, read in part, Information included in the resident's medical records is confidential. Unauthorized persons shall not be allowed to review these records without the Resident's written consent except as required or permitted by law. On 03/26/25 at 12:27 p.m., the ADON returned to the cart and stated they were busy collecting a Vanco trough (antibiotic lab draw) and had just forgotten to close the screen out. They stated they knew it was a violation of Health Insurance Portability and Accountability Act (HIPPA). On 03/27/25 at 8:40 a.m., the administrator stated the ADON knew not to leave protected health information unsecured.

Based on record review and interview, the facility failed to ensure the resident or their legal representative received education regarding the benefits and potential side effects of the influenza immunization and obtain consents before administering the immunization for three (#46, 49, and #55) of five sampled residents reviewed for immunizations. The DON identified 69 residents resided in the facility. Findings: The facility's Influenza Vaccination Program policy, revised on 10/11/05, read in parts, .It is the policy of this facility to provide all residents .who do not have allergy to the vaccine, the influenza vaccination yearly .obtain consent forms .Provide education to residents or resident representative on the benefits and potential side effects of the influenza vaccine .before administering the vaccine . 1. Res #55 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, diabetes mellitus, GERD, hyperlipidemia, HTN, and chronic pain. A influenza immunization record, dated 12/07/22, documented the resident received an influenza immunization. There was an influenza vaccination consent/declination form, dated 12/07/22, which included documentation the resident or their legal representative received education regarding the benefits and potential side effects of the immunization. A influenza immunization record, dated 10/19/23, documented the resident received an influenza immunization. There was no influenza vaccination consent/declination form which included documentation the resident or their legal representative received education regarding the benefits and potential side effects of the immunization for the 10/01/22 through 03/31/23 flu season. On 11/15/23 at 3:08 p.m., the IP was asked if there was an influenza vaccination consent/declination form which included documentation the resident or their legal representative received education regarding the benefits and potential side effects of the immunization. They stated there was a form completed on 12/07/22. They stated the form would also cover 2023. They were asked how often the influenza immunization was offered. They stated it was offered every year. They stated flu season was October through March. They were made aware the resident was admitted on [DATE], the influenza vaccination consent/declination form which included documentation the resident or their legal representative received education regarding the benefits and potential side effects of the immunization was dated 12/07/22, and the EHR documented the resident received an influenza immunization on 12/07/22. They were made aware before offering the influenza immunization on 10/19/23 there was no influenza vaccination consent/declination form which included documentation the resident or their legal representative received education regarding the benefits and potential side effects of the immunization. 36191 2. Res #46 had diagnoses which included Alzheimer's disease, dementia, and anxiety. A consent for the influenza vaccination, dated 11/09/21, documented the resident's partial signature and no signature from the resident's representative. A note attached to the consent form, documented Unable to consent. There were no consent for the 2023 flu season. A quarterly resident assessment, dated 08/04/23, documented the resident's cognition was severely impaired. The resident's EHR documented the resident had a case worker as their substitute decision maker. The record documented the resident was administered the influenza vaccination on 10/19/23. There was no documentation the resident's decision maker had been given education on the risks, benefits and/or consent was obtained prior to being administered the vaccine for the current 2023 flu season. On 11/15/23 at 3:02 p.m., the IP stated Res #46 was unable to make their own medical decisions and did not have a valid consent for the flu vaccine administered on 10/29/23. 3. Res #49 had diagnoses which included COPD and dementia. A consent for the influenza vaccination, dated 09/29/21, documented the resident's signature and no signature from the resident's representative. There was no consent for the 2023 flu season. A quarterly assessment, dated 08/18/23, documented the resident's cognition was severly impaired. The resident's EHR documented the resident had family members documented as their financial responsible party and clinical contact. The record documented the resident was administered the influenza vaccination on 10/19/23. There was no documentation the resident or their family members had been given education on the risks, benefits and/or a consent was obtained prior to being administered the vaccine for the current 2023 flu season. On 11/15/23 at 2:43 p.m., the IP stated Res #49 was not able to make their own medical decision. They stated they would not contact the family for a new consent if the resident had previously consented to receive the vaccination. They stated they had not contacted the resident's family prior to administering the influenza vaccination. The IP stated Res #49 received the influenza vaccination without the responsible party's consent.

Based on observation and interview, the facility failed to ensure the kitchen and dining area were kept clean and maintained in good repair. The DM identified 67 residents received services from the kitchen. Two residents received nutrition and hydration solely through a feeding tube. Findings: On 11/13/23 at 7:33 a.m., a tour of the kitchen was conducted. The following observations were made: a. there was a hole in the wall around the piping below the dish machine, b. ceiling lights were burned out and/or not working. End caps were missing on the light shields, c. there was an accumulation of black residue on the floor and the walls below and behind the dish machine and cook area, and d. there was food splatter on the ceiling above the three compartment sink. On 11/14/23 at 1:19 p.m., a tour of the kitchen and dining area was conducted. The following observations were made. a. there was black residue and multiple rodent droppings inside of the cabinets in the drink station area. There were holes, trim missing, and cabinet material was peeling off of the cabinets, and b. the shelving inside of the cabinets above the food preparation table were warped and wood pieces were chipping off of the shelving. The cabinet doors did not close properly and there was a gap between the ceiling and the cabinets. On 11/14/23 at 1:28 p.m., the DM was asked how staff ensured the kitchen and dining area were kept clean and maintained in good repair. They stated they had a cleaning schedule on when areas were to be cleaned. They stated they cleaned daily. They stated there was a maintenance log to report maintenance concerns. The DM was shown the above findings.

Based on record review and interview, the facility failed to perform ongoing assessments and oversight of the resident prior to and after dialysis treatments for one (#56) of one sampled resident who received dialysis. The DON identified 69 residents resided in the facility. Findings: Res #56 had diagnoses which included end stage renal disease, diabetes with chronic kidney disease, hypertensive heart, chronic kidney disease with heart failure stage five, and dependence on renal dialysis. A physician order, dated 01/19/23, documented the resident was to receive dialysis treatments Tuesday, Thursday, and Saturday at 11:30 a.m. A physician order, dated 01/19/23, documented to remove AVF dressing four hours after dialysis treatment. If access is still bleeding after dressing removal, re-apply sterile gauze to area using slight pressure to stop bleeding. A physician order, dated 01/19/23, documented check AVF for thrill and bruit every shift. If absent notify physician. A physician order, dated 01/19/23, monitor AVF for signs and symptoms of trauma and/or infection every shift. A quarterly MDS assessment, dated 10/16/23, documented the resident was severely cognitively impaired and received renal dialysis. A dialysis communication form, dated 11/14/23, documented no information under Pre-Dialysis information (completed by nursing facility and sent with resident). The document had spaces to record the bruit/thrill, status of access graft/catheter, skin issues with the access site, peripheral pulses, and vital signs. The dialysis form was blank except for the vital signs, that were documented as being completed on 11-09-23 at 10:27 a.m. five days prior to the day of the dialysis treatment. The Post Dialysis section documented no information. The last dialysis communication form completed by the nursing staff was dated 07/18/2023. On 11/15/23 at 11:22 a.m., LPN # 1 was asked what the process was for completing dialysis pre and post assessments forms. They stated they had not been completing them. They were asked if 07/18/23 was the last time a dialysis communication form was completed for Res #56. They stated, Yes. On 11/15/23 at 11:31 a.m., the DON was asked what the process was for completing the dialysis pre and post assessment form. They stated the form was to be completed on the resident's dialysis days prior to departing from the facility and upon return to the facility. The DON was made aware there had been no dialysis communications forms completed for Res #56 since 07/18/23.

Based on observation, record review, and interview, the facility failed to ensure residents with limited range of motion received restorative services and/or assistance to prevent further decrease in range of motion for two (#30 and #220) of two sampled residents reviewed for mobility. The DON identified 6 residents with impaired range of motion. Findings: A facility policy dated 10/01/2001, titled Range of Motion, read in part .Active or passive range of motion is done to reduce muscle wasting, weakening, and prevents or reduces the development of contractures. EQUIPMENT: Adaptive equipment or supportive devices as ordered by the physician and part of the plan of care . 1. Res #30 was admitted to the facility on [DATE] and had diagnoses which included blindness right eye, senile degeneration of brain, lack of coordination, muscle wasting, atrophy, and stroke. A baseline assessment and care plan, dated 11/06/19, documented Res #30's weight bearing ability as full weight bearing. An annual assessment, dated 12/07/22, documented the resident was severely cognitively impaired; required moderate assistance with most ADL's; and had impaired range of motion to the lower extremities. The assessment documented the resident was not steady without assistance. A quarterly assessment, dated 09/07/23, documented the resident was severely cognitively impaired; required extensive assistance with most ADL's; and had impaired range of motion to the lower extremities. The assessment documented the resident's balance during transition and walking did not occur. The restorative schedule documented the resident had received restorative up until 10/27/23. On 11/13/23 at 7:58 a.m., LPN #2 was observed to apply triad ointment on the resident's groin area. The resident's lower extremities were were observed to be severely contracted up toward their chest. The resident was unable to straighten their lower extremities. On 11/13/23 at 8:09 a.m., the DON was asked if the resident was receiving restorative therapy. They stated, Yes. The DON was asked when Res #30 last received restorative therapy. They reviewed the resident's EHR and stated on 10/27/23. They were asked what the physician order read for the restorative therapy. They stated three times per week. They were asked if the resident had received restorative therapy three times per week. They stated no but they should have been. 2. Res #220 was admitted to the facility on [DATE] and had diagnoses which included osteoarthritis, neuralgia and neuritis, sciatica, and epilepsy. A physician order, dated 11/02/23, documented place brace to left hand, monitor skin daily for s/s of breakdown, and to maintain skin integrity. A physician order, dated 11/02/23, documented to float the resident's heels with pillows while in bed. On 11/13/23 at 9:23 a.m., Res #220 was observed without their left-hand brace and their heels were not floated on pillows. The resident's feet were observed with bilateral foot drop. On 11/14/23 at 12:55 p.m., Res #220 was observed without their left-hand brace and their heels were not floated on pillows. There was a rolled wash cloth in the resident's left hand. On 11/14/23 at 1:05 p.m., LPN #2 was asked if the resident had orders for a left-hand brace and for their feet to be placed on pillows. They stated the resident did. They were made aware there was no hand brace on the resident's left hand and their feet were not floated on pillows. LPN #2 was observed to enter the resident's room and place the brace on and place their feet onto pillow. On 11/14/23 at 1:22 p.m., the DON was asked if the resident had orders for a left-hand brace and for their feet to be placed on pillows. They stated, Yes. They were made aware there was no hand brace on the resident's left hand and their feet were not floated on pillows. They stated it should had been done.

Based on record review and interview, the facility failed to ensure labs were not collected without a physician order for one (#55) of five sampled residents reviewed for lab services. The DON identified 69 residents resided in the facility. Findings: Res #55 had diagnoses which included diabetes mellitus, deficiency of other vitamins, and HTN. A lab report, dated 07/05/23, documented a CBC, CMP, and HbA1c were collected. There was no physician order to collect the labs. On 11/15/23 at 2:22 p.m., the DON was asked if there was a physician order to collect the labs for the resident. On 11/15/23 at 2:30 p.m., the DON stated the physician order to collect the labs did not get reactivated when the resident returned from the hospital in February. They stated there were standing orders to collect the labs.

Based on observation, record review, and interview, the facility failed to ensure wrist blood pressure monitors were cleaned in between residents for two (#50 and #57) of two residents observed during medication administration. The DON identified 69 residents who resided in the facility. The facility's Infection Control policy, dated 06/23/17, read in parts, .Medical equipment and instruments/devices must be cleaned and maintained according to the manufactures' instructions to prevent patient-to-patient transmission of infectious agents . On 11/15/23 at 8:02 a.m., CMA #3 obtained Res #57's blood pressure with a wrist blood pressure monitor, after obtaining the blood pressure, CMA #3 removed the device from the resident's wrist and placed the wrist blood pressure monitor on their wrist without cleaning the blood pressure cuff. On 11/15/23 at 8:15 a.m., CMA #3 removed the wrist blood pressure monitor from their wrist and placed it on Res #50's wrist, without cleaning the device, after the CMA obtained the resident's blood pressure, they placed the wrist blood pressure monitor on Res #50's nightstand. CMA #3 left Res #50's room and placed the wrist blood pressure monitor on their wrist without cleaning the blood pressure cuff. CMA #3 did not clean the device when they went back to the medication cart. On 11/15/23 at 8:18 a.m., CMA #3 stated they were supposed to clean the wrist blood pressure monitor between each resident. They stated they usually used the disinfectant wipes located in the bottom drawer of the medication cart. On 11/15/23 at 2:41 p.m., the IP was made aware of the observations during the medication administration pass. The IP stated the wrist blood pressure monitor should have been cleaned after each use with the disinfectant wipes.

Based on observation, record review, and interview, the facility failed to provide assistance with eating for a dependent resident for one (#30) of five sampled residents who were reviewed for activities of daily living care. The DON identified four residents who required assistance with eating. Findings: Res #30 had diagnoses which included blindness right eye, anorexia nervosa, senile degeneration of brain, severe protein-calorie malnutrition, lack of coordination, muscle wasting, atrophy, stroke, and vitamin deficiency. An annual assessment, dated 12/07/22, documented the resident required moderate assistance with eating which included oversight, encouragement, or cueing, and was severely cognitively impaired. A quarterly assessment, dated 09/07/23, documented the resident required moderate assistance with eating which included oversight, encouragement, or cueing, and was severely cognitively impaired. On 11/13/23 at 7:38 a.m., the resident was observed in their bed asleep, with their breakfast plate on the over-the-bed table in front of them. The resident had not been adjusted to sit up. The plate appeared to be untouched. On 11/15/23 at 11:22 a.m., the resident was observed in their recliner with her lunch plate on the over-the-bed table in front of her. The resident was slumped over with their eyes closed. The plate appeared to be untouched. The silverware package was unopened. On 11/15/23 at 11:45 a.m., the resident was observed in her recliner with their lunch plate on the over-the-bed table in front of them. The resident was slumped over with their eyes closed. The plate appeared to be untouched. The silverware package was unopened. There was no staff assistance observed during the lunch meal. On 11/15/23 at 11:47 a.m., CNA #2 was asked if they had assisted Res #30 with eating. They stated they had not, the resident was not hungry. On 11/15/23 at 11:49 a.m., CNA #4 was asked if they had assisted Res #30 with eating. They stated they had not. On 11/15/23 at 11:51 a.m., the DON was informed Res #30 was observed on two separate occasions with their meal tray on the over-the-bed table in front of them. The meal appeared to be untouched. The silverware package was unopened and there was no staff assistance observed during either meal. The DON was asked if Res #30 required assistance with eating. They stated they did.

Based on observation, record review, and interview, the facility failed to ensure resident care equipment was maintained in good repair for one (#61) of one sampled resident observed for resident care equipment. The DON identified 69 residents resided in the facility. Findings: Res #61 had diagnoses which included morbid obesity. A quarterly resident assessment, dated 08/06/23, documented the resident's cognition was intact. On 11/13/23 at 9:29 a.m., the resident stated their mattress was old and torn. They stated staff were aware. Their bed was made and the mattress could not be seen. On 11/15/23 at 10:16 a.m., the resident's mattress was observed with CNA #1. The bottom of the mattress had multiple large tears. The CNA was asked if they were aware the resident's mattress was torn. They stated they were not. They stated if a residents mattress was in bad repair they would report it to the charge nurse and maintenance. On 11/15/23 at 10:28 a.m., LPN #2 was asked if they were aware the resident's mattress was torn. They stated they were not aware. They were asked what was the protocol when resident equipment was in found to be in bad repair. They stated the aides were to report the issue to the charge nurse and/or maintenance. On 11/15/23 at 10:33 a.m., the maintenance supervisor was asked what was the protocol when resident care equipment was in bad repair. They stated staff were to report the concern to maintenance. They were asked if they had been notified Res #61 had a torn mattress. They stated they were not aware.

Based record review and interview, the facility failed to ensure quarterly financial statements were provided in writing to the resident and/or their representative for one (#61) of one sampled resident reviewed for personal funds. The BOM identified 34 residents who had trust accounts. Findings: Res #61 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction effecting left side, and major depressive disorder. A court document, dated 11/07/22, documented the resident had a legal guardian. A quarterly resident assessment, dated 08/06/23, documented the resident's cognition was intact. On 11/13/23 at 9:29 a.m., Res #61 stated they had a trust account and did not know how much money they had. They stated staff did not tell them anything. They stated they had to ask how much money they had. A resident trust account legers, dated 11/14/23, documented the resident had a trust account. There was no documentation the resident and/or their legal representative had received quarterly statements. On 11/14/23 at 2:04 p.m., the BOM was asked how often financial statements were provided to residents and/or their representatives who had trust accounts. They stated residents would ask when they wanted to know how much money they had. They stated they had not provided quarterly statements to residents and/or their representatives since they had been the BOM.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for one (#15) of five sampled residents reviewed for medications. The DON identified 69 residents resided in the facility. Findings: Res #15 had diagnoses which included major depressive disorder. A physician order, dated 04/25/23, documented venlafaxine HCL (an antidepressant) 75 mg three times a day. The October 2023 MAR and order administration notes documented venlafaxine was not administered 17 out of 68 opportunities. It was documented the medication was not in the facility. On 11/16/23 at 10:45 a.m., CMA #3 was asked what was the protocol for reordering medications. They stated the medication card indicated when the medication was to be reordered. They stated they were to notify the nurse and call the pharmacy if medications had not been received. On 11/16/23 at 10:52 a.m., the DON was asked what was the protocol for reordering medications. They stated the medication card indicated when to reorder. They stated staff were to reorder seven days prior to the medication needing to be refilled. They were shown Res #15's MAR and made aware the order administration notes documented they did not receive their venlafaxine due to the medication not being in the facility.

Based on record review, observation, and interview, the facility failed to perform monitoring for anticoagulant medications for two (#9 and #42) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: 1. Resident #42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 11/10/21, documented to administer [MEDICATION(S)] 5 mg by mouth two times a day for shortness of breath. A five day MDS assessment, dated 08/30/22, documented the resident was severely cognitively intact, wandered daily, required supervision with most ADLs, utilized a wheelchair, was frequently incontinent of bowel and bladder, and received anticoagulant medication. On 11/16/22 at 9:41 a.m., the DON stated the anticoagulant medication did not have monitoring. She stated the resident received general monitoring for change in status and if there was an incident, a more in-depth monitoring was initiated. On 11/16/22 at 9:01 a.m., the MDS coordinator stated the monitoring for anticoagulants should be in the care plan but were not. On 11/16/22 at 11:01 a.m., Res #42 was observed being pushed in a wheelchair by staff to the dining room. Res #9 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 11/01/22, documented resident #9 was to be administered [MEDICATION(S)] 5mg two times a day for blood thinner. The clinical record did not contain documentation of the side effects of the blood thinner. On 11/16/22 at 02:06 p.m., the MDS coordinator was asked to look at care plan for this resident on [MEDICATION(S)]. The MDS coordinator was asked if side effects to monitor [MEDICATION(S)] were care planned. The MDS coordinator stated Staff should be monitoring for abnormal bruising and bleeding, it is not being monitored.

Based on record review, observation, and interview, the facility failed to ensure a resident with limited range of motion received services to increase, maintain, or prevent further decline in range of motion for two (#20 and #26) of two residents reviewed for limited range of motion. The Resident Census and Conditions of Residents documented 61 residents resided in the facility. Findings: 1. Res #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 07/28/22, documented the resident was moderately cognitively impaired, did not walk, required extensive assistance with most ADLs, and had range of motion impairment in the upper and lower extremities. A care plan, dated 08/24/22, documented nursing restorative to do active assistive ROM LUE in all planes 2 repetitions of 10 and passive ROM RUE within functional limits 2 repetitions of 10, three times weekly. A physician order, dated 08/24/22, documented nursing restorative: active assistive ROM LUE in all planes 2 repetitions of 10 and passive ROM RUE within functional limits 2 repetitions of 10, three times weekly. This order was documented as discontinued on 08/31/22 by the MDS Coordinator. The November 2022 TAR had no documentation the staff had provided Res #20 restorative care. On 11/14/22 at 10:51 a.m., the resident was observed lying in bed. Res #20 stated she is bed bound due to leg weakness and was not sure why she had not ever received any therapy. The resident stated she thought therapy would be beneficial. On 11/14/22 at 10:30 a.m., the MDS coordinator was unable to locate a current restorative care order for Res #20. The MDS coordinator stated the facility had not had restorative aide staff to provide these services since August 2022. She stated Res #20 would have benefited from restorative care but has not received restorative care since August 2022. On 11/16/22 at 12:40 p.m., CNA #1 was asked if Res #20 had been provided with restorative care. She stated there were no orders on the nurse aide task list to perform this task and it had not been done. CNA #1 stated she thought this task was a restorative aide's responsibility and that she was not a restorative aide. On 11/16/22 at 1:20 p.m., the DON reported Res #20 would have benefited from restorative therapy but the facility had not been able to keep restorative aides employed long enough to provide restorative care to residents. The DON stated the restorative order for Res #20 should not have been discontinued in August 2022. 2. Res #26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 07/12/22, documented nursing rehab: ROM to all extremities. Get out of bed and into recliner in the am and afternoon, three days per week. A care plan, dated 07/13/22, documented ROM to all extremities, get out of bed and into recliner in the am and afternoon, three days per week. A quarterly assessment, dated 09/07/22, documented the resident was cognitively intact, did not walk, required extensive assistance with most ADLs, and had range of motion impairment in the lower extremities. The November 2022 TAR had no documentation the staff had provided Res #26 restorative care. On 11/14/22 at 1:52 p.m., the resident was observed lying in bed. Res #26 stated she had not received assistance with range of motion exercises from the staff. On 11/16/22 at 10:30 a.m., the MDS coordinator stated the TAR was blank for November 2022 and the care must not have been provided by nurse aides but it should have been. On 11/16/22 at 12:40 p.m., CNA #1 was asked if ROM documented on the TAR had been provided to Res #26. She stated she was not a restorative nurse aide. CNA #1 stated the task was entered as a restorative aide responsibility and she thought only a restorative nurse aide could perform this duty. On 11/16/22 at 1:14 p.m., the DON stated the facility had not had a consistent restorative aide since she began employment in August 2022. She stated the facility has struggled with trying to find and keep restorative aides employed. The DON stated Res #26 should have received restorative therapy but had not.

Based on observation, record review, and interview, the facility failed to: a. update the comprehensive care plan with an intervention following a fall for one (#35) of three residents reviewed for falls and b. invite the resident or resident's representative to participate in developing the care plan for one (#22) of 17 residents whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: 1. Res #35 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS, dated [DATE], documented the resident was severely cognitively intact, required extensive assist of one staff with most ADL's, and was always incontinent of bowel and bladder. A fall incident report, dated 10/10/22 at 2:45 p.m., documented an intervention to toilet the resident before lying her down for bed. A fall care plan, revised on 11/14/22, did not document the intervention from the 10/10/22 fall. On 11/17/22 at 10:24 a.m., the DON was asked the post-fall process. She stated the staff were to perform a head to toe assessment to check for injuries. She stated the staff were to initiated neuro-checks for unwitnessed falls. She stated staff were to notify the doctor on call and the family of the resident. She stated the staff completing the incident report were responsible for initiating an intervention. She stated the interventions should be tailored to the cause of the fall to prevent it from happening again. On 11/17/22 at 10:41 a.m., the MDS coordinator stated her process for updating the care plan with fall interventions was to review the incident reports and progress notes. She stated there was a morning meeting in which the incident reports were reviewed. She stated she did not see that the intervention for the 10/10/22 fall was care planned and whoever was there that morning should have updated the care plan with the intervention. 2. Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan for the resident was last reviewed on 08/24/22. A quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired, had daily wandering, was independent with bed mobility; transfer; walking; and eating, required limited assistance of one staff for dressing; toilet use; and personal hygiene, required extensive assistance of one staff for bathing, and was frequently incontinent of bowel and bladder. On 11/14/22 at 3:49 p.m., Res #22 was observed ambulating in the halls and was observed to be offered a shower by staff. On 11/16/22 at 1:48 p.m., Res #22's representative stated he had not received a letter or phone call notifying him of a meeting to discuss Res 22's care. He stated he had never attended or participated in a care plan meeting for the resident. On 11/17/22 at 9:20 a.m., the MDS coordinator stated she has not had care plan meetings. She stated that it has been too hard trying to get people to attend since COVID and she did not currently send out invites or host a formal care plan meeting. She stated she was aware the requirement was to do them quarterly, but she had not been able to get the process started.

Based on record review, observation, and interview, the facility failed to ensure residents did not receive an as needed antianxiety medication without justification for administration for one (#39) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 14 residents received antianxiety medications. Findings: 1. Resident #39 had diagnoses which included dementia, [CONDITION(S)], depression, hypertension, and anxiety disorder. A quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired, had no behaviors, required supervision with most ADLs, was occasionally incontinent of urine, and received anti-anxiety medications one out of seven days during the review period. A physician order, dated 09/14/22, documented to record behaviors and interventions every shift. A physician order, dated 10/03/22, documented to administer [MEDICATION(S)] (an antianxiety medication) 1 gm/1 ml gel topically to inner wrists every four hours as needed for anxiety for 14 days. An order administration note, dated 10/03/22 at 10:45 p.m., documented the [MEDICATION(S)] was administered. The reason for administration was documented as increased anxiety. Attempts at non-pharmacological interventions were not documented. The TAR documented 0 for every shift on the behavior monitoring. An order administration note, dated 10/06/22 at 9:37 a.m., documented the [MEDICATION(S)] was administered. The reason for administration was not documented. Attempts at non-pharmacological interventions were not documented. The TAR documented 0 for every shift on the behavior monitoring. An order administration note, dated 10/10/22 at 6:02 p.m., documented the [MEDICATION(S)] was administered. The reason for administration was not documented. Attempts at non-pharmacological interventions were not documented. The TAR documented 0 for every shift on the behavior monitoring. A physician order, dated 10/13/22, documented to administer [MEDICATION(S)] 1 gm/1 ml gel topically to inner wrists every four hours as needed for anxiety for 14 days. An order administration note, dated 10/19/22 at 7:37 a.m., documented the [MEDICATION(S)] was administered. The reason for administration was not documented. Attempts at non-pharmacological interventions were not documented. The TAR documented 0 for every shift on the behavior monitoring. An order administration note, dated 10/19/22 at 8:18 p.m., documented the [MEDICATION(S)] was administered. The reason for administration was not documented. Attempts at non-pharmacological interventions were not documented. The TAR documented 0 for every shift on the behavior monitoring. A physician order, dated 11/02/22, documented to administer [MEDICATION(S)] 1 gm/1 ml gel topically to inner wrists every four hours as needed for anxiety for 14 days. An order administration note, dated 11/02/22 at 8:30 a.m., documented the [MEDICATION(S)] was administered. The reason for administration and was not documented. Attempts at non-pharmacological interventions were not documented. The TAR documented 0 for every shift on the behavior monitoring. An order administration note, dated 11/02/22 at 6:06 p.m., documented the [MEDICATION(S)] was administered. The reason for administration was not documented. Attempts at non-pharmacological interventions were not documented. The TAR documented 0 for every shift on the behavior monitoring. An order administration note, dated 11/03/22 at 12:24 a.m., documented the [MEDICATION(S)] was administered. The reason for administration was not documented. Attempts at non-pharmacological interventions were not documented. The TAR documented 0 for every shift on the behavior monitoring. An order administration note, dated 11/03/22 at 7:03 a.m., documented the [MEDICATION(S)] was administered. The reason for administration was not documented. Attempts at non-pharmacological interventions were not documented. The TAR documented 0 for every shift on the behavior monitoring. An order administration note, dated 11/06/22 at 6:11 p.m., documented the [MEDICATION(S)] was administered. The reason for administration was not documented. Attempts at non-pharmacological interventions were not documented. The TAR documented 0 for every shift on the behavior monitoring. An order administration note, dated 11/14/22 at 11:29 a.m., documented the [MEDICATION(S)] was administered. The reason for administration was documented as increased anxiety. Attempts at non-pharmacological interventions were not documented. The TAR documented 0 for every shift on the behavior monitoring. On 11/16/22 at 10:55 a.m., CMA #1 stated she would use non-pharmacological interventions with the resident. She stated she would attempt redirection with walking, or talking to her. She stated she would attempt reminiscing or offering to assist the resident to lay down for a nap. She stated when these interventions do not work she would notify the nurse of what she has attempted. She stated she was not able to document the non-pharmacological interventions in the resident's records. On 11/16/22 at 10:57 a.m., LPN #1 stated staff will try to redirect the resident before administering an as needed medication. She stated it should be documented in a nurses note. She stated the EHR has a box that pops up when the medication is administered and non-pharmacological interventions attempted and the reason for the administration of the medication should be documented there. She stated she did not see that this was done in the resident's record. On 11/16/22 at 12:04 p.m., the DON stated staff should be documenting any anxiety behaviors prior to administering an as needed medication. She reviewed the behavior monitoring and stated the 0 coding on the resident's TAR indicated there were no behaviors. When asked if the reason for administration or non-pharmacological interventions were documented in the residents chart she shook her head no.

Based on interview and record review, the facility failed to ensure residents were free from mental abuse for one (#1) of three sampled residents reviewed for abuse and neglect. The facility failed to prevent a staff member from photographing a resident after an incontinent episode and posting the photograph on social media. The deficient practice was determined to be past-noncompliance since the facility identified the situation and implemented interventions to prevent the recurrence of the situation. The administrator identified 66 residents who resided in the facility. Findings: The Resident Abuse, Neglect, and Misappropriation of Property policy, read in part, .Mental abuse includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings, regardless of whether the resident provided consent and regardless of the resident's cognitive status, in any manner that would demean or humiliate a resident . Resident (Res) #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 10/29/21, documented the resident was severely impaired with cognition; frequently incontinent of bowel and bladder; and required extensive assistance of staff for most ADLs. A staff schedule, dated 11/01/21, documented CNA #2 worked an eight hour day shift on the hall the resident resided and then worked an evening shift the same day on different hall. A Oklahoma State Department of Health incident report, form 283, dated 11/02/21, documented an allegation of abuse for the resident. The report, read in parts, .Employee [CNA #1 name deleted] came to administrator stating another employee, [CNA #2 name deleted] had taken inappropriate pictures of [Res #1 name deleted] and posted them on snap chat . The report documented the staff member was terminated effective immediately. A ''Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property'' form 718, dated 11/02/21, read in parts, .The photo was a picture of resident from the chest to the knees. He was in bed, wearing only a shirt and brief. The brief was soiled and the resident has bowel movement on his leg. The caption on the photo was This is how my morning is lmao [sic][OBSCENITY]Y!!! But for this extra $20 an hour I get off early so it's a win win. A progress note, dated 11/02/21, documented a focused assessment was completed. The progress note documented the resident had zero behaviors that would indicate he felt fearful or unsafe. An unsigned document titled, Investigation Report, dated 11/02/21, read in parts, [CNA #1 name deleted] stated emp. [CNA #2 name deleted] had posted pics & showed them to admin. - stated emp. had posted other things in past, but not this bad. Stated [CNA #3 name deleted] saw the pics, because she was standing there .[CNA #2 name deleted] admitted she posted the picture, however, she did not understand it was wrong since his face was not in the picture. The report documented the resident resided on the Alzheimer's unit and was unaware the picture was taken. The report documented other residents were unable to be interview and no other staff was interviewed. An in-service document, dated 11/02/21, documented 36 staff members were educated on abuse and neglect, patient rights to privacy, confidentiality agreement, and personal conduct. Course completion documentation for staff documented 52 staff members completed the course, ''HIPAA Do's and Don'ts: Electronic Communication and Social Media,'' between 11/02/21 through 11/15/21. On 11/18/21 at 11:00 a.m., the administrator stated on 11/02/21 at 8:00 a.m. CNA #1 showed her a picture on her telephone. She stated the picture was of a person from the chest to their knees, wearing a tee shirt and a brief, and had feces up and down their legs. The administrator stated she recognized the resident by previous care provided. The administrator stated CNA #1 confirmed the picture was of the resident. The administrator stated she did not know when the picture was taken. The administrator stated CNA #1 reported she and another staff member saw the posted picture late the night before and decided to wait until the next morning to report the incident. The administrator stated the Oklahoma State Department of Health incident report, form 283, was her documented investigation and findings. On 11/22/21 at 11:39 a.m., the family stated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The family stated if the resident's cognition was as prior to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, it was determined the facility failed to provide supervision for two (#3 and #5) of six residents reviewed for sexual abuse. The facility identified a census of 43 residents. Findings: 1. Resident #3 was admitted with [DIAGNOSES REDACTED]. A care plan, dated 09/13/18, documented the resident was sexually active. A nurse's note, dated 09/13/18 at 10:07 a.m., documented resident #3 was in the dining room hugging and caressing resident #5's back. A quarterly assessment, dated 11/29/18, documented the resident was moderately impaired in cognition. The assessment documented the resident required limited assistance with transfers. The assessment documented the resident was self-sufficient with locomotion in a wheel chair. The assessment documented an additional [DIAGNOSES REDACTED]. A behavior note, dated 12/03/18 at 1:48 p.m., documented the resident had increased sexual behaviors with resident #5 in the dining room. The note documented the residents were separated. A behavior note, dated 12/06/18 at 2:21 a.m., documented the resident was trying to get resident #5 into his room to go to bed with him. The note documented the female resident was removed from the room. A physician's orders [REDACTED]. An intervention on the care plan, dated 12/15/18, documented to administer [MEDICATION NAME] as ordered by the physician. A behavior note, dated 12/17/18 at 11:18 p.m., documented the resident had sexual behaviors toward resident #5. The note documented the resident was redirected out of the dining area. A behavior note, dated 02/22/19 at 4:32 p.m., documented the resident was observed in the dining room kissing resident #5 romantically. The note documented the residents were separated. A behavior note, dated 02/24/19 at 8:44 a.m., documented the resident was observed kissing resident #5 on the mouth. The staff attempted to redirect the residents. The note documented the staff would continue to monitor the residents. A nurse's note, dated 03/11/19 at 11:19 a.m., documented the medication [MEDICATION NAME] was discontinued by the physician at the request of the resident's wife. A nurse's note, dated 03/12/19 at 11:29 a.m., documented the resident was observed at the dining room table with resident #5 holding hands. Resident #5 kissed the resident's hand and laid her head on his shoulder. The resident kissed resident #5 on the lips and continued to hold hands. A nurses note, dated 03/30/19, documented the resident was observed sucking on a female resident's left breast. The note documented the residents were separated and redirected. The note documented the female resident was assessed and had no signs or symptoms of physical or emotional distress noted. The note documented the facility notified the local police, director of nursing, administrator, daughter, and the physician of the incident. A behavior note, dated 03/30/19 at 12:58 p.m., documented the resident was observed with another resident #1 inappropriately engaging in physical behaviors with sexual undertones. The residents were separated. The resident was sent to the emergency department related to the sexual behaviors observed. The wife, assistant director of nursing, director of nursing, and the physician were notified. A behavior note, dated 04/01/19 at 8:19 a.m., documented due to recent increase in sexual behaviors, the resident was to be supervised when in the common areas. A behavior note, dated 04/01/19 at 8:21 a.m., documented the resident had returned from the emergency department with no new orders. The on call physician ordered [MEDICATION NAME] 10 mg twice a day to be resumed. A social service progress note, dated 04/01/19 at 10:34 a.m., documented a certified nursing assistant (CNA) reported hearing resident #2 yelling stop. The CNA observed the resident with his hands in a female resident's pants. He removed his hand when he was told to stop and reported, he wasn't doing nothing. The female resident reported he's bad, he's bad. The resident was removed from the dining area and placed one on one. The physician was notified and gave an order for [REDACTED]. An intervention on the care plan, dated 04/01/19, documented administer [MEDICATION NAME] as ordered by the physician and the resident will be supervised while in common areas. On 05/14/19 at 9:50 a.m., CNA #1 reported resident #3 was problem from admit to discharge. The CNA reported she could not tell any difference with the medication. On 05/14/19 at 10:05 a.m., CNA #3 reported resident #3 would mess with some of the residents. The CNA reported hearing about resident #3 sucking on resident #1's breast, the CNA did not see it. The CNA reported she was told to keep a close eye on resident #3. The CNA reported another incident with resident #2, she did not witness that incident. The CNA reported resident #3 could move down the hallway in his wheel chair. The CNA reported the administrator called in (MONTH) 2019 to do an inservice regarding abuse. On 05/14/19 at 2:00 p.m., CNA #2 reported she was talking with dietary and heard a female yell stop, stop, he's a bad man. I looked and resident #3 had his hand in resident #2's pants. The CNA reported no one was in the common area with him. The CNA reported resident #3 had tried to get resident #5 in his room. 2. Resident #5 was admitted with dementia without behaviors, mood disorder, anxiety, depression, and heart failure. A care plan, dated 12/18/16, documented the resident had impaired cognitive function related to dementia, the interventions were to administer [MEDICATION NAME]. The care plan documented the resident got agitated with care, hitting and kicking staff. The care plan did not document the resident's sexual behaviors. An annual assessment, dated 04/15/19, documented the resident was severely impaired in cognition. The assessment documented the resident required extensive assistance with transfers. The assessment documented the resident was self-sufficient with locomotion in a wheel chair. A behavior note, dated 5/13/19, documented the resident had spent the last two hours groping males and females sexually. The resident was redirected each time. On 05/14/19 at 9:45 a.m., the resident was observed sitting in her wheelchair. On 05/14/19 at 10:05 a.m., two residents who were roommates reported the resident liked to touch everyone and wandered into other resident rooms. The residents reported the resident could be aggressive. On 05/14/19 at 4:00 p.m., licensed practical nurse (LPN) #2 reported the groping behavior was the resident rubbing other residents' arms progressing to the legs and then to the groin. On 05/14/19 at 4:10 p.m., resident #7 reported the resident tried to touch him the previous night. The resident reported he would get away from the resident. On 5/14/19 at 2:45 p.m. the director of nurses (DON) reported they did not consider the behaviors between resident #3 and resident #5 abuse.

On 11/01/17, an immediate jeopardy situation was determined to exist due to the facility's failure to provide adequate supervision to prevent falls including one which resulted in a head injury requiring surgical intervention for resident #65. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of an immediate jeopardy situation. At 2:04 p.m., the corporate licensed practical nurse (LPN), the general manager (GM) and the interim director of nursing (DON) were notified of the existence of an immediate jeopardy situation. On 11/02/17 at 12:12 p.m an acceptable plan of removal was received. The plan of removal was as follows: .Resident (initials removed) will be placed on 1 on 1 until appropriate interventions have been utilized. Identified resident will have an RN (registered nurse) complete focusing on falls and root cause, pharmacy review of medications complete, RN updated fall assessment complete, RN call to physician and review medications and fall interventions complete and then an updated fall care plan reflect appropriate interventions. All above assessments and reviews for identified resident will be completed by midnight on [DATE], (YEAR). Any resident who has had more than 3 falls in the last 30 days will have an RN assessment complete focusing on falls and root cause, call placed to their physician by RN to review fall interventions and medications, a pharmacist will do medication review, an RN will complete updated fall assessment and their care plans will be updated to reflect appropriate interventions. All above assessments and reviews will be complete by midnight on (MONTH) 1, (YEAR). Nurses will be inserviced by Administrative Nurses (three nurses' names deleted) on: 1. Fall assessment being complete after a fall to determine specific needed intervention focusing on why fall occurred. 2. Supervision - if resident has more than one fall in 30 day period call the DON/Admin (administrator) at the time of the fall and place resident on 1 on 1 until RN completes an assessment and notifies physician for further appropriate interventions. 3. Fall awareness policy including falling stars. All nurses inservicing will be complete on by midnight on (MONTH) 1, (YEAR). Nurses currently working at facility will be inserviced in person, nurses not currently working will be inserviced over the phone, any nurses (as determined by employee roster) not reached over the phone or in person will be suspended until inservicing is completed by the Director of Nurses. All CNA (certified nursing assistants)/CMA (certified medication aides) staff will be inserviced by Department heads (three staff names deleted) on: 1. Falling star program 2. If a resident falls immediately report to charge nurse. All CNA/CMAs inservicing will be complete by midnight on (MONTH) 1, (YEAR). CNA/CMAs currently working at the facility will be inserviced in person, CNA/CMAs not currently working will be inserviced over the phone, any CNA/CMAs (as determined by employee roster) not reached over the phone or in person will be suspended until inservicing is completed by administrator. The immediate jeopardy was removed on 11/02/17 at 3:10 p.m., after the plan of removal was carried out. The deficient practice remained at actual harm at a pattern. Based on observations, record review and interviews, it was determined the facility failed to ensure adequate supervision was implemented for a resident with a history of falls and head injury to prevent further falls and another head injury for one (#65) of three sampled residents who had falls with injuries. In addition, it was determined the facility failed to implement interventions and develop appropriate interventions to prevent repeated falls for a resident with a known history of falls for resident #65. Within 13 weeks of admission, resident #65 had suffered 28 falls, one resulting in a head injury that required surgical intervention. The resident continued to have falls after his return from the hospital. This had the potential to affect 64 residents identified by the facility as being at risk for falls. The 'Resident Census and Conditions of Residents' form documented 64 residents who resided in the facility. Findings: Findings: The facility's policy and procedure titled 'Fall Awareness Program, last revised on 03/21/16, documented: Purpose: The Fall Awareness Program is designed to Identify those residents who may be at risk for falls and injury. Policy: The fall risk assessment will be completed on all admissions, readmission, falls, and significant changes . Procedure: Evaluate Fall Risk Factors: .Review appliances and devices for possible problems as well as the resident's use of the appliance or device. .Review to determine whether restraints are currently in use. .Review and investigate previous falls if able. (time of day, last meal, usual or unusual activity, standing/ walking, reaching, crowd of people, bowel or bladder urgency, glare or liquid on the floor, foreign object, pattern of falls, medications given, vital signs taken, and resident's usual pattern of interaction) .Complete Fall Risk Assessment and Pain Assessment Tools. .Upon completion of Fall Risk Assessment numeric scores 25 or above, the resident is placed on Fall Prevention Protocols. .Frequent re-orient and repetitively reinforce use of call bell and ensure it is within reach. .Reinforce use of assistive devices. .Reassess for safe footwear. .Monitor use of eyeglasses, hearing aid, if appropriate. .Consider Rehabilitation Screen, if appropriate. .Evaluate need for an adjustment in resident's daily activity schedule. .Educate resident's family/ significant other regarding these interventions and encourage family assistance and support. .Develop care plan based on interventions used. Review quarterly and as needed. .Falling Star Program is initiated. .Implement chair or bed alarm, as appropriate. .Implement low bed, as appropriate. .Implement w/c (wheelchair)-seating alternatives (wedge cushion, reclining chair) as needed. Contact Occupational Therapy .Implement use of protective equipment (helmets, hip pads), as indicated. .Initiate placement of resident at nursing station, as appropriate. .Consider room change. Fall Occurs: .Assess resident for injuries, provide appropriate medical attention, and notify physician and family. Obtain orders for X-ray as indicated. Complete incident report and include neurological check sheet if suspect or confirmed the resident hit their head. .Complete additional fall risk assessment tool. .Assess current pain management and effectiveness. .Consider factors regarding the fall. Develop care plan using appropriate interventions from Fall Prevention Protocol I or II. .Determine if equipment/ supplies were faulty or used inappropriately. .Assess for functional declines such as weight loss, mobility changes. .Re-evaluate environment for contributing factors. .Re-evaluate resident's use of adaptive equipment or the need for adaptive equipment. .Re-evaluate toileting rounds to reduce unassisted trips to the bathroom. .Re-evaluate the mental status of of high-risk patients every shift. Reorient each resident as often as necessary. .Provide additional education of resident/family if indicated. Educate on the proper use of assistive devices (canes, walkers, wheelchairs) and safe transfer techniques. .Review and/ or revise plan of care as needed in Q2 meeting. Schedule care plan meetings as indicated for review and revisions. .Evaluate need for therapy to screen the resident. .Review the fall at the next Safety committee meeting and gain input for interdisciplinary team members to update and revise plan of care as indicated . Resident #65 was admitted to the facility, on 07/05/17, with [DIAGNOSES REDACTED]. Hospital discharge records, dated 07/05/17, documented the resident was discharged to the facility on medications (meds) which included: Prozac (a antidepressant) 20 mg (milligrams) daily and Lasix (a diuretic) 40 mg q (every) 24 hours. A nurses' note, dated 07/05/17 at 2:15 p.m., documented, .admitted to this facility .due to recent fall with subdural hematoma .Forgetful and confused at times. Speech clear .He and his family state he now has frequent headaches and medication only helps .Family reported .resident has 4 cracked ribs to left side due to a different fall .Frequently incontinent of bowel and bladder. Wears briefs at all times .very unstable when transferring and ambulating .leans to the right. Frequently forgets owns (sic) limitations and transfers and ambulates unassisted. Pressure alarms applied to bed, w/c and bedroom chair at all times. Beveled safety mat in place now at bedside. PT (physical therapy)/OT (occupational therapy)/ST (speech therapy) notified of orders to eval and treat as indicated. Oriented resident and family to call light . An incident report, dated 07/05/17 at 7:20 p.m., documented the resident was found lying on the bathroom (br) floor on his right side with head next to the toilet. The report documented the resident had a small abrasion above the right eyebrow. An incident report, dated 07/06/17 at 1:40 p.m., documented the resident was on the bathroom floor and did not remember what happened. No injury was documented. The report documented the resident had floor mat with alarm, bed alarm, and chair alarm which someone keeps turning alarms off. Interventions documented on the report was to remind resident to turn call light on and wait for help. The resident's care plan, initiated on 07/06/17, documented: Focus .is at risk/Actual for falls due to weakness from Closed Head Trauma r/t (related to) History of Fall prior to admit . Goal .Staff will review and evaluate all falls and intervene as needed to reduce the potential of injury through the review date . Interventions .7-05-2017 FALL RISK score: High risk 75 . 7/5/17: Fall w/ (with) small abrasion above right eyebrow. Intervention: Educate (Res name deleted) and family to leave bed alarms in place and on at all times . 7/6/17: Non injury fall. Intervention: Will place an alarming floor mat at bedside to alert staff to (Resident's name deleted) getting up without assistance . Pressure Pad to Bed . Pressure Pad to W/C (wheelchair) . PT, OT, ST to screen evaluate and treat as indicated. PT will see resident BID (twice daily) on weekdays, once daily on weekends and holidays. OT staff to see resident once daily for 5 of the 7 day LOS (sic) . Risk manager mat with beveled edges . Side Positioning Bar to bed . Resident continues to turn off alarms and transfer self without assist. This increases his fall risk. Family educated not to turn off alarms or show resident how to do so. Explained to family risks of fall injury up to and including death. Family verbalizes understanding. Alarms are in place to alert staff to resident attempts to get up unassisted, but due to alarms being turned off by family and having family educate resident how to turn off alarm the resident is at a higher risk for fall and injury associated with fall. Date Initiated: 07/07/2017 . An incident report, dated 07/08/17 at 3:34 p.m., documented the resident leaned forward in his wheelchair and fell to the floor in the lobby while visiting with family members. No injury was documented. The report documented the following interventions: .educate family to ask staff for assistance when visiting with resident in lobby or room. Educated resident the importance of asking for help and risks involved of hitting his head and causing more damage from previous injury he received when he fell in the community . The care plan, updated on 07/08/17, documented .Non injury fall. Intervention: Educate family to call for assistance and not transport or move him themselves . An incident report, dated 07/09/17 at 2:05 p.m., documented, .Resident was standing at bedside with assistance of wife. Wife states patient started leaning to right and she tried to catch him and she fell on wheelchair and hw (he) then fell on her and wheelchair. Resident was observed lying half on wheelchair and half on floor with head against the bedside table . The report documented the resident had two small skin tears on the left elbow. The report did not document any interventions to prevent recurrence. The care plan, updated on 07/09/17, documented, .Non injury fall. Intervention: Frequent toileting . physician's orders [REDACTED]. An incident report, dated 07/12/17 at 5:00 a.m., documented, .CNA notified this nurse that resident was lowered to floor in resident's bathroom. Upon entering resident bathroom, resident noted to be sitting on bottom in front of toilet. CNA stated, that resident was already in bathroom and leaning to right when she stopped resident from falling and then lowered resident to floor. No injuries or interventions to prevent recurrence were documented. An incident report, dated 07/12/17 at 8:20 a.m., documented, .resident's w/c pressure alarm was sounding. When staff went to check on resident, he was standing up in his bathroom and appeared to lose balance. Staff member slowly lowered resident to sitting position on the floor . No injury was documented. The report documented to continue current neurological monitoring and preventative fall measures. The report documented, .New order received to send to (Hospital name deleted) ER (emergency room ) for scan of brain, eval (evaluation) and treatment as indicated . A nurses' note, dated 07/12/17 at 8:20 a.m., documented, .New order received to transfer resident to (Hospital deleted) for scan of brain, eval and tx (treatment) as indicated due to increased H/A's (headaches) and multiple falls . The care plan, updated 07/12/17, documented, .non injury fall Intervention: keep urinal at bedside .non skid strips in BP (sic-bathroom) Bright tape to call light for visual reminder . An admission assessment, dated 07/12/17, documented the resident was understood, usually understood others and was severely impaired in cognitive skills for daily decision making. The assessment documented the resident required supervision/setup assistance with eating, limited assistance of one to two persons for locomotion, and extensive assistance of one to two persons for all other activities of daily living. The assessment documented the resident was not steady, only able to stabilize with human assistance in all areas of balance during transitions and walking, had impairment of functional limitation in range of motion of bilateral upper extremities and utilized a wheelchair for mobility. The assessment documented the resident was occasionally incontinent of bowel and bladder, had two or more falls with no injury and two or more falls with minor injury since admission, had received no antipsychotic or antianxiety medications during the seven days prior to the assessment, had received an antidepressant medication on one day and diuretic medication on seven of the seven days prior to the assessment and no restraints and/or alarms had been used during the seven days prior to the assessment. An incident report, dated 07/13/17 at 2:00 p.m., documented, .alarm sounding off in room .noted resident sitting on floor with back against bed. Noted small cut to left hand .Resident unable to give description on how the fall occurred .assisted back to bed and incontinent care provided .Call light and water within reach .D/C (discontinue) Depakote, Sinemet & Trazadone . A nurses' note, dated 07/13/17 at 3:24 p.m., documented, .(Physician's name deleted) here and upon med review gave orders to d/c (discontinue) Depakote, Sinemet and Trazadone . The care plan, updated 07/13/17, documented, .fall with s/t (skin tear) to left hand Intervention: med (medication) review . The care plan, updated 07/14/17, documented, .Protective helmet Non skid strips to floor in bathroom . An incident report, dated 07/15/17 at 3:30 p.m., documented, .Resident had gotten up and was found in bathroom with back sitting up against the door. No injuries noted . The report documented the following interventions: .Spoke with resident spouse regarding leaving helmet on at all times. Every other intervention in place for resident at this time . An incident report, dated 07/18/17 at 3:30 p.m., documented, .Nurse called to room resident wife states resident was trying to transfer self to wheel chair and when she tried to help he pushed her away and slipped on floor landing on bottom resident sitting on floor in front of chair wheel chair in front of him. I just slipped didn't hurt myself .no injuries .noted something wet on floor in front of resident and resident pants were wet .had regular socks on educated wife on importance of wearing non skid socks to avoid sliding on the floor several pair were placed in resident room wife verbalized understanding. Re-educated on letting staff assist with resident care for his safety and hers wife verbalized understanding . The resident's care plan was not updated at that time to include the resident was to wear non skid socks when he was not wearing shoes. The task sheets for (MONTH) (YEAR) documented the resident: ~ was continent of urine on 28 of 34 shifts from 07/05/17 through 07/16/17, ~ was continent of urine on 18 of 45 shifts from 07/17/17 through 07/31/17, and ~ was incontinent of bowels two times during the month. The task sheets did not document a toileting plan (prompted toileting) or that the safety alarms (chair, bed and floor mat) were checked for proper functioning. An incident report, dated 08/04/17 at 7:40 p.m., documented, .As CNA was walking by resident's room she noticed he was standing up in front of wheelchair. He slowly sat to floor. He stated, 'I just got weak so I sat down so I would not fall .No injuries noted. Resident had turned off wheelchair alarm. Battery replaced and attached to the back of the wheelchair where resident could not reach it . An incident report, dated 08/06/17 at 7:30 a.m., documented, .resident lying next to toilet in bathroom .lower left lip bleeding .noted resident had removed his helmet again .new intervention is a wedge pillow in w/c. Will continue with all other interventions in place for safety . An incident report, dated 08/11/17 at 12:09 p.m., documented, .resident lying on left side on floor just outside the bathroom door. Blood noted to floor and coming from laceration to left ear. Noted razor with blades off on the floor next to resident. hearing aide in left ear covered in blood. Resident states 'I was standing in the bathroom shaving and I turned around and stumbled fell on the floor.(') .Pressure applied to laceration on left ear, called (Ambulance service name deleted) .received orders to send to ER to eval and treat .Intervention Admin (administrative) nurses to evaluate w/c seatbelt with alarm .Resident needs frequent reminders to call for assistance with transfers for safety . An OSDH incident report, dated 08/11/17, documented the resident was sent to the ER for sutures and was transferred to another hospital for further follow-up. The care plan, updated 08/11/17, documented, .Fall in bathroom attempting to shave unassisted Intervention: wife education to not leave razors with resident, as he needs to be assisted or supervised to prevent unassisted standing . The resident's ER record, dated 08/11/17, documented on physical examination, the resident had a left earlobe laceration which measured roughly 4 cm (centimeters). It was documented the resident had a CT (computerized tomography) scan of the head, on 08/11/17 at 1:53 p.m., and the results were compared to a previous scan done on 07/12/17. The impression was documented as, .Increasing in the size of the right subdural hematoma. Acute on chronic hemorrhage is suspected . The emergency department provider notes, dated 08/11/17 at 2:24 p.m., documented, .Upon initial arrival patient had a CT scan of his head obtained that reveals an acute on chronic subdural hematoma. Roughly 1 cm of shift .discussed case .Patient will be transferred to (Hospital name deleted) for further .surgical evaluations. Patient will be sent via (Ambulance service name deleted). Family has been informed of these findings .Final Diagnoses: [REDACTED]. The task sheets for (MONTH) (YEAR) documented the resident: ~ was continent of urine on 21 of 33 shifts the resident was in the facility during the month, ~ was incontinent of bowels two times during the month. The task sheets did not document a toileting plan (prompted toileting) or that the safety alarms (chair, bed and floor mat) were checked for proper functioning. Resident was hospitalized from [DATE] to 09/06/17. A nurses' note, dated 08/13/17 at 9:12 a.m., documented, .update on resident's status in hospital. (Family member's name deleted) stated, 'they drilled two holes in his head to drain blood, the first had very little, but the second had a significant amount.' . Resident was readmitted to facility on 09/06/17 following hospitalization for surgical evacuation of subdural hematoma. physician's orders [REDACTED]. physician's orders [REDACTED]. A nurses' note, dated 09/09/17 at 1:17 a.m., documented, Focused assessment related to medication change of increase to Depakote and add Buspar 10mg every 6 hours PRN related to behaviors. Resident currently sitting on couch in lobby with staff member present due to resident trying to ambulate unassisted. Resident aggressive towards staff. Administered PRN Buspar with poor results . A nurses' note, dated 09/10/17 at 4:32 p.m., documented, .resident making multiple attempts to get up and walk, will not accept assistance, hitting at his daughter and the staff. Resident struck this nurse. (Physician's name deleted) .was notified and increased Depakote . physician's orders [REDACTED]. The care plan, updated 09/10/17, documented, .Clip alarm in place when resident is up in wheelchair . A nurses' note, dated 09/11/17 at 10:55 p.m., documented, .CNA called this Nurse to East Hallway. Resident observed on floor lying on his back. Resident had safety helmet on and had shoes on feet .upon removal of protective helmet large lump noted to back of right side of his head. Alarms observed to have been unplugged from the boxes. Resident un able (sic) to describe events leading up to fall. resident to receive a concave mattress, and sent to ER for evaluation . Resident returned from the ER with no new orders noted. A focused assessment on the resident was completed as well as an evaluation of his medication, foot wear, incident history, environmental, chart and record review. Upon completion of the investigation, the facility determined that the resident had turned off his alarms, got out of bed, lost his balance and fell hitting his head while the helmet was on. Neuro checks were initiated. Resident is being assessed for self releasing safety belt and a concave mattress has been placed on his bed. We are also checking alarms during rounds to be sure they are on and functioning . An incident report, dated 09/12/17 at 5:16 p.m., documented, .witnessed fall .res had had (sic) an (sic) partly assisted fall to the floor in main lobby while exhibiting behaviors, ambulating without assist from w/c and was assisted x 2 staff to w/c .did not strike head and fell to (floor) on buttocks .c/o (complains of) pain to right hip/buttock area .new orders to obtain stat right hip xray .Xray obtained and final report reads no acute fracture .Res with clip alarm in place, functional, res with helmet in place, and decrease in pain, declines any pain meds initially and also now . No new interventions were documented. physician's orders [REDACTED]. Dx: TBI. Self releasing seat belt will be removed during ADL care, meals, therapy treatments, supervised activities and q 2 hours for 10 min. and prn. An incident report, dated 09/16/17 at 3:30 p.m., documented, .Resident found sitting in the floor scooting toward the bathroom, the alarm sounding. Noted a small abrasion to interior posterior left arm with blood noted .New interventions is a pommel cushion plus all other interventions in place . An incident report, dated 09/18/17 at 3:51 p.m., documented, .Patient was on the floor on his bottom beside his bed .Patient states he fell on his bottom and hurt his hemorrhoid's. Denies hitting head .No visible signs of injury . No interventions to prevent recurrence were documented. The care plan, updated 09/18/17, documented, .non injury fall Intervention: staff to check alarms to be sure they are on and functioning during rounds . An incident report, dated 09/20/17 at 9:37 p.m., documented, .nurse was called to residents room by his spouse. She relayed she had assisted him to the toilet and he started hitting and kicking at her. She relayed that she gently assisted him to the floor. Upon my arrival he was sitting in the BR on his buttocks .was assisted to his wheelchair and the lobby for closer observation .Spouse instructed to call for assistance when transferring instead of trying to do it herself .No injuries observed . No new interventions to prevent recurrence were documented. An incident report, dated 09/20/17 at 10:49 p.m., documented, .Location: Other Common Areas .stood up from wheelchair and fell on his right side. He had helmet on I was standing within 5 feet from him. I heard helmet hit the floor but was not loud. Neuro checks were started .He appeared to have turned off his alarm. 'I was just going to get up to pee.' .No Injuries observed . No interventions to prevent recurrence were documented. physician's orders [REDACTED]. An incident report, dated 09/23/17 at 3:43 a.m., documented, .chair alarm alerted staff to room. Resident observed sitting on floor between wheelchair and recliner. Noted to be leaning his shoulder against wheelchair .Redness noted to left shoulder blade, denies tenderness or pain .Slip resistant socks placed on. Resident transferred to recliner in the lobby near the nurses station for observation . No new interventions to prevent recurrence were documented. On 07/18/17 the wife had been educated on the importance of the resident wearing non skid socks and several pair of non skid socks were placed in the resident's room. The care plan, updated 09/23/17, documented, .non injury fall Intervention: non skid socks if not wearing shoes . The non skid socks interventions should have been added to the resident's care plan after it was identified as an intervention after the resident's fall on 07/18/17. An incident report, dated 09/24/17 at 4:30 a.m., documented, .Was summoned to kitchen and noted resident laying on floor on right side. Noted purple liquid on the floor next to resident with empty pitcher on the floor .no apparent injuries found .Resident threw helmet and shoe at CNA .very aggressive toward staff both verbally and physically. Gait belt was placed around resident while resident was hitting this writer and CNA during transfer back to wheelchair. Resident assisted to bathroom and then placed in lobby in recliner for closer observation to nurses station .Neurological checks restarted per facility protocol .Slip resistant socks placed on resident .Snack and drink provided .Helmet replaced on head while in recliner . No new interventions to prevent recurrence were documented. An incident report, dated 09/26/17 at 1:30 p.m., documented, .CNA reported to nurse resident found on floor with alarms sounding in bathroom. Noted resident sitting on buttocks with right hand holding the hand rail states 'just help me stand up'. I was trying to get up to go to the bathroom and I fell on the floor bumped the back of my head and my buttocks .no injuries noted at this time slightly red area to left hip .received order for X-ray to left hip to rule out fracture . No interventions to prevent recurrence were documented. An incident report, dated 09/26/17 at 3:30 p.m., documented, .Resident observed by several staff sitting on floor in West hallway. Helmet on. Chair alarm on and sounding at low volume. Resident complains of pain to coccyx .Volume turned to high on chair alarm . No injuries or new interventions were documented. physician's orders [REDACTED]. Orders also documented, (MONTH) use lap buddy while in wheelchair to prevent unassisted ambulation and to promote resident safety secondary to unsteady gait, poor balance and poor safety awareness. Dx: TBI. Lap buddy will be removed during ADL care, meals and supervised activities and Q 2 hours for 10 min. (minutes) and prn . physician's orders [REDACTED]. The care plan, updated 09/26/17, documented, .non injury fall x 2 Intervention: grab bar in bathroom, medication changes . The care plan, updated 09/27/17, documented, .fall w/abrasion to right shoulder Intervention: half tray to w/c .half tray discontinued on 10/3/17 . The task sheets documented the resident was incontinent of bladder on at least one shift on 21 of 23 days and the resident was in the facility during the month and incontinent of bowels 11 times. There was no documentation that incontinent care was provided. The task sheets also documented the safety alarms (chair, bed and floor mat) were to be checked to ensure proper functioning. This was documented as being done every two hours beginning at midnight on 09/12/17. The alarms were put into place on 07/05/17. There was no documentation of alarms being checked for proper functioning from 07/05/17 until 09/12/17 (68 days). An incident report, dated 10/01/17 at 1:45 p.m., documented, .While charting on the computer hea (TRUNCATED)

Based on observations, record review and interviews, it was determined the facility failed to ensure one (#65) of five sampled residents reviewed for unnecessary medications was not chemically restrained for the convenience of staff. The resident had fallen 28 times in 13 weeks. The resident had been placed on [MEDICATION NAME] and [MEDICATION NAME] for behaviors of agitation/anxiety and being restless and getting up from wheelchair/bed without assistance. The facility did not increase staff supervision, but instead administered the medications. The resident was sleeping a lot. The resident started waking up after the medications were discontinued or decreased. The facility identified 51 residents who received psychoactive medications. Findings: Resident #65 was admitted to the facility, on 07/05/17, with [DIAGNOSES REDACTED]. Hospital discharge records, dated 07/05/17, documented the resident was discharged to the facility on medications (meds) which included: [MEDICATION NAME] (antidepressant) 20 mg (milligrams) daily and [MEDICATION NAME] (diuretic) 40 mg q (every) 24 hours. A nurse's note, dated 07/05/17 at 2:15 p.m., documented, .admitted to this facility .due to recent fall with subdural hematoma .Forgetful and confused at times .Family reported .resident has 4 cracked ribs to left side due to a different fall .Frequently incontinent of bowel and bladder. Wears briefs at all times .very unstable when transferring and ambulating .leans to the right. Frequently forgets owns (sic) limitations and transfers and ambulates unassisted. Pressure alarms applied to bed, w/c and bedroom chair at all times. Beveled safety mat in place now at bedside. PT (physical therapy)/OT (occupational therapy)/ST (speech therapy) notified of orders to eval and treat as indicated. Oriented resident and family to call light . An incident report, dated 07/05/17 at 7:20 p.m., documented the resident was found lying on the bathroom (br) floor on his right side with head next to the toilet. The report documented the resident had a small abrasion above the right eyebrow. An incident report, dated 07/06/17 at 1:40 p.m., documented the resident was on the bathroom floor and did not remember what happened. No injury was documented. The report documented the resident had floor mat with alarm, bed alarm, and chair alarm which someone keeps turning alarms off. Interventions documented on the report was to remind resident to turn call light on and wait for help. The resident's care plan, initiated on 07/06/17, documented: Focus .is at risk/Actual for falls due to weakness from Closed Head Trauma r/t (related to) History of Fall prior to admit . Goal .Staff will review and evaluate all falls and intervene as needed to reduce the potential of injury through the review date .Target Date: 07/31/2017 . Interventions .7-05-2017 FALL RISK score: High risk 75 . 7/5/17 .Intervention: Educate (Res name deleted) and family to leave bed alarms in place and on at all times . 7/6/17 .Intervention: Will place an alarming floor mat at bedside to alert staff to (Resident's name deleted) getting up without assistance . Pressure Pad to Bed Date Initiated: 07/06/2017 Pressure Pad to W/C (wheelchair) Date Initiated: 07/06/2017 . PT (physical therapy), OT (occupational therapy), ST (speech therapy) to screen evaluate and treat as indicated. PT will see resident BID (twice daily) on weekdays, once daily on weekends and holidays. OT staff to see resident once daily for 5 of the 7 day LOS (sic) Date Initiated: 07/06/2017 . Risk manager mat with beveled edges Date initiated: 07/06/17 . Side Positioning Bar to bed Date initiated: 07/06/2017 . Resident continues to turn off alarms and transfer self without assist. This increases his fall risk. Family educated not to turn off alarms or show resident how to do so. Explained to family risks of fall injury up to and including death. Family verbalizes understanding. Alarms are in place to alert staff to resident attempts to get up unassisted, but due to alarms being turned off by family and having family educate resident how to turn off alarm the resident is at a higher risk for fall and injury associated with fall. Date Initiated: 07/07/2017 . An incident report, dated 07/08/17 at 3:34 p.m., documented the resident leaned forward in his wheelchair and fell to the floor in the lobby while visiting with family members. No injury was documented. The report documented the following interventions: .educate family to ask staff for assistance when visiting with resident in lobby or room. Educated resident the importance of asking for help and risks involved of hitting his head and causing more damage from previous injury he received when he fell in the community . The care plan, updated on 07/08/17, documented .Non injury fall. Intervention: Educate family to call for assistance and not transport or move him themselves . An incident report, dated 07/09/17 at 2:05 p.m., documented, .Resident was standing at bedside with assistance of wife. Wife states patient started leaning to right and she tried to catch him and she fell on wheelchair and hw (he) then fell on her and wheelchair. Resident was observed lying half on wheelchair and half on floor with head against the bedside table . The report documented the resident had two small skin tears on the left elbow. physician's orders [REDACTED]. An incident report, dated 07/12/17 at 5:00 a.m., documented, .CNA notified this nurse that resident was lowered to floor in resident's bathroom. Upon entering resident bathroom, resident noted to be sitting on bottom in front of toilet. CNA stated, that resident was already in bathroom and leaning to right when she stopped resident from falling and then lowered resident to floor. An incident report, dated 07/12/17 at 8:20 a.m., documented, .resident's w/c pressure alarm was sounding. When staff went to check on resident, he was standing up in his bathroom and appeared to lose balance. Staff member slowly lowered resident to sitting position on the floor . No injury was documented. The report documented to continue current neurological monitoring and preventative fall measures. The report documented, .New order received to send to (Hospital name deleted) ER (emergency room ) for scan of brain, eval (evaluation) and treatment as indicated . A nurses' note, dated 07/12/17 at 8:20 a.m., documented, .New order received to transfer resident to (Hospital deleted) for scan of brain, eval and tx (treatment) as indicated due to increased H/A's (headaches) and multiple falls . An admission assessment, dated 07/12/17, documented the resident was understood, usually understood others and was severely impaired in cognitive skills for daily decision making. The assessment documented the resident required supervision/setup assistance with eating, limited assistance of one to two persons for locomotion, and extensive assistance of one to two persons for all other activities of daily living. The assessment documented the resident was not steady, only able to stabilize with human assistance in all areas of balance during transitions and walking, had impairment of functional limitation in range of motion of bilateral upper extremities and utilized a wheelchair for mobility. The assessment documented the resident was occasionally incontinent of bowel and bladder, had two or more falls with no injury and two or more falls with minor injury since admission, had received no antipsychotic or antianxiety medications during the seven days prior to the assessment, had received an antidepressant medication on one day and diuretic medication on seven of the seven days prior to the assessment and no restraints and/or alarms had been used during the seven days prior to the assessment. An incident report, dated 07/13/17 at 2:00 p.m., documented, .alarm sounding off in room .noted resident sitting on floor with back against bed. Noted small cut to left hand .Resident unable to give description on how the fall occurred .assisted back to bed and incontinent care provided .Call light and water within reach .D/C (discontinue) [MEDICATION NAME] & Trazadone . A nurses' note, dated 07/13/17 at 3:24 p.m., documented, .(Physician's name deleted) here and upon med review gave orders to d/c (discontinue) [MEDICATION NAME] and Trazadone . Physician orders, dated 07/13/17, documented to dc [MEDICATION NAME] and trazadone. The care plan, updated 07/13/17, documented, .fall with s/t (skin tear) to left hand Intervention: med (medication) review . An incident report, dated 07/15/17 at 3:30 p.m., documented, .Resident had gotten up and was found in bathroom with back sitting up against the door. No injuries noted . The report documented the following interventions: .Spoke with resident spouse regarding leaving helmet on at all times. Every other intervention in place for resident at this time . An incident report, dated 07/18/17 at 3:30 p.m., documented, .Nurse called to room resident wife states resident was trying to transfer self to wheel chair and when she tried to help he pushed her away and slipped on floor landing on bottom resident sitting on floor in front of chair wheel chair in front of him. I just slipped didn't hurt myself .no injuries .noted something wet on floor in front of resident and resident pants were wet .had regular socks on educated wife on importance of wearing non skid socks to avoid sliding on the floor several pair were placed in resident room wife verbalized understanding. Re-educated on letting staff assist with resident care for his safety and hers wife verbalized understanding . An incident report, dated 08/04/17 at 7:40 p.m., documented, .As CNA was walking by resident's room she noticed he was standing up in front of wheelchair. He slowly sat to floor. He stated, 'I just got weak so I sat down so I would not fall .No injuries noted. Resident had turned off wheelchair alarm. Battery replaced and attached to the back of the wheelchair where resident could not reach it . An incident report, dated 08/06/17 at 7:30 a.m., documented, .resident lying next to toilet in bathroom .lower left lip bleeding .noted resident had removed his helmet again .new intervention is a wedge pillow in w/c. Will continue with all other interventions in place for safety . An incident report, dated 08/11/17 at 12:09 p.m., documented, .resident lying on left side on floor just outside the bathroom door. Blood noted to floor and coming from laceration to left ear. Noted razor with blades off on the floor next to resident. hearing aide in left ear covered in blood. Resident states 'I was standing in the bathroom shaving and I turned around and stumbled fell on the floor.(') .Pressure applied to laceration on left ear, called (Ambulance service name deleted) .received orders to send to ER to eval and treat .Intervention Admin (administrative) nurses to evaluate w/c seatbelt with alarm .Resident needs frequent reminders to call for assistance with transfers for safety . An OSDH incident report, dated 08/11/17, documented the resident was sent to the ER for sutures and was transferred to another hospital for further follow-up. The care plan, updated 08/11/17, documented, .Fall in bathroom attempting to shave unassisted Intervention: wife education to not leave razors with resident, as he needs to be assisted or supervised to prevent unassisted standing . The resident's ER record, dated 08/11/17, documented on physical examination, the resident had a left earlobe laceration which measured roughly 4 cm (centimeters). It was documented the resident had a CT (computerized tomography) scan of the head, on 08/11/17 at 1:53 p.m., and the results were compared to a previous scan done on 07/12/17. The impression was documented as, .Increasing in the size of the right subdural hematoma. Acute on chronic hemorrhage is suspected . The emergency department provider notes, dated 08/11/17 at 2:24 p.m., documented, .Upon initial arrival patient had a CT scan of his head obtained that reveals an acute on chronic subdural hematoma. Roughly 1 cm of shift .discussed case .Patient will be transferred to (Hospital name deleted) for further .surgical evaluations. Patient will be sent via (Ambulance service name deleted). Family has been informed of these findings .Final Diagnoses: [REDACTED]. Resident was hospitalized from [DATE] to 09/06/17. A nurses' note, dated 08/13/17 at 9:12 a.m., documented, .update on resident's status in hospital. (Family member's name deleted) stated, 'they drilled two holes in his head to drain blood, the first had very little, but the second had a significant amount.' . Resident was readmitted to facility on 09/06/17 following hospitalization for surgical evacuation of subdural hematoma. Discharge orders from the hospital, dated 09/06/17, documented the resident was to receive [MEDICATION NAME] 250 mg q eight hours and 125 mg at bedtime, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 40 mg q 24 hours and [MEDICATION NAME] 20 mg daily. physician's orders [REDACTED]. physician's orders [REDACTED]. A nurse's note, dated 09/09/17 at 1:17 a.m., documented, Focused assessment related to medication change of increase to [MEDICATION NAME] and add [MEDICATION NAME] 10 mg every 6 hours PRN related to behaviors. Resident currently sitting on couch in lobby with staff member present due to resident trying to ambulate unassisted. Resident aggressive towards staff. Administered PRN [MEDICATION NAME] with poor results . A nurse's note, dated 09/10/17 at 4:32 p.m., documented, .resident making multiple attempts to get up and walk, will not accept assistance, hitting at his daughter and the staff. Resident struck this nurse. (Physician's name deleted) .was notified and increased [MEDICATION NAME] . physician's orders [REDACTED]. A nurses' note, dated 09/11/17 at 10:55 p.m., documented, .CNA called this Nurse to East Hallway. Resident observed on floor lying on his back. Resident had safety helmet on and had shoes on feet .upon removal of protective helmet large lump noted to back of right side of his head. Alarms observed to have been unplugged from the boxes. Resident un able (sic) to describe events leading up to fall. resident to receive a concave mattress, and sent to ER for evaluation . Resident returned from the ER with no new orders. A focused assessment on the resident was completed as well as an evaluation of his medication, foot wear, incident history, environmental, chart and record review. Upon completion of the investigation, the facility determined that the resident had turned off his alarms, got out of bed, lost his balance and fell hitting his head while the helmet was on. Neuro checks were initiated. Resident is being assessed for self releasing safety belt and a concave mattress has been placed on his bed. We are also checking alarms during rounds to be sure they are on and functioning . An incident report, dated 09/12/17 at 5:16 p.m., documented, .witnessed fall .res had had (sic) an (sic) partly assisted fall to the floor in main lobby while exhibiting behaviors, ambulating without assist from w/c and was assisted x 2 staff to w/c .did not strike head and fell to (floor) on buttocks .c/o (complains of) pain to right hip/buttock area .new orders to obtain stat right hip xray .Xray obtained and final report reads no acute fracture .Res with clip alarm in place, functional, res with helmet in place, and decrease in pain, declines any pain meds initially and also now . No new interventions were documented. The care plan, updated 09/12/17, documented: .Focus .uses antidepressant, antianxiety, antipsychotic, and mood medication r/t (related to) Depression, agitation, anxiety, restlessness/impulsiveness . Goal .will be free from discomfort or adverse reactions related to antidepressant therapy through the review date . Interventions .Administer [MEDICATION NAME] per Physician orders. Adjust dose/frequency per orders .Administer [MEDICATION NAME] per Physician orders. Adjust dose/frequency per orders .Monitor for side effects .Educate (Name deleted)/family/caregivers about risks, benefits and the side effects and/or toxic symptoms .[MEDICATION NAME] per physicians orders .Give antidepressant medications orders by physician. Monitor/document side effects and effectiveness .Monitor/document/report to MD (medical doctor) prn ongoing s/sx of depression unaltered by antidepressant meds . An incident report, dated 09/16/17 at 3:30 p.m., documented, .Resident found sitting in the floor scooting toward the bathroom, the alarm sounding. Noted a small abrasion to interior posterior left arm with blood noted .New interventions is a pommel cushion plus all other interventions in place . An incident report, dated 09/18/17 at 3:51 p.m., documented, .Patient was on the floor on his bottom beside his bed .Patient states he fell on his bottom and hurt his hemorrhoid's. Denies hitting head .No visible signs of injury . An incident report, dated 09/20/17 at 9:37 p.m., documented, .nurse was called to residents room by his spouse. She relayed she had assisted him to the toilet and he started hitting and kicking at her. She relayed that she gently assisted him to the floor. Upon my arrival he was sitting in the BR on his buttocks .was assisted to his wheelchair and the lobby for closer observation .Spouse instructed to call for assistance when transferring instead of trying to do it herself .No injuries observed . An incident report, dated 09/20/17 at 10:49 p.m., documented, .Location: Other Common Areas .stood up from wheelchair and fell on his right side. He had helmet on I was standing within 5 feet from him. I heard helmet hit the floor but was not loud. Neuro checks were started .He appeared to have turned off his alarm. 'I was just going to get up to pee.' .No Injuries observed . physician's orders [REDACTED]. An incident report, dated 09/23/17 at 3:43 a.m., documented, .chair alarm alerted staff to room. Resident observed sitting on floor between wheelchair and recliner. Noted to be leaning his shoulder against wheelchair .Redness noted to left shoulder blade, denies tenderness or pain .Slip resistant socks placed on. Resident transferred to recliner in the lobby near the nurses station for observation . An incident report, dated 09/24/17 at 4:30 a.m., documented, .Was summoned to kitchen and noted resident laying on floor on right side. Noted purple liquid on the floor next to resident with empty pitcher on the floor .no apparent injuries found .Resident threw helmet and shoe at CNA .very aggressive toward staff both verbally and physically. Gait belt was placed around resident while resident was hitting this writer and CNA during transfer back to wheelchair. Resident assisted to bathroom and then placed in lobby in recliner for closer observation to nurses station .Neurological checks restarted per facility protocol .Slip resistant socks placed on resident .Snack and drink provided .Helmet replaced on head while in recliner . An incident report, dated 09/26/17 at 1:30 p.m., documented, .CNA reported to nurse resident found on floor with alarms sounding in bathroom. Noted resident sitting on buttocks with right hand holding the hand rail states 'just help me stand up'. I was trying to get up to go to the bathroom and I fell on the floor bumped the back of my head and my buttocks .no injuries noted at this time slightly red area to left hip .received order for X-ray to left hip to rule out fracture . An incident report, dated 09/26/17 at 3:30 p.m., documented, .Resident observed by several staff sitting on floor in West hallway. Helmet on. Chair alarm on and sounding at low volume. Resident complains of pain to coccyx .Volume turned to high on chair alarm . physician's orders [REDACTED]. physician's orders [REDACTED]. The behavior monitoring sheet for (MONTH) (YEAR) documented the resident was receiving [MEDICATION NAME] and [MEDICATION NAME]. The behaviors being monitored were agitation/anxiety and restless-getting up from wheelchair/bed without assistance. An incident report, dated 10/01/17 at 1:45 p.m., documented, .While charting on the computer heard a loud thud, upon arising noted resident lying supine on the floor in the lobby next to a chair that had been turned over by resident .had his helmet in place .No noted injuries .New intervention put in place is to provide more frequent rest periods in bed or recliner . An incident report, dated 10/04/17 at 7:00 a.m., documented, .Was summoned to dining room. Upon entering dining room .noted resident laying in floor on right side in front of wheelchair .Resident removed lap buddy and safety belt and slide to the floor on buttocks after eating breakfast per kitchen staff .no new orders .Neurological continued .Lap buddy reapplied . physician's orders [REDACTED]. An incident report, dated 10/07/17 at 2:48 p.m., documented, .(Name deleted) was in the dining room when she saw resident standing up out of w/c. As she started to go towards him to assist him she stated 'he lost his balance and fell backwards on his right side, but he didn't hit his head. ' .New Intervention is to place resident at assisted table with staff members to be closer to him while in dining room .No Injuries observed . A significant change assessment, dated 10/08/17, documented the resident was usually understood, sometimes understood others and was severely impaired in cognitive skills for daily decision making. The assessment documented the resident was frequently incontinent of bowel and bladder, had two or more falls with no injury and two or more falls with minor injury since the previous assessment, had received antipsychotic, antianxiety, antidepressant and diuretic medications on seven of the seven days prior to the assessment, and had a bed alarm, chair alarm and motion sensor alarm used daily during during the seven days prior to the assessment. physician's orders [REDACTED]. physician's orders [REDACTED]. An incident report, dated 10/26/17 at 1:25 a.m., documented, .heard alarms in resident's room. Upon entering resident's room, resident was almost to the bathroom so he could wash his hands. Resident lost balance and fell forward and caught self on door. Resident slid down door to floor .Noted small skin tear to right inner upper arm . On 10/26/17 at 10:36 a.m., corporate nurse #1 was asked how many falls the resident had within the last 30 days. She stated, Seven. She was asked if any of the falls resulted in injury. She stated, Yes. She stated he fell twice on 09/26/17, one resulted in his left temple being slightly reddened and the physician ordered an x-ray. She stated the resident fell on [DATE] and had a small skin tear to his right posterior forearm and an abrasion to his right shoulder. At 11:10 a.m., a staff member was observed to push the resident into the dining room in his wheelchair. The resident was initially placed at an independent eating table, then moved to the assisted eating table and was observed to be sleeping with a helmet on. At 11:19 a.m., the resident was observed to remain asleep and his head was leaning to the left side. At 11:35 a.m., a staff member was observed placing his plate of food on the table in front of him. He continued to sleep. A staff member walked over to the resident and started talking to him and attempted to awaken him. The staff member pulled up a chair and attempted to feed him, he took one sip of orange liquid and went back to sleep and would not awaken again. At 11:39 a.m., the staff member was observed pushing the resident out of the dining room. At 11:46 a.m., the resident was observed in bed asleep with a family member at his bedside talking to a staff member about his not eating. On 10/26/17 at 2:04 p.m., a family interview was conducted at the resident's bedside while the resident slept soundly. Four immediate family members were present at the bedside. The family stated he slept all the time. A family member stated, They have him on too many meds (Medications). I talked to the nurse a couple of weeks ago and she said they decreased his meds, but I haven't seen any change. He still sleeps all the time. physician's orders [REDACTED]. On 10/31/17 at 2:42 p.m., the resident was observed sleeping in bed. An incident report, dated 11/01/17 at 1:10 a.m., documented, Called to Resident's room by .daughter .was sitting on floor with head against recliner .Daughter stated resident did not hit head .'I tried to help him get in his w/c.' Neuro checks initiated .Educated Resident's daughter to ask staff for assistance with transfers for Resident .No injuries observed . On 11/01/17 at 8:20 a.m., the resident was observed sitting in his wheelchair in the dining room at a table with no food in front of him. The resident was asked how he was doing. The resident did not respond to the question. At 8:59 a.m., the resident was observed siting in his w/c in the front lobby with his chair alarm, self-releasing/alarming seatbelt and helmet in place. The resident was asked how he was doing. He smiled and stated, Okay, I'm waiting on my car keys. At 11:15 a.m., CNA #3 was asked about the resident's care. She stated he was incontinent and they provided incontinent care every two hours. She then stated he sometimes goes to the bathroom by himself. At 11:20 a.m., the resident was observed sitting at dining room table with his helmet on, the chair alarm was on and his lap belt was not fastened. He was observed feeding himself without any difficulty. At 11:30 a.m., licensed practical nurse (LPN) #1 was asked about the resident. She stated he had multiple falls and sustained a subdural hematoma, along with slicing his ear. She stated when he returned from the hospital he was very groggy. She then stated prior to the hospitalization he was wheeling himself around in his w/c, but when returned he had not been moving a lot. The LPN was asked about his care. She stated he was total care, however some days he could feed himself. She was asked if he was on a toileting program. She stated she did not know if he was on a toileting program, however he was on a q two hour check. On 11/02/17 at 6:50 a.m., the resident was observed sitting in his w/c with his lap belt and helmet on, in the lobby with the maintenance man sitting with him and talking to him. At 8:50 a.m., the resident was observed sleeping in bed. A laundry staff member was observed sitting at bedside doing one on one. At 10:28 a.m., the resident was observed sleeping in bed with the laundry staff member at bedside. At 12:02 p.m., the resident was observed in the dining room in his wheelchair at a table with his helmet on and laundry staff sitting next to him. His helmet was in place, however, he had no alarms on. He had eaten all of his food except for one to two bites of mashed potatoes. On 11/06/17 at 8:55 a.m., resident was awake, lying in bed a staff member at bedside. Surveyor waved at resident, he winked and gave a small wave back. On 11/07/17 at 9:20 a.m., corporate nurse #2 was asked about the behaviors being monitored related to the [MEDICAL CONDITION] meds the resident was receiving. She stated the meds were not appropriate for the behaviors. The nurse was asked if this was considered chemical restraints. She stated he was on these medications when he returned from the hospital. She was asked why they had not attempted to reduce the meds and eventually discontinue them. She stated they had reduced the dose. The nurse was asked why they waited until five weeks after his return from the hospital and multiple increases and/or additions of psychoactive medications. No response was given. After [MEDICATION NAME] and [MEDICATION NAME] had been decreased and then discontinued, and after [MEDICATION NAME] was decreased the resident started waking up on 11/02/17.

Based on observations, record review and interviews, it was determined the facility failed to ensure one (#65) of five sampled residents reviewed for unnecessary medications did not receive psychoactive medications for inappropriate indications. The resident had fallen 28 times in 13 weeks. The resident had been placed on [MEDICATION NAME] and [MEDICATION NAME] for behaviors of agitation/anxiety and being restless and getting up from wheelchair/bed without assistance. The facility administered the medications without appropriate indications for use. The resident was sleeping a lot. The resident started waking up after the medications were discontinued or decreased. The facility identified 51 residents who received psychoactive medications. Findings: Resident #65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Hospital discharge records, dated 07/05/17, documented the resident was discharged to the facility on medications (meds) which included: [MEDICATION NAME] (antidepressant) 20 mg (milligrams) daily and [MEDICATION NAME] (diuretic) 40 mg q (every) 24 hours. Facility incident reports documented the resident had a fall on 07/05/17 and one on 07/06/17. The resident's care plan, initiated on 07/06/17, documented: Focus .is at risk/Actual for falls due to weakness from Closed Head Trauma r/t (related to) History of Fall prior to admit . Goal .Staff will review and evaluate all falls and intervene as needed to reduce the potential of injury through the review date .Target Date: 07/31/2017 . Interventions .7-05-2017 FALL RISK score: High risk 75 . 7/5/17 .Intervention: Educate (Res name deleted) and family to leave bed alarms in place and on at all times . 7/6/17 .Intervention: Will place an alarming floor mat at bedside to alert staff to (Resident's name deleted) getting up without assistance . Pressure Pad to Bed Date Initiated: 07/06/2017 Pressure Pad to W/C (wheelchair) Date Initiated: 07/06/2017 . PT, OT, ST to screen evaluate and treat as indicated. PT will see resident BID (twice daily) on weekdays, once daily on weekends and holidays. OT staff to see resident once daily for 5 of the 7 day LOS (sic) Date Initiated: 07/06/2017 . Risk manager mat with beveled edges Date initiated: 07/06/17 . Side Positioning Bar to bed Date initiated: 07/06/2017 . Resident continues to turn off alarms and transfer self without assist. This increases his fall risk. Family educated not to turn off alarms or show resident how to do so. Explained to family risks of fall injury up to and including death. Family verbalizes understanding. Alarms are in place to alert staff to resident attempts to get up unassisted, but due to alarms being turned off by family and having family educate resident how to turn off alarm the resident is at a higher risk for fall and injury associated with fall. Date Initiated: 07/07/2017 . Facility incident reports documented the resident had a fall on 07/09/17. physician's orders [REDACTED]. Facility incident reports documented the resident had two falls on 07/12/17. An admission assessment, dated 07/12/17, documented the resident was understood, usually understood others and was severely impaired in cognitive skills for daily decision making. The assessment documented the resident required supervision/setup assistance with eating, limited assistance of one to two persons for locomotion, and extensive assistance of one to two persons for all other activities of daily living. The assessment documented the resident was not steady, only able to stabilize with human assistance in all areas of balance during transitions and walking, had impairment of functional limitation in range of motion of bilateral upper extremities and utilized a wheelchair for mobility. The assessment documented the resident was occasionally incontinent of bowel and bladder, had two or more falls with no injury and two or more falls with minor injury since admission, had received no antipsychotic or antianxiety medications during the seven days prior to the assessment, had received an antidepressant medication on one day and diuretic medication on seven of the seven days prior to the assessment and no restraints and/or alarms had been used during the seven days prior to the assessment. A facility incident report documented the resident fell on [DATE]. The report documented the [MEDICATION NAME] and [MEDICATION NAME] were to be discontinued. A nurses' note, dated 07/13/17 at 3:24 p.m., documented, .(Physician's name deleted) here and upon med review gave orders to d/c (discontinue) [MEDICATION NAME] and [MEDICATION NAME] . The care plan, updated 07/13/17, documented, .fall with s/t (skin tear) to left hand Intervention: med (medication) review . Facility incident reports documented the resident fell on [DATE], 07/18/17, 08/04/17, 08/06/17 and 08/11/17. An OSDH incident report, dated 08/11/17, documented the resident was sent to the ER for sutures and was transferred to another hospital for further follow-up. The resident's ER record, dated 08/11/17, documented on physical examination, the resident had a left earlobe laceration which measured roughly 4 cm (centimeters). It was documented the resident had a CT (computerized tomography) scan of the head without on 08/11/17 at 1:53 p.m. and the results were compared to a previous scan done on 07/12/17. The impression was documented as, .Increasing in the size of the right subdural hematoma. Acute on chronic hemorrhage is suspected . The emergency department provider notes, dated 08/11/17 at 2:24 p.m., documented, .Upon initial arrival patient had a CT scan of his head obtained that reveals an acute on chronic subdural hematoma. Roughly 1 cm of shift .discussed case .Patient will be transferred to (Hospital name deleted) for further .surgical evaluations. Patient will be sent via (Ambulance service name deleted). Family has been informed of these findings .Final Diagnoses: [REDACTED]. Resident was hospitalized from [DATE] to 09/06/17. A nurses' note, dated 08/13/17 at 9:12 a.m., documented, .update on resident's status in hospital. (Family member's name deleted) stated, 'they drilled two holes in his head to drain blood, the first had very little, but the second had a significant amount.' . Resident was readmitted to facility on 09/06/17 following hospitalization for surgical evacuation of subdural hematoma. Discharge orders from the hospital, dated 09/06/17, documented the resident was to receive [MEDICATION NAME] 250 mg q eight hours and 125 mg at bedtime, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 40 mg q 24 hours and [MEDICATION NAME] 20 mg daily. physician's orders [REDACTED]. The care plan, updated 09/12/17, documented: .Focus .uses antidepressant, antianxiety, antipsychotic, and mood medication r/t (related to) Depression, agitation, anxiety, restlessness/impulsiveness . Goal .will be free from discomfort or adverse reactions related to antidepressant therapy through the review date . Interventions .Administer [MEDICATION NAME] per Physician orders. Adjust dose/frequency per orders .Administer [MEDICATION NAME] per Physician orders. Adjust dose/frequency per orders .Monitor for side effects .Educate (Name deleted)/family/caregivers about risks, benefits and the side effects and/or toxic symptoms .[MEDICATION NAME] per physicians orders .Give antidepressant medications orders by physician. Monitor/document side effects and effectiveness .Monitor/document/report to MD (medical doctor) prn ongoing s/sx of depression unaltered by antidepressant meds . physician's orders [REDACTED]. A nurses' note, dated 09/09/17 at 1:17 a.m., documented, Focused assessment related to medication change of increase to [MEDICATION NAME] and add [MEDICATION NAME] 10 mg every 6 hours PRN related to behaviors. Resident currently sitting on couch in lobby with staff member present due to resident trying to ambulate unassisted. Resident aggressive towards staff. Administered PRN [MEDICATION NAME] with poor results . A nurses' note, dated 09/10/17 at 4:32 p.m., documented, .resident making multiple attempts to get up and walk, will not accept assistance, hitting at his daughter and the staff. Resident struck this nurse. (Physician's name deleted) .was notified and increased [MEDICATION NAME] . physician's orders [REDACTED]. A facility incident report documented the resident fell on [DATE]. The resident was sent to the ER for evaluation. Resident returned from the ER with no new orders. Facility incident reports documented the resident fell on [DATE], 09/16/17, 09/18/17 and twice on 09/20/17. physician's orders [REDACTED]. A facility incident report documented the resident fell on [DATE], 09/24/17 and twice on 09/26/17. physician's orders [REDACTED]. physician's orders [REDACTED]. The behavior monitoring sheet for (MONTH) (YEAR) documented the resident was receiving [MEDICATION NAME] and [MEDICATION NAME]. The behaviors being monitored were agitation/anxiety and restless-getting up from wheelchair/bed without assistance. Facility incident reports documented the resident fell on [DATE] and 10/04/17. physician's orders [REDACTED]. A facility incident report documented the resident fell on [DATE]. A significant change assessment, dated 10/08/17, documented the resident was usually understood, sometimes understood others and was severely impaired in cognitive skills for daily decision making. The assessment documented the resident required supervision/setup assistance with eating and extensive assistance of one to two persons for all other activities of daily living. The assessment documented the resident was not steady, only able to stabilize with human assistance in all areas of balance during transitions and walking, had no impairment in functional limitation in range of motion and utilized a wheelchair for mobility. The assessment documented the resident was frequently incontinent of bowel and bladder, had two or more falls with no injury and two or more falls with minor injury since the previous assessment, had received antipsychotic, antianxiety, antidepressant and diuretic medications on seven of the seven days prior to the assessment, and had a bed alarm, chair alarm and motion sensor alarm used daily during during the seven days prior to the assessment. physician's orders [REDACTED]. physician's orders [REDACTED]. A facility incident report documented the resident fell on [DATE]. On 10/26/17 at 11:10 a.m., a staff member was observed to push the resident into the dining room in his wheelchair. The resident was initially placed at an independent eating table, then moved to the assisted eating table and was observed to be sleeping with a helmet on. At 11:19 a.m., the resident was observed to remain asleep and his head was leaning to the left side. At 11:35 a.m., a staff member was observed placing his plate of food on the table in front of him. He continued to sleep. A staff member walked over to the resident and started talking to him and attempted to awaken him. The staff member pulled up a chair and attempted to feed him, he took one sip of orange liquid and went back to sleep and would not awaken again. At 11:39 a.m., the staff member was observed pushing the resident out of the dining room. At 11:46 a.m., the resident was observed in bed asleep with a family member at his bedside talking to a staff member about him not eating. At 2:04 p.m., a family interview was conducted at the resident's bedside while the resident slept soundly. Four immediate family members were present at the bedside. The family was asked if the resident got up according to his previous routine prior to admission to the facility. A family member stated, the resident had not responded to her at all the previous ten days. She stated, I don't know if they are medicating him to keep him from being combative. The family stated he sleeps all the time. A family member stated, They have him on too many meds (Medications). I talked to the nurse a couple of weeks ago and she said they decreased his meds, but I haven't seen any change. He still sleeps all the time. physician's orders [REDACTED]. The [MEDICATION NAME] remained at 0.5 mg q six hours as needed. A physician's orders [REDACTED]. On 10/31/17 at 2:42 p.m., the resident was observed sleeping in bed. On 11/01/17 at 8:20 a.m., the resident was observed sitting in his wheelchair in the dining room at a table with no food in front of him. His helmet, chair alarm and self-releasing/alarming seatbelt were observed to be in place. The resident was asked how he was doing. The resident did not respond to the question. At 8:59 a.m., the resident was observed siting in his w/c in the front lobby with his chair alarm, self-releasing/alarming seatbelt and helmet in place. The resident was asked how he was doing. He smiled and stated, Okay, I'm waiting on my car keys. At 11:30 a.m., licensed practical nurse (LPN) #1 was asked about the resident. She stated he had multiple falls and sustained a subdural hematoma, along with slicing his ear. She stated when he returned from the hospital he was very groggy. She then stated prior to the hospitalization he was wheeling himself around in his w/c, but when returned he had not been moving a lot. On 11/02/17 at 6:50 a.m., the resident was observed sitting in his w/c with his lap belt and helmet on, in the lobby with the maintenance man sitting with him and talking to him. At 12:02 p.m., the resident was observed in the dining room in his wheelchair at a table with his helmet on and laundry staff sitting next to him. His helmet was in place, however, he had no alarms on. The resident was feeding himself with no difficulty and had eaten all of his food except for one to two bites of mashed potatoes. On 11/06/17 at 8:55 a.m., resident awake, lying in bed with one on one staff at bedside. Surveyor waved at resident, he winked and gave a small wave back. On 11/07/17 at 9:20 a.m., corporate nurse #2 was asked about the behaviors being monitored related to the [MEDICAL CONDITION] meds the resident was receiving. She stated the meds were not appropriate for the behaviors. She stated he was on these medications when he returned from the hospital. She was asked why they had not attempted to reduce the meds and eventually discontinue them. She stated they had reduced the dose. The nurse was asked why they waited until five weeks after his return from the hospital and multiple increases and/or additions of psychoactive medications. No response was given. After [MEDICATION NAME] and [MEDICATION NAME] had been decreased and then discontinued, and after [MEDICATION NAME] was decreased the resident started waking up on 11/02/17.

On 01/26/17, an immediate jeopardy situation was determined to exist due to the facility's failure to ensure resident #1 was free from neglect. The resident was administered (intentionally) a mixed dosage of insulins that were not ordered for the resident. The ordered insulin was not available. The Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy situation. At 5:00 p.m., the administrator, director of nursing (DON) and corporate nurse #1 were notified of the existence of the immediate jeopardy. On 01/27/17 at 12:51 p.m., an acceptable plan of removal was received. The plan of removal was as follows: Neglect All staff will be inserviced on abuse and neglect policy and procedure. Inservice will include that the failure to provide services that prevent harm are considered neglect. Inservice will also include that when neglect occurs it must be immediately reported to the physician and the abuse coordinator (administrator). This inservice will be complete by 11:59 pm on 1-26-17 to all employees working at the facility or before they (are) allowed to return to work. This inservice will also be given to any newly hired employee before they start to work . The immediate jeopardy was removed on 01/27/17 at 2:00 p.m., after the plan of removal was carried out. The deficient practice remained at actual harm that was a pattern. Based on record reviews and interviews, it was determined the facility failed to ensure resident #1 was free from neglect. The resident was administered (intentionally) a mixed dosage of insulins that were not ordered for the resident. The ordered insulin was not available. This resulted in harm due to her blood sugar reaching 376 and being sent to the emergency room where she was treated for [REDACTED]. This posed a potential for serious life threatening complications. The staff who administered the incorrect insulin did not assess the resident after the insulin was administered. The facility's failure to protect from neglect had the potential to affect all 71 residents residing in the facility. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The latest assessment, dated 11/09/16, documented the resident had no cognitive impairment, required supervision with all activities of daily living and had received insulin seven days/week of the prior week. The care plan, last updated 01/11/17, documented the resident had diabetes mellitus and was to be observed for complications related to diabetes. Interventions included: ~Humalog Mix 75/25 Suspension was to be administered per physician's orders [REDACTED]. ~Fax FSBS to physician weekly for his review, ~encouraged to drink sugar free drinks and limit juice intake to assist in controlling FSBS values. The January 2017 physician's orders [REDACTED]. ~Humalog Mix 75/25 suspension 35 units subq daily, to be administered at 6:30 a.m., ~Humalog Mix 75/25 suspension 20 units subq at bedtime, to be administered at 4:30 p.m., and ~FSBS were to be obtained prior to each injection. On 01/02/17 at 4:30 p.m., the insulin administration record documented the resident's FSBS was 358 and Humalog Mix 75/25 suspension 20 units was administered subq. Normal levels for non-fasting blood sugar levels are 70-140. On 01/03/17 at 6:30 a.m., the insulin administration record documented the resident's FSBS was 376 and Humalog Mix 75/20 suspension 35 units was refused. The resident's ordered insulin was not available at that time. The insulin was not received until 01/03/17, at 11:00 p.m. There was no documentation in the resident's progress notes the insulin had been refused or the physician had been notified the resident had refused insulin with a FSBS of 376. A nurse's progress note dated 01/03/17 at 2:19 p.m., documented, .resident family member requesting the resident go to ER for eval (evaluation) Resident refuses to go at this time. Call placed to residents primary care physician and am awaiting call back. A nurse's progress note dated 01/03/17 at 2:28 p.m., documented, .family insists resident goes out to ER, spoke with resident and she has agreed to go . A 'Prehospital Care Report Summary', dated 01/03/17 from (name deleted emergency transport service) documented the transport service had arrived at the nursing home at 2:33 p.m and left the nursing home at 2:45 p.m. The report documented the resident's blood sugar level at 2:41 p.m. and 2:54 p.m. was 448. Normal levels for non-fasting blood sugar levels are 70-140. The 'ED (Emergency Department) Provider Notes' documented the resident arrived at (name deleted hospital) on 01/03/17 at 3:15 p.m. and documented, Chief complaint .Pt present to ED with FSBS of 480 .Patient states that the nursing home ran out of her insulin yesterday. Her last dose was yesterday at 4:30 p.m. She was unable to receive her morning and afternoon dose .Patient has a blood glucose level of 368 .We did contact the nursing home who states they are receiving her insulin tonight, patient is given 20 units of [MEDICATION NAME] .Diagnoses: [REDACTED].>Nurse's progress notes dated 01/03/17 at 5:29 p.m., documented, .resident returned to the facility via med ride with transportation aide. No new orders received at this time. Continue all previous orders . A medication error report dated 01/03/17 at 5:50 p.m., documented, .Resident received medication that did not belong to her .Resident shows no adverse affects at this time .Physician notified and new orders received . (Name deleted family member) notified . A progress incident note dated 01/03/17 at 5:54 p.m. documented, Resident received wrong dose of insulin medication . There was no documentation the LPN who administered the incorrect dose of insulin assessed the resident's FSBS level after she administered the insulin. An incident progress note dated 01/04/17 at 2:24 a.m., documented, Focused assessment due to recent incident involving insulin .FSBS 235 . On 01/26/17 at 10:00 a.m., the DON was asked about documentation of the progress notes involving the administration of the wrong insulin. The DON stated LPN #1 had administered the wrong insulin to the resident on 01/02/16 at 4:30 p.m. She stated LPN #1 had not reported her actions to anyone until the afternoon of 01/03/17, and was was unable to recall the time but stated it was around the time the resident was going to the emergency room for evaluation. She stated the LPN reported to her the resident had been out of the Humalog Mix 75/25 suspension. She stated the LPN had called the pharmacy to order the medication, and was told it was too soon for the medication to be filled. She stated LPN #1 had mixed some insulin belonging to other residents and administered this mixture to the resident for her 4:30 p.m. dose of insulin. At 10:15 a.m., LPN #1 was asked about the incident. The LPN stated the resident's bottle of Humalog 75/25 insulin was empty at 4:30 p.m. on 01/02/17 when she got the bottle to prepare the resident's insulin, and there was no other insulin for her. She stated she notified the pharmacy for a refill, and they stated it was too early to refill the resident's insulin. The LPN was asked if she had notified the physician the resident was out of insulin and the resident's FSBS was 358. She stated, No. The LPN was asked what insulin she had administered to the resident. The LPN stated she mixed some Humalog and [MEDICATION NAME] insulins together to equal what she thought would be similar/equal to the resident's normal insulin orders, and administered that to her. She was asked if she had a physician's orders [REDACTED]. She stated, No. She was asked how she knew what insulins to use and what amounts to mix. She stated she didn't really know. She was asked what were the specific insulin amounts she mixed. She stated she couldn't recall. She was asked if the insulins she mixed belonged to the resident. She stated, No. She was asked if she had used another resident's insulins. She stated, Yes and couldn't recall whose insulins she had used. She was asked how she documented what she had done. She stated she had documented the administration of the Humalog Mix 75/25 suspension 25 units. She was asked if this was what the resident received. She stated, No. She was asked if she had reported the administration of incorrect insulin to the physician or anyone else at the time. She stated No. She was asked if she had assessed the resident's FSBS later in the shift after she had administered the incorrect dose of insulin. She stated, No. She was asked if she had reported the administration of incorrect insulin to the charge nurse at her shift change at 7 p.m. She stated, No. At 6:00 p.m., the DON was asked if she had considered the LPN's actions to be neglect. She stated she had just considered the actions to be a medication error.

On 01/26/17, an immediate jeopardy situation was determined to exist due to the facility's failure to notify the physician of a resident (#1) being administered (intentionally) a mixed dosage of insulins that were not ordered for the resident. The ordered insulin was not available. The facility's failure to notify the physician of the incorrect insulin administered and the omission of the correct insulin resulted in harm to the resident due to being transferred to the emergency room for a FSBS of 376. The FSBS was 480 when she arrived at the hospital where treatment was provided. The Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy situation. At 5:00 p.m., the administrator, director of nursing (DON) and corporate nurse #1 were notified of the existence of the immediate jeopardy. On 01/27/17 at 12:51 p.m., an acceptable plan of removal was received. The plan of removal was as follows: The nurses were inserviced on Notification of Physician. The nurses inservice included the following: Notify the physician if insulin is not available or if incorrect insulin is given, if FSBS is high or low based on order for parameter or if insulin is refused. If the insulin is not available, you must notify the pharmacy and order the medication STAT and notify the Director of Nurses. If you are unable to reach the primary physician you are to call the medical director (name deleted physician) at that time. The resident must be assessed immediately and this must be documented in the resident's clinical record. The resident family must also be notified and this must be documented in the clinical record. An incident report must also be completed. Nurses were also inserviced on the Notification of change in resident condition policy. This inservice will be complete by 11:59 pm on 1-26-17 to all employees working at the facility or before they allowed to return to work. This inservice will also be given to any newly hired nurse before they start work . The immediate jeopardy was removed on 01/27/17 at 2:00 p.m., after the plan of removal was carried out. The deficient practice remained at actual harm that was a pattern. Based on record reviews and interviews, it was determined the facility failed to ensure: a) the physician/family was notified when the incorrect insulins were mixed together and administered, and the correct insulin was not administered, to one resident (#1) and b) the physician was notified when the full dose of insulin was refused for one resident (#3) and only a partial dose was administered. There was a total of four sampled residents who received insulin. This caused harm to resident #1 when her blood sugar went up to 376 and she was transferred to the emergency room for treatment of [REDACTED]. The facility's failure to notify the physician of changes related to insulin administration had the potential to affect 20 of 71 residents who received insulin injections. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The latest assessment, dated 11/09/16, documented the resident had no cognitive impairment, required supervision with all activities of daily living and had received insulin seven days/week of the prior week. The care plan, last updated 01/11/17, documented the resident had diabetes mellitus and was to be observed for complications related to diabetes. Interventions included: ~Humalog Mix 75/25 Suspension was to be administered per physician's orders [REDACTED]. ~Fax FSBS to physician weekly for his review, ~encouraged to drink sugar free drinks and limit juice intake to assist in controlling FSBS values. The January 2017 physician's orders [REDACTED]. ~Humalog Mix 75/25 suspension 35 units subq daily, to be administered at 6:30 a.m., ~Humalog Mix 75/25 suspension 20 units subq at bedtime, to be administered at 4:30 p.m., and ~FSBS were to be obtained prior to each injection. On 01/02/17 at 4:30 p.m., the insulin administration record documented the resident's FSBS was 358 and Humalog Mix 75/25 suspension 20 units was administered subq. Normal levels for non-fasting blood sugar levels are 70-140. On 01/03/17 at 6:30 a.m., the insulin administration record documented the resident's FSBS was 376 and Humalog Mix 75/20 suspension 35 units was refused. The resident's ordered insulin was not available at that time. The insulin was not received until 01/03/17, at 11:00 p.m. There was no documentation in the resident's progress notes the insulin had been refused or the physician had been notified the resident had refused insulin with a FSBS of 376. A nurse's progress note dated 01/03/17 at 2:19 p.m., documented, .resident family member requesting the resident go to ER for eval (evaluation) Resident refuses to go at this time. Call placed to residents primary care physician and am awaiting call back. A nurse's progress note dated 01/03/17 at 2:28 p.m., documented, .family insists resident goes out to ER, spoke with resident and she has agreed to go . A 'prehospital care report summary', dated 01/03/17 from (name deleted emergency transport service) documented they had arrived at the nursing home at 2:33 p.m. and left the nursing home at 2:45 p.m. The report documented the resident's blood sugar level at 2:41 p.m. and 2:54 p.m. was 448. The 'ED (emergency department) Provider Notes' documented the resident arrived at (name deleted hospital) on 01/03/17 at 3:15 p.m. and documented, Chief complaint .Pt present to ED with FSBS of 480 .Patent states that the nursing home ran out of her insulin yesterday. Her last dose was yesterday at 4:30 p.m. She was unable to receive her morning and afternoon dose .Patient has a blood glucose level of 368 .We did contact the nursing home who states they are receiving her insulin tonight, patient is given 20 units of [MEDICATION NAME] .Diagnoses: [REDACTED]. A Nurse's progress note dated 01/03/17 at 5:29 p.m., documented, .resident returned to the facility via med ride with transportation aide. No new orders received at this time. Continue all previous orders . A medication error report dated 01/03/17 at 5:50 p.m., documented, .Resident received medication that did not belong to her .Resident shows no adverse affects at this time .Physician notified and new orders received . (Name deleted family member) notified . A progress incident note dated 01/03/17 at 5:54 p.m. documented, Resident received wrong dose of insulin medication. Resident is awake alert and oriented, able to make needs known . On 01/26/17 at 10:00 a.m., the DON was asked about documentation of the progress notes involving the administration of the wrong insulin. The DON stated LPN #1 had administered the wrong insulin to the resident on 01/02/16 at 4:30 p.m. She stated the LPN had not reported her actions to anyone until the afternoon of 01/03/17, and was was unable to recall the time, but stated it was around the time the resident was going to the emergency room for evaluation. She stated the LPN reported to her the resident had been out of the Humalog Mix 75/25 suspension. She stated the LPN had called the pharmacy to order the medication, and was told it was too soon for the medication to be filled. She stated the LPN had mixed some insulin belonging to other residents together and administered this mixture to the resident for her 4:30 p.m. dose of insulin on 01/02/17. At 10:15 a.m., LPN #1 was asked about the incident. The LPN stated the resident's bottle of Humalog 75/25 insulin was empty at 4:30 p.m. when she got the bottle to prepare the resident's insulin, and there was no other insulin for her. She stated she notified the pharmacy for a refill, and they stated it was too early to refill the resident's insulin, but they would send some. The LPN was asked if she had notified the physician. The LPN stated, No. The LPN was asked what insulin she had administered to the resident. The LPN stated she mixed some Humalog and [MEDICATION NAME] insulins together to equal what she thought would be similar/equal to the resident's normal insulin orders, and administered that to her. She was asked if she had a physician's orders [REDACTED]. She stated,No. She was asked how she knew what insulins to use and what amounts to mix. She stated she didn't really know. She was asked what were the specific insulin amounts she mixed. She stated she couldn't recall. She was asked if the insulins she mixed belonged to the resident. She stated, No. She was asked if she had used another resident's insulins. She stated, Yes and couldn't recall whose insulins she had used. She was asked how she documented what she had done. She stated she had documented the administration of the Humalog Mix 75/25 suspension 20 units. She was asked if this was what the resident received and she stated, No. She was asked if she had reported the administration of incorrect insulin to the physician/family or any other staff at the time. She stated, No. At 10:26 a.m., LPN #2 was asked about the resident's refusal of insulin on 01/03/17 at 6:30 a.m when the FSBS had been 376. The LPN stated the offgoing nurse had told her the resident's insulin had not come in. She stated she advised the DON the resident had no insulin. She stated the insulin was ordered stat at that time and was expected to arrive within four hours. The LPN was asked if the physician had been notified. She stated she had tried to call him but had received no answer. She was asked if this was documented in the resident's record. She stated it should have been, but wasn't. 2. Resident #3 was admitted to the facility with a [DIAGNOSES REDACTED]. An admission assessment, dated 12/12/16, documented the resident had no cognitive impairment and had received insulin injections the prior seven days. A care plan, dated 12/06/16, documented the resident had a [DIAGNOSES REDACTED]. The admission orders [REDACTED]. The insulin administration record documented the resident was to receive the insulin at 8:00 p.m., and FSBSs were to be performed at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 8:00 p.m. The December 2016 insulin administration record documented the resident's FSBS was 145 on 12/13/16 at 8:00 p.m., and the resident refused the [MEDICATION NAME] insulin. The record documented the physician was not notified of the resident's refusal. On 12/14/16 at 6:30 a.m., the following morning, the resident's FSBS was 221. At 11:30 a.m., the FSBS was 178. Normal blood sugar levels for non-fasting are 70-140. Nurse's progress notes dated 01/12/17 at 7:34 p.m. and 01/17/17 at 9:39 p.m., documented the resident refused 70 units of [MEDICATION NAME] insulin. The note documented the resident wanted only 30 units of insulin, which was then administered per her wishes. The resident's physician was not notified the resident had refused her insulin and was administered a partial dose. On 02/08/17 at 4:00 p.m., corporate nurse #4 was asked if the resident's physician should have been notified. She stated, Yes.

On 01/26/17, an immediate jeopardy situation was determined to exist due to the facility's failure to implement their neglect policy when a staff member was found to have mixed other resident's insulins and administered (intentionally) the mixture to resident #1, whose ordered insulin was not available. The Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy situation. At 5:00 p.m., the administrator, director of nursing (DON) and corporate nurse #1 were notified of the existence of the immediate jeopardy. On 01/27/17 at 12:51 p.m., an acceptable plan of removal was received. The plan of removal was as follows: .Failure to Follow the Neglect policy nurse (name deleted) has been suspended pending investigation at 5:25 pm. An initial report for neglect was completed and turned into the Oklahoma State Department of Health at 9:20 pm. A report was sent to the Oklahoma Board of Nursing related to the insulin negligence of (name deleted nurse) at 10:26 pm. Facility questioned all nurses related to insulin administration, mixing insulin and following physician's orders [REDACTED]. All staff will be inserviced on abuse and neglect policy and procedure. Inservice will include that the failure to provide services that prevent harm are considered neglect. Inservice will also include that when neglect occurs it must be immediately reported to the physician and the abuse coordinator (administrator). This inservice will be complete by 11:59 p.m. on 1/26/17 to all employees working at the facility or before they allowed to return to work. This inservice will also be given to any newly hired employee before they start to work . The immediate jeopardy was removed on 01/27/17 at 2:00 p.m., after the plan of removal was carried out. The deficient practice remained at no actual harm with potential for more than minimal harm, at a pattern. Based on record reviews and interviews, it was determined the facility failed to ensure their neglect policy was implemented when they became aware of a staff member administering the wrong insulins (intentionally) to resident #1 when the ordered insulin was not available for one (#1) of five sampled residents. The facility's failure to implement the abuse/neglect policy had the potential to affect all 71 residents residing in the facility. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The latest assessment, dated 11/09/16, documented the resident had no cognitive impairment, required supervision with all activities of daily living and had received insulin seven days/week of the prior week. The care plan, last updated 01/11/17, documented the resident had diabetes mellitus and was to be observed for complications related to diabetes. Interventions included: ~Humalog Mix 75/25 Suspension was to be administered per physician's orders [REDACTED]. ~Fax FSBS to physician weekly for his review, ~encouraged to drink sugar free drinks and limit juice intake to assist in controlling FSBS values. The January 2017 physician's orders [REDACTED]. ~Humalog Mix 75/25 suspension 35 units subq daily, to be administered at 6:30 a.m., ~Humalog Mix 75/25 suspension 20 units subq at bedtime, to be administered at 4:30 p.m., and ~FSBS were to be obtained prior to each injection. On 01/02/17 at 4:30 p.m., the insulin administration record documented the resident's FSBS was 358 and Humalog Mix 75/25 suspension 20 units was administered subq. Normal levels for non-fasting blood sugar levels are 70-140. A medication error report dated 01/03/17 at 5:50 p.m., documented, .Resident received medication that did not belong to her .Resident shows no adverse affects at this time .Physician notified and new orders received. (Name deleted family member) notified . A progress incident note dated 01/03/17 at 5:54 p.m. documented, Resident received wrong dose of insulin medication . On 01/26/17 at 10:00 a.m., the DON was asked about documentation of the progress notes involving the administration of the wrong insulin. The DON stated LPN #1 had administered the wrong insulin to the resident on 01/02/16 at 4:30 p.m. She stated the LPN had not reported her actions to anyone until the afternoon of 01/03/17, and was was unable to recall the time, but stated it was around the time the resident was going to the emergency room for evaluation. She stated the LPN reported to her the resident had been out of the Humalog Mix 75/25 suspension, had called the pharmacy to order the medication, and was told it was too soon for the medication to be filled. She stated the LPN told her she had mixed some insulin belonging to other residents and administered this mixture to the resident for her 4:30 p.m. dose of insulin. At 10:15 a.m., LPN #1 was asked about the incident. The LPN stated the resident's bottle of Humalog 75/25 insulin was empty at 4:30 p.m. when she got the bottle to prepare the resident's insulin and there was no other insulin for her. She stated she notified the pharmacy for a refill, and they stated it was too early to refill the resident's insulin. The LPN stated she had mixed some Humalog and [MEDICATION NAME] insulins together without a physician's orders [REDACTED]. She was asked how she documented what she had done. She stated she had documented the administration of the Humalog Mix 75/25 suspension, 20 units. She was asked if this was what the resident received. She stated, No. She was asked if she had reported the administration of incorrect insulin. She stated she had told no one what she had done until the afternoon of the next day when she reported it to the DON. At 6:00 p.m., the DON was asked if she had considered the LPN's actions to be neglect. She stated she had just considered the actions to be a medication error. She was asked what the facility had done. She stated a medication error report had been completed. She stated the LPN was sent home on 01/03/17 after the incident was reported to her, and returned on 01/06/17, for education inservice from a corporate nurse. The individual time report for LPN #1 documented she clocked in on 01/03/17 at 2:45 p.m. and clocked out at 6:00 p.m. On 01/06/17, the report documented she clocked in for education at 9:00 a.m. and clocked out at 10:45 a.m. On 01/07/17 through 01/26/17, the report documented she worked from 4.57 hours to 13.58 hours per day, as an LPN. On 01/04/17 and 01/05/17, an 'In-Service Educational Program' was provided to licensed and certified staff who were responsible for providing physician ordered medications and treatments. The subject of discussion was medication refills. The 'In-Service Educational Program' dated 01/06/17 and signed by LPN #1, documented, Subject of Discussion: Scope of Practice, Medication Ordering, Medication Administration .Scope of Meeting .Administering medications without a physician's orders [REDACTED]. By doing so you are [MEDICATION NAME] medicine without the training and license to do so. And by that you are potentially endangering the safety and well being of the resident's/patient's that you are entrusted with their care. It is your responsibility to administer medications and treatments as ordered and to notify the Director of Nursing and Physician if you cannot administer the medication or treatment so that you get further instructions and/or orders . The facility did not implement their neglect policies and procedures. An investigation was not conducted and a report was not sent to the Oklahoma State Department of Health. The facility's 'Resident Abuse, Neglect and Misappropriation of Property' policy and procedure documented, Residents, families and staff will be informed on how and to whom they may report concerns, incidents and grievances .neglect is defined as failure to provide goods and services necessary to avoid physical harm .neglect occurs on an individual basis when a resident receives a lack of care in one or more areas .All employees of a nursing facility are mandated reporters of resident abuse, neglect .Report the incident to the highest ranking person working in the facility at the immediate time of the allegation .The nurse should take immediate steps to protect the resident from further incident during this time .A member of the administrative staff will then conduct a thorough investigation of the incident .and complete ODH-283 .The facility will also file reports with agencies in accordance with state regulations .

On 01/26/17, an immediate jeopardy situation was determined to exist due to the facility's failure to provide and administer the correct insulin as ordered by the physician to resident #1. The resident was administered the wrong insulin (intentionally) on 01/02/17 at 4:30 p.m. The insulin was documented as being administered correctly. The resident's FSBS level at the time was 358. Normal levels for non-fasting blood sugar levels are 70-140. The ordered insulin was not available on 01/02/17 at 4:30 p.m. and 01/03/17 at 6:30 a.m. for the resident's routine doses. On 01/03/17 6:30 a.m., the resident was not administered any insulin. The resident's FSBS was 376. The resident was transferred to an emergency room at 2:39 p.m. and received treatment for [REDACTED]. The Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy situation. At 5:00 p.m., the administrator, director of nursing (DON) and corporate nurse #1 were notified of the existence of the immediate jeopardy. On 01/27/17 at 12:51 p.m., an acceptable plan of removal was received. The plan of removal was as follows: Pharmacy Nurses have been inserviced on insulin administration as ordered. Nurses have been inserviced on obtaining insulin from pharmacy. Nurses have been inserviced on acquiring STAT if the insulin is not available. When STAT order is received nurse will call pharmacy-pharmacy fills unless not authorized. If not authorized DON/Administrator notified and authorization given, staff notifies pharmacy of authorization, pharmacy fills or contacts local pharmacy for 1st dose as condition warrants. Physician will be notified if insulin is not available as quickly as condition warrants. This inservice will be complete by 11:50 pm on 1-26-17 to all nurses working at the facility or before they allowed to return to work. This inservice will also be given to any newly hired nurse before they start to work. All insulin orders have been reviewed for accuracy . The immediate jeopardy was removed on 01/27/17 at 2:00 p.m., after the plan of removal was carried out. The deficient practice remained at a level of actual harm, at a pattern. Based on record reviews and interviews, it was determined the facility failed to ensure insulin was available to be administered as ordered by the physician for one (#1) of four sampled residents. Resident #1 was administered (intentionally) a mixed dosage of insulins that were not ordered for the resident. The resident's ordered insulin was not available. This resulted in harm due to her blood sugar reaching 376 and being sent to the emergency room where she was treated for [REDACTED]. The facility's failure to provide medication as ordered, specifically insulin medication, had the potential to affect 20 of 71 residents who received insulin. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The latest assessment, dated 11/09/16, documented the resident had no cognitive impairment, required supervision with all activities of daily living and had received insulin seven days/week of the prior week. The care plan, last updated 01/11/17, documented the resident had diabetes mellitus and was to be observed for complications related to diabetes. Interventions included: ~Humalog Mix 75/25 Suspension was to be administered per physician's orders [REDACTED]. ~Fax FSBS to physician weekly for his review, ~encouraged to drink sugar free drinks and limit juice intake to assist in controlling FSBS values. The January 2017 physician's orders [REDACTED]. ~Humalog Mix 75/25 suspension 35 units subq daily, to be administered at 6:30 a.m., ~Humalog Mix 75/25 suspension 20 units subq at bedtime, to be administered at 4:30 p.m., and ~FSBS were to be obtained prior to each injection. On 01/02/17 at 4:30 p.m., the insulin administration record documented the resident's FSBS was 358 and Humalog Mix 75/25 suspension 20 units was administered subq. Normal levels for non-fasting blood sugar levels are 70-140. On 01/03/17 at 6:30 a.m., the insulin administration record documented the resident's FSBS was 376 and Humalog Mix 75/25 suspension 35 units was refused. The resident's ordered insulin was not available at that time. The insulin was not received until 01/03/17, at 11:00 p.m. There was no documentation in the resident's progress notes the insulin had been refused or the physician had been notified the resident had refused insulin with a FSBS of 376. A nurse's progress note dated 01/03/17 at 2:19 p.m., documented, .resident family member requesting the resident go to ER for eval (evaluation) Resident refuses to go at this time. Call placed to residents primary care physician and am awaiting call back. A nurse's progress note dated 01/03/17 at 2:28 p.m., documented, .family insists resident goes out to ER, spoke with resident and she has agreed to go . A 'prehospital care report summary', dated 01/03/17 from (name deleted emergency transport service) documented they had arrived at the nursing home at 2:33 p.m. and left the nursing home at 2:45 p.m. The report documented the resident's blood sugar level at 2:41 p.m. and 2:54 p.m. was 448. The 'ED (emergency department) Provider Notes' documented the resident arrived at (name deleted hospital) on 01/03/17 at 3:15 p.m. and documented, Chief complaint .Pt present to ED with FSBS of 480 .Patent states that the nursing home ran out of her insulin yesterday. Her last dose was yesterday at 4:30 p.m. She was unable to receive her morning and afternoon dose .Patient has a blood glucose level of 368 .We did contact the nursing home who states they are receiving her insulin tonight, patient is given 20 units of Novolog .Diagnoses: [REDACTED].>A nurse's progress note dated 01/03/17 at 5:29 p.m., documented, .resident returned to the facility via med ride with transportation aide. No new orders received at this time. Continue all previous orders . A nurse's progress note dated 01/03/17 at 5:42 p.m., documented, (name deleted physician assistant) returned call .New orders received for Humulin 75/25 increased to 40u at (6:30 a.m.) and increased to 25u at (4:30 p.m.). Also received new order for Humalog 5u before each meal. Orders faxed to pharmacy. (Name deleted family member) notified of changes. A medication error report dated 01/03/17 at 5:50 p.m., documented, .Resident received medication that did not belong to her .Resident shows no adverse affects at this time .Physician notified and new orders received . (Name deleted family member) notified . A progress incident note dated 01/03/17 at 5:54 p.m. documented, Resident received wrong dose of insulin medication . On 01/26/17 at 10:00 a.m., the DON was asked about documentation of the progress notes involving the administration of the wrong insulin. The DON stated LPN #1 had administered the wrong insulin to the resident on 01/02/16 at 4:30 p.m. She stated the LPN had not reported her actions to anyone until the afternoon of 01/03/17, and was was unable to recall the time, but stated it was around the time the resident was going to the emergency room for evaluation. She stated the LPN reported to her the resident had been out of the Humalog Mix 75/25 suspension. She stated the LPN had called the pharmacy to order the medication, and was told it was too soon for the medication to be filled. She stated the LPN had mixed some insulin belonging to other residents and administered this mixture to the resident for her 4:30 p.m. dose of insulin. At 10:15 a.m., LPN #1 was asked about the incident. The LPN stated the resident's bottle of Humalog 75/25 insulin was empty at 4:30 p.m. when she got the bottle to prepare the resident's insulin and there was no other insulin for her. She stated she notified the pharmacy for a refill, and they stated it was too early to refill the resident's insulin. The LPN was asked what insulin she had administered to the resident. The LPN stated she mixed some Humalog and Humulin insulins together to equal what she thought would be similar/equal to the resident's normal insulin orders, and administered that to her. She was asked if she had a physician's orders [REDACTED]. She stated, No. She was asked how she knew what insulins to use and what amounts to mix. She stated she didn't really know. She was asked what were the specific insulin amounts she mixed. She stated she couldn't recall. She was asked if the insulins she mixed belonged to the resident. She stated, No. She was asked if she had used another resident's insulins. She stated, Yes and couldn't recall whose insulins she had used. She was asked how she documented what she had done. She stated she had documented the administration of the Humalog Mix 75/25 suspension 20 units. She was asked if this was what the resident received. She stated, No. At 10:30 a.m., LPN #2 was asked about the resident's refusal of insulin on 01/03/17 at 6:30 a.m. She stated the offgoing nurse reported the resident's insulin was not in. She stated she advised the DON the resident's insulin was not available and spoke with the pharmacy to obtain the insulin stat. She stated the facility expected stat orders to be fulfilled within four hours. She stated she left a message with the physician on 01/03/17 at 2:19 p.m. that the resident's insulin was not available and had not been administered that morning. She stated she let a family member know on 01/03/17 at 2:28 p.m. the insulin was not available and had not been administered that morning. On 01/26/17 at 5:50 p.m., resident #1 was asked if she remembered an incident recently where she had not received her insulin. She stated she did recall the incident, and also stated it was not the first time the facility had not provided insulin because they had run out. The resident was unable to recall the date of the incident, but stated her FSBS had been high that morning and the facility did not have her insulin, so she called a family member. She stated she went to the emergency room later in the day as the facility still did not have her insulin, and was administered insulin in the emergency room . She was asked is she had refused her insulin or FSBSs. She stated, No, I don't refuse insulin because I know I need it and they only do FSBS before I get insulin.

On 01/26/17, an immediate jeopardy situation was determined to exist due to the facility's failure to ensure resident #1 was free of significant medication errors for two days. The resident was administered the wrong insulin (intentionally) on 01/02/17 at 4:30 p.m., and the dose was not documented as such. The resident's FSBS level at the time was 358. Normal levels for non-fasting blood sugar levels are 70-140. The resident was not administered any insulin on 01/03/17 at 6:30 a.m., as ordered. The resident's FSBS reached 376. The resident was transferred to an emergency room at 2:39 p.m. Enroute to the emergency room the resident's FSBS was 448 and 480 at the hospital, where treatment was provided. The Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy situation. At 5:00 p.m., the administrator, director of nursing (DON) and corporate nurse #1 were notified of the existence of the immediate jeopardy. On 01/27/17 at 12:51 p.m., an acceptable plan of removal was received. The plan of removal was as follows: Significant Medication Error Nurses will administer insulin per the 5 right policy. Nurses have been inservice on completing an incident report and assessment and notifying the physician if a medication error occurs. This inservice will be complete by 12:59 pm on 1/26/17 to all nurses working at the facility or before they allowed to return to work. This inservice will also be given to any newly hired nurse before they start to work. All insulin orders have been reviewed for accuracy . The immediate jeopardy was removed on 01/27/17 at 2:00 p.m., after the plan of removal was carried out. The deficient practice remained at the level of actual harm, at a pattern. Based on record reviews and interviews, it was determined a significant medication error was made when one (#1) of four sampled residents was administered (intentionally) a mixed dosage of insulins that were not ordered for the resident. The resident's ordered insulin was not available. This resulted in harm due to her blood sugar reaching 376 and being sent to the emergency room where she was treated for [REDACTED]. This failure had the potential to affect all 71 residents. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The latest assessment, dated 11/09/16, documented the resident had no cognitive impairment, required supervision with all activities of daily living and had received insulin seven days/week of the prior week. The care plan, last updated 01/11/17, documented the resident had diabetes mellitus and was to be observed for complications related to diabetes. Interventions included: ~Humalog Mix 75/25 Suspension was to be administered per physician's orders [REDACTED]. ~Fax FSBS to physician weekly for his review, ~encouraged to drink sugar free drinks and limit juice intake to assist in controlling FSBS values. The January 2017 physician's orders [REDACTED]. ~Humalog Mix 75/25 suspension 35 units subq daily, to be administered at 6:30 a.m., ~Humalog Mix 75/25 suspension 20 units subq at bedtime, to be administered at 4:30 p.m., and ~FSBS were to be obtained prior to each injection. On 01/02/17 at 4:30 p.m., the insulin administration record documented the resident's FSBS was 358 and Humalog Mix 75/25 suspension 20 units was administered subq. Normal levels for non-fasting blood sugar levels are 70-140. On 01/03/17 at 6:30 a.m., the insulin administration record documented the resident's FSBS was 376 and Humalog Mix 75/25 suspension 35 units was refused. The resident's ordered insulin was not available at that time. The insulin was not received until 01/03/17, at 11:00 p.m. There was no documentation in the resident's progress notes the insulin had been refused or the physician had been notified the resident had refused insulin with a FSBS of 376. A nurse's progress note dated 01/03/17 at 2:19 p.m., documented, .resident family member requesting the resident go to ER for eval (evaluation) Resident refuses to go at this time. Call placed to residents primary care physician and am awaiting call back. A nurse's progress note dated 01/03/17 at 2:28 p.m., documented, .family insists resident goes out to ER, spoke with resident and she has agreed to go . A 'prehospital care report summary', dated 01/03/17 from (name deleted emergency transport service) documented they had arrived at the nursing home at 2:33 p.m and left the nursing home at 2:45 p.m. The report documented the resident's blood sugar level at 2:41 p.m. and 2:54 p.m. was 448. The 'ED (emergency department) Provider Notes' documented the resident arrived at (name deleted hospital) on 01/03/17 at 3:15 p.m. and documented, Chief complaint .Pt present to ED with FSBS of 480 .Patent states that the nursing home ran out of her insulin yesterday. Her last dose was yesterday at 4:30 p.m. She was unable to receive her morning and afternoon dose .Patient has a blood glucose level of 368 .We did contact the nursing home who states they are receiving her insulin tonight, patient is given 20 units of [MEDICATION NAME] .Diagnoses: [REDACTED].>Nurses progress notes dated 01/03/17 at 5:29 p.m., documented, .resident returned to the facility via med ride with transportation aide. No new orders received at this time. Continue all previous orders . A nurse's progress note dated 01/03/17 at 5:42 p.m., documented, (name deleted physician assistant) returned call .New orders received for [MEDICATION NAME] 75/25 increased to 40u at (6:30 a.m.) and increased to 25u at (4:30 p.m.). Also received new order for Humalog 5u before each meal. Orders faxed to pharmacy. (Name deleted family member) notified of changes. A medication error report dated 01/03/17 at 5:50 p.m., documented, .Resident received medication that did not belong to her .Resident shows no adverse affects at this time .Physician notified and new orders received. (Name deleted family member) notified . A progress incident note dated 01/03/17 at 5:54 p.m. documented, Resident received wrong dose of insulin medication . A progress incident note dated 01/04/17 at 2:24 a.m., documented, Focused assessment due to recent incident involving insulin .FSBS 235 . The insulin administration record dated January 2017 documented the resident's FSBS was 253 on 01/04/17 at 6:30 a.m., and the resident was administered Humalog Mix 75/25 suspension 40 units. On 01/26/17 at 10:00 a.m., the DON was asked about documentation of the progress notes involving the administration of the wrong insulin. The DON stated LPN #1 had administered the wrong insulin to the resident on 01/02/16 at 4:30 p.m. She stated the LPN had not reported her actions to anyone until the afternoon of 01/03/17, and was unable to recall the time, but stated it was around the time the resident was going to the emergency room for evaluation. She stated the LPN reported to her the resident had been out of the Humalog Mix 75/25 suspension. She stated the LPN had called the pharmacy to order the medication, and was told it was too soon for the medication to be filled. She stated the LPN had mixed some insulin belonging to other residents and administered this mixture to the resident for her 4:30 p.m. dose of insulin. At 10:15 a.m., LPN #1 was asked about the incident. The LPN stated the resident's bottle of Humalog 75/25 insulin was empty at 4:30 p.m. when she got the bottle to prepare the resident's insulin and there was no other insulin for her. She stated she notified the pharmacy for a refill, and they stated it was too early to refill the resident's insulin. The LPN was asked if she had notified the physician the resident was out of insulin and the resident's FSBS was 358. She stated, No. The LPN was asked what insulin she had administered to the resident. The LPN stated she mixed some Humalog and [MEDICATION NAME] insulins together to equal what she thought would be similar/equal to the resident's normal insulin orders, and administered it to her. She was asked if she had a physician's orders [REDACTED]. She stated, No. She was asked how she knew what insulins to use and what amounts to mix. She stated she didn't really know. She was asked what were the specific insulin amounts she mixed. She stated she couldn't recall. She was asked if the insulins she mixed belonged to the resident. She stated, No. She was asked if she had used another resident's insulins. She stated, Yes and couldn't recall whose insulins she had used. She was asked how she documented what she had done. She stated she had documented the administration of the Humalog Mix 75/25 suspension of 25 units. She was asked if this was what the resident received. She stated, No. She was asked if she had reported the administration of incorrect insulin to the physician or anyone else at the time. She stated, No. She was asked if she had reported the administration of incorrect insulin to the charge nurse at her shift change at 7 p.m. She stated, No. At 10:30 a.m., LPN #2 was asked about the resident's refusal of insulin on 01/03/17 at 6:30 a.m. She stated the offgoing nurse reported the resident's insulin was not in. She stated she advised the DON the resident's insulin was not available and spoke with the pharmacy to obtain the insulin stat. She stated the facility expected stat orders to be fulfilled within four hours. She stated she left a message with the physician on 01/03/17 at 2:19 p.m. that the resident's insulin was not available and had not been administered that morning. She stated she let a family member know on 01/03/17 at 2:28 p.m. the insulin was not available and had not been administered that morning. She was asked if the resident's FSBS level had been assessed at any time on 01/03/17 from 6:30 a.m. until the resident left the facility to go to the emergency room . She stated the resident had refused any other FSBS levels. There was no documentation the resident refused FSBSs on 01/03/17. On 01/26/17 at 5:50 p.m., resident #1 was asked if she remembered an incident recently where she had not received her insulin. She stated she did recall the incident, and also stated it was not the first time the facility had not provided insulin because they had run out. The resident was unable to recall the date of the incident, but stated her FSBS had been high that morning and the facility did not have her insulin, so she called a family member. She stated she went to the emergency room later in the day as the facility still did not have her insulin, and was administered insulin in the emergency room . She was asked is she had refused her insulin or FSBSs. She stated, No, I don't refuse insulin because I know I need it and they only do FSBS before I get insulin.

Based on observation, record review and interview, it was determined the facility failed to provide interventions according to resident's needs to prevent the development of avoidable moisture associated skin damage (MASD) for one (#99) of four sampled residents. The facility's failure to provide interventions according to the resident's needs resulted in harm with the development of avoidable MASD in two areas. The director of nurses identified 39 residents who were dependant on staff for assistance with incontinent care. Findings: Resident #99 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident exhibited clear speech, was able to understand and be understood. The assessment further documented the resident required extensive assistance from two staff for bed mobility, hygiene, toilet use, and was always incontinent of bowel and bladder and was totally dependant on staff for transfers. A care plan last updated 07/12/16, documented the resident had an overactive bladder, was at risk for skin breakdown due to frequent incontinence, brief use and medications. The goal was to remain free from skin breakdown by preventing any new breakdown by checking the resident frequently and as required for incontinence. Interventions included to use two persons and the Hoyer lift (machine used to lift) for all ADLs (activities of daily living), incontinent care as needed, and apply a protective moisture barrier after all incontinent episodes. Physicians orders, dated 08/07/16 and 09/08/16, documented, [MEDICATION NAME] (water pill) 40 milligrams (mg), one tablet daily for excess fluid, and [MEDICATION NAME] (potassium sparing water pill) 25 mg, one time daily for [MEDICAL CONDITION]. On 09/27/16 at 1: 55 p.m., the resident was observed sitting in a recliner in the corner of her room. She was interviewed and asked about the care she received. The resident was able to answer the questions slowly, but appropriately. She stated the care she received was, OK most of the time. She was asked when was the care not OK. She stated, When I have to sit in a wet diaper for 2 or 3 hours. She was asked how often did she wait 2 to 3 hours in a wet brief. She stated she wasn't sure, But its more often than not. At 2:30 p.m., 3: 50 p.m., and again at 4:40 p.m., the resident was observed to remain in the recliner. Staff was not observed to reposition, offer or provide incontinent care during this time period. On 09/27/16 at 9:00 a.m., the resident was observed in bed, with her eyes closed. A family member was seated at the bedside. The family member was interviewed regarding the resident's allegations of lack of care. She was asked if the staff provided care for the resident as expected. She stated she didn't think so and she thought there was not nearly enough staff working to make sure residents were provided with timely care. She stated she had been in the room for an entire evening and the call light, if turned on, would never be answered and incontinent care was only done if they insisted on it. She was asked how often the resident's briefs were changed while she visited. She stated two to three times a day. She was asked to clarify if this meant two to three times while she was present or two to three times during the entire day. The family member asked the resident to answer the question posed by the surveyor. The resident clearly stated, All day. An ADL record documenting incidents of incontinence was reviewed from 09/01/16 through 09/27/16, and documented the resident was incontinent of bladder, once a day for six days, twice a day for 16 days and three times a day for five days during the 26 day time frame. The resident was then asked if she was experiencing any other problems. She stated, Yes, my bottom hurts. The family member then stated she had spoken with the facility staff regarding providing more timely incontinent care after finding the resident lying in bed completely saturated in urine one day. She was asked how long ago had the incident occurred. She stated, About three weeks. A nurses note, dated 09/08/16 at 12:10 p.m., documented, Focused assessment r/t (related/to) residents care. This writer spoke with residents daughter (name withheld) on 9/7/2016 to discuss residents care and family concerns to schedule a care plan meeting. (Name withheld) reported to this writer that she had addressed her concerns and felt comfortable with her mother's care at present because she received a quick response with her concerns. This writer discussed with (Name withheld) that the IDT (interdisciplinary department team) would still like to meet with family to have a care conference with (Name withheld) agreeing to meeting. (Name withheld) wanted to communicate with her sister and father to discuss convenient times and that she would call back with times. Awaiting return call at present. A second nurses note, dated 09/08/16 at 1600 (4:00 p.m.) documented, Resident, husband, DON (director of nursing), Corporate Nurse, Administrator and (name withheld) via phone, met for care plan conference. Resident and family expresses concerns involving her care and necessary interventions. Resident is on diuretic and is unable to tell when she needs to void, until it happens. She is wet often, resident would prefer to wear a brief day and night for comfort. Staff to check on resident frequently. Resident has agreed to be up for noon meal and follow with going to an activity. This will hopefully increase resident's strength . Weekly skin assessments dated 09/05/16, 09/12/16, and 09/19/16, did not identify any type of MASD on the resident. The weekly skin assessment, dated 09/26/17, documented, New skin breakdown was identified on the left and right buttocks and the sacrum. Treatments were in place. On 09/27/16 at 9:15 a.m., certified nurse aide (CNA) #1 was observed in the north east hall pushing a Hoyer lift. She was asked which hall she was working. The CNA stated she had been called in to perform baths for the day, but was changed to work on the north east hall due to another CNA who had called in. She was asked how many residents on the north east hall required the use of the Hoyer lift for ADLs. The CNA stated she wasn't sure because she did not usually work this hall, but she thought there were at least four residents who required the lift. She was asked how many staff members were needed to provide care when the Hoyer lift was used. She stated at least two staff members were always required. CNA #1 observed CNA #2 coming down the hall and asked for her assistance. She then stated, This is her hall so she will know more about the residents. CNA #2 was asked how long it took to provide incontinent care when using the Hoyer lift. She stated the lift takes two persons and generally 10 to 15 minutes. She was asked if there were any incidents in which it took longer or more staff to help. The CNA pointed to the room in which resident #99 resided and stated, She's heavier and taller and it takes us a while longer to change her. At 9:30 a.m., registered nurse (RN) #1 was asked to assist the resident and staff to position the resident so an observation of her skin could be made. At 9:45 a.m. licensed practical nurse (LPN) #1, and LPN #2, entered the residents room. LPN #1 was observed to have a small container with a creme ointment inside. She stated,Were going to go ahead and do her treatment now. The LPN was then asked how often incontinent care should be provided for incontinent residents'. She stated. Every two hours or more if necessary. She was asked when care had last been provided for the resident. She stated, At 7:30 this morning. The two LPNs and the director of nursing (DON) entered the resident's room and repositioned her onto her left side, and removed the draw sheet and the bed pad. The residents buttocks, sacrum/coccyx area was observed. The left upper inner buttock was observed to have an area approximately 2 inches in length and 1 inch in width which was reddened and excoriated. The areas were not observed to blanche when wiped during incontinent care. Once care was completed the resident was repositioned onto the right side and the left buttock was observed to have a smaller reddened area on the outer most part of the buttock. This area also did not blanche when cleansed by the LPN. LPN #2, (wound care nurse) was asked if she knew what the cause of the reddened areas were. She stated, Moisture. LPN #1 was asked again how often incontinent care was provided for the resident. She stated, They come in and ask her if she's wet all the time. She was asked if the lift was needed for incontinent care if the resident was up in her recliner. LPN #1 stated, No, sometimes she is placed on the bedside commode to toilet. The three staff members assisting with the positioning were asked since the resident received two water pills every day, wouldn't that put her at an even higher risk for MASD. The DON was heard to say, The [MEDICATION NAME] (water pill) she gets does make it difficult to keep her dry. The DON was asked if she thought this type of MASD was avoidable. She stated, Yes. This is avoidable. On 09/27/16 at 3:00 p.m., the administrator, corporate administrator, DON, corporate nurse, and a QA (quality assurance) nurse were all informed of the above findings and asked if they had questions. The administrator stated, We have added staff and use bath aides to help make sure everyone gets their baths and timely care. What else are we supposed to do? The corporate administrator stated, We are going to have to make sure the staff we have are doing their job.

Based on observation, record review and interview, it was determined the facility failed to ensure incontinence care was provided for one (#99) and nail care was provided for one (#17) of four sampled residents reviewed for assistance with activities of daily living (ADLs). The facility's failure to provide incontinent care resulted in the development of moisture associated skin damage (MASD) to the resident's buttocks, resulting in harm. The facility identified 70 residents who required assistance with ADLs and 39 residents who were incontinent of bladder. Findings: 1. Resident #99 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident exhibited clear speech, was able to understand and be understood. The assessment further documented the resident required extensive assistance from two staff for bed mobility, hygiene, toilet use, was always incontinent of bowel and bladder and was totally dependant on staff for all aspects of transfers. A care plan last updated 07/12/16, documented the resident had an overactive bladder, was at risk for skin breakdown due to frequent incontinence, brief use and medications. The goal was for the resident to remain free from skin breakdown. Interventions included to use two persons and the Hoyer lift (machine used to lift) for all ADLs (activities of daily living), incontinent care as needed, and apply protective moisture barrier cream after all incontinent episodes. Physician orders, dated 08/07/16 and 09/08/16, documented, daily medications included: [MEDICATION NAME] 40 milligrams (mg), one tablet daily for excess fluid, and [MEDICATION NAME] 25 mg, one time daily for [MEDICAL CONDITION]. On 09/27/16 at 1: 55 p.m., the resident was observed sitting in a recliner in the corner of her room. She was interviewed and asked about the care she received from the staff. The resident was able to answer questions slowly, but appropriately. She stated the care she received was, OK most of the time. She was asked when was the care not OK. She stated, When I have to sit in a wet diaper for 2 or 3 hours. She was asked how often did she think she had to wait long periods before being provided incontinent care. She stated she wasn't sure, But it's more often than not. At 2:30 p.m., 3: 50 p.m and 4:40 p.m., the resident was observed to remain in the same recliner. Staff was not observed to reposition, offer or provide incontinent care for the resident during this time. On 09/27/16 at 09:00 a.m., the resident was observed in bed, with her eyes closed. A family member was seated at the bedside. The family member was interviewed regarding the resident's allegations of lack of care. She was asked if the facility staff provided care for the resident as expected. She stated she didn't think so and she thought there was not nearly enough staff working to make sure residents were provided with timely care. She stated she had been in the room for an entire evening and the call light, if turned on, would never be answered and incontinent care was only done if they insisted on it. She was asked how often the resident's briefs were changed while she visited. She stated two to three times a day. She was asked to clarify if this meant two to three times while she was present or for the entire day. The family member asked the resident to answer the question posed by the surveyor. The resident clearly stated, All day. The resident was then asked if she was experiencing any other problems. She stated, Yes, my bottom hurts. The family member then stated she had spoken with the facility staff regarding providing more timely incontinent care after finding the resident one day lying in bed completely saturated in urine. She was asked how long ago did the incident occur. She stated, About three weeks. A nurses note, dated 09/08/16 at 12:10 p.m., documented, Focused assessment rt (related/to) residents care. This writer spoke with residents daughter (name withheld) on 9/7/2016 to discuss residents care and family concerns to schedule a care plan meeting. (Name withheld) reported to this writer that she had addressed her concerns and felt comfortable with her mothers care at present because she received a quick response with her concerns. This writer discussed with (Name withheld) that the IDT (interdisciplinary department team) would still like to meet with family to have a care conference with (Name withheld) agreeing to meeting. (Name withheld) wanted to communicate with her sister and father to discuss convenient times and that she would call back with times. Awaiting return call at present. A second nurses note, dated 09/08/16 at 1600 (4:00 p.m.) documented, Resident, husband, DON, Corporate Nurse, Administrator and (name withheld) via phone, met for care plan conference. Resident and family expresses concerns involving her care and necessary interventions. Resident is on diuretic and is unable to tell when she needs to void, until it happens. She is wet often, resident would prefer to wear a brief day and night for comfort. Staff to check on resident frequently. Resident has agreed to be up for noon meal and follow with going to an activity. This will hopefully increase resident's strength . An ADL record for episodes of bladder incontinence, dated 09/01/16 through 09/27/16, documented the resident was incontinent of bladder, once a day for six days, twice a day for 16 days and three times a day for five days. On 09/27/16 at 9:15 a.m., certified nurse aide (CNA) #1 was observed in the north east hall pushing a Hoyer lift. She was asked which hall was she assigned to. The CNA stated she had been called in to perform baths for the day, but was changed to work on the north east hall due to another CNA who had called in. She was asked how many residents on the north east hall required the use of the Hoyer lift for ADLs. The CNA stated she wasn't sure because she did not usually work this hall, but she thought there were at least four residents who required the lift. She was asked how many staff members were needed to provide care when the Hoyer lift was used. She stated at least two staff members were always required. CNA #1 observed CNA #2 coming down the hall and asked for her assistance. She then stated, This is her hall so she will know more about the residents. CNA #2 was asked, how long it took to provide incontinent care when using the Hoyer lift. She stated the lift took two persons and usually 10 to 15 minutes. She was then asked which of the four residents usually took the longest. The CNA pointed to the room in which resident #99 resided and stated, Shes heavier and taller and it takes us awhile to change her. The LPN was asked how often incontinent care should be provided for the resident. She stated. Every two hours or more if necessary. She was asked when care had last been provided for the resident. She stated, At 7:30 this morning. The two LPNs and the DON repositioned the resident onto her left side, removed the draw sheet and bed pad, exposing the residents buttocks. The left upper inner buttock was observed to have an area approximately 2 inches in length and 1 inch in width, to be reddened and excoriated. The areas were not observed to blanche when wiped during the care. Once care was completed the resident was repositioned onto the right side and the left buttock was observed to have a smaller reddened area on the outer most part of the buttock. This area also did not blanche when cleansed by the LPN. LPN #2, was asked if she knew what the cause of the reddened areas were. She stated, Moisture. LPN #1 was asked again how often incontinent care was provided for the resident. She stated, They come in and ask her if she's wet all the time. The DON was heard to say, With all the [MEDICATION NAME] (water pill) she gets makes it difficult to keep her dry. The DON was asked if she thought this type of MASD was avoidable. She stated, Yes, this is avoidable. 2. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 07/15/16, documented the resident was cognitively intact and was able to understand others and make himself understood. The resident required extensive to total assistance with all ADLs except eating. The resident's care plan, last updated 08/29/16, documented: .Focus .limited physical mobility r/t (related to) Disease Process (OA [MEDICAL CONDITION]) . Interventions .Bath days are Mon (Monday)-Wed (Wednesday)-Fri (Friday) in the evening .prefers a bed bath only . Requires one person assist with dressing, and personal hygiene . On 09/26/16 at 1:52 p.m., the resident was observed to have long jagged fingernails on both hands. The fingernails were observed to have brownish black debris under all ten nails. The resident stated staff had not cut or cleaned his fingernails in a long time. At 3:40 p.m., certified nursing assistant (CNA) #2 was asked when residents' fingernails were to be trimmed and cleaned. She stated they were to be trimmed and cleaned when they received their baths. At 3:55 p.m., licensed practical nurse (LPN) #1 was asked when residents' fingernails were to be trimmed and cleaned. She stated the CNAs were to trim nails with baths unless the resident was diabetic. The LPN then stated fingernails were to be cleaned with baths and as needed. She stated they should be cleaned with baths and checked and cleaned as needed after meals. At 4:10 p.m., LPN #1 and the director of nursing were shown the resident's fingernails. They both agreed they were long/dirty and should be trimmed and cleaned.

Based on observation, record review and interview, it was determined the facility failed to: a) provide interventions according to resident's needs to prevent the development of an avoidable stage 2 pressure ulcer for two (#40 and #78), b) provide interventions to prevent the worsening of a stage 2 pressure ulcer for one (#78) of two residents sampled for pressure ulcers. The facility's failure to provide interventions according to the residents' needs resulted in harm with the development and worsening of avoidable stage 2 pressure ulcers for two (#40 and #78) of two sampled residents with pressure ulcers. The Resident Census and Condition of Resident Report, dated 08/02/16, documented three residents with pressure ulcers. Findings: 1. Resident #40 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 02/28/16, documented the resident was severely impaired in cognition, wandered daily and was frequently incontinent of bladder. The assessment further documented the resident required supervision with bed mobility, walking in his room, the corridor, on and off the unit and required limited supervision from one person for most transfers and toilet use. The range of motion assessment documented the resident was not steady while standing, but able to stabilize without staff assistance when moving from a seated to standing position, walking, turning around, moving on and off the toilet and when performing surface to surface transfers. The assessment documented a wheelchair was utilized as a mobility device. Weekly assessments utilizing the Braden scale (an evaluation for predicting pressure ulcer risk) dated 02/15/16 through 03/07/16, documented a Braden score of 19, indicating the resident was not at a high risk for development of pressure ulcers. A care plan, dated 03/09/16, documented the resident had the potential for pressure ulcer development and was incontinent of bladder. The goal was for the resident to be free of skin breakdown due to incontinence and brief use, and remain free of blisters or discoloration. Interventions included to educate the resident/family as to causes of skin breakdown, the importance of frequent repositioning, monitor labs and nutritional values, follow facility policies/protocols for the prevention /treatment of [REDACTED]. A daily wound charting record, dated 03/14/16, documented, Wounds on the left buttock which were a scattered field of open areas Stage II noted w (with) pink granulation and some [MEDICATION NAME] yellow tissue present. Right buttock open Stage II area noted with pick granulation tissue, no drainage, redness of s/sx (signs and symptoms) of infection. Groin Scrotum with small open areas, one pink granulation and one scabbed, no drainage, redness or s/sx of infection. A monthly nurses summary note, dated 03/15/16, documented the resident now used a wheelchair for mobility, a positioning device for turning every 2 hours and required the assistance of two persons for repositioning, had good skin turgor and a wound on the left buttock. The summary also documented the resident was frequently incontinent of bowel and bladder, wore briefs all the time and required one person assist for toilet use. A nurses note dated 03/16/16 at 3:35 p.m., documented, focus assessment r/t (related to) skin assessment, resident has open areas noted to the left and right buttocks as well as scrotum. The left buttocks/upper thigh has a field of open areas with pink granulation tissue and some [MEDICATION NAME] tissue, no drainage, redness or s/sx of infection, 2cm (centimeters) x (by) x 7cm x 0.1 cm, approx (approximately) 4 areas within the field. The right buttocks/upper thigh has a 2cm x 2cm x 0.1cm area with pink granulation tissue, no drainage, redness or s/sx of infection noted to area, is an l (L) shaped area. The scrotum has 2 open areas one being scabbed and the other with pink granulation and no drainage, or s/sx of infection. The scrotum has light redness A quarterly assessment dated [DATE], documented the resident was severely impaired in cognition, frequently incontinent of bowel and bladder, and wandered daily. The assessment further documented the resident now required extensive assistance with transfers eating, toilet use and bathing and limited assistance with bed mobility, dressing and hygiene. The range of motion assessment documented the resident was not steady, and now only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, moving on and off the toilet and when performing surface to surface transfers. On 07/28/16 at 9:31 a.m., registered nurse (RN) #1 was interviewed and asked to review the documentation dated 03/16/16. After reviewing the documents she was asked if there were any other nurses' note prior to the one on 03/16/16, which document the pressure wounds. She stated, Not that I can see. Maybe they (staff) documented on the wrong person. Let me review this further. At 10:10 a.m., RN #1 returned with documentation dated 03/14/16 from a skin/wound assessment identifying the new pressure ulcer areas, and signed by a previous wound care nurse. RN #1 stated, The resident was actually evaluated on 3/14/16, but it wasn't charted in the record until 03/16/16, which is the same day he transferred to the hospital. She was asked to identify in the record where preventive measures were implemented to prevent the development of pressure ulcers for the resident. She stated she would have to review the clinical record to find out. No interventions to prevent the development of the pressure ulcers were documented as provided from 02/28/16 when the resident was admitted to the facility through 03/14/16, when the resident developed stage 2 pressure ulcers to the left and right buttocks. On 08/01/16 at 11:30 a.m., the residents skin was observed with assistant director of nurses #1. The residents buttock area was observed to be free of any wounds. 2. Resident #78 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The resident was receiving hospice services. A quarterly assessment, dated 03/12/16, documented the resident displayed severe cognitive impairment, sometimes understood others, required extensive assistance with bed mobility, transfers, walking in room, toileting, personal hygiene and bathing. The assessment documented the resident was at risk for the development of a pressure ulcer, and had no pressure ulcer. A quarterly assessment, dated 06/12/16, documented the resident no changes in cognition, understanding others or level of assistance required with activities of daily living. The assessment documented the resident had one stage 2 pressure ulcer, and there had been no pressure ulcer on the prior assessment. The care plan care plan, dated 03/22/16, documented the resident had a potential for skin breakdown. Interventions included the use of at least three pillows while positioned in bed or chair if applicable to reduce pressure to bony prominences and 1-2 person assistance with activities of daily living. A weekly skin evaluation dated 05/23/16, documented the resident had no areas of skin breakdown. Interventions for preventions of skin breakdown included the use of three pillows while positioned in bed or chair to reduce pressure to bony prominences and 1-2 person assistance with activities of daily living. A skin/wound progress note dated 05/24/16, documented, .noted Stage ll PU (pressure ulcer) to left heel. Area is 1.5cm (centimeters) x 2cm x 0.1 cm. No drainage noted. Surrounding tissue red/pink . There was no documentation the resident had been provided with repositioning assistance or pillows for positioning in April or May. A skin/wound progress note dated 06/04/16, documented, .assessment related to left heel Stage ll wound. Area is now 5.2cm x 5cm x 0.1cm. Area has red/purple area, surrounding skin is pink/red. Scant amount of serous sanguineous drainage. No odor noted . The pressure ulcer had worsened. A skin/wound progress note dated 06/11/16, documented, .assessment related to left heel Stage ll wound. Area is now 5.5cm x 5.5cm x 0.1cm. Area has red/purple area, yellow slough noted, surrounding skin is pink/red. Scant amount of serous sanguineous drainage. No odor noted . The pressure ulcer had worsened. There was no documentation the resident had been provided with repositioning assistance or pillows for positioning from 06/01/16 through 06/13/16. an order for [REDACTED]. Nurses progress notes dated 06/21/16, documented an air bed was provided for the resident, and a foul smell to the pressure ulcer, with yellowish/brownish area in center of the wound was identified. An x-ray of the left heel was obtained to rule out osteo[DIAGNOSES REDACTED]. A nurses progress note dated 06/22/16, documented, Posterior heel soft tissue defect, underlying which is evidence of subtle osteo[DIAGNOSES REDACTED] of the posterior calcaneus . On 07/25/16, the resident was observed sitting in her recliner at 10:30 a.m., 11:30 a.m., 1:30 p.m., 3:30 p.m., 5:00 p.m. and 6:00 p.m. Both feet were observed to be on the floor, with padded heel protectors on both feet. The resident was leaning to her right side in the recliner. The resident's position did not change during this time frame; no staff was observed to assist the resident with repositioning. On 07/27/2016, the resident was observed lying on the air mattress in bed turned to her right side, with padded heel protectors on both heels, at 10:45 a.m., 11:15 a.m., 1:30 p.m., and 3:30 p.m. No staff was observed to assit the resident with repositioning during this time. On 07/27/16 at 3:35 p.m., certified nurse aides #2 and #5 were asked about the care needed for the resident. They stated the resident needed to be assisted with repositioning every two hours. They were asked if the resident changed positions independently and they stated she liked to lay on her right side and often kicked off the padded heel protectors. They stated they didn't have time to reposition residents needing assistance as often as needed at times. On 07/279/16 at 12:40 p.m., LPN #4 was asked about the care the resident required and interventions that had been provided to prevent the development and worsening of the resident's pressure ulcer. She stated the resident needed to be repositioned every two hours. She stated pillows had been used to keep the ankles/heels off the bed but not consistently and not until after the pressure ulcer had developed. She was asked if making sure there was no pressure to the resident's heels for any prolonged time would have been an appropriate intervention to prevent the development of the pressure ulcer. She stated yes. She was asked how that could have been accomplished and she stated by ensuring heels were more consistently floated.

On 06/08/15 at 4:40 p.m. an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure hot water temperatures were maintained at a safe level to prevent resident exposure to hazardous hot water temperatures. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 4:48 p.m., the administrator and DON were informed of the IJ regarding the hot water temperature and of the required plan of removal. They were informed this placed the facility in an extended survey. At 7:31 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: .Water Temperature.Immediate Jeopardy 06/08/2015.Immediate Response: Water temperature was immediately lowered to achieve safety regulation temperatures in the dining room sink to reduce risk of harm to residents. An employee was assigned to stay at the sink until safe temperatures could be achieved. Water temperature was 98 degrees at 5:25 p.m. Dishwashing was held until temperatures could be increased to appropriate standards for washing. A plumber was called at 5:40pm (sic) to install a regulator on the sink in question. Estimated time of completion to install a regulator to the dining room sink is 8:00pm. Administrator in-serviced department heads. Staff in the building was in-serviced immediately by department heads. Calls were started for staff not currently in the building. Any staff that was not able to come in for in-servicing was in-serviced over the phone. (Name withheld), Housekeeping Supervisor, will in-service housekeeping staff not reachable by phone at start of shift 06/09/15 at 7:00am. Employees include (name withheld). This employee will not be allowed to return to the floor until she has been in-serviced. (Name withheld), ADON, will in-service nursing staff not reachable by phone at start of shift 06/08/15 at 11:00pm. Employees include (names withheld). These employees will not be allowed to return to the floor until they have been in-serviced. (Name withheld), DON, will continue to try to reach the remaining employees by 12:00pm on 06/09/15. Employees include (names withheld). These employees will not be allowed to return to the floor until they have been in-serviced. (Name withheld), DON, will in-service (name withheld) when she returns from National Guard Drill on 06/21/15. In-service Topic: Maintaining appropriate temperature from water sources not to exceed 115 degrees in resident areas. Appropriate documentation of temperature logs. All staff needs to notify administration if they feel the water is too hot. Follow up Response: Maintenance Director will check all residential areas, including the sink in the dining room, for appropriate temperature daily for two weeks and twice a week for two weeks. Weekly audits will be completed after that. Administrator will oversee audits and report to QA committee accordingly. The immediacy of the IJ was removed on 06/08/15 at 8:00 p.m., when the sink had been repaired as the plan of removal documented. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to maintain a safe hot water temperature in the dining room sink. The facility identified 19 ambulatory residents. The hot water temperature in the sink in the resident dining room was 146 degrees Fahrenheit. This resulted in an Immediate Jeopardy Situation. Findings: An undated facility policy titled water temperature, documented, .State Licensure (sic) requires water temperature in the resident bath and toilet areas to fall in a range between 100 degrees and 115 degrees.It is suggested using thermometers designed for testing liquids. Check water temperatures regularly by running water over the thermometer. If you check it frequently, even daily and through the day, you will learn what causes it to fluctuate and can take the necessary action to see that it falls within an acceptable range.Note: Report water temperature that exceeds the requirement immediately to your Administrator. On 06/08/15 at 4:15 p.m. the temperature of the dining room sink was measured at 146 F. On 06/08/15 at 4:48 p.m., the administrator and DON were asked if the dining room was available for resident use between meals, in the evening, and at night. The administrator stated the dining room was available for resident use all the time. The administrator was asked if she had monitored the hot water temperatures in the building. She stated she had only been in the building for four weeks but had asked if hot water was monitored and had been told maintenance had documented the hot water temperatures routinely in a log. On 06/08/15 at 4:57 p.m., cook #1 was observed with a kitchen thermometer, checking the water temperature of the dining room sink. The thermometer was observed to read 146 F. The cook was asked what the temperature read. He stated the temperature had been down as low as 125 F but had just increased to 146 F with his last measurement. The cook was asked if he ever observed residents who had utilized the dining room sink to wash their hands. He stated some of the residents utilized the dining room sink to wash their hands. On 06/08/15 at 5:03 p.m., the dietary manager was asked if he ever observed residents utilize the dining room sink to wash their hands. He stated he had seen residents wash their hands in the dining room sink once or twice. On 06/08/15 at 5:45 p.m., the hot water log maintained by the maintenance department was reviewed from January 2015 to current. The log documented water temperatures were monitored an average of two to three times a month on the resident halls. The log documented the dining room sink temperature was measured at 120 F on 03/11/15. There was no further documentation of the temperature of the hot water of the dining room sink. On 06/08/15 at 6:15 p.m., the maintenance supervisor was asked if he monitored the temperature of the hot water in the dining room sink. He stated the hot water temperature for the kitchen had been maintained above 120 F and the hot water tank that supplied the kitchen also supplied the dining room sink. On 06/11/15 at 9:25 a.m., the administrator was asked what the potential outcome might have been to a resident washing their hands in the dining room sink. The administrator stated there was a potential for burns to the resident. She stated she was not aware the hot water source for the dining room sink was the same tank which supplied the hot water to the kitchen and was happy there had not been any resident burned.

Based on observation, clinical record review and staff interviews, it was determined the facility failed to provide supervision to ensure a resident did not ingest bar soap for one (#4) of four sampled residents who were reviewed with behaviors. This deficient practice resulted in actual harm for resident #4 who required transfer to the emergency room for treatment of [REDACTED]. This had the potential to affect 29 residents identified by the facility who had behaviors. Findings: Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan conference summary note, dated 06/04/13, documented, "...Diagnosis: [REDACTED]. A nurse's note, dated 02/18/14, documented, "...Seldom will sit (and) eat d/t advanced Alzheimer's c behaviors. Will carry food around (and) eat...wanders daily..." A nurse's note, dated 06/03/14, documented, "...reg diet (and) eats whenever she choose (sic). Wanders daily. Does not sit very long anywhere...Especially if food is involved..." An annual assessment, dated 08/11/14, documented the resident was severely impaired in cognitive skills for daily decision making. She had behaviors of wandering. A care plan, dated 09/01/14 and last updated 09/13/14, documented, "...Focus: (named resident) has a behavior problem r/t pacing/wandering and elopement attempts. Is hard to redirect when she has decided to go into someone else's room or attempting to go out the doors... Goals: (named resident) will have decreased episodes of pacing and elopement attempts by review date... Interventions: If continues to be agitated ensure she is safe, leave, then return when noted to be calmer. Notify charge nurse of agitation... Anticipate and meet (named resident) needs. Caregivers to provided (sic) opportunity for positive interaction, attention. Stop and talk with him/her as passing by... Intervene as necessary to protect the rights and safety of others. Approach/Speak in calm manner. Divert attention. Remove from situation and take to alternate location as needed... Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes..." A nurse's note, dated 09/29/14 at 4:45 p.m., documented, "Staff reports that resident had a bar of soap at supper trying to put it on her bread (and) eat it. Resident spit it out. This nurse located resident and noted nothing in her mouth. Res given water to rinse mouth but resident swallowed it instead. Family (and) Dr. notified of transfer" A nurse's note, dated 09/29/14 at 5:30 p.m., documented, "Staff notices (sic) that resident is swollen around her mouth and lips are swollen as well. Resident appears to have a foreign object in mouth...Don notified. DON assessed (and) directed to call 911. Foreign (sic) object finally retrieved out of residents mouth. 1/4 long off white 1/8 (inch) thick (and) approximately 1/2 (inch) wide. 911 arrived and left facility c res (at) (6:10 p.m)..." An emergency room note, dated 09/29/14, documented, "...Reason: Allergic Reaction From NH with allergic reaction Complaint comment...via (named emsa) from (named facility) AO x 1 found with soap in mouth and edematous lips and tongue..." An emergency room physician note, dated 09/29/14, documented, "...Chief complaint: Allergic reaction Stated complaint: Allergic reaction... Physician comments: The patient is a [AGE] year old white female with history of advanced dementia who was sent from the nursing home for swelling of the lips likely due to allergic reaction. According to (named EMS) staff reportedly found the patient and noted her lips were swollen. The patient then spat a chewed up piece of a bar of soap. The patient has been given 50 milligrams of Benadryl IV by (named EMS) prior to arrival. She is in no respiratory distress... Physical exam: ...Angioedema of the upper and lower lips. Oropharynx does not show any significant swelling... The patient is observed in the emergency department with no progression of the swelling. She has no airway involvement is in no distress. I will tender back to the nursing home with prescriptions for steroids, H2 blocker and Benadryl to use as needed..." An emergency discharge note, dated 09/29/14, documented, "...Prescriptions: Pepcid...Prednisone...transport back to (named facility)..." A nurse's note, dated 09/29/14 at 8:30 p.m., documented, "Resident rtn to facility via ambulance...Lips and oral area still swollen very sleepy...new orders received..." A care plan, dated 09/01/14 and last updated 09/29/14, documented, "...Focus: (named resident) has impaired cognitive function or impaired thought processes r/t dx of Alzheimer... (written in) 9/29/14: Res noted to have swollen lips. Sent to ER... Goals: (named resident) will be able to communicate basic needs on a daily basis through the review date... Interventions: ...(written in) 9/29/14 Benadryl as ordered. Pepcid as ordered..." A nurse's note, dated 09/30/14 and untimed, documented, "Resident was sitting (at) dining table mouth was noted to have swelling by staff. Resident had taken bite out of a bar of soap et immediately spit it out per staff. Upon assessment resident noted to have swelling to right side of face et lip et was not opening mouth very wide. Resident did not have anything in her mouth. Resident was sent to hospital d/t swelling to r/o allergic reaction. Investigation was performed. Staff who have known resident report that this has happened to this resident before it was related to a 'nerve issue'. Resident had been treated with Benadryl (at) ER but the swelling continues to lip it et face and is not indicative of an allergy. Sweep of building was done...no soap was found throughout facility. Object patient had bit on may have been a hardened cookie or piece of bread." On 10/16/14 at 12:00 p.m., the DON was asked to recount the details of the incident due to contradictions in the nurse's notes. She stated, during the earlier nurse's note the resident was in the dining room and found to have an object in her mouth. She had taken a bite of the object. The staff were unaware what the object was for sure. The staff had the resident spit it out in the waste basket. She then said the resident was observed later in the hallway. The resident's lips and mouth appeared swollen. She examined the resident's mouth and nothing was found inside. Emergency services were initiated and the resident was transferred to the emergency room . She stated the resident had an episode before of an allergic type reaction to her mouth and lips and was treated. The DON was asked if they were unsure what the object was the resident bit on why was a sweep of the facility conducted for bar soap. She stated they wanted to check and make sure there was no bar soap with bite marks on it. She reported none was found on the sweep. On 10/16/14 at 12:00 p.m., the DON was asked to review the resident's care plan. She was then asked can you determine from looking at the resident's care plan if you have addressed the resident's most recent behavior in which an item was found in her mouth. She stated, "No I can't." She was then asked if the resident's care plan should be updated and revised to prevent the recurrence of the behavior. She stated, "Yes. I do think it should be." At 12:10 p.m., CNA #7 was asked to recount her observations of the incident. She explained she obtained the item from the waste basket in the dining room. She stated she was unable to determine what the item was. She further stated the item looked like it could have been a hardened cookie or piece of dried bread.

Based on observation, clinical record review, staff and resident interviews, and review of policies and procedures, it was determined the facility failed to assess, monitor, and intervene with issues related to pain for six (#1, 2, 7, 10, 12 and #13) of twelve sampled residents who received pain medication. This had the potential to effect 27 residents identified by the facility as needing pain management. Findings: A policy and procedure titled Pain Assessment, documented, "Policy: It is the policy of this facility to assure that residents with pain are identified and have interventions for relief. Purpose: To assure that residents with pain are identified and have interventions to relieve the pain so they can have an enhanced quality of life. Monitor documentation of the effectiveness of treatment. Procedure: 1. All residents are assessed for pain on admission. A pain assessment form is used and is placed in the resident's clinical record. Pain Management is also addressed in the MDS and Care Plan...3. Residents requiring pain medication on a routine basis will be assessed monthly by the LPN and documented on the MAR using scale 0-10...4. Residents requiring pain medication on a prn basis will be assessed at the time of medication administration and 1 hr later for relief and documented on the back of the MAR form..." 1. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A pain evaluation, dated 10/11/10, documented, "On routine pain meds, but staff need to cont (continue) to observe for pain sx + tx as indicated." The November 2010 TAR documented, "Clean coccyx + sheer to (L) buttock c N.S. Pat dry, loosely pack c gauze strip impregnated c wound gel. Surround wound c skin prep + cover c [MEDICATION NAME] absorbent drsg Q.O.D. + prn." The resident received dressing changes on the odd days in the month of November 2010. The November 2010 MAR documented the resident received [MEDICATION NAME] ([MEDICATION NAME]) 0.25 ml prn (5mg) on the following dates: 11/02/10 at 2:15 p.m. 11/10/10 at 3:00 a.m. 11/21/10 at 10:00 a.m. 11/21/10 at 9:45 p.m. 11/23/10 at 11:45 a.m. 11/23/10 at 2:30 p.m. 11/25/10 at 10:20 a.m. 11/28/10 at 6:30 a.m. 11/29/10 at 12:50 p.m. There was no documentation to indicate the resident was medicated with [MEDICATION NAME] prior to wound treatment or restorative care. A restorative care note, dated 11/07/10, documented, "Patient cries the whole time during the exercises. She states that its killing her." A restorative care note, dated 11/14/10, documented, "Patient hurts really bad when we do exercises with her." A physician's telephone order, dated 11/15/10, documented, "[MEDICATION NAME] 5mg 1 1/2 tabs bid." A restorative care note, dated 11/21/10, documented, "Resident hurts really bad when exercises are done." A nurse's monthly summary, dated 11/25/10, documented the resident had frequent, moderate pain. It documented the resident had vocal complaints of pain and showed facial expressions of pain. A restorative care note, dated 11/28/10, documented, "Patient crys (sic) when exercises are being done. She says that it hurts." The December 2010 TAR documented, "Cleanse coccyx c antimicrobial wound cleanser. Pat dry. Pack wound c Calcium Alginate + cover c [MEDICATION NAME] absorbent. (Change) every other day. May change outer drsg prn." The resident received dressing changes on the odd days in the month of December 2010. The resident also received dressing changes on 12/16/10 and 12/18/10. The December 2010 MAR documented the resident received [MEDICATION NAME] 0.25 ml (5mg) on the following dates: 12/04/10 at 11:00 a.m. 12/08/10 at 3:30 p.m. 12/10/10 at 9:25 a.m. 12/10/10 at 11:00 a.m. 12/17/10 at 10:20 a.m. 12/21/10 at 5:15 p.m. The December 2010 MAR documented the resident received [MEDICATION NAME] 0.50 ml (10mg) on the following dates: 12/22/10 at 9:25 a.m. 12/25/10 at 9:20 a.m. 12/26/10 at 10:00 a.m. There was no documentation to indicate the resident was medicated with [MEDICATION NAME] prior to wound treatment. A nurse's note, dated 12/01/10 at 9:00 a.m., documented, "Res wound to coccyx cleaned, + dressed. Res had some discomfort c this." The January 2011 monthly physician's orders [REDACTED]." A hospice nurse's note, dated 12/16/10, documented, "...Wound care provided to stg III on coccyx. Pt states 'It hurts so bad' 'Hurts like hell'...LPN gave [MEDICATION NAME] prior to drsg..." A nurse's note, dated 12/21/10 at 5:45 p.m., documented, "...Began to c/o ear pain + then generalized pain. CMA gave [MEDICATION NAME], but did not relieve pain or c/o pain...Resident not relieved of pain c 0.25 ml of [MEDICATION NAME]. (Hospice nurse) suggested to give complete ml for [MEDICATION NAME] + [MEDICATION NAME] x1 for prn pain. Gave 0.75 ml of [MEDICATION NAME]" A nurse's note, dated 12/21/10 at 6:30 p.m., documented, "(Family member) reports to this nurse resident still having pain. This nurse communicated c this resident + now does not have pain..." A monthly nurse's summary, dated 12/31/10, documented the resident had moderate pain daily to her coccyx area. The January 2011 MAR documented the resident received [MEDICATION NAME] 0.50 ml (10mg) on the following dates: 01/07/11 at 9:30 a.m. 01/08/11 at 3:50 p.m. 01/08/11 at 9:20 p.m. 01/09/11 at 11:00 a.m. There was no documentation to indicate the resident was medicated with [MEDICATION NAME] prior to wound treatment. The resident had physician orders [REDACTED]. The resident never received a full ml except on 12/21/10. A quarterly resident assessment, dated 01/04/11, documented the resident was severely impaired in cognitive skills for daily decision making. It also documented the resident was on a scheduled pain medication regimen and received prn pain medications. The assessment documented the resident made non-verbal sounds of pain, had vocal complaints of pain and also showed facial expressions of pain. The assessment documented the resident had indicators of pain or possible pain observed three to four days in the past five days. A nurse's note, dated 01/09/11 at 10:00 a.m., documented, "Tx to res coccyx performed, foul odor noted. Res had discomfort noted to tx..." A care plan, dated 01/26/10, documented the following: "Problem (Resident) has the potential for pain daily r/t dx of chronic pain Goal (Resident) will show no unrelieved pain sx daily through next review Approach -Administer routine and prn medications for pain per MD orders -Assess pain levels before and after administering prn pain medications -Assess for cause of pain and attempt to eliminate -Position for comfort -Alternate relief measures (e.g. backrub, relaxation exercises, guided imagery) -Notify hospice/physician if pain levels are not controlled with current pain meds -Observe for adverse reactions r/t the use of [MEDICATION NAME] and [MEDICATION NAME], notify physician as indicated." On 1/12/11 at 10:25 a.m., resident #7 was observed during wound care. The resident was observed lying on her left side with her face turned toward the wall. The resident was uncovered from her mid chest down. A Foley catheter was observed in place. The resident had a wound on her coccyx approximately the size of a silver dollar. The wound edges were rolled. An area approximately 1 to 2 inches surrounding the wound was red in color. LPN #2 stated the wound had drainage present and the wound had a foul odor. She further stated the wound was getting worse. She also stated there was tunneling at 6:00. The resident moaned throughout wound care however, when the wound was being cleaned and packed she cried out. The resident cried out, "That is hurting." The resident continued to cry until the wound care was finished. LPN #2 was asked if the resident had medication ordered. She stated, "Yes." She was asked if the resident had received pain medication prior to the wound treatment. She stated, "No." The LPN was asked if this resident was ever pre-medicated for pain prior to wound care. She stated, "It doesn't make any difference." On 01/13/11 at 9:30 a.m., LPN #4 was asked why the resident was transferred out of bed just three times a week. She stated, "Because it hurts her so much. She's in a lot of pain when moved." At 9:35 a.m., LPN #2 was asked why the resident was transferred out of bed just three times a week. She stated, "She's in a lot of pain and it hurts her." At 12:05 p.m., the resident was observed in bed. The resident responded to her name being called by opening her eyes. She was asked if she had any pain. The resident mumbled something which could not be understood. She was asked if she hurt. Again, the resident mumbled something. At 2:30 p.m. LPN #2 was asked if the resident was given any pain medication before her dressing change. She stated the resident was given pain medication after her treatment. The LPN stated the resident would cry all the time after her treatment and would complain of pain to her coccyx when lying on it. She was asked if the pain medication was effective for the resident. The LPN stated it was effective to a point. She went on to say the resident was actively dying that day and she felt there was a stage where the resident would just hurt all of the time. She stated the medication didn't seem to help the resident. She was asked how much [MEDICATION NAME] she gave the resident. She stated 0.5 ml (10 mg). She was asked if she ever gave the resident 1 ml which was ordered. She stated, "No." At 3:45 p.m., LPN #3 was asked if the resident was ever in pain. She stated, "Yes, she hurts when turned." She was asked if she had ever changed the resident's dressing. She stated she had on occasion and the resident would cry during the dressing change. She was asked if the resident was ever premedicated before the dressing change. She stated, "No, I couldn't say she was premedicated." On 01/14/11 at 8:40 a.m., CMA #2 was asked if the resident was medicated for pain before her dressing change. She stated they usually medicated her with [MEDICATION NAME] at 8:00 a.m. At 8:45 a.m., Hospice HHA #1 was asked if she had witnessed the resident in pain. She stated the resident was in pain off and on. She stated if the resident was moved she would complain of pain. She was asked if the resident complained of pain during a dressing change. She stated, "At one point she did holler when they were packing the wound." She stated she gave the resident a bath three times a week. When she received a whirlpool bath she would ask for the resident to be medicated first. She stated the medication didn't seem to help. She was asked what pain the resident complained of. The HHA stated she felt the resident's bottom hurt the most. She stated the resident once yelled, "There's something under my bottom and it hurts like hell." At 9:45 a.m., Hospice RN #1 was asked about the resident's pain issues. She stated the resident hadn't needed much more than [MEDICATION NAME] until the last few months when she started [MEDICATION NAME]. She stated it was reasonable to assume the resident was in pain when the wound was being packed. She stated the facility medicated the resident with [MEDICATION NAME] in the morning at 8:00 a.m. She stated she had visited with the facility a couple of times about premedicating the resident with [MEDICATION NAME] before her dressing change. She stated she would revisit this issue with them. 2. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 03/19/10, documented the resident had daily pain. Approaches to the problem included, "...address pain levels before and after administering prn pain medications - document results... assess pain characteristics... monitor factors effecting pain...notify physician if pain medication is not controlling pain symptoms..." Monthly physician's orders [REDACTED]. A MAR for October 2010 documented the resident received prn [MEDICATION NAME] 70 times between 10/01/10 and 10/31/10. There was no documentation the physician was made aware of the amount of prn pain medication used by the resident. A MAR for November 2010 documented the resident received prn [MEDICATION NAME] 78 times between 11/01/10 and 11/29/10. There was no documentation the physician was made aware of the amount of prn pain medication used by the resident. A MAR for December 2010 documented the resident received prn [MEDICATION NAME] 88 times between 12/01/10 and 12/31/10. There was no documentation the physician was made aware of the amount of prn pain medication used by the resident. A quarterly assessment, dated 12/20/10, documented the resident received scheduled and prn pain medications. The assessment documented the resident had frequent, moderate pain that effected daily function. A pharmacist's consultation report, dated 12/27/10, documented, "...(resident) frequently requests prn [MEDICATION NAME] medication for pain relief, i.e. [MEDICATION NAME] 10-500 prn and occasionally Tylenol 325 mg prn. The only routine medications she receives for pain are Daypro 600 mg 2 PO QD (daily) for arthritis and [MEDICATION NAME] 100 mg one PO TID ([MEDICAL CONDITION]). Would she now benefit from the addition of a routine pain med?... If so....please consider the addition of 1). [MEDICATION NAME] 50 mg one PO q 8 hours. After one week of therapy, have nursing evaluate her pain control. If, at that time, her pain is not being addressed, 2). increase to [MEDICATION NAME] 50 mg two PO q 8 hours....Hopefully this will...better manage her pain...Rationale for Recommendation - ...Initiating routine [MEDICATION NAME] therapy should improve pain control and decrease the frequency with which this individual must locate a caregiver to request prn medications... Physician's Response: (x) I decline the recommendation(s) above due to the reasons below...Would put her on routine Tylenol instead; consider stopping [MEDICATION NAME] if she does not take often..." The form was signed and dated by the physician on 01/06/11. A MAR for January 2011 documented the resident received prn [MEDICATION NAME] 45 times between 01/01/11 and 01/14/11 (less than half of the month). On 01/14/11 at 1:00 p.m., LPN #1 was asked to describe resident #12's pain. She stated, "She has pain frequently - daily. She usually complains of pain in her knees due to arthritis. Also her lower back. She has had pretty severe pain since she's been here and takes a lot of pain medication." At 3:00 p.m., the DON was asked if the physician was aware of the resident's frequent use of prn [MEDICATION NAME]. She stated the physician had recently responded to a pharmacy recommendation and had "threatened" to discontinue the [MEDICATION NAME] and replace it with Tylenol. She stated, "The resident wouldn't stand for that, so we left it alone." The DON was asked to review the pharmacy consultation note. She was asked if the response by the physician indicated he was aware how much [MEDICATION NAME] the resident needed to get pain relief. She stated, "I think I misunderstood what the physician wrote. I don't think he was aware of how much pain the resident is in. He doesn't know how much [MEDICATION NAME] she takes." 3. Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. A Pain Evaluation form, dated 10/07/10, was incomplete. It did not document what increased the resident's pain, times when the pain was worse, how the pain felt one hour and three hours after medication was administered, or what was the resident's acceptable pain level. The form documented pain management was necessary and to 'refer to the resident's plan of care'..." Monthly physician's orders [REDACTED]. There was no MAR for prn medications available for October 2010. A monthly pain rating on the MAR, dated 10/19/10, documented the resident had pain at a level "6" on a 1 to 10 pain scale. There was no other pain assessment found in the resident's clinical record. The MAR for November 2010 documented the resident [MEDICATION NAME] times between 11/01/10 and 11/08/10. There was no documentation of a pain level score on the MAR for November 2010. Monthly physician's orders [REDACTED]. as needed for pain..." The MAR for November 2010 also documented the resident received [MEDICATION NAME] 25 times between 11/01/10 and 11/30/10. A nurse's note, dated 11/14/10 at 11:30 a.m., documented, "...asked res how his hip was & if he was having any pain (that was) worse than before the fall...Res stated, 'I don't hurt (because) of the fall. I fell (because) I hurt.'" A radiology report, dated 11/16/10, documented, "...Impression: Right Hip: Old impacted [MEDICAL CONDITION] of the femur with varus deformity and flattening of the head of the right femur..." A radiology report, dated 11/29/10, documented, "Impression: Right Hip: [MEDICAL CONDITION] arthritis with narrowing of the joint space and marginal [MEDICAL CONDITION] reveals extensive [MEDICAL CONDITION] arthritic changes..." There was no documentation of a pain assessment in November 2010. A December 2010 restorative nursing progress note documented the resident refused to do his exercises on eight occasions (12/05/10, 12/07/10, 12/08/10, 12/16/10, 12/20/10, 12/23/10, 12/26/10 and 12/27/10) due to pain. An initial assessment, dated 12/09/10, documented the resident had a scheduled pain medication regimen and had frequent pain of moderate intensity. A care plan, dated 12/09/10, documented the resident had "...debilitating disease of the joints...pain and discomfort...that required assessment for pain management and monitoring for irritability..." The care plan failed to address a pain management program to include resident-specific information about: ? how often the resident should be assessed for pain, ? the characteristics of the resident's pain, to include the causes of pain, the location of pain, the intensity, frequency and duration of the pain, and any other descriptors used by the resident, ? non-verbal cues expressed by the resident that indicated pain, ? how often the resident used prn medication, ? what non-medication interventions for pain control were effective, or ? when the resident's pain should be evaluated after interventions were instituted. There was no pain assessment for December 2010 located in the clinical record. There was no pain rating scale documented on the MAR for December 2010. On 01/12/11 at 9:10 a.m., resident #10 was observed in his room sitting in a motorized wheelchair. Two CNAs were preparing to transfer him to the bed. As they slightly lifted his feet from the footrest, he cried out in pain and began moaning. He was asked about his pain symptoms. He stated he had severe pain in his hips in the mornings and was told he couldn't have his prn pain medication because he got routine [MEDICATION NAME] in the morning. He stated he was told by CMA #1 and others that he had to wait 2-4 hours for the prn [MEDICATION NAME]. He stated until he got the [MEDICATION NAME], he could not move at all in the mornings. At 9:15 a.m., CMA #1 was asked if she questioned residents about pain symptoms when she was giving routine medications. She stated she did not. She was asked about resident #10's pain symptoms and requests for prn pain medication. She stated, "He wants a prn [MEDICATION NAME] with his regular morning medications. I've been told by the LPN to wait four hours to give the prn [MEDICATION NAME]." LPN #2 was asked if resident #10 had to wait four hours to get his prn [MEDICATION NAME] in the mornings. She stated, "He has to wait two hours after his morning meds. Maybe it's just one hour." She was asked who determined that time frame. She stated she didn't know. She was asked if she referred to the resident care plan for information on how to care for the resident's pain. She stated she did not. At 9:20 a.m., the MDS nurse was asked to characterize the resident's pain. She stated the resident says his pain is always bad. 4. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Monthly physician's orders [REDACTED]. A Pain Evaluation form, dated 10/07/10, documented the resident had generalized pain that was "aching and throbbing", the pain was worse in the pre-dawn hours, and required medication and frequent position changes to provide relief. The form documented, "...pain management intervention is necessary, refer to resident plan of care..." The MAR for October 2010 documented the resident received prn [MEDICATION NAME] 14 times between 10/08/10 and 10/31/10. There was no pain assessment documented for October 2010. Monthly physician's orders [REDACTED]. The MAR for November 2010 documented the resident received prn [MEDICATION NAME] 24 times between 11/01/10 and 11/30/10. There was no pain assessment for November 2010. The MAR for December 2010 documented the resident received prn [MEDICATION NAME] 17 times between 12/01/10 and 12/31/10. An initial assessment, dated 12/08/10, documented the resident was receiving scheduled and prn pain medication, received non-medication intervention for pain and had frequent pain the resident described as "moderate." A care plan, dated 12/08/10, documented the resident had "...chronic debilitating disease of the joints...(that required) assessment for pain management..." The care plan failed to address a pain management program to include resident-specific information about: - what type of pain scale should be used to assess pain; - how often the resident should be assessed for pain; - the characteristics of the resident's pain, to include the causes of pain, the location of pain, the intensity, frequency and duration of the pain, and any other descriptors used by the resident; - non-verbal cues expressed by the resident that indicated pain; - how often the resident used prn medication; - what non-medication interventions for pain control were effective; - increases in pain medication orders; or - when the resident's pain should be evaluated after interventions were instituted. There was no pain assessment for December 2010. On 01/12/11 at 9:10 a.m., the resident was observed lying in her bed with her eyes closed. She stated she was in pain and preferred to lie very still to stay comfortable. She was asked if the facility provided pain medication when she needed it. She stated she had to ask for prn pain medication two hours in advance of when she may need it because it takes the staff so long to respond to the request. She stated sometimes when she asks for medication early, the staff won't give it to her. Then, the staff forget to come back and give it to her when it's time. On 01/13/11 at 4:00 p.m., LPN #3 was asked to characterize residents #2 and #10's pain. She stated, "They complain of pain a lot. I can tell they are in pain. He cries out and grimaces when he moves. She (resident #2) sometimes asks for pain medication but falls asleep before she can get it. But she wants to be woken up for it." She was asked if resident #2 and #10 were sedated. She stated, "No. But I think they were used to taking a lot of pain medication at home before they came here. I'm not here to judge." She was asked if the residents had a care plan specific to pain management. She stated she did not know. 5. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 03/18/10, documented the following: "Problem (Resident) is receiving restorative nursing care to maintain physical functioning. Goal (Resident) will participate with restorative nursing as ordered and will maintain current level of physical functioning through next review. Interventions 1) Restorative nursing as ordered 2) RNA to document progress weekly on back of restorative sheets 3) Observe for need of changes in restorative orders as indicated 4) Notify P.T. of need for changes in restorative nursing care treatments. 5) Restorative aides to notify charge nurse or R.N. of decline in physical functioning. 6) Restorative nursing to be performed at least 3 times wkly or as ordered." A restorative care note, dated 11/07/10, documented, "Resident performs his exercises but it hurts his legs he crys (sic) the hole (sic) time." A restorative care note, dated 11/14/10, documented, "Patient says it hurts to do his exercises." A restorative care note, dated 11/21/10, documented, "Resident crys (sic) when exercises are done to his legs." A restorative care note, dated 11/28/10, documented, "Patient's legs hurts when exercises are done." The December 2010 monthly physician's orders [REDACTED]. The November 2010 and December 2010 MAR documented the resident did not receive any Tylenol during these months. A Pain Evaluation, dated 12/18/10, documented, "Reminded CNA's to alert LPN of res pain to legs for intervention and pain control before proceeding c ROM." A quarterly assessment, dated 12/24/10, documented the resident was severely impaired in cognitive skills for daily decision making. It also documented the resident received non-medication intervention for pain within the last five days. On 01/12/11 at 12:55 p.m., CNA #1 was asked if she performed range of motion with the resident. She stated they straightened out his arms and legs when they assisted him with dressing. The CNA was asked if the resident complained of pain when dressing. She stated the resident did complain of pain when doing range of motion with dressing. She stated he would say, "That hurts." She stated he complained of pain pretty frequently. The CNA also stated the restorative aides usually performed the range of motion. At 1:00 p.m., the resident stated no one did exercises with his legs or arms and that he didn't remember ever having pain. At 1:20 p.m., restorative aide #2 (RA) was asked if the resident ever complained of pain. She stated the resident was in pain every time he received his range of motion from them. Restorative aide #1 agreed with RA #2. RA #2 stated she thought the resident received pain meds before he received range of motion because she saw the nurse giving peg tube medications to the resident. The resident did not receive pain medication in November 2010 or December 2010. He did receive other meds through his peg tube. 6. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. A careplan, dated 10/22/10, documented, "Problem: (Resident) has alteration in pain and comfort; chronic back pain; takes [MEDICATION NAME] 7.5/500 mg ii p.o. tid. Goals: Pain will be relieved within 30 minutes of intervention thru next review date. Interventions: -Position resident for comfort. -Medicate as ordered and needed. -Notify MD (physician) if pain medication not effective. -Encourage to rest after being medicated to facilitate relief. -Observe resident for side effects from medication (i.e. nausea/vomiting, pain in abdomen and distention, constipation, etc.) and notify MD if any seen. -Assess resident for pain management. -Monitor nonverbal cues that may indicate pain or discomfort. -Apply prn topical Sore-no more to knees and back per MD orders." The admission assessment, dated 11/02/10, documented the resident's cognitive skills for daily decision making were moderately impaired. The resident was documented as having been on a pain medication regimen and had severe pain frequently. The monthly Physicians Orders, dated January 2011, documented: "Hyrdocod/Acetamin ([MEDICATION NAME]/[MEDICATION NAME]) 7.5/500 table: 2 tabs by mouth three times daily for 60 days and renew. [MEDICATION NAME]/Acetamin 7.5/500 table: 1 tab by mouth every 4 hours during night 8pm-6am as needed for breakthrough pain for 60 days and renew. [MEDICATION NAME] 600 mg tablet: 1 tablet by mouth every 6 hours as needed for pain (alternate with Tylenol). Tylenol Extra Strength 500 mg tablet: 2 tabs by mouth every 4 HRS. (hours) as needed for pain or elevated temperature." On 01/14/11 at 9:45 a.m., resident #13 was observed in bed. The resident stated she had back pain and they wouldn't give her any pain medication. She stated the nurse would come and say she would go get someone to give her medication but they would not return. The resident stated she had asked for pain medication two hours ago. At 10:03 a.m., the resident asked an unidentified housekeeper for pain medication. She stated she would go tell the nurse. At 10:05 a.m., the housekeeper told the resident that she had let the nurse know of her request for pain medication. The nurse told the housekeeper she would be there in a minute. At 10:13 a.m., an unidentified CMA assisted the resident to the restroom. The resident told the the CMA of her back pain. She stated she would let the nurse know. At 10:30 a.m., the resident continued to complain of pain. The nurse had not presented to the resident's room. At 10:37 a.m., The resident had not been assessed or medicated for pain. At 10:45 a.m., the resident continued to complain of back pain. The resident had not been assessed or medicated for pain. At 10:50 a.m., LPN #2 was asked if the resident had anything for pain. She stated the resident received [MEDICATION NAME] at 8:00 a.m. today and she received it three times each day. She presented to the resident's room and asked her if she was in pain. The resident stated she was having back pain. On a scale of 0 to 10, she rated her pain 9 of 10. LPN #2 directed CMA #2 to give the resident [MEDICATION NAME] 7.5/500 m.g. CMA #2 administered the [MEDICATION NAME] to the resident. At 11:30 a.m., the DON (director of nurses) was informed of the resident's complaints of pain and the length of time before she was medicated. The DON stated the nurse should have come to assess and medicate the resident sooner. She stated she would in-service the staff.