Every finding on record at Lakeview Nursing & Rehab

Based on observation, record review, and interview, the facility failed to ensure the deep fryer was clean and free of food particles and the splash guard on side of stove was cleaned routinely. The administrator identified 55 residents resided in facility and received their food from the kitchen. Findings: A Sanitization policy, revised October 2008, read in part, the food service area shall be maintained in a clean and sanitary manner, and for fixed equipment, the removable components will be scraped to remove food particle accumulation. On 02/10/25 at 10:20 a.m., a tour of the kitchen was conducted. The deep fryer was dirty with dried food particles and there was an accumulation of grease on the splash guard attached to the stove. On 02/11/25 at 8:53 a.m., a tour of the kitchen was conducted. The deep fryer was dirty with dried food particles and there was an accumulation of grease on the splash guard attached to the stove. On 02/11/25 at 8:56 a.m., dietary aide #1 was asked when was the deep fryer and the side of the stove cleaned. They stated they thought the food was from last night and they thought the fryer got cleaned every week, but was not sure. 02/11/25 at 12:54 p.m., the CDM was asked how long had the food particles on the inside tray of the deep fryer been there. They stated probably from yesterday and should have been cleaned. The CDM was then asked when the splash guard on the stove next to the deep fryer was wiped down and/or cleaned. They stated they did not remember when the last time it was cleaned.

Based on record review and interview, the facility failed to ensure a referral to the LOCEU was made when a resident had a diagnosis of a serious mental illness for one (#30) of 2 sampled residents reviewed for PASARR. The administrator identified 55 residents who resided in the facility. Findings: Resident #30 had diagnoses which included schizoaffective disorder and anxiety disorder. A PASARR form, dated 03/03/22, showed the resident did not have a diagnosis of a serious mental illness. The care plan, dated 09/24/24, showed the resident received psychotropic medication. An annual assessment, dated 12/20/24, showed the resident had a psychiatric/mood disorder. The assessment showed the resident was not currently considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. On 02/11/25 at 3:06 p.m., MDS/PASARR coordinator #1 stated the level l was correct, but with a new diagnosis of schizoaffective disorder a level ll referral should have been made.

Based on observation, record review, and interview, the facility failed to ensure an insulin vial was cleaned prior to administration for 1 (#27) of 1 sampled resident observed for insulin administration. The assistant director of nursing identified four residents received insulin. Findings: A Specific Medication Administration policy, dated April 2018, showed staff were to clean the stopper and the top of the vial, with an alcohol pad, and allow it to air dry. On 02/11/25 at 10:42 a.m., LPN #1 was observed to prepare an insulin injection for Resident #27. They did not clean the top of the insulin vial prior to drawing up the insulin. On 02/11/25 at 10:44 a.m., LPN #1 administered the insulin to Resident #27. On 02/11/25 at 10:47 a.m., LPN #1 stated they were supposed to clean the top of the insulin vial but, forgot.

Based on record review, observation, and interview, the facility failed to prepare and distribute food under sanitary conditions. The Resident Census and Conditions of Residents report documented 38 residents resided in the facility. Findings: A policy titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices documented .Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens .Employees must wash their hands: .After handling soiled equipment or utensils .During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks .After engaging in other activities that contaminate the hands . On 10/17/23 at 12:08 p.m., Dietary Aide #1 was assisting with preparation of the cart for the hall. A lid covering a meal plate fell off the cart to the floor. The aide picked up the lid and returned it to cover the plate. On 10/17/23 at 12:13 p.m., Dietary Cook #1 was observed in the kitchen serving the noon meal. The cook had a beard that was long enough to rubber band in a ponytail. The cook was not wearing a beard restraint. On 10/17/23 at 12:16 p.m., Dietary Cook #1 stated if the beard was in a ponytail it was acceptable. At that time the DM stated it was not acceptable. On 10/19/23 at 12:28 p.m., Dietary Cook #2 donned a pair of gloves to serve the noon meal. The cook opened a package of flour tortillas and placed the tortilla on a plate. The cook scooped a ladle of meat placing it on the tortilla and with a different ladle scooped a ladle of corn. With different tongs for each item, the cook obtained cheese from a bag and lettuce and tomatoes from different containers. The cook prepared four trays with the same process obtaining a new plate from a stack beside the steam table. Using the same gloved hands touching other surfaces the cook handled the flour tortilla without using a utensil or changing their gloves and washing their hands. On 10/19/23 at 12:50 p.m., Dietary Cook #2 stated they did not change their gloves or wash their hands when touching different surfaces.

Based on record review, observation, and interview, the facility failed to assist a resident with ADLs for one (#18) of 12 residents reviewed for activities of daily living. The Resident Census and Conditions of Residents report documented 38 residents resided in the facility. Findings: A policy titled Safe Lifting and Movement of Residents documented .Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices .Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary . Res #18 was admitted to the facility on [DATE] with diagnoses which included Huntington's disease, anxiety disorder, and major depressive disorder. A quarterly assessment, dated 09/07/23, documented the resident was moderately impaired for daily decision making and required extensive to total assistance with ADLs. The care plan, last reviewed on 09/07/23, documented the resident required assistance with all ADL care. The care plan documented the resident required extensive assistance with eating, bathing, and must be shaved by staff. On 10/17/23 at 1:08 p.m., the resident was observed lying on a fall mat beside their bed. The resident was asleep and was unshaven. The resident's meal tray was on the bedside table and untouched. The resident's roommate stated the resident was not awake for the meal. On 10/17/23 at 1:12 p.m., CNA #3 picked up the meal tray from the resident's room and stated the resident did not eat. The staff stated they would get the resident some soup. On 10/17/23 at 2:00 p.m., an observation was made of the resident during incontinent care. There was debris between the resident's toes. The resident remained unshaven. The staff stated hospice services provided baths for the resident. On 10/18/23 at 10:08 a.m., the resident was observed in the lobby area in high back wheelchair with no foot/leg extensions and was unshaven. CNA #1 was standing beside the resident and the resident stiffened their body and slid off the seat of the chair. Restorative Aide #1 assisted CNA #1 to position the resident back in the wheelchair. The staff hooked their arm under each side of the resident's upper arm and grabbed the resident's pants to position the resident back in the wheelchair. CNA #1 then pushed the resident in the wheelchair to their room. The resident's bare feet and heals bouncing and dragging on the floor. CNA #1 and Restorative Aide #1 transferred the resident to bed using the same method of hooking under the resident's arms and grabbing the resident's pants. On 10/18/23 10:12 a.m., CNA #1 was asked how to transfer a resident. The CNA stated to grab the back of their pants and hook your arm under their arm/arm pit. On 10/23/23 at 08:40 a.m., the resident was observed in the dining room for breakfast. The staff was assisting the resident with the meal. The resident was unshaven. On 10/24/23 at 9:20 a.m., the DON reviewed the resident's clinical records for hospice services. The DON stated their was no documentation regarding ADL care provided by the hospice services. On 10/24/23 at 9:40 a.m., the resident was lying in bed, sleeping, and unshaven.

On 07/06/22 an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent falls and to consistently identify and implement interventions to prevent falls for Res #15, 24, and #30. Resident #15 fell multiple times including one where the Res had sustained a laceration to the right leg which required sutures and subsequently became infected and required further hospitalization . Res #24 fell multiple times and with one fall received a large bump to the upper right forehead and was later found face down in the floor of another resident's room. Res #24 was not responsive and subsequently sent to the hospital for evaluation. Res #24 continued to fall. Res #30 had fallen multiple times with different injuries including one where the Res had sustained a hematoma to his right eyebrow. A week later Res #30 was sent to the hospital for evaluation of [CONDITION(S)] like activity. On return from the hospital, Res #30 continued to fall. On 07/06/22 at 2:10 p.m., OSDH verified the existence of the IJ situation in regard to the failure of the facility to provide interventions and supervision to prevent falls. On 07/06/22 at 2:19 p.m., the administrator was notified of the IJ situation. On 07/06/22 at 6:12 p.m., a plan of removal was accepted. The plan of removal read in part, Plan of Removal: On July 6th, 2022 at 2:19pm [sic], fall assessments initiated and will be completed on 50 of 50 residents residing in facility with the potential to fall (to be completed by 11am on 7/7/2022[)] Immediate interventions put in place for residents #15, #24, and #30 as well as interventions for residents who's [sic] assessment place them at high-risk for falls (to be completed by 2pm on 7/7/2022[)] Fall Interventions care planned on residents #15, #24, and #30 as well as others who are at high-risk for falls (to be completed by 2pm on 7/7/2022) Direct care staff in serviced on reporting falls, incident/fall scene investigations, interventions, fall policies and procedures, location of quick reference fall guide (completed by 2pm on 7/7/2022[)] Non-direct care staff in serviced on preventing and identifying fall hazards (to be completed by 12pm on 7/7/2022) Quick reference guide with fall policy & Procedure placed at nurse's station (to be completed by 7pm on 7/6/2022) On 07/07/22 in-services were provided by the DON/designee to all staff. Topics of the in-service included reporting falls, incidents, accidents, fall scene investigation, witness statements, interventions, a review of the fall policy and procedure, and quick reference guide for falls. On 07/07/22 at 11:45 a.m., the IJ was removed when all components of the plan of removal had been completed. The deficient practice remained at an actual harm at a pattern. Based on record review, observation, and interview, the facility failed to ensure each resident received supervision and interventions to prevent falls for four (#15, 21, 24, and #30) of four residents reviewed for accident hazards. The administrator identified 29 residents had fallen in the previous six months. Findings: A facility protocol, titled Falls - Clinical Protocol revised in September 2012, read in parts: .Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .Monitoring and Follow-Up a. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall .If a resident continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (bedsides those that have already been identified) and will re-evaluate the continued relevance of current interventions . A facility policy, titled Accidents and Incidents - Investigating and Reporting, revised February 2014, read in parts, .1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: .k. Any corrective action taken; .6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence . 1. Resident #15 had diagnoses which included [CONDITION(S)], embolism of deep veins of the lower extremities, pulmonary embolism, and [CONDITION(S)]. A care plan, dated 12/03/20, documented Res #15 was at risk for falls. The plan of care did not document a goal or interventions to prevent falls. An incident report, dated 07/22/21, documented Res #15 had attempted to transfer from bed to BSC and appeared to have lost her balance. The report documented Res #15 hit her head on the bathroom door, sustained a small knot to crown of her head, and a small abrasion to left inner eye from her glasses. The incident report did not document any STPR of falls. A care plan, dated 08/02/21, documented Res #15 had a history of falling, with a goal of falls will not cause injury through the next review date, and interventions that read in part, .Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician Remind to use call light for assistance . An incident report, dated 09/12/21, documented the staff found Res #15 sitting on the floor up against the wall. The incident report documented Res #15 stated she hit the top of her head and neuro checks were started. A STPR was documented as to move the BSC closer and to encourage Res #15 to use the call light. The care plan for Res #15 did not document the intervention. An incident report, dated 10/12/21, stated the staff were called to Res #15's room and found her on the floor near her bed. The report documented Res #15 stated she was getting off the bed to use commode and fell . The report documented Res #15 was not injured. The STPR was to instruct Res #15 to use her call light and staff were to make sure it was in reach. A fall risk assessment form, dated 12/16/21, documented Res #15 scored 14. The form documented a score of ten or more indicated a high risk for falls. A quarterly assessment, dated 02/14/22, documented the resident was intact in cognition and required extensive assistance with most ADLs. The assessment did not document Res #15 had fallen. An x-ray report, dated 12/14/21, read in part, .marked lateral displacement of patella . No incident report or documentation was found related to injury was provided by the facility. A fall risk assessment for Res #15, dated 03/12/22, documented Res #15 scored 14. The form documented a score of ten or more indicated a high risk for falls. An incident report, dated 03/19/22, documented Res #15 was laying on the floor beside the bed face down. The report documented Res #15 complained of pain to her face, right leg, neck pain, and sustained a laceration to her right leg. The incident report documented CNA #3 had attempted to provide a bed bath to Res #15 without assistance. The form documented when the CNA attempted to turn Res #15 she rolled off the bed. The report documented Res #15 was sent to the hospital via EMS. The STPR were documented as address to Res #15's safety needs on return from the hospital, to make sure the wheels of the bed were locked, and staff were to be in-serviced on care plans. The care plan was not updated related to this fall. An entry to a sheet on the Res #15's care plan, dated 03/19/22, documented Fall with Laceration. The entry did not include new interventions to prevent falls. A nurse note, dated 03/24/22, documented Res #15 was given antibiotics and was to be transferred to the hospital for wound treatment related to laceration sustained on 03/19/22. A staff in-service, dated 04/12/22, was conducted and staff members were instructed to follow residents' care plans or ask a nurse if there were any questions. A hospital discharge record, dated 04/13/22, documented Res #15 had been admitted from the nursing home due to right lower extremity [CONDITION(S)] after having a laceration on the leg which was caused from a fall. A quarterly assessment, dated 05/11/22, documented Res #15 was cognitively intact, required two plus person physical assist for bed mobility, and had no falls. On 06/29/22 at 9:54 a.m., Res #15 was observed in her bed. The bed was in a high position. Res #15 stated she had fallen several times. On 07/06/22 from 9:45 a.m., to 9:55 a.m., four CNA's and CMA's were interviewed regarding the fall prevention for Res #15. They stated the only intervention was is 4 person assist, one CNA added to keep the call light close. On 07/06/22 at 10:35 a.m., the MDS coordinator was asked how the facility notified her of resident falls and for any new interventions. The MDS coordinator stated she was getting copies of incident reports for a time. The MDS coordinator reviewed Res #15's care plan and stated it did not have the appropriate interventions to prevent falls for this resident. The MDS coordinator stated she did add Res #15 required a four person assist under the ADL care plan however this intervention should have been added to the fall care plan as well. 2. Res #24 was admitted to the facility on [DATE] with diagnoses which included acute [MEDICATION(S)] with hematuria, unspecified dementia with behavioral disturbance, and [CONDITION(S)]. A Fall Risk assessment, dated 12/17/21, documented the resident was at high risk for falls. An incident report, dated 01/12/22, documented the resident attempted to sit in a geri-chair and missed the chair without injury. No new STPR were added to the care plan. A quarterly assessment, dated 02/21/22, documented the resident was severely impaired with cognition, required supervision and limited assistance of one person physical assistance with transfers and locomotion. An incident report, dated 03/04/22, documented the resident was walking and lost his balance without injury. No new STPR were added to the care plan. A nurse's note, dated 03/31/22, documented the resident stumbled on a wheelchair that had a resident in it and fell face first. The note documented the resident received a large bump to the upper right forehead. The note documented the resident refused neuro checks. The note documented an hour later the resident found in a women's room face down in the floor in the corner of the room. The note documented the resident was sent to the emergency room due to not responding to voice normally, and had to shake him or other stimuli for him to respond. No new STPR were added to the care plan. No incident or state reportable reports were found. An incident report, dated 04/05/22, documented the resident was sitting on his bottom just inside his room without injury. The report documented to add the resident to the restorative program. No new STPR were added to the care plan. A nurse note, dated 04/27/22, documented the staff went to check the resident to see if he was dry and found him in the floor without injury. No new STPR were added to the care plan. An incident report, dated 05/21/22, documented the resident was wandering and ambulating independently about the day room in front of the desk when he suddenly became weak and fell backwards. The report documented he did not hit his head and to continue neuro checks. No new STPR were added to the care plan. An incident report, dated 06/05/22, documented the resident was wandering around facility into the dining room and tripped over a wet floor sign without injury. The report documented to redirect when ambulating close to an area where signs are being utilized. STPR were not added to the care plan. A Fall Risk Assessment, dated 06/13/22, documented the resident was a high risk for falls. An incident report, dated 06/22/22, documented the resident was laying on his back on the floor with a small abrasion to his left arm and neuro checks were initiated. No new STPR were added to the care plan. On 07/06/22 at 1:57 p.m., the MDS coordinator stated the last review of resident's care plan was 02/28/22. The MDS coordinator reported the care plan should have been revised and interventions put in place after each fall. 3. Res #30 had diagnoses which included dementia with behavioral disturbance, [CONDITION(S)], and diabetes. A quarterly resident assessment, dated 02/11/22, documented the resident was moderately cognitively impaired, required total assistance for bed mobility, transfers, toileting, and personal hygiene, had limited range of motion in both lower limbs, and had one fall with minor injury since the last assessment. An incident report, dated 03/21/22, documented Res #30 had a fall from bed without injury. An intervention of a fall mat was documented. The care plan was not updated with STPR. A fall risk assessment, dated 03/29/22, documented a score of 18 which placed the resident at high risk for falls. A nurse progress note, dated 04/17/22 at 3:00 p.m., documented Res #30 had a fall from the bed without injury. No intervention was documented for this fall. A nurse progress note, dated 04/18/22, at 3:15 p.m., documented Res #30 had a fall from bed which resulted in a 3 x 4 cm abrasion to the right knee. No intervention was documented for this fall. An incident report, dated 04/24/22, documented Res #30 had a fall from the bed which resulted in swelling and bleeding to the left eyebrow. No intervention was documented for this fall. A nurse progress note, dated 04/30/22 at 10:20 a.m., documented Res #30 was sent to the emergency room for evaluation due to [CONDITION(S)]-like activity. A nurses progress note, dated 04/30/22 at 1:30 p.m., documented Res #30 was sent via life-flight to a different hospital. A hospital discharge record, dated 05/09/22, documented Res #30 was to return to the facility with hospice to provide terminal care. A care plan, reviewed 05/20/22, documented Res #30 was at risk for falls. The interventions included: remind resident to ask for staff assistance with transfers and monitor for changes which may warrant increased supervision or assistance. An incident report, dated 05/21/22, documented Res #30 had a fall from the bed without injury. No intervention was documented for this fall. A significant change assessment, dated 05/23/22, documented Res #30 was severely cognitively impaired, required extensive assistance with bed mobility, required total assistance with transfers, dressing, toileting, personal hygiene and bathing, and had one fall without injury since last assessment. An incident report, dated 05/31/22, documented Res #30 had a fall from the bed resulting in a hematoma to the right eyebrow. No interventions were documented for this fall. On 07/05/22 at 2:34 p.m., Res #30 was observed in bed with a fall mat pushed underneath the bed. On 07/06/22, at 10:17 a.m., CNA #1 stated the fall precautions for Res #30 was a fall mat, and that she could ask the nurse for access to the care plan to see what interventions were required. On 07/06/22 at 10:18 a.m., CNA#2 stated she asked the nurse what to do for each patient and did what the nurse asked. She could not state any specific interventions for resident #30. On 07/06/22 at 10:22 a.m., the MDS coordinator stated she did not care plan any fall interventions after each of the falls. 4. Res #21 was admitted to the facility with diagnoses which included [CONDITION(S)] and [CONDITION(S)] disorder. A care plan, dated 01/26/22, documented Res #21 had a history of falls with interventions in place. A quarterly assessment, dated 04/29/22, documented Res #21 was cognitively intact and required assistance with ADLs. A nurse progress note, dated 05/03/22, read in parts, .at approx 6 pm this evening .fell as leaving the dining room .C/o head pain and shoulder and arm pain. sent to er. family notified.'' A nurse progress note, dated 05/16/22, read in part, .res cont to c/o arm pain. Sent to ER for xray. reveals fx of humerous [sic] . A physician progress note, dated 6/21/22, read in part, '' .she sustained a fall last month and C/O Right arm pain. The initial xray was negative for fracture: however, per the staff, she eventually went to the ER where a Right humeral fracture was identified . On 07/06/22 at 4:30 p.m., the MDS coordinator reported the resident did have a care plan for falls but it had not been revised since 01/26/22. The MDS coordinator stated the care plan should have been revised with interventions after the resident fell . On 07/06/22 at 4:38 p.m., the administrator reported the care plan had not been updated since 01/26/22 and the care plan should have been updated on 05/03/22 with additional interventions for falls.

Based on observation and interview, it was determined the facility failed to ensure the removal of expired medications and supplies from the medication storage room. This had the potential to affect all 50 residents who resided in the facility. Findings: On 07/07/22 at 11:00 a.m., the medication room was observed. Expired medications and supplies were found in the facility's medication storage room for the following: One bottle of Control Solution for blood glucose monitoring with an expiration date of 06/05/22. Two boxes of 12 gauge flip lock needles with an expiration date of 06/2020. Two boxes of [MEDICATION(S)] solution 2.5mg/3ml with a use by date of 11/10/2021. On 07/07/22 at 11:00 a.m., the CMA reported the expired medications and supplies should have been removed from the medication storage room.

Based on record review, observation, and interview, the facility failed develop a comprehensive care plan which included goals and interventions for three (#15, 30 and #35) of 21 residents whose care plans were reviewed. The facility failed to develop a care plan related to: a. the use of a urinary catheter for Res #15. b. pressure ulcers for Res #30. c. bathing needs for Res #35. The Resident Census and Conditions of Residents documented 50 residents resided in the facility. Findings: 1. Res #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for Res #15, dated 04/14/22, documented Res #15 had occasional urinary incontinence and would have no further decline in urinary continence through the next review period. A quarterly assessment, dated 05/11/22, documented Res #15 had a urinary catheter. On 06/29/22 at 9:19 a.m., Res #15 stated she received a urinary catheter when was in the hospital in April and the facility had not attempted to remove it. Res #15 stated she did not know why she had a catheter. On 07/06/22 at 3:45 p.m., the MDS coordinator reviewed Res #15's care plan and stated she had not know about the urinary catheter until this week. She stated she had not put interventions in for the use of a catheter. 2. Resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound physician summary, dated 03/17/22, documented new unstageable deep tissue injuries to the right and left ankles. A physician order, dated 03/18/22, documented low air loss mattress related to the deep tissue injuries. A wound physician summary, dated 04/14/22, documented the wounds to the right and left ankle as stage IV pressure ulcers. A care plan, revised 05/20/22, documented resident #30 was at risk for pressure ulcers. The care plan did not document the active pressure ulcers, treatment, monitoring, or preventative measures. A significant change resident assessment, dated 05/23/22, documented the resident was severely cognitively impaired, required extensive assistance with bed mobility, required total assistance with transfers, dressing, toileting, personal hygiene and bathing, and had two stage four pressure ulcers. A wound physician summary, dated 06/02/22, documented the wound to the left ankle had resolved. A wound physician summary, dated 06/30/22, documented resident #30 had a stage IV pressure ulcer on his right ankle with a duration of greater than 97 days. On 07/06/22, at 10:22 a.m., the MDS coordinator stated she did not care plan resident #30's pressure ulcers, treatments, monitoring, or preventative measures. 3. Res #35 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly assessment, dated 06/13/22, documented the resident required extensive one person assistance with hygiene and one person physical help in part of bathing activity. The care plan, dated 03/07/22, did not address Res #35's bathing needs. On 07/05/22 at 2:17 p.m., MDS coordinator stated she was responsible for completing/updating care plans. The MDS coordinator stated Res #35's bathing needs were not on the resident care plan. The MDS coordinator stated it should have been care planned.

Based on record review, observation, and interview, the facility failed to update resident care plans to accurately address the residents' current needs for four (#15, 21, 24, 30, and #40) of 21 residents whose records were reviewed. The facility failed to update resident care plan related to: a. falls for resident #15, 21, 24, and #30. b. code status and use of hypnotic medications for Res #40. The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: 1. Res #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 12/03/20, documented Res #15 was at risk for falls. The plan of care did not document a goal or interventions to prevent falls. An incident report, dated 07/22/21, documented Res #15 had attempted to transfer from bed to BSC and appeared to have lost her balance. The report documented Res #15 hit her head on the bathroom door and sustained a small knot to crown of her head and small abrasion to left inner eye from her glasses. The incident report did not document any STPR of falls. A care plan, dated 08/02/21, documented Res #15 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .] Remind to use call light for assistance. An incident report, dated 09/12/21, documented the staff found Res #15 sitting on the floor up against the wall. The incident report documented Res #15 stated she hit the top of her head and neuro checks were started. A STPR was documented as to move the BSC closer. The care plan for Res #13 did not document the intervention. An incident report, dated 10/12/21, stated the staff were called to Res #15's room and found her on the floor near her bed. The report documented Res #15 stated she was getting off bed to use commode and fell . The report documented Res #15 was not injured. The STPR was to instruct Res #15 to use her call light and staff were to make sure it was in reach. A quarterly assessment, dated 02/14/22, documented the resident was intact in cognition and required extensive assistance with most ADLs. The assessment did not document Res #15 had fallen. A fall risk assessment for Res #15, dated 03/12/22, documented the resident had a fall risk score of 14 or high risk for falls. An incident report, dated 03/19/22, documented Res #15 was laying on the floor beside the bed face down. The report documented Res #15 complained of pain to her face, right leg, neck pain, and sustained a laceration to her right leg. The report documented Res #15 was sent to the hospital via EMS. The STPR were documented as address Res #15's safety needs on return from the hospital, to make sure the wheels of the bed were locked, and staff were to be in-serviced on care plans. The care plan was not updated related to this fall. A staff in-service, dated 04/12/22, was conducted and staff members were instructed to follow the residents' care plans or ask a nurse if there were any questions. On 06/29/22 at 9:54 a.m., Res #15 was observed in her bed. The bed was in a high position. Res #15 stated she had fallen several times. On 07/06/22 at 10:35 a.m., the MDS coordinator was asked how the facility notified her of resident falls and any new interventions. The MDS coordinator stated she was getting copies of incident reports for a time. The MDS coordinator reviewed Res #15's care plan and stated it did not have the appropriate interventions to prevent falls for this resident. The MDS coordinator stated she did add Res #15 required a four person assist in the ADL care plan but should have been added to the fall care plan as well. 2. Res #21 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 01/26/22, documented Res #21 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly assessment, dated 04/29/22, documented Res #21 was cognitively intact and required assistance with activities of daily living. A nurses progress note, dated 05/03/22, read in parts, .at approx 6 pm this evening .fell as leaving the dining room .C/o head pain and shoulder and arm pain. sent to er. family notified . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .she sustained a fall last month and C/O Right arm pain. The initial xray was negative for fracture: however, per the staff, she eventually went to the ER where a Right humoral fracture was identified . On 07/06/22 at 4:30 p.m., the MDS coordinator reported the resident did have a care plan for falls but it had not been revised since 01/26/22. The MDS coordinator stated the care plan should have been revised with interventions after the resident fell . On 07/06/22 at 4:38 p.m., the administrator reported the care plan had not been updated since 01/26/22. The administrator reported the care plan should have been updated on 05/03/22 with additional interventions for falls. 3. Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 06/13/21, documented for staff to remind resident to ask for assistance, call light in reach when in room, and staff to ensure resident was wearing well fitting and appropriate footwear. A fall risk assessment, dated 12/17/21, documented Res #24 was at high risk for falls. A quarterly assessment, dated 02/21/22, documented the resident was severely impaired with cognition and required supervision and limited assistance with ADLs. A care plan, last reviewed on 02/28/22, documented no new interventions related to falls. On 07/06/22, Res #24's clinical records and incident reports were reviewed. The records documented Res #24 had nine falls from 01/12/22 through 06/22/22. On 07/06/22 at 1:57 p.m., the MDS coordinator reported the care plan should have been reviewed and revised after each fall. 4. Res #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 02/11/22, documented the resident had one fall with minor injury since the last assessment. A fall incident report, dated 03/21/22, documented Res #30 had a fall in his room and a fall mat was placed. A discharge assessment, dated 04/30/22, documented Res #30 had two or more falls without injury since last assessment. A DNR form, dated 05/08/22, was documented in the resident's chart. A care plan, revised 05/20/22, documented the resident was a full code. The care plan documented an intervention to provide life saving measures/cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. A care plan, reviewed 05/20/22, documented the resident was at risk for falls. The interventions included: remind resident to ask for staff assistance with transfers, and monitor for changes that may warrant increased supervision or assistance. A significant change resident assessment, dated 05/23/22, documented the resident was severely cognitively impaired, required extensive assistance with bed mobility, total assistance with transfers, dressing, toileting, personal hygiene, bathing, and had one fall without injury since the last assessment. On 07/06/22, at 10:22 a.m., the MDS coordinator stated the code status care plan was not updated. On 07/06/22, at 10:24 a.m., the MDS coordinator stated she did not care plan resident #30's fall mat. 5. Res #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, last reviewed 01/25/22, did not document hypnotic use. A quarterly resident assessment, dated 04/07/22, documented resident #40 was cognitively intact, was independent with most ADL's, and received hypnotic medications seven out of seven days. An order summary, dated 06/24/22, documented [MEDICATION(S)] 15 mg at bedtime for [CONDITION(S)]. On 07/06/22, at 5:09 p.m., the MDS coordinator stated the care plan was reviewed in June of 2022, but the review was not documented. She stated the hypnotic was not care planned, and it should have been.

Based on record review and interview the facility failed to ensure the consultant pharmacist recommendations were acted on for two (#24 and #40) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: 1. Res #24 had diagnoses which included acute [MEDICATION(S)] with hematuria, unspecified dementia with behavioral disturbance, and [CONDITION(S)]. A MRR, dated 11/29/21, documented the pharmacist requested a reduction for [MEDICATION(S)] (an antipsychotic medication). The review was not signed by the physician or dated. On 07/07/22 at 11:44 p.m., The IP stated the MRR for 11/29/21 was not addressed and there is no record to indicate if or when the physician received the MRR. 2. Res #40 had diagnoses which included [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)], and depression. A MRR, dated 07/26/21, requested an end date or medical justification for as needed [MEDICATION(S)] (an antianxiety medication). There was no physician response documented. A MRR, dated 09/27/21, requested an end date or medical justification for as needed [MEDICATION(S)]. There was no physician response documented. A MRR, dated 11/29/21, documented a request to reduce [MEDICATION(S)] (an antidepressant) from 60 mg daily to 40 mg daily and [MEDICATION(S)] (an antipsychotic) from 10 mg BID to 5 mg a.m. and 10 mg p.m. There was no physician response documented. A MRR, dated 12/30/21, documented a request for clinical rationale and a renewal of the order of as needed [MEDICATION(S)]. There was no physician response documented. A quarterly resident assessment, dated 04/07/22, documented the resident was cognitively intact, independent with most ADL's, and received antidepressant, antipsychotic, and hypnotic medications. On 07/07/22, at 11:44 a.m., the infection preventionist stated the medication regimen reviews for July 2021, September 2021, November 2021, and December 2021 were not addressed. She stated the facility had no record to indicate if or when the physician received the MRR. She stated process was for the DON or ADON to send it to the physician, but there was no way to show if or when this was done.

Based on record review and interview, the facility failed to ensure three (#24, 30, and #42) of four residents whose PASRR documents were reviewed. The administrator reported 35 residents who resided in the facility required a Level II PASRR. Findings: 1. Res #42 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the resident's medical records revealed no PASRR level I was documented. On 07/07/22 at 8:48 a.m., the administrator provided a PASRR, dated 07/06/22. The administrator stated the PASRR for Res #42 had not been done upon admit. The administrator stated the PASRR was done on 07/06/22 and should have been done upon admission. 2. Res #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR level I report, dated 12/04/2020, did not indicate the resident had a serious mental illness. A quarterly assessment, dated 05/18/22, documented the resident was severely impaired with cognition, required extensive assist with most activities of daily living, and received antipsychotic and antidepressant medications. On 07/06/22 at 1:56 p.m., the assistant director of nursing (ADON) reported she could not find a PASRR level II report for the resident. On 07/06/22 at 4:25 p.m., MDS coordinator was asked to review the resident's PASRR level I. MDS coordinator #1 reported the form was filled out incorrectly which resulted in no PASRR level II being completed. 3. Res #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A level I PASARR, completed on 11/20/20, documented the resident had a recent history of mental illness or had been prescribed a [CONDITION(S)] medication for a possibly undiagnosed mental illness in the absence of a justifiable neurological disorder within the last two years. On 07/06/22 at 9:10 a.m., the administrator stated should have been referred for a level II PASRR evaluation based on the responses on the level I screening. She stated she could not locate a level II PASSR.

Based on record review, observation, and interview, the facility failed to monitor for target behaviors and side effects and failed to act on a MRR request for reduction for one (#15) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 50 resident resided in the facility. Findings: Res #15 had diagnoses which included major depressive disorder and generalized anxiety disorder. The current care plan documented Res #15 experienced feeling down, depressed, or hopeless. The care plan documented the staff were to monitor the target behaviors for Res #15. A quarterly assessment, dated 05/11/22, documented the resident was moderately to severely depressed and received antidepressant medications seven days of the seven day assessment period. On 05/25/22, following a hospitalization , the physician ordered the following medications: Airpiprazole 5 mg daily for depression, [MEDICATION(S)] 30 mg daily at bedtime for depression, and [MEDICATION(S)] 50 mg daily for depression, On 07/05/22, Res #15's clinical records were reviewed and did not contain documentation of target behaviors, behavioral monitoring, or side effect monitoring. On 07/06/22 at 1:30 p.m., the ADON stated she could not find any documentation target behaviors, behavioral monitoring, or side effect monitoring had occurred for Res #15.

Based on record review and interview the facility failed to provide letters of NOMNC and/or ABN for two (#12 and #21) of three residents reviewed Beneficiary Notices. The Beneficiary Notice - Residents discharged Within the Last Six Months, documented 20 residents were discharged from Medicare covered Part A stay with benefit days remaining in the last six months. Findings: 1. The ''SNF Beneficiary Protection Notification Review form, documented Res #21 was admitted to Part A skilled services on 01/25/22, discharged from Part A skilled services on 02/19/22, and remained in the facility. The facility did not provide Res #21 with a NOMNC or ABN letter. 2. The ''SNF Beneficiary Protection Notification Review form, documented Res #12 was admitted to Part A skilled services on 05/07/22, discharged from Part A skilled services on 05/17/22, and remained in the facility. The facility did not provide Res #12 with an ABN letter. On 07/05/22 at 4:23 p.m., the administrator stated the discharge for Res #21 occurred in February and a corporate nurse was responsible for completing and providing the resident with the ABN and NOMNC letters, but it must not have occurred because no documentation can be found.

Based on record review, observation, and interview, the facility failed to ensure accurate documentation of residents' code status for two (#30 and #42) of two residents reviewed for advanced directives. The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: 1. Resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Oklahoma DNR form, dated [DATE], documented it had been signed by two physicians signifying Res #30 was not to receive cardio-pulmonary resuscitation if he experienced a cessation of his heart beat or stopped breathing. Res #30's significant change assessment, dated [DATE], documented he had modified independence with daily decision making, required extensive assistance with ADLs, had a prognosis of less than six months to live, and was receiving hospice services. On [DATE] at 11:24 a.m., Res #30 was observed in his bed and appeared to be sleeping. He did not awaken when the room was entered or when his name was spoken. On [DATE] at 3:30 p.m., Res #30's chart was reviewed. The spine of the chart indicated Res #30's code status was full code. On [DATE] at 4:04 p.m., the administrator reported if a resident was unable to sign for a DNR and the family did not have privileges to sign for one, then two physicians would have to sign for the resident to have DNR status. The administrator reviewed Res #30's chart and confirmed he should have had his chart marked as DNR. The administrator stated the new DNR status should have been caught and his chart updated when he returned from the hospital. 2. Res #42 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A history and physical note, dated [DATE], documented in part, .Code status: DNR/no CPR . physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Code status: Do not attempt Resuscitation (DNR/No CPR) . On [DATE] at 9:45 a.m., Res #42's chart was observed with a sticker on the spine of the chart that read DNR. A review of Res #42's medical records revealed no DNR document was in the chart. On [DATE] at 2:13 p.m., the administrator stated a signed DNR form should have been in the medical records. The administrator reported Res #42 would have to be a full code until a DNR document could be obtained.

Based on record review, observation, and interview, the facility failed to assess and monitor for pain every shift according to the plan of care for one (#26) of one resident reviewed for pain. The Resident Census and Conditions of Residents form documented 27 residents on a pain management program. Findings: Res #26 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A policy and procedure, labeled Pain-Clinical Protocol, read in parts, .Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level .The staff will reassess the individuals pain . A physician order, dated 06/15/21, documented [MEDICATION(S)] 5/325mg every eight hours PRN for pain. A physician order, dated 06/21/21, documented refer to spine surgeon with chronic neck and back pain. A physician order, dated 02/10/22, documented the facility was to order an MRI of the spine. A care plan, dated 02/14/22, documented the resident had intermittent episodes of mild pain. The interventions documented to monitor for worsening of pain symptoms and notify the physician of changes; assess pain daily using 1-10 scale; and administer pain medication PRN. An annual assessment, dated 05/07/22, documented Res #26 was cognitively intact and was independent with activities of daily living. A physician order, dated 05/20/22, documented [MEDICATION(S)] 4mg TID PRN for neck pain. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Res #26's chart revealed routine pain assessments had not been documented on a 1-10 scale every day as care planned. On 07/07/22 at 9:00 a.m., Res #26 was observed sitting on the bed. Res #26 stated they were in constant pain and pain medications helped the intensity of the pain. On 07/07/22 at 9:42 a.m., LPN #1 reported pain assessments have not been documented as care planned. On 07/07/22 at 10:41 a.m., Corporate Nurse #2 reported Res #26's pain level had not been documented. Corporate Nurse #2 stated the pain levels should have been assessed daily and reassessed after medication administration for effectiveness.

Based on record review, observation, and interview, the facility failed to ensure an assessment for risk of entrapment was conducted and an informed consent and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: Res #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change resident assessment, dated 05/23/22, documented the resident was severely cognitively impaired; required extensive assistance with bed mobility; required total assistance with transfers, toileting, and personal hygiene; and had one fall without injury since last assessment. On 07/05/22 at 2:34 p.m., Res #30 was observed in bed with an air mattress and half side rails in the up position on both sides of the head of the bed. The resident's medical chart was reviewed and no documentation of a physician order, assessment, or consent for bed rail use was found. On 07/06/22 at 2:59 p.m., LPN #2 stated she did not think the facility used bed rails and they were placed when either the physician or the resident requested them for repositioning. She stated she was unaware of any assessment or documentation for bed rails, and was unaware of the risks associated with bed rails. On 07/07/22 at 5:00 p.m., the administrator stated she was unaware of the requirements for bedrails.

Based on record review and interview, the facility failed to complete a significant change assessment after a resident decline for one (#12) of 21 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents documented 50 residents resided in the facility. Findings: Res #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 02/07/22, documented the resident was moderately impaired in cognition; was independent in bed mobility and transfers; required supervision for eating; and required extensive assistance with toileting. A quarterly assessment, dated 05/13/22, documented the resident was severely cognitively impaired, was total assist with bed mobility, eating, and toileting, and no longer transferred. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/07/22, at 10:00 a.m., the MDS coordinator stated the resident had declined after the hospitalization and a significant change assessment should have been completed but was not.

Based on record review and interview, the facility failed to transmit resident assessments to the CMS system within 14 days of completion for one (#2) of two residents reviewed for resident assessments. The Resident Census and Conditions of Residents documented 50 residents resided in the facility. Findings: Resident #2 admitted to the facility on [DATE]. An admission assessment, dated 02/23/22, was not transmitted to CMS until 04/07/22. On 07/07/22, at 10:00 a.m., the MDS coordinator stated assessments should be transmitted within 14 days, but it was missed.

Based on record review, observation, and interview, the facility failed to ensure a resident with urinary incontinence did not continue to have a urinary catheter after a hospitalization without a clinical condition which documented a catheter was necessary for one (#15) of one resident reviewed for catheterization. The Resident Census and Conditions of Residents report documented four residents had indwelling urinary catheters. Findings: Res #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 02/14/22, documented Res #15 was frequently incontinent of urine. A care plan, dated 04/12/22, documented Res #15 had occasional urinary incontinence with a goal of having no further decline in urinary incontinence through the review period. A quarterly assessment, dated 05/11/22, documented Res #15 had an indwelling urinary catheter. On 06/29/22 at 9:19 a.m., Res #15 was observed in her bed. She stated when she was in the hospital she received a urinary catheter. Res #15 stated the facility had not attempted to remove the catheter and she did not know why she had a catheter. On 07/06/22, Res #15's clinical records were reviewed and the records did not document a reason or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/06/22 at 3:45 p.m., the MDS coordinator stated she did not update Res #15's care plan until the present week when she noted the resident had a urinary catheter. The MDS coordinator stated she only noted the presence of the catheter on the care plan but had not initiated any care plan interventions. On 07/06/22 at 3:57 p.m., the ADON was interviewed regarding why Res #15 had a urinary catheter. The ADON stated Res #15 had returned from a hospitalization with the urinary catheter. At that time the Corporate RN #2 stated to the ADON Res #15 would have to have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/06/22 at 5:59 p.m., Corporate RN #2 stated Res #15 had the catheter placed at the hospital as she had a wound infection from a laceration below her knee that she received from a fall and was getting urine in the wound. The Corporate RN stated the ADON just contacted Res #15's physician and an order was received on that day to discontinue the urinary catheter.

Based on record review, observation, and interview, the facility failed to reduce a medication which had been identified by the pharmacist consultant as appropriate for reduction and the physician agreed for one (#15) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report documented 50 residents resided in the facility. Findings: Res #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A consultant pharmacist MRR, dated 10/27/21, asked if the physician would consider a reduction in [MEDICATION(S)] (a medication used to treat GERD). Resident #15's physician agreed to the request. Res #15's clinical record did not document the dose of [MEDICATION(S)] had been reduced. A quarterly assessment, dated 05/11/22, documented the resident required set up and supervision with eating. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/06/22 at 9:06 a.m., the ADON was asked if the medication had ever been reduced. She stated she would have to look as the recommendation happened before she was employed at the facility. On 07/06/22 at 9:38 a.m., the ADON stated she could find no documentation the medication was ever reduced and could not find the original order.