Every finding on record at Latimer Nursing Home

Based on observation and interview, the facility failed to provide an environment free of urine odors for 1 of 2 halls. The Point of Care Rooms/Beds roster showed there were 14 residents residing on the South hall. Findings: On 05/05/25 at 12:30 p.m., there was a strong urine odor present on the South hall. On 05/06/25 at 7:50 a.m., there was a strong urine odor present on the South hall. On 05/07/25 at 7:55 a.m., there was a strong urine odor present on the south hall. On 05/07/25 at 4:07 p.m., LPN #3 stated in the morning the South hall smelled of urine. LPN #3 stated the odor got stronger when they opened the hopper room door. LPN #3 stated the strong urine smelled like the residents on the hall needed to drink more water. LPN #3 stated they provided water to all their residents and encouraged them to drink. On 05/07/25 at 4:29 p.m., CNA #3 stated the odor on the South hall was urine. CNA #3 stated they thought the strong urine odor was coming from one particular room. CNA #3 stated they changed the resident in that room and changed their linen, but even after cleaning the mattress, it still smelled strongly of urine. CNA #3 stated there was another resident whose mattress smelled of urine as well. CNA #3 stated while they waited for help to transfer and change the resident, they cleaned the resident's mattress and made up their bed with clean linen. CNA #3 stated even though they cleaned the mattress, it still smelled of urine. On 05/12/25 at 3:50 p.m., the administrator stated they addressed the facility odors by changing the cleaning and sanitizing chemicals used, added an odor deodorizer, and scheduled routine stripping and buffing of the floors. The administrator stated due to the strong odor of some residents' urine, those residents routinely received new mattresses.

Based on record review and interview, the facility failed to ensure a resident received their pain medication as ordered by the physician for 1 (#20) of 1 sampled resident reviewed for narcotic pain medication use. The MDS coordinator identified 15 residents received narcotic pain medications. Findings: Resident #20's quarterly assessment, dated 03/24/25, showed Resident #20 was cognitively intact with a BIMS score of 15 and had diagnoses which included multiple sclerosis and chronic pain. Physicians orders, dated 03/26/25, showed Resident #20 was to receive: a. hydrocodone/acetaminophen (narcotic pain reliever) 10/325 mg, Give one tablet every six hours; b. cyclobenzaprine (muscle relaxant) 10 mg. Give one tablet in the morning, afternoon, and at bedtime; c. ibuprofen (nonsteroidal anti-inflammatory drug) 600 mg. Give one tablet every six hours as needed for pain; and d. Voltaren arthritis pain gel 1%. Administer topical every four hours as needed. A May 2025 medication administration record showed Resident #20 did not receive their hydrocodone/acetaminophen on 05/11/25 at 12:00 a.m., 6:00 a.m., 12:00 p.m., or 6:00 p.m. and on 05/12/25 at 12:00 a.m. and 6:00 a.m. A nursing note, dated 05/11/25 at 1:34 p.m., showed Resident #20 was given ibuprofen 600 mg for a pain level of 7. A nursing note, dated 05/11/25 at 2:30 p.m., showed Resident #20 had no complaints of pain. On 05/12/25 at 12:47 p.m., the administrator stated they were waiting on prior authorization on the hydrocodone/acetaminophen. They stated it usually it took about two days. On 05/12/25 at 12:47 p.m., the administrator stated Resident #20 was given their last hydrocodone/acetaminophen 10/325 mg on 05/10/25 at 6:45 p.m. They stated the facility was waiting for prior authorization from Resident #20's insurance. On 05/12/25 at 1:24 p.m., Resident #20 was asked their pain level and they stated they were dying without their pain medication. They stated their pain was bad.

Based on observation, record review, and interview, the facility failed to utilize EBP for 1 (#21) of 1 resident who was observed to receive catheter care. The Matrix for Providers identified three residents with urinary catheters. Findings: On 05/05/25 at 1:13 p.m., Resident #21 was observed in bed with a catheter bag hooked to the side of the bed. There was no sign to utilize enhanced barrier precautions nor was there enhanced barrier precaution equipment visible near the entrance to the resident's room or in the resident's room. On 05/08/25 at 2:50 p.m., CNA #4 was observed to drain the resident's urinary catheter. There was a towel, washcloth, and gloves lying on the floor near the foot of the resident's bed. CNA #4 was observed to remove gloves from their pocket, don gloves, kneel in front of the urinary catheter drainage bag, pull the towel and wash cloth from the foot of the bed and position the towel under the urinary drainage bag. CNA #4 removed the drainage tube and drained the urine from the bag into a used urinal. CNA #4 wiped the drainage tube with the wash cloth lying on the floor and stored the urinary drainage tube. CNA #4 then exited the room, holding the urinal, wash cloth, and towel in their gloved hands. CNA #4 opened the hopper door with the same gloved hands and then asked if it was ok to wear the gloves if they were still carrying the urinal and dirty washcloth/towel. CNA #4 poured the urine out and ran water from the hopper, to rinse the urinal. CNA #4 then disposed of the washcloth/towel in the dirty linen. CNA #4 doffed their gloves and sanitized their hands. CNA #4 did not wear an isolation gown or mask. On 05/08/25 at 3:30 p.m., LPN #1 was observed to perform urinary catheter care for Resident #21. The urinary catheter tubing was not anchored/secured to the resident's leg. LPN #1 donned gloves to perform the urinary catheter care. LPN #1 did not wear a mask or isolation gown. An undated facility policy titled Policy and Procedure for Enhanced Barrier Precautions, read in part, It is the policy of this facility that any resident that has one of the following must fall under the enhanced barrier precaution rule .colostomy, foley cath, suprapubic cath, rectal tube, peg tube [percutaneous endoscopic gastrostomy], any stoma. EBP rule .When doing any care that requires the staff to come into contact with the artifical [sic] opening into the body or any tubing that is entering the body of a resident the staff member must act as if the resident is in isolation .wearing gloves, a gown, a face shield. This practice is to help prevent infections that can be introduced into the body through the stoma or catheters. A quarterly assessment for Resident #21, dated 04/25/25, showed the resident's cognition was intact with a BIMS score of 15. The assessment showed the resident had an indwelling catheter. On 05/05/25 at 1:15 p.m., Resident #21 stated the facility nursing staff wore gloves when performing urinary catheter care and not all the other stuff the hospital nurses wore. Resident #21 stated the urinary catheter was not secured/anchored. On 05/08/25 at 2:55 p.m., CNA #4 stated they were taught to wear gloves and clean around the drain tube after clamping it, but before securing the drain tube to the drainage bag. CNA #4 denied knowledge of enhanced barrier precautions. After leaving the resident's room with gloves still on from draining the resident's urinary catheter, CNA #4 asked if it was ok to wear gloves into the hall if they were carrying the soiled towel and washcloth and the urinal filled with urine. On 05/08/25 at 3:45 p.m., LPN #1 stated they noticed the resident's urinary catheter was not secured/anchored earlier in their shift and would anchor the catheter after they completed urinary catheter care. LPN #1 stated urinary catheters were to be secured/anchored. LPN #1 stated they wore gloves for infection control when performing urinary catheter care. LPN #1 stated they were not aware of enhanced barrier precautions. On 05/08/25 at 3:52 p.m., the IP stated they expected the nurses to wear gloves when performing urinary catheter care. The IP was asked if the facility staff utilized any other infection control practices when performing urinary catheter care. The IP stated they expected the nurses to wash their hands, wear gloves, and utilize clean technique when performing urinary catheter care. The IP was asked if the nursing staff utilized enhanced barrier precautions when performing urinary catheter care. The IP stated enhanced barrier precautions was where the staff were to wear the isolation masks, gowns, and gloves. The IP stated they had a policy for enhanced barrier precautions somewhere in their binder, but would need time to find it.

Based on record review and interview, the facility failed to ensure an admission resident assessment was completed within the required timeframe for 1 (#126) of 12 sampled residents whose resident assessments were reviewed. The administrator identified 27 residents resided in the facility. Findings: An admission assessment, dated 01/20/25, showed Resident #126 admitted on [DATE]. The assessment was signed as completed on 04/14/25. The assessment should have been completed by the resident's fourteenth day in the facility. On 05/07/25 at 2:08 p.m., the MDS coordinator stated the admission resident assessment was not completed timely. They stated the assessment dated [DATE] was not competed until 04/14/25.

Based on observation, record review, and interview, the facility failed to ensure residents were assisted with incontinent care for 1 (#20) of 1 sampled resident reviewed for ADL care. The administrator identified 27 residents resided in the facility. Findings: On 05/05/25 at 1:39 p.m. CNA #1 was observed to assist Resident #20 with incontinent care. Resident #20's brief was observed to be very saturated with dark yellow substance. There was a very strong urine odor in the room. An undated policy titled Behavioral Programs and Toileting Plans for Urinary Incontinence, read in part, A 'check and change' strategy involves check the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort to protect the skin. Resident #20's quarterly assessment, dated 03/24/25, showed the resident was cognitively intact with a BIMS score of 15 and had diagnoses which included multiple sclerosis and urinary incontinence. The assessment showed Resident #20 was totally dependent upon staff for assistance with all of their ADL's. On 05/05/25 at 1:09 p.m., Resident #20 stated bed checks were not done every two hours. They stated on most days they were only changed once a day. On 05/05/25 at 1:45 p.m., CNA #1 stated the last time they had changed Resident #20 was a bit after 10:00 a.m. They stated the resident had not been changed from 6:45 a.m. to 10:00 a.m. CNA #1 stated the policy for providing incontinent care was to change the residents every two hours. CNA #1 stated they had not changed Resident #20 every two hours because they had been too busy.

Based on observation, record review, and interview, the facility failed develop, implement a policy and procedure for a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. The administrator identified 23 residents who resided in the facility. Findings: There was no policy and procedure for Legionella and other opportunistic waterborne pathogens in the building water system. On 05/03/24 at 10:16 a.m., the maintenance man stated the facility did not have a policy and procedure for Legionella at this time, but they were working on writing a policy and procedure for Legionella and other waterborne pathogens for the facility.

Based on observation and interview, the facility failed to ensure medication cards were labeled appropriately with an expiration date for 49 of 55 sampled medication cards. The administrator identified 23 residents who resided in the facility. Findings: The labeling of medications policy, undated, read in part, .ALL PRESCRIPTION MEDICATIONS WILL HAVE THE FOLLOWING LABELING REQUIREMENTS SATISFIED: .To every box, bottle, jar, tube or other container of a prescription legend med which is dispensed, there shall be affixed a label bearing: .the expiration of the medication. On 05/02/24 at 2:40 p.m., the medication cart for female residents was inspected with 30 of 34 medication card labels to have no expiration date. The expiration date at the bottom of the label is cut off or cannot be read. On 05/02/24 at 2:50 p.m., the medication cart for male residents was inspected with 19 of 21 medication card labels to have no expiration date. The expiration date at the bottom of the label is cut off or cannot be read. On 05/02/24 at 2:51 p.m., CMA #1 was unable to read the expiration date on the medication cards. CMA #1 reported they would have no way to know what the expiration date is for the medication and stated, We would just have to basically guess. 05/03/24 at 9:15 a.m., the consultant pharmacist reported they were not aware there was no expiration date on the labels.

Based on observation and interview, the facility failed to serve food under sanitary conditions for 23 residents who ate meals prepared by the kitchen. The administrator identified 23 residents who resided in the facility. Findings: On 05/02/24 at 12:12 p.m., the dietary manager was observed serving lunch trays to the residents in the dining room wearing gloves. The dietary manager would exit the kitchen with a food tray wearing gloves, place the food tray on the table for the resident in the dining area, and then enter the kitchen again to collect another food tray for another resident. The dietary manager did this several times wearing the same set of gloves and without proper hand washing in between residents. On 05/02/24 at 12:23 p.m., the dietary manager stated they thought if they were wearing gloves they could exit and enter the kitchen without washing their hands to serve the residents in the dining area. They also stated they would begin handing the food trays to the aides without leaving the kitchen so they would not cross-contaminate from the kitchen to the dining area.

Based on record review and interview, the facility failed to ensure a consultant pharmacist reviewed the medications of each resident in the facility monthly for four (#2, 10, 16, and #21) of five sampled residents reviewed for unnecessary medications. The administrator identified 23 residents who resided in the facility. Findings: 1. Res #2 was admitted to the facility with diagnoses of diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, and heart failure. A quarterly assessment, dated 11/22/23, documented the resident was cognitively intact and dependent on most ADLs. This assessment also documented the resident was taking antianxiety, antidepressants, and diuretics. 2. Res #10 was admitted to the facility with diagnoses of fracture of hip, malaise, multiple sclerosis, history or schizophrenia, convulsions, atrial fibrillation, and mood disorder. An annual assessment, dated 12/14/23, documented the cognitive with daily decision making and independent with all ADLs. The assessment also documented the resident was taking antipsychotics and opioids. 3. Res. #16 was admitted to the facility with diagnosis of malignant neoplasm of the bone, myocardial infarction, diabetes mellitus type II, and HTN. A significant change assessment, dated 08/17/23, documented the resident was cognitively impaired and required total assistance with all ADLs. The assessment also documented the resident was also taking opioid's and diuretics. 4. Res #21 had diagnoses which included Alzheimer's, diabetes, depression, anxiety, and atrial fibrillation. Physician's orders documented Res #21 was taking an anti-anxiety, anti-coagulant, insulin, and an anti-depressant. There was no policy and procedure provided for drug regimen review. On 05/01/24 at 9:46 a.m., the DON stated when they returned to the facility in September 2024, after a short leave of absence, they discovered the pharmacist had completed the monthly reviews for May, June, July, and August 2024 but the acting DON did not follow through with the gradual dose reductions. They also stated as soon as they returned as DON, they contacted the pharmacist to implement all the recommendations for gradual dose reductions.

Based on observation, interview, and record review, it determined the facility failed to ensure regular inspections of resident beds equipped with side rails were conducted for eight (#6, 8, 9, 10, 13, 16,17, and #25) of eight residents reviewed for accident hazards. The administrator identified 23 residents residing in the facility. Findings: 1. Res #6 was admitted to the facility with diagnoses of cerebral palsy, chronic pain syndrome, anxiety disorders, and cardiomegaly. A quarterly assessment, dated 03/01/24, documented the resident was cognitively intact and required total assistance with all ADLs. On 04/30/24 at 09:51 a.m., an observation was made of the resident lying in their bed with bedrails on each side of the bed. On 05/02/24 at 8:36 a.m., CNA #3 stated the resident cannot remove or lower the bedrails but they do use them to help roll from side to side. On 05/03/24 at 1:08 p.m., the ADON/MDS Coordinator stated there was no assessment for bedrails and the bedrails were not added to the care plan. 2. Res #8 was admitted to the facility with diagnoses of multiple fractures of ribs, fracture of the second cervical vertebra, anorexia, and dementia. A significant change assessment date 02/26/24, documented the resident had problems with short- and long-term memory. The assessment also documented the resident required total assistance with all ADLs. On 04/30/24 at 09:48 a.m., an observation was made of the resident lying in the bed with a half bedrail raised on the outer side of bed the other side of bed was up against the wall. On 05/03/24 at 1:08 p.m., the ADON/MDS Coordinator stated there was no assessment for bedrails and the bedrails were not added to the care plan. 3. Res #9 had diagnoses which included dementia and osteoarthritis. There was no documented alternatives attempted prior to initiating side rails or side rail/entrapment risk assessments in the clinical record. On 05/01/24 at 2:00 p.m., Res #9 was sitting on the side of the bed. Half rails were in the upright position. 4. Res #10 was admitted to the facility with diagnoses of fracture of hip, malaise, multiple sclerosis, convulsions, atrial fibrillation, and mood disorder. An annual assessment, dated 12/14/23, documented the cognitive with daily decision making and independent with all ADLs. On 04/29/24 at 5:16 p.m., an observation was made of half bedrails on bed but are not up at this time. 5. Res #13 was admitted to the facility with diagnoses of dementia, depressive disorder, encephalopathy, and Parkinson's disease. A significant change assessment, dated 03/04/24, documented the resident had problems with short- and long-term memory and required moderate assistance with all ADLs. On 05/03/24 at 10:56 a.m., an observation was made of half bedrails on the resident's bed. 6. Res #16 was admitted to the facility with diagnosis of malignant neoplasm of the bone, myocardial infarction, diabetes mellitus type II, and HTN. A significant change assessment, dated 08/17/23, documented the resident was cognitively impaired and required total assistance with all ADLs. On 04/29/24 AT 5:38 p.m., an observation of bedrails bilaterally on the upper bed with a padding taped on the outer rail. The resident the bedrails stop them from falling out of bed. 7. Res #17 had diagnoses which included osteoarthritis, bilateral hip replacements and right knee replacement. There was no documented alternatives attempted prior to initiating side rails or side rail/entrapment risk assessments in the clinical record. On 05/01/24 at 2:45 p.m., Res #17 was in their bed with both side rails up. 8. Res #25 was admitted to the facility with diagnoses including convulsions, peripheral vascular disease, anemia, and anxiety disorder. An admission assessment, dated 01/10/24, documented the resident was cognitively intact and maximum assist with showering and dressing the upper body and dependent with lower body dressing, putting on and off footwear, and toileting. On 04/29/24 at 5:28 p.m., bed rails bilateral to upper bed, residents stated they requested them for fear of falling out of bed. On 05/03/24 at 8:16 a.m., the maintenance man stated they only check the bedrails when someone reports a problem or when they move the bed. 46909

Based on record review and interview, the facility failed to ensure residents were offered the choice to formulate advanced directives for three (#17, 20 and #25) of six sampled residents reviewed for advanced directives. The administrator identified 23 residents residing in the facility. Findings: 1. Res #17 was admitted with diagnoses which included hypertension and diabetes. There was no advance directive or advance directive acknowledgement in Res #17's electronic health record or paper chart. 2. Res #20 was admitted with diagnoses which included diabetes. There was no advance directive or advance direcgtive acknowledgement in Res 20's electronic health record or paper chart. The ADON was unable to provide documentation Res #17 and #20 had been offered the choice to formulate an advance directive. 3. Res. #25 was admitted to the facility with diagnoses including convulsions, peripheral vascular disease, anemia, and anxiety disorder. An admission assessment, dated 01/10/24, documented the resident was cognitively intact and maximum assist with showering and dressing the upper body and dependent with lower body dressing, putting on and off footwear, and toileting. A record review was conducted on 04/30/24, and a document titled Acknowledgement of Receipt Advanced Directive/Medical Treatment Decisions was marked that Res #25 had chosen to formulate an advanced directive by the durable power of attorney on 05/25/23. On 05/03/24 at 11:10 a.m., the ADON reported the durable power of attorney should have assisted Res #25 with filling out an advanced directive. The ADON reported there was no documentation Res #17 had been offered the choice to formulate an advance directive. The ADON reported there may not be an advance directive acknowledgement in the chart for Res #20 because they are a fairly new admission. The ADON reported Res #17 and #20 should have an advance directive or advance directive acknowledgment in their medical record. 46909

Based on record review and interview, the facility failed to ensure resident assessments were accurate for three (#2, 5, and #16 ) of 14 sampled residents whose resident assessments were reviewed for accuracy. The administrator identified 23 residents who resided in the facility. Findings: 1. Res #2 was admitted to the facility with diagnoses of diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, heart failure. A quarterly assessment, dated 01/22/23, documented the resident was cognitively intact and dependent on most ADLs. This assessment also documented the resident was taking an anti-anxiety and anit-depressive medications. On 02/07/24, a physician's order, documented bupropion 100 mg, give one tab by mouth daily for depressive disorder. On 05/03/24 at 11:16 a.m., the ADON/MDS Coordinator stated the resident was only taking antidepressive medication and they marked anti-anxiety by mistake. 2. Res #5 was admitted to the facility with diagnoses of transient cerebral ischemic attack, HTN, convulsions, injury of kidney, and depressive disorder. A quarterly assessment, dated 02/06/24, documented the resident was severely impaired with cognition and required maximal assistance with most ADLs. The assessment also documented the resident's weight was 131 pounds and had a weight loss. On 05/03/24 at 11:03 a.m., the ADON/MDS Coordinator stated the 131 pounds was a typo and it should have been 121 pounds instead. 3. Res #16 was admitted to the facility with diagnosis of malignant neoplasm of the bone, myocardial infarction, diabetes mellitus type II, and HTN. A significant change assessment, dated 08/17/23, documented the resident was cognitively impaired and required total assistance with all ADLs. The assessment also documented the resident was taking opioid's for pain. There was no documentation of malignant neoplasm cancer on the significant change assessment. On 05/03/24 at 11:16 p.m., the ADON/MDS Coordinator stated the significant change assessment should have malignant neoplasm cancer documented.

Based on observation, record review, and interview, the facility failed to attempt appropriate alternatives and perform an entrapment risk assessment prior to installing bed or side- rails for (#6, 8, 9, 10, 13, 16, 17, and #25) of eight residents reviewed for accident hazards. The administrator identified 23 residents residing in the facility. Findings: A restraints policy, written in by hand and read in part, .6. Full bedrails/siderails (assist rails or 1/2 rails is not restraints) NO RESTRAINT WITH LOCKING DEVICEs WILL BE USED. NOTE: Restraing assessment will be done prior to use . 1. Res #6 was admitted to the facility with diagnoses of cerebral palsy, chronic pain syndrome, anxiety disorders, and cardiomegaly. A quarterly assessment, dated 03/01/24, documented the resident was cognitively intact and required total assistance with all ADLs. On 04/30/24 at 09:51 a.m., an observation was made of the resident lying in their bed with bedrails on each side of the bed. On 05/02/24 at 8:36 a.m., CNA #3 stated the resident cannot remove or lower the bedrails but they do use them to help roll from side to side. On 05/03/24 at 1:08 p.m., the ADON/MDS Coordinator stated there was no assessment for bedrails and the bedrails were not added to the care plan. 2. Res #8 was admitted to the facility with diagnoses of multiple fractures of ribs, fracture of the second cervical vertebra, anorexia, and dementia. A significant change assessment date 02/26/24, documented the resident had problems with short- and long-term memory. The assessment also documented the resident required total assistance with all ADLs. On 04/30/24 at 09:48 a.m., an observation was made of the resident lying in the bed with a half bedrail raised on the outer side of bed the other side of bed was up against the wall. On 05/03/24 at 8:25 a.m., CNA #3 stated the resident cannot remove or lower the rails. They also stated the bedrail is up to prevent the resident from falling out of bed related to them lean on the bedrail. On 05/03/24 at 1:08 p.m., the ADON/MDS Coordinator stated there was no assessment for bedrails and the bedrails were not added to the care plan. 3. Res #9 had diagnoses which included dementia and osteoarthritis. There was no documented alternatives attempted prior to initiating side rails or side rail/entrapment risk assessments in the clinical record. On 05/01/24 at 2:00 p.m., Res #9 was sitting on the side of the bed. Half rails were in the upright position. On 05/01/24 at 2:05 p.m., CNA #1 reported the rails were in place to keep the Res #9 from falling out of bed. 4. Res #10 was admitted to the facility with diagnoses of fracture of hip, malaise, multiple sclerosis, convulsions, atrial fibrillation, and mood disorder. An annual assessment, dated 12/14/23, documented the cognitive with daily decision making and independent with all ADLs. On 04/29/24 at 5:16 p.m., an observation was made of half bedrails on bed but are not up at this time. On 05/03/24 at 10:56 a.m., CNA #3 stated the resident was not able to put the bedrails down, so they stay down all the time. On 05/03/24 at 1:10 p.m., the ADON/MDS Coordinator stated there was no assessment for bedrails and the bedrails were not added to the care plan. 5. Res #13 was admitted to the facility with diagnoses of dementia, depressive disorder, encephalopathy, and Parkinson's disease. A significant change assessment, dated 03/04/24, documented the resident had problems with short- and long-term memory and required moderate assistance with all ADLs. On 05/03/24 at 10:56 a.m., an observation was made of half bedrails on the resident's bed. 6. Res #16 was admitted to the facility with diagnosis of malignant neoplasm of the bone, myocardial infarction, diabetes mellitus type II, and HTN. A significant change assessment, dated 08/17/23, documented the resident was cognitively impaired and required total assistance with all ADLs. On 04/29/24 at 5:38 p.m., an observation of bedrails bilaterally on the upper bed with a padding taped on the outer rail. The resident the bedrails stop them from falling out of bed. 05/02/24 at 8:36 a.m., CNA #3 stated the resident cannot remove or lower the rails but she utilizes the bedrails to pull up in the bed. 7. Res #17 had diagnoses which included osteoarthritis, bilateral hip replacements and right knee replacement. There was no documented alternatives attempted prior to initiating side rails or side rail/entrapment risk assessments in the clinical record. On 05/01/24 at 2:45 p.m., Res #17 was in their bed with both side rails up. 8. Res #25 was admitted to the facility with diagnoses including convulsions, peripheral vascular disease, anemia, and anxiety disorder. An admission assessment, dated 01/10/24, documented the resident was cognitively intact and maximum assist with showering and dressing the upper body and dependent with lower body dressing, putting on and off footwear, and toileting. On 04/29/24 at 5:28 p.m., bed rails bilateral to upper bed, residents stated they requested them for fear of falling out of bed. On 05/03/24 at 11:35 a.m., the ADON/MDS Coordinator reported they were not aware side rails/entrapment risk assessments were required. The ADON/MDS Coordinator was not aware of any alternative attempted prior to using side rails for Res #9 and Res #17 On 05/03/24 at 1:13 p.m., the ADON/MDS Coordinator stated there was no assessment for bedrails and was not aware they should be assessing bedrails for residents. They also stated they just discovered there was a bedrail assessment in the EHR. 46909

Based on record review and interview, the facility failed to implement a comprehensive care plan: a. for five (#6, 8, 10, 16, and #25) of five reviewed for bedrails, b. for one (#13) of one reviewed for hospice care, c. for two (#2 and #13) of two reviewed for respiratory care, and d. for three (#13, 16, an #21) of 4 reviewed for unnecessary medications. The administrator identified 23 residents who resided in the facility. Findings: A. Bedrails 1. Res #6 was admitted to the facility with diagnoses of cerebral palsy, chronic pain syndrome, anxiety disorders, and cardiomegaly. A quarterly assessment, dated 03/01/24, documented the resident was cognitively intact and required total assistance with all ADLs. On 04/30/24 at 9:51 a.m., an observation was made of the resident lying in their bed with bedrails on each side of the bed. On 05/02/24 at 8:36 a.m., CNA #3 stated the resident cannot remove or lower the bedrails but they do use them to help roll from side to side. On 05/03/24 at 1:08 p.m., the ADON/MDS Coordinator stated there was no assessment for bedrails and the bedrails were not added to the care plan. 2. Res #8 was admitted to the facility with diagnoses of multiple fractures of ribs, fracture of the second cervical vertebra, anorexia, and dementia. A significant change assessment date 02/26/24, documented the resident had problems with short- and long-term memory. The assessment also documented the resident required total assistance with all ADLs. On 04/30/24 at 9:48 a.m., an observation was made of the resident lying in the bed with a half bedrail raised on the outer side of bed the other side of bed was up against the wall. On 05/03/24 at 8:25 a.m., CNA #3 stated the resident cannot remove or lower the rails. They also stated the bedrail is up to prevent the resident from falling out of bed related to them lean on the bedrail. On 05/03/24 at 1:08 p.m., the ADON/MDS Coordinator stated there was no assessment for bedrails and the bedrails were not added to the care plan. 3. Res #10 was admitted to the facility with diagnoses of fracture of hip, malaise, multiple sclerosis, convulsions, atrial fibrillation, and mood disorder. An annual assessment, dated 12/14/23, documented the cognitive with daily decision making and independent with all ADLs. On 04/29/24 at 5:16 p.m., an observation was made of half bedrails on bed but are not up at this time. On 05/03/24 at 10:56 a.m., CNA #3 stated the resident was not able to put the bedrails down, so they stay down all the time. On 05/03/24 at 1:10 p.m., the ADON/MDS Coordinator stated there was no assessment for bedrails and the bedrails were not added to the care plan. 4. Res #16 was admitted to the facility with diagnosis of malignant neoplasm of the bone, myocardial infarction, diabetes mellitus type II, and HTN. A significant change assessment, dated 08/17/23, documented the resident was cognitively impaired and required total assistance with all ADLs. On 04/29/24 at 5:38 p.m., an observation of bedrails bilaterally on the upper bed with a padding taped on the outer rail. The resident the bedrails stop them from falling out of bed. On 05/02/24 at 8:36 a.m., CNA #3 stated the resident cannot remove or lower the rails but she utilizes the bedrails to pull up in the bed. On 05/03/24 at 1:13 p.m., the ADON/MDS Coordinator stated there was no assessment for bedrails and was not aware they should be assessing bedrails for residents. They also stated they just discovered there was a bedrail assessment in the EHR. 5. Res #25 was admitted to the facility with diagnoses including convulsions, peripheral vascular disease, anemia, and anxiety disorder. An admission assessment, dated 01/10/24, documented the resident was cognitively intact and maximum assist with showering and dressing the upper body and dependent with lower body dressing, putting on and off footwear, and toileting. On 04/29/24 at 5:28 p.m., bed rails bilateral to upper bed, residents stated they requested them for fear of falling out of bed. B. Hospice Care 1. Res #13 was admitted to the facility with diagnoses of dementia, depressive disorder, encephalopathy, and Parkinson's disease. A significant change assessment, dated 03/04/24, documented the resident had problems with short- and long-term memory and required moderate assistance with all ADLs. The assessment did document the resident was on hospice. On 02/21/24, a physician's order documented to admit resident to hospice. On 05/03/24 at 1:14 p.m., the ADON/MDS Coordinator stated the care plan should have included hospice care. C. Respiratory Care 1. Res #2 was admitted to the facility with diagnoses of diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, and heart failure. A quarterly assessment, dated 11/22/23, documented the resident was cognitively intact and dependent on most ADLs. This assessment also documented the resident was on oxygen. There was no care plan documentation for oxygen. On 05/03/24 at 12:00 p.m., the ADON/MDS Coordinator stated there was no care plan for the oxygen. 2. Res. #13 was admitted to the facility with diagnoses of dementia, depressive disorder, encephalopathy, and Parkinson's disease. A significant change assessment, dated 03/04/24, documented the resident had problems with short- and long-term memory and required moderate assistance with all ADLs. The assessment also documented the resident was on oxygen. There was no care plan documentation for oxygen. On 05/03/24 at 12:00 p.m., the ADON/MDS Coordinator stated there was no care plan for the oxygen. D. Unnecessary Medications 1. Res. #13 was admitted to the facility with diagnoses of dementia, depressive disorder, encephalopathy, and Parkinson's disease. A significant change assessment, dated 03/04/24, documented the resident had problems with short- and long-term memory and required moderate assistance with all ADLs. There was no documentation of anti-psychotics on the assessment. There was no documentation of anti-psychotics on the care plan. On 05/03/24 at 11:52 a.m., the ADON/MDS Coordinator stated the anti-psychotics should have been on the care plan. 2. Res. #16 was admitted to the facility with diagnosis of malignant neoplasm of the bone, myocardial infarction, diabetes mellitus type II, and HTN. A significant change assessment, dated 08/17/23, documented the resident was cognitively impaired and required total assistance with all ADLs. The assessment also documented the resident was taking Lasix for myocardial infarction. There was no documentation of anti-diuretics on the care plan. On 05/03/24 at 11:16 a.m., the ADON/MDS Coordinator stated there was not a care plan for Lasix. 3. Res #21 was admitted with diagnoses which included congestive heart failure, ischemic cardiomyopathy and atrial fibrillation. A physician's order, dated 11/17/23, documented Res #21 was on Brilinta (a blood thinner/anticoagulant) 90mg twice a day. There was no comprehensive care plan for Res #21's use of an anticoagulant. On 05/03/24 at 11:40 a.m., the MDS Coordinator reported there should have been a care plan for anticoagulant use. The MDS Coordinator reported they are new to the position and still learning care plans and what should be care planned.

Based on observation, record review, and interview, the facility failed to revise a care plan for one (#11) of nine sampled residents whose care plans were reviewed for accuracy. The administrator identified 23 residents who resided in the facility. Findings: Res #11 had diagnoses which included peripheral vascular disease and a right above the knee amputation. Res #11's care plan, dated 02/23/24, documented Res #11 has the potential for skin issues. The care plan was not revised when Res #11 developed their right stump wound. A physician's order, dated 03/26/24 documented a wound care treatment of silvadene cream to Res #11's right stump daily. On 05/02/24 at 10:05 a.m., observed Res #11's wound care treatment to their right stump wound. On 05/03/24 at 11:40 a.m., the MDS Coordinator reported the care plan should have been revised when Res #11 developed a right stump wound. The MDS Coordinator reported they are new to the position and still learning care plans and what should be care planned.

Based on observation, record review, and interview, the facility failed to develop and implement physician's orders for oxygen tubing care maintenance for two (#2 and #13) of two resident sampled for oxygen therapy. The administrator identified 23 residents residing in the facility. Findings: A document titled, Orientation of Residents to the Facility, read in part, .Oxygen Administration .Procedure .12. At regular intervals, check and clean oxygen equipment, masks, tubing, and cannula's . 1. Res #2 was admitted to the facility with diagnoses of diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, and heart failure. A quarterly assessment, dated 11/22/23, documented the resident was cognitively intact and dependent on most ADLs. This assessment also documented the resident was on oxygen. There were no physician orders to check and clean oxygen equipment, masks, tubing, and/or cannula's. 2. Res #13 was admitted to the facility with diagnoses of dementia, depressive disorder, encephalopathy, and Parkinson's disease. A significant change assessment, dated 03/04/24, documented the resident had problems with short- and long-term memory and required moderate assistance with all ADLs. The assessment also documented the resident was on oxygen. There were no physician orders to check and clean oxygen equipment, masks, tubing, and/or cannula's. On 05/03/24 at 12:00 p.m., the ADON/MDS Coordinator stated there was nothing telling our nursing staff when to change the oxygen equipment. There should have been an order to let our nursing staff know when to change the oxygen equipment.

Based on record review and interview, the facility failed to document a recapitulation of a resident's stay on a discharge summary for one (#26) of two sampled residents whose closed records were reviewed. The administrator identified 23 residents who resided in the facility. Findings: Res #26 was admitted on [DATE] and discharged to another facility on 02/05/24. There was no recapitulation of Res #26's stay in the facility on the discharge summary. On 05/03/24 at 12:15 p.m., the MDS Coordinator/ADON reported they recently received an example of how a discharge summary should be documented and reported they will be documenting a recap of the resident's stay going forward.

Based on observation and interview, the facility failed to ensure a resident was treated with dignity during a transfer for one (#1) of one sampled resident observed for dignity. The administrator identified 23 residents residing in the facility. Findings: Res #1 Res #1 was admitted to the facility with cerebral brain stem hemorrhage without loss of consciousness, anxiety disorder, and depression disorder. A quarterly assessment, dated 04/12/24, documented the resident had problems with short- and long-term memory and required total assistance with most ADL's. On 05/02/24 at 9:17 a.m., an observation was made of CNA # 3 transporting Res #1 to their room from the shower room exposing their body to those in the hallway. On 05/02/24 at 9:18 a.m. CNA #3 stated they should have utilized two sheets to cover Res #1 lower part of her body. They also stated they did not notice the lower part of the Res #1 body was even exposed while transporting the Res #1 in the hallway.

Based on record review and interview, the facility failed to ensure residents were informed and provided written information concerning the right to accept or refuse to formulate an advance directive. The Resident Census and Conditions of Residents, dated 03/21/23, documented a census of 27 residents. Findings: A review of the facility's policies failed to show implementation of a policy for advance directives. A review of records failed to show written advanced directive information had been provided to residents. On 03/22/23 at 4:00 p.m., the DON reported they were unaware of the requirement to inform and provide written information to residents regarding the right to accept or refuse to formulate an advance directive.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for a resident with gradual dose reduction for one (#8) of one resident reviewed for antipsychotic medication and for a resident with behaviors for one (#10) of one resident reviewed for behaviors. A Roster Sample Matrix, dated 03/21/23, documented six residents were taking antipsychotic medications. The Resident Census and Conditions of Residents, dated 03/21/23, documented a census of 27 residents. Findings: Res #8 was admitted with diagnoses which included paranoid schizophrenia A physician's order for a gradual dose reduction, dated 01/26/23, read in part, Decrease Seroquel 50mg 1 PO BID. A quarterly assessment, dated 03/04/23, read in parts, .has a gradual dose reduction been attempted? No . On 03/23/23 at 1:10 p.m., the MDS Coordinator reported the gradual dose reduction for Res #8 on 01/26/23 should have been documented on the assessment for 03/04/23. Res #10 was admitted with diagnoses which included dementia with behavioral disturbances. A nursing note, dated 03/04/23 at 11:32 a.m., read in parts, Call placed to Dr (name withheld) .order received for Depakote 250mg PO BID .continues to yell out, get in front of other residents; curses at staff and spits at staff .will pinch staff. A quarterly assessment, dated 03/06/23, did not document any physical, verbal, or other behavioral symptoms for Res #10. On 3/23/23 at 1:10 p.m., the MDS Coordinator reported they felt the nursing note for 03/04/23 was a summary of Res #10's behaviors versus an account of Res #10's behavior on 03/04/23. On 03/23/23 at 1:12 p.m., The DON reported she felt the resident was demonstrating behaviors on 03/04/23 and why the nurse called the physician for orders regarding the behaviors. The DON reported the behaviors should have been documented on the assessment.

On 10/13/16 a past-noncompliance immediate jeopardy (IJ) was determined to exist related to the facility's failure to provide adequate supervision and have a system in place to effectively and consistently identify residents who required supervision. The facility was made aware of inappropriate sexual behavior of resident #2 with residents #4 and #5. The facility was aware of an incident of inappropriate sexual behavior related to resident #1 and resident #2 on 04/12/16. The facility failed to implement interventions for supervision and protection for the residents until 05/25/16. On 10/13/16 the Oklahoma State Department of Health (OSDH) was notified and verified the past-noncompliance IJ situation. The deficient practice was determined to be past-noncompliance related to the facility identifying the immediate jeopardy situation and implementing interventions to prevent recurrence of the situation. On 05/25/16 the facility conducted an in-service related to supervision, inappropriate behavior of residents, and reporting incidents of inappropriate behavior. The facility put protection interventions in place and addressed the incident of inappropriate behavior in the quality assurance meeting. The facility placed resident #2 on every shift charting to monitor the residents behavior and location. On 10/13/16 at 4:15 p.m., the administrator and director of nursing (DON) were notified of the past noncompliance immediate jeopardy situation which constituted substandard quality of care. Based on observation, interview, and record review, it was determined the facility failed to provide adequate supervision and have a system in place to effectively and consistently identify residents who required supervision for four (#1, #2, #4, and #5) of five residents sampled for supervision. The facility was made aware of incidents of inappropriate sexual behavior related to resident #1 and resident #2 on 04/12/16 and failed to provide an intervention to prevent recurrence or protect residents until 05/25/16. Findings: The facility policy on abuse documented patients, families, and staff were encouraged to report any concerns, incidents, or grievances to the administrator or charge nurse. The policy documented incidents would be thoroughly investigated by the administrator. The policy documented the facility would protect residents from harm during an investigation. 1. Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An annual assessment, dated 02/08/16, and a quarterly assessment, dated 08/10/16, documented the resident had severe cognitive impairment. The assessment documented the resident was independent with ambulation and had no range of motion limitations. A care plan, dated 02/08/16, documented the resident had cognitive impairment. The care plan documented the resident had inappropriate behavior of touching a female friend. A nurse note, dated 04/20/16, documented close observation was required due to the resident would get very handsy with others. The care plan, updated on 05/25/16, documented the staff was to monitor the resident's where abouts and chart in the nurse notes. The care plan, updated on 08/10/16, documented a resident reported to the social service director the resident and his female friend were being handsy with one another. The update documented the resident was taken to the administrator's office and was told the behavior was inappropriate. The resident stated he understood. On 10/12/16 at 6:50 p.m., the resident was interviewed. The resident was asked if he went into other rooms. The resident stated, Yeah. On 10/13/16 at 9:15 a.m., the resident was observed in his room in bed. The resident was observed throughout the two day survey in his room and in the lobby. The resident was observed to ambulate independently. 2. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An annual assessment, dated 03/04/16, and a quarterly assessment, dated 09/04/16, documented the resident had severely impaired cognition and had short and long term memory problems. The assessment documented the resident required total assistance with all activity of daily living needs. A care plan, dated 03/04/16, documented the resident was unable to make his needs known. The care plan documented the resident was able to answer yes or no questions. The care plan documented the resident required total assistance with activities of daily living. On 10/12/16 at 1:16 p.m., the resident was asked if a man ever came into his room at night and bothered him. The resident stated, Yes. The resident did not provide a name of the man or state what the man did to him. The resident was observed to turn red when questions were asked related to someone coming in his room. Interviews were conducted on 10/12/16 and 10/13/16. Seventeen staff were interviewed. Five staff reported they had heard of an incident of resident #2 being inappropriate with resident #1. The staff reported they had heard of resident #2 having his hands in the pants of resident #1. Unidentified staff #4 reported hearing of resident #2 going into another resident's room and touching the other resident inappropriately but the unidentified staff could not remember who the other resident was. Unidentified staff #6 reported hearing resident #2 had done something sexually inappropriate, like touched the other male. Unidentified staff #7 reported observing resident #2 entering the room of resident #1 and stated, It scared me. The staff reported being concerned resident #2 might sexually abuse resident #1. Unidentified staff #2 reported an incident of resident #1 shaking the bed rails. The staff member stated it was reported resident #2 had put resident #1's hands in his pants. The staff member reported the director of nursing (DON) was told of the incident. During the interviews staff reported resident #1 and resident #2 had shared a room prior to the incident of sexually inappropriate behavior. The staff reported the DON gave permission to move resident #1 to another room after the incident was reported. An unidentified staff member reported unidentified staff member #1 stated the DON had been notified of the incident and had instructed unidentified staff #1 not to document the incident. 3. Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/15/16, and an annual assessment, dated 09/13/16, documented the resident had severely impaired cognition and had short and long term memory problems. The assessment documented the resident required total assistance with all activities of daily living. A care plan, dated 09/13/16, documented the resident had a loss of short and long term memory related to Alzheimer's dementia. The care plan documented the resident required total assistance with all activities of daily living. On 10/12/16 at 1:05 p.m., the resident was observed sitting in the wheelchair in the lobby. On 10/13/16 at 1:19 p.m., the resident was observed sitting in the wheelchair in the lobby. The resident's eyes were closed. Interviews were conducted on 10/12/16 and 10/13/16. Seventeen staff were interviewed. Four staff reported they had heard of resident #2 being inappropriate with resident #4. Unidentified staff #5 reported the resident was heard to say resident #2 wouldn't quit coming in his room. Unidentified staff member #2 reported there had been an incident between resident #2 and resident #4. The staff member reported resident #4 had stated, That man keeps coming in here and messing with me. The staff reported resident #4 had told unidentified staff #10 that the resident would go in his room at night and touches his privates. Unidentified staff #2 reported staff #10 reported the incident to the DON. 4. Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A nurse note, dated 04/22/16, documented the resident was restless and into everything. The nurse note documented the resident went into everyone's personal rooms. A quarterly assessment, dated 06/22/16, and an annual assessment, dated 09/19/16, documented the resident had severely impaired cognition and had short and long term memory problems. The assessment documented the resident required total assistance with all activities of daily living. A care plan, dated 09/19/16, documented the resident had a loss of short and long term memory related to Alzheimer's dementia. The care plan documented the resident required total assistance with all activities of daily living. On 10/12/16 at 1:20 p.m., the resident was observed sitting in the wheelchair in the lobby. On 10/13/16 at 1:20 p.m., the resident was observed sitting in the lobby. The surveyor attempted to speak with the resident. The resident did not respond. Interviews were conducted on 10/12/16 and 10/13/16. Seventeen staff were interviewed. Three staff reported they had heard of resident #2 being inappropriate with resident #5. Unidentified staff #3 stated she had observed resident #5 being fondled by resident #2. The unidentified staff member then stated, don't know if I saw anything inappropriate. The staff member stated the incident was reported to staff in charge. Unidentified staff #5 reported resident #5 wandered. The staff member reported resident #5 was in the room of resident #2. The staff member reported staff had heard resident #2 had his hands in the pants of resident #5. The staff member stated the incident was reported to another staff member. Unidentified staff #8 reported resident #5 was observed in the room of resident #2. The staff member reported resident #2 had his hands near the crotch of resident #5. The staff member reported the hands of resident #2 were four to five inches away from the crotch of resident #5. The staff member reported it didn't sit right and the incident was reported to the staff in charge. An unidentified staff member reported unidentified staff member #1 stated the DON had been notified of the incident and had instructed unidentified staff #1 not to document the incident. On 10/12/16 at 6:10 p.m., the director of nursing (DON) was interviewed. The DON stated she wasn't aware of any allegations until protective health came in May. The DON stated the investigator asked her about resident #2 and then asked her about resident #1 and resident #5. The DON stated she had received a report from the investigator with specifics. The DON stated there was an allegation related to resident #5. The DON stated a certified nurse aide (CNA) had seen something inappropriate between resident #5 and resident #2. The DON reported there was also something about resident #2 being inappropriate with resident #1. The DON reported she had an in-service with all the staff the day following the investigators visit. The DON was asked if she had reported to the Oklahoma Stated Department of Health (OSDH) after she received the report from the investigator. The DON stated, No. He (the protective health investigator) said he would be reporting it. The DON stated she thought that was what the investigator was there for and did not think she needed to report because the investigator was going to report. The DON was asked what interventions she had implemented since the investigation. The DON stated she had an in-service related to abuse and neglect. She stated the facility started documenting every shift on the location of resident #2 and she had questioned all the staff. The DON reported she had not interviewed residents. An in-service report, dated 05/25/16, and 08/03/16, documented training was provided for abuse and who to report to if abuse was witnessed. The in-service documented if staff observed inappropriate behavior with resident #2 and any other resident they were to tell the charge nurse. On 10/12/16 and 10/13/16 seventeen staff were interviewed. The staff was asked if the DON or anyone had conducted an investigation related to the incidents of inappropriate behavior. Five staff members reported they had been asked about the allegation following the visit by the Adult Protective Services. The other staff members reported they were not aware of an investigation. Two staff members reported they attended quality assurance meetings and the sexually inappropriate behaviors had been addressed at the meetings. On 10/13/16 at approximately 10:00 a.m., the DON provided eight staff statements related to observation of inappropriate behavior. Several statements were not dated. The remaining statements were dated 07/13/16. The DON reported she had interviewed all staff after the allegations of inappropriate sexual behavior but did not know where the other statements were at the time. She stated she could not find them. The DON was asked if she had interviewed any residents. The DON stated she had not interviewed residents.

On 06/22/16 at 6:40 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to ensure supervision and/or interventions were provided to prevent falls for resident #34 who had experienced falls with injuries and interventions were not put in place to prevent recurrence. On 06/22/16 at 6:43 p.m., the director of nursing (DON) was informed of the IJ situation related to recurring falls without corrective measures. The DON was informed the immediate jeopardy situation constituted substandard quality of care. The DON verbalized understanding. On 06/22/16 at 8:25 p.m., the DON provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: Plan of removal of IJ for Latimer Nursing Home. 1. Resident in question placed on toileting schedule of Q2 to establish his pattern R/T his last 3 falls all other residents with potential for fall R/T toileting will also be B/B assessed and placed on toileting schedule. All will be assessed and if indicated at risk placed on toileting schedule by Thursday 6-23-16. 2. A fall risk assessment will be done on all residents to determine if they are at risk for falls. Once identified plan of approaches will be care planned. How to identify residents at risk for fall will be inserviced about falling star on there door and what that means and how to monitor them. A list will also be kept at Nurses station of all residents identified at risk for fall. 3. Post fall assessment has been implemented that will identify causative factors and interventions to prevent recurrence. This was started 6-22-16 and all charge nurses inserviced on 6-22-16 and if not present by phone. 4. All employees have been inserviced of what falling star means, what it is, employees inserviced of list of residents at risk for falls that is at nurses station and the plan put into place that identifies intervention to prevent recurrence. This will be done thru inservice on 06-22-16 and if any employee is out of town will be inserviced by phone by 6-23-16. 5. Plan of care will have interventions in place that R/T each fall occurred to prevent reoccurrence and that are individualized- residents in question care plan updated 6-22-16 all other residents who are identified at risk for fall will have a plan of care updated by 6-23. 6. All new residents will be assessed for falls upon admission, or fall and change of condition and then quarterly thereafter. This new plan will monitored by fall committee. On 06/27/16 at 11:30 a.m., the facility was informed the IJ was removed, effective 06/23/16 at 2:50 p.m., when all components of the plan of removal had been implemented including the completion of inservices and staff verbalization of understanding of the in-services. The deficiency remained at the level of actual harm not immediate jeopardy at a pattern level. Based on observation, interview, and record review, it was determined the facility failed to provide supervision and/or interventions to prevent falls for two residents (#34 and #20) of three residents sampled for falls. Resident #34 had experienced falls with injuries and interventions were not put in place to prevent recurrence. The facility identified 10 residents who experienced a fall in the last 90 days. Findings: The facility's policy on safety documented the facility would create a safe environment for the resident. The policy documented to place the resident's call light within reach of the resident. The policy documented if the resident had dementia or was unable to use a call light the staff were to check on the resident often. The policy was not specific to falls. 1. Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment, dated 5/14/15, documented the resident was a high fall risk. An incident report, dated 05/15/16, documented the staff was called to the resident's room by the roommate. The incident report documented the resident was found sitting on the floor. The incident report documented the resident reported he had fallen on the floor. The incident report documented the resident was observed with a 4 centimeter (cm) x 3cm hematoma to the left side of his forehead above his eye. The incident report documented the resident was assessed. The incident report documented the resident's family and physician were notified. The steps taken to prevent recurrence were the resident was instructed of the necessity of using a walker when ambulating or calling staff for assistance to use the bathroom. An quarterly assessment, dated 5/17/16, documented the resident was moderately impaired with cognition. The assessment documented the resident required extensive to total assistance with activities of daily living. The assessment documented the resident was not steady, but able to stabilize without staff assistance when moving from a seated to a standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. The assessment documented the resident had no impairment with range of motion. The assessment documented the resident used a walker. The assessment documented the resident was always continent with bowel and bladder. The assessment documented the resident had two falls. The assessment documented one fall resulted in an injury. A care plan, dated 05/17/16, documented the resident had an alteration in cognition. The care plan documented the resident had fallen and had a history of [REDACTED]. An incident report, dated 06/08/16, documented the resident reported he stood up to urinate, went to sit back down in the wheelchair, slid down the front of the wheelchair missing the seat, and landed on his buttocks. The steps taken to prevent recurrence documented the resident was instructed to use the call light. An incident report, dated 06/09/16, documented the resident attempted to walk to the bathroom to void and fell striking his head on the bedside table. The incident report documented the resident had a 0.5cm laceration to both sides of the bridge of his nose, a 1cm x 2cm abrasion to the right side of his forehead, and a 1cm x 2cm abrasion to his right shoulder. The incident report documented the resident's physician was notified and the resident was sent to the emergency room for evaluation. The incident report documented the steps to prevent recurrence were the resident was encouraged to call and wait for assistance. The care plan, updated on 06/09/16, documented the resident fell on the floor in his room. The care plan documented a noted injury. The care plan documented the resident's physician was notified and an order was received to send the resident to the emergency room for evaluation. The care plan documented the resident was diagnosed with [REDACTED]. An incident report, dated 06/11/16, documented the resident was found sitting on a pad in front of his bed. The incident report documented the resident stated, I slid off. The incident report documented the resident was assisted back to bed. The incident report documented the resident was incontinent. The incident report documented steps taken to prevent recurrence were a personal alarm was placed on the resident, the resident's call light was placed in his hand, and he was reminded to use it when he needed assistance. The care plan, updated on 06/11/16, documented the resident was found sitting on the floor in his room. The care plan documented no injuries were sustained. The care plan documented the resident was needing to toilet. The care plan documented the resident was assisted back to bed, the alarm was placed, and the resident was told to use the call light if he needed assistance. On 06/22/16 at 10:06 a.m., the resident was observed in the day room in his wheelchair. The resident appeared to doze at times. A reading activity was currently taking place. On 06/22/16 at 11:51 a.m., certified nurse aide (CNA) #4 was interviewed regarding the facility's policy on falls. The CNA reported the facility had a fall committee that met once a week. The CNA reported the facility would discuss the residents who were considered a high fall risk. The CNA reported it had been a couple of weeks since they had met for a falls meeting. The CNA was asked if resident #34 used his call light for assistance. The CNA reported the resident never used his call light. The CNA reported the resident was not able to remember to ask for help. The CNA reported the resident fell in his room when he was trying to use the bathroom. On 06/22/16 12:28 p.m., CNA #1 was interviewed regarding the resident's memory and cognition. The CNA was asked if the resident would remember to use a call light or use his walker before getting up to use the bathroom. The CNA reported the resident would not remember to call for assistance before getting up out of bed. On 06/22/16 at 4:37 p.m., CNA #5 was interviewed regarding the resident's activity of daily living needs. The CNA reported the resident would urinate on the floor and slip on it. The CNA reported the resident could not go to the bathroom by himself. The CNA reported she was told to check on the resident every hour to see his needs were met. The CNA reported the resident would not turn on the call light for assistance. The CNA reported the resident was not on a toileting program. On 06/22/16 at 4:59 p.m., certified medication aide (CMA) #2 was interviewed regarding the resident's cognition and activity of daily living assistance. The CMA reported the resident never used his call light. The CMA reported the resident had used a walker in the past. The CMA reported the resident would go to the bathroom by himself. The CMA reported the resident did not understand to use his call light for assistance. A review of the resident's clinical record did not contain documentation the resident was on a toileting program or the resident received hourly checks. On 06/22/16 at 5:08 p.m., licensed practical nurse (LPN) #1 was interviewed regarding the resident's cognition and fall history. The LPN reported the resident would not use his call light. The LPN reported the resident started falling and the facility gave him a walker to use, but the resident continued to fall while using the walker. The LPN reported the resident was to be checked every two hours. The LPN reported the staff would toilet the resident every two hours and the resident would not use the toilet. The LPN reported the resident was incontinent and the facility began using diapers on the resident. The LPN reported the resident would take off the diapers and urinate on himself. On 06/22/16 at 5:14 p.m., the minimum data set (MDS) coordinator was interviewed regarding the resident's plan of care. The MDS coordinator was asked if an assessment had been conducted on the resident to determine the root cause of the falls. The MDS coordinator reported she was not aware of any assessment conducted for the resident. The MDS coordinator reviewed the resident's care plan care and was asked about the interventions put in place to prevent recurrence for the falls. The MDS coordinator reported an alarm had been placed and the resident was told to use the call light. The MDS coordinator reported the resident's physician gave an order for [REDACTED]. The MDS coordinator reported it was questionable if the resident would use his call light. ON 06/22/16 at 5:35 p.m., the DON was interviewed. The DON was asked to review the resident's care plan and the interventions put in place to prevent the recurrence of falls. The DON reported, I see what you are talking about, using a call light is not an effective intervention. The DON was asked if an assessment was conducted to determine the cause of the falls. The DON reported, No. The DON reported the fall committee had discussed a toileting program for the resident but the resident was never placed on one. The DON reported their goal for the falls committee was to determine the cause of the falls. The DON reported she had put something at the nurses' desk for steps to prevent recurrence. The DON reported she was aware the facility needed a plan in place to do better. The DON reported after the resident's falls started the resident was not placed on a every two hour check. The DON reported no assessment or investigation was conducted after each fall. 2. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 04/06/16, documented the resident was severely impaired with cognition. The assessment documented the resident required extensive to total assistance with activities of daily living. The assessment documented the resident was not steady and only able to stabilize self with staff assistance, with moving from a seated to a standing position, turning around, moving on and off the toilet, and surface to surface transfer. The assessment documented the resident had impairment with range of motion to the upper and lower extremities. The assessment documented the resident had experienced two falls. The assessment documented one fall resulted in an injury. A care plan dated 04/06/16, documented the resident had cognitive loss, dementia, and memory impairment. An incident report, dated 05/08/16, documented the resident reported she did not want to bother anyone and had gotten up on the commode by herself. The incident report documented the resident reported her knees gave out and she fell . The incident report documented the resident had a large bruise to her upper left back that measured 8cm x 11 cm. The incident reported documented the resident stated she thought she hit her head against the trash can. The steps to prevent recurrence were to educate the resident to call for help. The incident report documented the resident was a high fall risk and was easily confused and forgetful. An incident report, dated 05/12/16, documented CNA's called the nurse to resident's room. The incident report documented the resident was found on the floor, lying on her left side. The report documented bleeding was noted to the resident's forehead. The report documented a hematoma which measured 4cm x 2cm. The report documented the resident was sent to the emergency room for evaluation. The incident report documented the resident would forget she could not walk and would get up. The report documented the facility were to use a bed/chair alarm, wheel chair for mobility, bed in low position, and remind the resident not to get up without help. The care plan, updated 05/12/16, documented the resident would forget she no longer could ambulate and the resident used a wheel chair for ambulation. The care plan documented the resident had a history of [REDACTED]. The care plan documented to encourage the resident to use the call light for assistance (if she could remember.) The care plan did not documented the resident's falls or the interventions put in place to prevent recurrence. A fall risk assessment, dated 05/14/15, documented the resident was a high risk for falls. An incident report, dated 06/01/16, documented the resident reached for her washcloth on the floor and fell forward hitting the back of her head. The report documented the resident had a 3cm circular raised area. The report documented ice was applied and the bed alarm was in use. The steps to prevent recurrence were bed alarm on, frequent checks for the resident, and keep floor free of clutter. An incident report, dated 06/08/16, documented the resident woke up very confused, got up out of bed, and slid to the floor on her knees. The report documented the resident's waist was up leaning on the bed. The report documented the resident was very confused. The report documented the bed alarm was on and working. The steps to prevent recurrence were bedside floor mat and check the resident 1/2 to 1 hours. A review of the resident's clinical record contained no documentation the resident was checked every 1/2 to 1 hour. On 06/21/16 3:57 p.m., the resident was observed in the dayroom napping on the sofa. On 06/23/16 at 10:07 a.m., registered nurse (RN) #3 was interviewed regarding the resident's cognition and memory. The RN reported the resident was disoriented at times, but knew her family. The RN reported the resident was unable to use her call light due to arthritis in her hands. The RN reported the resident would usually call out for help if she needed something. On 06/23/16 at 10:21 a.m., the DON was interviewed regarding the steps to prevent recurrence of falls for the resident. The DON was asked if she thought asking the resident to use the call light for assistance before getting out of bed was an effective intervention for a resident with a severely impaired cognition. The DON reported, No, I agree it is not a proper intervention for a confused and disoriented resident. The DON reported the resident had since been evaluated and assessed. On 06/23/2016 at 11:03 a.m., CNA #4 was interviewed regarding the resident's cognition and memory. The CNA reported the resident was always confused and disoriented. The CNA was asked if the resident would use her call light for assistance before she got up. The CNA reported the resident did not use her call light to ask for help. The CNA reported the resident had a bed alarm. The CNA reported when the bed alarm sounded the resident had already gotten up or had fallen. On 06/23/16 at 11:09 a.m., CNA #3 was asked if the resident used her call light when needing assistance. The CNA reported the resident had a bed alarm that would sound when she attempted to get up. On 06/23/16 10:44 a.m. the physical therapy assistant (PTA) was asked if the resident had received any physical therapy for her falls. The PTA reported the resident had not received any physical therapy.

On 03/15/13 an immediate jeopardy (IJ) situation was determined to exist regarding the facility's failure to: a) assess, monitor, and or provide interventions for resident #4 who was experiencing unrelieved pain. The facility failed to monitor the effectiveness of pain medication, and/or notify the resident's physician of unrelieved pain. b) assess and monitor resident #3 after a fall. The facility failed to notify the resident's physician and/or staff on the on-coming shift of the resident's fall. An x-ray report for resident #3, dated 02/07/13, documented a subacute appearing [MEDICAL CONDITION] medial acetabulum with medial protrusion of the femoral head as a result of the fracture. On 03/15/13 the Oklahoma State Department of Health (OSDH) was notified and verified the immediate jeopardy situation related to the facility's failure to assess and provide interventions for unrelieved pain for resident #4 and failed to assess and monitor resident #3 after the resident experienced a fall. The facility failed to notify the on-coming staff that the resident had fallen. On 03/15/13 at 1:50 p.m., the administrator and licensed practical nurse (LPN) #1 were informed of the IJ situation which also constituted substandard quality of care related to the facility's failure to assess and provide interventions for unrelieved pain and assess, monitor, and report to the resident physician and on-coming staff after a resident experienced a fall with a fracture. On 03/15/13 at 9:55 p.m., the administrator and LPN #1 provided the survey team an acceptable plan of removal which stated: "Latimer Nursing Home Survey 3-15-2013 Citation of immediate jeopardy for pain and failure to assess and monitor the residents condition. This citation is very serious and requires immediate attention and to be addressed as soon as possible with all staff members. A in-service was held on the eve. of 3-15-2013 with all staff regarding the serious (sic) of this issue, being monitoring pain and the failure to assess and monitor of a residents condition, or change in condition. All employees of Latimer Nursing Home were in serviced to this important matter on 3-15-2013 at 8:20 p.m. (Names-deleted administrator, director of nurses and LPN #1) gave a inservice to all employees of pain monitoring and failure to monitor and assess the residents condition. This is first and foremost the most importance is the residents condition. See record of inservice meetings pg 1,2,3. If any employee was not able to attend the emergency inservice they were inserviced on the phone with a witness to ensure the importance of monitoring pain and the failure to assess and to monitor the residents condition. This plan of corrections will be monitored by the administrator and RN DON to ensure continued compliance. This will be QA for 6 weeks to ensure compliance. QA committee will be observing and monitoring to ensure continued compliance. The medical director will be invited to attend all meetings. Pain management policy attachment #1 will be followed with the RN will assess for pain and or any change in condition. The physician will be notified if necessary and all Dr's orders will be followed. Pain management policy was adopted the RN, will be doing the initial assessment on all residents for pain or any changes in conditions. The nursing staff will assess for signs or symptoms of pain on ongoing basis. All staff will observe for the presence of pain and report any change in a resident to the charge nurse. Medications will be administered as ordered and the RN's, LPN;s, (sic) will assess for the effectiveness of the medication. If medication does not alleviate or reduce the pain the attending physician will be notified to identify the effectiveness of the residents pain medication. The nursing staff will monitor the effectiveness of the pain medication. This monitoring of effectiveness of the meds will be monitored and other measures will also be implemented for pain relief. Other measures such as one-one-will also be done.. (such as one-one) to observe the residents condition. A new charting guidelines are now in place and have been adopted. (see attachment #3) Each resident will be charted on by the RN, or LPN daily and the resident will be assessed for pain daily and monitoring and assessing the residents condition. The RN DON will monitor to ensure continued compliance. Chart audits will be done weekly to ensure continued compliance by (name-deleted LPN #1). This monitoring will be kept in a log for further reference or evaluation. Pain evaluation and assessing and monitoring of the residents will be done by the RN and will be monitored by the administrator and (name-deleted LPN #1) to ensure continued compliance. See attachment #2. This will be in a log also for reference. The charge nurse will document any changes and report to the RN or (name-deleted LPN #1). Pain evaluation is now in place and will be done weekly by the RN, or LPN to monitor for pain this will be monitored weekly by the RN DON for continued compliance. See pain evaluation sheet part 1 and 2. All staff will be inservice twice a year on the importance of reporting pain, monitoring pain and the importance of monitoring, and assessing the resident and any changes occur or change in a residents status. All new hires will be inserviced before working the job title, about the importance of pain, and assessing and monitoring for pain or any changes in the residents status. The new employees will also be inserviced twice yearly for refreshers on the very important issue. A team will be formed and audits will be done weekly to monitor for pain and assess the residents condition and for any changes and documented on each residents and kept in a log for evaluation." On 03/16/13 at 6:45 a.m., the immediate jeopardy was removed when all components of the plan of removal had been completed. The deficient practice remained at a level of harm at a pattern. Based on record review and interview, it was determined the facility failed to provide the necessary care and services to attain and/or maintain the highest level of well-being for two (#3 and #4) of eight sampled residents reviewed for assessment, monitoring, interventions, and/or reporting of incidents. The facility failed to: a) thoroughly assess and provide interventions to alleviate pain and to thoroughly assess for the effectiveness of pain medication for one (#4) of three residents sampled for pain management. The facility identified 41 residents who were on a pain management program. b) thoroughly assess and monitor a resident after a fall and failed to notify the resident's physician and on-coming staff of the fall with an injury for one (#3) of three residents sampled for falls. An x-ray report for resident #3 documented a subacute appearing [MEDICAL CONDITION] medial acetabulum with medial protrusion of the femoral head as a result of the fracture. The facility identified 59 incidents of falls in the past six months. Findings: The facility policy for pain management documented it was the policy of the nursing home to utilize an interdisciplinary approach to the management of pain to assure that each resident was provided with effective interventions for the relief of unwanted pain and suffering. The policy documented pain could only be measured by the person who experienced the pain and treatment would be based on the resident's report of or signs/symptoms of pain. The policy documented the facility's approach to pain and symptom management would be individualized through careful assessment, planning, and monitoring by the resident, family, and members of the nursing staff. The policy documented all staff would observe for the presence of pain. The policy documented pain should be reported promptly to the charge nurse. The policy documented if the pain medication did not alleviate or reduce the pain to an acceptable level the nurse should contact the resident's attending physician. The facility policy on falls documented when a resident fell the charge nurse must assess the resident for any signs or symptoms of injuries. The policy documented if no signs of injuries, the resident could be assisted back to the bed or chair. The policy documented the charge nurse must be the one to call their physician and family. The policy documented the resident was to be monitored x 72 hours for any residual from the fall. The policy documented an accident/incident report must be filled out and reports made to the Oklahoma State Department of Health if it was a reportable incident. 1. The closed record of resident #4 was reviewed. The record documented the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent pain evaluation, dated 07/05/12, documented the resident had a cognitive impairment and was able to verbalize pain. No pain assessment was available for the resident after she fractured her hip and had a significant change in condition. A quarterly assessment, dated 10/05/12, documented the resident was moderately impaired with cognitive skills. The assessment documented the resident required total assistance with all activities of daily living needs. The assessment documented the resident was incontinent of bowel and bladder. The assessment documented the resident required total assistance with bed mobility. The assessment documented the resident received as needed pain medication and that pain was observed daily. A care plan, updated 10/05/12, documented the resident had a problem with pain and was given [MEDICATION NAME] 5/500 milligram (mg) one tablet every eight hours as needed for pain. The care plan documented the resident would not experience a decline in overall function related to pain. The care plan documented the staff was to administer and monitor for effectiveness of pain medication. The care plan had not been updated to reflect the resident's fracture and pain. A nurse's note, dated 11/05/12 at 8:45 p.m., documented the resident was found on the floor on top of blankets. The nurse's note documented the resident's left lower extremity was behind the left leg and to the left side. The nurse's note documented after transferring the resident back to the Broda (recliner) chair the resident complained of left knee joint pain. The nurse's note documented no swelling, redness, bruising or skin tears were noted. The nurse's note documented the director of nurses (DON) was notified and instructed staff to watch the resident carefully and to check the resident frequently every hour throughout the night. The nurse's note documented oral [MEDICATION NAME] was given for the resident's complaint of left knee pain. The nurse's note stated the resident was complaining of being hungry. The nurse's note documented the resident consumed 8 ounces of apple juice, cheese puffs, and 1/2 of a sandwich. The nurse's note documented at 10:00 p.m. the resident stated the knee was better and a bruise on the knee cap, redness, and slight swelling was noted. The nurse's note documented the resident was "mainly" resting. An incident report, dated 11/05/12 at 9:00 p.m., documented the resident was found on blankets on the floor and had slipped down from the Broda (special recliner) chair. The incident report documented the left lower extremity was bent down to the left side. The incident report documented no skin tears or bruises were noted when the resident was transferred back to the Broda chair. The incident report documented the resident complained of pain to the joint of the left knee. The incident report documented there was no swelling noted. The incident report documented the family was notified but the physician was not notified. A nurse's note, dated 11/05/12 at 11:00 p.m., documented the resident was sitting in a wheelchair in the lobby. The nurse's note documented a 4 centimeter (cm) x 6 cm bruise on the front of the leg below the left knee and a 2 cm red area in the center of the left knee. The nurse's note documented the resident was yelling out frequently. A nurse's note, dated 11/06/12 at 12:00 a.m., documented the resident was yelling out and complaining of left leg pain in the knee and below the knee. A nurse's note, dated 11/06/12 at 1:00 a.m., documented the resident continued yelling and her leg was hurting. A nurse's note, dated 11/06/12 at 2:00 a.m., documented the resident continued to yell and the left leg "appears same." A nurse's note, dated 11/06/12 at 3:00 a.m., documented the resident was quiet and transferred to bed by two nurse-aides. The nurse's note documented the resident complained of pain to the left leg to touch "or more." A nurse's note, dated 11/06/12 at 4:00 a.m., documented [MEDICATION NAME] was given for pain. A nurse's note, dated 11/06/12 at 5:00 a.m., documented the resident was sleeping and a red area was on the knee and a bruise below the knee. A nurse's note, dated 11/06/12 at 9:00 a.m., documented [MEDICAL CONDITION] was noted to the left knee and above the left knee. The nurse's note documented the resident was in bed and kept immobile. The nurse's note documented the physician was notified and an order was received for an x-ray. The note documented the resident was transported for the x-ray and the family was notified. A nurse's note, dated 11/06/12 at 7:00 p.m., documented the family called the facility and the resident was going to have surgery. The nurse's note documented the resident was having surgery for [REDACTED]. A hospital discharge order, dated 11/09/12, documented [MEDICATION NAME] one or two tablets oral every four hours as needed for pain. A hospital discharge summary, dated 11/10/12, documented the principle [DIAGNOSES REDACTED]. The discharge summary documented the resident had a urinary tract infection. A nurse's note, dated 11/10/12 at 12:45 p.m., documented the resident returned to the facility via stretcher from the hospital. The Medication Administration Record, Temporary relief." No additional interventions were documented. One entry on the MAR indicated [REDACTED]. Review of the medical record did not identify a recent assessment of the resident's pain, the ineffectiveness of the pain medication or physician notification. A nurse's note, dated 11/10/12 at 2:30 p.m., documented the resident was yelling out, "My leg hurts." The nurse's note documented the resident was medicated with [MEDICATION NAME]. A nurse's note, dated 11/10/12 on the 3- 11 shift, documented the resident was up in a Gerichair in the lobby. The nurse's note documented the resident was crying out in pain and was medicated twice during the shift. The note documented the resident was very anxious and jerking her left leg around. The note documented [MEDICATION NAME] was given to ease anxiety and for the pain medication to be more effective. A nurse's note, dated 11/11/12 at 1:00 a.m., documented [MEDICATION NAME] 5/500 was given for complaints of left knee pain. The nurse's note documented 28 staples were intact to the left leg and bruising was noted. A nurse's note, dated 11/11/12 at 10:00 a.m., documented the resident was yelling out and complaining of pain all over and leg pain. The note documented [MEDICATION NAME] was given, 2 tablets. A nurse's note, dated 11/11/12 at 5:30 p.m., documented the resident was crying out yelling she hurt and wanted a pain pill. The resident was given [MEDICATION NAME], two tablets with water. A nurse's note, dated 11/11/12 at 7:00 p.m., documented the resident was yelling, hollering, restless, and very anxious. The note documented [MEDICATION NAME] was given to the resident. A nurse's note, dated 11/11/12 at 10:00 p.m., documented the resident was very tearful and crying out in pain. The note documented the resident stated, "My leg is killing me." The note documented [MEDICATION NAME], two tablets were given for pain. Nurse's notes from 11/11/12 through 11/23/12 documented the resident had pain daily and was medicated multiple times every day for pain on an as needed basis. The nurses' notes did not document the physician had been notified of the resident's frequent complaints of pain. A nurse's note, dated 11/20/12, documented the resident's incision site was red and irritated. The note [MEDICATION NAME] milligram (mg) was ordered for the resident for 7 days. A nurse's note, dated 11/22/12 at 2:00 p.m., documented the resident's left leg was red, warm, draining copious amounts of serosanguinous "material." The note documented the wound was cleaned good and the leg was wrapped with a clean dressing. The note documented several minutes later the leg was checked again and now the drainage was bright red and beginning to have a foul odor. The note documented the resident was put to bed and soft gloves were put on both of the resident's hands to keep the resident from scratching. The note documented the resident was crying with pain and two [MEDICATION NAME] tablets were given for pain. A medical necessity report, dated 11/23/12, documented the resident required oxygen related to a surgical wound infection that was hot to touch and had drainage. The report documented the resident was not swallowing water. A nurse's note, dated 11/23/12 at 4:45 a.m., documented the resident's dressing was changed and a large amount of fresh bloody drainage was noted. The note documented there was a slight odor when the dressing was removed. A nurse's note, dated 11/23/12 at 5:30 a.m., documented the director of nursing (DON) was notified of the resident refusing fluids and drainage of the wound. A nurse's note, dated 11/23/12, 7 - 3 shift, documented the resident had pain to the left leg and had serosanguinous light brown drainage. The nurse's note documented the resident's left leg was hot to touch, swollen, and painful to touch. The note documented the resident was transferred to the hospital. A hospital discharge summary, dated 11/30/12, documented the principle [DIAGNOSES REDACTED]. On 03/14/13 at 3:20 p.m., LPN #1 was interviewed regarding pain assessments on residents. LPN #1 stated there was a list at the nurses' station when the residents were assessed for pain. LPN #1 stated the charge nurses did the pain assessments. The LPN reported the pain assessments rotated by the different charge nurses. LPN #1 stated there should probably be a new pain assessment if there was a change in a resident. The LPN stated the resident should have been reassessed for her pain with the ineffectiveness of her pain medication. On 03/15/13 at 10:20 a.m., certified medication (CMA) #2 was interviewed regarding pain medication. CMA #2 stated she would ask the resident if they were hurting and she would start with Tylenol and work up to something stronger. CMA #2 stated the nurse-aides reported to her if someone was hurting and she would go check the resident and give them pain medication. CMA #2 stated the charge nurses did the pain assessments. On 03/15/13 at 12:20 p.m., CMA #3 was interviewed regarding giving pain medications. CMA #3 stated the nurse-aides would report to her if a resident was having pain. CMA #3 was asked about resident #4 and her complaints of recurring pain. CMA #3 stated the resident did not express pain thoroughly but she could tell by the resident's facial expressions if she was hurting. CMA #3 stated the doctor should have been called for stronger pain medication for the resident. CMA #3 was asked what the procedure was for reporting pain if pain was not relieved. CMA #3 stated the CMAs reported to the charge nurse and the charge nurse told the DON. CMA #3 stated the DON decided if the physician should be notified. On 03/15/13 at 12:50 p.m., LPN #1 stated the DON did some pain assessments and the pain assessments hadn't been done recently. The most recent pain assessment for forty one residents was done on 07/25/12. The LPN was asked regarding tracking and trending of falls. The LPN stated the facility did not track and trend falls. The LPN stated the staff reviewed the incident reports when there was a concern. 2. A closed record for resident #3 documented the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 11/13/12, documented the resident was severely impaired with cognitive skills. The assessment documented the resident required total assistance with activities of daily living. The assessment did not document the resident had experienced any falls. A care plan, dated 11/13/12, documented the resident had impaired cognitive skills. The care plan documented the resident required total assistance with all activities of daily living. The care plan documented the resident was on hospice services. The care plan documented the resident was at risk for a fall related injury due to an unsteady gait and weakness. The care plan documented to report falls to the resident's physician and responsible party. An incident report, dated 02/03/13 at 6:00 p.m., documented the resident was found on his right side in the lobby. The incident report documented the resident had no swelling, bruises, or open areas noted. The incident report documented the resident denied any discomfort. The incident report documented the resident had unclipped the chair alarm. The incident report did not contain documentation the resident's physician or family had been notified of the incident. The incident report documented the steps taken to prevent recurrence were to do one hour checks on the resident and the facility could evaluate the resident for a Broda (recliner) chair while the resident was up. A late entry nurse's note, dated 02/03/13 at 6:00 p.m., documented the resident was found on the floor of the lobby on his right side. The incident report documented the resident was assisted back up to the wheelchair by licensed practical nurse (LPN) #2 and certified nurse aide (CNA) #1. The nurse's note documented no open areas or swelling to any joints. The nurse's note documented the resident's vital signs were obtained. The nurse's note documented after assessing the resident, he was wheeling himself to the door and to the nurses' station. The nurse's note documented at 6:30 (a.m. or p.m. not documented) [MEDICATION NAME] 0.5 milligram sublingual was given for anxiety as needed for restlessness. The nurse's note documented at 8:00 p.m. the resident was transferred back to bed with assist of one staff and was resting. A final incident report, dated 02/07/13, documented the "resident complained of signs and symptoms of pain in his left hip and left leg area. The incident report documented there was no [MEDICAL CONDITION] or bruises noted. The incident report documented the physician was notified and the resident was sent to the hospital for x-ray of his hips. The x-ray results revealed subacute fracture to the left posterior acetabulum. The incident report documented the resident returned to the facility. The incident report documented the orthopedic physician was consulted and no surgery was recommended due to the resident's age and condition. The incident report documented a new order for complete bed rest for 3 weeks then to obtain a follow-up x ray. The incident report documented the resident required total care with all activities of daily living. The incident report documented the resident had a history of [REDACTED]. The incident report documented the resident was on hospice care and required assistance with transfers. The incident report documented the last known fall was on 02/03/13 and at that time "charge nurse assessed no signs or symptoms of any injuries." The incident report documented the resident was placed on bedrest for 3 weeks. The incident report documented the bed/chair alarm was on at all times. The incident report documented the staff would check on the resident often and the resident's room was close to the nurses' station. The nurses' notes, dated 02/04/13, 02/05/13, and 02/06/13, contained no documentation regarding the fall the resident sustained [REDACTED]. A nurse's note, dated 02/07/13 at 2:30 p.m., documented the resident complained of leg/hip pain. The nurse's note documented there were no reports of the resident falling. The nurse's note documented the physician had been notified. The nurse's note documented a telephone order to send the resident to the hospital for x-rays of bilateral hips/legs. The nurse's note documented the results were pending. An x-ray report, dated 02/07/13, documented a subacute appearing [MEDICAL CONDITION] medial acetabulum with medial protrusion of the femoral head as a result of the fracture. A nurse's note, dated 02/07/13 at 4:45 p.m., documented the physician reported the resident was not a candidate for surgery at this time. The nurse's note documented the resident was to be placed on bed rest only. A written reprimand, dated 02/08/13, documented LPN #2 was given a verbal warning. The verbal warning documented, "A resident fell on Sunday 02/03/13 and the charge nurse LPN did not report it to the physician or family." A nurse's note, dated 02/09/13 at 5:42 p.m., documented, "The resident's respirations and heart rate ceased- family at bedside." On 03/14/13 at 4:00 p.m., an interview was conducted with certified medication aide (CMA) #1 regarding the incident on 02/03/13. The CMA reported a facility staff member motioned her to come to the lobby. The CMA reported the resident was laying on his right side. The CMA reported licensed practical nurse (LPN) #2 stated "What are you doing in the floor." The CMA reported she and LPN #2 put the resident back in the chair. The CMA reported the resident was not assessed. The CMA reported the resident began having pain a couple of days later. The CMA reported the resident received routine pain medication. The CMA reported she had no idea the nurse had not followed up on the resident's fall. On 03/14/13 at 4:10 p.m., an interview was conducted with an unidentified staff member, for confidentiality, regarding the incident on 02/03/13. The staff member reported the resident fell out of his chair in the lobby. The staff member reported she got the charge nurse. The staff member reported certified medication aide (CMA) #1 and licensed practical nurse #2 picked the resident up and put him back in his chair. The staff member reported the resident was not assessed before being put back in his chair. The staff member reported the resident ended up with a broken hip and nobody knew what happened. On 03/14/13 at 4:20 p.m., LPN #2 was interviewed regarding the resident's fall on 02/03/13. The LPN stated, "I apologized for not charting and filling out an incident report." The LPN reported a staff member came and got her and told her the resident was in the floor. The LPN reported the resident was on his right side. The LPN reported she asked the resident if he was hurt and he said no. The LPN reported she got CMA #1 to help her get the resident up in his chair. The LPN reported the resident had taken his chair alarm off. The LPN reported the resident continued to roll himself around in his wheelchair and was trying to stand up at the nurses' station. The LPN reported the resident did not complain of pain. The LPN stated, "It was my fault that I did not chart or fill out an incident report. I put it on the back burner." The LPN reported she should have immediately assessed the resident, filled out an incident report, and sent it to the state. The LPN reported if she thought a resident was injured, the resident should be sent to the emergency room . The LPN reported the resident's physician and family should have been called. The LPN reported the resident's physician was not called regarding the fall and she did not believe she had discussed the fall in report to the on-coming shift. The LPN reported she had been off for about four days and the hospice aide told her the resident's leg was hurting on 02/06/13. The LPN stated, "I did everything I was supposed to do. I just didn't chart it." The LPN reported she was not working on the day the resident was sent to the hospital for his x-ray. The LPN reported the director of nursing called her at home on 02/08/13 regarding the incident. The LPN reported she came in to the facility and documented an incident report and a late entry nurse's note on 02/08/13 after the DON called her at home. The LPN stated, "I did not assess the resident. We put him in his wheelchair. I just put this incident on the back burner."

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received care and services to maintain their highest level of well-being for 3 (#2, #3, and #7) of 12 sampled residents reviewed for well-being and functioning ability. The facility failed to: a. consistently identify, assess, evaluate, and provide interventions for pain relief for two (#2 and #7) of six sampled residents with pain. The failure to consistently assess, evaluate, and treat pain for residents #2 and resident #7 resulted in unrelieved pain for the two residents. The facility identified eight residents who were on pain management programs. b. ensure a physician ordered Geri-psych evaluation was obtained for one (#7) of one resident sampled for behaviors. The facility census and condition identified five residents with behavior symptoms. c. provide catheter care to prevent potential infection for one (#3) of two sampled residents reviewed for indwelling urinary catheter care. The facility census and condition identified four residents with indwelling urinary catheters, The facility census and condition report documented 46 residents lived at the facility. Findings: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital x-ray record, dated 12/29/10, documented the impression as, "Severe osteoarthritic changes left hip with [DIAGNOSES REDACTED]." A nurse's note, dated 04/16/11, for the 11-7 shift documented the resident was yelling at the staff and her roommate. The nurse's note documented the resident "finally" told the nurse that her hips hurt. The nurse's note documented the resident was given [MEDICATION NAME] 400 mg with poor results. The nurse's note documented at 1:00 a.m. the resident was trying to climb out of bed, kept pulling her personal alarm off, and continued to complain of pain. The nurse's note documented that Tylenol #3 was given at 1:00 a.m. A nurse's note, dated 04/22/11, for the 7-3 shift documented the resident complained of pain at 1:00 p.m. [MEDICATION NAME] 200 milligrams (mg.) was administered at 2:00 p.m. The nurse's note documented the results of the pain medication was "helpful." A nurse's note, dated 04/23/11, for the 3-11 shift documented Tylenol #3 was administered to the resident for complaints of pain to the left hip. The nurse's note documented, "Pain scale pending." A quarterly assessment, dated 05/12/11, documented the resident required total assistance with all activities of daily living tasks. The assessment documented the resident was moderately impaired in cognition and was independent with bed mobility. The assessment documented the resident had pain frequently and the pain was rated a 3. The pain scale documented that pain was rated a 1-10, and 10 was the most severe type of pain. The resident's care plan, dated 05/12/11, documented the resident was at risk for pain. The care plan documented [MEDICATION NAME] 200 mg., two tablets, were to be given as needed every six hours. Tylenol #3 was to be given as needed every eight hours. The care plan documented the facility staff would administer pain medication, monitor the effectiveness, and consult as needed for the pain. A nurse's note, dated 05/27/11, documented the resident was easily irritated when her hips hurt and could be combative with the staff and other residents. A nurse's note, dated 05/29/11, documented the resident complained of hip pain and became irritated when she was in pain. The nurse's note documented the resident yelled out when in pain. A nurse's note, dated 06/28/11, at 12:00 a.m. documented the resident was crying out again that her hips hurt when she was taken to the bedside commode. The nurse's note documented [MEDICATION NAME] 200 mg was given. The nurse's note documented the resident was "finally" resting at 2:00 a.m. A nurse's note, dated 07/08/11, documented the resident was yelling and complaining of pain all over. The nurse's note documented [MEDICATION NAME] was administered with poor results. A nurse's note, dated 07/09/11, documented the resident was yelling and complaining of pain all over. The nurse note documented [MEDICATION NAME] was administered with poor results. A nurse's note, dated 07/14/11, documented the resident complained of pain to her hips. The nurse's note documented [MEDICATION NAME] was given per physician orders [REDACTED]. The nurse's note documented the resident remained anxious and tearful. The nurse's note documented an [MEDICATION NAME] that was ordered as needed was given at 10:30 a.m. with good results. There was no documentation the physician had been consulted regarding the current pain medication not being effective to control the resident's pain. On 07/14/11 at 10:45 a.m., the resident was observed in bed. Certified nurse aide (CNA) #1 stated to the resident, Mrs. (name deleted) we need to give you a bath and help you get dressed. It's almost lunch time." The resident stated she did not want to get up and she did not want to go to the dining room. The resident stated, "My hips are killing me and I hurt all over." LPN #1 asked the resident to allow the nurse-aide to assist with hygiene. The resident stated she wanted to be left alone and did not want anyone bothering her. LPN #1 stated the resident had pain on a regular basis and she was given [MEDICATION NAME] at 7:30 a.m. that morning. On 07/15/11 at 10:20 a.m., LPN #1 was interviewed regarding the resident's pain. LPN #1 stated she believed the resident's pain was unrelieved and there were nurses' notes available about the behaviors related to the pain. LPN #1 was asked if the physician was aware of the resident's pain and the medication not effectively relieving the pain. LPN #1 stated the physician was aware of the pain not being relieved by her medication. LPN #1 stated if the resident's behaviors continued after pain medication was given the resident was given an [MEDICATION NAME]. LPN #1 stated she did not know of a pain assessment used in the facility. LPN #1 stated there might be a miscommunication between the staff on how to assess pain. On 07/15/11 at 11:00 a.m., CNA #1 was interviewed regarding the resident's pain and interventions to relieve the pain. CNA #1 stated the resident's pain was worse when she was repositioned on her side. CNA #1 stated the resident seemed to rest better when she was on her back. CNA #1 stated the resident complained almost every day with pain and when she was transferred. On 07/15/11 at 1:50 p.m., the director of nurses was interviewed regarding the resident's pain. The director of nurses stated the resident had a previous wrist fracture and she was medicated during the treatment. The director of nurses stated the resident was started on [MEDICATION NAME] for behaviors and pain. On 07/15/11 at 2:35 p.m., the physician was interviewed regarding the resident's pain. The physician stated he was unaware the resident's pain was interfering with her activity of daily living needs. The physician stated he was aware the resident had behavior problems. The physician stated he had referred the resident for a Geri-psych evaluation and it had not been done. The physician stated he did not understand why the Geri-psych evaluation could not be done. On 07/15/11 at 3:15 p.m., the director of nurses was interviewed regarding the resident's referral for a Geri-psych evaluation that the physician had ordered. The director of nurses stated the temporary entity that was the legal guardian at the time had refused for the resident to go for a Geri-psych evaluation. The director of nurses stated she did not document any of the interventions or phone calls she had done to try and get the Geri-psych evaluation. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/01/11, documented the resident required total assistance with all activities of daily living tasks. The assessment documented the resident was moderately impaired in cognition. The assessment documented the resident had short and long term memory problems. The assessment documented the resident was totally dependent with bed mobility. The assessment documented the resident had pain frequently, three to four times a week. The care plan, dated 06/01/11, documented the resident required total assistance with all activity of daily living tasks. The care plan documented the resident had alteration in comfort and joint pain and stiffness related to a [MEDICAL CONDITION]. The care plan documented [MEDICATION NAME] 5/600 milligram (mg), one tablet was given at 6:00 p.m., per peg tube and [MEDICATION NAME] 5/500 mg one tablet was given as needed per peg tube. The care plan documented Tylenol 650 mg liquid was to be given every four hours for pain or temperature. The care plan documented for staff to assess non-verbal signs of pain such as wrinkled brow, clenched fists, reluctance to move, rubbing her joints, and restlessness. On 07/13/11 at 10:15 a.m., the resident was observed in bed. CNA #1 washed the resident's face and applied chap stick to the resident's lips. The resident's bed became wet and soiled during the bed bath. The resident was observed grimacing, opening her mouth moaning, and raising her left leg. CNA #1 stated, "She stays in pain all the time with her left leg." On 07/15/11 at 10:10 a.m., LPN #1 was interviewed regarding the resident's pain. LPN #1 stated the resident should be medicated before her daily care and that was not done routinely. LPN #1 stated the resident's legs cramped, her toes would draw up, and she complained of pain when her leg was moved. LPN #1 stated she did not know of a pain assessment that was used in the facility. On 07/15/11 at 1:50 p.m., the director of nurses was interviewed regarding the resident's pain. The director of nurses stated the staff nurses were to use a pain scale from 1-5, 5 being the worst pain. The director of nurses stated that a pain scale from 1-10 was too broad to use. The director of nurses stated the nurses should document weekly in the nurses' notes. The director of nurses stated the resident had severe muscle cramps that would cause her toes to contract. The director of nurses stated the resident could probably use pain medication before her daily care. The director of nurses stated the physician was not contacted because the resident was given pain medication as needed. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/26/11, documented the resident was moderately impaired in cognition. The assessment documented the resident required extensive assistance with hygiene, bathing, and activities of daily living. A care plan, updated 05/26/11, documented the resident was incontinent of bowel and bladder. The assessment documented the resident required assistance with all activities of daily living needs. A patient information record, dated 07/02/11, documented the resident was hospitalized from [DATE] to 07/02/11 with the primary [DIAGNOSES REDACTED]. On 07/13/11 at 11:10 a.m., catheter care was observed being performed for the resident. CNA #3 was observed to clean the catheter tubing using one wipe from the tubing up toward the insertion site. The CNA was then observed to clean around the tip of the penis without changing wash cloths or areas of the wash cloth. On 07/15/11 at 6:10 p.m., the director of nursing, (DON), was interviewed concerning how an indwelling urinary catheter should be cleaned. The DON reported the catheter tubing should be cleaned from the penis down the tubing. The DON reported the same wash cloth should not be used to clean the resident's penis.