Every finding on record at Linwood Village Nursing & Retirement Apts

Based on record review and interview, the facility failed to ensure baseline care plans were completed within 48 hours of admission for 3 (#47, 54, and #161) of 15 sampled residents reviewed for baseline care plans. The administrator identified 55 residents resided in the facility. Findings: A Care Plans- Baseline policy, revised March 2022, read in part, The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social Services; and f. PASARR recommendation, if applicable. 1. An undated admission Record, showed Resident #47 was admitted to the facility on [DATE]. There was no baseline care plan completed within 48 hours of admission. The comprehensive care plan was initiated on 03/27/25. 2. An undated admission Record, showed Resident #54 was admitted to the facility on [DATE]. There was no baseline care plan completed within 48 hours of admission. The comprehensive care plan was initiated on 04/01/25. 3. An undated admission Record, showed Resident #161 was admitted to the facility on [DATE]. There was no baseline care plan completed within 48 hours of admission. The comprehensive care plan was initiated on 03/03/25. On 05/22/25 at 2:01 p.m., the DON stated Resident #161's baseline care plan was actually entered into the computer on 03/03/25 and was not completed in the expected time frame. They stated the baseline care preferences form they were using did not provide interventions, but just preferences of the resident. The DON stated Resident #47 did not have a baseline care plan and the comprehensive care plan was not initiated until 03/27/25. The DON stated Resident #54 did not have a baseline care plan and the comprehensive care plan was not initiated until 04/01/25

Based on record review and interview, the facility failed to ensure the direct care staffing hours on the Quality of Care report were accurately reported. The administrator identified 55 residents resided in the facility. Findings: A policy titled Quality of Care (QOC) Reporting policy, read in part, This policy establishes a structured approach to tracking, reporting, and improving Quality of Care in SNF's, (Skilled nursing facility) ensuring compliance with CMS (Centers for Medicaid/Medicare) regulations, PDPM (payment driven patient module) documentation standards, and Quality Reporting Programs (QRP). Review of the Quality of Care Report for February, March, and April 2025, showed the following days were below the state required minimum of 2.9%: a. 02/02/25 = census 57, total direct care hours were 161.78= 2.8%, b. 02/09/25 = census 60, total direct care hours were 159.06= 2.6%, c. 02/15/25 = census 60, total direct care hours were 156.77=2.6%, d. 02/16/25 = census 60, total direct care hours were 155.53=2.5%, e. 02/22/25 = census 60, total direct care hours were 150.29=2.5%, f. 03/01/25 = census 57, total direct care hours were 161.81=2.8%, g. 03/02/25 = census 57, total direct care hours were 150.2=2.6%, h. 03/15/25 = census 56, total direct care hours were 161.25=2.8%, i. 03/29/25 = census 58, total direct care hours were 167.51=2.8%, j. 03/30/25 = census 57, total direct care hours were 148.06=2.5%, k. 04/06/25 = census 52, total direct care hours were 146.26=2.8%, l. 04/26/25 = census 57, total direct care hours were 147.10=2.5%, and m. 04/27/25 = census 57, total direct care hours were 141.26=2.4% On 05/22/25 at 12:05 p.m., the DON stated the calculations for the QOC report were completed by the administrator. The DON stated the previous administrator completed them monthly and nursing would give them the information. The DON stated they were not familiar with what it looked like and would seek the administrator. On 05/22/25 at 12:15 p.m., the administrator stated the regional administrator had completed the reports since they were newly started. On 05/22/25 at 12:16 p.m., the regional administrator stated the QOC report was calculated by trying to stay above a 3.2%. The regional administrator stated therapy was added on the QOC side of the numbers given by a report by the regional operations manager for the therapy company. The regional administrator stated the state requirement was 2.9%. On 05/22/25 at 12:19 p.m., the regional administrator was shown the QOC reports for February, March, and April 2025. The regional administrator stated they needed to pull the report to see and calculate. The regional administrator wrote the dates in question and stated they were to calculate and provide whatever they find. On 05/22/25 at 2:24 p.m., the regional administrator stated they did not show the same calculations. On 05/22/25 at 2:26 p.m., the regional administrator stated for the date of 03/01/25, they had the direct staff hours to have been 164.85 at 2.9%. The regional administrator stated the therapy hours were not added and believed that was the issue. The regional administrator stated they were aware of the deficient practice since the QOC report was not reported accurately. The regional administrator stated they would continue reviewing all the dates. On 05/23/25 at 8:27 a.m., the DON provided a yellow paper of the dates in question, and stated the QOC reports provided were not accurate. The form provided showed different direct care hours.

Based on record review and interview, the facility failed to ensure a water management plan to prevent waterborne pathogens had been implemented. The administrator reported 55 residents resided at the facility. Findings: A facility policy titled Water Management Program, implemented 09/08/23, read in part, It is the policy of this facility to establish water management plans for reducing the risk of Legionellosis and other opportunistic pathogens in the facility's water systems based on nationally accepted standards .Documentation of all the activities related to the water management program shall be maintained in the water management program binder for a minimum of three years. On 05/23/25 at 10:31 a.m., the DON, regional administrator, and maintenance director were unable to provide documentation of any measures to prevent growth of Legionella. The maintenance director stated they did not really know about Legionella prevention.

Based on record review and interview, the facility failed to ensure a thorough investigation was completed for an allegation of abuse for 1(#162) of 2 sampled residents reviewed for abuse. The administrator identified 55 residents resided in the facility. Findings: A policy titled Abuse,Neglect and Exploitation, dated 01/01/25, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect.The facility will make efforts to ensure all residents are protection from physical and psychosocial harm. An initial OSDH Incident Report Form, for the incident on 02/07/25 Part B, read in part, Resident #162] told the shower aids, late Friday afternoon, that in the night [Resident #162] had asked the aide for ice water and [Resident #162] threw a cup of water in [CNA #1] face. No injuries were noted. [Resident #162] has been a resident since 12/27/24 on skilled services. [Resident #162] had a slip and fall accident in November 2024 which has left [Resident #162] with partial paralysis. [Resident #162] has lucid days and confused days. Part C read in part, The CNA was put on suspension pending investigation. A final OSDH Incident Report Form, for the 02/07/25 incident, showed, Part C read in part, The CNA was put on suspension pending investigation. An investigation substantiated the claim. Resident #162's quarterly MDS assessment, dated 04/05/25, showed a BIMS of 6 meaning severe cognitive impairment, dependent with ADLs, and diagnoses of traumatic spinal cord dysfunction, quadriplegia, and anxiety. On 05/22/25 at 2:12 p.m., CNA #1 stated abuse was if residents were not taken care of or if they saw any bruising. CNA #1 stated they would get the nurse or administrator immediately. CNA #1 stated Resident #162 was total care and had to be fed. On 05/22/25 at 2:18 p.m., the DON, with the regional administrator present, stated for an abuse investigation they do a state reportable On 05/22/25 at 2:20 p.m., the DON stated the resident and the 2 CNA's were the only ones in the room with the resident at the time of the incident. The DON stated Resident #162 was cognitively intact at times and was adamant that it happened. On 05/22/25 at 2:38 p.m., the DON stated they did not do resident interviews other than Resident #162. They stated there was no other staff to interview about the incident as there were only the two CNA's in the room at the time of the incident, other than when Resident #162 told the CNA's giving them the shower. The DON stated CNA #2 had other complaints about them from residents prior. The DON stated they were not sure if the reporting to the registry was done. The Oklahoma State Department of Health Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property, notification fax transmission was not located. On 05/23/25 at 9:35 a.m. the regional administrator stated they did not send to the nurse aide registry, they just sent to OSDH. They stated they had just found out they needed to send to both. On 05/23/25 at 9:40 a.m., the regional administrator stated the BOM had pulled the file and CNA #2 had not completed the actual training in the computer software system used. They stated staff was given fourteen days to complete the training's and CNA #2 never turned it in. The facility did not perform any additional resident interviews to ensure other residents were not affected by the allegation. The facility did not interview any staff regarding the CNA's behavior towards resident to ensure the CNA had not affected them. The facility was unable to provide proof of notification of CNA #2's allegations to the state agency for CNA reporting.

Based on observation, record review, and interview, the facility failed to ensure dented cans, and opened bottles were removed from circulation in the dry storage. The administrator identified 55 residents resided in the facility and ate from the kitchen. Findings: On 05/20/25 at 9:53 a.m., two 2.6 pound cans of hot dog chili sauce, and a can of tuna were observed to have dents along the seals. A plastic bottle of red food dye had torn foil covering the opening, leaving the bottle open to air. The date of receival written on the cans was 02/25. A policy Food Receiving and Storage, revised November 2022, read in part, Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. On 05/20/25 at 10:03 a.m., the DM stated the staff had dropped the chili cans, so the dietician told them they could serve the chili since they knew when the damage occurred. The DM stated he did not notice the can of tuna was bent or that the foil did not secure the bottle of food coloring. On 05/23/25 at 11:20 a.m., the dietician stated if the cans were damaged, they should have been thrown out if they were not served that day.

Based on record review and interview, the facility failed to ensure a resident's DNR was valid for 1 (#212) of 15 sampled residents reviewed for advance directives. The administrator identified 55 residents resided in the facility. Findings: An Advance Directives policy, revised [DATE], read in part, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives .Advance Directive is a written instruction, such as a living will or durable power of attorney .Durable Power of Attorney for Health Care' a document that delegates authority to a legal representative to make health care decisions in case the individual delegating that authority subsequently becomes incapacitated .Do Not Resuscitate (DNR)- indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used .On admission, the facility will determine if the resident has executed an advance directive .should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. A Resident Profile showed Resident #212 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure and atrial fibrillation. Resident #212's clinical record included a DNR that was approved by the resident's family member over the phone on [DATE]. The clinical record did not contain a copy of their POA. On [DATE] at 11:26 a.m., the SSD said Resident #212 came from the hospital with the DNR already signed by the resident's family member. The SSD stated Resident #212 told them they did not want CPR during their interview. The SSD stated they spoke with the resident's family member yesterday and asked about POA, but the family member avoided answering during the conversation. On [DATE] at 11:46 a.m., the DON stated when residents come from the hospital, they use the hospitals DNR. The DON stated, No I don't think that is a valid DNR, we would normally catch it.

Based on record review and interview, the facility failed to ensure abuse training on hire was conducted for 1 (CNA #2) of 3 staff members files who's employee files reviewed. The administrator identified 55 residents resided in the facility. Findings: The employee file for CNA #2 showed a hire date of 01/28/25. There was no abuse training on hire located in the employee file. On 05/23/25 at 9:40 a.m., the regional administrator stated the BOM had pulled the file and CNA #2 had not completed the actual training in the computer software system used. They stated staff was given fourteen days to complete the training's and CNA #2 never turned it in.

Based on record review and interview, the facility failed to ensure a resident was free from abuse for 1 (#162) of 2 sampled residents reviewed for abuse. The administrator identified 55 residents resided in the facility. Findings: A policy titled Abuse,Neglect and Exploitation, dated 01/01/25, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect.The facility will make efforts to ensure all residents are protection from physical and psychosocial harm. An initial OSDH Incident Report Form, for the incident date 02/07/25 Part B, read in part, [Resident #162] told the shower aids, late Friday afternoon, that in the night [they] had asked the aide for ice water and [they] threw a cup of water in [their] face. No injuries were noted. [Resident #162] has been a resident since 12/27/24 on skilled services. [Resident #162] had a slip and fall accident in November 2024 which has left [them] with partial paralysis. [Resident #162] has lucid days and confused days. Part C , read in part, The CNA was put on suspension pending investigation. A final OSDH Incident Report Form, for the 02/07/25 incident, showed, Part C read in part, The CNA was put on suspension pending investigation.An investigation substantiated the claim. Resident #162's quarterly MDS assessment, dated 04/05/25, showed a BIMS of 6 meaning severe cognitive impairment, dependent with ADLs, and diagnoses of traumatic spinal cord dysfunction, quadriplegia, and anxiety. On 05/22/25 at 2:12 p.m., CNA #1 stated abuse was if residents were not taken care of, or if they saw any bruising,.CNA #1 stated they would get the nurse or administrator immediately. CNA #1 stated Resident #162 was total care and had to be fed. On 05/22/25 at 2:18 p.m., the DON, with the regional administrator present, stated the policy for abuse was if someone was concerned to report to a superior or tell your administrator. On 05/22/25 at 2:20 p.m., the DON stated the resident and the 2 CNA's were the only ones in the room with the resident at the time of the incident. The DON stated Resident #162 was cognitively intact at times and was adamant that it happened.

Based on record review and interview, the facility failed to ensure: a. fall interventions were care planned after falls and have a process for notifying staff of interventions for one (#34), b. fall interventions were implemented and care planned after falls for one (#40), and c. a fall assessment was completed for one (#32) of three sampled residents reviewed for falls. The Administrator identified 49 residents resided in the facility. Findings: A Fall Risk Assessment policy, dated 01/02/24, documented the assessment will be completed when a significant change was identified. It documented the care plan will be completed for each resident to identify each item on the risk assessment and will be updated accordingly. It documented to monitor the effectiveness of the care plan interventions and modify the interventions as necessary. 1. Resident #34 had diagnoses which included dementia. A Care Plan for falls, was last updated 01/09/24. Progress Notes, dated 02/07/24 and 02/10/24, documented the resident fell . It documented on 02/07/24 Resident #34 sustained a right clavicle fracture. It documented no injuries sustained from fall on 02/10/24. Risk Management notes, dated 02/07/24 and 02/10/24 documented Resident #34 returned from the hospital on 02/07/24 with no treatment recommended. It documented a medication adjustment was completed related to fall on 02/10/24. The care plan did not reflect any changes related to falls. On 02/23/24 at 9:17 a.m., CNA #1 stated they weren't aware of how new interventions were implemented. They stated they were unsure what interventions were in place for Resident #34. On 02/23/24 at 9:38 a.m., LPN #1 stated they were familiar with most of the residents. They stated they were aware Resident #34 had a closed right clavicle fracture but was unsure how the resident sustained it. LPN #1 was asked what fall interventions were in place after Resident #34 sustained the fracture. They stated they monitored for signs and symptoms of pain, swelling, heat, edema, and not using their arm. On 02/23/24 at 10:02 a.m., the DON stated they verbally tell the staff regarding new fall interventions. The DON stated staff should be revising the care plans after falls but they weren't. 43023 2. Res #40 had diagnoses which included Parkinson's and anxiety. An incident report, dated 11/06/23, documented the resident was on the floor seated next to the bed. The report documented the resident had a skin tear to the left elbow. No interventions were put in place and the care plan was not revised. An incident report, dated 11/30/23, documented the resident reported they had missed their wheelchair. The resident was observed on the floor on their side with their right arm tucked under the right side of their head. The resident had a knot to the side of their head. Neuro checks started. No interventions were put in place and the care plan was not revised. An incident report, dated 12/28/23, documented the resident was found on the floor of their bathroom on their right side. It documented the resident reported they hit their head on the wall. Neuro's started. No interventions were put in place and the care plan was not revised. An incident report, dated 01/12/24, documented the resident was observed sitting on the floor by their wheelchair. The resident had a small skin tear to the left elbow. No interventions were put in place and the care plan was not revised. An incident report, dated 01/14/24, documented the resident was on the floor attempting to transfer self to the bathroom, no injuries noted. No interventions were put in place and the care plan was not revised. An incident report, dated 01/15/24, documented a CNA was walking by the resident's room and witnessed the resident sliding off the bed onto the ground, no injuries noted. No interventions were put in place and the care plan was not revised. An incident report, dated 01/16/24, documented the resident was found on the floor of their room, no injuries noted. No interventions were put in place and the care plan was not revised. An incident report, dated 01/22/24, documented the resident was seated on the floor, no injuries noted. No interventions were put in place and the care plan was not revised. An incident report, dated 01/30/24, documented the resident was observed sitting on the floor at the foot of the bed, no injuries noted. No interventions were put in place and the care plan was not revised. An incident report, dated 02/15/24, documented the resident reported they slid out of bed trying to go to the bathroom, no injuries noted. No interventions were put in place and the care plan was not revised. An incident report, dated 02/16/24, documented the resident was observed sitting on the floor in front of their toilet putting their socks and shoes on, no injuries noted. No interventions were put in place and the care plan was not revised. On 02/23/24 at 10:02 a.m., the DON reported the care plan should have been revised and interventions put in place. 45462 3. Resident #32 had diagnoses that included Alzheimer's disease and dementia. Resident #32's most current fall assessment was completed on 10/18/2023. Resident #32's clinical record documented the resident had falls on 11/07/23, 11/29/23, 12/10/23, 12/17/23, and 01/06/24. An MDS assessment, dated 12/18/23, documented a significant change of condition for Resident #32. On 02/22/24 at 2:23 p.m., the DON reported, according to the facility's policy, fall assessments were done on admission and quarterly on everyone or when a significant change is identified. The DON was asked if a fall assessment was completed for Resident #32 after they had five falls and a significant change in December. They stated no, it should have been done.

Based on record review and interview, the facility failed to ensure care plans were revised for three (#34, 40, and #32) of 13 sampled residents reviewed for care plans. The Administrator identified 49 residents resided in the facility. Findings: A Fall Prevention Program policy, dated 01/02/24, documented the plan of care would be revised as needed. 1. Resident #34 had diagnoses which included dementia. A Care Plan for falls, was last updated 01/09/24. Progress Notes, dated 02/07/24 and 02/10/24, documented the resident fell . It documented on 02/07/24 Resident #34 sustained a right clavicle fracture. It documented no injuries sustained from fall on 02/10/24. Risk Management notes, dated 02/07/24 and 02/10/24 documented Resident #34 returned from the hospital on 02/07/24 with no treatment recommended. It documented a medication adjustment was completed related to fall on 02/10/24. The care plan did not reflect any changes related to falls. On 02/23/24 at 10:02 a.m., the DON stated staff should be revising the care plans after falls but they weren't. 43023 2. Res #40 had diagnoses which included Parkinson's, dementia, psychotic disorder with delusions, major depressive disorder, and insomnia. A care plan, dated 01/29/24, documented the following interventions: a. Attempt to anticipate and meet the resident's needs. Date initiated: 06/27/22, b. Be sure the call light was within reach and encourage the resident to use it for assistance as needed. Answer the call light in timely manner. Date Initiated: 06/27/22, c. The resident will get out of the bed onto the fall matt next to the bed at times. If the resident was seated on the fall matt next to the bed with no s/s of injury, the resident has not fallen. Date Initiated: 12/08/23 d. The family will discuss with the resident their need for therapy and the family will encourage the resident to participate with therapy. Therapy will reattempt to evaluate the resident. Date Initiated: 04/17/23, and e. Please ensure the resident has non-slip shoes or socks on when walking in their room or hallways with their walker. Date Initiated: 06/27/22. The care plan did not document interventions after falls on 11/06/23, 11/30/23, 12/28/23, 01/12/24, 01/14/24, 01/15/24, 01/22/24, 01/30/24, 02/15/24, and 02/16/24. On 02/23/24 at 10:02 a.m., the DON stated the falls should have been care planned with interventions after each fall. 45462 3. Resident #32 had diagnoses that included Alzheimer's disease and dementia. Resident #32's most current care plan documented Resident #32's last fall was on 10/15/23. Resident #32's clinical record documented resident had falls on 11/07/23, 11/29/23, 12/10/23, 12/17/23, and 01/06/24. An MDS assessment, dated 12/18/23, documented a significant change of condition for Resident #32. On 02/22/24 at 2:23 p.m., the DON was asked if, according to the facility's policy, should Resident #32's care plan have been updated after they experienced five additional falls and a significant change of condition. They stated yes, definitely.

Based on record review and interview, the facility failed to act upon grievances presented during resident council meetings or provide rationale as to why concerns could not be met. The Administrator identified 49 residents resided in the facility. Findings: A Resident Council Meeting policy, dated 01/02/24, documented the facility shall act upon concerns, make attempts to accommodate, and communicate their decisions to the council. Resident Council minutes, dated 11/30/23, documented concerns with nurses yelling down the hall, medications were administrated late, call lights in the morning not being answered while food was being delivered, residents not being assisted timely, hamburgers were dry, not enough vegetables, and resident items were missing. Resident Council minutes, dated 12/28/23, documented continued problems with medications, food, and missing items. There was no documentation concerns were acted upon or a response was provided to the council. On 02/22/24 at 1:57 p.m., a resident meeting was conducted with six residents in attendance. Residents stated staff don't respond to their concerns brought to resident council. On 02/23/24 at 11:42 a.m., the SSD stated they fill out a form with concerns from resident council meetings and give them to department managers. They stated they don't always get the forms back.

Based on record review and interview, the facility failed to ensure staff investigated reports of misappropriation of resident items for one (#1) of one sampled resident for misappropriation of property. The Administrator identified 49 residents resided in the facility. Findings: An Abuse policy, dated 01/02/24, documented misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings without the resident's consent. It documented investigating different types of violations. It documented taking all necessary actions as a result of the investigation, which may include, but not limited to: analyzing occurrences, to determine why misappropriation of resident property occurred, and what changes were needed to prevent further occurrences; define how care provision will be changed and/or improved to protect residents receiving services; training of staff on changes made and demonstrate of staff competency after training implemented; identification of staff responsible for implementation of corrective actions; the expected date for implementation; and identification of staff responsible for monitoring the implementation of the plan. Resident Council minutes, dated 11/30/23, documented items disappeared from residents' rooms. It documented Administration keeps saying they are ordering [Resident #1]'s stuff that was stolen but never do. Resident Council minutes, dated 12/28/23, documented Resident #1's items have not been replaced. A Resident Council Action Form, dated 12/28/23, documented communication to the Administrator regarding Resident #1's items have not been replaced. There was no documentation items had been investigated, or replaced. On 02/22/24 at 2:09 p.m., Resident #1 stated they had bought a gift for their family member and it was missing. They stated they have brought it up in resident meetings. They stated the gift has not been replaced. On 02/23/24 at 11:38 a.m., the SSD stated when a resident reported missing items, they write up a grievance, and put it in the grievance book. They stated the Administrator looked at the book. They stated they help the resident look for item and if it isn't located, the resident was reimbursed. The SSD was asked if any items were reported missing in November and December 2023 resident council minutes. They stated Resident #1. They stated they recalled asking the resident what was missing but couldn't recall what it was. They stated they reported missing items to the Administrator. On 02/23/24 at 11:47 a.m., the Administrator stated when a resident reported missing items, staff looked for items, the SSD wrote up a grievance, and it was brought to the Administrator. She stated if staff were unable to locate items, it was replaced. The Administrator was shown the action form from December 2023. They stated they don't call Resident #1 reporting anything and they didn't get a copy of the action form. The Administrator was asked if it was considered misappropriation of residents' property if resident missing items/property was not located. They stated, Could be considered misappropriation.

Based on record review and interview, the facility failed to ensure influenza and pneumococcal vaccinations were offered for one (#104) of five sampled residents reviewed for immunizations. The Administrator identified 49 residents resided in the facility. Findings: A Pneumococcal Vaccine (Series) policy, undated, read in parts, .Each resident will be assessed for pneumococcal immunization upon admission .Each resident will be offered a pneumococcal immunization . An Influenza Vaccination policy, undated, read in part, .Influenza vaccinations will be routinely offered annually from October 1st through March 31st . Resident #104 had diagnoses that included dementia. Resident #104's immunization record did not document the resident, nor their representative, had been offered or received an influenza or pneumonia immunization. On 02/23/24 at 11:38 a.m., the DON was asked if residents were offered influenza and pneumonia vaccines on admission. They stated not really. The DON acknowledged neither Resident #104 or their representative were informed of the availability of the vaccines nor offered the immunizations on admission.

Based on record review and interview, the facility failed to ensure a resident's specialist appointment was completed timely for one (#34) of one sampled resident reviewed for social services. The Administrator identified 49 residents resided in the facility. Findings: A Social Services policy, dated 01/02/24, documented the social worker or designee would pursue the provision of any identified need which may include making referrals and obtaining needed services from outside entities. Resident #34 had diagnoses which included dementia. An Incident Note, dated 02/07/24 documented Resident #34 fell and was sent to a local hospital. A Nurse Progress Note, dated 02/07/24, documented the nurse from the hospital called and stated Resident #34 had a fractured right collar bone and needed to follow up with an orthopedic surgeon to determine if it needed a repair. It documented the DON was notified. There was no documentation Resident #34 had followed up with an orthopedic surgeon. On 02/23/24 at 10:02 a.m., the DON stated Resident #34 was suppose to see someone after the resident sustained the fracture. On 02/23/24 at 11:00 a.m., the DON stated she failed to follow up on the appointment.

Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#51) of two sampled residents reviewed for discharge. The Administrator identified 49 residents resided in the facility. Findings: A Discharge Summary policy, dated 01/02/24, documented upon discharge of a resident, other than emergency discharge or death, a discharge summary will be provided that should include: a. recapitulation of the resident's stay, b. final summary of the resident's status, c. reconciliation of all pre-discharge medications, and d. a post-discharge plan of care. Resident #51 had diagnoses which included wedge compression fracture of the fourth lumbar vertebra. A Nurse Progress Note, dated 11/24/23, documented Resident #51 discharged from the facility. On 02/23/24 at 9:56 a.m., the DON stated the discharge nurse completed the discharge summary. She stated if she saw the discharge summary had not been completed, then she would complete it. On 02/23/24 at 9:59 a.m., the DON stated the discharge summary for Resident #51 hadn't been completed.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for psychotic disorder with delusions for one (#40) of 13 sampled residents whose care plans were reviewed. The Administrator reported 49 residents resided in the facility. Findings: Res #40 was readmitted to the facility on [DATE] with a diagnosis of psychotic disorder with delusions. A care plan, dated 01/29/24, contained no documentation the resident had a diagnosis of psychotic disorders with delusions and did not include goals or interventions. On 02/23/24 at 11:03 a.m., the DON reported the psychotic disorder should have been care planned.

Based on record review and interview, the facility failed to refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#40) of one sampled resident reviewed for PASRR. The Administrator reported 49 residents resided in the facility. Findings: Res #40 was readmitted to the facility on [DATE] with a new diagnosis of psychotic disorder with delusions. The resident's record contained no documentation the facility contacted OHCA with the new diagnoses. On 02/23/24 at 11:17 a.m., MDS coordinator #1 reported state was not notified of the new mental health diagnosis.

Based on record review, observation, and interview, the facility failed to ensure two trash dumpster's were covered. The Daily Census, dated 02/09/24, documented 52 residents resided in the facility. Findings: A Disposal of Garbage policy, dated 01/02/24, documented containers and dumpster's were to be kept covered when not being used. On 02/09/24 at 10:16 a.m., two outside trash dumpster's were observed. Both dumpster's were observed to have an open lid. One black glove, one black sock, two clumps of paper towels, plastic spoons and forks were observed around the dumpster's. On 02/09/24 at 10:26 a.m., the Administrator stated the dumpster's were suppose to be closed after staff took out the trash.

Based on record review and interview, it was determined the facility failed to provide supervision to ensure a resident's safety while outside on the facility's patio, resulting in heat exhaustion for one (#1) of three residents who were reviewed for supervision. It resulted in the resident being treated for heat exhaustion at a local emergency room . This had the potential to affect 29 residents which required supervision outside of the facility. Findings: Resident #1 had diagnoses which included COVID-19, [CONDITION(S)], hypertension, cardiomegaly, major depressive disorder, [CONDITION(S)] disorder and [CONDITION(S)]. An activities monthly progress note, dated [DATE], documented, .She enjoys sitting outside on the patio, feeding the birds, playing on her tablet . A quarterly assessment, dated [DATE], documented, the resident's cognition was moderately impaired, required limited assistance on and off the unit, and used a wheelchair for mobility. A nursing alert note, dated [DATE] at 16:01, documented, Resident noted to be sitting on patio we brought inside and she wasn't responding at this time tried (sig) to open her eyes. Vs ,d+[DATE], pulse 102, T 100.2, O2 sat 88 on room air. 911 and Dr. [name withheld] notified. The ambulance arrived and the resident started to say her name. Transferred to [name withheld] hospital per EMSA. An incident report form sent to the Oklahoma State Department of Health, dated [DATE], documented, Description of Incident.Resident noted by CMA to be outside on the patio with eyes closed. CMA brought resident inside to nurses station but unable to awaken resident, CMA alerted Charge Nurse who also was unable to awaken resident, pulse noted. Charge nurse contacted PCP and resident sent to [hospital name withheld] ER via EMS. resident was able to awaken and state name prior to leaving facility via EMS. Resident admitted to [name withheld] Hospital with heat related diagnosis . Part C of the incident report documented, Investigation completed and noted that a dietary staff let resident outside onto patio and did not notify charge nurse, instead notified a CNA, resident fell asleep on patio and became overheated. 1:1 education provided to dietary staff member to confer with charge nurse prior to letting residents outside. Resident received IV fluid at hospital and returned to facility at 1222 with no new orders. An emergency department to hospital admission report, dated [DATE], documented, Chief Complaint: Patient presents with: Altered Mental Status, Heat Exposure. Vital signs for last 24 hours: Temp (39.8*C) (103.7*F) Heart Rate: 112 Resp: 22 BP: ,d+[DATE] FiO2(%): 21% .presents to ER with decreased level of consciousness and elevated body temperature after being outside of [name withheld] for an unrecorded amount of time. EMS was activated and the patient was transported to ED. She received IV fluids en route and revived somewhat. Initial temperature in the ED was 103.7*F rectal .Clinical Impressions as of Aug. 25, 17:47: Heat exhaustion .Therapeutic Measures: IV fluids, cooling measures. Result of treatments: the patient became alert, no distress, repeat temperature 98.3 .Final diagnosis: heat exhaustion A care plan, last updated [DATE], documented, Focus - I need assistance with daily care needs because I am forgetful and need verbal reminders of assistance to meet my daily care needs. Goal - I will have all my needs anticipated and met by the staff over the next 90 days since I am reliant upon them for all my care needs. Interventions - .LOCOMOTION ON/OFF THE UNIT: I am able to move (propel) my wheelchair some but still need staff to help me to and from places on/off the unit . On [DATE] at 1:51 p.m., the dietary manager was asked to relate what happened with the resident on [DATE]th. She stated, That day I was cleaning the dining room and she asked if I would let her outside. I then went and told her aide (CNA). She usually asks to go out, she saves her bread from her meals to feed the birds. The dietary manager was asked to describe what happened after the incident with the resident. She stated the administrator did one on one training with her and explained to never let a resident outside without asking the charge nurse first. She stated everyone received training. If there is a heat advisory there must be someone outside with the residents and they can only stay out for 15 minutes at a time. She was asked how she would know if there was a heat advisory. She stated, I put an app on my phone that alerts me. At 2:35 p.m., the resident was asked if she remembered being outside on the patio recently. She stated she did, she stated she went out and stayed too long. She stated she ended up in the hospital. She was asked if anyone had checked on her while she was outside. She stated, I thought they had. The resident expressed her disappointment at the new rules, saying I miss going outside because they only let me stay 15 minutes now. She was asked if staff would take her out and sit with her if she wanted to go out. She said they would, but only for 15 minutes. At 3:40 p.m., CNA #1 was asked to describe the incident on [DATE]th. She stated the kitchen staff let the resident outside and she came and told me. I did not tell the charge nurse. I went to assist another resident with a shower. Then another CNA came and told me they were sending the resident to the hospital. She can roll herself and usually comes and knocks to be let in. I was shocked she didn't knock to come in. CNA #1 was asked if she received any education after the incident. She stated she did. There was a facility wide in-service. Staff were given new protocols for reporting what residents were doing. She stated if someone tells me, I am to immediately tell my charge nurse, or if I let someone outside, I go tell the charge nurse. The protocol states that we have to stay outside with them if there is a heat advisory or it is really cold and we can only stay outside for 15 minutes at a time. I set a timer on my phone every time now. The new facility policy, dated [DATE], titled Heat Advisory and/or Inclement Weather, documented, Purpose: 1. To ensure all staff are knowledgeable how to address weather advisories. 2. To ensure all staff are knowledgeable how to address extreme temperatures. 3. To promote weather awareness and resident safety amongst staff. Protocol: 1. Any staff member must inform the Charge Nurse of any resident that is let outside. 2. If the temperature is above 90 degrees or below 50 degrees, the resident must be accompanied by a staff member for the entirety of the time the resident is outside . Staff were also provided a handout titled, Tip Sheet: Hot Weather Safety Tips for Older Adults Staff members from housekeeping, maintenance, nursing and dietary were interviewed. All staff received the same in-service on new protocols for heat advisory or inclement weather. The facility immediately put interventions into place to prevent another occurrence of this kind.

Based on observation, interview, and record review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for one (#3) of eight sampled residents whose care plans were reviewed. The facility identified 33 residents who resided in the facility. Findings: A Catheter Care, Urinary policy and procedure, revised September 2014, documented, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. Resident #3 had diagnoses which included, generalized muscle weakness, retention of urine, chronic kidney disease, and obstructive and reflux uropathy. An undated document titled, UTI PREVENTION documented, Foley Catheter Care .Foley Cath Care should be done every shift and PRN . A care plan, dated 06/30/21, documented, Focus: I need assistance with daily care needs because I get easily short of breath and tire easily .Goal: I will have all my needs anticipated and met by the staff over the next 90 days since I am reliant upon them for all my care needs .Interventions: TOILETING: I need staff to provide FOLEY CATHETER care for me. A physician's order, dated 07/01/21, documented, Foley Catheter change every evening shift every 1 month(s) starting on the 1st for 1 day(s) related to CHRONIC KIDNEY DISEASE, UNSPECIFIED. The resident had an appointment with his urologist on 07/01/21. The following orders were received by the facility. Dr. [name withheld] - urology visit 7/1/21, - cont foley catheter - daily foley catheter care - clean well - change foley catheter monthly - renal us at next available - RTC in 4-6 weeks for f/u Noted 7/2/21 No documentation was located in the resident's chart that the order for daily foley catheter care - clean well had been placed on the resident's order sheet or care plan. A quarterly assessment, dated 08/04/21, documented the resident's cognition was intact, required extensive assistance for ADLs, had a Foley catheter with no urinary toileting program. On 08/16/21 at 12:30 p.m., the director of nursing (DON) was asked how many residents had a Foley catheter. She stated, One. She was asked who provided catheter care. She stated, primarily the CNAs. The DON was asked how often she expected catheter care to be provided. She stated, every shift. She was asked where catheter care had been documented. She stated as of 08/12/21 on the treatment sheet. She was asked how she knew that catheter care had been provided. She stated, you would not know because it was not being documented. The DON was asked, following a urology appointment on 7/1/21, the urologist ordered, daily catheter care - clean well, where that order had been documented. She stated, it should have been documented on the TAR. She was asked who was responsible for ensuring new physician's orders were noted and documented. She stated, the charge nurse reviewed the orders, updated accordingly, updated the progress notes and was to upload any new orders. The DON was asked if catheter care had been provided every day as ordered by urologist. She stated, No. I could not find any documentation to support it had been done. The DON was asked where Foley catheter care had been care planned. She stated it was briefly noted in the care plan. She was asked if it was an adequate care plan for Foley catheter care. She stated, I would say no. The DON was asked how staff knew what the plan of care was for indwelling catheters if it had not been care planned. She stated, without it care planned, they don't. She was asked if Foley catheters and catheter care should be care planned with more detail. She stated, Yes.

Based on clinical record review, review of policy and procedures, and staff and resident interviews, it was determined the facility failed to notify the physician and a legal representative or a family member of a change in condition after a fall, for one (#1) of seven sampled residents who experienced a fall and/or were at risk for falls. This resulted in an immediate jeopardy situation. This deficient practice had the likelihood to affect all 55 residents residing in the facility. Findings: A facility policy titled, "Condition Change, of the Resident (Observing, Recording and Reporting)", documented, "...Basic responsibility: licensed nurse Procedure ...Performed By: CNA, LPN, LVN, RN, RT, CMA (handwritten in) Purpose To observe record and report any condition change to the attending physician so proper treatment will be implemented. Procedure:... 1. After all resident falls, injuries or changes in physical or mental function, monitor the following... a. observe for lacerations; if present, clean and apply dry, sterile dressing. Note size, depth and amount of bleeding or drainage. b. Observe for swelling and discoloration; if present, chart size, site, amount and color. c. Observe for convulsions; chart time began, precipitating factors, duration, vital signs and time ended. Also chart whether or not resident had difficulty breathing. d. Observe and inquire if resident has headache or pain. e. Observe for personality changes. f. Observe for alterations in consciousness. g. Observe for incontinence. h. Observe for sensory weakness. i. Observe for generalized weakness. j. Observe for speech disorder. k. Observe for gait, posture or balance disorder. l. Observe for stiff neck. m. Observe for proper reflexes (response to painful stimuli). n. Take vital signs and include temperature. o. Observe for abdominal spasm or pain. p. Observe for bleeding from ears, nose, throat. q. Observe for unequal pupils r. Observe for dyspnea or variations in respiration (irregular). s. Observe for flushing or cyanosis. t. Observe for pain. u. Observe for abduction, adduction, shortening or improper position of extremities. 2. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director. 3. Complete an incident, accident or risk management report per facility policy. 4. Notify resident's responsible party. 5. Monitor resident's condition frequently until stable. General Documentation Guidelines Documentation may appear on any form used in the facility. 1. Date, time condition change was identified. 2. Observation of the resident's findings. 3. Emergency care provided. 4. Notification of a physician. 5. Notification of the resident's responsible party. 6. Signature and title. Note: Document observation of the resident at least every shift until condition is stable." Resident #1 was admitted with a diagnosis, history of falls. A care plan dated 07/07/11 documented, Problem At risk for falls. Takes [MEDICAL CONDITION] medications q day. Goals Interventions will be in place to reduce the risk of falls by 10/05/11. Approach Review and assess medication profile to determine if medication side effects are causative factor(s) in fall risk. Assess for any side effects to antidepressant which could be dizziness, headache, increased anxiety. Report any of these side effects or any unusual behavior to the charge nurse. Nurse to contact primary physician with findings. QS (every shift). Everyday (Night, Day, Evening). A quarterly assessment dated [DATE], documented the resident was independent in her skills for daily decision making. It also documented the resident was unable to walk and had no history of falls since her admission on 06/09/11. She was continent of bowel and bladder. A nursing note dated 11/08/11 at 1:50 p.m., documented, "Resident reports falling around 0300 (3:00 a.m.) on 11/08/11 purple bruise noted on L side of head & outside L hand. T (temperature) 96.8 P bp 114/62 R 18 pupils equal & reactive grips equal reports pain in L hand. Denies H/A (headache) or n/v (nausea, vomiting). Left message @ physician office POA (power of attorney) in facility---DON notified neuro (neurological) (check) initiated." A nursing note documented at 5:20 p.m., "Administrator (name deleted) and this nurse spoke with POA at this time. POA voiced "I want her sent to the ER since you have not heard from the Dr." (name deleted) Administrator stated "ok we will get an order to have her sent." POA stated "we already called the ambulance." At 5:20 p.m., a nursing note documented, "call placed to (name deleted) physician N.O. (new order) received send to ER to eval (evaluate)." A nursing note at 5:25 p.m., documented, "Ambulance here with 2 EMT (emergency medical technician) transported out of facility. Report called to (name deleted) hospital." At 10:00 p.m. a nursing note documented,... "Staff received report from (name deleted) hospital Dx: (diagnosis) medial carpal Fx (fracture of hand)..." A late entry nursing note charted by LPN #1, who was the charge nurse on duty, dated 11/08/11, timed for 4:30 a.m., documented, "Was told by CNA (name deleted) resident was sitting on bedside mat and they had placed her back in bed, told them I would check her out. When I came up the hall she (name deleted)resident was up at her request in w/c drinking coffee in dining room no c/o or s/s (signs or symptoms) of distress or discomfort, she is toileted every 2 hours at hs (hour of sleep)12-2-4-6." On 11/14/11, at 7:20 a.m., LPN #1, who was the charge nurse on duty at the time of the fall, was asked if the resident had had a fall. He stated, CNA #2 told me the resident was on her mat again and we (CNA #1) helped her back to bed. I told her I would check her later. He stated, he observed her around 5:00 a.m. peddling toward the dining room and stopped and spoke with her. He stated, She did not appear any different to me. He was asked if the incident would require an assessment of the resident. He stated, "Yes I should have followed up with her history and assessed her, but I didn't." The nursing notes did not document an assessment of the resident after the charge nurse became aware of the fall on 11/08/11, at 4:30 a.m. No assessment was documented on the resident until 1:50 p.m. that afternoon, approximately ten hours after the fall. The nursing notes did not document the physician and or family had been notified of the resident's fall and change in condition, in a timely manner. On 11/14/11, at 11:40 a.m., OSDH was notified and verified the existence of an immediate jeopardy (IJ) situation related to the facility's failure to notify the physician and a legal representative or a family member of the change in condition after the resident's fall. At 1:02 p.m., the administrator and the DON were notified of an IJ situation related to the facility's failure to notify the physician and POA, family member or responsible party of a resident's change in condition. They were notified the IJ situation indicated a substandard quality of care and the facility would enter into an extended survey. At 1:05 p.m., the DON was asked about the fall. She stated, "We looked to see if LPN #1 had made a note and just forgot to tell us about it, but we could find nothing. That's when I told the nurse to get vitals, start neurological checks and call the doctor." On 11/14/11, at 5:35 p.m., the facility submitted an acceptable Plan of Removal. The Plan of Removal documented, "Failure to Immediately Notify Family and Physician of a Residents Change of Condition All residents will be considered at risk of this deficient practice of failure to immediately notify the resident's Representative and the Resident's Physician of a Resident's Change of Condition. As of Midnight (12am) 11/14/11, all Licensed Nursing Staff will be in-serviced in person or by phone, on Linwood's Policies and procedures for notifying the attending Physician and the Residents Representative of a Resident's Change of Condition. Upon completion of the in-service the staff member will sign an in-service sheet to acknowledge their understanding of the importance of the Policy and Procedures for notifying the resident's representative and resident's Physician immediately of a resident's change of condition. The phone in-services will be signed by the DON for the staff member until the staff member can sign the in person to acknowledge their understanding. All Direct Care Staff will be in-serviced before returning to their next scheduled shift. Licensed Nursing staff will be monitored for the understanding of Linwood's Policies on Notification of resident's representative and Physician. Monitoring will be done at the time of new hire orientation scheduled nursing in-service and random one-on-one interviews. The random interviews will occur during scheduled shifts, throughout the day by the DON or designee. The on-on-one interviews will be recorded and signed by the staff member to note their understanding. All in-services and random interview information will be record and covered during Linwood's Quality Assurance Committee Meeting beginning in November, 2011. Date of completion: 11/14/11, Midnight (12am) On 11/15/11, at 9:00 a.m, licensed staff were interviewed concerning when and who to notify about a change in a resident's condition. All staff answered questions appropriately. On 11/15/11, at 10:05 a.m., the IJ was removed effective 11/14/11, at 12:00 a.m. The deficiency remained at a level of actual harm which was isolated, with one or a very limited number of residents affected.

Based on clinical record review, review of policy and procedures and staff and resident interviews, it was determined the facility failed to assess, monitor and intervene in a timely manner, for one (#1) of seven sampled residents who had experienced a fall and/or were at risk for falls. This deficient practice resulted in an immediate jeopardy situation and had the likelihood to affect 40 of 55 residents who were at risk for falls. This information was obtained from the DON. Findings: A facility policy titled, "Condition Change, of the Resident (Observing, Recording and Reporting)", documented, "...Basic responsibility: licensed nurse Procedure ...Performed By: CNA, LPN, LVN, RN, RT, CMA (handwritten in) Purpose To observe record and report any condition change to the attending physician so proper treatment will be implemented. Procedure:... 1. After all resident falls, injuries or changes in physical or mental function, monitor the following... a. observe for lacerations; if present, clean and apply dry, sterile dressing. Note size, depth and amount of bleeding or drainage. b. Observe for swelling and discoloration; if present, chart size, site, amount and color. c. Observe for convulsions; chart time began, precipitating factors, duration, vital signs and time ended. Also chart whether or not resident had difficulty breathing. d. Observe and inquire if resident has headache or pain. e. Observe for personality changes. f. Observe for alterations in consciousness. g. Observe for incontinence. h. Observe for sensory weakness. i. Observe for generalized weakness. j. Observe for speech disorder. k. Observe for gait, posture or balance disorder. l. Observe for stiff neck. m. Observe for proper reflexes (response to painful stimuli). n. Take vital signs and include temperature. o. Observe for abdominal spasm or pain. p. Observe for bleeding from ears, nose, throat. q. Observe for unequal pupils r. Observe for dyspnea or variations in respiration (irregular). s. Observe for flushing or cyanosis. t. Observe for pain. u. Observe for abduction, adduction, shortening or improper position of extremities. 2. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director. 3. Complete an incident, accident or risk management report per facility policy. 4. Notify resident's responsible party. 5. Monitor resident's condition frequently until stable. General Documentation Guidelines Documentation may appear on any form used in the facility. 1. Date, time condition change was identified. 2. Observation of the resident's findings. 3. Emergency care provided. 4. Notification of a physician. 5. Notification of the resident's responsible party. 6. Signature and title. Note: Document observation of the resident at least every shift until condition is stable." Resident #1 was admitted with a [DIAGNOSES REDACTED]. A care plan dated 07/07/11 documented, Problem At risk for falls. Takes [MEDICAL CONDITION] medications q day. Goals Interventions will be in place to reduce the risk of falls by 10/05/11. Approach Review and assess medication profile to determine if medication side effects are causative factor(s) in fall risk. Assess for any side effects to antidepressant which could be dizziness, headache, increased anxiety. Report any of these side effects or any unusual behavior to the charge nurse. Nurse to contact primary physician with findings. QS (every shift). Everyday (Night, Day, Evening). A quarterly assessment dated [DATE], documented the resident was independent in daily decision making. The assessment documented the resident was unable to walk and had no history of falls since her admission on 06/09/11. She was continent of bowel and bladder. A nursing note dated 11/08/11 at 1:50 p.m., documented, "Resident reports falling around 0300 (3:00 a.m.) on 11/08/11 purple bruise noted on L side of head & outside L hand. T (temperature) 96.8 P bp 114/62 R 18 pupils equal & reactive grips equal reports pain in L hand. Denies H/A (headache) or n/v (nausea, vomiting). Left message @ physician office POA (power of attorney) in facility---DON notified neuro (neurological) (check) initiated." At 5:20 p.m., a nursing note documented, "(Administrator) and this nurse spoke with POA ( power of attorney) at this time. POA voiced "I want her sent to the ER since you have not heard from the Dr." (name deleted) The administrator stated, "Ok we will get an order to have her sent." POA stated, "We already called the ambulance." The nursing note documented, "call placed to Dr. (name deleted) N.O. received send to ER to eval (evaluate)." At 5:25 p.m. a nursing note documented, "Ambulance here with 2 EMT (emergency medial technicians) transported out of facility. Report called to (name deleted) hospital." At 10:00 p.m. a nursing note documented, "Return to facility via private auto. Assisted to room in w/c by family & staff. Received report from (name deleted hospital). DX: medial carpal FX & head ok..." A late entry nursing note charted by LPN #1, who was the charge nurse on duty, dated 11/08/11, timed for 4:30 a.m., documented, "Was told by CNA (name deleted) resident was sitting on bedside mat and they had placed her back in bed, told them I would check her out. When I came up the hall she (name deleted) resident was up at her request in w/c drinking coffee in dining room no c/o or s/s (signs or symptoms) of distress or discomfort, she is toileted every 2 hours at hs (hour of sleep)12-2-4-6." On 11/14/11, At 6:55 a.m., CNA # 1 was asked about the residents fall. She stated, the resident was on her mat and said her arm and hand hurt, my partner helped me get her in her chair from the mat. She just said it hurt she did not give detail. She further stated she assisted the resident to the bathroom and found a bump on her head. She then asked her partner, CNA #2 to go inform the charge nurse. At 7:05 a.m., CNA #2 was asked if she had informed her charge nurse of the resident having complaints of her head hurting. She stated, she believed she told him that the resident was complaining of pain (head) and that CNA #1 found a bump on her head. On 11/14/11, at 7:20 a.m., LPN # 1 was asked about the resident's fall. He stated, CNA #2 told me the resident was on her mat again and they helped her back to bed. I told her I would check her later. He was asked if he should have assessed the resident. He stated, "Yes I should have followed up, with her history and assessed her, but I didn't. The nursing notes did not document an assessment of the resident after the charge nurse became aware of the fall on 11/08/11, at 4:30 a.m. No assessment was documented on the resident until 1:50 p.m. that afternoon, approximately ten hours after the fall. On 11/14/11 at 11:40 a.m., OSDH was notified and verified the existence of an immediate jeopardy (IJ) situation related to the facility's failure to assess, monitor and intervene in a timely manner, for a resident who experienced a fall with injury. At 1:02 p.m., the administrator and the DON were notified of the IJ situation related to the facilities failure to assess monitor and intervene for a resident who experienced a fall with injury. At 1:05 p.m., the DON was asked about the residents fall. She stated, "We looked to see if LPN #1 had made a note and just forgot to tell us about it, but we could find nothing that's when I told the nurse to get vitals, start neurological checks and call the doctor." They were notified the IJ situation indicated a substandard quality of care and the facility would enter into an extended survey. At 5:35 p.m., the facility submitted an acceptable plan of removal. The Plan of Removal documented, "Failure to Assess and Monitor with Intervention For a Resident's Change in Condition. All residents will be considered at risk of this deficient practice of failure to Assess and Monitor with Appropriate Intervention for the Resident's Change of Condition. On 11/11(14)/11 by Midnight (12am) all Licensed Nursing Staff will be in-serviced in person or by phone on Linwood's policies and Procedures for Assessing Monitoring and Appropriate Interventions for a Resident's Change of Condition. On 11/14/11 by Midnight (12am) all Nurses Aides will be in-serviced in person or by phone on the Policies and Procedures for reporting a Resident's Change of Condition to the Charge Nurse. Upon completion of the in-service the staff member will sign an in-service sheet to acknowledge their understanding of reporting a resident's change of condition. The phone in-services will be signed by the DON for the staff member until the staff member can sign the in person to acknowledge their understanding of Assessing and Monitoring with Appropriate Interventions for a resident's change of condition. All Direct Care Staff will be in-serviced before returning to their next scheduled shift. All direct Care Staff will be monitored for the understanding of Linwood's Policies and Procedures for Assessing, Monitoring with Intervention for a resident's change of condition. Monitoring will be done at the time of new hire orientation, scheduled Nursing and CNA in-services and random one-on-one interviews. The random interviews will occur during scheduled shifts, throughout the day, by the DON or designee. The on-on-one interview will be recorded and signed by the staff member to note their understanding. All in-services and random interview information will be recorded and covered during Linwood's Quality Assurance Committee Meeting beginning in November, 2011. Completion Date:11/14/11, Midnight (12am)" On 11/15/11 at 9:00 a.m, facility staff were interviewed about their training regarding assessing, monitoring and intervening for a resident with a change of condition. Licensed nursing staff were asked when to assess, how to monitor and intervene for a resident with a change in condition. They were able to answer questions appropriately. On 11/15/11, at 10:05 a.m., the IJ was removed effective 11/14/11, at 12:00 a.m. The deficiency remained at a level of actual harm which was isolated, with one or a very limited number of residents affected.

Based on observation, record review, and interview, it was determined the facility failed to: a. provide pressure relieving devices and follow up on wound consultant recommendations for one (#3) of three sampled residents with pressure ulcers; and b. monitor and assess the residents skin and failed to prevent the re-occurrence of a pressure ulcer for one (#1) of three sampled residents with pressure ulcers. This constituted actual harm. The facility had identified two residents who had pressure ulcers. A third resident was observed to have pressure ulcers which had not been identified by the facility (resident #1). Findings: The facility's pressure ulcer policy documented: ~ documentation may appear on any form used in the facility, ~ date, time, or shift as appropriate, ~ date and time the treatment to pressure ulcer, ~ preventative measures used, ~ condition of the resident's skin, ~ physician notification, if appropriate, ~ preventative equipment used, ~ if a pressure ulcer is present the licensed practical nurse is responsible to record the condition of the skin. Including the stage, size, site, depth, color, drainage, and odor as well as the treatment provided. Notification of the physician is required when a new pressure ulcer is identified, as well as, when treatment is not effective. ~ sign your signature and title. General guidelines for assessment may include, but are not limited to: ~ skin at risk ~ general condition of skin ~ report any pain to physician ~ status of peripheral circulation ~ nutritional status ~ hydration/fluid balance ~ mobility status ~ limitation in range of motion ~ deformities ~ use pressure ulcer risk assessment tools per facility policy. Briggs,Norton, and Braden are available and may be included in the facility computerized medical record. The policy for pressure ulcer, care and prevention of, documented: "...Purpose: To prevent and treat further breakdown of pressure sores... General guidelines for assessment may include, but are not limited to: ~ Skin at risk ~ General condition of skin ~ Any pain; report to physician... General infection control guidelines... Apply preventive measures to maintain skin integrity, if necessary... Equipment... pressure reducing mattress... Procedure... Use pressure reducing devices to relieve pressure... Treatment... The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers..." 1. Resident #1 had [DIAGNOSES REDACTED]. The Braden Scale scores for the dates of 05/19/10, 08/04/10, 11/03/10, and 03/06/11, documented scores of 12 or less; which represented the resident was a high risk for pressure ulcers. A care plan update, dated 01/24/11, documented: Problem: ~ Impaired skin integrity to the right buttock related to decreased mobility and pressure. Goal: ~ evidence of new granulation tissue will be present weekly until healed. Approach: ~ administer treatment as ordered. Document weekly and as necessary. Seek changes to treatment as needed. ~ seek wound care consultant as needed. ~ provide nutritional supplement as needed to promote wound healing. ~ encourage adequate nutrition and hydration daily. ~ CNAs to observe general appearance of skin and bony prominences with daily care. Report abnormal appearance to nurse. ~ apply body lotion after shower and as necessary to promote skin integrity. ~ keep bed linens and clothing dry and wrinkle free. ~ Use a draw sheet for repositioning. ~ avoid positions that apply pressure to affected area. ~ discourage the use of an incontinent brief when in bed to allow circulation of air to promote healing. Hand written, at the bottom, was a note which documented, "Clean with normal saline, pat dry, and apply [MEDICATION NAME] daily until healed." Hand written, at the top was a note which documented, "Healed 02/15/11." A nurse's note, dated 03/21/11 at 1200 p.m., documented the hospice nurse had informed the facility of an abrasion to the resident's left buttock. A physician's order, dated 03/21/11, documented to apply [MEDICATION NAME] ointment two times a day to the abrasion on the resident's buttock. There was no documentation to indicate the physician or family had been notified of the wound. No documentation was available of skin assessments conducted. The care plan had not been revised to address the current status of pressure ulcers/abrasions to the resident's right buttocks. The care plan, dated 04/25/11, documented the resident was at risk for pressure ulcers related to impaired mobility, incontinence, and history of pressure ulcers. The care plan documented: Goal: Her skin will be assessed by the staff. Any signs or symptoms of skin breakdown will be reported to the charge nurse by 07/25/11. Approach: a. the staff is to monitor for signs and symptoms of skin breakdown, open areas, or red areas each time she is changed or bathed. b. report any problem areas to the charge nurse and or the wound care nurse. c. reposition every 2 hours when in bed or Geri-chair (every shift) (every day, night, evening). The annual assessment, dated 04/27/11, documented the resident's cognition was severely impaired for daily decision-making, she was at high risk for developing pressure ulcers, and required total assistance with activities of daily living. She was incontinent of bowel and bladder. She had pressure relieving devices on her bed and Geri-chair. The hospice nursing visit notes, dated 05/02/11 and 05/06/11, documented the bandage to the resident's buttocks was clean, dry, and intact. There was no other documentation of skin or wound assessments conducted. The care plan had not been revised to reflect the current status of the resident's pressure ulcers/abrasions. On 05/12/11 at 8:30 a.m., LPN #1 was asked if the resident had pressure ulcers. She stated she had in the past, but they had healed. She stated she was only applying cream to a slightly pink area now. At 8:50 a.m., LPN #1 was observed as she provided wound treatment for [REDACTED]. The resident had a circular pressure ulcer on her right buttock, near the Ischial Tuberosity area. The pressure ulcer had a bright red wound bed. The appearance was consistent with a stage II, and was approximately 1 cm in size. The LPN did not indicate there was a wound on the resident's back. No treatment was provided to that pressure ulcer during this observation. During wound treatment, the LPN cleansed the right buttock area with normal saline on a 4 by 4 and applied [MEDICATION NAME] ointment. She was asked if she was responsible for performing the daily wound treatment. She stated she was, but the hospice wound nurse provided wound treatment once a week. She was asked if this pressure ulcer was the same wound she had described earlier this morning. She stated yes. She was asked if it had changed in appearance. She stated no. She was asked if she had ever staged or measured it. She stated she thought it was a stage I because the first layer of skin was gone. She stated she didn't know she was supposed to measure it. She was asked if she had conducted skin assessments or had wound treatment documentation. She stated no. She produced wound treatment documentation from last October and stated this was the most recent. She was asked if the clinical records contained documentation the staff had conducted skin assessments. She stated she didn't know. She was asked if she had notified the physician of the condition of the wound. She stated she had not. She was asked if hospice had notified the physician. She stated she did not know what hospice had done. She stated she had not talked with them about it. There was no documentation to indicate the physician or family had been notified of the pressure ulcer. There was no documentation of skin assessments conducted. The most recent wound treatment documentation was dated 09/23/10, for a stage II on the right buttock. It documented the wound had healed on 10/08/10. On 05/12/11 at 5:00 p.m., the DON stated LPN #1 and the hospice aide had just observed the resident's wounds. She notified the physician and the resident's family. The physician had given her a new treatment order for the pressure ulcers. The DON was asked if daily or weekly skin assessments had been conducted. She said, "Not unless they have a pressure ulcer. The resident had a shear injury, so it wasn't considered a pressure ulcer." The DON described the condition of the pressure ulcers as: ~ three pin point shear stage II areas on the resident's right buttocks. ~ one stage I area on the resident's back which measured 1 (by) 0.5 cm. She handed the surveyors two weekly pressure ulcer forms, dated 05/12/11, which documented three pressure ulcers on the right buttock and one pressure ulcer to the back. She stated she and the LPN had just completed them. Form number one documented three pressure ulcers to the right bottom: ~ #1 was described as a stage II with measurements of 0.3 (by) 0.3 cm. ~ #2 was described as a stage II with measurements of 0.1 (by) 0.1 cm with a depth of 0.1 cm.. ~ #3 was described as a stage II with measurements of 0.1 (by) 0.1 cm. Form number two documented one pressure ulcer to the middle of the back: ~ it was described as a stage I with measurements of 1 (by) 0.5 cm. On 05/13/11 at 09:20 a.m., pressure ulcer treatment was observed. LPN #1 was asked to measure the pressure ulcer on the right buttock. She stated it was a stage II with a measurement of 1 (by) 1 cm. The DON was asked why she thought the wound was three separate wounds. She used a pin light to illuminate the pressure ulcer. She stated if you look closely you could see a thread of skin between the pressure ulcers. During the observation, the DON was asked when she first became aware of the pressure ulcers. She stated yesterday (05/12/11). She was asked when was the last time the resident had pressure ulcers. She stated the resident had a pressure ulcer last October (2010). She was asked if she was aware hospice had informed the facility the resident had an abrasion to her bottom on 03/21/11. She stated she did not think an abrasion/shear was to be documented as a pressure ulcer. She was asked if she was aware hospice had documented the resident had a dressing to her buttock on 05/02/11 and 05/06/11. She stated she was not. 2. Resident #3 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident-data collection admission notes, dated 05/05/11, documented the resident was alert, oriented, had quick comprehension, and had clear communication. The resident required assistance with most activities of daily living and was independent with eating/nutrition. The resident was seen by a wound specialist consultant on 05/05/11. The wound specialist consultant identified the following venous/pressure ulcers on a wound assessment progress report, dated 05/05/11: a. two venous ulcers on the right leg b. one venous ulcer on the left leg, and c. a left ischial pressure ulcer. An un-timed nurse's note, dated 05/05/11, documented the following: "Wound nurse here- to complete assessment of wounds- Resident has pressure ulcer to left buttocks- measures 1 (by) 1 centimeter (cm) stage 3- scant (amount) of serous drainage noted... Left leg- venous ulcer- measures 9.5 (by) 6.5 depth unable to determine(UTD)... Right leg has two venous ulcers #1 measures 5.0 (by) 5.5- depth UTD... #2 venous ulcer measures 1.5 (by) 1.0 cm depth- UTD..." The following comments were documented by the wound specialist consultant on the wound assessment progress report dated 05/05: ~ Under pressure relief interventions: "*Consider specialty mattress.." ~ Under nutritional interventions: "*Consider pre [MEDICATION NAME], (registered dietitian) referral, and (laboratory tests as needed)..." A comprehensive admission skin assessment, dated 05/05/11, documented, "Stage #3 pressure ulcer to left buttocks measures 1 x 1 cm..." The weekly pressure ulcer record, dated 05/06/11, documented, "preventive measures/progress: a. -turned (every 2 hours) b. -pressure relieving interventions gel pad in (wheelchair) -air mattress high protein supplements- multivitamins/Zinc." There were no physician's orders or documentation to show the resident had received the interventions as documented on the weekly pressure ulcer record, dated 05/06/11, for the pressure relieving mattress, the high protein supplements, and the multivitamins/Zinc. The facility had failed to implement the use of a pressure relieving mattress as a therapeutic device for the resident: ~ after the resident had been assessed to have a Stage III ischial pressure ulcer, and ~ after the wound specialist consultant had recommended a specialty mattress. On 05/13/11 at 10:00 a.m., the pressure ulcer to the resident's right ischial area was observed to be approximately 1 x 1 cm, with no drainage and no odor. The wound had the appearance of a Stage II. On 05/13/11 at 2:45 p.m., the DON and LPN #1 (the wound treatment nurse) were asked about following up on the recommendations by the wound specialist consultant and the preventive measures documented on the weekly pressure ulcer record. LPN #1 stated, "I found a gel pad in storage myself for her wheelchair." When asked about the intervention of the specialty mattress. The DON and LPN #1 stated, "Hospice gets the air mattresses and she is not hospice." As of 05/13/11 at 5:30 p.m., the resident had not been provided the following, which had been documented on the weekly pressure ulcer record, dated 05/06/11, as preventive measures: "~ Pressure relieving interventions of ...an air mattress, ~ High protein supplements, and ~ Multivitamins/Zinc."

Based on observation, record review, and interview, it was determined the facility failed to: a. monitor, assess, address, and re-evaluate a resident's complaints of pain and attempt to determine the underlying cause of the pain for one (#3) of one sampled resident with a constant complaint of pain. The facility failed to communicate with the resident, on an on-going basis, and provide interventions to meet the resident's need for pain relief. The resident was determined to have an unidentified fracture. The facility identified six residents with fractures and two residents who triggered for pain on the facility's roster matrix. b. monitor a resident's on-going complaints of pain for one (#3) of one sampled resident who was observed to repeatedly cry out in pain before, during, and after wound treatments to both legs. The facility identified two residents with a history of pain. The facility's failure to assess and monitor the resident's pain and to provide interventions to relieve her pain constituted actual harm for resident #3. c. ensure one (#1) of one sampled residents with a risk of choking and/or aspiration remained at a 90 degree position during intake of food and fluids at the noon meal. The facility identified 16 residents who triggered for swallowing problems on the facility's roster matrix. Findings: The pain management policy documented the following: "Purpose: To provide each resident with effective interventions for the relief of unwanted distress caused by pain and suffering." The policy statement documented the following: "To utilize an interdisciplinary approach to the management of pain to assure that each resident is provided with effective interventions for the relief of unwanted pain and suffering. We believe that pain can only be measured by the person who is experiencing the pain and treatment must be based on the person's reports of pain and/or suffering. * Our approach to pain and symptom management will be individualized through careful assessment, planning, and monitoring with input from the resident, family, and members of the interdisciplinary team. * We do not accept that pain is an inevitable part of the aging process and while we acknowledge that all forms of pain cannot be controlled in all resident 100% of the time, every effort will be made to alleviate and/or reduce a resident's complaints of pain." The facility policy on implementation and responsibilities documented the following: "1. Those resident who have been diagnosed with [REDACTED]. 2. Those residents who have a change in status/medical condition will be assessed as soon as possible following the status change. 3. The level of pain will be determined by using the assessment tool defined by the facility. 4. The interdisciplinary team will review the pain assessment, including this in the care plan, and determine goals and approaches to be used to decrease or alleviate the pain, discomfort or distress caused by pain. 5. All employees are responsible and empowered to alert the nurse on duty whenever they suspect or observe a resident to be in discomfort or distress. 6. All nursing staff, including CMA's, must assess for signs and symptoms of pain, discomfort or distress on an on-going basis and report the presence of symptoms to their nursing supervisor and/or DON immediately. 7. Medications to lessen symptoms of pain, discomfort or distress will be administered as prescribed by the resident's physician. 8. Medications administered on a PRN basis will have documentation indicating the level of pain prior to administration of the medication using the approved pain assessment tool (scale) and the level of pain after the administration of medication to evaluate the efficacy of the medication (s). This is to (be) thoroughly documented in the resident's record. (a) The findings of the assessment will be placed in the resident's record. (b) Education will be provided to the resident to insure that they understand the purpose of the medication, possible side effects, and to report, if possible, how they feel following the medication administration. (c) Families, resident, guardian, and/or responsible party (ies) will be notified... (d) The physician should regularly assess the efficacy of the pain management plan with input from the resident and the interdisciplinary team. (e) If the resident's pain and/or suffering continues, this unmet need for care and comfort should be brought to the attention of DON who will notify the attending physician. 9. The DON or his/her designee, will update the physician regarding the effectiveness or ineffectiveness of pain management medication based upon the resident's response to treatment and condition as needed. 10. If pain management medication does not alleviate pain or reduce the resident pain to an acceptable level as determined by the resident, the nurse will contact the attending physician and request a change in medication or additional medication for the management of pain. (If the attending physician is not the Medical Director, the Medical Director is to be notified about the condition of the resident.) 11. The DON or his/her designee will communicate any changes in the pain management protocol to the resident, families, guardian, and/or responsible party and document such in the resident's record. 12. Non-pharmacological interventions may be initiated by the resident's interdisciplinary team and included in the resident's plan..." The policy for pressure ulcer, care and prevention of, documented: "...Any pain; report to physician..." 1. Resident #3 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident-data collection admission notes, dated 05/05/11, documented the resident was alert, oriented, had quick comprehension, and had clear communication. The resident required assistance with most activities of daily living and was independent with eating/nutrition. It documented the resident had complained of mild back pain on admission. On a pain evaluation, dated 05/05/11, the following questions/responses were documented: ~ "Does the resident have any diagnosis (es) which would give reason to believe he/she would be in pain?" The response was "Yes" ~ "Does the resident verbalize pain?" The response was "Yes." The date of pain onset had not been documented. ~ "As the patient describes it, what does the pain feel like? (check all that apply.)" The responses were aching and shooting. ~ "Pain is increased by (describe circumstances or activities):" No response had been documented. ~ Any language and/or culture barriers: "No" had been checked. The resident had been examined by a wound specialist consultant on 05/05/11. The wound specialist consultant had identified the following venous/pressure ulcers on a wound assessment progress report, dated 05/05: a. two venous ulcers on the right leg b. one venous ulcer on the left leg, and c. a left ischial pressure ulcer. An untimed nurse's note, dated 05/05/11, documented the following: "Wound nurse here - to complete assessment of wounds - Resident has pressure ulcer to left buttocks - measures 1 (by) 1 centimeter (cm) stage 3 - scant (amount) of serous drainage noted... Left leg - venous ulcer - measures 9.5 (by) 6.5 depth unable to determine (UTD)... Right leg has two venous ulcers #1 measures 5.0 (by) 5.5 - depth UTD...#2 venous ulcer measures 1.5 (by) 1.0 cm depth - UTD..." A nurse's note, dated 05/05/11 at 12:30 p.m., documented, "...(Complained of) pain in low back (especially) on (right) side. has not taken anything for pain... " A nurse's note, dated 05/07/11 at 3:40 p.m., documented, "...(Reporting) pain in (right upper quadrant)..." On 05/10/11 at 3:15 p.m., the resident stated she fell at home a few times. She stated after the last fall, she had been unable to get up from her porch. She stated her daughter was unable to assist her to get up and had to summon her grandson to lift and carry her to her bed. She stated she had never been the same since her last fall. She stated she often experienced excruciating back pain. During the interview, the resident grimaced, gripped her covers, hesitated, and moaned. When the resident was asked if there was a problem; she stated she was in pain. When the resident was asked where her pain was located; she stated everywhere and especially her back. When asked to describe the pain; she stated it was sharp and shooting. When asked if it hurt more when she moved or when she was sedentary; she stated it hurt when she was moving and/or still. When asked how often she had pain; she stated it was almost constant. When asked the intensity of her pain; she stated it always hurt and presently it was worse. When the resident was asked if she had received medication for her pain; she stated she had not. When asked if she had told her nurse about her pain; she stated she had. The surveyor explained to the resident that if she desired relief by pain medication, she would have to call her nurse, describe her pain, and request the medication. There was no documentation to indicate the resident had been monitored, re-assessed, re-evaluated or offered any relief for her complaints of pain; after she had complained of pain on 05/05/11 and 05/07/11. There was no physician's order for pain medication, nor were there nursing interventions documented in response to the resident's complaints of pain after the complaints of pain on 05/05/11 and 05/07/11. A nurse's note, dated 05/10/11 at 5:15 p.m., documented, "Resident requesting something for pain before (dressing changes) Notified (Dr./name deleted) via phone (new order) [MEDICATION NAME] 7.5/500 (one) 20 minutes before (dressing change)..." On 05/11/11 at 2:45 p.m., the surveyor entered the room to interview the resident. The resident had leaned forward, her brow was furrowed, she was tearful, and tugged at her covers. When the resident was asked if there was a problem; she stated she was hot and her pain was really bad. When asked if her nurse had intervened in any way to diminish her pain and discomfort, she stated she had received pain medication before the nurse had changed her bandages. She stated the pain had become worse after the nurse had changed her bandages. When the resident was asked if she had told her nurse about her worsened pain, she stated she had not. A nurse's note, dated 05/11/11 at 3:15 p.m., documented, "Res (complained of) (lower) back pain. Call to (Dr./name deleted) (new order) received [MEDICATION NAME] 7.5/500 (one) (orally) (every) 4 (hours) (as needed) (diagnosis) pain..." On 05/12/11 at 9:55 a.m., treatments to the venous ulcers on the resident's legs was provided by LPN #1. The resident grimaced and moaned as the LPN began the treatment of [REDACTED]. The resident grimaced, moaned, and complained of pain during the treatment of [REDACTED]. When the resident was asked if she had requested medication for pain relief, LPN #1 responded and stated the resident had been given pain medication 20 minutes before the dressing change. When the resident was asked if the medication had relieved her pain, she moaned, became tearful, and pulled at her covers. She stated she was in bad pain. She added, "I wish the Lord would just take me away." The resident was observed to repeatedly cry out in pain before, during and after the treatment of [REDACTED]. At 2:45 p.m., an interview was conducted with the DON and the treatment nurse (LPN #1). The surveyor discussed with the DON and LPN #1 the resident's multiple complaints related to pain and her episodes of falls. The DON and LPN #1 were asked if they thought the pain could possibly be related to the falls the resident had experienced. They were asked if they had assessed and evaluated the resident to rule out a fracture. The DON stated, "She fell at home and due to her religion, she is very against x-rays." They were asked if the resident had been observed to have pain often, had they considered obtaining orders for routine pain medications. The DON stated, "We have prn and routine medication to administer before treatments." When they were asked their plans for the resident, the DON stated they could get with her to see if she wanted an x-ray now. When they were asked about the facility policy related to pain assessments, the DON stated the resident should have pain assessments on admission, conducted by the RN quarterly, and conducted by the LPN monthly. When they were asked if the resident had been re-assessed to ascertain specifically if she would agree to be administered routine medication for her pain, the DON stated she had asked the resident on admission if she would like medication. LPN #1 stated, "I think if you would ask her directly if she wanted an x-ray, she would. She wants to get better." The administrator presented the resident's application for admission, dated 05/04/11, which documented the following comments; "...Wishes not to go to the hosp. takes herbs not medication educated res (resident) on ABT (antibiotic therapy). Agrees to receive ABT therapy. Wishes to follow religious beliefs. Agreed to let staff (treat) wounds." A nurse's note, dated 05/12/11 at 4:00 p.m., documented, "...Resident asked about pain. Resident stated 'the pain medication takes the edge off.' Resident asked if she would like to try the pain medication routine, resident stated that she has discomfort when she moves on her left and right hip. (Dr./name deleted) notified. New orders received for x-ray of lumbar spine, left and right hip and pelvis. [MEDICATION NAME] 7.5/500 routine (one) (orally) at (9:00 a.m., 1:00 p.m., and 6:00 p.m. for pain management." At 4:55 p.m., the resident stated, "I am resting better and I think they (the nurses) have finally gotten enough pain pills in me to help. This is the best I have been in a while." At 5:00 p.m., the DON stated she had obtained results from the x-ray which had been taken at the facility the last evening. She stated the physician and the daughter had been notified. She stated the daughter was at the facility to speak with the physician related to the results of the x-ray. The DON stated the physician had increased the pain medication to a routine dosage of four times daily. The following x-ray reports were obtained from the DON: ~ The final x-ray report documented the following results of the portable L spine exam for her complaint of back pain: "...Mild compression fractures of L1 and L2, age indeterminate. There is also a compression fracture suggested on a T11 on the AP view, age indeterminate...Impression: ...Compression fractures of L1 and L2 as well as T11, age indeterminate...Follow-up as clinically indicated." ~ The final x-ray report documented the following results of the portable bilateral hips with pelvis for her complaint of pain: "...There is a subcapital [MEDICAL CONDITION] proximal femur with a superior lateral displacement of the left femoral shaft with respect to the femoral head fracture fragment... Impression: Subcapital [MEDICAL CONDITION] proximal femur with bony displacement...Follow-up as clinically indicated." The DON stated they had discussed at length the resident's beliefs and use of herbs for pain prior to and after her admission. She stated they had inquired if she had wanted to resume the treatment with herbs and had discussed getting a physician's order if the resident had requested the treatment. Explained to the DON that information had not been documented in the clinical record. She stated they had failed to document and/or relay that information to the nurses on the floor, but they had discussed the resident's treatment at length in the office. The facility had not followed through to determine if the resident had desired to resume the therapeutic use of herbs for her pain relief. There was no documentation the therapeutic use of herbs had been discussed with the physician, nor that an order had been requested for the therapeutic use of herbs. 2. Resident #1 had [DIAGNOSES REDACTED]. The care plan, dated 04/25/11, documented, "The resident is at risk for choking and aspiration. Be sure she is in an upright position (90 degrees) when feeding, eating, and drinking." The annual assessment, dated 04/27/11, documented the resident had severely impaired cognition for daily decision-making, was on hospice, and required total assistance with eating. The current physician's orders for May 2011, documented the resident was to be served pureed food due to choking or aspiration risks. On 05/11/11, the noon meal was observed. The resident was seated in a Geri-chair at the assisted feeding table. The resident was slumped to the right side of her chair in such a manner that her upper right arm rested on the arm of her chair. Her head was hanging down, so that her chin rested on her chest. No attempt was made to lift the resident up into a normal seating position. The resident was sleeping. CNA #1 was seated beside the resident. The CNA was observed to lift the resident's face by placing her hand under the resident's chin and putting a spoonful of pureed food in the resident's mouth. The CNA then instructed the resident to wake up and eat. The CNA allowed the resident's head to return to resting on her chest between bites. The resident would immediately return to sleep. This continued throughout the meal. On 05/13/11 at 3:00 p.m., the DON was asked if it had been safe to feed the resident while she was in that position with her state of consciousness. She stated, "No."