Every finding on record at McLoud Nursing Center

Based on observation, record review, and interview, the facility failed to: a. ensure assistive devices were used to prevent accidents for 1 (#4) of 15 sampled residents reviewed for accidents; andb. ensure the temperatures of the hot water in residents' rooms and bathrooms were safe to prevent potential burns. The DON identified 16 residents required the assistance of a mechanical lift and 55 residents required assistance with showers. Findings:On 07/21/26 at 5:17 p.m., Resident #4 was observed in a geriatric chair with a mechanical lift sling under the resident in the dining room. A care plan for Resident #4, dated 04/04/19, showed the resident required extensive assistance with ADL care. The care plan showed Resident #4 required a mechanical lift to transfer and two staff to assist in the transfers. A policy titled Safe Lifting and Movements of residents, revised 06/2017, read in part, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. A policy titled Hazardous Areas, Devices and Equipment, dated 06/2024, read in part, 3. Resident vulnerability is based on risk factors including the individual's resident's functional status, medical condition, cognitive abilities, mood, and health treatments .5. Improper or inappropriate use of equipment and devices will be identified as part of the hazard assessment and analysis.Interventions will be accompanied by communication with staff and leadership, residents, family and visitors. A quarterly assessment for Resident #4, dated 05/11/26, showed the resident had a BIMS score on 8 which indicated the resident was moderately impaired in cognition. The assessment showed Resident #4 had diagnoses which included generalized muscle weakness, cognitive communication deficit, and history of traumatic brain injury. The assessment showed Resident #4 had lower extremity impairments on both sides, used a wheelchair to ambulate, required substantial to maximal assist with bed mobility, and was dependent for bed to chair transfers. A discharge summary hospital record for Resident #4, dated 06/29/26, showed the resident was diagnosed with closed bicondylar fracture of the right femur from a witnessed fall. Physician orders for Resident #4, dated 07/06/26, showed the resident had orders for oxycodone (narcotic medication) HCI 5 mg every six hours for pain as needed and morphine tartrate (narcotic medication) oral tablets 25 mg two times a day. A final incident report, dated 07/09/26, showed Resident #4's legs were contracted and required the use of a mechanical lift to transfer. The report showed on 06/27/26, two CNAs had been assisting Resident #4 without the use of a mechanical lift to transfer the resident from the bed to a wheelchair. The report showed Resident #4 had been assisted to sit on the side of the bed by two CNAs. The report showed CNA #1 and CNA #2 held the resident's arms and assisted the resident to a standing position without the use of a mechanical lift. The report showed Resident #4 was unable to bear weight and was lowered to the resident's knees. The report showed Resident #4 was transported to the emergency room, had x-rays, and was diagnosed with a closed bicondylar fracture of the right femur which required surgery. The report showed the family representative refused surgery and the resident's pain was managed with medications. On 07/21/26 5:52 p.m., Resident Representative #1 stated Resident #4's leg was broken after the fall, and they refused the suggested surgery because the resident would refuse after care. Resident Representative #1 stated Resident #4 had cognitive impairments and would tell staff frequently they could perform ADLs outside their assessed ability. On 07/22/26 at 10:09 a.m., CNA #1 stated Resident #4 seemed cognitive and had informed CNA #1 and CNA #2 they could transfer without the use of a mechanical lift. CNA #1 stated they were a new employee and had never worked with the residents on that hall. They stated they did not know the resident's needs and the charge nurse had not informed the CNAs that Resident #4 required a mechanical lift to transfer. CNA #1 stated CNA #2 and themself had assisted Resident #4 to transfer from the bed to a wheelchair by holding the resident's arms on each side. CNA #1 stated when Resident #4 was shifting to the wheelchair from the bed after standing, the resident's knees could not bear the weight, and the resident was lowered to the resident's knees. CNA #1 stated LPN #3 was notified and assessed the resident. CNA #1 stated CNA #2 and LPN #3 assisted Resident #4 without a lift off of the resident's knees and into a wheelchair. CNA #1 stated Resident #4's knees were red, the resident complained of pain, and an x-ray was ordered later in the evening. On 07/22/26 at 10:29 a.m., CNA #2 stated they had assisted CNA #1 with transferring Resident #4 from the bed to a wheelchair without the use of a mechanical lift. CNA #2 stated they had not checked the care plan for Resident #4 prior to assisting the resident for appropriate interventions for transfers. CNA #2 stated CNA #1 and CNA #2 got on each side of Resident #4, held the resident's arms, and assisted the resident to stand from the side of the bed when Resident #4 fell to the resident's knees. CNA #2 stated LPN #3 assessed Resident #4 and CNA #1, CNA #2, and LPN #3 assisted the resident to the wheelchair from the resident's knees without a lift. CNA #2 stated Resident #4 was complaining later in the evening of right knee pain and was sent out for an x-ray. CNA #2 stated they knew they had made a mistake because Resident #4 required two persons and a mechanical lift to transfer. CNA #2 stated they should have checked Resident #4's care plan to see what interventions the resident required to transfer. On 07/22/26 12:58 p.m., the DON stated the CNA #1 and CNA #2 had not looked at Resident #4's care plan which showed the resident required two people and a mechanical lift to transfer. The DON stated CNA #1 and CNA #2 attempted to transfer Resident #4 from the bed to a wheelchair without the use of a mechanical lift which resulted in the resident falling to the resident's knees. The DON stated Resident #4 had to be sent to the hospital and was diagnosed with bruising on the left leg and a fracture to the right femur. The DON stated the CNAs should not have listened to Resident #4 who told the aides the resident could transfer without a lift because the resident's cognition was impaired. On 07/22/26 at 5:44 p.m., LPN #3 stated CNA #1 and CNA #2 transferred Resident #4 without the uses of a mechanical lift because CNA #1 was new and CNA #2 did not know the resident. LPN #3 stated Resident #4 had told the CNAs the resident could stand. 2. On 07/21/26 at 10:26 a.m., the water temperature in the sink in room [ROOM NUMBER] was observed to be 128.4 F. On 07/21/26 at 10:28 a.m., the water temperature in the sink in room [ROOM NUMBER] was observed to be 132 F. On 07/21/26 at 10:30 a.m., the water temperature in the sink in room [ROOM NUMBER] was observed to be 132.4 F. On 07/21/26 at 10:31 a.m., the water temperature in the sink in room [ROOM NUMBER] was observed to be 128.9 F.On 07/21/26 at 10:40 a.m., the water temperature in the sink in room [ROOM NUMBER] was observed to be 128.7 F.On 07/21/26 at 10:41a.m., the water temperature in the sink in room [ROOM NUMBER] was observed to be 128 F.On 07/21/26 at 10:43 a.m., the water temperature in the sink in room [ROOM NUMBER] was observed to be 126.3 F.On 07/21/26 at 11:16 a.m., the water temperature in the shower room on the north hall was observed to be 135 F.A document from the Consumer Product Safety Commission titled Avoiding Tap Water Scalds, undated, showed keeping hot water at the tap no higher than 120 F. was suggested to significantly reduce the risk of scald burns, especially for children, the elderly, and people with reduced mobility. The document showed burns could occur with exposure to water temperatures in excess of 130 F. within 30 seconds. A policy titled Water Temperature, Safety of, revised 12/2009, read in part, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures no more that 110 F, or the maximum allowable temperatures per state regulation. A quarterly assessment for Resident #30, dated 07/21/26, showed the resident had a BIMS score of 15 which indicated the resident's cognition was intact. The assessment showed Resident #30 had diagnosis which include peripheral vascular disease and congestive heart failure. On 07/24/26 at 10:09 a.m., Maintenance #1 stated they checked the water temperatures daily and water should not have been beyond 100 F. They stated the water temperature was high on the previous day, so they adjusted the temperature. On 07/21/26 at 10:43 a.m., Resident #30 stated the water in their room got hot immediately and they had to be careful to avoid being burned.On 07/21/26 10:58 a.m., Maintenance #1 stated residents' skin could have been scorched, scalded, or burned. Maintenance #1 stated there were 10 rooms that were exceeding water regulation temperatures.

Based on observation, record review, and interview, the facility failed to ensure staff were educated on how to access care plans for 1 (CNA #1) of 5 sampled staff reviewed for competent nursing staff. The DON identified 47 staff provided direct care to the residents. Findings: On 07/21/26 at 5:17 p.m., Resident #4 was observed in a geriatric chair with a mechanical lift sling under the resident in the dining room. A care plan for Resident #4, dated 04/04/19, showed the resident required extensive assistance with ADL care. The care plan showed Resident #4 used a mechanical lift to transfer and two staff to assist in the transfers. A Nurse [NAME] Qualifications and Training Requirements, policy revised 05/2019, read in part, 5. Our facility will not use any individual as a nurse aide who has worked less than four months unless the individual a. Is a full-time employee participating in a state-approved training and competency evaluation program; or B. Has demonstrated competence through satisfactory participation in the state approved, nurse aid, training, and competency evaluation program; .6. Applicants who meet the qualifications for a nurse aide and are in training will have a minimum of 16 hours of training in the following area prior to direct contact with the residents; .(8) Transfers, positioning, and turning, .(2) Use of assistive devices in transferring, ambulation, eating, and dressing; A policy titled Using the Care Plan, dated 06/2024, read in part, The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have the responsibility for providing care and services to the resident. A [name withheld] Nursing Center New Hire Checklist for CNA #1 dated 06/12/26, showed skills Checklist Completed (if applicable) was not checked off as completed. A Nursing Assistant Skills Review Checklist for CNA #1, dated 06/13/26, showed CNA #1 was hired on 06/12/26. The checklist, read in part, Directions: Participant identified knowledge of topic by entering 1, 2 or 3 in the Self-Evaluation column for each topic area prior to meeting with facilitator. Facilitator enters the date when skills are reviewed and when validation/return demonstration is completed and then adds signature in the adjoining column. The checklist showed CNA #1 did not self-evaluate the skill of Computer use/Fax/ Copier Use and Reports: 24 hour/Stand up/Shift to Shift. The skills check list did not show the date when the skills were reviewed and when validation/return demonstration was completed on any of the skills. The checklist did not show the date the DON signed off the skills check had been completed. A quarterly assessment for Resident #4, dated 05/11/26, showed the resident had a BIMS score on 08 which indicated the resident was moderately impaired in cognition. The assessment showed Resident #4 had diagnoses which included generalized muscle weakness, cognitive communication deficit, and history of traumatic brain injury. The assessment showed Resident #4 had lower extremity impairments on both sides, used a wheelchair to ambulate, required substantial to maximal assist with bed mobility, and was dependent for bed to chair transfers. A final incident report, dated 07/09/26, showed Resident #4's legs were contacted and required the use of a mechanical lift to transfer. The report showed on 06/27/26, two CNAs had been assisting Resident #4 without the use of a mechanical lift to transfer from the bed to a wheelchair. The report showed Resident #4 had been assisted to sit on the side of the bed by two CNAs. The report showed CNA #1 and CNA #2 held the residents' arms and assisted the resident to a standing position without the use of a mechanical lift. The report showed Resident #4 was unable to bear weight and was lowered to the residents' knees. The report showed Resident #4 was transported to the emergency room, had x-rays, and was diagnosed with a closed bicondylar fracture of the right femur which required surgery. The report showed the family representative refused surgery and the resident's pain was managed with medications. On 07/22/26 at 10:09 a.m., CNA #1 stated Resident #4 seemed cognitive and informed CNA #1 and CNA #2 they could transfer without the use of a mechanical lift. CNA #1 stated they had never worked with the residents on that hall, was new employee, did not know the resident's needs, was not trained on how to access the care plan, and the charge nurse did not inform the CNAs the resident required a mechanical lift to transfer. On 07/22/26 at 5:13 p.m., the DON was asked about skills review check list for CNA #1. The DON stated the CNAs worked through nursing assistance skill review check list, keep it with the CNA during their shift, and the nurse watched these skills, and they signed off on the list. The DON stated they signed off on 06/30/26 showing CNA #1 was trained on the mechanical lift. The DON stated nurses told them and they did not know name of nurse or the date, but they did sign off CNA #1 passed the skills check list. The DON stated they were not sure when CNA #1 skills were reviewed and/or demonstrated. On 07/22/26 at 5:44 p.m., LPN #3 stated CNA #1 and CNA #2 transferred Resident #4 without the use of a mechanical lift because CNA #1 was new.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours a day, seven days a week. The administrator identified 43 residents who resided in the facility. Findings: A document titled, Nursing Department Schedule as Worked, dated 06/08/24, documented there was not an RN who had worked on the day, evening, or night shift. On 06/13/24 at 1:52 p.m., the administrator stated they did not have an RN scheduled to work on 06/08/24 and 06/09/24. They stated an RN had not worked on 06/08/24. The administrator stated they did not utilize staffing agencies.

Based on observation and interview, the facility failed to ensure proper food service sanitation and storage requirements were followed. The DON identified 43 residents who received their meals from the kitchen. Findings: The facility's undated, Food Storage policy, read in part, It is the policy .to follow all state and federal guidelines on food storage. The policy also read, Plastic containers with tight fitting covers must be used for storing .flour .Scoops must be provided for .flour .Scoops are not to be stored in food. The policy also read, Perishable food such as meat .fruits, vegetables and frozen products must be refrigerated immediately to ensure nutritive value and quality. Refrigeration temperatures should be thermostatically controlled to maintain food temperatures at or below 40 degrees F. The policy also read, Leftover food is used within 24 hours or discarded. The policy also read, Temperatures for refrigerators should be between 35-39 degrees Fahrenheit. Thermometers should be checked at least three times a day .Frozen meat .should be defrosted in a refrigerator for 24 to 48 hours, and should be used immediately after thawing. The facility's undated, General Food Preparation and Handling policy, read in part, The kitchen and equipment are clean .The food is kept refrigerated except when being handled .All meats are to be heated to a safe minimum internal temperature. The policy also read, If a fridge .running at unacceptable temperature the staff is to clear the food items from the fridge .and place in alternate appropriate storage. Any foods without proper temperature from fridge .will be disposed of immediately. Non operational equipment with be locked if applicable and out of order sign placed until equipment is either fixed or replaced. The refrigerator temperature log, dated 06/01/24 through 06/09/24, documented the following temperatures: 06/01/24 morning temperature: 50 degrees F/evening temperature was documented; 06/02/24 morning temperature: not documented/evening temperature 51 degrees F; 06/03/24 morning temperature: 51 degrees F/evening temperature 49 degrees F; 06/04/24 morning temperature: 54 degrees F/evening temperature 53 degrees F; 06/05/24 morning temperature: 53 degrees F/evening temperature not documented; 06/06/24 morning temperature: 46 degrees F/evening temperature not documented; 06/07/24 morning temperature: 49 degrees F/evening temperature 46 degrees F; 06/08/24 morning temperature: 49 degrees F/evening temperature 51 degrees F; and 06/09/24 morning temperature: not documented. The refrigerator temperatures were above 41 degrees F for nine out of nine days. On 06/09/24 at 8:09 a.m., dietary aide #1 was asked about the wet blankets by the ice machine. The dietary aide stated the drain leaked and pointed to the pipe behind the ice machine. On 06/09/24 at 8:10 a.m., an initial tour of the kitchen was done with cook #1. The cook stated the refrigerator was not working and several companies had been out to look at it. On 06/09/24 at 8:10 a.m., the following was observed: a. the refrigerator temperature reading was 44.4 degrees F., the following was observed in the refrigerator: cut up cantaloupe, water melon, pineapple, and whole grape fruit platters x2, three pitchers of tea, whole blueberries and strawberries, mixed vegetables in a storage container was dated 06/08/24, barbeque meat thawing in the bottom of the refrigerator. whole intact seedless cucumbers and a box of uncrustables. The refrigerator had a foul odor; b. the ice machine had multiple areas of calcification, debris under and behind the ice machine; c. the oven and stove had black build up of food, food splatters and debris; d. debris under and behind the ice machine and wet blankets on the floor in front of and on the side of the ice machine. On 06/09/24 at 8:31 a.m., the housekeeper #2 stated the debris under and behind the ice machine was coming from what leaked out of the pipe behind the ice machine. On 06/09/24 at 9:11 a.m., cook #1 stated the meat in the refrigerator was shredded beef for lunch and had been in the refrigerator overnight (temperature of refrigerator was 44.4 degrees F.). [NAME] #1 stated they had put the meat in the oven to cook for lunch. [NAME] #1 obtained the temperature of the items in the refrigerator: vegetable mixture: 45.6 degrees F, cut up cantaloupe: 47.3 F, cut up pineapple: 46.5 F, grapes: 47.1, whole red grape not sealed: 47.1 F, and, whole green grape not sealed: 55.0 F. On 06/09/24 at 9:20 a.m., cook #1 was asked what temperature cold food should be stored. They stated 36- 45 degrees F. [NAME] #1 was asked about the odor in the refrigerator. They stated they had just thrown out some cabbage and did not know what was causing the odor. On 06/09/24 at 9:33 a.m., the administrator was made aware of the food stored in the refrigerator and the meat that was placed in the oven after being thawed in the non working refrigerator. They stated they were going to throw the meat out and cook the residents something else. The administrator stated they ordered a new refrigerator and the staff were not supposed to be using that refrigerator. On 06/12/24 at 6:25 a.m. a follow up observation was made in the kitchen. The vent above the door to the kitchen was observed to be dirty, white build up on the dish machine and dish machine baskets, dirty wash cloth was on top of a yellow barrel. On 06/12/24 at 6:25 a.m., cook #2 stated the ice machine was cleaned monthly by maintenance. On 06/12/24 at 6:50 a.m., the temperature of the food on the steam table was obtained by cook #2. The following foods were not held at a temperature at or above 135.0 degrees F: a. pureed eggs: 132.0 degrees F; b. pureed sausage: 118.9 degrees F; and c. sausage links: 131.5 degrees F. On 06/12/24 at 7:06 a.m., cook #2 was observed serving the pureed eggs and sausage. They did not heat the food to the correct holding temperature prior to serving. On 06/12/24 at 7:14 a.m., cook #2 was asked what temperature the food should be held at on the steam table. They stated no lower than 130 degrees F. The cook was asked if the sausage links, pureed eggs and pureed sausage had been held at or above 135 degrees F. They stated, No. [NAME] #2 was asked if there was anything they could have done to ensure the food was heated to the correct temperature. They stated they could have reheated it in the microwave. On 06/12/24 at 7:26 a.m., cook #2 continued to serve the pureed eggs, sausage and sausage links. On 06/12/24 at 7:28 a.m., a bin of flour was observed in the dry storage area with a styrofoam cup inside the flour container. A clear plastic container with a blue lid contained thickner for thickening food. The container and lid were cracked and a styrofoam cup was observed inside the container. On 06/12/24 at 7:34 a.m., the dietary manager stated the meat was not thawed correctly, they stated it should have been thawed in a working refrigerator, under cold running water, or microwave. The dietary manager stated the staff were aware they should not use the refrigerator. They stated it had not been working since the past week. The dietary manager stated the pipes were backing up and debris was flowing out the pipe behind the ice machine in the dining room. The dietary manager stated the food was not held at the appropriate temperature on the steam table. The dietary manager was shown the pictures of the oven from 06/09/24. They stated the cleaning schedule was weekly and the oven did not look like it had been cleaned weekly and they could not tell by the schedule when it had been cleaned. The dietary manager stated the bins should have been tightly closed and the styrofoam cups should not have been stored in the bins, and the dirty washcloth should not have been stored on top of the yellow barrel. On 06/12/24 at 1:00 p.m., the ice machine was observed with maintenance supervisor. The ice machine had white build up on the inside and outside of the ice machine.

Based on record review and interview, the facility failed to complete a SNF ABN for two (#1 and #42) of three sampled residents reviewed for beneficiary notices. The administrator reported 43 residents resided in the facility. Findings: The DON identified 17 residents who had been discharged from a Medicare Part A covered stay with benefit days remaining in the past six months. 1. Res #1 admitted to Part A skilled services on 03/26/24 and discharged from skilled services on 05/30/24. There was no documentation a SNF ABN was provided to Res #1 or their representative. 2. Res #42 admitted to Part A skilled services on 05/08/24 and discharged from skilled services on 06/06/24. There was no documentation a SNF ABN was provided to Res #42 or their representative. On 06/12/24 at 9:28 a.m. the social service director stated they were not aware the form SNF ABN needed to be completed for residents discharged from Part A services. The director stated the SNF ABN form had not been completed for resident #1 and #42.

Based on record review and interview, the facility failed to ensure a new PASARR Level I screening was conducted when a new serious mental illness diagnosis was received for one (#13) and the PASARR level I included the mental health diagnoses for one (#14) of two sampled residents reviewed for PASARR assessments. The administrator identified 43 residents who resided in the facility. Findings: 1. Res #13 had diagnoses, dated 06/02/23, which included unspecified psychosis not due to a substance or known physiological condition. On 06/11/24 at 1:46 p.m., the MDS coordinator stated they were unaware they needed to submit a PASARR level I for a new diagnosis of serious mental illness. 2. Res #14 had diagnoses which included major depressive disorder single episode on 04/23/15 and psychotic disorder with delusions due to known physiological condition on 07/27/15. A PASARR Level I Screening, submitted on 08/17/15, documented Res #14 did not have a diagnosis of a serious mental illness. On 06/13/24 at 11:36 a.m., the DON stated Res #14 had diagnoses of depression and serious mental illness on admission. The DON stated the PASARR Level I screening had not been filled out correctly and they did not have any documentation another PASARR Level I with the correct information had been submitted.

Based on observation, record review, and interview, the facility failed to ensure a care plan was updated to include oxygen therapy and enhanced barrier precautions for one (#14) of eight residents reviewed for care plans. The DON identified four residents who had catheters, two residents who had wounds, and seven residents who utilized oxygen. Findings: The facility's Care Plans, Comprehensive Person-Centered policy, revised 12/2016, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan also read, The comprehensive, person-centered care plan will .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Incorporate identified problem areas. Res #14 had diagnoses which included asthma, urinary retention, and stage four pressure ulcer. A physician's order, dated 04/07/23, documented to administer oxygen at 3 liters nasal cannula as needed for shortness of breath. An ADL care plan for Res #14, documented a catheter was placed on 11/23/23 for urinary retention; interventions included to provide catheter care every shift. The care plan also documented Res #14 had a stage four pressure ulcer. The care plan was not updated with the EBP to include when and what PPE to wear. The care plan was reviewed and did not document Res #14 utilized oxygen. Res #14's annual assessment, dated 04/20/24, documented they had severe cognitive impairment, required substantial/maximal assistance for toileting, showering, dressing, and bed mobility, was dependent on staff for transfers, had an indwelling catheter, and had one stage four pressure ulcer which required a dressing. On 06/09/24 at 10:05 a.m., Res #14 stated they had a pressure ulcer on their bottom. They stated the staff performed the wound care. On 06/09/24 at 10:05 a.m., Res #14 was observed in their bed, they had a catheter and had an oxygen concentrator in their room and was utilizing oxygen. On 06/12/24 at 10:16 a.m., the MDS coordinator stated since the resident had an open wound and a catheter they would need to be on EBP. They stated the use of EBP was not on the care plan. The MDS coordinator stated the care plan should document the flow rate of the oxygen and monitoring for shortness of breath. The MDS coordinator stated Res #14's care plan had not been updated to include the oxygen therapy.

Based on observation, record review, and interview, the facility failed to ensure a portable electric space heater was not utilized in resident rooms for one (#3) of one sampled resident observed with a portable electric space heater in their room. The DON identified 43 residents who resided in the facility and two residents who utilized electric space heater in their rooms. Findings: The facility's undated, Electrical Safety for Residents policy, read in part, The resident will be protected from injury associated with the use of electrical devices, including electrocution, burns and fire. The policy also read, Portable space heaters are not permitted in the facility. Res #3 had diagnoses which included psychotic disorder with hallucinations and dementia. On 06/10/24 at 9:15 a.m., Res #3 was asked why they were using a portable electric space heater. They stated because they were cold. Res #3 stated they covered the heat and air vent because it blew out cold air. On 06/10/24 at 11:03 a.m., a portable electric space heater was observed plugged in and turned on in Res #3's room. On 06/12/24 at 12:54 p.m., the administrator observed the portable electric space heater in Res #3's room. On 06/12/24 at 12:55 the administrator stated the space heater in Res #3's room did not meet safety guidelines. The administrator stated the facility's policy prohibited space heaters.

Based on observation, record review, and interview, the facility failed to post the required staffing information. The DON identified 43 residents who resided in the facility. Findings: On 06/09/24 at 8:00 a.m., a white dry erase board was observed hanging on the wall at the nurses' station. The white dry erase board was not filled out. A schedule was observed in a book at the nurses' station. The schedule did not document the current census. On 06/10/24, 06/12/24, and 06/13/24 the white dry erase board was observed on the wall at the nurses' station. The dry erase board did not document the name of the facility, census or the hours worked for each staff member. On 06/13/24 at 3:04 p.m., the DON stated the required information was not documented on the dry erase board at the nurses' station.

Based on observation, record review, and interview, the facility failed to ensure medication was necessary to treat a specific condition indicated in the clinical record for one (#42) and failed to ensure a rationale was documented for declining a gradual dose reduction for one (#3) of five sampled residents reviewed for unnecessary medications. The DON identified 30 residents who received psychotropic medication. Findings: The facility's Consultant Pharmacist Reports policy, dated 04/2018, read in part, Recommendations are acted upon and documented by the facility staff and/or the prescriber .Prescriber accepts and acts upon suggestions or rejects and provides an explanation for disagreeing. 1. Res #42 had diagnoses which included myocardial infarction, acute respiratory distress, muscle weakness, lack of coordination, acute on chronic systolic heart failure, chronic obstructive pulmonary disease, cognitive communication deficit, age-related physical debility, essential hypertension, and hyperlipidemia. A physician order, dated 05/11/24, documented the resident received Lexapro (a antidepressant medication) 20 mg by mouth one time a day for depression and anxiety. A physician order, dated 05/11/24, documented the resident received Buspirone (a antianxiety medication) 5mg by mouth three times a day for anxiety. An admission assessment, dated 05/15/24, documented the resident was cognitively intact and had no behaviors or potential indications of psychosis. The assessment documented the resident did not have a diagnosis of an anxiety disorder, depression, or a psychotic disorder. The care plan, dated 05/20/24, documented the Res #42 received Lexapro for depression and Buspar for anxiety. The care plan also documented the resident received Seroquel (a antipsychotic medication). A physician order, dated 05/23/24, documented the resident received Seroquel 25 mg by mouth at bedtime for sleep. The order documented the medication had been discontinued on 05/24/24. A physician progress note, dated 05/24/24, documented the resident was pleasant and cooperative. The note documented the Res #42 stated the initiation of Seroquel had helped and they had a good night sleep. A physician order, dated 05/24/24, documented the Res #42 received Seroquel 25 mg by mouth at bedtime for psychosis. On 06/09/24 at 10:47 a.m., the resident was lying in bed. The Res #42 was pleasant and calm during the interview. The Res #42 verbalized no concerns at this time. On 06/13/24 at 9:32 a.m., the DON reviewed the Res #42's clinical records and stated there was no diagnosis for the use of an antidepressant, antianxiety, or a antipsychotic medication. 36191 2. Res #3 had diagnoses which included psychotic disorder with hallucinations. A physician's order, dated 05/26/23, documented to administer Seroquel 50 mg every evening for psychosis. A gradual dose reduction request for Seroquel from the pharmacist, dated 04/15/24, documented a request to consider reducing Seroquel. The physician's response to the request documented they disagreed. The physician did not document a rationale for not decreasing the Seroquel. On 06/13/24 at 9:13 a.m., the DON stated the physician did not document a rationale for disagreeing with the pharmacist request for the gradual dose reduction of the Seroquel for Res #3.

Based on record review and interview, the facility failed to guarantee the person designated to serve as the DM met the State requirement for DM. The administrator identified all 43 residents received their meals from the kitchen. Findings: The dietary manager was transferred to the kitchen on 11/16/20. There was no documentation provided the dietary manager had obtained their certification for dietary manager. On 06/12/24 at 12:41 p.m., the DON stated the dietary manager had finished their training and was waiting to take the test. On 06/12/24 at 4:57 p.m., the dietary manager stated they were not certified. The dietary manager stated they needed to take the test.

Based on observation, record review, and interview, the facility failed to ensure: a. nebulizer masks were stored in a manner to prevent cross contamination for two (#12 and #32) of two sampled residents observed for infection control with breathing treatments; b. staff wore appropriate PPE and performed hand hygiene during wound care for one (#14) of two sampled residents who were observed during wound care. c. staff wore appropriate PPE during provision of care for two , (#17, and #38) of three sampled residents reviewed for enhanced barrier precautions; and d. IV tubing was changed per facility policy for intermittent use for one(#17) of one sampled resident who was reviewed for IV therapy. The DON identified seven residents who were placed on enhanced barrier precautions, five residents who received nebulizer treatments, and one resident who received IV medication. Findings: The facility's, Departmental (Respiratory Therapy)-Prevention of Infection, revised 11/2011, documented to remove nebulizer container after completion of therapy, rinse the container with fresh tap water, dry on a clean paper towel or gauze sponge, reconnect to the administration set-up when air dried, reconnect tubing, and store the circuit in plastic bag, marked with date and resident's name, between uses and discard every seven days. A policy titled Guidelines for Preventing Intravenous Catheter-Related Infections read in part .change intermittent sets every 24 hours, immediately upon suspected contamination, or when integrity of product or system has been compromised. Once a secondary administration set (piggyback) is detached from the primary set, it is considered an intermittent set . There was no policy for enhanced barrier precautions. An in-service record, dated 04/03/24, read in part .EPB expands the use of personal protective equipment (PPE) to donning gown an gloves during high-contact care .residents for whom EBP is employed when performing the following high-contact resident care activities: .device care or use: central line urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing . 1. Res #12 On 06/09/24 at 11:53 a.m., a nebulizer mask was observed sitting on the nightstand. The nebulizer mask was dated 05/26/24 and was not stored in a bag. 2. Res #32 On 06/10/24 at 9:55 a.m., the nebulizer mask was sitting on the counter next to the sink. The tubing was not stored in a bag and was labeled 05/26/24. On 06/12/24 at 8:41 a.m., the DON observed the pictures of the nebulizer masks and stated they were not stored correctly. The DON stated the nebulizer masks should be changed weekly and were supposed to be stored in a bag after being cleaned and air dried. 3. Res #14 had diagnoses which included urinary retention and stage four pressure ulcer. An ADL care plan for Res #14, documented a catheter was placed on 11/23/23 for urinary retention; interventions included to provide catheter care every shift. The care plan also documented Res #14 had a stage four pressure ulcer. Res #14's annual assessment, dated 04/20/24, documented they had severe cognitive impairment, required substantial/maximal assistance for toileting, showering, dressing, and bed mobility, was dependent on staff for transfers, had an indwelling catheter, and had one stage four pressure ulcer which required a dressing. On 06/09/24 at 10:05 a.m., Res #14 stated they had a pressure ulcer on their bottom. They stated the staff performed the wound care. On 06/09/24 at 10:31 a.m., Res #14 stated the staff did not wear an isolation gown when they were providing care unless they had an infection. On 06/11/24 at 11:12 a.m., LPN #3 was observed performing wound care. The LPN donned gloves and removed Res #14's dressing. LPN #3 removed their gloves disposed of the soiled dressing and left the room. LPN #3 was not observed to clean their hands prior to leaving the room after removing their gloves. LPN #3 returned to the room washed their hands donned gloves and cleaned the wound removed their gloves and donned a new pair of gloves without cleaning their hands. LPN #3 applied medicated ointment to the wound as ordered, and covered with dressing. LPN #3 did not wear a gown while they performed wound care. There were no signs indicating the resident was on enhanced barrier precautions. On 06/11/24 at 11:25 a.m., LPN #3 stated they were nervous and should have performed hand hygiene each time they removed their gloves. LPN #3 stated they had not performed hand hygiene. The LPN stated they had not been provided education on enhanced barrier precautions and did not know which residents required enhanced barrier precautions. 33097 4. Res #17 had diagnoses which included encephalopathy, muscle weakness, and sepsis. A physician order, dated 06/06/24, documented the resident was to receive wound care two times a day for a wound to the left buttock. A physician order, dated 06/11/24, documented the resident was to receive Meropenem Solution (a antibiotic medication) 1 gram intravenously every eight hours for UTI for 14 days. The order documented the staff was to change the IV tubing every 24 hours and label. On 06/09/24 at 10:04 a.m., the resident was lying in bed. The resident had an IV access to the right upper arm and a catheter bag was hanging from the side of the bed. There was no signage regarding enhanced barrier precautions or PPE by the residents door. On 06/11/24 at 10:32 a.m., RN #1 performed wound care to the residents buttock. There was no signage posted or PPE available for advance barrier precautions when entering the resident's room. The RN did not wear a gown when providing care. The RN stated they were not aware of any residents requiring special contact precautions or enhance barrier precautions in the facility at this time. On 06/11/24 at 10:38 a.m., RN #1 disconnected the IV tubing from a used bag of IV fluid and connected it to a new IV bag of fluid. The RN stated the tubing should be changed every 24 hours. The RN noted the tubing used was not dated and stated they needed to get new tubing because the tubing was not dated. On 06/11/24 at 12:14 p.m., the DON stated the facility currently does not have a policy for enhanced barrier precautions at this time. The DON stated information was provided by the corporate office and an in-service was held for the staff, but no policy had been developed. The DON stated there should be signage and PPE for enhanced barrier precautions by the door for residents with IV access or residents with infections to wounds or urine. The DON stated resident #17 should have enhanced barrier precautions in place due to having IV access and infection in the urine. On 06/11/24 at 2:39 p.m., the DON stated they misunderstood the guidance regarding enhanced barrier precautions the resident had to have an IV or an infection. Upon review of the information provided by the corporate office the DON stated anyone with an IV, wound, or catheter the staff needed to do enhanced barrier precautions with their care. The DON stated they would need to re-educate staff. 5. Res #38 had diagnoses which included malignant neoplasm, unilateral inguinal hernia, and retention of urine. A physician order, dated 05/31/24, documented the resident had wound care one time a day for an abscess to the right buttock. On 06/11/24 at 2:14 p.m., LPN #3 performed wound care for the resident. There was no signage posted or PPE available for advance barrier precautions when entering the resident's room. The LPN did not wear a gown when providing care.

Based on observation, record review, and interview, the facility failed to ensure the hot water was at a comfortable temperature for one (#12) of one sampled resident who was observed for hot water temperatures. The administrator identified 43 residents who resided in the facility. Findings: The facility's Water Temperatures, Safety of policy, revised 12/2009, read in part, Maintenance staff shall conduct periodic tap water temperature checks. The temperature logs were reviewed and revealed Resident #12's water temperatures had not been monitored in May and June 2024. On 06/09/24 at 11:49 a.m., Res #12's family member stated the resident did not have hot water at their sink faucet. On 06/09/24 at 11:49 a.m., the hot water was turned on the water felt cool and was not warm. On 06/12/24 at 12:50 p.m., the hot water temperature in Res #12's room was 71.2 degrees F. On 06/12/24 at 1:09 p.m., the maintenance supervisor obtained the hot water temperature in Res #12's room; the temperature was 68 degrees F. They stated they could adjust the water temperature. On 06/12/24 at 1:11 p.m., Res #12 stated their hot water had never been warm and they would like it to be warmer. On 06/13/24 from 10:10 a.m. through 10:13 a.m., the hot water was turned on in Res #12's sink faucet in their room. The hot water temperature was 73.9 F after it had been turned on for three minutes and did not feel warm.

Based on record review and interview, the facility failed to ensure professional accepted standards of quality were met related to a mental health diagnoses given to one (#42) of five sampled residents reviewed for unnecessary medication and diagnoses. The administrator identified 43 residents who resided in the facility. Findings: Res #42 had diagnoses which included myocardial infarction, acute respiratory distress, muscle weakness, lack of coordination, acute on chronic systolic heart failure, chronic obstructive pulmonary disease, cognitive communication deficit, age-related physical debility, essential hypertension, and hyperlipidemia. A physician order, dated 05/11/24, documented the resident received Lexapro (a antidepressant medication) 20 mg by mouth one time a day for depression and anxiety. A physician order, dated 05/11/24, documented the resident received Buspirone (a antianxiety medication) 5mg by mouth three times a day for anxiety. An admission assessment, dated 05/15/24, documented the resident was cognitively intact and had no behaviors or potential indications of psychosis. The assessment documented the resident did not have a diagnosis of an anxiety disorder, depression, or a psychotic disorder. The care plan, dated 05/20/24, documented the resident received Lexapro for depression and Buspar for anxiety. The care plan also documented the resident received Seroquel (a antipsychotic medication). A physician order, dated 05/23/24, documented the resident received Seroquel 25 mg by mouth at bedtime for sleep. The order documented the medication had been discontinued on 05/24/24. A physician progress note, dated 05/24/24, documented the resident was pleasant and cooperative. The note documented the resident stated the initiation of Seroquel had helped and they had a good night sleep. A physician order, dated 05/24/24, documented the resident received Seroquel 25 mg by mouth at bedtime for psychosis. On 06/09/24 at 10:47 a.m., the resident was lying in bed. The resident was pleasant and calm during the interview. The resident verbalized no concerns at this time. On 06/13/24 at 9:32 a.m., the DON reviewed the residents clinical records and stated there was no diagnosis for the use of an antidepressant, antianxiety, or the antipsychotic medication.

Based on record review and interview, the facility failed to complete a discharge summary with a recapitulation of stay for one (#47) of one sampled resident reviewed. The administrator identified 49 residents who had been discharged in the last six months. Findings: Res #47 A review of the progress notes, documented Res #47 was discharged home with medication and belongings on home health via family transport on 03/28/24. There was no documentation in the clinical record the facility completed a discharge summary for Res #47 with a recapitulation of their stay. On 06/11/24 at 2:35 p.m., the DON stated there was not a discharge summary for Res #47.

Based on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter was anchored to prevent dislodgement and injury for one (#14) of three sampled residents who had a urinary catheter. The administrator identified four residents who had urinary catheters. Findings: The facility's policy titled, Catheter Care, Urinary, revised 09/2014, read in part, Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) Res #14 had diagnoses of urinary retention. Res #14's ADL care plan, dated 11/24/23, documented to provide catheter care every shift. Res #14's annual assessment, dated 04/20/24, documented they had an indwelling catheter. On 06/09/24 at 10:15 a.m., Res #14 was observed in bed, the catheter bag was hanging off the bed below the bladder. On 06/13/24 at 10:22 a.m., LPN #3 was observed providing pericare to Res #14. Res #14's catheter tubing was not anchored. The resident had small amount of dark reddish colored dried drainage on their vulva area. On 06/13/24 at 10:34 a.m., LPN #3 stated it looked liked the catheter had pulled and the tubing was in the crease of Res #14's leg and may have caused the drainage that looked like old blood.

Based on record review and interview, the facility failed to ensure a medication had a diagnosis for use for one (#3) of five sampled residents reviewed for unnecessary medications. The DON identified 43 residents who resided in the facility. Findings: Res #3 had diagnoses which included MDD, dementia, and psychotic disorder with hallucinations. The DON identified 43 residents who resided in the facility. Findings: A physician's order, dated 05/14/24, documented to administer Lamictal 25 mg two times a day. There was not a diagnosis for the medication. On 06/13/24 at 9:10 a.m., the DON stated there was not a diagnosis for the Lamictal. They stated the nurse practitioner's note documented based on last week's assessment.

Based on record review and interview, the facility failed to convey remaining funds to the legal representatives of deceased residents within 30 days for two (#1 and #2) three sampled residents reviewed for finances. The assistant administrator identified 10 residents who had discharged from the facility with funds remaining. Finds: A policy titled Conveyance of Resident Funds documented .The resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative or to the resident's estate (individual or probate jurisdiction per state law), as applicable, within thirty (30) days from the date of the resident's discharge or eviction from the facility, or death . 1) Res #1 was admitted to facility on [DATE] and discharged on [DATE]. A form documented invoice search with a check request date identified as [DATE]. The form documented an invoice amount of $1,010.62 and a check was sent on [DATE]. 2) Res #2 was admitted to the facility on [DATE] and discharged on [DATE]. A form documented invoice search with a check request date identified as [DATE]. The form documented an invoice amount of $1,649.00 and a check was mailed on [DATE]. On [DATE] at 10:05 a.m., a telephone interview was conducted with the corporate BOM. The BOM stated the remaining funds for the residents were late being processed. The BOM stated no excuse, they just fell between the cracks.

Based on observation, record review, and interview, the facility failed to ensure sufficient staff to complete mechanical lift transfers for two (#25 and #26) of two residents reviewed for staffing. The Resident Census and Conditions of Residents report, dated 05/04/23, documented 38 residents resided in facility. The DON identified 16 residents used mechanical lifts for transfers. Findings: A Using a Mechanical Lift policy, undated, read in part, .Two (staff members) are to be used when a mechanical lift is in use to ensure resident's safety . A Staffing policy, dated October 2017, read in part, .Our facility provides sufficient numbers of staff .to provide care and services for all residents in accordance with resident care plans . Resident #25's Care Plan, dated 12/20/21, read in part, .I require limited to extensive assist with ADL care .[two] person assist with Hoyer [mechanical] lift for transfer . On 05/03/23 at 6:30 a.m., CNA #1 was observed to transfer Resident #25 by using a mechanical lift. CNA #1 was the only staff member observed in the room during the transfer. On 05/03/23 at 6:47 a.m., CNA #1 was observed to transfer Resident #26 by using a mechanical lift. CNA #1 was the only staff member observed in the room during the transfer. On 05/04/23 at 6:14 a.m., CNA #1 was asked how many staff members were needed to complete transferring a resident using a mechanical lift. They stated, Suppose to be two. They were asked why they were the only one present during yesterday's transfers. CNA #1 stated there wasn't any other help available. On 05/05/23 at 2:20 p.m., the DON was asked to describe the procedure for using a mechanical lift for transfers. She stated it was the facility's policy to have two people. The DON was asked how they ensured sufficient staff to complete safe transfers. She stated, We have educated them to come get someone if the other aide is busy.

Based on observation, record review, and interview, the facility failed to ensure mechanical lifts were completed with two staff members for two (#25 and #26) of two sampled residents reviewed for accidents. The Resident Census and Conditions of Residents report, dated 05/04/23, documented 38 residents resided in facility. The DON identified 16 residents used a mechanical lift for transfers. Findings: A Using a Mechanical Lift policy, undated, read in part, .Two (staff members) are to be used when a mechanical lift is in use to ensure resident's safety . 1. Resident #25 had diagnoses which included unsteadiness on feet and other lack of coordination. A Care Plan, dated 12/20/21, read in part, .I require limited to extensive assist with ADL care .[two] person assist with Hoyer [mechanical] lift for transfer . A Resident Assessment, dated 02/19/23, documented Resident #25 was total dependent with two or more staff assistance for transfers. On 05/03/23 at 6:30 a.m., CNA #1 was observed to respond to Resident #25's call light. Resident #25 requested to get out of bed. CNA #1 was observed to position the lift sling under Resident #25 and connected the sling to the mechanical lift. On 05/03/23 at 6:36 a.m., CNA #1 was observed to use the remote control to the mechanical lift and lift the resident up into the air, maneuvered the resident in the lift sling over to the wheelchair, and lowered the the resident into the wheelchair. One staff member was observed in the room during the transfer. 2. Resident #26 had diagnoses which included muscle weakness. A Resident Assessment, dated 02/06/23, documented Resident #26 was total dependent with two or more staff assistance for transfers. On 05/03/23 at 6:47 a.m., CNA #1 was observed to take the mechanical lift into Resident #26's room. Resident #26 was observed laying in bed with the lift sling under them. On 05/03/23 at 6:50 a.m., CNA #1 was observed to position the mechanical lift over Resident #26 and connected the lift sheet to the mechanical lift. CNA #1 was observed to use the remote control of the mechanical lift to lift the resident up into the air, maneuvered the resident in the lift sling over the wheelchair, and lower the resident into the wheelchair. One staff member was observed in room during transfer. On 05/04/23 at 6:14 a.m., CNA #1 was asked how many staff members were needed to complete a transfer of a resident using a mechanical lift. They stated, Suppose to be two. They were asked why they were the only one present during yesterday's transfers. CNA #1 stated there wasn't any other help available. On 05/05/23 at 2:20 p.m., the DON was asked to describe the procedure for using a mechanical lift for transfers. She stated it was the facility's policy to have two people.

Based on record review and interview, it was determined the facility failed to notify the physician and a family member concerning a fall which occurred on 12/18/15, for one (#1) of three sampled residents reviewed for falls. This was actual harm for resident #1 when he was diagnosed with [REDACTED]. This had the potential to affect all 69 residents that resided in the facility. Findings: A facility policy for Falls Prevention Program documented, .Fall Investigation . The nurse must contact the Physician, P.O.A. (Power of Attorney) or responsible party .Fall Checklist .4. Notify ---DR (doctor)---Family----DON (director of nursing)---ADMIN (administrator) . Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A comprehensive annual MDS (Minimum Data Set) assessment, dated 11/01/16, documented the resident had unclear speech, was usually able to make himself understood, usually understood others and had severe cognitive deficits. The assessment also documented the resident required total assistance of one (1) staff with all activities of daily living (ADLs), including transfers, that he had balance problems and was unable to stabilize himself without staff assistance when moving from a seated to a standing position and with surface to surface transfers (between the bed and chair and/or wheelchair). The assessment further documented the resident had not experienced any falls since the prior assessment. An incident report dated 12/18/15 documented, .CNAs x 2 (CNAs #8 and #9) were transferring resident from his chair to the bed when his knees buckeled (sic) and they lowered him to the floor. They reported it to the charge nurse and no injuries were noted with assessment .when the CNAs involved transferred him without using a lifting device (mech lift) this incident and injury occurred .The CNAs have both been re-educated on providing the appropriate equipment for safe transfers on all residents, using 2 persons at all times and always use the mechanical lift for persons that cannot bear wt. (weight) at all. The CNAs were also re-educated on not moving the resident after a fall (or sit down) . The report was faxed to the Oklahoma State Department of Health on 12/22/15. A Late Entry nurse's note by licensed practical nurse (LPN) #1, dated 12/19/15 at 2:04 p.m., documented, Resident right knee is swollen and elevated on pillow to help reduce swelling. Resident has some grimacing noted to face and PRN [MEDICATION NAME] 5/325 mg (milligram) one tablet given by cma (certified medication aide). v/s (vial signs) 97.4 - 80 - 18 - 123/74. Applied warm wash cloths to right knee to help with pain. A Late Entry nurse's note by LPN #1, dated 12/19/15 at 3:03 p.m., documented, Resident granddaughter at bedside and nurse inform her of his knee swollen. He had prn [MEDICATION NAME] and effective at this time. Continues to have right knee elevated on pillow. A nurses's note by LPN #1, dated 12/20/15 at 11:53 a.m., documented, Resident was resting in bed, right knee less swollen and warm to touch, no complaint of pain of s/s (signs/symptoms) of discomfort when staff getting him out of bed and transferred to wheelchair for lunch. 97.9 - 72 - 18 - 138/76 (vital signs). A nurse's note by LPN #1, dated 12/20/15 at 1:30 p.m., documented, Resident alert, left facility in his wheelchair assisted by two staff in company van to family gathering. No s/s of discomfort noted upon leaving facility. A nurses's note by LPN #1, dated 12/20/15 at 4:54 p.m., documented, Resident returned and right knee swollen, warm to touch. Sitting up in high chair and routine pain medication [MEDICATION NAME] 5 mg being given by cma. v/s 98.1 - 87 - 20 - 148/82. Very alert no grimacing noted to face. A nurses's note by LPN #1, dated 12/20/15 at 5:57 p.m., documented, Resident sitting in recliner in lobby with eyes closed, no s/s discomfort noted. Pain medication effective. A nurses's note by LPN #3, dated 12/21/15 at 8:00 a.m., documented, 0800 Assessment done on resident. VS 131/85 95 pulse 24 respiration's temp 99 axilliary O2 sats (oxygen saturation) are 92% on room air. Resident is lethargic, grips are weak and unequal. Right knee is swollen up to thigh, plus three [MEDICAL CONDITION]. States, Pain is a 10/10 (ten out of ten pain level). 0815 (8:15 a.m.) (Name withheld - director of nursing) notified, advised to call doctor. A nurses's note by LPN #3, dated 12/21/15 at 8:20 a.m., documented, Called Dr. (doctor) (Name withheld) about resident. Advised he was in a meeting to call back in 30 minutes. A nurses's note by LPN #3, dated 12/21/15 at 9:25 a.m., documented, 0900 (9:00 a.m.) Received call from Dr. (Name withheld) to send out to hospital. 0910 (9:10 a.m.) Emergency transport called. 0915 (9:15 a.m.) Family notified of status of resident and made aware of being transported out. 0930 (9:30 a.m.) Emergency transport arrived. 0935 (9:35 a.m.) transported to (Name withheld - hospital) per (Name withheld - emergency transport). On 01/21/16, at 1:10 p.m. CNA #7 was interviewed. She was asked what occurred with the resident on 12/18/15. She stated the resident complained about his leg hurting. She stated he squinched his eyes and grimaced, which indicated to her that he was experiencing a high level of pain. She stated she reported the pain to the charge nurse, LPN #1, but she didn't know what was done after it was reported. At 1:20 p.m., LPN #1 was interviewed about the incident that occurred on 12/18/15. She stated she was told by the CNAs that a male resident had started falling when they were transferring him from the bed to his wheelchair, but they were able to sit him down on the floor. She stated they also told her the resident was not hurt. She was asked if she notified anyone about the resident's fall. She stated she didn't notify anyone, including the family, because she assessed the wrong resident. At 1:45 p.m., CNA #8 was interviewed. She was asked to describe what occurred with the resident on 12/18/15. She stated during a transfer the resident's legs started buckling and they heard a pop. She stated the resident was lowered to the floor by her and CNA #9. She was asked if the resident experienced any pain. She stated he complained to them both that his leg hurt and they reported this to LPN #1, the charge nurse. She was asked what the charge nurse did after they reported it? She stated the charge nurse told them she was going to take care of it. At 2:50 p.m., the administrator was interviewed regarding the incident on 12/18/15. She was asked when she first had knowledge of the incident? She stated she was notified on 12/19/15, regarding the resident's knee being swollen, but was not told about the fall. She was asked if the resident's family was notified of the resident's fall. She stated, No, no one was notified. At 4:00 p.m., the director of nursing (DON) was interviewed. She was asked if she had been notified about the resident's fall on 12/18/15. She stated, No, I didn't know about that until the following Monday (12/21/15). She further stated no one was notified because the nurse (LPN #1) got the resident mixed up with another resident. She was asked why the resident was sent out to the hospital on [DATE]. She stated the charge nurse on that day, LPN #3, reported the resident's right leg was more swollen, from the knee to the thigh. She stated she still did not know about the fall. She stated when she got the report from the hospital stating the resident's right femur was fractured, she knew something had to have occurred and started an investigation on 12/22/15, when she first learned of the fall. She was asked what the facility policy was for resident falls. She stated whoever has knowledge of a fall, is supposed to notify the nurse of the fall when it occurs and the family and physician are to be notified, regardless whether there was an injury or not.

Based on record review and interview, it was determined the facility failed to assess and treat a resident's new onset of pain after a fall for one (#1) of three sampled residents whose records were reviewed for falls and/or unknown injury to a leg. The resident sustained [REDACTED]. The facility identified 40 residents who were at high risk for falls, 11 residents who required a mechanical lift and two staff assistance with transfers, and 27 residents who required two staff assistance with transfers. Findings: The facility policy for Low Lift documented, It is the policy of (Name withheld) to utilize a Low Lift Program to eliminate the need for manual resident transfers by using mechanical lifting devices and aids. Two staff members are required when using a mechanical lift. The facility policy for Pain Assessment documented, Residents will be assessed for pain . when a resident experiences a new onset of pain or experiencing uncontrolled pain. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A comprehensive annual MDS (Minimum Data Set) assessment, dated 11/01/15, documented the resident had unclear speech, was usually able to make himself understood, usually understood others and had severe cognitive deficits. The assessment also documented the resident required total assistance of one (1) staff with all activities of daily living (ADLs), including transfers, that he had balance problems and was unable to stabilize himself without staff assistance when moving from a seated to a standing position and with surface to surface transfers (between the bed and chair and/or wheelchair). The assessment further documented the resident had not experienced any falls since the prior assessment. The resident's care plan dated 11/20/14, and last revised 12/08/15, documented, Focus I am at risk for ADL deficit r/t (related to) Parkinson, dementia . Goal I will remain ADL score in transferring through review date. Interventions TRANSFER: I am extensive assistance with transfer . The November 2015 and December 2015, Medication Administration Records (MARs), documented the following orders: [MEDICATION NAME] Tablet 7.5-325 MG (milligram) Give 1 tablet by mouth four times a day related to CHRONIC PAI[DIAGNOSES REDACTED]. Start Date-10/29/2015. [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-300 MG Give 1 tablet by mouth every 4 hours as needed for Pain Start Date-08/21/2015. Monitor for pain twice daily utilizing 0-10 pain scale. Two times a day for Pain monitoring. Start Date-08/13/2015. A Fall Risk Evaluation dated 11/15/15, documented a score of 60, which indicated the resident was a high risk for falling due to a history of falls, two or more [DIAGNOSES REDACTED]. A Pain Evaluation with an effective date of 11/24/15, documented the resident had experienced no change in behaviors over the past 7 days, had mild back pain less than weekly, most likely caused from arthritis and [MEDICAL CONDITION], received routine and PRN (as needed) narcotic pain medication, which was documented as satisfactory pain management. The Comments section documented, Resident has no c/o (complaints of) pain at this time. Resident is on routine [MEDICATION NAME] and has order for [MEDICATION NAME] PRN. Has utilized PRN [MEDICATION NAME] this month for c/o back pain. An incident report dated 12/18/15 documented, .CNAs x 2 (CNAs #8 and #9) were transferring resident from his chair to the bed when his knees buckeled (sic) and they lowered him to the floor. They reported it to the charge nurse and no injuries were noted with assessment .when the CNAs involved transferred him without using a lifting device (mech lift) this incident and injury occurred .The CNAs have both been re-educated on providing the appropriate equipment for safe transfers on all residents, using 2 persons at all times and always use the mechanical lift for persons that cannot bear wt. (weight) at all. The CNAs were also re-educated on not moving the resident after a fall (or sit down) . The report was faxed to the Oklahoma State Department of Health on 12/22/15. A Late Entry nurse's note by licensed practical nurse (LPN) #1, dated 12/19/15 at 2:04 p.m., documented, Resident right knee is swollen and elevated on pillow to help reduce swelling. Resident has some grimacing noted to face and PRN [MEDICATION NAME] 5/325 mg (milligram) one tablet given by cma (certified medication aide). v/s (vial signs) 97.4 - 80 - 18 - 123/74. Applied warm wash cloths to right knee to help with pain. A nurses's note by LPN #1, dated 12/20/15 at 11:53 a.m., documented, Resident was resting in bed, right knee less swollen and warm to touch, no complaint of pain of s/s (signs/symptoms) of discomfort when staff getting him out of bed and transferred to wheelchair for lunch. 97.9 - 72 - 18 - 138/76 (vital signs). A nurse's note by LPN #1, dated 12/20/15 at 1:30 p.m., documented, Resident alert, left facility in his wheelchair assisted by two staff in company van to family gathering. No s/s of discomfort noted upon leaving facility. A nurses's note by LPN #1, dated 12/20/15 at 4:54 p.m., documented, Resident returned and right knee swollen, warm to touch. Sitting up in high chair and routine pain medication [MEDICATION NAME] 5 mg being given by cma. v/s 98.1 - 87 - 20 - 148/82. Very alert no grimacing noted to face. A nurses's note by LPN #1, dated 12/20/15 at 5:57 p.m., documented, Resident sitting in recliner in lobby with eyes closed, no s/s discomfort noted. Pain medication effective. A nurses's note by LPN #3, dated 12/21/15 at 8:00 a.m., documented, 0800 Assessment done on resident. VS 131/85 95 pulse 24 respiration's temp 99 axilliary O2 sats (oxygen saturation) are 92% on room air. Resident is lethargic, grips are weak and unequal. Right knee is swollen up to thigh, plus three [MEDICAL CONDITION]. States, Pain is a 10/10 (ten out of ten pain level). 0815 (8:15 a.m.) (Name withheld - director of nursing) notified, advised to call doctor. The resident's Medication Administration Record [REDACTED] A nurses's note by LPN #3, dated 12/21/15 at 8:20 a.m., documented, Called Dr. (doctor) (Name withheld) about resident. Advised he was in a meeting to call back in 30 minutes. A nurses's note by LPN #3, dated 12/21/15 at 9:25 a.m., documented, 0900 (9:00 a.m.) Received call from Dr. (Name withheld) to send out to hospital. 0910 (9:10 a.m.) Emergency transport called. 0915 (9:15 a.m.) Family notified of status of resident and made aware of being transported out. 0930 (9:30 a.m.) Emergency transport arrived. 0935 (9:35 a.m.) transported to (Name withheld - hospital) per (Name withheld - emergency transport). On 01/21/16 at 1:00 p.m., CNA #6 was interviewed. She was asked how much pain the resident experienced after the incident. She stated the resident was in a lot of pain due to his knee. She was asked what the resident's pain level appeared to be after the incident. She stated, By the way he was acting, grimacing, it was a lot more than normal. She stated it was probably a 9 out of 10. At 1:10 p.m., CNA #7 was interviewed. She stated she worked on week-ends and helped transport the resident to a family event on 12/20/15. She was asked how the resident acted on 12/20/15, if he stated he was in pain. She stated the resident complained about his leg hurting. She stated he squinched his eyes and grimaced, which indicated to her that he was experiencing a high level of pain. She stated she reported the pain to the charge nurse, LPN #1, but she didn't know what was done after it was reported. At 1:20 p.m., LPN #1 was interviewed regarding what occurred on 12/18/15. She stated she was told by the CNAs a male resident had started falling when they were transferring the resident and his knees started buckling, so they sat him down in the floor. She stated they also told her the resident was not hurt. She was asked if she assessed the resident after his fall. She stated it was her first day on the floor and she didn't identify the right resident, so she didn't assess the resident on the night of the fall. She stated the resident attended a family gathering on 12/20/15, and did not exhibit any pain when staff were getting him ready. She was asked if she assessed the resident when he returned to the facility. She stated the CNAs told her the resident had a lot of discomfort while at the family event and had been moaning in pain. She stated she wrote down what was told to her, went to look at the resident and talked with him. She stated she didn't do a full pain assessment or anything, because he was eating. She stated the resident wasn't moaning when she observed him. She was asked if she notified anyone. She stated she didn't report the incident to anyone, did not assess the resident or notify anyone including the family, because she had checked on the wrong resident. At 1:45 p.m., CNA #8 was interviewed. She was asked to describe what occurred with the resident on 12/18/15. She stated during a transfer the resident's legs started buckling and they heard a pop. She stated the resident was lowered to the floor by her and CNA #9. She was asked if the resident experienced any pain. She stated he complained to them both that his leg hurt and they reported this to LPN #1, the charge nurse. She was asked what the charge nurse did after they reported the incident. She stated the charge nurse told them she was going to take care of it. She further stated the charge nurse didn't have her or the other CNA fill out an incident report or anything, that the nurse didn't even question them about the incident. She stated the fall occurred on a Friday, she was off on Saturday and then worked again on Sunday. She stated she assisted the resident to a family event on Sunday the 20th. She was asked how much assistance the resident required with transfers. She stated he required a lift, but they didn't use one when they were transferring him on 12/18/15. At 2:00 p.m., CNA #9 was interviewed about the incident of 12/18/15. She was asked if the resident complained of leg pain before the fall. She stated, Not to my knowledge. She was asked how the resident was transferred. The CNA stated she and CNA #8 were assisting the resident to his bed and his knees buckled. She stated they then lifted the resident up into his bed. She was asked if this was reported to anyone. She stated they reported the incident to the charge nurse. She was asked when the resident started to complain or exhibit signs of pain. She stated during their rounds the resident started complaining of pain. When they reported this to the charge nurse (LPN #1), she stated the resident was fine, that nothing was wrong with him. CNA #9 stated the charge nurse (LPN #1) never reported the fall. She stated the LPN didn't ask her or CNA #8 what happened and didn't take their statements. She stated the resident's legs turned inward when it all happened. On 01/21/16 at 2:50 p.m., the administrator was interviewed regarding the incident of 12/18/15. She was asked when she first had knowledge of the resident's fall on 12/18/15. She stated she was notified on 12/19/15, regarding the resident's knee being swollen, but was not told about the fall. She was asked when the resident was assessed after the fall. She stated licensed practical nurse #1 confused resident #1 with another resident, so she actually looked at the wrong resident. At 4:00 p.m., the director of nursing (DON) was interviewed. She was asked if she had been notified about the incident that occurred on 12/18/15. She stated, No, I didn't know about that until the following Monday (12/21/15). She further stated no one was notified because the nurse (LPN #1) got the resident mixed up with another resident. She stated the nurse was brand new and it was her first day to work alone. She was asked if she was notified of the resident's increased pain. She stated she was notified on 12/19/15, of the resident's increased knee pain and she told the nurse (LPN #1) to apply Bio-freeze to the knee, to use his routine pain medication and if that was not effective, they would call the doctor. The Bio-Freeze was ordered to use only on the hands. She was asked if the resident had any difficulty on 12/20/15, when he was taken to the family event. She stated she was told on 12/21/15, that he seemed to tolerate going to the event okay, that the only time he expressed he was having pain was during transfers in and out of the van. She was asked why the resident was sent out to the hospital on [DATE]. She stated the charge nurse on that day, LPN #3, reported the resident's right leg was more swollen, from the knee to the thigh. She stated she told the nurse to call the doctor and see about sending the resident to the emergency room for evaluation, because he might have a blood clot. She stated she still did not know about the fall. She stated when she got the report from the hospital stating the resident's right femur was fractured, she knew something had to have occurred and started an investigation on 12/22/15, when she first learned of the fall. She was asked what the facility's policy was regarding transfers for this resident. She stated a mechanical lift and two staff should have been used. She stated both CNAs (#8 and #9) were aware of this resident requiring a mechanical lift for all transfers. She stated they were also not to have moved the resident back to the bed, that one CNA should have stayed with the resident while the other went to notify the charge nurse. She was asked if resident #1 was able to verbalize when he was in pain. She stated, Somewhat. She stated he was not dependable with communication, that the facility anticipated his needs and looked for non-verbal signs and symptoms of pain. She was asked what types of non -verbal signs and symptoms the resident exhibited. She stated on the day of the family event (12/20/15) he had facial grimacing and exhibited he was having pain when moved.

On 05/04/15, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure hazardous chemicals, sharps and razors were securely stored out of the reach of residents in the back charting room, the laundry room, in one of five shower/whirlpool rooms and on the crash carts. At 2:30 p.m., the existence of the IJ was verified with the Oklahoma Stated Department of Health (OSDH). At 2:40 p.m., the ADM and the DON were notified of the existence of the IJ. At 4:30 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: May 4, 2015 4:30 p.m. The DON and ADON have sweep (sic) the facility and removed all chemicals from unsecure areas and have verified that all doors are locked that should be locked. As of 4:30pm today (5/4/2015) the nursing staff for 6am-2pm & 2-10pm, housekeeping, dietary, laundry and all department heads have been in-service (sic) on the requirement to keep hazardous chemical (sic) locked up and doors locked to the hazardous chemicals, equipment. The remaining 6 employees will be in-serviced prior to the next scheduled shift. The DON/ADON and/or Administrator will make rounds every other hour to ensure the doors are locked & that all chemicals are properly stored & locked up. At the end of the day that duty will be assigned to the charge nurse. Everyone will be sign (sic) off after each round verifying that they have specifically checked that all doors are locked and verify that all chemicals are secure. At 3:00pm today The Activity Director has been specifically in-serviced on leaving the nail polish remover and nail polish out and has been instructed on keeping the chemicals locked up when not in use. Maintenance was in-serviced at 3:15pm today (5/4/2015) by the administrator on the requirement for all outside doors needing to be locked that go into areas that have access to hazardous chemicals and equipment, and on the requirement to keep all chemicals securely locked up. Laundry & nursing staff have been inserviced on the need to securely shut the exit door that leads into the facility hall way. All staff will be re-inserviced again on 5/8/2015 at the regularly scheduled in-service time on the laundry door, securing chemicals, locking all doors that are suppose to be locked. On 05/05/15 at 8:20 a.m., the in-service documentation was reviewed. The staff were educated in the safe storage of chemicals. At 8:30 a.m., eight staff members were interviewed. All stated they had been inserviced and were able to verbalize the safe storage of chemicals and need to keep the doors locked. The IJ was removed on 05/04/15 at 4:30 p.m. when all components of the plan of removal had been completed. The deficient practice remained at a pattern with no actual harm with the potential for more than minimal harm. Based on observations, record review and staff and resident interviews, it was determined the facility failed to ensure hazardous chemicals, sharps and razors were securely stored out of the reach of residents in the back chart room, the laundry room, in one (Melody Avenue Shower Room) of five shower/whirlpool rooms and on the crash carts. The administrator identified two cognitively impaired residents who wandered the facility. The Resident Census and Conditions report, dated 05/07/15, documented 64 residents resided in the facility. Findings: Resident #10 had [DIAGNOSES REDACTED]. The resident assessment, dated 02/03/15, documented the resident had severely impaired cognitive skills. She had short and long term memory deficits, inattention, disorganized thinking and psychomotor retardation. She had a behavior of wandering. On 05/04/15 at 6:00 a.m., an environmental tour was conducted and the following observations were made. Resident #10 was observed wandering the halls in the facility. The door to the back chart room was observed to be standing open. A spray bottle of Quat Disinfectant Cleanser was observed under the sink. The warning label documented, Caution: May cause eye, skin, nose and throat irritation.Keep out of the reach of children. If swallowed: Do not induce vomiting unless instructed to do so by medical personnel. A bottle of DermaTech Hand Sanitizer with Aloe was observed in the cabinet labeled wound supplies. The warning label documented, Keep out of reach of children. If swallowed get medical help or consult a Poison Control Center right away. A 13.5 oz. pump bottle of hand sanitizer was observed on the left cabinet. The warning label documented, Keep out of reach of children. If swallowed get medical help or consult a Poison Control Center right away. A bottle of finger nail polish remover was observed in a pink segmented carrying tray on the left cabinet. The warning label documented, Harmful if ingested. In case of accidental ingestion, give fluids liberally and consult with local POISON CONTROL CENTER. The laundry room exit door into the hallway was open and resting ajar against the door frame. No laundry staff was present in the laundry room. A CNA passed in the hallway and stated the door was broken and should have been replaced. She stated when the door was locked it was very hard to open again. She was asked how long the door had been broken. She stated, Couple of months. The following items were observed in an unlocked cabinet located in the shower room on Melody Avenue: ~ 1 box of Dawnmist triple blade razors; ~ 1 box of advanced relief A&D ointment containing 144 5 gram packets. The warning label documented, .for external use only.avoid contact with eyes.keep out of reach of children.If swallowed, get medical help or contact a poison control center right away. ~ 1 P.A.W.S antimicrobial hand wipe. The warning label documented, .Keep out of reach of children.If swallowed get medical help or contact a poison control center right away.for external use only.Flammable: keep away from fire or flame. ~ 1 Sanizide Plus tm germicidal towelette. The warning label documented, .Keep out of reach of children.Hazards to Humans and Domestic Animals: causes moderate eye irritaion.avoid contact with eyes or clothing.wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, or using tobacco. ~ 1 2 oz Redz tm Solidifier Pouch. The warning label documented, .Keep out of reach of children.First Aid if inhaled, remove to fresh air. If in contact with eyes (skin), flush with water for 15 minutes.If ingested, drink a large quantity of water. Do not induce vomiting. Consult a physician. Read the Material Safety Data Sheet. ~ and 1 gallon size DermaRite Total Bath Lotionized Skin and Hair Cleanser enriched with Vitamin E and essential oils 2/3 full. The label read FOR EXTERNAL USE ONLY. At 6:45 a.m., resident #10 had been escorted into the dining room and sat at a table for breakfast. She immediately stood up and wandered out of the dining room. She was again returned to the dining room, where after being seated, she stood up and wandered out of the dining room again. This behavior was observed three times over the next few minutes. At 7:00 a.m., the back chart room was observed unlocked and open. LPN #1 was asked if the chart room door was ever locked or closed. She stated, No. She stated the chart room was always left open because this was the only place the residents had to use the phone in private. At 7:35 a.m., the laundry room door was unlocked and ajar. The back chart room door was standing open and the chemicals were observed as before. At 8:05 a.m., resident #10 was observed wandering the halls with a wall sign and some papers in her hands. At 10:10 a.m., resident #10 was observed in the back chart room looking at the pink tray with the fingernail polish still present. She reached out, touched the pink tray and then turned and left the room. A staff member followed her out of the chart room. At 12:15 p.m., resident #10 was observed wandering the halls. When she reached the exit door at the back of the facility, she pushed on the door a couple of times and then turned and continued wandering. At 12:20 p.m., the back chart room and the laundry room door were still unlocked and opened. At 12:30 p.m., the ADM was asked how many wanderers were in the facility. She identified two residents but stated one of the residents was now in a wheelchair and not able to wander much any more. She was asked what was the policy on chemical storage. The ADM asked what kind of chemicals. She was informed chemicals like hand sanitizers and disinfectants. She stated they were allowed on the housekeeping carts but were locked up in the carts at all times. She was asked about the laundry room. She stated the laundry room door was always supposed to be locked. She was asked about chemicals in the shower rooms and the back chart room. She stated the chemicals in the shower rooms should be locked up and there should be no chemicals in the back chart room. She was asked about razors in the shower rooms. She stated they should be locked up. She was asked if the chemicals could be a danger to resident #10. She stated, Could be. She was taken to the back chart room and shown the chemicals. She stated she had told the activity director to remove the fingernail polish remover already. She removed all chemicals from the chart room at this time. At 12:40 p.m., an environmental tour of the laundry room was conducted. A sign located on the laundry room door documented, PER REGULATIONS YOU MUST KEEP THIS DOOR LOCKED. The laundry room door was observed unlocked with the following items inside: ~ 1 five gallon bucket of Tri-Star Aqua Soft located on a pallet between the washing machines. The warning label documented, .KEEP OUT OF REACH OF CHILDREN. DANGER.May be corrosive to metals. Causes severe skin burns and eye damage. IF SWALLOWED: Immediately call a POISON CENTER or physician. Rinse mouth. Do NOT induce vomiting. IF ON SKIN (or hair): Take off immediately all contaminated clothing. Rinse skin with water or shower. Wash contaminated clothing before reuse. Immediately call a POISON CENTER or physician. IF IN EYES: Rinse cautiously with water for several minutes. ~ 1 five gallon bucket of ECOLAB Laundri Destainer located on a pallet between the washing machines. The warning label documented, .KEEP OUT OF REACH OF CHILDREN. DANGER.May be corrosive to metals. Causes severe skin burns and eye damage. IF SWALLOWED: Immediately call a POISON CENTER or physician. Rinse mouth. Do NOT induce vomiting. IF ON SKIN (or hair): Take off immediately all contaminated clothing. Rinse skin with water or shower. Wash contaminated clothing before reuse. Immediately call a POISON CENTER or physician. IF IN EYES: Rinse cautiously with water for several minutes. ~ 1 container of Super Sani-Cloth Germicidal Disposable Wipe located on the hand sink. The warning label documented, .KEEP OUT OF REACH OF CHILDREN.DANGER. PRECAUTIONARY STATEMENTS Hazards to Humans and Domestic Animals.DANGER: Causes irreversible eye damage. Do not get in eyes or on clothing. Avoid contact with skin. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, using tobacco, or using restroom. Remove and wash contaminated clothing before reuse. FIRST AID Call a poison control center or doctor for treatment advice.If in eyes: Hold eye open and rinse slowly and gently with water for 15-20 minutes.If on skin: Take off contaminated clothing. Rinse skin immediately with plenty of water for 15-20 minutes. PHYSICAL OR CHEMICAL HAZARD Combustible. Do not use or store near heat or open flame. ~ 2 five gallon buckets of Tri-Star Neutralizer Concentrated Laundry Sour located on a pallet between the washing machines. The warning label documented, .KEEP OUT OF REACH OF CHILDREN.Danger.May be corrosive to metals. Causes severe skin burns and eye damage. Wear protective gloves. Wear eye or face protection. Wear protective clothing.Wash hands thoroughly after handling. IF INHALED: Remove victim to fresh air and keep at rest in position comfortable for breathing. Immediately call a POISON CENTER or physician. Rinse mouth. Do NOT induce vomiting. IF ON SKIN (or hair): Take off immediately all contaminated clothing. Rinse skin with water or shower. Wash contaminated clothing before reuse. Immediately call a POISON CENTER or physician. IF IN EYES: Rinse cautiously with water for several minutes.Immediately call a POISON CENTER or physician. ~ 1 five gallon bucket of Tri-Star L2000 XP Super Concentrated Emulsion Detergent located on a pallet between the washing machines. The warning label documented, .KEEP OUT OF REACH OF CHILDREN.Danger.Causes severe skin burns and eye damage.Wash skin thoroughly after handling. Wear protective gloves/protective clothing/eye protection/face protection. IF SWALLOWED: rinse mouth. Do NOT induce vomiting. IF ON SKIN (or hair): Remove/Take off immediately all contaminated clothing. Rinse skin with water/shower. IF INHALED: Remove victim to fresh air and keep at rest in a position comfortable for breathing. IF IN EYES: Rinse cautiously with water for several minutes.Immediately call a POISON CENTER or doctor/physician. Wash contaminated clothing before reuse. ~ 1 bottle of Hydrogen Peroxide located in an unlocked cabinet on the east wall just south of the hand sink. The warning label documented, .For external use only.Do not use.in the eyes or apply over large areas of the body.Keep out of reach of children. If swallowed get medical help or contact a Poison Control Center. Housekeeper #2 was asked if the door should be closed and locked. She stated, Yes. She stated the door is warped and is very hard to open and close. She was observed applying force to shut the door. She was asked if the hydrogen peroxide should be locked in the cabinet. No response was verbalized. She was then observed throwing the hydrogen peroxide in the trash. At 2:35 p.m., an outside environmental tour was conducted. The exterior door to the laundry room, behind the pallet of five gallon buckets of chemicals, was observed to be unlocked. Housekeeper #2, who was in the laundry room, was asked if the door was supposed to be locked. She stated, It usually is. She was observed shutting the door and locking it. On 05/05/15 at 8:50 a.m., CMA #1 was asked if the crash carts were kept locked. She stated the crash carts were secured with a zip tie. She reported the crash carts were not kept behind a locked door. At 8:55 a.m., the crash cart located in the back chart room was observed to be unlocked. There were several needles, varying in size, located inside the drawers of the cart. At 9:00 a.m., the crash cart located in the hallway on Melody Avenue was observed to be unlocked. There were several needles, varying in size, located inside the drawers of the cart. At 9:22 a.m., the pharmacist was asked what the policy was on locking the crash cart. He stated he would locate a copy of the policy. At 9:30 a.m., a confidential group interview was conducted. All seven residents stated resident #10 wandered the facility. They were asked if the resident entered their rooms. All stated,Yes. They were asked if it helped to keep the doors closed to their rooms. One resident stated, (Resident #10) knows how to open doors. They were asked if she removed items from their rooms. They stated she would handle items in their rooms. They voiced frustration with resident #10 entering their rooms. At 10:15 a.m., the ADM reported staff were placing zip ties on the crash carts to lock them so the residents could no longer access them. At 10:20 a.m., the pharmacist stated there was not a policy stating the crash cart had to be locked. The pharmacist stated sharps were an issue if residents could get to them. At 4:20 p.m., resident #10 was observed in another resident's room. The other resident was upset and kept stating resident #10 was going to get her purse. A housekeeper assisted resident #10 from the room. On 05/07/15 at 4:40 p.m., the ADM was asked to locate a policy on the storage of chemicals. At 5:15 p.m., the ADM stated they could not locate a policy on chemical storage.

Based on interview and record review, it was determined the facility failed to: A. Ensure one (#36) of two sampled residents who were reviewed for psychosocial needs did not suffer actual harm when the facility failed to prevent resident #47's behaviors from affecting the resident. Resident #36 and her family had expressed fear of resident #47 to facility staff. Staff did not implement any new interventions to protect resident #36 from resident #47's behaviors and did not inform resident #36 when resident #47 was discharged from the facility. Resident #36 continued to verbalize fear of resident #47 even after the resident had been discharged from the facility. This had the potential to affect 57 residents who resided at the facility; B. Assess and monitor resident's pain and/or ensure pain medication was administered prior to wound treatments for one (#1) of one sampled resident who was reviewed for wound treatments and pain. This resulted in actual harm for resident #1 when the facility did not medicate her prior to beginning a wound treatment that was known to cause pain. The facility identified two residents with non-pressure related wounds and 36 residents as being on a pain management program; C. Provide bowel incontinent care and urinary catheter care in a manner to prevent infection for one (#1) of one sampled resident who was observed to receive bowel incontinent and urinary catheter care. The facility identified 15 residents as occasionally incontinent of bowel and 2 residents with urinary catheters; and D. Ensure medications were discontinued as per physician orders [REDACTED].#65) of seven sampled residents whose medications were reviewed. This had the potential to affect 57 residents who received medications. Findings: 1. Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note for resident #47, dated 12/21/13 at 6:00 p.m., documented, "...Res has entered 30 plus res rooms of others taking belongings. Attempted to redirect 30 plus times throughout day. Res becomes easily agitated trying to hit staff and yelling 'stop', 'leave me alone', 'this is is my property leave me be'. Res requires prompt attention to redirect from other ladies rooms because they scare easily, one female resident was crying and upset because a "strange man" was in her room taking her things. After multiple attempts to re-direct and provide activities, res cont to take items not belonging to him (and) enter other res rooms. Some items include but not limited to 2 scissors, 3 pair glasses (eye), poise pads, socks, shoes, sugar, spoons, shampoo, body wash, body spray, hair head bands, and other items that still remain on this person d/t not being able to obtain. Will cont to have all staff assist c trying to keep from entering rooms/taking things that aren't his..." A facsimile to the physician for resident #47, dated 01/11/14, documented, "...behaviors have (increased). Today he was found numerus (sic) times in other res rms taking their belongings while they were in their rms and while they were in the showers. Redirected res to common area and his rm. All has occurred (sic) from 645 am - 12:00. Night nurse found him in a female res (resident #36) rm naked. Grateful she was asleep as not to scare her. Most of the residents are afraid of him and know he goes into their rms and takes their belongings. Any suggestions? I know you will not get this until Monday 1-13-14. I will be off until Wednesday 1-15-14 - but (MDS coordinator) is aware of..." Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment for resident #36, dated 01/15/14, documented the resident was moderately cognitively impaired. A physician extender's progress note, dated 01/15/14, documented the resident had moderate cognitive impairment and was oriented to person, place, and time. It was documented the resident had moderate short and long term memory deficits. The resident's care plan, dated 01/29/14, documented a focus problem, "...I have impaired thought processes r/t Alzheimer (sic). I am easily distracted..." The goals included, "...I will be able to communicate basic needs on a daily basis through the review date..." Interventions included, "...Keep...routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion..." Another focus problem was, "...I block the door at night with a chair..." The goal was, "...I will have decrease (sic) numbers of blocking the door through next review date..." Interventions included, "...Encourage...not to block door with a chair at night by redirection with calm environment...Monitor/document blocking the door with a chair per facility policy..." A nurse's note, dated 02/02/14 at 1:20 p.m., documented, "...Called to residents room, reported fall. Upon arrival client sitting up in floor leaned on (right) buttock. Client comments another resident (resident #47) wandered into her room, sitting in her chair (and) vanity drawer was open. Client became apprehensive yelling at other resident to leave her room, she shook her fist at him, lost balance (and) fell to ground...(family member) called @ (1:45 p.m.). Thanked nurse for calling (and) voiced concerns d/t client mentioned (resident #47) has wandered into this room before. (Administrator) notified of situation..." On 02/26/14 at 4:21 p.m., resident #36 was asked if a man had come into her room. She stated, "Yes, two or three times. He scared me." She was asked what happened. She stated, "He came into my room and was going through my stuff." The resident was asked if she fell while the resident #47 was in her room. She stated, "Yes." When asked what caused her to fall, she stated, "I don't know. I was just scared." Resident #36 was asked if resident #47 had touched her. She stated, "No." She stated, "I yelled at him to get out of here. I told him this was my room. He said it was his room and I told him no, it was my room." Resident #36 stated, "I yelled and someone came. I had told the nurses he kept coming in here. I don't know if they did anything about him or not. I was scared. You never know. They could rape you or anything." Resident #36 stated she pulled her chair and trash can over to the door at night so that she would hear if someone came into her room. Resident #36 stated, "I asked my (family member) if they would let me put a lock on my door but he said he didn't think they would." Resident #36 stated her family member had informed staff she was scared of resident #47. Resident #36 stated, "I cry all the time." When asked why she cried all the time, resident #36 stated, "My (family member) asked me to come live with him but I said no, I would come here. And now I'm scared." Resident #36 was asked why she kept her door closed. She stated, "So people I don't know won't come in here." She stated she did not want "that man" coming back into her room. On 02/27/14 at 8:46 a.m., employee #15 was asked if she had taken care of resident #47. She stated, "Yes." She was asked what the resident's mentality was like. She stated, "It's hard to say. He was just all over the place. He had Alzheimer's. He just roamed from room to room, all over the place." Employee #15 was asked what kind of behaviors the resident exhibited. She stated he did not have violent behaviors. She stated he was "constantly on the go, doing something." She was asked if he went into other residents' rooms. She stated, "Yes." When asked what he did in the other resident rooms, employee #15 stated, "Pick up stuff, put in his pocket. More than likely he was looking for a bathroom. we finally figured that out. When he would start, we would take him to the bathroom. It seemed to help." Employee #15 was asked what kinds of things were done when the resident exhibited behaviors. She stated, "Re-direct him, toilet him." She stated, "I don't know about the others, but I would always ask him to help me. It seemed to help." Employee #15 was asked how she knew what to do when the resident was having behaviors. She stated, "Process of trial and error." She was asked if her charge nurse or anyone else every talked to her about what to do for the resident when he was having behaviors. She stated, "Yes, they would say to try to re-direct him." She was asked who she reported the resident's behaviors to. She stated, "The charge nurse." Employee #15 was asked what kind of supervision was provided for resident #47. She stated, "Just to watch him." Employee #15 was asked what training she had received in dealing with residents with dementia and behaviors. She stated, "Inservices on re-directing them, what to do if they hit you." On 02/27/14 at 9:07 a.m., employee #6 was asked if she had taken care of resident #47. She stated, "Yes." She was asked if the resident had behaviors. She stated, "Yes." Employee #6 was asked what kind of behaviors the resident exhibited. She stated, "Taking others belongings every minute of every day. We couldn't figure out when he was actually doing it. He would have lip gloss, money, glasses. In his pockets, socks, down his pants. Other residents would see him doing it. Cigarettes, everything." Employee #6 was asked what was done to help control the resident's behaviors. She stated, "We would just re-direct him or take him to his room or the shower. Most of the time a nurse would go in there (to the shower) with him. All we could do was re-direct." Employee #6 was asked who she reported the resident's behaviors to. She stated, "The DON, social services, (family member), who ever else was in the office, the doctor constantly." Employee #6 was asked how the identified interventions worked. She stated, "They didn't. He was so far with his Alzheimer's. He couldn't remember. In here there is a lot of stimuli and he was able to freely room." She was asked how long the resident had behaviors. She stated, "The whole time he's been here. They progressively increased." She was asked when he had behaviors. She stated, "It was constant." Employee #6 was asked if the other residents were afraid of resident #47. She stated, "Yes." She was asked how she knew they were afraid. She stated, "They said that. They would say I'm afraid of him, that (resident #47)." She was asked if he every tried to hit another resident. She stated, "They would confrontate with him and we would go over there and intervene. We had one lady, (resident #12) who would not sit at the dining room table long enough to eat her meal. We figured out if was (resident #47). She would get up to go check on her stuff. She stated she was afraid of him, he scares me. He takes my stuff." Employee #6 stated, "We saw we had to get him into the dining room, but it was still anxiety for the residents." She stated residents would leave the dining room to go and make sure resident #47 was not going into their rooms. Employee #6 was asked if resident #47 had been sexually inappropriate with any resident. She stated he had been in their room, including the room of resident #36. She stated the resident probably thought that was where he was supposed to urinate. Employee #6 was asked what had occurred between residents #47 and #36 on 02/02/14. She stated, "All I know he was in her room sleeping and started to urinate. She was telling him to get out of the room. They went down there and told him he had to leave." She was asked if resident #47 had ever been found naked in another resident's room. She stated, "Yes, but I don't know who it was because they, the office, didn't talk about it very long. They said they had it taken care of. It was (resident #36)." Employee #6 was asked if resident #36 had told her she was afraid of resident #47. She stated, "No, she doesn't speak much. She doesn't talk about things like that." Employee #6 stated resident #36 put her chair by the door at night to keep people from coming in her room. Employee #6 stated she had been informed of the incident during shift report and had notified the physician. Employee #6 was asked what was done about the resident's behaviors after he was found naked in resident #36's room. She stated, "Just make sure he didn't go down that direction. Try to keep him up here. We don't mean one on one, but when you are up here, just try to make sure you know where (resident #47) was at." Employee #6 was asked if she had talked with the DON about the resident's behaviors. She stated she had told the MDS coordinator. She stated, "They have the stand up meeting every morning. The nurses aren't there but the department heads are. I let her know about it so it could be taken care of, addressed in standup. Sometimes it take (physician name withheld) a couple of days to answer a fax." Employee #6 was asked how the other residents were protected. She stated, "We assured them we were watching him." She was asked if staff had ever done one on one with the resident. She stated, "No, they don't do one on one. We don't have the staff to do one on one." On 02/27/14 at 10:09 a.m., the SSD was asked what had been done to protect the other residents from the increasing behaviors of resident #47 and what had been done to protect resident #36. She stated, "You're absolutely right. I do not recall doing anything different except for trying to find placement elsewhere." The SSD was asked if the residents had been afraid of resident #47. She stated, "I imagine probably some of them, but I've never had a resident come tell me they were scared of him. I do not think there was anything special done in protecting (resident #36) on any of us." She was asked if anyone had spoke to resident #36 and informed her the resident was no longer at the facility. She stated, "I didn't." On 02/27/14 at 10:55 a.m., the administrator was asked to tell the surveyor about resident #47. She stated, "He was harmless, never hurt anybody, but he prowled." She was asked if the residents were afraid of resident #47. She stated, "There were some of the ladies that were. He would go in their and take their stuff. There were times we would call his (family member) to come and search his rooms and pockets. Always things, never money." The administrator was asked if she was aware resident #47 had been found with scissors. She stated, "Yes, we found scissors. You never know what you might find on (resident #47)." The administrator was asked what was done to protect the residents and their property. She stated, "Every single staff member was inserviced. Everyone kept their eyes on (resident #47). There were 10 to 20 people watching (resident #47) at all times." She was asked if the resident had been found naked in the room of resident #36. She stated, "Nobody told me he was naked. I don't recall that." The administrator was asked what they did to protect resident #36. She stated, "We did the same thing we had been doing. Evidently they (the staff) had not been doing their part." The administrator was asked if the interventions had been successful. She stated, "Up to that point." She was asked if the resident had ever been put on one on one. She stated, "There have been time we did that." She was asked if the resident was put on one on one after the incident with resident #36. She stated, "I would have to ask the nurses. I don't recall." The administrator was asked if she was aware of the incident on 02/02/14 when resident #47 was found naked in the room of resident #36. She stated, "I did know they found him in her room." She was asked what she did to protect resident #36 and the other residents after the incident. She stated, "That's when I went to the staff and told them I needed all eyes on (resident #47)." The administrator was asked if staff was watching resident #47, why was he found in other's rooms, including resident #36. She stated, "Somebody didn't do their job." The administrator was asked if resident #36 was afraid of resident #47. She stated, "Yes." She was asked how she knew resident #36 was afraid. She stated, "Because of the note and her (family member) came to me the next day and told me (resident #36) was afraid." The administrator was asked if resident #36 was aware the resident was no longer at the facility. She stated, "I didn't tell her." She stated she did not know she was allowed to tell the resident. The administrator stated some of the other residents had asked her where resident #47 was and she had told them "he had went away to be with people like him." 2. An admission assessment for resident #1, dated 01/10/14, documented the resident was cognitively intact, had an indwelling urinary catheter, and was frequently incontinent of bowel. The resident's care plan, dated 01/11/14, documented a focus problem, "...I have chronic pain r/t...open areas on buttocks..." The goals included, "...I will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date..." Interventions included, "...Anticipate...need for pain relief and respond appropriately to any complaint of pain..." Another focus problem was, "...I have indwelling catheter related (sic) open sore on buttocks...I am at risk for UTIs r/t chronic UTIs and catheter placement..." The goals included, "...I will show no s/sx of urinary infection through review date..." Interventions included, "...Provide peri/cath care per facility policy..." Another focus problem was, "...I have open areas to buttocks and chest r/t self inflected (sic) by scratching..." The goal was, "...I have open areas will show signs of healing and remain free from infection by/through review date..." Interventions included, "...Monitor pain level prior, during and after treatment. If in pain stop treatment and administer medication. Then attempt after medication effective..." The resident was admitted to the hospital on [DATE] for psychiatric evaluation. A hospital progress note, dated 01/19/14, documented, "...The patient's cultures of wound and urine came back today. She does have E. coli in her urine...Also, on culture of her (buttocks) wound, she has grown out Proteus mirabilis...Also, [MEDICAL CONDITION] swab was positive..." Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Monthly physician orders, dated 02/2014, documented to cleanse the buttock wounds with normal saline, apply hydrogel, cover and secure with ABD pads twice daily at 8:00 a.m. and 8:00 p.m. A physician's telephone order, dated 02/16/14, documented to change the resident's pain medication to [MEDICATION NAME] 7.5/500 mg every four hours as needed. A nurse's note, dated 02/21/14 at 9:40 a.m., documented, "...Resident c/o pain to buttocks crying in pain. sitting (up) in w/c p tx to buttocks 10/10..." A nurse's note, dated 02/25/14 at 10:30 a.m., documented, "...Tx to bil buttocks complete as ordered. Assisted to wc via sit-to-stand lift. C/o buttock hurting/crying - prn [MEDICATION NAME] 7.5/500mg admin @ this time. Rates 8/10..." On 02/25/14 at approximately 3:00 p.m., the resident was observed near the back dining room. Her urinary catheter bag was observed resting on the floor. On 02/27/14 at approximately 10:00 a.m., the resident was observed on the center hall. Her urinary catheter bag was observed resting on the floor. Medication administration records, dated 02/28/14 at 7:00 a.m., documented the resident was medicated with one [MEDICATION NAME] 7.5/500 mg. It was documented at 8:00 a.m. the pain medication had been "effective." On 02/28/14 at 8:20 a.m., the resident was observed sitting in her wheelchair in the center hall. The resident told the surveyor that her buttocks hurt. Her urinary catheter bag was resting on the floor. At 9:01 a.m., the resident was observed sitting in her wheelchair in her room. Her urinary catheter bag was resting on the floor. She stated her buttocks were hurting. She was asked if she had informed the staff. She stated, "Yes." She stated staff had given her pain medication "earlier." The resident stated she had two "sores" on her buttocks. On 02/28/14 at 9:15 a.m., LPN #3 was asked if any residents on the resident's hall had pressure ulcers. She stated two residents had wounds. She stated resident #1 had sores but they were due to the resident scratching herself. LPN #3 was asked if she had any residents she monitored for pain. She stated, "All of them." She stated resident #1 would ask for pain medication when she had been sitting up in her chair. LPN #3 was asked what the facility's policy was for monitoring pain. She stated she asked the residents to rate their pain on a 0 to 10 scale, and if they could not speak, she would watch for nonverbal signs and symptoms of pain. On 02/28/14 at 9:25 a.m., the surveyor asked to complete a skin observation for the resident. The resident agreed but refused to be put to bed. CNAs #3 and #2 were asked to lift the resident so that a skin observation could be completed. The CNAs lifted the resident with the sit-to-stand lift and pulled down her pants and brief. The resident's brief was stuck to one of the buttock wounds and there were no ABD pads covering the wounds. CNA #2 pulled the brief from the wounds. The resident's buttocks were red. Six open areas of varying sizes were noted on the resident's right buttock. The largest measured approximately 2 x 3 cms. The smallest measured approximately 0.5 x 0.5 cms. The brief had been stuck to the largest wound on the right buttock and began to drip blood when the brief was removed. Eight open areas of varying sizes were noted on the resident's left buttock. The largest measured approximately 2 x 3 cms and the smallest measured approximately 0.5 x 0.5 cms. A small amount of bowel movement was noted on the resident's brief. CNAs #3 and #2 provided bowel incontinent care. The CNAs did not wash the resident's urinary catheter. Each time CNA #2 touched the resident's buttock wounds, the resident cried out. At 9:30 a.m., CNA #2 asked LPN #3 if she wanted to complete the resident's wound treatments since she was up. LPN #3 stated, "Yes." At 9:39 a.m., LPN #3 entered the resident's room with dressing supplies. LPN #3 did not assess the resident's pain prior to beginning the dressing change. The CNAs did not inform LPN #3 there were no ABD pads on the resident's wounds when they removed her brief. The right buttock wound continued to drip blood. LPN #3 washed her hands, gloved, and cleaned the left buttock wounds. She then ungloved, washed her hands, and regloved. She applied hydrogel to the resident's left buttock wounds and placed an ABD pad over the wounds. LPN #3 removed her gloves, washed her hands, and regloved. The large right buttock wound continued to drip blood. LPN #3 washed the right buttock wounds. When she touched the large wound, the resident winced and jerked. LPN #3 began to apply hydrogel to the right buttock wounds. The resident gasped and began crying. She continued to cry as LPN #3 applied the hydrogel. LPN #3 completed the dressing change and left the room without addressing the resident's pain. At 9:50 a.m., the CNAs were asked if they informed LPN #3 that ABDs were not in place over the resident's wounds. They stated, "No." At 9:52 a.m., LPN #3 was asked if the dressing change caused the resident pain. She stated, "A little bit it seems like on her right side. I gave her a pain med earlier." LPN #3 was asked if she had assessed the resident's pain prior to beginning the dressing change. She stated, "Not right now. I did when I gave her eye drops." LPN #3 was asked what the facility's policy was related to pain and dressing changes. She stated, "There was another resident that we would give pain meds to 30 minutes before." At 9:55 a.m., the resident continued to cry. She was asked why she was still crying. She stated, "My bottom, it hurts." She stated, "It starts hurting after they do the treatment." LPN #3 entered the resident's room and asked the resident if she wanted some Tylenol. The resident stated, "Yes." LPN #3 left the room to obtain Tylenol for the resident. At 9:58 a.m., the resident was asked if her wounds hurt each time her dressing change was completed. She stated, "A lot of times." LPN #3 re-entered the room and asked the resident, "Do you want to try some Tylenol at this time? And if that doesn't help, I can give you some more [MEDICATION NAME] when it's time." The resident nodded her head yes. At 10:07 a.m., Tylenol was provided to the resident by a CMA. On 02/28/14 at 11:21 a.m., the DON was asked if the resident complained of pain to her buttocks. She stated, "Sometimes she does and they will medicate her. They will medicate her before her dressing changes if she is complaining to them about pain." The DON was asked what the facility's policy was related to pain management and wounds. She stated, "I ask them to get a pain level before doing treatments. If they complain of pain, medicate and come back. If they complain of pain during, they need to stop, medicate, and come back." The DON was asked if the resident had infections in her wounds previously. She stated she would have to look at the wound books. She was asked why there were no ABD pads covering the wounds as ordered by the physician. She stated, "There should have been." The DON was asked why urinary catheter bags were kept off the floor. She stated, "To help avoid infection." She was asked why the resident's catheter bag had been noted on the floor at various times during the survey. She stated it should not have been. 3. Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/17/13, documented the resident was usually able to understand others and was usually able to be understood by others. It documented her cognition was severly impaired and that she received an antipsychotic and antidepressant for the last seven days prior to the assessment. A physician's telephone order, dated 09/27/13, documented to start [MEDICATION NAME] 4.6 mg topically every 24 hours. It was documented to discontinue the resident's [MEDICATION NAME] when the [MEDICATION NAME] became available. A nurse's note, dated 09/27/13 and untimed, documented the advanced practice registered nurse was in the facility to see the resident and a new order was received to start [MEDICATION NAME] 4.6 mg patch topically every 24 hours. The Medication Administration Record [REDACTED]. On 02/28/14 at 11:20 a.m., the MDS Coordinator was shown the MARs and the physicians order. She was asked if the [MEDICATION NAME] was discontinued per the physician's orders [REDACTED].

Based on observation, record reviews, and interviews, it was determined the facility failed to ensure a resident with recurring falls and with interventions in place to aide in the prevention of falls had the interventions implemented for one (#5) of six sampled residents reviewed for falls. This deficient practice resulted in an actual harm. The DON identified four residents with recurring falls. The facility also failed to ensure water temperatures were safe in the shower room and at the hand sink in residents' rooms located on the South hall. The temperature readings ranged from 119 degrees F to 128 degrees F. This had the potential to affect 21 residents who resided on the South hall. Findings: Falls: The Falls and fall Risk, Managing policy documented, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling...identify interventions: The staff...will identify appropriate interventions to reduce the risk of falls...if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant...minimizing serious consequences of falls: staff will identify and implement relevant interventions... to try to minimize serious consequences of falling..." The Falls Risk Assessment policy documented, "...Monitoring subsequent falls and fall risk...the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling...if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change interventions..." Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident had clear speech, usually was understood by others and sometimes understood others. The assessment further documented the resident had severely impaired cognitive skills for daily decision making, required supervision with transfers, mobility and required extensive assistance with toilet use and had no falls prior to admission. A fall risk assessment dated [DATE], documented the resident was a high risk for falls with a score of 11. A score above 10 on the fall risk indicated the resident was a high risk. A care plan dated 10/18/11, documented, "Fall status: I am at risk for falls due to medications I receive. I have not had any falls since my admission. I am currently on the falling star program with a fall score of 11. Goals: I want to remain free from falls and injuries related to falls." A Mcloud Nursing Center CAA Summary, dated 10/18/11, documented, "Falls AEB: (Resident) is at risk for falls due to medications he receives. He has not had any falls since his admission. He is currently on the falling star program with a fall score of 11, will continue to monitor for changes in falls." An undated entry on the care plan documented, "Res. bent over to pick something up fell & hit head- neuro (checks)." A incident report, dated 11/17/11, documented, "Heard loud boom. Resident found on floor blocking door inside room. Res denies hitting head. 0 apparent injuries noted...steps taken to prevent recurrence: psych eval..." A care plan entry, dated 11/17/11, documented, "Fall no injury." A nurse's note, dated 11/19/11 at 10:20 p.m., documented, "Res resting in recliner in lobby (arrow down) agitation noted...no redirection or 1:1 needed at this time..." A incident report dated 11/20/11, documented, "Summoned to res room, wife stated that res fell against wall. Res was found sitting on floor beside chair at foot of bed. 0 apparent injuries noted. Res did not hit head...steps taken to prevent recurrence: 1:1 & redirect." A care plan entry, dated 11/20/11, documented, "Fall no injury." No interventions were added to the care plan to prevent recurrence of the fall. A incident report, dated 11/21/11, documented, "Resident attempting to walk across front lobby. Resident stumbled & fell -landed on bottom. Resident didn't hit head & able to move all extremities...steps taken to prevent recurrence: 1:1 & redirect." A care plan entry, dated 11/21/11, documented, "Fall no injury." No interventions were added to the care plan to prevent recurrence of the fall. Fall risk assessments, dated 11/21/11 and 12/02/11, documented the resident was a high risk for falls with a score of 16. A incident report, dated 12/03/11, documented, "Summoned to Res room. Res found sitting on floor beside recliner, skin tear noted to (R) FA. Res denies hitting head. denies pain/discomfort..steps taken to prevent recurrence: remind and encourage resident to use call-light for assistance." A care plan entry, dated 12/03/11, documented, "Fall- S/T (L) forearm." The care plan was not updated to include new interventions to prevent further recurrence of falls. A incident report, dated 12/06/11, documented, "Was observed by staff to have a small abrasion & hematoma to (R) forehead area. No c/o n/v or headache. ROM to ext. WNL Unable to follow commands to assess hand grasps @ this time d/t confusion neuro's initiated, see flow sheet denies pain. Alert to name-confused...steps taken to prevent recurrence: frequent observation. 1:1 observation for safety reported to state." A care plan entry, dated 12/06/11, documented, "Fall hematoma to (R) forehead neuro (checks)." The care plan was not updated to include new interventions to prevent the recurrence of falls. A fall risk assessment, dated 12/08/11, documented the resident was a high risk for falls with a score of 16. A incident report, dated 12/09/11, documented, "Resident found on floor beside bathroom door. Resident has open gash on left side of back of head...level of consciousness: confused & drowsy...steps taken to prevent recurrence: one on one, ER for evaluation..." A care plan entry, dated 12/09/11, documented, "Fall laceration to back of head-sent to ER neuro (checks)." There were no updated interventions on the resident's care plan to address the recurrence of falls. A incident report, dated 12/13/11, documented, "While leaning forward- kept going down on knees, and kept going forward- bumped head, no obvious injury neuro (checks) with a small 3.4 X 4 cm skin tear (L) posterior - lateral...complained of floor moving...Level of consciousness: disoriented...steps taken to prevent recurrence: 1:1 /c staff." There was no documentation to indicate the resident had 1:1 supervision as indicated on the incident reports on the following dates: 11/20/11, 11/21/11, 12/06/11, 12/09/11 and 12/13/11. An incident report, dated 12/27/11, documented, "Res. leaned forward in w/c and fell on buttocks. No injuries noted...steps taken to prevent recurrence: 1:1 /c staff - direct supervision..." A care plan entry, dated 12/27/11 and 01/02/12, documented, "Fall 0 injury." The resident's care plan was not updated with new interventions to prevent the recurrence of falls. The first documentation of 1:1 supervision was dated 12/26/11, thirty- seven days after the facility was to implement the 1:1 supervision to prevent further falls. A interview was conducted on 02/15/12 at 3:15 p.m., with the DON regarding the recurring falls of resident #5. She was asked what interventions the facility put in place to prevent the recurring falls. She stated, "1:1 supervision with the resident." She was asked if there was documentation to indicate the facility implemented the 1:1 supervision to prevent recurring falls. She stated, "The documentation started 12/10/11. There is no other documentation of the 1:1 being done." She was asked if the care plan had been updated and reviewed with new interventions to aide in the prevention of recurring falls. She stated, "The 1:1 is not on the care plan." She was asked if the interventions on incident reports should be included in the resident's care plan. She stated, "The care plan should reflect the interventions from the incident report." She was asked about the staff following the interventions addressed on the incident report. She stated, "Yes, they are there to try and protect the resident." A request was made for documentation to show the facility implemented 1:1 to prevent recurring falls and/or any other interventions the facility had implemented to prevent falls. No further documentation was provided. Hot water: The facility policy for Controlling Hot Water Temperatures documented, "...Standards for water temperatures for resident usage areas: 100 degrees F. minimum, 110 degrees F. maximum..." A review of the Water Temperature Check Sheet for 10/01/11 through 02/13/12, documented the water temperature on the South hall ranged from 117 degrees F to 122 degrees F. On 02/13/12, from 2:18 p.m. through 3:31 p.m., the following water temperatures were recorded on the South hall: ? room 15: 126.8 degrees F. ? room 3: 119.0 degrees F. ? room 1: 119.9 degrees F. ? room 9: 119.9 degrees F. ? room 7: 123 degrees F. ? shower stall: 125.6 degrees F. ? shower room hand sink: 128 degrees F. A interview was conducted on 02/13/12 at 3:10 p.m., with the maintenance supervisor regarding the elevated water temperatures. He was asked what the highest temperature reading should be. He stated, "113 degrees Fahrenheit should be the top." He was asked how often he checked the hot water temperatures in the facility. He stated, "All the days I work." He was asked where he checked the water temperatures. He stated, "One room on each hall, shower rooms and whirlpool room." He was asked about the elevated water temperatures on the South hall. He stated, "We had plumbing problems and they changed the hot water heater." He then stated, "There is still a problem. The water heater didn't fix the high water temperatures on the South hall." He was asked how long the water temperatures had been elevated. He stated, "Since we had the water heaters replaced." A request was made for the work order and invoice for the replacement on the hot water heater that serviced the South hall. He stated, "The business office manager would have that." The maintenance supervisor left and returned with a job work order dated 10/24/11. The work order documented, "Install new water heater/North wing. Install new thermostatic mixing valve & circ pump."