Every finding on record at Mitchell Care & Rehab Center

Based on record review and interview, the facility failed to ensure residents were educated and offered the opportunity to create an advance directive for 4 (#16, 17, 56, and #58) of 5 sampled residents reviewed for advance directives. The administrator identified 57 residents who resided in the facility. Findings: 1. Resident #16 was admitted to the facility on [DATE]. A review of Resident #16's electronic health records showed no advance directive information had been provided. 2. Resident #17 was admitted to the facility on [DATE]. A review of Resident #17's electronic health records showed no advance directive information had been provided. 3. Resident #56 was admitted to the facility on [DATE]. A review of Resident #56's electronic heath record showed no advanced directive information had been provided. 4. Resident #58 was admitted to the facility on [DATE]. A review of Resident #58's electronic health records showed no advanced directive information had been provided. On 03/25/25 at 3:17 p.m., the administrator stated there were no advance directive acknowledgement forms signed by the residents. The administrator stated an advance directive acknowledgement form was part of the admission packet, but must have been left out. The administrator stated the advance directive information should have been reviewed with the resident and the acknowledgement form signed at that time.

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained for 1 (#16) of 13 residents sampled for infection control during the administration of medications. The administrator identified 57 residents resided in the facility. Findings: On 03/26/25 at 1:02 p.m., CMA #1 was observed popping Resident #16's gabapentin (an anticonvulsant) from the blister pack into their bare hand. On 03/26/25 at 1:04 p.m., Resident #16 was observed dropping their tramadol (an opioid analgesic) tablet on their shirt while attempting to take both medications. CMA #1 was observed to immediately pick up the tablet from the resident's shirt with their bare hands and returned it to the medication cup. On 03/26/25 at 1:05 p.m., Resident #16 took both of their medications as administered. An undated facility policy titled Emergency Pharmacy Services, read in part, Does not handle pills with bare hands. Resident #16 had diagnosis which included chronic pain syndrome. A physician's order, dated 10/29/24, showed gabapentin capsule 300 mg, give one capsule by mouth three times a day. A physician's order, dated 02/28/25, showed tramadol tablet 50 mg, give one tablet by mouth every eight hours. On 03/26/25 at 1:16 p.m., CMA #1 stated the policy for medication administration was to not touch medications with bare their hands. CMA #1 stated they had popped the gabapentin into their bare hand. They stated they should have scooped the tramadol up with the medication cup not their bare hands. On 03/27/25 at 12:28 p.m., the DON stated CMA #1 should have pick up the medication, destroyed it, and pulled it again. The DON stated CMA #1 should not have given the medication that had touched their bare hands.

Based on record review and interview, the facility failed to update a care plan for 1 (#60) of 1 sampled resident for hospice services. The administrator identified 57 residents resided in the facility. Findings: A facility policy titled Comprehensive Person-Centered Care Plan, dated 10/23/19, read in part, Upon a Change in Condition, the Comprehensive Person-Centered Care Plan or Baseline Care Plan will be updated. Resident #60 had diagnosis which included senile degeneration of the brain. A physician's order, dated 01/16/25, showed Resident #60 was admitted to hospice. There was no documentation in Resident #60's care plan to reflect they had been admitted to hospice care. On 03/26/25 at 9:47 a.m., the ADON stated Resident #60's care plan had not been updated to reflect them being admitted to hospice.

Based on record review and interview, the facility failed to ensure a significant change assessment was completed within 14 days of electing the hospice benefit for 1 (#60) of 1 sampled resident who was reviewed for hospice services. The administrator identified 57 residents resided in the facility. Findings: Resident #60 had diagnosis which included senile degeneration of the brain. A physician's order, dated 01/16/25, showed Resident #60 was admitted to hospice. Resident #60's quarterly assessment, dated 02/05/25, did not show hospice while a resident. A significant change assessment was not located in the residents electronic health record. On 03/25/25 at 9:43 a.m., the ADON stated Resident #60 was admitted to hospice services on 01/16/25. On 03/25/25 at 9:44 a.m., the ADON stated a significant change assessment had not been completed for Resident #60 after they were admitted to hospice. They stated the assessment should have been completed after the resident admitted to hospice care.

Based on observation, record review, and interview, the facility failed to ensure electrical outlets on both the East and [NAME] side hallways, nurses' stations, and living room areas had protective plates covering them. The administrator identified 60 residents resided in the facility. Findings: A Safe Homelike Environment policy, dated 04/28/2022, read in parts, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment .'Environment' refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas .6. a. The maintenance Director will perform periodic rounds to ensure functioning lights .9. General Considerations: f. Report any environmental concerns to the Administrator. 1. Res #1 had diagnoses which included Alzheimer's disease and cognitive communication deficit. A significant change in status assessment, dated 05/15/24, documented the resident's cognition was severely impaired, did not have any ROM functional impairments, and required moderate assistance with most ADL's. The care plan, initiated 05/23/24, documented the resident was at risk for wandering. The goal documented the resident's safety would be maintained through the next review date. On 01/16/25 at 12:08 p.m., Res #1 was observed ambulating around the [NAME] hallway and living room area. On 01/16/25 at 1:52 p.m., Res #1 was observed ambulating around the [NAME] hallway and living room area. 2. Res #2 had diagnoses which included dementia and disorientation. The annual assessment, dated 11/06/24, documented the resident's cognition was severely impaired, did not have any ROM functional impairments, utilized a wheelchair for mobility, and required substantial assistance with most all ADL's. On 01/16/25 at 11:04 a.m., Res #2 was observed propelling themselves throughout the [NAME] hallway and living room area. There were no staff members observed monitoring the resident. On 01/16/25 at 1:58 p.m., Res #2 was observed propelling themselves in their wheelchair throughout the [NAME] hallway and living room area. There were no staff members observed monitoring the resident. 3. Res #3 had diagnoses which included diabetes and HTN. An annual assessment, dated 01/16/2024, documented the resident's cognition was moderately impaired, did not have any ROM functional impairments, and was independent of most all ADL's. On 01/16/25 at 10:20 a.m., there were four uncovered electrical outlets observed on the [NAME] end of the facility, two in the living room area, one in the hall by the [NAME] nurses station, and one behind the nurses station. On 01/16/25 at 10:37 a.m., there were four uncovered electrical outlets observed on the East end of the facility, three in the living room area, and two behind the nurses station. On 01/16/25 at 11:43 a.m., Res #3 was asked how long the electrical outlet covers had been missing from the outlets. They stated about a month. They were asked if the administrator was aware the electrical outlets were uncovered. They stated, Yes. They were asked if they were aware of any injuries occurring. They stated yes about two weeks ago a staff member was electrocuted and was sent to the emergency room . They were asked if any residents had been injured. They stated they not, but they worry about the residents with dementia On 01/16/25 at 12:20 p.m., LPN #1 was asked how long the electrical outlets had been uncovered. They stated about two weeks. They were asked if the administrator was aware the electrical outlets were uncovered. They stated, Yes. They were asked if they were aware of any injuries occurring. They stated, Yes. The LPN stated about two weeks ago a staff member was electrocuted and was sent to the emergency room . They were asked if any residents had been injured. They stated, No. On 01/16/25 at 12:48 p.m., the DON was asked if they were aware the electrical outlets were uncovered. They stated, No. They were asked how long the electrical outlets had been uncovered. They stated about two weeks. They were asked if they were aware of any injuries occurring. They stated, Yes. The DON stated about two weeks ago a staff member was electrocuted and was sent to the emergency room . They were asked if any residents had been injured. They stated, No. They were asked if the uncovered outlets were a safety hazard to the residents. They stated, Yes. On 01/16/25 at 12:52 p.m., the administrator was asked if they were aware the electrical outlets were uncovered. They stated, No. They were asked if they were aware of any injuries occurring. They stated, Yes. The administrator stated about two weeks ago a staff member was electrocuted and was sent to the emergency room . They were asked if any residents had been injured. They stated, No. They were asked if the uncovered outlets were a safety hazard to the residents. They stated, Yes. On 01/16/25 at 2:09 p.m. the maintenance person was asked how often they made general and safety rounds throughout the facility They stated they were all over the facility daily. They were asked when the electrical outlet covers were removed. They stated about two weeks ago. They stated the construction company workers removed the covers and they thought the workers had replaced them. They were asked if the uncovered outlets were a safety hazard to the residents. They stated, Yes.

Based on record review and interview, the facility failed to report an allegation of abuse to the proper authorities for one (#2) of four sampled residents reviewed for abuse. The administrator reported there were 52 residents residing in the facility. Findings: An Abuse Prevention policy, revised 10/21/24, read in parts, The Administrator, or designee, shall report any allegations of abuse .to the Department of Health as required. Resident #2 had diagnoses that included muscle weakness, lack of coordination, and chronic respiratory failure. A MDS, dated [DATE], documented Resident #2 required one person assistance for hygiene and dressing, experienced shortness of breath with exertion, was oxygen dependent, and was currently using a wheelchair for mobility. A formal complaint submitted to the OSDH on 08/15/24 alleged that LPN #1 had been abusive towards Resident #2. The report documented Resident #2 had asked LPN #1 to get them a cup of coffee. It documented LPN #1 went and got a wheelchair, put it in the resident's doorway, and told the resident if they wanted a cup of coffee they would have to get it themselves. It documented LPN #1's response was considered abusive. On 11/05/24 at 2:35 p.m., LPN #1 reported they had taken Resident #2 to the DON to report the incident when it happened. There was no documentation the alleged allegation of abuse had been reported to the OSDH. On 11/05/24 at 4:13 p.m., the DON acknowledged Resident #2 had reported the above incident to them and had expressed they felt the staff had been abusive. The DON was asked if Resident #2's reporting of the incident would be considered an allegation of abuse by a staff member. They stated, Yes. They were asked if the incident had been reported to the proper authorities and they stated, No, we did not do a State Reportable.

Based on record review and interview, the facility failed to ensure a residents were free from abuse for two (#3 and #4) of four sampled residents reviewed for abuse. The DON identified 52 residents resided in the facility. Findings: An Abuse Prevention policy, revised 10/21/22, read in part, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff .Mental Abuse: The use of verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame 1. Resident #3 had diagnoses which included major depressive disorder and morbid obesity. A 5-day resident assessment, dated 09/09/24, documented Resident #3's cognition was moderately impaired. It documented the resident made themselves understood and was able to understand others. On 11/05/24 at 2:35 p.m., Resident #3 was asked how they were treated by staff. They reported CNA #1 would talk mean to them and called them disgusting. Resident #3 stated it made them feel bad and they were glad CNA #1 was no longer at the facility. 2. Resident #4 had diagnoses which included severe vascular dementia and other impulse disorders. A quarterly resident assessment, dated 10/16/24, documented Resident #4's cognition was severly impaired. On 11/05/24 at 2:08 p.m., an interview was attempted with Resident #4. The resident would smile, but did not respond to any of the questions which were asked. An initial incident report form, incident date 08/20/24, documented CNA #1 was overheard telling Resident #4 if they did not stop misbehaving they were not getting another cigarette. The report documented CNA #1 was later overheard telling Resident #3 several times that they were a disgrace. A facsimile transmission report documented the incident report was faxed to the OSDH on 08/21/24 at 4:33 p.m. A final incident report form, with a facsimile transmission date of 08/23/24 at 6:03 p.m., documented the above allegations of abuse were substantiated and CNA #1 was terminated. On 11/05/24 at 4:30 p.m., the administrator stated CNA #1 was terminated on 08/21/24 for being verbally abusive towards Resident #3 and #4. They reported the facility had six in-services within the last year on abuse.

Based on record review and interview, the facility failed to investigate an allegation of abuse for one (#2) of four sampled residents reviewed for abuse. The administrator reported there were 52 residents residing in the facility. Findings: An Abuse Prevention policy, revised 10/21/22, read in part, The facility will initiate at the time of any finding of potential abuse or neglect an investigation .and provide protection to any alleged victims to prevent harm during the continuance of the investigation. Resident #2 had diagnoses which included muscle weakness, lack of coordination, and chronic respiratory failure. A formal complaint submitted to the OSDH on 08/15/24 alleged that LPN #1 had been abusive towards Resident #2. The report documented Resident #2 had asked LPN #1 to get them a cup of coffee. It documented LPN #1 went and got a wheelchair, put it in the resident's doorway, and told the resident if they wanted a cup of coffee they would have to get it themselves. It documented LPN #1's response was considered abusive. On 11/05/24 at 2:35 p.m., LPN #1 reported they had taken Resident #2 to the DON to report the incident when it happened. LPN #1 denied being asked to write a statement describing their account of the incident or being removed from their work assignment while an investigation of the incident was completed. On 11/05/24 at 4:13 p.m., the DON acknowledged Resident #2 had reported the above incident to them and expressed they felt the staff had been abusive. When asked if there had been a formal investigation conducted the DON stated, No. They agreed facility policy had not been followed.

Based on record review and interview, the facility failed to complete nurse aide performance reviews at least yearly for 18 of 22 nurse aides employed by the facility. The administrator identified 22 full time nurse aides currently employed by the facility. Findings: An employee list documented 22 staff members currently working as certified nurse aides. On 07/22/24 at 3:17 p.m., the administrator provided documentation regarding a nurse aide skills performance checklist for four certified nurse aides currently working for the facility. On 07/22/24 at 4:00 p.m., the administrator stated only four of the 22 nurse aides currently working had a completed performance review. The administrator stated a previous employee had not completed the required task for all certified nurse aides.

Based on observation, record review, and interview, the facility failed to ensure the physician was notified and interventions in place for weight loss for one (#54) of one sampled resident reviewed for nutrition. The administrator identified 60 residents who resided in the facility. Findings: Res #54 was admitted on [DATE] and had diagnoses which included displaced avulsion fracture/chip fracture of right talus, osteoarthritis, depression, and malignant neoplasm of tongue. A admission assessment, dated 08/03/23, documented the resident was cognitively intact and required minimal assistance with ADLs. The assessment also documented the resident's weight was 181 pounds. The vital sign record, dated 10/18/23, documented a weight of 153.6 pounds. A dietary note, dated 10/23/23, documented a recommendation of health shakes twice a day between meals related to weight loss. A quarterly assessment, dated 11/03/23, documented the resident had a weight of 152 pounds and a weight loss of 5% or more in the last month or 10% or more in the last six months. The vital sign record, dated 11/16/23, documented a weight of 150.6 pounds. This was a 16% weight loss in three months. There was no documentation the physician was notified of the significant weight loss. The care plan did not document the weight loss. On 11/27/23 at 12:52 p.m., an observation was made of snacks and crackers in the resident's room. On 11/30/23 at 1:07 p.m., an interview with the DON was conducted and they stated recommendation for the health shakes got missed until now and the weight loss was missed completely.

Based on record review and interview, it was determined the facility failed to ensure professional accepted standards of quality were met related to a mental health diagnoses given to one (#34) of five sampled residents reviewed for unnecessary medication and diagnoses. The administrator identified 60 residents who reside in the facility. Findings: Res #34 was admitted to the facility on [DATE] and had diagnoses which included anxiety, insomnia, dementia with behavioral disturbances, and delusional disorders. On 08/31/22, the physician ordered risperidone (an antipsychotic medication) 0.25 mg at bedtime. A quarterly assessment, dated 06/21/23, documented the resident had no diagnoses of schizophrenia. On 06/24/23, the physician documented, the resident had a new diagnoses of schizophrenia. An annual assessment, dated 09/11/23, documented the resident had a diagnoses of schizophrenia. On 11/30/23 at 8:55 a.m., the DON stated the physician just added the diagnoses of schizophrenia on 06/24/23 for the medication, risperidone, instead of using the diagnoses of delusional disorders.

Based on record review and interview, the facility failed to complete correctly a PASARR level l evaluation for one (#11) of three residents reviewed for PASARR. The administrator identified 60 resident's resided in the facility. Findings: Res #11 was admitted to the facility with a diagnosis of major depressive disorder. The EHR documented the resident was diagnosed with schizoaffective disorder on 08/02/18. A PASSARR level l screen, dated 09/17/18, documented the resident did not have a diagnosis of a serious mental illness. A referral was not made to the state agency. On 11/29/23 at 10:35 a.m., the DON reviewed the PASARR level l and stated the form was not completed correctly. The DON stated a referral should have made to the state agency with the admitting diagnosis of major depressive disorder and with the new diagnosis of schizoaffective disorder.

Based on record review and interview, it was determined the facility failed to ensure the code status was identified and correct for one (#12) of one resident whose code status was reviewed. The administrator identified 60 residents who resided in the facility. Findings: Res #12 was admitted to the facilty on 06/05/17 with diagnoses which included dementia and diabetes. A form titled ''Oklahoma DNR'' was signed by the resident's POA on 06/06/17. The EHR documented the resident's code was full code. A physician order, dated 03/24/20, documented the resident's code status was a full code. On 11/30/23 at 9:29 a.m., the DON stated they miss-understood the new regulations regarding advanced directives and the DNR was revoked.

Based on record review and interview, the facility failed to provide assistance with transportation to a scheduled physician appointment for one (#24) of one sampled resident reviewed for transportation. The administrator identified 60 residents who resided in the facility. Findings: A document titled [NAME] Manor Transportation Policy documented .[NAME] Manor will plan for transportation for all residents that reside at [NAME] Manor . Res #24 was admitted to the facility on [DATE] with diagnoses which included infection and inflammatory reaction due to internal joint prosthesis, chronic pain, and diabetes. A form titled Appointment NOV. 27---DEC. 2 documented the resident had an appointment scheduled on 11/27/23 at 1:00 p.m. On 11/27/23 at 11:21 a.m., the resident stated they had a doctor appointment scheduled for today, but couldn't make it. The resident stated they were informed there was no staff available for transportation. On 11/28/23 at 3:40 p.m., the social service staff stated the resident had a doctor appointment scheduled for 11/27/23. Staff stated they were the only staff working as social services, activities, and transportation that day, so the appointment was rescheduled.

Based on record review, observation, and interview, the facility failed to provide meals to a dependent resident for one (#1) of two residents reviewed for actitivities of daily living. The Resident Census and Conditions of Residents, dated 03/09/23, documented 31 residents were dependent with meals. Findings: A Special considerations policy, dated 08/18, read in parts, .Assist with eating as needed . A care plan for Res #1, revised on 04/12/22, read in parts .I am dependent for eating . An assessment, dated 12/18/22, documented Res #1 was moderately impaired with cognition and was dependent on staff for eating. On 03/09/23 at 2:40 p.m., Res #1 was observed in bed sleeping. On 03/09/23 at 4:10 p.m., a family member reported they had observed the staff placing the meal tray on the bedside table and had not offered to feed Res #1. On 03/09/23 at 5:30 p.m., CMA #1 was observed to deliver the meal tray and placed it on the bedside table. On 03/09/23 at 5:40 p.m., CNA #1 entered Res #1's room and stated she is sleeping. The meal tray remained on the bedside table untouched and CNA #1 did not attempt to wake the resident. On 03/09/23 at 6:08 p.m., corporate nurse #1 observed the meal tray on the bedside table and reported the staff should have attempted to wake the resident and feed them.

Based on record review and interview, the facility failed to notify the family of a change in condition on two (#1 and #2) of three residents reviewed. The Resident Census and Conditions of Residents, documented a census of 64 residents. Findings: A Condition Changes/Episodic policy, dated 04/12, read in part, Notify family and document . 1. Res #1 was admitted with diagnoses which included pseudobulbar affect, dementia and hypertension. A progress note, dated 08/20/22, documented Res has rash to abdomen, breast appears to have pustule and resident has been itching. A physician's order, dated 08/20/22, documented permethrin cream 5% (used to treat scabies), apply to entire body one time for rash. A quarterly assessment, dated 10/16/22, documented Res #1 was severely impaired in cognition and required moderate assistance with activities of daily living. On 12/29/22 at 10:55 a.m., Res #1 was observed in the lobby. Res was not interviewable. Upon record review, no documentation of family notification of the new medication or diagnoses was found. 2. Res #2 was admitted with diagnoses which included malnutrition, dementia, and diabetes mellitus. A progress note, dated 08/23/22, read in parts, resident c/o severe itching to her upper chest and abdomen. Noted to have a red rash to her chest, back, abdomen, pubic area, thighs, buttocks . Call out to Dr. (name withheld) to update. See new orders. A physician's order, dated 08/24/22, documented permethrin 5% apply from neck to toes topically one time only. A quarterly assessment, dated 11/17/22, documented Res #2 was moderately impaired in cognition and required moderate assistance with activities of daily living. On 12/29/22 at 10:40 a.m., Res #2 was observed in the lobby sitting in a chair. On 12/29/22 at 11:05 p.m., Res #2's family member reported the facility had not contacted them regarding the new medication or diagnoses of scabies. On 12/29/22 at 11:10 a.m., the DON reported the facility had not reported to Res #1's or Res #2's family of the new diagnoses or new medication. The DON reported the family should have been notified. On 12/29/22 at 11:20 a.m., the corporate nurse reported the family should have been notified of the new diagnoses and new medication.

Based on observation, interview, and record review, it was determined the facility failed to conduct assessments which accurately reflected the residents' current status for three (#25, 36, and #63) of 19 residents whose assessments were reviewed. The facility failed to accurately assess for: a. anticoagulant use for resident #25. b. the presence of a serious mental illness related to the preadmission screening and resident review (PASRR) level II evaluation for resident #36 and #25. c. a gradual dose reduction for resident #63. The director of nursing (DON) identified 76 residents who resided in the facility. Findings: 1. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An active physician order, dated 08/30/18, documented to administer [MEDICATION NAME] (an anticoagulant medication) to the resident for a [DIAGNOSES REDACTED]. An annual assessment, dated 06/06/19, documented the resident was intact in cognition, required limited assistance with activities of daily living, and did not walk. The assessment documented the resident was not considered by the state level II PASRR to have a serious mental illness. The assessment did not document the resident had received an anticoagulant medication. A quarterly assessment, dated 12/05/2019, documented the resident did not receive an anticoagulant medication. On 02/21/20 at 8:51 AM, the resident was observed sitting on his wheel chair in his room. He stated he had problems with depression but took medication for it and it helped. On 02/24/20 at 5:07 PM, the minimum data set (MDS) coordinator confirmed she did not code the annual assessment correctly for the presence of a serious mental illness according to the state level II PASRR. On 02/25/20 at 11:06 AM, the MDS coordinator stated she did not know [MEDICATION NAME] was an anticoagulant. She confirmed she had not coded the assessments to include an anticoagulant. 2. Resident #36 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 06/17/19, documented the resident was intact in cognition and independent or requiring supervision with activities of daily living. The assessment documented the resident was not considered by the state level II PASRR process to have a serious mental illness. On 02/26/20 at 10:23 AM, the minimum data set (MDS) coordinator confirmed the admission MDS had been coded incorrectly. On 02/26/20 at 11:00 AM, the resident was observed sitting in a wheelchair. She stated she was satisfied with the care she received in the facility. 3. Resident #63 was admitted to the facility with [DIAGNOSES REDACTED]. A medication regimen review (MRR), dated 09/16/19, documented a request to reduce [MEDICATION NAME] (an antipsychotic medication) 2.5 milligrams (mg) in the morning and 5 mg in the evening. A physician order, dated 10/19/19, documented to administer [MEDICATION NAME] 5 mg in the morning for a [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/25/20, documented the resident was severely impaired with cognition and required limited to extensive assistance with activities of daily living. The assessment documented an antipsychotic was received on a daily basis and a GDR had not been attempted or contraindicated. On 02/24/20 at 2:26 PM, the resident was observed lying awake in bed. She was unable to be interviewed. On 02/24/20 at 4:54 PM, the minimum data set (MDS) coordinator stated she missed the GDR for [MEDICATION NAME] and the quarterly assessment was coded wrong.

Based on observation, interview, and record review, it was determined the facility failed to develop comprehensive person-centered care plans for three (#25, 42, and #61) of 19 sampled residents whose care plans were reviewed. The facility failed to care plan: a) anticoagulant use for residents #25 and #61. b) antianxiety, antidepressant, [MEDICAL CONDITION], and diuretic medication use and the related [DIAGNOSES REDACTED]. The director of nursing identified 76 residents who resided in the facility. Findings: 1. Resident #42 had [DIAGNOSES REDACTED]. An active physician order, dated [DATE], documented to administer [MEDICATION NAME] (a diuretic medication) for localized swelling. An active physician order, dated [DATE], documented to administer [MEDICATION NAME] (an antidepressant medication) for dysthymic disorder. An active physician order, dated [DATE], documented to administer [MEDICATION NAME] (a hormone supplement) for [MEDICAL CONDITION]. An active physician order, dated [DATE], documented to administer [MEDICATION NAME] (an anxiolytic medication) for anxiety. An active physician order, dated [DATE], documented to administer [MEDICATION NAME] (an antidepressant medication) for dysthymic disorder. A quarterly assessment, dated [DATE], documented the resident was cognitively intact and independent with most activities of daily living. The assessment documented the resident received antianxiety, antidepressant, and diuretic medications. On [DATE] at 8:31 AM, the resident stated her dog, who had lived with her in the facility, died last October and her depression increased at that time. On [DATE] at 5:32 PM, the care plan coordinator stated the resident did not have a care plan for anxiety, depression, [MEDICAL CONDITION], or diuretic use. 2. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An active physician order, dated [DATE], documented to administer [MEDICATION NAME] (an anticoagulant medication) to the resident for a [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident was intact with cognition and did not receive an anticoagulant medication. The resident's care plan was reviewed and did not document an anticoagulant plan of care. On [DATE] at 8:51 AM, the resident was observed sitting on his wheel chair in his room. He stated he had problems with depression but took medication for it and it helped. On [DATE] at 11:23 AM, the care plan coordinator reviewed the resident's care plan and stated it did not include a plan for the resident's use of an anticoagulant. She confirmed the resident should have had a care plan developed related to anticoagulant usage. 3. Resident #61 had [DIAGNOSES REDACTED]. A physicians order, dated [DATE], documented Eliquis five milligrams two times a day. A quarterly assessment, dated [DATE], documented the resident was severely impaired with cognition and required extensive assistance with most activities of daily living. The assessment documented the resident received an anticoagulant medication. A review of the resident's care plan did not contain information the resident was on an anticoagulant medication. On [DATE] at 8:52 AM, the resident was observed lying on her bed and no bruising or bleeding observed. On [DATE] at 3:19 PM, the care plan coordinator stated the only thing she could find on the care plan was the resident had a [MEDICAL CONDITION]. She stated monitoring for anticoagulant use was not on the care plan.

Based on observation, interview, and record review, it was determined the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) for two (#33 and #63) of four residents sampled for PASRR. The facility failed to: a) refer a resident with a possible serious mental illness for a state level II PASRR for resident #63. b) obtain a PASRR level II for resident #33. The director of nursing (DON) identified 76 residents who resided in the facility. Findings: 1. Resident #63 was admitted to the facility with [DIAGNOSES REDACTED]. A PASRR level I screening assessment, dated 08/25/19, documented the resident did not have a serious mental illness. An admission assessment, dated 08/28/19, documented the resident was not currently considered by the state level II PASRR process to have a serious mental illness. The assessment documented the resident was severely impaired in cognition and required supervision to extensive assistance with activities of daily living. On 02/21/20 at 4:21 PM, the assistant director of nursing (ADON) stated she used to do the level I PASRR evaluations but was not doing them correctly. She confirmed this resident should have been referred for an evaluation for a state level II PASRR due to her [DIAGNOSES REDACTED]. On 02/24/20 at 2:26 PM, the resident was observed lying awake in bed. She was unable to be interviewed. 2. Resident #33 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A PASRR level I screening evaluation, dated 06/11/18, documented the resident had a [DIAGNOSES REDACTED]. The assessment documented the resident had evidence of possible mental [MEDICAL CONDITION] or related condition. The assessment documented the resident had a PASRR II completed 04/24/18. A quarterly assessment, dated 12/11/19, documented the resident was cognitively intact and was independent with most activities of daily living. The assessment documented the resident had no behaviors. The assessment documented the resident received antipsychotic and antidepressant medications. On 02/24/20 at 3:47 PM, the DON stated the resident had a PASRR II but the facility did not have a copy. On 02/24/20 at 3:54 PM, corporate registered nurse (RN) stated she spoke with a worker at the Department of Human Services (DHS) and the resident had a PASRR level II with no specialized services required. She said they do not have the PASRR in the facility but are working on getting the document.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident with an indwelling catheter received the appropriate care and services to prevent urinary tract infections for one (#71) of one resident sampled for indwelling urinary catheters. The facility failed to ensure the resident's catheter bag was kept off the floor. The director of nursing (DON) identified three residents in the facility who had catheters. Findings: Resident #71 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 01/25/20, documented the resident was severely impaired with cognition, required total assistance with activities of daily living, and had a urinary catheter. On 02/21/20 at 9:40 AM, the resident's catheter bag was observed touching the floor. On 02/21/20 at 10:30 AM, the resident's catheter bag was observed on the floor. On 02/24/20 at 8:50 AM, the resident was observed in the bed with the catheter bag on the floor. On 02/25/20 at 11:00 AM, the resident's catheter bag was observed lying on the floor. On 02/27/20 at 10:37 AM, the administrator and DON confirmed the catheter bag should not have been on the floor.