Every finding on record at Oklahoma Memory Care Institute

Based on record review and interview, the facility failed to offer residents a choice to formulate an advance directive for 3 (#18, 36 and #37) of 3 sampled residents reviewed for advance directive acknowledgements. The administrator identified 35 residents resided at the facility. Findings: A policy titled Advance Directives, dated 11/2022, read in part, 1. The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. 2. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 1.An annual assessment for Resident #36, dated 07/07/26, showed a BIMS score of 3, which indicated the resident was severely cognitively impaired for daily decision making. The assessment showed a diagnosis of dementia. A care plan for Resident #36, revised 07/07/26, showed the resident had a DNR and no advance directive. The care plan did not show an advance directive had been offered. There was no documentation in the clinical record to show Resident #36 had been offered a choice to formulate an advance directive. 2.An annual assessment for Resident #18, dated 07/07/26, showed a BIMS score of 3, which indicated the resident was severely cognitively impaired for daily decision making. The assessment showed a diagnosis of dementia. A review of the clinical record for Resident #18 showed the advance directive acknowledgement form was blank and there was no documentation to show it had been reviewed with the resident or representative. 3.An admission assessment for Resident #37, dated 08/24/26, showed a BIMS score of 3, which indicated the resident was severely cognitively impaired for daily decision making. The assessment showed a diagnosis of dementia. There was no documentation in the clinical record to show Resident #37 had been offered a choice to formulate an advance directive. On 08/25/26 at 3:30 p.m. the DON stated each resident should have an advance directive acknowledgment form completed and was uncertain as to why the completed forms were not in the residents' records.

Based on observation, record review, and interview, the facility failed to ensure a resident's room was not used to store facility equipment for 1 (#28) of 40 sampled resident rooms reviewed for homelike environment.The administrator identified 35 residents resided in the facility. On 08/27/26 at 10:55 a.m., two mechanical lifts were observed to be stored in a room [ROOM NUMBER] where Resident #28 resided.A policy titled Means of Egress - Corridors and Exits, revised 08/27/26, read in part, Lift equipment shall be stored in storage area of Hall 2.A policy titled Homelike Environment, dated 02/2021, read in part, Residents are provided with a safe, clean, comfortable and homelike environment.On 08/27/26 at 10:56 a.m., LPN #1 observed room [ROOM NUMBER] and stated Resident #28 resided in the room. They stated mechanical lifts should not have been stored in the room. LPN #1 stated the lifts did not create a homelike environment.On 08/27/26 at 10:58 a.m., the DON stated storing mechanical lifts in a resident's room did not create a homelike environment and created opportunity for accidents.

Based on record review and interview, the facility failed to ensure a discharge summary was completed 1 (#41) of 2 sampled residents reviewed for discharge. The administrator identified 35 residents resided in the facility. The clinical record for Resident #41 showed the resident admitted on [DATE] and discharged on 06/03/26. The record showed diagnoses which included Alzheimer's disease and vascular dementia with severe agitation. A progress note for Resident #41, dated 06/03/26, showed the resident discharged to home by an outside transport. The note showed all of the resident's items were placed back in their suitcase. The note showed a medication list and remaining medications were sent with the resident. The note showed a resident skin assessment was completed and the skin was intact. The note showed family was notified of Resident #41's transport home. A discharge assessment for Resident #41, dated 06/03/26, showed the resident was discharged as return not anticipated. The assessment showed Resident #41 had an active discharge plan and had no referrals to local agencies due to their request. A care plan for Resident #41, dated 06/01/26, showed a comprehensive plan had not been developed. There was no documentation to show a discharge summary had been completed for Resident #41. On 08/26/26 at 2:02 p.m., the DON stated the discharge summary should have been completed when Resident #41 discharged . They stated it should have included where they were going, how they left, who accompanied them, if referrals to community agencies were made, reason for discharge, their clothing and valuables were received by them, a physical evaluation, mental function at discharge, any physical impairments, the resident's nutritional status, psychosocial status, mental status, and protentional for rehabilitation. The DON stated a discharge order was required before discharge from the facility. They stated each department should have been involved in the discharge summary. The DON stated Resident #41 did not have a discharge summary.

Based on observation, record review, and interview, the facility failed to ensure all components of the daily staffing information was posted and was readily accessible to residents and visitors for 5 of 5 staffing board observations. The administrator identified 35 residents resided in the facility. Findings:On 08/25/26 at 8:46 a.m., observation of the staffing assignment board did not show the facility name, titles of all direct care staff, total or actual hours worked by each direct care staff member, or resident census.On 08/25/26 at 4:12 p.m., observation of the staffing assignment board did not show the facility name, titles of all direct care staff, total or actual hours worked by each direct care staff member, or resident census.On 08/26/26 at 8:00 a.m., observation of the staffing assignment board did not show the facility name, titles of all direct care staff, total or actual hours worked by each direct care staff member, or resident census.On 08/26/26 at 3:45 p.m., observation of the staffing assignment board did not show the facility name, titles of all direct care staff, total or actual hours worked by each direct care staff member, or resident census.On 08/27/26 at 8:49 a.m., observation of the staffing assignment board did not show the facility name, titles of all direct care staff, total or actual hours worked by each direct care staff member, or resident census.Daily staffing sheets, dated 06/01/26 to 08/27/26, did not show the titles of all direct care staff or resident census.On 08/27/26 at 8:25 a.m., the ADON stated the daily staffing information was posted on a whiteboard at the nurses' station. They stated they were responsible for filling out the daily staffing sheets. The ADON stated the daily staffing sheets were in a binder in the nurses' station. They stated the staffing assignment board did not show the facility name, titles of all direct care staff, total or actual hours worked by each direct care staff member, or resident census.On 08/27/26 at 9:37 a.m., the DON stated the staffing assignment board did not show the facility name, titles of all direct care staff, total or actual hours worked by each direct care staff member, or resident census.On 08/27/26 10:23 a.m., the ADON reviewed daily staffing sheets and confirmed the resident census number was not documented on the sheets. They stated staffing could not be confirmed safe or adequate without the resident census number.

Based on observation, record review, and interview, the facility failed to ensure medication carts were kept locked and secured when unattended for 1 of 2 medication carts observed.The administrator identified 35 residents received medication in the facility. Findings:On 08/27/26 at 11:06 a.m., CMA #1 was observed to leave the medication cart unlocked and unattended and enter the medication room.On 08/27/26 at 11:07 a.m., CMA #1 was observed to return to the medication cart.A policy titled Security of Medication Cart, revised 04/2007, read in part, Medication carts must be securely locked at all times when out of the nurse's view.When the medication cart is not being used, it must be locked.On 08/27/26 at 11:07 a.m., CMA #1 stated they should not have left the medication cart unlocked while unattended.On 08/27/26 at 11:09 a.m., the DON stated medication and treatment carts were to be locked at all times when not in use.

Based on record review and interview, the facility failed to ensure psychotropic medication was discontinued as ordered for 1 (#30) of 5 sampled residents reviewed for unnecessary psychotropic medications. The administrator identified 29 residents received psychotropic medications in the facility. Findings:A physician's order for Resident #30, dated 08/25/26, showed to administer lorazepam (Ativan) (anti-anxiety medication) 0.5 mg daily for anxiety disorder. GDR documentation, dated 11/17/25, showed lorazepam (Ativan) 0.5 mg daily to be discontinued. The documentation was signed by the previous DON, the pharmacist, and the medical director.A provider note for Resident #30, dated 11/25/25, read in part, Patient currently on buspirone, Ativan, mirtazapine, trazodone, sertraline for depression anxiety. Patient is stable. Will DC [discontinue] Ativan and monitor behavior.Medication administration records for Resident #30, dated 11/17/25 to 08/25/26, showed the resident had received lorazepam (Ativan) 0.5 mg daily.Narcotic count sheets for lorazepam (Ativan) 0.5 mg for Resident #30, dated 11/17/25 to 08/25/26, showed the resident received lorazepam (Ativan) 0.5 mg daily.A care plan for Resident #30, revised 06/23/26, showed no documentation of discontinuation of lorazepam (Ativan).On 08/26/26 at 2:12 p.m., the DON reviewed the GDR report for Resident #30, dated 11/17/25. The DON stated the lorazepam (Ativan) should have been discontinued. The DON reviewed Resident #30's active orders as of 08/26/26 and stated the lorazepam (Ativan) had not been discontinued. They stated Resident #30 had received the psychotropic medication after the provider ordered the medication to be discontinued.

Based on record review and interview, the facility failed to maintain an abuse free environment for 3 (#2, 3, and #4) of 5 sampled residents reviewed for abuse. The administrator identified 38 residents resided in the facility. Findings:A facility policy titled Abuse, Neglect and Exploitation, implemented 01/2026, read in part, The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse.1. A quarterly assessment for Resident #2, dated 01/09/26, showed the resident had a BIMS score of 3, which indicated the resident was severely impaired in cognition, and utilized a manual wheelchair for mobility.A nurse's progress note for Resident #2, dated 02/20/26, showed CNA #1 reported Resident #2 was on the floor in a resident's room. The progress note showed CNA #1 observed Resident #1's walker outside of the room and when CNA #1 attempted to enter the room, they met some resistance from a wheelchair pushed against the inside of the door. The progress note showed CNA #1 observed Resident #1 attempting to remove the shirt off Resident #2. CNA #1 pulled the shirt back in place, separated the residents, and called for assistance. The progress note showed LPN #1 entered the room and escorted Resident #1 back to the common area. LPN #1 described Resident #1's mentation as at baseline, confused, with the resident not knowing where they were and what they had done. The progress note showed Resident #2 was initially anxious but calmed quickly and returned to their baseline. On 03/11/26 at 5:25 p.m., CNA #1 stated they observed Resident #1's walker outside of a resident's room. CNA #1 stated they entered the room and observed Resident #1 sitting on the bed with Resident #2 sitting on the floor and Resident #1 holding onto the waistband of Resident #2's pants, at the hip, and pulling downward, exposing the edge of Resident #2's underwear. CNA #1 stated Resident #2's hip was barely exposed and when they asked Resident #1 to stop, they did. CNA #1 stated there was a wheelchair, an oxygen concentrator, and a walker which was purposefully spread in a crescent shape around Resident #2. CNA #1 stated they kept the two residents separated and called for assistance. CNA #1 stated LPN #1 escorted Resident #1 from the room without incident. CNA #1 stated a short time later, neither resident was upset. CNA #1 stated the facility staff closely monitored Resident #1. CNA #1 stated they received training on abuse, neglect, and working with residents diagnosed with dementia. On 03/16/26 at 12:45 p.m., the DON stated they were notified CNA #1 found Resident #1 and Resident #2 barricaded in a resident's room with Resident #1 attempting to remove clothing from Resident #2. The DON stated they placed Resident #1 on close supervision and started screening residents, asking if they saw or experienced abuse at the facility, and if they felt safe in the facility. 2. A comprehensive assessment for Resident #3, dated 02/12/26, showed the resident had a BIMS score of 00, which indicated they were severely impaired in cognition, and was completely dependent with activities of daily living. A nurse's progress note for Resident #3, dated 03/03/26, showed LPN #1 was notified by CMA #1 that while they were in Resident #3's room administering medications to their roommate, they overheard CNA #2 and CNA #3 working with Resident #3. The progress note showed CMA #1 claimed to have overheard the two CNAs refer to Resident #3 in a derogatory manner. The progress note showed LPN #1 and LPN #2 assessed Resident #3 and determined the resident was frightened and had several small, round shaped, bruises measuring approximately one to two centimeters and had two crescent shaped skin tears to their right forearm.On 03/11/26 at 4:35 p.m., LPN #1 stated they, along with LPN #2, assessed Resident #3. LPN #1 stated they found the resident to be very tense with their arms drawn in toward themselves. LPN #1 stated Resident #3 had bruising about the size of fingertips and two crescent shaped skin tears similar in shape and size to the curve of a fingernail. On 03/11/26 at 5:00 p.m., CMA #1 stated they were in the room of Resident #2, next door to Resident #3, when they overheard CNA #4 refer to Resident #3 in a derogatory manner. CMA #1 stated they returned to their medication cart, gathered the medications for Resident #3's roommate, and entered Resident #3's room. CMA #1 stated the two CNAs were no longer in the room and CMA #1 checked on both residents. CMA #1 stated Resident #3 usually laughed when they entered the room but instead, Resident #3 was tense with their back straight and arms drawn tightly into the body. CMA #1 stated they asked Resident #3 if the CNAs who were just in the room hurt them and Resident #3 responded yes. CMA #1 stated Resident #3 was rarely verbal but would sometimes answer with one- or two-word responses. CMA #1 stated they reported what they overheard and observed to their charge nurse. 3. The quarterly assessment for Resident #4, dated 02/19/26, showed the resident had a BIMS score of 3, which indicated the resident was severely impaired in cognition, and was dependent in activities of daily living. A state reportable incident report, dated 03/03/26, read in part, [CNA #3] stated [they] witnessed [CNA #2] 'pop' [Resident #4] on [their] arm/hand after resident hit [CNA #2] after changing. The incident report showed CNA #2 stated they only tapped Resident #4 on the wrist four times because Resident #4 allegedly grabbed CNA #2 by their waist and chest.On 03/16/26 at 12:44 p.m., the DON stated when the allegation of abuse toward Resident #4 was made, the nurse assessed Resident #4 and no injuries were noted.On 03/16/26 at 12:45 p.m., the DON stated on 03/03/26, the charge nurse contacted them and reported an allegation of abuse against CNA #2 and CNA #3. The DON stated they immediately returned to the facility and started their investigation. The DON stated during the investigation, they interviewed CNA #2 and CNA #3 separately. The DON stated neither CNA knew who came forward with the allegation of abuse toward Resident #3. The DON stated when they interviewed CNA #3, the CNA accused CNA #2 of abusing Resident #4. The DON stated both CNAs turned on each other and accused the other of abuse towards residents, but neither could answer why they had not reported the abuse to their charge nurse. The DON stated the two CNAs were terminated because of the allegations of abuse and not following the facility's abuse policy.

Based on record review and interview, the facility failed to perform a background check for 1 (PCW #1) of 1 personal care worker contracted by a family to care for an individual resident. The DON identified one resident whose family contracted a private sitter.Findings:A facility policy titled Abuse, Neglect and Exploitation, implemented 01/2026, read in part, Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants.On 03/18/26 at 10:20 a.m., PCW #1 stated they were a home health aide contracted with the family of Resident #5 to provide care and company to Resident #5. PCW #1 stated they worked with Resident #5 for several years and continued to work with them when they moved to the facility in September of 2025. On 03/18/26 at 11:00 a.m., the DON stated they were not aware the facility needed to perform a background check on someone contracted by the family to provide care to a particular resident and doubted the facility had performed a background check on PCW #1. On 03/18/26 at 11:30 a.m., corporate nurse #1 stated the facility had not performed a background check on PCW #1. The corporate nurse reviewed the facility policy and stated they did not follow the screening portion of their policy.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 01/30/25 related to the facility's failure to supervise and prevent a resident from elopement. The facility failed to prevent Resident #1 from eloping from the facility which had the potential to result in serious injury or harm. On 02/11/24, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to protect and prevent accident hazards related to elopement. The past noncompliance IJ was removed effective 01/31/25 after the facility put measures in place to prevent recurrence. On 01/31/25 compliance rounds were initiated, the quality assurance committee met, an inservice on elopement risk and documentation of hourly rounds were completed by all direct care staff, outside window locks were replaced by locks that allowed limited opening, Based on observation, record review, and interview, the facility failed to provide supervision to prevent elopement for 1 (#1) of 3 sampled residents reviewed for supervision. The administrator identified 47 residents in the facility. Findings: Resident #1 had diagnoses which included dementia. A Medicare admission assessment, dated 01/15/25, showed the resident was severely impaired for daily decision making. A progress note, dated 01/29/25 at 8:31 p.m., showed the resident had barricaded their door with a chair. A progress note, dated 01/30/25 at 7:30 a.m., showed the facility received a phone call from a local hospital inquiring if Resident #1 was a resident at the facility. A final incident report, dated 01/31/25, showed after an investigation the facility determined the resident was last seen in the facility on 01/29/25 at 10:30 p.m. The window in the resident's room was found to be opened and the screen removed. The report showed Resident #1 was picked up by an ambulance service at a convenience store on 01/30/25 at 1:29 a.m. and transported to a local hospital. The hospital found Resident #1 to be uninjured and the resident was returned to the facility at 8:55 a.m. where the resident was placed on continuous supervision. Resident #1 was sent to a local hospital for a psychological evaluation at 12:21 p.m. at the request of resident's guardian. Resident #1 returned to the facility at 7:30 p.m. that day and was kept on continuous supervision with a sitter in their room. Resident #1 was discharged from the facility on 1/31/25 at 1:32 p.m. for further psychological evaluation. On 02/03/25 at 10:42 a.m., the administrator stated the two staff members who failed to round on the resident were terminated and all other staff were immediately educated regarding making hourly rounds. The administrator stated a new system for hourly documented rounds was initiated that day and new locks were ordered for all outside windows. The administrator stated the new locks allow for a limited opening of all outside windows. The administrator stated the locks were installed on 01/31/25. The administrator stated the locks were monitored weekly by the maintenance staff and they also monitored with their own check of the windows. The administrator stated the director of nursing monitored the hourly rounds by staff, and all were reviewed at the facility quality assurance meeting. Documentation of the monitoring, education of staff, and review by the quality assurance committee was provided.

Based on record review and interview, the facility failed to report injuries of unknown origin to required agencies for one (#1) of three sampled residents who were reviewed for injuries of unknown origin. The DON identified 47 residents resided at the facility. Findings: Resident #1 had diagnoses which included vascular dementia, anxiety, and frequent falls. A review of incident reports for Resident #1 revealed two incident reports for injuries of unknown origin on 10/26/24 and 12/10/24. Both were bruising, first to the temple and then to the right upper thigh. Review of state reports revealed the injury of unknown origin, dated 01/16/25, for a right subcaptial femoral neck fracture (a fracture that occurs in the neck of the femur, specifically at the junction where the femoral head meets the neck), was reported to OSDH on 01/17/25. No state reports were located for the 10/26/24 and 12/10/24 injuries of unknown origin. On 01/29/25 at 3:00 p.m., CNA #1 stated they reported falls, wounds, skin tears, pain, soreness, and red and purple bruises to the nurse. On 01/29/25 at 3:05 p.m., LPN #1 stated when they received reports of injuries of unknown origin, they checked the resident, provided care, and notified the DON, physician, and resident representative(s). On 01/29/25 at 3:20 p.m. the DON stated they reported to the state, falls with injuries, abuse allegations, and injuries of unknown origin. The DON stated they investigated and tried to determine how the injury occurred. On 01/29/25 at 3:27 p.m., the DON stated they had completed the risk management, but were unable to locate the state reports for 10/26/24 and 12/10/24. They stated they did not know why the state reports were not completed.

Based on observation, interview, and record review, the facility failed to ensure insulin was dated when opened for one (treatment cart #1) of two medication carts observed for medication storage. The DON identified four medication carts in the facility and five residents who were ordered insulin. Findings: An undated Labeling of Medications and Biologicals policy, read in part, .Labels for multi-use vials must include .The date the vial was initially opened or accessed . An undated Insulin Pen policy, read in part, .Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation . On 10/30/24 at 9:58 a.m., treatment cart #1 was observed with LPN #1. The following medications were observed to be opened and not dated. a. Lantus insulin vial for Resident #15; b. Fiasp flex touch pen for Resident #10; c. insulin aspart pen for Resident #27; d. insulin aspart pen and Basaglar pen for Resident #42; e. Levemir pen and insulin aspart for Resident #1; and f. glucose check strips. On 10/30/24 at 10:02 a.m., LPN #1 stated they did not know what date the above listed insulin vial, insulin pens, or glucose check strips had been opened. On 10/30/24 at 10:08 a.m., the DON reviewed the above listed insulin vial, insulin pens, and glucose check strips and stated staff were to date insulin and glucose check strips when they were opened. They stated medication/treatment carts were monitored monthly by the pharmacy consultant.

Based on record review and interview, the facility failed to ensure documentation was maintained that staff were educated and offered the COVID-19 vaccine for two of two employees reviewed for the COVID-19 vaccination. The COVID-19 Vaccination policy, dated 06/27/23, read in part, .The facility will maintain documentation related to staff COVID-19 vaccination and includes at a minimum: a. Education to the staff regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. The offering of the COVID-19 vaccine or information on obtaining the COVID-19 vaccine; c. The COVID-19 vaccine status of staff . On 10/31/24 at 3:03 p.m., the infection preventionist stated they did not have any documentation related to staff education of the COVID-19 vaccination for CNA #2. On 10/31/24 at 3:55 p.m., the administrator stated they did not have documentation for CNA #4 regarding staff education of the COVID-19 vaccination. On 10/31/24 at 4:08 p.m., the administrator stated they discussed the COVID-19 vaccination with new employees during orientation, but they did not maintain documentation of the education/information provided for any of the staff.

Based on observation, record review, and interview, the facility failed to ensure residents were treated with dignity by being called their preferred name for three (#18, 20, and #24) and failed to ensure dignity with dining for nine (#5, 10, 12, 15, 18, 26, 33, 34, and #44) of eight sampled residents who were reviewed for dignity. The DON identified eight residents who were dependent on staff for meals who ate in the dining room. Findings: An undated Promoting/Maintaining Resident Dignity During Mealtimes policy, read in part, .All staff will be seated, if possible, while feeding a resident . 1. On 10/28/24 at 8:21 a.m., the DON was observed to assist dependent residents with the morning meal in the dining room. The DON was observed to stand while assisting Resident #44, 33, and Resident #5. On 10/28/24 at 12:12 p.m., the DON was observed to assist dependent residents with the noon meal in the dining room. The DON was observed to stand while assisting Resident #18, 15, 26 and Resident #10. On 10/28/24 at 12:18 p.m., the ADON was observed to assist dependent residents with the noon meal in the dining room. The ADON was observed to stand while assisting Resident #12, 5, 33, and Resident #34. On 10/30/24 at 1:51 p.m., the DON stated the wheel chairs and geri chairs were too large for them to sit while assisting the residents with meals. The DON stated they should sit while assisting residents with meals to ensure dignity was maintained. 2. Resident #18 had diagnoses which included Alzheimer's disease. The Care Plan, dated 10/10/24, read in part, .Personal Preference Care Plan .I prefer to be address [sic] by being called [Resident's first name withheld] . On 10/29/24 at 1:36 p.m., CNA #1 stated to Resident #18, Take a bite grandma, in the common area of the facility. On 10/29/24 at 1:58 p.m., CNA #2 stated to Resident #18, Hold on momma, alright momma? 3. Resident #24 had diagnoses which included Alzheimer's disease. The Care Plan, dated 01/08/24, read in part, .Personal Preference Care Plan .I prefer to be address [sic] by being called [Resident's first name withheld] . On 10/29/24 at 1:55 p.m., CNA #2 stated to Resident #24, What you doing momma? 4. Resident #20 had diagnoses which included dementia. The Care Plan, dated 10/10/24, read in part, .Personal Preference Care Plan .My name is [Resident's first name withheld] . On 10/28/24 at 8:47 a.m., CNA #2 was observed to call Resident #20 momma while assisted them with the morning meal. On 10/29/24 at 11:42 a.m., LPN #1 stated to Resident #20, [NAME] I'm gonna put [their] on our face ok? [NAME], [NAME], we are gonna do your breathing treatment, okay? On 10/30/24 at 1:06 p.m., CNA#2 stated they addressed residents as sir or ma'am. CNA #2 stated it was a bad habit to call residents names other than their preferred name. They stated no residents had asked them to call them momma. On 10/30/24 at 1:09 p.m., CNA #1 stated they called Resident #18 'grandma' as a term of endearment, but should address the resident by their preferred name. On 10/30/24 at 1:18 p.m., LPN #1 stated '[NAME]' was not the preferred name for Resident #20. They stated staff should address residents by their preferred name. On 10/30/24 at 2:04 p.m., the DON stated staff were to address residents by their preferred name. 41809

Based on observation, interview, and record review, the facility failed to ensure residents were transferred safely with a mechanical lift for two (#21 and #18) of two sampled residents reviewed for mechanical transfers. The DON identified four residents who utilized a mechanical lift. Findings: 1. Resident #21 had diagnoses which included dementia, anxiety, and heart failure. A care plan for Resident #21, initiated 02/28/24, documented to transfer with two staff using the mechanical lift. On 10/28/24 8:04 a.m., CNA #2 entered the room of Resident #21 alone with the mechanical lift. On 10/28/24 at 8:29 a.m., CNA #2 opened the door to the room of Resident #21. The mechanical lift was observed in the room and the resident was observed to be in their wheel chair with the sling under them. On 10/30/24 at 1:37 p.m., CNA #2 stated Resident #21 was transferred using the mechanical lift. CNA #2 stated they did not transfer Resident #21 using two staff because the resident told them to go ahead and get him up without two staff. 2. Resident #18 had diagnoses which included Alzheimer's and dementia. A care plan focus for daily care, initiated 12/29/23, documented Resident #18 required two staff with the mechanical lift to transfer them. On 10/29/24 at 1:45 p.m., Resident #18 was observed to be taken to their room by CNA #2 after returning from the doctor with the lift sling under the them. On 10/29/24 at 1:47 p.m., CNA #2 left the room. On 10/29/24 at 1:52 p.m., CNA #2 was observed to enter the room of Resident #18 with the mechanical lift. On 10/29/24 at 1:58 p.m., the surveyor entered the room of Resident #18 and observed one staff. CNA #2 was observed to lower Resident #18 onto the bed. CNA #2 instructed Resident #18, Hold on momma, alright momma. On 10/30/24 at 2:00 p.m., the DON stated two staff were required for all mechanical lift transfers. They stated the staff had been in-serviced multiple times with no effect. The DON was asked the reason staff were not using two staff with mechanical lift despite in-services. They stated, I just keep in-servicing over and over again. 35474

Based on record review and interview, the facility failed to ensure assessments were accurate for one (#9) of one sampled residents reviewed for accuracy of assessments. The administrator identified 48 residents who resided in the facility. Findings: Resident #9 had diagnoses which included dementia. The admission assessment, dated 08/11/24, documented the resident was on an anticoagulant medication and was not on an antiplatelet medication. Review of the physician orders revealed the resident was on Plavix (an antiplatelet medication), but there was no documentation an anticoagulant medication had been ordered. On 10/30/24 at 11:31 a.m., the MDS coordinator stated the resident was on Plavix and they had coded the medication as an anticoagulant instead of an antiplatelet medication. On 10/30/24 at 12:59 p.m., the DON stated the corporate office reviewed the assessments for accuracy.

Based on observation, record review, and interview, the facility failed to ensure residents were monitored during nebulizer treatments for one (#20) of one sampled residents reviewed for respiratory care. The DON identified one resident who had orders for nebulizer treatments. An undated Nebulizer Therapy policy, read in part, .Observe resident during the procedure for any change in condition . Resident #20 had diagnoses which included chronic obstructive pulmonary disease. A physician order, dated 10/06/24, documented the resident was ordered ipratropium-albuterol (broncodilator) 0.5-2.5 (3mg/3ml) inhale every six hours. On 10/28/24 at 8:47 a.m., CNA #2 was observed to turn off the nebulizer machine and remove the nebulizer mask from Resident #20. On 10/29/24 at 11:42 a.m., LPN #1 was observed to prepare and administer ipratropium-albuterol via nebulizer to Resident #20. LPN #1 stated, Sometimes [they] keep it on, sometimes [they] won't when they placed the nebulizer mask on the resident. On 10/29/24 at 11:48 a.m., LPN #1 left the resident's room with the nebulizer mask in place. LPN #1 stated they normally left the nebulizer in place six or seven minutes then returned and removed it. On 10/29/24 at 12:05 p.m., Resident #20 was observed to hold the nebulizer mask in their right hand away from their face. On 10/29/24 at 12:12 p.m., LPN #1 returned to the resident's room and turned off the nebulizer machine. Resident #20 was observed to still hold the nebulizer mask in their right hand away from their face. On 10/30/24 at 1:27 p.m., LPN #1 stated they did not know how much of the medication the resident had received during the breathing treatment. They stated they had been informed on 10/29/24, after the breathing treatment for Resident #20, they were to stay in the room with the resident during breathing treatments to ensure the full treatment was received. On 10/30/24 at 1:59 p.m., the DON stated nurses were to stay with the residents for the entirety of nebulizer treatments.

Based on observation, record review, and interview, the facility failed to ensure a resident was accurately assessed for the safe use of bed rails for one (#98) of three sampled residents reviewed for bed rails. The DON identified four residents who had bed rails applied to their beds. Findings: An undated facility Proper Use of Bed Rails policy, read in part, Appropriate alternative approaches are attempted prior to installing or using bed rails .If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails . Resident #98 had diagnoses which included, Alzheimer's disease, dementia, and repeated falls. A review of falls for Resident #98 revealed a witnessed fall on 10/09/24, a witnessed fall on 10/16/24, an un-witnessed fall on 10/17/24, and an un-witnessed fall on 10/30/24 in their room during the hours of sleep. A Fall Risk Assessment, dated 10/23/24, documented Resident #98 was a high fall risk. A care plan, initiated 10/28/24, documented bed rails (two half rails), were added to Resident #98's bed for sacral wound, comfort, and mobility. A Bed Rail/Assist Bar Evaluation, dated 10/28/24, documented Resident #98 had no cognitive deficit and had no balance issues. On 10/31/24 at 11:57 a.m., CNA #3 stated Resident #98 transferred with one person assist and was independent for bed mobility. They stated Resident #98 had not fallen out of bed to their knowledge. On 10/31/24 at 12:02 p.m., LPN #2 stated Resident #98 transferred with one person assist and required some assistance with bed mobility. LPN #2 stated Resident #98 had fallen the night before and was on neuro checks. They stated bed rails were checked to ensure they were secure by staff and maintenance conducted a bed rail check. On 10/31/24 at 12:06 p.m., the ADON stated they thought Resident #98 was bed bound from the initial records received, but when Resident #98 was admitted they had tolerated the wheel chair well and was getting stronger. They stated the ADON, DON, and MDS nurses were responsible to complete bed rail/assist bar evaluations. The ADON stated they had completed the assessment for Resident #98. They stated they had been involved with the care for Resident #98 and so they knew what the resident could and could not do. The ADON was asked how they determined Resident #98 had no cognitive deficit. They stated they just took it as fluctuations of consciousness and Resident #98 was pretty baseline with everything. The ADON was asked how they determined Resident #98 had no balance issues. They stated, Just by [their] balance sitting up in the chair. The ADON stated Resident #98 had not had any falls out of bed since the bed rails were installed. They reviewed the clinical record and stated, Oh, [they] had one last night. On 10/31/24 at 12:16 p.m., the DON stated they and the ADON were responsible to ensure evaluations/assessments were completed accurately. They stated bed rails were utilized for Resident #98 to assist them with bed mobility. The DON stated Resident #98 could get up because the rails were quarter rails and the rails were mainly to assist the resident and keep them safe. The DON clarified the previous statement to keep Resident #98 from injury. The DON stated the IDT made the final determination for bed rails based on risk and benefits and if the bed rails were safe and not a potential accident hazard. The DON reviewed the bed rail/assist bar evaluation for Resident #98 and stated the assessment was not accurate. They stated they had not reviewed the bed rail/assist bar evaluation after it was completed by the ADON on Monday. The DON stated the bed for Resident #98 was changed to a bed with rails on Monday 10/28/24. On 10/31/24 at 12:28 p.m., the director of maintenance stated they installed the bed rails but, they did not perform continued safety checks. They stated they just checked them if they were informed the bed rails were loose, and then they tightened the bed rails. On 10/31/24 at 12:37 p.m., the bed rail on the resident's bed was observed. There was a gap of more than a hand's width between the mattress and the bed rail.

Based on observation and interview, the facility failed to ensure infection control was maintained during dining for two (morning and noon meal) of two meals observed. The DON identified eight residents who were dependent on staff for meals. On 10/28/24 at 8:27 a.m., the DON was observed to assist four residents with the morning meal. The DON was observed to pick up a biscuit with jelly with their bare hands and place it to a resident's mouth without sanitizing their hands. On 10/28/24 at 12:12 p.m., the ADON was observed to assist four residents with the noon meal. The ADON was observed to assist a resident with a drink by touching the straw then continue to assist other residents with their meal without sanitizing their hands. On 10/28/24 at 12:18 p.m., the DON was observed to pick up a dinner roll and hand it to a resident they were assisting without sanitizing their hands. On 10/30/24 at 1:51 p.m., the DON stated staff should not directly touch residents' food or straws with their bare hands.

Based on observation, interview, and record review, the facility failed to ensure ongoing monitoring and supervision of bed rails for one (#98) of one resident sampled for bed rails. The DON identified four residents who had bed rails. Findings: An undated facility Proper Use of Bed Rails policy, read in part, Appropriate alternative approaches are attempted prior to installing or using bed rails .If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails . Resident #98 had diagnoses which included, Alzheimer's disease, dementia, and repeated falls. On 10/31/24 at 12:16 p.m., the DON was asked what kind of assessment was done after the bed rails were applied. They stated a bed rail assessment was completed by the ADON. On 10/31/24 at 12:28 p.m., the director of maintenance stated they installed the bed rails, but they did not perform continued safety checks. They stated they just checked them if they were informed the bed rails were loose, and then tightened the bed rails. On 10/31/24 at 12:37 p.m., the bed rail on the resident's bed was observed. There was a gap of more than a hand's width between the mattress and the bed rail.

Based on record review and interview, the facility failed to provide financial quarterly statements for four (#2, 3, 4, and #5) of four sampled residents who had monies deposited in the facility's resident trust. The trust account balance statement, dated 10/15/24, documented 10 residents with funds deposited in the facility trust. Findings: 1. Resident #2 had diagnoses with included dementia and was listed on the trust account balance statement as having funds deposited in the facility's resident trust. 2. Resident #3 had diagnoses with included dementia and was listed on the trust account balance statement as having funds deposited in the facility's resident trust. 3. Resident #4 had diagnoses with included dementia and was listed on the trust account balance statement as having funds deposited in the facility's resident trust. 4. Resident #5 had diagnoses with included dementia and was listed on the trust account balance statement as having funds deposited in the facility's resident trust. On 10/16/24 at 3:45 p.m., the BOM stated they were somewhat new to their position and had forgot to provide quarterly financial statements to the residents and/or the residents' representative. The BOM stated none of the residents with funds deposited in the resident trust received an accounting of their monies.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent accidents for two (#43 and #26) of three sampled residents reviewed for falls. The facility failed to: a) Fully develop a comprehensive care plan related to fall prevention for the residents. b) Complete a thorough analysis and investigation after each fall to determine the underlying cause of the falls for the residents. c) Implement resident specific interventions to prevent further falls for the residents. d) Provide the necessary staff supervision to prevent avoidable falls for the residents. Resident #43 fell , hit his head, and sustained a laceration requiring sutures. The facility identified 27 residents fell in the last three months. Findings: The facility policy and procedures for fall prevention documented the facility was committed to fall prevention and a culture of safety. The policy documented prevention of falls involved all staff and departments. The policy documented ongoing education for staff, families, and residents to address effective interventions. The policy documented staff would be trained at the time of hire and annually regarding fall risk factors and how to prevent them. The policy documented a fall risk assessment was used at the time of admission, quarterly, and after each fall to identify the risk for falls and assure care plans were current. The policy documented a care plan would be implemented for residents who were at high risk for falls. The policy documented if a resident scored high on the falls assessment tool, a yellow leaf or other identifier would be placed on their wheelchair or walker, and above the resident's bed. The policy documented falls were to be reported and an investigation done by the charge nurse to determine causes and interventions. The policy documented the purpose of the investigation was to determine root causes for falls. 1. Resident #43 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment, dated 10/05/18, documented the resident was high risk for falls. The significant change assessment, dated 10/16/18, did not document the resident was at risk. The quarterly assessment, dated 01/16/19, documented the resident was severely impaired for daily decision making; had no [MEDICAL CONDITIONS], or behaviors; required extensive to total assistance with the activities of daily living (ADLs); and was always incontinent of bowel and bladder. The assessment documented the resident was not steady, only able to stabilize with staff assistance, and used a wheelchair. The assessment documented the resident had two or more falls since admission. The assessment documented medications included antianxiety, antidepressant, and opioid. The assessment documented the resident received hospice care. The care plan, dated 01/21/19, did not document the resident was at risk for falls. Incident reports documented the resident had multiple falls between (MONTH) (YEAR) and (MONTH) 2019. The incident reports did not document investigations were completed. Incident reports for (MONTH) 2019 documented the resident had 11 falls. The incident reports did not document completed fall analysis and investigations for the falls. The resident's care plan was not updated to include falls. The previous care plan was not updated to identify the resident was at risk for falls. A nurse note, dated 06/26/19 at 14:30 PM, documented hospice delivered a scoop chair as an intervention to reduce falls. The note documented the resident was transferred to the scoop chair. An incident report, dated 07/10/19, documented the resident was found on the floor next to the bed. The incident report did not document investigations were completed and the care plan was not updated to include falls. An incident report, dated 07/12/19, documented the resident attempted to get out of the chair and fell on to the floor, hitting his head. The report documented the resident sustained [REDACTED]. The incident reports did not document investigations were completed and the care plan was not updated to include falls. A Morse Fall Scale, dated 07/13/19, documented the resident was high risk for falling. A care plan, dated, 07/15/19, documented the resident had seven falls between 05/27/19 and 07/12/19. The care plan had inappropriate interventions for the cognitively impaired resident. On 08/18/19 at 5:50 PM, resident was sitting in a scoop chair in the dining area. On 08/19/19 at 9:15 AM, the resident was sitting in a scoop chair in his room taking a nebulizer treatment. The resident was leaning to the left side of the chair. At 9:25 AM, the resident still had the nebulizer mask on his face with a dry chamber. On 08/19/19 at 9:45 AM, the resident was sitting in a scoop chair in the common area with other residents during an activity group. On 08/19/19 at 11:45 AM, the resident was sitting in a scoop chair in dining area receiving assistance with his noon meal. On 08/21/19 at 1:00 PM, the resident was in common area with peers during a group activity. On 08/22/19 at 10:45 AM, the resident was sitting in scoop chair in front of the nurses desk in the common area. 08/22/19 11:00 AM, certified nurse aide (CNA) #1 stated she felt the resident fell due to the medications he had been on. She stated after his medications were changed the resident appeared to be more alert and had fallen less. 08/22/19 11:46 AM, registered nurse (RN) #1 stated she knew a resident was a high risk for falling from the risk assessment done at the time of admission, and if they had fallen prior to admission. She stated when a resident fell , it was communicated to the next shift. She stated interventions were put into place if a resident was a fall risk. She stated some of the interventions used for a fall risk resident included a fall mat, assistance with transfers, proper shoes, gripper socks, and rounding every two hours. She stated the resident was a high risk for falls. She stated she felt the resident's falls in (MONTH) were related to his dementia, hallucinations, and he thought he needed to get up. She stated the resident did not sleep well at night. She stated the resident was placed where staff could observe him. She stated the resident was sleeping a lot, a medication change was made and he was now more alert. She stated the resident's dementia was progressing. She stated the resident used to be able to use the call light. She stated a resident's needs were communicated, specifically a fall risk, to new aides, certified medication aides, and nurses. She stated at one time a binder of interventions to prevent falls was in the facility, but she did not know where the binder was located. She stated the newly hired CNAs were educated on who was at risk for falls and how to care for them. She stated CNA #1 was the lead CNA and educated new CNAs. She stated the facility had a falling star program to alert staff a resident was a fall risk. On 08/22/19 at 12:25 PM, the resident did not have a falling star on his door. On 08/22/19 at 12:15, the director of nurses (DON) stated the cause of falls was determined after reading the incident report. The DON stated the staff from all departments met to discuss interventions. The DON stated since she had been at the facility, there had been no root cause analysis completed for incidents. She stated there was no documentation to see the effectiveness of interventions. 2. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, dated 05/01/19, documented the resident was severely impaired and a high risk for falls. The care plan documented activities of daily living (ADL) care with interventions. The significant change assessment, dated 06/15/19, documented the resident was severely impaired for daily decision making and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident was frequently incontinent. The assessment documented the resident had two or more falls, one fall resulted in an injury since prior assessment. Incident reports for (MONTH) 2019, documented the resident had two falls. The incident reports did not document an investigation was completed. The resident's care plan did not document a new intervention for the falls. The physician orders [REDACTED]. Incident reports for (MONTH) 2019, documented the resident had six falls. The incident reports did not document investigations were completed for the falls. The resident's care plan documented new interventions were added after the falls but were not appropriate for the cognition of the resident. The incident report, dated 08/09/19, documented the resident was found on the dining room floor. The incident report did not document an investigation was completed. The resident's care plan had not been updated with a new intervention. On 08/18/19 at 5:15 PM, the resident was sitting in the dining in a wheel chair. The resident was clean, groomed and free of odor. The resident's daughter was assisting her with the evening meal. On 08/18/19 at 5:30 PM, the resident's daughter stated her mother had fallen several times at the facility. The daughter stated staff gave her the call light and told her to use it when she needed assistance. The daughter stated her mother was unable follow instructions due to her disease process. On 08/19/19 at 10:50 AM, the resident was provided peri care by certified nurse aides #1 and #2 (CNAs). The CNAs assisted the resident with getting dressed and out of bed. On 08/21/19 at 11:40 AM, LPN #2 stated she provided restorative care for the residents. The LPN stated she had not been able to do restorative care due to having to provide resident care on the floor. On 08/22/19 at 11:00 AM, LPN #2 stated resident #26 was not able to understand some of the interventions due to her cognition. 08/22/19 at 11:45 AM, registered nurse (RN) #1 stated the facility had a falling star program to alert staff the resident was a fall risk. RN #1 stated a resident who was considered a fall risk should have a star on their door. The RN stated the fall interventions in place for resident #26 were not appropriate due to the resident's cognition. On 08/22/19 at 12:25 PM, resident #26 did not have a star on her door indicating the resident was a fall risk.

Based on observation, interview, and record review, it was determined the facility failed to prevent the development and/or the worsening of avoidable pressure ulcers for three (#3, #38, and #44) of six sampled residents reviewed for pressure ulcers. The facility failed to: a) Notify the primary physician per policy for the development of a pressure ulcer for resident #3 and #44. b) Complete assessments and monitoring of skin and pressure ulcers for residents #3 and #44. c) Provide pressure ulcer treatments for residents #33 and #44. d) Provide preventative care for residents #38 and #44. Resident #44 was admitted in (MONTH) of (YEAR) and did not have a pressure ulcer on the left hip. In (MONTH) (YEAR) a stage III pressure ulcer measuring 4.0 centimeters (cm) by 2.0 cm was identified. On 07/16/18 the wound was observed and was measured. The wound measured 5.2 cm by 5.2 cm by 2.8 cm. A significant change assessment documented resident #3 did not have a pressure ulcer. A wound care evaluation documented the resident had developed a stage III pressure ulcer to the left lateral ankle and a stage II pressure ulcer to the right heel. A skin observation tool documented the resident had developed four stage II pressure ulcers to the coccyx. A nursing admission screen documented resident #38 was admitted to the facility with one stage I pressure ulcer to his coccyx. A skin assessment for resident #38 documented the resident developed a stage II pressure ulcer to the right heel measuring 6 cm by 3.5 cm. A skin observation tool documented the resident developed a stage I pressure ulcer to his buttocks measuring 5.0 cm by 5.0 cm. The tool documented the resident had a stage II pressure ulcer to his buttocks measuring 3.0 cm by 1.0 cm. The facility census and condition identified nine residents with pressure ulcers resided in the facility. Findings: The facility pressure ulcer/skin breakdown policy documented the nursing staff and physician would assess and document the resident's significant risk factors for developing pressure ulcers. The policy documented the nursing staff would document the contributing causes of skin breakdown, treatment and management of the wounds, and monitor the healing progress. 1. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing evaluation, dated 03/19/18, documented the resident had wounds and was totally dependent for activities of daily living (ADLs). The nursing evaluation documented the resident had a pressure ulcer on the coccyx measuring 1.0 cm by 0.5 cm by 0.5 cm. The hospice admission note, dated 03/19/18, documented the resident had a stage II sacral pressure ulcer measuring 1.0 cm by 0.3 cm by 0.2 cm. The note documented the resident had a suprapubic catheter and a [MEDICAL CONDITION], The facility care plan, dated 03/19/18, documented the resident was admitted with a stage II pressure ulcer on his coccyx. The care plan documented the resident's pressure ulcer was to be assessed, recorded, and monitored weekly. The wound was to be measured for length, width, and depth when possible. The care plan documented the resident was to be repositioned every two hours. The care plan documented the resident's nutritional status was to be monitored. The care plan documented improvement and decline of the pressure ulcer was to be reported to the physician. The hospice care plan, dated 03/19/18, documented the facility staff was to be instructed on how to assess and avoid skin breakdown. The care plan documented the staff was to turn and reposition the resident. The hospice care plan documented the buttock wound was to be cleansed with wet to dry dressing, pat dry, and apply Santyl to the wound bed. The ADL record, dated (MONTH) (YEAR), did not document repositioning of the resident 50 percent of the month. The treatment administration record (TAR) for (MONTH) (YEAR) did not document the application of zinc oxide ointment for the coccyx on 03/27/18 on the 11-7 shift. The ADL record for (MONTH) (YEAR) did not document the resident had been repositioned 60 percent of the month. The care plan, dated 04/04/18, documented the resident had a suprapubic catheter. The care plan documented the catheter was to be monitored for kinks and the amount of urine output. The ADL record for (MONTH) (YEAR) did not document the resident had been repositioned 62 percent of the month. The coordination of care note, dated 05/10/18, documented the resident had a newly developed wound on his left buttocks measuring 4.0 cm by 2.0 cm. The note documented the left buttock wound was cleansed and dried. The note did not document the physician was notified. The hospice physician order, dated 05/11/18 at 1:00 p.m., documented the resident was to lay down after breakfast and lunch to relieve pressure to the resident's stage III pressure ulcer on his buttock. The order documented the staff was to apply Silvadine ointment to the pressure ulcer twice daily till the wound was healed. The coordination of care note, dated 05/16/18, documented the pressure ulcer to the resident's left buttock measured 4.0 cm by 2.0 cm and a second wound measured 2.8 cm by 0.5 cm. The note documented the left buttock wound was cleansed, dried with gauze, medic-honey was applied, and the ulcer was covered with a bordered foam dressing. A physician order, dated 05/18/18, documented the resident was to be repositioned every two hours. The TAR for (MONTH) (YEAR) documented the dressing to the left buttocks was to be changed on Monday, Wednesday, and Friday by the hospice nurse and as needed by the facility staff. The TAR documented the dressing was changed on 05/30/18 by the facility nurse. The TAR did not document the completion of other scheduled dressing changes. The coordination of care note, dated 05/28/18, documented the left buttock wound measured 4.5 cm by 3.0 cm and had 80 percent slough. The coordination of care note, dated 05/30/18, documented the stage III pressure ulcer on left buttock measured 5.0 cm by 4.0 cm by 0.5 cm. The ADL sheet for (MONTH) (YEAR) did not document repositioning of the resident 60 percent of the month. The nurses note, dated 06/02/18 at 9:30 a.m., documented the resident's clothing was wet. The note documented urine was leaking from the suprapubic catheter. The hospice skilled nurse note, dated 06/01/18, documented the resident had a stage III pressure ulcer on his left buttocks. The note documented the wound had not healed and was worse. The note documented the resident was left up in the Broda chair for extended periods of time. The note documented the resident's brief was often saturated with urine from his leaking suprapubic catheter. The note documented the facility had received orders not to put a brief on the resident and to lay him down after meals. The note documented these orders were frequently not implemented. The coordination of care note, dated 06/04/18, documented the buttock wound was cleansed. The note documented an increase in vascular tissue and decrease in slough. The note documented crushed [MEDICATION NAME], CaAlgineat, and [MEDICATION NAME] were placed in the wound and covered with a dressing. The coordination of care note, dated 06/18/18 at 07:40 a.m., documented the buttocks wound had become worse. The note documented the wound was dark gray, had a foul odor, and slough was present. The note documented the physician was notified and orders were received to continue the Bactrim for another 30 days. The note documented the hospice physician had ordered zinc to be added to the wound care treatment. The note documented the physician ordered the hospice nurse to change the dressing daily. A physician order, dated 06/22/18, ordered the wound to be cleaned, pat dry, apply Santyl to wound bed, pack with moisten saline gauze, and covered with bordered foam gauze. The physician order [REDACTED]. The physician orders [REDACTED]. The coordination of care note, dated 06/24/18, documented the buttock wound was cleansed, packed with saline soaked gauze, and covered with a bordered foam dressing. The note documented the air flow mattress was completely deflated when the hospice aides arrived. The bed was unplugged from the electrical outlet. The note documented the dressing was dislodged and saturated with urine. The coordination of care note, dated 06/27/18, documented the buttock wound was 5.0 cm by 5.0 cm with orange size induration. The note documented the wound had 90 percent slough with small areas of beefy red tissue. The note documented the dressing was soiled and dislodged. The physician order, dated 06/28/18, documented the resident was to receive another prescription for Bactrim DS two times per day for for 30 days for wound infection. The orders documented the resident was to receive Zinc 220 milligrams (mg) for 30 days for wound healing. The orders documented an order to crush a [MEDICATION NAME] 500 mg tablet and apply the [MEDICATION NAME] to the buttock wound bed. The order documented Santyl was to be applied on the wound for odor. The quarterly assessment, dated 06/29/18, documented the resident was severely impaired for daily decision-making and required total assistance with ADLs. The assessment documented the resident was at risk for developing pressure ulcers. The assessment documented the resident was admitted to the facility with one stage II pressure ulcer. The assessment documented the resident had acquired one stage IV pressure ulcer. The coordination of care note, dated 06/29/18, documented the buttock pressure ulcer had slough and blood tinged drainage. On 07/10/18 at 8:17 a.m., the resident's room was observed to have a very strong odor of urine. The bed was observed to be saturated with urine. On 07/11/18 at 8:40 p.m., a hospice registered nurse (RN) documented the resident had a stage III pressure ulcer on his left buttocks. The note documented the pressure was caused by not keeping the resident dry. On 07/11/18 at 4:09 p.m., the administrator (ADM) was interviewed regarding the care of the residents receiving hospice services. The administrator was asked who was ultimately responsible for the care of the residents who resided in the facility. The ADM stated the facility was ultimately responsible for the care of the residents. On 07/12/18 at 7:50 a.m., the resident's pressure ulcer on his left buttocks was observed with the assistance of CNA #5. The resident was lying on his right side and the left buttock dressing had visible blood tinged drainage. The CNA turned the resident right side up. The right hip was observed, was red, and had sheet mark impressions to his skin. On 07/12/18 at 9:40 a.m., CNA #5 stated the resident required the use of a Hoyer lift for transfers. The CNA stated a Hoyer lift required the use of two staff persons. The CNA stated she had assisted another CNA in getting the resident out of bed for breakfast. On 07/16/18 at 7:00 a.m., the resident was observed resting on his back. On 07/16/18 at 7:45 a.m., the resident was observed in bed on his back. On 07/16/18 at 8:10 a.m., the resident was observed in the dining room for breakfast. On 07/16/18 at 10:15 a.m., an observation of the resident's buttocks pressure ulcer was completed. The wound appeared to be deep, had eschar over one third of the wound, the site was gray around the edges, and the wound measures 5.2 cm by 5.2 cm by 2.8 cm. On 07/12/18 at 8:50 a.m., RN #1 stated CNAs were to report new skin breakdown to the nurse. The RN stated the nurse should assess the skin breakdown. The RN stated the nurse should notify the physician and obtain an order for [REDACTED]. The nurse stated it was the responsibility of the charge nurse to ensure skin assessments were completed. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 07/25/17, documented the resident had an ADL self care deficit related musculoskeletal impairment, limited mobility, and impaired balance. The care plan documented the resident had an over all decline, was debilitated, and required extensive assistance with bed mobility. The care plan documented the resident had a stage two pressure ulcer to the left ankle. A significant change, dated 04/06/18, documented the resident was severely impaired for daily decision making and required extensive to total assistance with activities of daily living (ADLs). The assessment documented the resident did not have a pressure ulcer. A wound care evaluation, dated 07/02/18, documented the resident had a stage three pressure ulcer to the left lateral ankle. The evaluation documented the resident had a stage two pressure ulcer to the right heel. The quarterly assessment, dated 07/06/18, documented the resident was severely impaired for daily decision making and required extensive to total assistance with activities of daily living (ADLs). The assessment documented the resident did not have a pressure ulcer. A skin observation tool, dated 07/13/18, documented the resident had four stage two pressure ulcers to the coccyx and one stage two pressure ulcer to the right heel. The TAR for (MONTH) (YEAR) documented the resident was to receive wound care treatments daily to the left outer ankle. The TAR documented one of 16 wound care treatments were not documented as completed. The TAR documented the resident was to receive wound care treatments twice a day to the right heel. The TAR documented seven of 31 wound care treatments were not documented as completed. The TAR did not document wound care treatments were completed for the resident's coccyx. The physician orders [REDACTED]. On 07/16/18 at 9:55 a.m., the resident was observed sitting in a geri-chair in her room yelling for help. The facility staff entered the room and the resident told the staff member her buttock hurt. The staff stated she would let the nurse know and exited the room. On 07/16/18 at 10:05 a.m., the charge nurse/ licensed practical nurse (LPN) #1 was interviewed regarding pressure ulcers for the resident. The LPN stated the resident had a stage II pressure ulcer to the left ankle. The LPN stated the wound doctor was in the facility that morning. The nurse stated the doctor assessed and provided treatment to the resident's left ankle pressure ulcer. The LPN stated the wound doctor did not assess or treat any other pressure ulcers for the resident. The LPN stated three days ago she and hospice staff assessed wounds on the resident's coccyx. The LPN stated the hospice staff wrote orders for wound care. On 07/16/18 at 10:15 a.m., the resident's coccyx wounds were observed. The LPN stated three open areas were noted on the resident's coccyx. The LPN stated no treatment was being provided for the resident's coccyx wounds. The LPN stated hospice was to provide an air mattress for the resident but it had not arrived. On 07/16/18 at 11:10 a.m., the hospice staff stated it was the responsibility of the facility nurse to notify the physician and obtain treatment orders for the newly identified wounds for the resident. The hospice staff stated they would provide supplies for ordered wound care. On 07/16/18 at 11:12 a.m., the director of nurses (DON) was interviewed regarding wounds for the resident. The DON stated wounds identified as greater than a stage one with broken skin would be immediately reported to the physician. The DON stated she observed the wounds to the resident's coccyx six days ago with hospice staff. The DON stated the hospice staff should have obtained a physician's orders [REDACTED]. 3. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nurse admission screening, dated 06/15/18, documented the resident was incontinent of bladder. The screening documented the resident had a stage one pressure ulcer to his coccyx measuring 5.0 cm by 5.0 cm. The screening documented an order for [REDACTED]. A physician order, dated 06/19/18, documented an order for [REDACTED]. A physician order, dated 06/20/18, documented the staff would perform weekly skin assessments every Friday. The care plan, dated 06/22/18, documented the resident had an ADL self care performance deficit. The care plan documented the resident would have a weekly skin inspection. The care plan documented the resident had pressure ulcers. The care plan documented the facility would assess, record, and monitor wound healing weekly. The care plan documented the facility would measure length, width, depth, and the healing progress. The care plan documented the staff would report improvements and declines to the physician. The care plan documented the facility would avoid positioning the resident on areas prone to pressure. The care plan documented upon admission the resident had a stage one pressure ulcer to his buttocks. The care plan documented a stage two pressure ulcer on the resident's heel. The skin assessment, dated 06/25/18, documented the resident had an open stage two pressure ulcer on his right heel measuring 6.0 cm by 3.5 cm. The assessment documented a new order to apply zinc ointment to the ulcer and cover with a foam pad daily. A physician order, dated 06/25/18, documented an order for [REDACTED]. The 14 day assessment, dated 06/28/18, documented the resident was independent for daily decision making. The assessment documented the resident required extensive assistance for bed mobility and transfers, limited assistance for locomotion, toileting, personal hygiene, and dressing. The assessment documented the resident required a wheelchair for mobility. The assessment documented the resident was frequently incontinent of bladder and occasionally incontinent of bowel. The assessment documented the resident had one stage one pressure ulcer and one stage two pressure ulcer. The skin assessment, dated 06/29/18, documented a right heel blister at a stage two measuring five centimeters by 2.5 centimeters. The assessment documented redness to the buttocks, multiple bruising, and senile purpura to the resident's bilateral upper extremities. The skin assessment, dated 07/06/18, documented the resident had a right heel stage II ulcer measuring 3.5 cm by 2.8 cm. The assessment documented redness to the buttocks, multiple bruising, and senile purpura to the resident's bilateral upper extremities. On 07/10/18 at 1:18 p.m., the resident's wife stated the resident had a pressure ulcer on his buttocks when the resident was admitted to the facility but it had healed. The resident's wife stated the pressure ulcer on his heel was acquired in the facility. The skin observation tool, dated 07/10/18, documented the resident had a stage one pressure ulcer on his buttocks measuring five centimeters by five centimeters. The observation tool documented the resident had a stage II pressure ulcer measuring 3.0 cm by 1.0 cm. The observation tool documented bruising to both of the resident's arms. The observation documented a dark pink, blanchable, stage I pressure ulcer measuring 5.0 cm by 5.0 cm on the residents buttocks. The observation tool documented an open stage II pressure ulcer measuring 3.0 cm by 1.0 cm inside the pink area on the resident's buttocks. On 07/11/18 at 8:20 a.m., LPN #3 stated the resident had a new area open up on his buttocks during the night. On 07/11/18 at 9:30 a.m., the resident was observed sitting in his wheelchair going to therapy. On 07/11/18 at 10:40 a.m. the resident was observed sitting in his wheelchair in his room watching television and working a word search puzzle. On 07/11/18 at 11:28 a.m. the resident was observed lying in bed on his back watching television. On 07/11/18 at 1:20 p.m. the resident was observed lying in bed on his back sleeping. On 07/11/18 at 3:00 p.m. the resident was observed lying in bed on his back sleeping. On 07/11/18 at 4:48 p.m. the resident was observed lying in bed on his back sleeping. The skin assessment tool, dated 07/12/18, documented a stage I pressure ulcer on the resident's coccyx measuring 8.0 cm by 8.0 cm. The assessment documented a stage II pressure ulcer to the resident's coccyx measuring 6.0 cm by 3.0 cm. The assessment documented the resident had a dark pink/purple area measuring 8.0 cm by 8.0 cm (stage one) and an open area inside that area measuring 6.0 cm by 3.0 cm. The assessment documented the dressing was to be changed daily. The assessment documented a new order for staff to turn the resident every two hours. A physician order, dated 07/12/18, documented an order to turn the resident every two hours when in bed. The order documented to clean the left buttock with wound cleaner, pat dry, apply zinc, and a dry dressing for the stage II pressure ulcer. On 07/12/18 at 7:50 a.m., LPN #3 was observed to provide wound care for the resident. When turning the resident it was observed the resident was saturated with urine from head to toe. The resident's wound dressing on his buttocks was observed to be loose, green in color, and urine soaked. The nurse asked, Do you see this? The resident's mattress, sheet, and bed pad were saturated with urine. The nurse stated she finds the resident's like that about once or twice a week after the night shift. The LPN stated the night nurse was sitting in the dining room playing on her phone even after the CNA stated surveyors were in the building. The LPN stated the resident's wound was larger. The LPN stated the resident was able to move a little but really needed assistance for bed positioning. The LPN stated she should probably write an order to turn the resident every two hours. On 07/12/18 at 8:51 a.m., the director of nurses (DON) stated the medical director/primary physician did not manage pressure ulcer care and stated the physician felt it was not in his scope of practice. The DON stated the staff notify the primary physician if a resident develops a pressure wound. The DON stated the physician would write an order for [REDACTED]. The DON stated if skin breakdown was noted by the aid the nurse would complete a wound assessment. The DON stated weekly skin assessments and wound measurements should have been performed. The DON stated weekly skin assessments were not being completed. The DON stated skin breakdown was caused by not having enough staff to provide resident care. The DON stated if the hospice nurse measured wounds the facility used those measurements. The DON stated the facility staff still had to assess the resident's wounds. The DON stated the facility did not have a nurse to cover the night shift recently and an agency nurse was scheduled to cover the shift. The DON stated the agency nurse did not feel comfortable with the staff to resident ratio and the nurse would not accept the responsibility for the shift. The DON stated the agency sent a second nurse out and the nurse would not take responsibility for the shift due to the high resident to nurse staffing ratio. The DON stated she worked the shift with an agency nurse to improve the resident to nurse ratio and cover the night shift. On 07/12/18 at 9:05 a.m., the registered nurse (RN) #1 stated ultimately the DON was responsible to ensure wound assessments were completed. The charge nurse stated she had a weekend assistant who helped her keep the skin assessments up to date. The RN stated the weekend staff person quit and the assessments were then the responsibility of the DON. The nurse stated the skin assessments were not being completed. The nurse stated there was not enough staff available to provide for the resident needs. The nurse stated that was why she had stepped down as DON. The nurse stated after the survey was completed the past year, the owners had told her the facility was not making any money and they had to be smart with staffing. The nurse stated the new DON was overwhelmed. The nurse stated she had been told not to use agency staffing. The nurse stated they were told if an employee called in sick they would have to make do with the staff available. The nurse stated other staff were called to come in to meet staffing needs. On 07/16/18 at 3:02 p.m., CNA #2 was interviewed. The CNA stated she tried to turn the residents every two hours during her shift but it was hard. The CNA stated she wasn't very familiar with the resident. The CNA stated the resident used a urinal and his wife would let the staff know when the resident needed assistance. The CNA stated she did not check the resident for incontinence. The CNA stated she had not changed the resident's bedding.

Based on observation, interview, and record review, it was determined the facility failed to provide care and services to maintain the highest well being for two (#5 & #10) of ten sampled residents reviewed for care and service provision. The facility failed to: a) ensure pain medication was available to treat the resident's verbalized high level of pain for resident #5. The resident stated she had sharp pain identified at "10" for greater than 14 hours and was not medicated before receiving physical therapy services. The facility census and condition report identified 38 residents were on a pain management program. b) consistently monitor the fingerstick blood sugar (FSBS) according to a physician's orders [REDACTED]. The DON identified 18 diabetic residents were living in the facility. Findings: A facility policy for medication refill orders documented when a resident had a 3-5 day supply of medication it was to be re-ordered from the pharmacy. 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted for skilled physical therapy services. The resident-data collection sheet, dated 05/29/14 at 2:55 p.m., documented the resident had "...a [DIAGNOSES REDACTED]." The pain evaluation, dated 05/29/14, was completed by the admitting nurse. The evaluation documented the resident showed nonverbal signs of pain and rated her pain at 10 on a scale of 0-10 at the time of the assessment. The evaluation documented the resident's acceptable pain level was 2 on a scale of 0-10. The physical therapy evaluation, dated 05/30/14, documented the resident was to receive therapy 5-7 times per week for 14 days. The undated temporary care plan documented the resident was oriented and spoke well. The care plan did not address the resident's pain. The monthly physician's orders [REDACTED]. A fax confirmation sheet, dated 06/02/14 at 9:07 a.m., documented the physician was contacted for a new prescription for the resident's [MEDICATION NAME]. The May 2014 Medication Administration Record [REDACTED] A hand written note, dated 06/03/14, titled for the care plan, documented an intervention for the pain diagnosis. The intervention was to administer medications as ordered. On 06/03/14 at 10:08 a.m., the resident was observed standing in the bathroom area of her room, using a walker to ambulate. The resident complained of (c/o) right knee and hip pain. The resident stated the facility let her pain pills run out. The resident stated the facility didn't have pain pills all night the night before. The resident stated she asked for pain medicine 3 times during the night. The resident stated her pain was at a 10 on a scale of 0-10 at the time of the interview and the pain was sharp all night. On 06/03/14 at 11:00 a.m., licensed practical nurse (LPN) #1 was interviewed regarding the resident's c/o pain and if the resident had any pain medicine in the facility at that time. The LPN stated the resident was a clock watcher for pain medicines. The LPN reported she had faxed a note to the physician for a prescription for the resident's pain medicine Monday morning (06/02) at 9:00 a.m. The LPN stated the resident had 8 pain pills left at morning shift change on 06/02/14. The LPN stated the resident did not have any pain medicine in the facility at the time of the interview. On 06/03/14 at 11:05 a.m., the resident was observed in the physical therapy room. The resident was observed moving from a sitting position to standing. The resident had a facial grimace during the transfer. The therapy note for 06/03/14 documented the resident had an antalgic gait (a painful gait, i.e. the patient attempted to avoid putting weight on one leg due to pain). The therapy note documented the resident c/o pain in the right lower extremity (RLE) and stated she had not had a pain pill since the day before. The therapy note documented the therapy staff member talked to nursing and the pain medicine had not arrived from the pharmacy. On 06/03/14 at 1:00 p.m., the director of nursing (DON) was interviewed about the facility policy when no pain medicine was available for a resident. The DON stated if a resident told the nurse she was in pain and no medicine was available, the nurse should have sent the resident to the emergency room for pain medicine. On 06/04/14 at 8:05 a.m., the resident was interviewed regarding her pain. The resident was asked if she had requested pain medicine at any time between 06/02/14 at 7:30 p.m. (when she took her last dose) and 06/03/14 at 11:30 a.m. (when the new prescription of pain medicine was delivered to the facility). The resident stated she asked for pain medicine 3 times during that period of time and was told she did not have any pain medicine in the facility. The resident was asked if any staff member had offered any other pain control options. The resident stated the staff gave her some plain Tylenol but it did not help her pain at all. The resident stated physically she got set back in her recovery. The resident stated not getting pain medication before physical therapy made the therapy much more difficult to perform. The resident stated she had told the charge nurse if her pain was controlled she would get well quicker. On 06/04/14 at 3:40 p.m., registered nurse (RN) #1 was interviewed regarding the resident not having pain medicine in the facility after 7:30 p.m. on 06/02/14. The RN stated the day shift nurse had told her the physician had been contacted (on 06/02/14 at 9:00 a.m.) for a new pain medicine prescription. RN #1 stated she did not make any attempt to contact the physician to follow up. On 06/05/14 at 3:17 p.m., the director of nurses (DON) was interviewed regarding the facility not having pain medicine available when the resident asked for it. The DON stated she was not notified by staff when the resident ran out of pain medicine. The DON stated she should have been notified the staff was unable to get pain medicine for the resident. The DON stated she would have sent the resident to the emergency room for pain medicine. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 08/28/12, documented an approach to check the resident's fingerstick blood sugar (FSBS) per the doctor's orders and administer sliding scale (s/s) and routine insulin per orders. A quarterly assessment, dated 04/21/14, documented the resident was not impaired for daily decision making and required supervision with the activities of daily living (ADLs). The monthly physician's orders [REDACTED]. The insulin was given (or held) 4 times per day according to the FSBS measurement. The orders documented if the resident's FSBS was greater than 450 mg/dl to give 13 units of [MEDICATION NAME]and re-check the FSBS in 30 minutes and repeat until the FSBS was less than 450 mg/dl. The Medication Administration Record [REDACTED]. The resident's blood sugar was not re-checked according to the physician's orders [REDACTED]. On 06/03/14 at 9:30 a.m., the resident was interviewed and stated the staff at the facility did not give his medicine right. On 06/04/14 at 2:35 p.m., the resident was observed sitting in a wheelchair in the dining room playing bingo with other residents. The resident did not exhibit any signs or symptoms of hypo/[MEDICAL CONDITION]. On 06/05/14 at 5:00 p.m., the director of nursing (DON) was interviewed regarding the FSBS of 504 mg/dl and the staff's failure to re-check the FSBS as ordered by the physician. The DON stated if the staff did not document the FSBS was rechecked when it was 504 mg/dl, it probably was not done.

Based on record review and interview, it was determined the facility failed to provide care and services to maintain the highest practicable well-being for one (#10) of ten sampled residents reviewed for care and service provision. The facility failed to ensure the resident received the prescribed pain medication after the admission assessment documented the resident was experiencing pain rated 10/10. The resident was transferred to the hospital for pain management ten hours after admission to the facility. The facility census and condition documented 14 residents who currently resided in the facility were on a pain management program. Findings: The facility policy for pain management and assessment documented the purpose was to alleviate or minimize the resident's pain and assist the resident to maintain as high a level of functioning as possible. The policy documented during the admission process a physical exam would be conducted and a thorough history and physical would be obtained. The policy documented the resident's pain would be anticipated if possible and occurrence of the painful condition would be prevented if possible. The policy documented the resident's pain would be treated promptly, effectively, and for as long as necessary. The policy documented an individualized pain assessment would be conducted by a registered nurse in conjunction with the admission. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital discharge records dated 01/28/13 documented the resident had received [MEDICATION NAME]/[MEDICATION NAME] for pain at 10:30 a.m. before being transported to the nursing facility. A narrative nurse's note, dated 01/28/13 at 12:30 p.m., documented the resident arrived via the ambulance service. The note documented the resident was alert and oriented and the vital signs were taken. The note documented the resident's blood pressure was 124/56, the pulse was 72, the respirations were 18 and the temperature was 96.5 degrees Fahrenheit. The note documented the resident's bowel sounds were positive. The note documented the resident reported pain in the lower legs which was 10/10. The note documented the resident was incontinent of bowel and bladder. There were no additional nurses' notes until 5:00 p.m. The admission orders [REDACTED]. The time stamp from the pharmacy documented the orders had been received at 4:58 p.m. on 01/28/13. The resident could have received the first dose of pain medication as early as 1:30 p.m. if the medication had been available from the pharmacy. The time stamp for the hard script for the [MEDICATION NAME]- [MEDICATION NAME] documented the script had been received at the pharmacy at 5:35 p.m. on 01/28/13. A nurse's note, dated 01/28/13 at 5:00 p.m., documented the resident was alert and lying in bed. The note documented the certified medication aide (CMA) asked the nurse if the resident could be given some Tylenol until her medications came from the pharmacy. A telephone order, dated 01/28/13 at 5:00 p.m., documented an order for [REDACTED]. The medication administration record (MAR) for January 2013 documented the resident had been given Tylenol at 5:00 p.m. The MAR did not document the effectiveness of the Tylenol. A nurse's note, dated 01/28/13 at 8:00 p.m., documented a certified nurse aide (CNA) stated the resident's room was warm and two fans had been provided to the resident. The note documented the aide had reported being in the resident's room several times to change her. A nurse's note, dated 01/28/13 at 8:30 p.m., documented the resident's family wanted to know when the medications would arrive from the pharmacy. The note documented the family was told the medication should arrive in a "couple of hours." A nurse's note, dated 01/28/13 at 9:00 p.m., documented the CNA had stated the resident had been changed approximately 11 times since the beginning of the shift. A nurse's note, dated 01/28/13 at 9:15 p.m., documented the CNA stated the family requested to speak to the nurse to request the pharmacy be called to determine when the medication would arrive. The note documented the nurse paged the pharmacy and told them the resident was not happy and a stat order would be placed on the medication A nurse's note, dated 01/28/13 at 9:30 p.m., documented the family was told it could be up to four hours before the medication would be delivered and that was too long. The note documented the family insisted the ambulance be called to send the resident to the hospital to get some relief from the pain and the family would call 911 if the facility would not. The note documented the resident's upper arms were shaking and the resident complained of abdominal pain and discomfort. The note documented the resident did not have signs and symptoms of distress. A nurse's note, dated 01/28/13 at 9:35 p.m., documented the resident's call light was within reach with fluids available. The note documented the ambulance was called. A nurse's note, dated 01/28/13 at 9:40 p.m., documented the ambulance arrived and transferred the resident without incident. The ambulance report, dated 01/28/13, documented the time of dispatch to the facility was 10:28 p.m. and the ambulance arrived at the facility at 10:34 p.m. The report documented the resident stated she had abdominal pain for three days but it had gotten worse. The report documented the licensed practical nurse (LPN) reported the resident was in severe pain but could not be given the ordered medications because they were not available from the pharmacy. The report documented the resident's BP was 142/114 at 10:46 p.m. and 168/81 with the pulse 86 at 10:51 p.m. The report documented the ambulance left the facility at 11:14 p.m. and arrived at the hospital at 11:24 p.m. The hospital emergency room (ER) report, dated 01/28/13, documented the resident had arrived at the ER at 11:30 p.m. The report documented the nursing assessment included the resident's abdomen was distended, with hyperactive bowel sounds, and generalized abdominal tenderness. The report documented an indwelling urinary catheter had been inserted with a return of 1600 milliliters of cloudy urine. The report documented the resident's abdomen became less distended and the resident seemed more relaxed at that time. The report documented the resident had been given intravenous pain medication and relief was achieved. The report documented the resident was admitted for observation. The pharmacy receipt log documented the [MEDICATION NAME]-[MEDICATION NAME] had been delivered to the facility from a local pharmacy on 01/29/13 at 12:30 a.m. On 04/17/13 at 10:30 a.m., the director of nurses (DON) was interviewed regarding the process for completing the pain assessments and obtaining pain medication from the pharmacy. The DON stated the admission pain assessments were to be completed within the first 12 hours of admission but were usually completed at the same time the admission nursing assessment was conducted. The DON was asked what was done if the pain assessment documented the resident had pain at the time of the assessment. The DON stated if they did not have documentation when the resident was medicated prior to arriving at the facility the admitting nurse would contact the hospital. The DON stated it was now the practice to write "stat" on the orders and send them to the pharmacy immediately. The DON stated if the order was for a narcotic pain medication a hard script had to be provided by the physician before the medication could be sent from the pharmacy. The DON stated sometimes it was a problem getting a hard script at the time of the residents' admission. On 04/17/13 at 4:45 p.m., LPN #3 was interviewed regarding the resident's condition on 01/28/13 the day of admission. The LPN stated the resident had complained of pain and being warm around dinner time but seemed comfortable. The LPN stated she had contacted the physician for an order for [REDACTED]. The LPN was asked how long it normally took to receive medications from the pharmacy. The LPN stated the medications could take up to four hours to come from the pharmacy in Oklahoma City. The LPN was asked to look at the MAR and nurse's notes and describe the type of pain the resident was experiencing at the time the Tylenol was given. The LPN stated the documentation was not specific. The LPN was asked if she had been given report about the resident pain assessment indicating the resident had pain 10/10. The LPN stated she had been given report regarding the resident being admitted at 12:30 p.m. The LPN was asked if she had evaluated the resident at the time the Tylenol had been given. The LPN stated she had not evaluated the resident at that time. The LPN stated the resident was transferred to the hospital and had not returned to the facility. On 04/18/13 at 11:25 a.m., registered nurse (RN) #1 was interviewed regarding the admission process of the resident and the timeliness of ordering the medications. The RN stated two new residents had been admitted on [DATE] close to the same time. The RN stated both residents had issues at the time of admission and she had been going between both residents to get the admissions completed. The RN stated she usually tried to fax the start-up orders to the pharmacy as soon as she could because it took a long time for the medications to come in. The RN stated she was unsure why the time stamp showed the pharmacy received the order at approximately 5:00 p.m. unless the orders had been re-faxed. The RN stated she thought the hard script had not been available when the resident came from the hospital and the pharmacy would not send narcotic pain medications without a hard script. The RN was asked what had been done for the resident at the time the resident reported pain 10/10. The RN stated she could not give the resident any pain medication because it had not been sent from the pharmacy. The RN was asked if the physician had been notified the resident had pain 10/10. The RN looked at the nurse's notes and stated she had not documented the physician had been notified. The RN was asked when she had re-evaluated the resident. The RN stated she had been in the resident's room several times that afternoon but had not asked the resident to rate her pain by number. The RN was asked if the resident's pain had worsened. The RN stated she did not think the resident's pain had worsened but thought the resident's anxiety level had increased. The RN was asked if the resident had medication ordered for anxiety. The RN stated the resident did not have anxiety medication ordered. The RN was asked to describe procedures put into place by the facility and pharmacy to manage pain for newly admitted residents. The RN stated an inservice by the pharmacist had been given to the nursing staff with the instructions to identify pain medication as a stat order on the admission/start up orders and obtain hard scripts before admission whenever possible. The RN stated stat meds were received within two hours or less. On 04/18/13 at 3:40 p.m., the director of nursing (DON) described newly developed and implemented policy and procedures to ensure all residents received pain medications as ordered, including newly admitted residents. The DON described newly developed and implemented policy and procedures to ensure the facility and pharmacy managed pain for newly admitted residents and other residents. The DON stated the new policy included procedures to document new orders for pain medications as "stat" orders to be ordered and delivered as quickly as possible. She stated the policy included to communicate with the discharging hospital to ensure a hard script for pain medication was sent with the resident to the facility. The DON stated inservices were provided to ensure the facility and pharmacy managed pain for newly admitted residents and other residents. The DON stated an inservice by the pharmacist had been given to the nursing staff with the instructions to identify pain medication as a stat orders on the admission/start up orders and to obtain hard scripts before admission whenever possible. The RN stated stat meds were received within two hours or less. During the survey, resident and staff observations; resident, family, and staff interviews; and record reviews revealed no issues with resident pain management.

Based on observation, interview, and record review, it was determined the facility failed to ensure the physician was consulted for three (#1, #4, and #7) of nine sampled residents reviewed for physician notification. The facility failed to consult with the physician related to pain for residents #1, #4, and #7 who verbalized pain that was not controlled. The facility census and condition report identified seven residents were on a pain management program. Findings: A facility policy for notifying the physician of a resident's pain documented the physician was to be notified if a resident had received as needed (prn) pain medication three consecutive days consistently as ordered. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual assessment, dated 07/11/11, documented the resident's cognition was moderately impaired with memory problems. The quarterly assessment, dated 01/07/12, documented the resident's cognition was moderately impaired with memory problems. The care plan, dated 01/14/11, documented the resident was at risk for pain due to [MEDICAL CONDITION] and arthritis. The care plan documented the resident's pain occurred mostly in the morning. The care plan documented the resident could tell the staff if she was in pain. The care plan documented the resident was to be monitored for non-verbal signs of pain. The monthly physician's orders [REDACTED]. The most current pain assessment, dated 03/03/12, documented the resident denied pain at the time of the assessment. The assessment documented the resident could not determine the intensity of the pain. The assessment documented the resident occasionally exhibited non-verbal signs of pain which included facial grimacing, frowning, wrinkled brow, and increased grunting. The assessment documented the resident's pain was relieved by medication and deep relaxation. The assessment documented the resident took Tylenol as needed and the medication was effective. On 03/06/12 at 11:45 a.m., the resident was observed propelling herself in the wheelchair out of her room. As the resident was leaving the room she stated, "My foot hurts." Licensed practical nurse (LPN) #1 was asked why the resident complained of her foot hurting. The LPN stated the resident had an area of pressure on her left heel which had been identified as a stage I. The resident was observed making grunting noises. On 03/06/12 at 5:00 p.m., the resident was observed propelling herself to the dining room. The resident stated, "My foot hurts." The resident was observed making grunting noises. On 03/07/12 at 11:20 a.m., the resident was observed in bed. LPN #2 removed the dressing from the resident's left heel and performed a treatment. The resident's left heel had an open area which measured approximately 0.25 centimeters (cm) with redness around the area. During the procedure the resident stated, "Oh, oh, my foot hurts." The LPN was asked to remove the sock on the resident's right foot for observation of the heel. When the resident's leg was moved the resident stated, "Oh, oh my foot hurts." On 03/07/12 at 3:00 p.m., LPN #1 was asked if the resident's grunting was a sign of pain. The LPN stated the resident had been grunting for a long time and they did not feel the grunting was related to pain. On 03/07/12 at 4:30 p.m., the director of nurses (DON) was asked to look at the resident's right heel with the surveyor. Upon arrival to the resident's room, the resident was observed lying in bed with her eyes closed and was snoring. The DON removed the resident's sock and observed the heel was red. The DON touched the heel. The DON was asked to describe the heel. The DON stated the resident's heel was soft and mushy. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. On 03/07/12 at 4:45 p.m., CMA #2 was asked what time the resident had been given Tylenol. The CMA stated she wasn't sure of the exact time but that it had been given before 4:00 p.m. The CMA was asked where the resident's pain was located. The CMA stated she had given the pain medication to the resident because the nurse had asked her to give it for the resident's grunting. On 03/08/12 at 7:30 a.m., the physician was interviewed regarding the resident's pain. The physician stated he was not aware the resident was complaining of pain. The physician stated he was not aware the resident was not receiving Tylenol for complaints of pain. The physician was asked if the resident's grunting behavior could be a symptom of pain. The physician stated the resident had the grunting behavior for a while but he had not considered the possibility of pain. 2. Resident #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The undated admission care plan did not include interventions for pain management. An admission pain evaluation, dated 02/24/12, documented the resident had received the pain medication [MEDICATION NAME] ([MEDICATION NAME] hcl). The MAR for February 2012 documented the resident received [MEDICATION NAME] hcl 50 mg as needed for pain a total of three times. The significant change assessment, dated 03/01/12, documented the resident had no cognitive impairment and required assistance with activities of daily living (ADLs). The assessment documented the resident had pain almost constantly, with a pain intensity rating of 7 on a pain scale of one to ten (ten being the most severe pain) described as mild. The March 2012 physician's orders [REDACTED]. On 03/06/12, the facility drug receipt ledger documented a new medication card with 30 tablets of [MEDICATION NAME] hcl 50 mg 1 tab was received into the facility for the resident. On 03/06/12 at 11:45 a.m., the resident was interviewed regarding the intensity of her pain. The resident stated her pain had increased the past week to the point the pain was excruciating. The resident stated she had requested pain medication the evening of 03/05/12 and had not received pain medication. The resident stated she was later informed her pain medication had to be reordered and was not in the facility. The resident stated at some time in the middle of the night she finally received her pain medication. The resident repeated the pain was excruciating. The resident stated she could not complete the ordered physical therapy exercises on 03/06/12 because of the pain. The resident stated when she complained of pain, she always had to wait a long time for the pain medication. On 03/07/12 at 11:10 a.m., the director of nurses (DON) was interviewed regarding the resident's complaints of pain. The DON stated it seemed like nothing was working for her (the resident). The DON stated the resident was complaining of increased pain in the latter part of each day. The DON stated the physician had not been notified of the resident's pain. On 03/07/12 at 3:15 p.m., certified medication aide (CMA) #2 was interviewed regarding the resident's complaints of pain. The CMA stated the resident asked for the [MEDICATION NAME] quite frequently. The CMA stated she had not documented the resident's complaints of pain. The CMA stated the resident had previously taken [MEDICATION NAME] and probably needed something like that to control the resident's pain. On 03/07/12 at 3:30 p.m., the licensed practical nurse (LPN) #4 was interviewed regarding the resident's complaints of pain. The LPN stated the resident usually complained of pain late in the evening. The LPN stated she had passed the report of pain on to the next shift's nurse the evening of 03/05/12. The LPN stated she did not speak to the resident regarding the intensity of the resident's pain. The LPN stated she did not notice the resident's pain was uncontrolled. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change assessment, dated 12/05/11, documented the resident had severe cognitive impairment and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident experienced pain occasionally, the pain was rated at a six on a pain scale of one to ten (ten being the most severe pain), and was described as moderate. The care plan, updated 10/10/11, documented the resident had pain throughout the day, the resident had received routine pain medication, and had received as needed (PRN) pain medication. The care plan documented the resident could inform staff when pain occurred, but the staff needed to watch for non-verbal signs or symptoms (s/s) like crying, refusing to do things, and yelling "help me" repeatedly. The February 2012 monthly physician's orders [REDACTED]. Re-evaluate pain after the first dose of [MEDICATION NAME], if pain is more than four on a pain scale of one to ten (ten being the most severe pain) give as needed [MEDICATION NAME], and [MEDICATION NAME] 400 mg one tablet by mouth every six hours as needed for pain. The February 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The February 2012 MAR indicated [REDACTED] On 02/06/12, a physician's orders [REDACTED]. The February 2012 MAR indicated [REDACTED]. The March 2012 monthly physician's orders [REDACTED]. Re-evaluate pain after the first dose of [MEDICATION NAME], if pain is more than four on a pain scale of one to ten (ten being the most severe pain) give as needed [MEDICATION NAME] 400 mg one tablet by mouth every six hours as needed for pain, and [MEDICATION NAME] ([MEDICATION NAME]) 100 mg two caplets by mouth three times daily. On 03/07/12, the March 2012 MAR indicated [REDACTED]. The pain evaluation, dated 03/03/12, documented the resident described her pain at seven on a pain scale of one to ten (ten being the most severe pain). The assessment documented the resident's acceptable pain level was "0". The assessment documented the resident had nonverbal and noncognitive (facial expressions, vocalizations, body actions, and observed behavioral) signs of pain. The assessment documented the resident was on a scheduled pain regimen and received prn pain medication. On 03/06/12 at 5:15 p.m., the resident was observed sitting in her wheelchair in the dining room. The resident stated, "My legs and back hurt." The resident was asked if she received pain medication. The resident stated she had received pain medication, but the pain medication did not help the pain. On 03/08/12 at 9:00 a.m., the resident was observed lying in bed with her eyes open. The resident was crying out, "I hurt. I hurt. Help me." On 03/08/12 at 9:05 a.m., the resident was interviewed regarding her complaint of pain. The resident stated she never received her pain medications when she needed them. The resident stated, "I hurt. I always hurt." On 03/08/12 at 9:15 a.m., the certified nurse aide (CNA) was interviewed regarding the resident's complaint of pain. The CNA stated the resident did appear to be in pain and the resident had just received her pain medication from the certified medication aide (CMA) before being brought to her room. The CNA was asked how often the resident complained of pain. The CNA stated the resident cried out all of the time saying she (the resident) was in pain. On 03/08/12 at 9:16 a.m., the licensed practical nurse (LPN) #2 was interviewed regarding the resident's pain. The LPN stated she thought the resident pretty much cried out all of the time saying she (the resident) hurts. The LPN was asked if the resident was in pain at that time. The LPN stated the resident appeared to be in pain.

Based on observation, interview, and record review, it was determined the facility failed to provide care and services to maintain the highest well being for three (#1, #4, #7) of 11 sampled residents reviewed for the highest practicable well being. The facility failed to treat and manage pain for residents #1, #4, and #7 who verbalized pain that was not controlled. The facility census and condition report identified seven residents were on a pain management program. Findings: A facility policy for pain monitoring documented a pre-pain medication evaluation and one hour post pain medication evaluation must be completed by the charge nurse and documented in the clinical record. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual assessment, dated 07/11/11, documented the resident's cognition was moderately impaired with memory problems. The quarterly assessment, dated 01/07/12, documented the resident's cognition was moderately impaired with memory problems. The care plan, dated 01/14/11, documented the resident was at risk for pain due to [MEDICAL CONDITION] and arthritis. The care plan documented the resident's pain occurred mostly in the morning. The care plan documented the resident could tell the staff if she was in pain. The care plan documented the resident was to be monitored for non-verbal signs of pain. The monthly physician's orders [REDACTED]. The most current pain assessment, dated 03/03/12, documented the resident denied pain at the time of the assessment. The assessment documented the resident could not determine the intensity of the pain. The assessment documented the resident occasionally exhibited non-verbal signs of pain which included facial grimacing, frowning, wrinkled brow, and increased grunting. The assessment documented the resident's pain was relieved by medication and deep relaxation. The assessment documented the resident took Tylenol as needed and the medication was effective. A physician's telephone order, dated 03/05/12, documented an order for [REDACTED]. On 03/06/12 at 11:45 a.m., the resident was observed propelling herself in the wheelchair out of her room. As the resident was leaving the room she stated, "My foot hurts." Licensed practical nurse (LPN) #1 was asked why the resident complained of her foot hurting. The LPN stated the resident had an area of pressure on her left heel which had been identified as a stage I. The resident was observed making grunting noises. On 03/06/12 at 5:00 p.m., the resident was observed propelling herself to the dining room. The resident stated, "My foot hurts." The resident was observed making grunting noises. On 03/07/12 at 11:20 a.m., the resident was observed in bed. LPN #2 removed the dressing from the resident's left heel and performed a treatment. The resident's left heel had an open area which measured approximately 0.25 centimeters (cm) with redness around the area. During the procedure the resident stated, "Oh, oh, my foot hurts." The LPN was asked to remove the sock on the resident's right foot for observation of the heel. When the resident's leg was moved the resident stated, "Oh, oh my foot hurts." The resident's right heel was dark red. The LPN was asked if the resident had been given pain medication prior to the wound treatment. The LPN stated she had not been medicated prior to treatment being done. The LPN stated he would ask the certified medication aide (CMA) to give the resident some pain medication if she continued to hurt. On 03/07/12 at 3:00 p.m., LPN #1 was asked if the resident's grunting was a sign of pain. The LPN stated the resident had been grunting for a long time and they did not feel the grunting was related to pain. On 03/07/12 at 4:30 p.m., the director of nurses (DON) was asked to look at the resident's right heel with the surveyor. Upon arrival to the resident's room, the resident was observed lying in bed with her eyes closed and was snoring. The DON removed the resident's sock and observed the heel was red. The DON touched the heel. The DON was asked to describe the heel. The DON stated the resident's heel was soft and mushy. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The time or reason the medication was administered was not documented. The MAR indicated [REDACTED]. On 03/07/12 at 4:45 p.m., CMA #2 was asked what time the resident had been given Tylenol. The CMA stated she wasn't sure of the exact time but that it had been given before 4:00 p.m. The CMA was asked where the resident's pain was located. The CMA stated she had given the pain medication to the resident because the nurse had asked her to give it for the resident's grunting. On 03/08/12 at 7:30 a.m., the physician was interviewed regarding the resident's pain. The physician stated he was not aware the resident was complaining of pain. The physician stated he was not aware the resident was not receiving Tylenol for complaints of pain. The physician was asked if the resident's grunting behavior could be a symptom of pain. The physician stated the resident had the grunting behavior for a while but he had not considered the possibility of pain. 2. Resident #4 was admitted to the facility on [DATE] and remained in the facility for a short time, and was transferred back to the hospital. The resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The undated admission care plan did not include interventions for pain management. An admission pain evaluation, dated 02/24/12, documented the resident had received the pain medication [MEDICATION NAME] ([MEDICATION NAME] hcl). The MAR for February 2012 documented the resident received [MEDICATION NAME] hcl 50 mg as needed for pain a total of three times. The significant change assessment dated [DATE], documented the resident had no cognitive impairment and required assistance with activities of daily living (ADLs). The assessment documented the resident had pain almost constantly, with pain intensity rating of 7 on a pain scale of one to ten (ten being the most severe pain) described as mild. The March 2012 physician's orders [REDACTED]. The MAR for March 2012 documented the resident received [MEDICATION NAME] hcl 50 mg as needed for pain a total of six times between 03/01/12 and 03/08/12. On 03/06/12, the facility drug receipt ledger documented a new medication card with 30 tablets of [MEDICATION NAME] hcl 50 mg was received into the facility for the resident. On 03/06/12 at 11:45 a.m., the resident was interviewed regarding the intensity of her pain. The resident stated her pain had increased the past week to the point the pain was excruciating. The resident stated she had requested pain medication the evening of 03/05/12 and had not received pain medication. The resident stated she was later informed her pain medication had to be reordered and was not in the facility. The resident stated at some time in the middle of the night she finally received her pain medication. The resident repeated the pain was excruciating. The resident stated she could not complete the ordered physical therapy exercises on 03/06/12 because of the pain. The resident stated when she complained of pain, she always had to wait a long time for the pain medication. On 03/07/12 at 11:10 a.m., the DON was interviewed regarding the resident's complaints of pain. The DON stated it seemed like nothing was working for her (the resident). The DON stated the resident complained of increased pain in the latter part of each day. The DON stated the physician had not been notified of the resident's pain. On 03/07/12 at 3:15 p.m., CMA #2 was interviewed regarding the resident's complaints of pain. The CMA stated the resident asked for the [MEDICATION NAME] quite frequently. The CMA stated she had not documented the resident's complaints of pain. The CMA stated the resident had previously taken [MEDICATION NAME] and probably needed something like that to control the resident's pain. On 03/07/12 at 3:30 p.m., the LPN #4 was interviewed regarding the resident's complaints of pain. The LPN stated the resident usually complained of pain late in the evening. The LPN stated she had passed the report of pain on to the next shift's nurse the evening of 03/05/12. The LPN stated she did not speak to the resident regarding the intensity of the resident's pain. The LPN stated she did not notice the resident's pain was uncontrolled. On 03/08/12 at 7:30 a.m., the physician was interviewed regarding the resident's pain. The physician stated he was not aware the resident had complained of pain. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change assessment, dated 12/05/11, documented the resident had severe cognitive impairment, and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident was experiencing pain occasionally, rated at a six on a pain scale of one to ten (ten being the most severe pain), and described as moderate. The care plan updated 10/10/11 documented the resident had pain throughout the day, the resident had routine pain medication, in addition to as needed (PRN) pain medication. The resident could inform staff when pain occurred, but the staff needed to watch for non-verbal signs or symptoms like crying or refusing to do things, and when the resident yelled "help me" repeatedly. The February 2012 monthly physicians order documented the following medications: [REDACTED]. Re-evaluate pain after the first dose of [MEDICATION NAME]. If the resident's pain is more than four out of 10 when the pain is re-evaluated, administer the as needed [MEDICATION NAME]. The February 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident's [MEDICATION NAME] was applied a total of ten times. On 02/06/12, a physician's orders [REDACTED]. The resident did not receive this medication in February. The March 2012 monthly physician's orders [REDACTED]. Administer the [MEDICATION NAME] at the first complaint of pain and re-evaluate pain after the first dose. If the resident's pain is more than four on a pain scale of one to ten (ten being the most severe pain), administer the as needed [MEDICATION NAME]. The March monthly physician's orders [REDACTED]. The most current pain evaluation, dated 03/03/12, documented the resident described her pain at a 7 on a pain scale of one to ten (ten being the most severe pain). The assessment documented the resident's acceptable pain level was "0". The assessment documented the resident received prn pain medication. On 03/06/12 at 5:15 p.m., the resident was observed sitting in her wheelchair in the dining room. The resident stated, "My legs and back hurt." The resident was asked if she had received pain medication. The resident stated, "Yes, but it does not help." On 03/08/12, the March 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident had received [MEDICATION NAME] one time in March. The resident's [MEDICATION NAME] was applied two times in March. On 03/08/12 at 9:00 a.m., the resident was observed lying in bed with her eyes open. The resident was crying out, "I hurt. I hurt. Help me." On 03/08/12 at 9:05 a.m., the resident was interviewed regarding her complaint of pain. The resident stated, "I never get my pain medications when I need them. I hurt. I always hurt." On 03/08/12 at 9:15 a.m., the CNA was interviewed regarding the resident's complaint of pain. The CNA stated the resident did appear to be in pain. The CNA stated the resident had just received her pain medication from the CMA before being brought to her room. The CNA was asked if the resident complained of pain often. The CNA stated the resident cried out all of the time saying she was in pain. On 03/08/12 at 9:15 a.m., LPN #2 was interviewed regarding the resident's pain. The LPN stated the resident pretty much cried out all of the time saying she hurts. The LPN was asked if the resident was in pain at that time. The LPN stated the resident appeared to be in pain. On 03/08/12 at 7:30 a.m., the physician was interviewed regarding the resident's pain. The physician stated he was not aware the resident had complained of pain.