Every finding on record at Osage Nursing Home, LLC

Based on observation, record review, and interview, the facility failed to ensure residents were free from verbal abuse and neglect for 1 (#1) of 4 sampled residents reviewed for abuse and neglect.The DON identified 22 residents resided in the facility.Findings:On 08/13/26 at 9:40 a.m., Resident #1 was observed watching television in their room. Resident # 1 was observed appropriately dressed and groomed with no signs of injuries. A policy titled POLICY AND PROCDURE REGARDING PROHIBITION OF RESIDENT ABUSE INCLUDING CORPORAL PUNISHMENT, NEGLECT, AND EXPLOITATION, dated 10/11/22, read in part, It is the policy of this facility to prohibit abuse.The willing infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.A quarterly assessment for Resident #1, dated 06/28/26, showed a BIMS (brief interview for mental status) score of 4 which indicated severe cognitive impairment. The assessment showed diagnoses which included cerebrovascular disease, congestive heart failure, anxiety disorder, and vascular dementia.An Incident Investigation Report for Resident #1, dated 08/09/26, showed CNA #1 had cursed at Resident #1 in the hall.On 08/13/26 at 9:45 a.m., Resident #1 was unable to describe or recall the incident with CNA #1.On 08/13/26 at 10:00 a.m., LPN #1 stated on 08/09/26 at 6:30 a.m., CNA #1 came to the nurse's station and stated Resident #1 would not allow them to provide ADL care. LPN #1 instructed CNA #1 to leave the care to CNA #2 and CNA #3, end their shift, and leave the facility. LPN #1 stated the observed CNA #1 continue to enter Resident #1's room.On 08/13/26 at 10:40 a.m., CNA #2 stated on 08/09/26 at approximately 6:30 a.m., they observed CNA #1 shove Resident #1 down on their bed cursing at Resident #1. CNA #2 stated CNA #3 was present in the room when this occurred. CNA #2 stated as Resident #1 was walking down the hall to the smoking area, they observed CNA #1 shoulder check Resident #1 while walking by them. CNA #1 then left the facility. CNA # 2 stated there has been no change to the behavior of Resident #1 since the incident.On 08/13/26 at 11:00 a.m., the DON stated on 08/09/26 at 9:00 a.m., they received a text from LPN #1 informing them there was abuse against Resident #1 involving CNA #1. They stated they instructed LPN #1 to contact the administrator. The DON stated on 08/09/26 at 3:14 p.m., they were contacted by the administrator to inform them CNA #1 had been suspended. The DON stated there has been no change to the behavior of Resident #1 since the incident.On 08/13/26 at 11:10 a.m., CNA #3 stated on 8/9/26 at 6:30 a.m., CNA #1 requested assistance providing ADL care to Resident #1. CNA #3 stated the resident was agitated and pacing the floor. CNA #3 stated they were attempting to calm the resident when CNA #1 forcefully pulled the resident's pants down. CNA #3 stated the resident became aggressive and CNA #1 shoved Resident #1 down on their bed cursing at them. CNA # 3 stated when they were walking the resident down the hall to the smoking area, CNA #1 passed by and shoulder checked the resident. CNA # 3 stated there has been no change to the behavior of Resident #1 since the incident.On 08/13/26 at 11:50 a.m., CNA #1 stated on 08/09/26 at 6:30 a.m., they were attempting to provide ADL care to Resident #1. They stated the resident was aggressive and swinging on them while they pulled the residents pants down. CNA #1 stated while redirecting the residents' swings, the resident sat down on the bed. They stated they had cursed at Resident #1, and they could have handled it better.On 08/13/26 at 12:00 p.m., the administrator stated on 08/09/26 at 2:30 p.m., they were informed by LPN #1 about the abuse against Resident #1 by CNA #1. The administrator stated on 08/09/26 at approximately 3:15 p.m., they contacted the DON and stated CNA #1 was suspended pending an investigation. The administrator stated CNA #1 was terminated from employment on 08/11/26.

Based on record review and interview, the facility failed to provide residents who received Medicare part A services a Notice of Medicare Non-Coverage form for 3 (#20, 25, and #27) of 3 sampled residents reviewed beneficiary notices. The DON identified 10 residents who had been discharged from skilled services during the six months prior to the survey. Findings: The MDS coordinator was given SNF Beneficiary Protection Notification Review forms to be filled out regarding Residents #20, 25, and #27. 1. A SNF Beneficiary Protection Notification Review form filled out by the MDS coordinator, showed Resident #20 had received part A services on and between 10/14/24 and 12/25/24. The form also showed the resident had not been given a Notice of Medicare Non-Coverage form for that period of skilled services. 2. A SNF Beneficiary Protection Notification Review form filled out by the MDS coordinator, showed Resident #25 had received part A services on and between 11/08/24 and 12/20/24. The form also showed the resident had not been given a Notice of Medicare Non-Coverage form for that period of skilled services. 3. A SNF Beneficiary Protection Notification Review form filled out by the MDS coordinator, showed Resident #27 had received part A services on and between 07/26/24 and 09/06/24. The form also showed the resident had not been given a Notice of Medicare Non-Coverage form for that period of skilled services. On 02/03/25 at 1:01 p.m., MDS coordinator stated they had not been aware of the existence of the Notice of Medicare Non-Coverage form and had not given such a form to residents. They stated they would contact their sister facilities to get information about the form and that requirement. On 02/03/25 at 2:17 p.m., the administrator stated they had not been providing the Notice of Medicare Non-Coverage and had not known about the requirement.

Based on record review and interview, the facility failed to ensure a care plan was revised after a resident had multiple falls for 1 (#25) of 2 sampled residents reviewed for falls. The DON stated 29 residents resided in the facility. Findings: A Resident Care Plan policy, dated 03/27/17, read in part, The comprehensive care plan of care will be reviewed and updated by the IDT after each quarterly and annual assessment thereafter. Resident #25 had diagnoses which included postviral fatigue syndrome and chronic atrial fibrillation. A Fall Risk Evaluation form, dated 11/08/24, showed the resident had a high risk for falls. A progress note, dated 11/09/24 at 11:14 p.m., showed the resident had a fall while they attempted to go to the bathroom. An admission assessment, dated 11/15/24, showed in section J the resident had fallen prior to admission to the facility and had experienced one fall at the facility since admission. A care plan problem, dated 11/18/24, showed the resident had a risk for falls. The corresponding interventions included anticipating the resident's needs, to keep the residents call light within reach and encourage the resident to use it if they had a need, for staff to respond to the resident's requests for assistance promptly, and for staff to follow the facility's fall protocol. Each of the interventions were dated 11/18/24. A progress note, dated 12/17/24 at 3:35 a.m., showed the resident had a fall while in the bathroom. A progress note, dated 01/09/25 at 12:56 a.m., showed the resident had a fall when they tried to travel to the bed. They were retrieving their shoes that were on another bed. The note showed the resident was sent to a local acute care hospital to be assessed. A progress note, dated 01/29/25 at 2:08 a.m., showed the resident thought it was lunch time and fell while trying to put on their shoes. On 02/03/25 at 8:43 a.m., Resident #25 stated they had falls before and after coming to the facility. They stated they had been hurt during a fall. On 02/05/25 at 9:12 a.m., the MDS coordinator stated new interventions should have been added to the resident's care plan following the successive falls. They stated the care plan should include keeping the resident's shoes within reach and replacing non-skid socks regularly when they get worn out. They stated the staff needed education about adding new interventions. On 02/05/25 at 10:24 a.m., DON stated they were unaware of where the current interventions in Resident #25's care plan came from. They stated there should have been more interventions put in place following the new falls. They stated they will work with the core nurse to get them to put in new interventions when necessary.

Based on observation, record review, and interview, the facility failed to ensure damaged and uneven flooring did not exist in a room of a resident who had fallen because of a damaged floor for 1 (#25) of 2 sampled residents reviewed for falls. The DON stated 29 residents resided in the facility. Findings: An undated Accident Prevention policy, read in part, It shall be the policy of this facility to keep the resident's environment as free of accident hazards as possible. Resident # 25 had diagnoses which included postviral fatigue syndrome and chronic atrial fibrillation. A Fall Risk Evaluation form, dated 11/08/24, showed Resident #25 had a high fall risk. A care plan problem, dated 11/18/24, showed Resident #25 had a high risk for falls. An Incident Note, dated 11/09/24 at 11:14 p.m., showed Resident #25 had been found on the floor in their room and had reported their foot got caught in an area of damaged flooring and they had fallen. On 02/02/25 at 8:43 a.m., Resident #25 stated they had fallen at the facility since their admission. On 02/05/25 at 8:50 a.m., Resident #25's room was inspected. The floor was found to have had a missing piece of tile approximately 1.5 feet long and 1.5 inches wide at its widest point. The entrance to the resident's bathroom was a linoleum tile and the floor in the bathroom was an interlocking wood type material. The bathroom floor was approximately 0.125 to 0.25 inches higher than the flooring in the resident's room. On 02/05/25 at 8:55 a.m. Resident #25 stated they do use the bathroom in their room. On 02/05/25 at 9:04 a.m. DON stated they had told the maintenance supervisor about two weeks earlier about the damaged flooring and uneven flooring between the bedroom and the bathroom. The DON stated since the resident had previously fallen because of flooring they would expect the current flooring would have been repaired already. They stated the current condition of the flooring was not acceptable and they would ensure it was repaired, or the resident would be moved. On 02/05/25 at 9:52 a.m., CMA #2 stated Resident #25 had always used the bathroom in their room and as far as they knew Resident #25 had never been instructed to use a different bathroom.

Based on observation, record review and interview, the facility failed to ensure the temperature log was maintained for the medication refrigerator in the medication room. The administrator reported the facility census was 26. Findings: An undated policy titled Procedure for Storage of Medication read in part, A refrigerator will be available for medications requiring refrigeration, and will be in or near the storage area of the medications. A method of locking must be provided. The temperature in the refrigerator will be 36 to 48 degrees F [Fahrenheit]. On 02/05/25 at 10:40 a.m., a tour of the medication room was conducted with CMA #1. Temperature logs for the medication refrigerator were reviewed. No daily temperatures were logged for December 2024 or January 2025. The temperature log for February 2025 contained one entry. On 02/05/25 at 10:45 a.m., CMA #1 stated they worked for a staffing agency and was not aware until today that CMAs were responsible for monitoring the temperature of the medication refrigerator daily. On 02/05/25 at 12:12 p.m., the DON stated the charge nurse and the DON were responsible to ensure the medication refrigerator was at an appropriate temperature and the temperature was documented daily.

Based on record review and interview, the facility failed to ensure a dishwasher temperature and appropriate amount of sterilizing solution was used when cleaning resident dishes in the kitchen. The DON stated 26 residents receive their meals from the facility kitchen. Findings: An undated Food Storage, Preparation, and Distribution policy and procedure showed the facility dishwasher would maintain a 120 degrees Fahrenheit water temperature and 25 ppm (parts per million) of sanitizer when in operation. A Dish Machine Temp Sheet form, dated 01/01/25 through 01/31/25, did not document water temperatures on 01/18/25, 01/19/25, 01/25/25, and 01/26/25. The form did not document the sanitizer level was within range on 01/30/25. On 02/03/25 at 11:27 a.m., dietary aide #1 stated the January dishwasher log did not have water temperature entries for 01/18/25, 01/19/25, 01/25/25, and 01/26/25. They stated there was no sanitizer test documentation for 01/30/25. They stated a dishwasher log for February 2025 had not been started at that time, so there were not water temperature or sanitizer documentation for 02/01/25 and 02/02/25. They stated they could not say if the missing readings for January and February had been taken.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (#18) of 5 sampled residents reviewed for unnecessary medications. The administrator reported the facility census was 26. Findings: Resident #18 had diagnoses which included dementia and anxiety disorder. A physician's order, dated 09/13/23, showed Resident #18 was to receive acetaminophen (pain reliever) 1000 mg by mouth twice a day for pain. A physician's order, dated 11/9/23, showed Resident #18 was to receive tramadol (an opiod) 50 mg by mouth twice a day for pain. A physician's order, dated 12/27/24, showed Resident #18 was to receive clonazepam (anxiety medication) 1 mg by mouth twice a day for anxiety. A January 2024 MAR did not document if Resident #18 was offered or received the morning dose of acetaminophen for 11 of 31 opportunities; tramadol for 11 of 31 opportunities; and clonazepam for 11 of 31 opportunities. On 02/05/25 at 8:09 a.m., CMA #1 stated the MAR was not complete and accurate if the MAR had missing entries. On 02/05/25 at 8:20 a.m., licensed practical nurse #1 stated if the MAR was blank they could not determine if the medication was given or not. On 02/05/25 at 12:12 p.m., the DON stated medication administration and refusals should be documented on the MAR.

Based on record review and interview, the facility failed to ensure the accuracy of an MDS assessment for 1 (10) of 5 sampled residents reviewed for MDS accuracy. The administrator reported the facility census was 26. Findings: Resident #10 had diagnoses which included chronic obstructive pulmonary disease and respiratory failure. A physician's order, dated 07/28/21, showed Resident #10 was to be admitted to hospice services. A care plan, initiated 08/05/21, showed Resident #10 was receiving hospice care for respiratory failure. An annual assessment, dated 08/07/24, showed in section O, item 0110 K1, Resident #10 was not receiving hospice services while a resident at the facility. A quarterly assessment, dated 11/07/24, showed in section O, item 0110 K1, Resident #10 was not receiving hospice services while a resident at the facility. On 02/04/25 at 3:05 p.m., the MDS coordinator stated Resident #10 had been on hospice for years and the assessments had been miscoded.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for 1 (#18) of 18 sampled residents whose care plans were reviewed. The administrator reported the facility census was 26. Findings: An undated Policy and Procedure Regarding Care Plans read in part, The care plan will be person-centered, considering the resident's personal goals, past routines and interests. The care plan will be developed with measurable goals to meet the resident's identified medical, nursing, mental and psycho-social needs. Resident #18 had diagnoses which included anxiety disorder and unspecified psychosis. A physician's order, dated 12/27/24, showed Resident #18 was to receive clonazepam (an antianxiety medication) 1 mg by mouth twice a day. Resident #18's care plan was reviewed and did not address the use of an antianxiety medication. On 02/04/25 at 3:05 p.m., the MDS coordinator stated antianxiety medications should be included on the care plan. They stated they were usually notified when a medication was started so they could incorporate it on the care plan, but they were not notified this time.

Based on observation, record reviewed, and interview, the facility failed to ensure gloves were changed during catheter care for 1 (#17) of 1 sampled resident reviewed for catheter care. The DON reported one resident in the facility with a urinary catheter. Findings: An undated Catheter Care Policy, read in part, Prevent infection via the catheter insertion site by daily cleansing and maintaining a closed system .Wash hands immediately before and after handling any part of the system. Wear clean disposable gloves when handling the drainage system. Resident #17 had diagnoses which included chronic kidney disease and diabetes mellitus. A physician's order, dated 04/04/24, showed Resident #17 was to receive urinary catheter care every shift. On 02/05/25 at 10:07 a.m., CNA #1 and CNA #2 were observed providing catheter care to Resident #17. CNA #1 was observed to hand soiled washcloths to CNA #2. CNA #1 and CNA #2 did not remove their soiled gloves prior to adjusting the resident's clothing, moving the resident's bed, and touching the resident's call light. On 02/05/25 at 10:20 a.m., CNA #1 stated they should have performed hand hygiene and changed gloves because they could have contaminated things in the room they touched with soiled gloves. On 02/05/25 at 12:12 p.m., the DON stated soiled gloves should be removed prior to touching clean surfaces.

Based on record review and interview, the facility failed to fully develop the activities section of a comprehensive care plan for one (#20) of 12 sampled residents reviewed for comprehensive care plans. The DON reported 32 residents resided in the facility. Findings: Resident #20 had diagnoses which included profound intellectual disabilities, blindness of the left eye, and cerebral palsy. A facility policy titled Policy & Procedure on Activities Program, undated, read in part, .This facility will provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical , mental, and psychosocial well being of each resident . A care plan, revised date 11/28/22, read in part, .[Resident #20] has little or no activity involvement r/t [related to] profound ID [intellectual disability]. [Resident #20] will throw away any type of sensory item. [Gender withheld] does seem to enjoy when staff talks to [gender withheld] . The care plan documented one intervention which was the resident liked to watch cartoons. The intervention date was 11/29/21. On 11/16/23 at 10:48 a.m., the activities director stated during activities the resident enjoyed smells, sound machines, touch, texture balls, and going to the lobby to sit two to three times per week. They stated those activities were not in the resident's care plan but would be in the future. They stated they had been performing those activities with the resident since the resident had been admitted [11/17/21]. They stated the only documentation for the resident activities was their monthly activity notes. The activities director presented the activity notes for Resident #20 covering one year prior to the survey. The ten notes were dated 11/30/22 through 07/31/23. There were no notes for the months of January, April, August, September, October, or November of 2023, as of 11/16/23 at 11:27 a.m. The notes documented the resident's use of items for tactile stimulation which is contrary to the activity focus of the resident's care plan. On 11/17/23 at 9:04, the DON stated they did not see any activities listed in Resident #20's care plan and did not meet the organization's expectations. They stated the activities director should develop the activities section of the care plan.

Based on record review and interview the facility failed to maintain licensed nurses on duty in the facility on a 24 hour basis. The DON reported there were 32 residents in the facility. Findings: A [NAME] Report 1705D, documented the facility failed to have 24 hour nursing coverage on 04/22/23, 04/23/23, 04/30/23, 05/21/23, 05/28/23, 06/11/23, and 06/25/23. On 11/17/23 at 8:18 a.m., the administrator stated they believed the coding was off because the DON had clocked in the dates indicated on the 1705D report as the DON and not as a registered nurse. They stated they understood what occurred and would work on the problem. Facility Upload Reports for April, May, and June of 2023 were reviewed. The DON was clocked in on 05/12/23. The other dates did not have the DON's name or the title, director of nursing, on the reports.

Based on observation and interview the facility failed to provide timely response to a resident calling out for assistance for one (#25) of 24 sampled resident reviewed for call lights. The DON reported 32 residents resided in the facility. Resident #25 had diagnoses which included generalized weakness and age related physical debility. On 11/14/23 at 2:39 p.m., a repeated call for assistance was heard coming from inside Resident #25's room. The resident was repeatedly saying, help, help me. Over a period of 11 minutes two staff members (one unidentified and CNA #2) were observed passing by the resident's room as they called out. Neither checked on the resident but continued walking up and down the hallways assisting others. On 11/14/23 at 2:53 p.m., a family member arrived at the facility and checked on the resident then came to the hallway and stated, girls my [resident #25] needs help. After the staff went to help the resident the family member stated Resident #25 no longer knew how to use the call light and calls out instead. They stated that is why they think it takes so long to give the resident assistance. On 11/15/23 at 2:05 p.m., Resident #25 was observed calling out for help from their assigned room. CNA #3 was observed walking by the resident's room without checking on them. The resident was checked on after five minutes of the initial call for help. On 11/17/23 at 8:27 a.m., the DON stated their and the facility's expectation is that anytime a resident calls out for assistance the staff will immediately respond because they do not know what is wrong. At 9:56 a.m., CNA #1 stated in the case of a resident calling out for assistance they would finish what they were doing and then go check. They stated if they saw another aide they would ask them to respond. At 9:57 a.m., CMA #1 stated in the case of a resident calling out for assistance they would finish was they were doing then go help. At 9:57 a.m., CMA #2 stated in the case of a resident calling out for assistance they stated they had several residents who call out a lot so they would finish what they were doing and then go. They further stated if it was someone who did not normally call out they would go quicker and the ones that call out a lot they would finish what they were doing. At 9:59 a.m., LPN #1 stated they would stop what they were doing, depending what they were doing at the time so not to cause any safety concerns and then go see what was wrong. If need they stated they would send someone else. At 10:11 a.m., the DON stated they could not locate a policy on the subject of call systems. They reiterated their position the calls for help should be answered immediately.

Based on record review and interview, the facility failed to ensure section F (Preferences for Routines and Activities) in an annual assessment was completed for one (#20) of 12 sampled residents reviewed for comprehensive assessments. The DON identified 32 residents at the facility. Findings: Resident #20 had diagnoses which included profound intellectual disabilities and cerebral palsy. A facility policy titled Frequency of Completion of MDS, undated, document a comprehensive assessment would be completed at least once every twelve months. An annual assessment, dated 11/26/22, documented the section for determining a residents preferences for routine daily and activity preferences (section F) was not completed. The assessment documented the activity director conducted neither the assessment interview with the resident or family member, nor the staff assessment. On 11/16/23 at 12:36 p.m., the MDS coordinator stated the activities director was responsible for completing section F of the comprehensive assessments. At 12:47 p.m., the activities director stated they did not know why they had not completed section F of the annual assessment. They stated it should have been completed. On 11/17/23 at 8:49 a.m., the DON stated Resident #20's annual assessment, dated 11/26/22, did not have a completed section F as required and it was important and required that all the sections be completed accurately.

Based on record review and interview, the facility failed to conduct a significant change assessment following an elopement and a fall with fracture for one (#17) of 12 sampled residents reviewed for significant change assessments. The DON reported 32 residents resided in the facility. Findings: Resident #17 had diagnoses which included Alzheimer's Disease and unspecified fracture of the right radius. The facility's Frequency of Completion of MDS policy, undated, read in part, .If a significant change in the resident's condition does occur, an assessment must be done within (14) days of when the change in condition was identified . A progress note, dated 7/09/23 at 11:18 p.m., documented the resident was found outside and had a fall and sustained a fracture of their wrist. A comprehensive care plan, reviewed date 08/29/23, documented Resident #17 had a care plan focus, dated 07/11/23, of an actual fall which resulted in a fracture of their right wrist. It documented the resident received occupational therapy to assess and treat. On 11/17/23 at 9:26 a.m., the MDS coordinator stated Resident #17 should have had a significant change assessment following the elopement and fall with a fracture which occurred in July of 2023. They stated the a care plan meeting did occur in August of 2023 where the issue was discussed and a decision to start occupational therapy was made but there was no decision to do a significant change assessment. They further stated the resident had a decline in the area of eating as well so that combined with the other two should have been enough for a significant change assessment to have been done.

Based on record review and interview, the facility failed to ensure a resident was not prescribed Risperdal [antipsychotic medication] for the diagnosis of Alzheimer's disease and failed to ensure a resident was assessed for the existence of an approved condition prior to the administration of Risperdal for one (#28) of five sampled resident reviewed for unnecessary medication. The DON reported six residents had active orders for antipsychotic medications. Findings: Resident #28 had diagnoses which included Alzheimer's Disease. A Pharmaceutical Consultant Report dated 10/30/23, documented the diagnosis used for the Risperdal 0.25 mg order was not approved by the Centers for Medicare and Medicaid Services. The form did not have a physician's reply or signature. A care plan, dated 10/31/23, documented Resident #28 was taking Risperdal for behavioral management and Alzheimer's Disease. It further documented a warning that Risperdal was not approved for the treatment of patients with dementia related psychosis. An Order Summary report, dated 11/15/23, documented the resident had an active medication order for Risperdal [an antipsychotic medication] 0.25 mg administered orally twice daily for Alzheimer's Disease. It further documented the medication was started on 10/30/23. A Medication Administration Record dated 11/01/23 through 11/30/23, documented the resident had been administered 29 doses of Risperdal 0.25 mg between 11/01/23 and 11/15/23. On 11/15/23 at 1:39 p.m., the DON stated she understood Risperdal was not approved for the treatment of Alzheimer's disease. They further stated they were unsure if their physician had assessed the resident prior to ordering Risperdal. On 11/17/23 at 8:39 a.m., the DON stated their physician had not assessed the resident prior to ordering the medication. They restated Risperdal was not approved for the treatment of Alzheimer's disease.

Based on observation, interview, and record review, it was determined the facility failed to have the previous survey results available to all residents and to have the COVID-19 focused infection control survey results in the survey book. The facility identified 25 residents resided at the facility. Findings: On 05/10/21, 05/11/21, and 05/12/21, the black survey results notebook was observed behind a medication cart when the cart was not in use. On 05/12/21 at 2:00 p.m., LPN #1 was asked where the previous survey results were located. She stated she did not know. CMA #1 stated the survey results were on the other side. She went out of the nurses' station and stated she just needed to move the cart. She pointed to the black notebook. The CMA was asked how a resident could get to the notebook if the cart was stored in front of the notebook. She stated, They couldn't. She stated the staff would give the resident the notebook if they asked for it. The black notebook did not contain the information from the facility's 06/11/20 COVID-19 focused infection control survey result. On 05/13/21 at 1:00 p.m., the administrator was told about the medication cart being stored in front of the survey results notebook. He stated that the notebook would be moved. He was asked why the COVID-19 infection control survey information was not in the notebook. He stated he was not aware the result was not in the notebook and would have it added to the notebook.

Based on interview and record review, it was determined the facility failed to ensure yearly NA competency reviews were completed for four (CNA #1, #2, #3, and CNA #4) of four CNAs who had worked at the facility for over one year and were reviewed for yearly NA competency reviews. The facility identified 25 residents who resided at the facility. Findings: On 05/13/21 at 10:00 a.m., the BOM was asked for the yearly NA competency reviews for CNA #1, #2, #3, and CNA #4. At 10:35 a.m., the DON brought the incomplete yearly NA competency review paperwork. The DON stated she had not completed the NA yearly competency reviews as needed as she did not have time to complete them with everything that had been going on with COVID and everything. The CNA DDCA CMA job specific orientation and annual evaluation forms dated the following dates of when they should have been completed were: CNA #1 - 01/20/21, CNA #2 - 03/11/21, CNA #3 - 10/22/20, and CNA #4 - 04/19/21.

Based on observation, interview, and record review, the facility failed to ensure staff implemented the facility's infection control policies and procedures as evidenced by the failure of staff to wear the required PPE when they provided care for a quarantined resident (#126) and wash/sanitize their hands between residents on the medication pass. The facility identified 25 residents who resided in the facility. Findings: An OSDH PPE grid for nursing homes, updated 04/06/21, documented an N-95 mask was required for direct care staff, if available and fit tested , for care of quarantined and COVID-19 positive residents. 1. On 05/10/21, resident #126 was identified by the facility as being quarantined due to a recent hospitalization . A list of residents vaccinated for COVID-19 was reviewed. The resident was not on the list. On 05/10/21 at 4:45 p.m., LPN #2 and CNA #5 were observed to don PPE and entered the resident's room. They both wore surgical masks. They did not wear N-95 masks. On 05/11/21 at 11:31 a.m., CNA #4 was observed to enter the resident's room and stated she was going to feed the resident her lunch meal. She was wearing a gown, gloves, face shield, and surgical mask. She did not wear an N-95 mask. On 05/11/21 at 11:37 a.m., LPN #3 entered the resident's room to check her blood sugar. She was wearing a gown, gloves, goggles, and a surgical face mask. She did not wear an N-95 face mask. At 11:40 a.m., brown paper bags which contained N-95 masks were observed behind the nurses' station in shelves labeled with staff names. On 05/12/21 at 9:35 a.m., LPN #1 was observed to perform wound care for the quarantined resident. She wore full PPE and a surgical mask. She did not wear an N-95 mask. On 05/13/21 at 11:33 a.m., CNA #4 was asked what PPE was required when providing care to a quarantined resident. She stated all PPE. She was asked about the N-95 mask. She stated she only wore the surgical mask and had not been told she had to wear the N-95 mask. She stated she had worn it when they had an outbreak of COVID, but since COVID was not in the facility currently, she did not wear it. At 11:39 a.m., LPN #3 was asked what PPE was required for the quarantined resident. She stated full PPE. She was asked about the observation of her not wearing an N-95 mask when she checked the resident's blood sugar. She stated, As far as I knew, she was tested at the hospital. She was asked if that meant she could not become positive during her quarantined time. She stated she should have worn the N-95 mask due to the resident would not be tested again for 10 days and could have a positive test at that time. At 11:43 a.m., the DON was asked about N-95 mask use for the quarantined resident. She stated the staff should be wearing the N-95 mask due to the resident could become positive during her quarantined time. She was informed of the observations. She stated she was not sure why they were not wearing the N-95 masks. At 12:20 p.m., the IP was asked about residents in quarantine for COVID-19 precautions. She was asked if the resident had been vaccinated. She stated no. She was asked if staff had N-95 masks. She stated yes, the core staff did have their own N-95 masks and had been fit tested . She stated she was not sure if agency staff had N-95 masks. The IP was asked why staff had not worn N-95 masks when they provided care to the resident. She stated they should have worn their N-95 masks. She was asked if she had identified staff were not wearing them. She stated no. 2. On 05/13/21, CMA #2 was observed to pass medications to several residents on the West hall. She was observed to hand residents medication cups and water. Residents were observed to touch her hands as she handed them the medication cups and water. She was also observed to take residents' blood pressures and touch their arms as she applied the blood pressure cuff. She did not wash or sanitize her hands between residents or upon return to the medication cart. On 05/13/21 at 11:29 a.m., the CMA was asked about the observations during the medication pass. She was asked if she should have washed/sanitized her hands. She stated she did not know why she had not. She stated she should have sanitized up to three times and then washed her hands between residents. At 11:43 a.m., the DON was informed of the observations. She stated the CMA should have washed/sanitized her hands between residents. She was asked if not washing/sanitizing hands between residents was an infection control concern. She stated yes.

Based on interview and record review, it was determined the facility failed to ensure code status was documented for two (#15 and #126) of 16 residents whose clinical records were reviewed for advance directives. This had the potential to affect 25 residents who resided in the facility. Findings: 1. Resident #126 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/10/21, the resident's clinical record was reviewed. There was no code status found documented for the resident in the clinical record. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/12/21 at 1:00 p.m., CNA #6 was asked how she determined a resident's code status. She stated if they had a red or green sign on their door. She was asked to show the surveyor what she meant. She identified a red lantern with LAMP written on the lantern on one resident's door and stated that meant she was a DNR. At 1:05 p.m., CNA #3 was asked how she determined a resident's code status. She stated if they had a red sign with their name it meant the resident was a DNR code status, and if the sign was green with their name, it meant the resident was a full code status. She was asked what the red lantern sign meant. She stated it meant the resident was a fall risk and the LAMP stood for Look at me please. At 1:10 p.m., the charge nurse, LPN #1, was asked how she identified a resident's code status. She stated it should be in the electronic health record at the top of their name page. She was asked to review the records for resident #15 and #126 for code status. After she reviewed the records, she stated the code status was not documented for either of the two residents. She stated, I know there are signs on the doors but not sure at this time what they mean. She stated she would have to ask someone if she could not find the code status in the electronic health record. She stated it should be listed there but if not, the resident would be a full code unless she could locate documentation regarding an advance directive/code status. At 1:20 p.m., the DON and IP were asked about the resident's code status. The DON stated it should be in the electronic record. After review, the IP stated she had failed to put the code status in when she documented the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] They both stated the code status should be on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the residents should then have either green or red paper with their name on it placed on their door. They were asked if the red lantern with LAMP on it was considered a DNR status. They both stated no. They stated the red lantern was part of the Look at me please fall program and did not indicate code status. After review, the DON stated she had scanned the DNR document for resident #126 but had failed to upload it into the clinical record. The DON was asked if anyone checked behind the nurse who entered the physicians' orders into the residents' electronic health record to ensure they were accurate. She stated no. 2. Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/10/21, the resident's clinical record was reviewed. There was no code status found documented for the resident in the clinical record. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/12/21 at 1:00 p.m., CNA #6 was asked how she determined a resident's code status. She stated by if they had a red or green sign on their door. She was asked to show the surveyor what she meant. She identified a red lantern with LAMP written on the lantern on one resident's door and stated that meant she was a DNR. At 1:05 p.m., CNA #3 was asked how she determined a resident's code status. She stated if they had a red sign with their name, it meant the resident was a DNR code status and if the sign was green with their name, it meant the resident was a full code status. She was asked what the red lantern sign meant. She stated it meant the resident was a fall risk and the LAMP stood for Look at me please. At 1:10 p.m., the charge nurse, LPN #1, was asked how she identified a resident's code status. She stated it should be in the electronic health record at the top of their name page. She was asked to review the records for resident #15 and #126 for code status. After she reviewed the records, she stated the code status was not documented for either of the two residents. She stated, I know there are signs on the doors but not sure at this time what they mean. She stated she would have to ask someone if she could not find the code status in the electronic record. She stated it should be listed there but if not, the resident would be a full code unless she could locate documentation regarding an advance directive/code status. At 1:20 p.m., the DON and IP were asked about the resident's code status. The DON stated it should be in the electronic health record. After review, the IP stated she had failed to put the code status in when she documented the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] They both stated the code status should be on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the resident should then have either green or red paper with their names on them placed on their doors. They were asked if the red lantern with LAMP on it was considered a DNR status. They both stated no. They stated the red lantern was part of the Look at me please fall program and did not indicate code status. The DON was asked if anyone checked behind the nurse who entered the physicians' orders into the residents' electronic health record to ensure they were accurate. She stated no.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls. Resident #5 had experienced 50 falls from [DATE] through [DATE]. The resident sustained [REDACTED]. On [DATE], an additional Immediate Jeopardy situation was determined to exist regarding the facility's failure to ensure resident's were transferred in a safe manner to prevent accidents. Resident #11, who was taking aspirin and an antiplatelet medication, sustained a fall from an elevated whirlpool chair. The resident was unsecured in the whirlpool chair and fell forward out of the chair while being pushed into the whirlpool room. The resident fell face first onto the floor of the whirlpool room. The resident sustained [REDACTED]. The resident also sustained an abrasion below his breast area. The resident had mental status changes two days after the fall and was admitted to the hospital with [REDACTED]. The resident expired at the hospital two days after being admitted to the hospital. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the two IJ situations. At 5:20 p.m., the administrator, the director of nurses, and the corporate consultant were informed of the IJs regarding falls and accident hazards. They were informed this placed the facility in an extended survey and a plan of removal was required. At 6:17 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: .Plan of removal for alleged IJ called on [DATE], at approximately 5:17 pm, regarding supervision to prevent injury. 1. The whirlpool has been placed out of service effective 5:17pm on [DATE]. All staff will receive inservice training on the proper use of the whirlpool and the lift, prior to the use of the whirlpool and lift. Staff will be instructed on the requirement to use a seatbelt each time the lift is used. Staff will be instructed on the weight restriction of 330 pounds on the lift. No staff will be permitted to use the whirlpool until they have received this training. Inservice training regarding the above, has been provided to the immediate staff on duty at this time. All other staff will receive inservice training regarding the above by 11:59 pm on [DATE]. For those staff members who are unable to attend inservice, this inservice training will be provided by telephone. If they cannot be reached by telephone, they will receive this training on their next scheduled shift, prior to the provision of care. 2. The resident identified (name deleted) has been placed on one on one supervision indefinitely. Staff will receive inservice training on this requirement of one on one for resident (name deleted) by 11:59 pm on [DATE]. Any staff member who is not able to come in for inservice will receive inservice by telephone. If the staff member cannot be reached by telephone, they will be instructed on this requirement on their next scheduled shift, prior to providing care . An inservice sign in sheet for the employees currently in the facility was attached to the plan of removal. On [DATE] at 6:20 p.m., resident #5 was observed sitting in the lobby area with a one on one staff member present. The whirlpool room door was observed to be locked. A note on the door documented effective [DATE] at 5:17 p.m., the whirlpool was temporarily closed until further notice. The note had been signed by the administrator. On [DATE] at 9:30 a.m., the administrator gave this surveyor an inservice sign-in sheet of all the employee's who had been inserviced regarding falls and accident hazards. Staff were interviewed on [DATE] in regard to their knowledge of the inservice relating to falls and accident hazards: to ensure their understanding of all aspects of the plan of removal. On [DATE] at 10:00 a.m., CNA #1 was asked if she had been inserviced prior to working her shift. She stated yes, by phone last night and she had reviewed the written information this morning and had signed the inservice sheet. The CNA was asked what had been discussed in the inservice. She stated resident #5 had to have a one on one staff member with her at all times. She stated the whirlpool room was closed at this time and there was now a weight limit for the whirlpool chair and the strap must always be used when a resident was in the chair. The IJ was removed effective [DATE] at 9:20 a.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to: ~ Provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for one (#5) of five sampled residents who had experienced falls. Resident #5 experienced 50 falls in 13 ,[DATE] months. The resident sustained [REDACTED]. ~ Ensure resident's were transferred in a safe manner to prevent accidents for one (#11) of five sampled resident who had experienced falls. Resident #11, who was taking aspirin and an anti-platelet medication, sustained a fall from an elevated whirlpool chair. The resident was unsecured in the whirlpool chair and fell forward out of the chair while being pushed into the whirlpool room. The resident fell face first onto the floor of the whirlpool room. The resident sustained [REDACTED]. The resident also sustained an abrasion below his breast area. The resident had mental status changes two days after the fall and was admitted to the hospital with [REDACTED]. The resident expired at the hospital two days after being admitted to the hospital. The ADON identified four residents resided in the facility who had experienced a fall with major injury. Findings: An accident prevention policy, undated, documented, .It shall be the policy of this facility to keep the resident's environment as free of accident hazards as possible .Each resident will receive adequate supervision and assistive devices to prevent accidents . A facility whirlpool tub instruction booklet, dated [DATE], documented, .Always make sure that: .the resident is sitting firmly and securely fastened to avoid injuries .all safety straps are in good condition and properly fastened . 1. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An incident report, dated [DATE] at 2:00 p.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Resident became unstable on her feet. I assisted resident to sit down on the floor. Attempted to get VS while resident still on floor sitting. Resident demanded to get up. Staff assisted res. to her room. Res layed down. VS then taken @ that time .CORRECTIVE ACTION TAKEN (IF NEEDED): Resident encouraged to ask for help when ambulating, will monitor closely. Monitor resident closely when unsteady - offer w/c . An incident report, dated [DATE] at 9:15 a.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED While ambulating in lobby - resident became unsteady and began to go backward - Caught by staff x2 and lowered to floor. (No) injury noted .CORRECTIVE ACTION TAKEN (IF NEEDED): Sent to ER for evaluation per orders of PCP . An initial investigation, dated [DATE] at 9:15 a.m., documented, .What?? (Nature of Incident or allegation) While walking in lobby - resident became very unsteady, started to fall backwards. Caught by staff x2 and lowered to floor. (No) injuries .Why?? (May or May Not Know) (Increased) unsteadiness .How?? (Keep from Happening Again) w/c provided as needed, assist. provided as needed .Immediate Corrective Action Sent to E.R. for evaluation per PCP orders .Resident has become (increase) weakness. Pale. Fluid intake markedly decreased. Food intake (decreased) . A nurse's note, dated [DATE] at 2:00 p.m., documented, found in BR laying on L side in floor. Stated head hurt. then stated privates hurt. BP ,[DATE], P 80, T 98.9, SaO2 86% RA. Dr. (name deleted) out to see. states no need to see in hospital - no need for res to go out. Bed alarm, chair alarm to be used. (Increase) fluids. Monitor closely . An incident report, dated [DATE] at 2:00 p.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Found laying on L side in her bathroom. Stated just fell down. Stated head hurt. Then stated hurt in her privates .CORRECTIVE ACTION TAKEN (IF NEEDED): Bed alarm & chair alarm in place @ 1415. Educated (by dr) to use call light. to ask for assistance when getting (up) out of bed. A care plan, dated [DATE], documented, Problem Actual Fall [DATE] 0915 Unsteady gait started to fall backward - caught by staff x2 lowered to floor - CXR done - clear lab drawn @ E.R. 200 pm Found laying on floor of her bathroom stated she just fell down Goal 1. Resident will have no further falls. 2. Resident will have no significant injury related to falls. Approaches Assess for injury, notify physician and responsible party with any fall. Make sure resident area is well lit and free of obstacles or clutter. Make sure call light is placed within easy reach of the resident. Make sure frequently used items are within easy reach of the resident. Discourage reaching, bending, stretching for items .Encourage use of ambulation aid .wheelchair .and staff .Transfer with staff assist specify: number of staff: (1 - 2) .Encourage use of appropriate foot wear. Provide assist of staff (1 - 2) as needed and w/c as needed Sent to E.R. for evaluation per PCP .Bed/chair alarms placed on Bed/chair following Dr. (name deleted) visit to facility . A focused fall risk assessment, dated [DATE], documented a score of 22. The form documented if the total score was ten or above falls should be addressed on the resident's care plan. A nurse's note, dated [DATE] at 6:05 p.m., documented, Staff member heard resident fall in the lobby, and when she turned around, resident was sitting on the floor - Resident said she was trying to transfer herself from her wheelchair onto a recliner, when she felt weak, lost her balance, and fell on her buttocks. ROM revealed no s/s of injuries, likewise, skin assessment. Family was notified and physician faxed. Chair alarm did not work at time of fall. It was fixed and is working normally. Resident was encouraged to call for assistance c ADL'S. Will keep monitoring resident and assist as needed . An incident report, dated [DATE] at 6:05 p.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Staff heard resident falling and when she turned around, saw resident sitting on the floor in the lobby Resident said she tried to transfer self from wheelchair onto recliner, but felt weak, lost her balance and fell on her buttock. ROM and skin assessment showed no s/s of injuries .CORRECTIVE ACTION TAKEN (IF NEEDED): 1) Encourage to call for assistance c ADL'S 2) Chair alarm fixed 3) Monitor resident frequently and assist as needed . A care plan, dated [DATE], documented, Problem Actual Fall [DATE] found sitting on floor in lobby (after hearing noise) Resident stated she tried to transfer self from w/c into recliner - felt weak and lost her balance Goal 1. Resident will have not further falls. 2. Resident will have no significant injury related to falls. Approaches Assess for injury, notify physician and responsible party with any fall. Make sure resident area is well lit and free of obstacles or clutter. Make sure call light is placed within easy reach of the resident. Make sure frequently used items are within easy reach of the resident. Discourage reaching, bending, stretching for items. Transfer with staff assist .Encourage use of appropriate foot wear. Close supervision when resident is up d/t unsteady gait Instruct resident repeatedly to ask for help to transfer Bed alarm, chair alarm . A care plan, dated [DATE], documented, Problem .Risk for falls r/t routine use of psychotropic medications, shuffling gait loss of balance and coordination This resident has recently become more w/c dependent for mobility due to increased balance & coordination problems with several falls in last 4 weeks personal and bed alarms are currently in use to let staff know when (resident name deleted) is up so we can be of assist .Goal .Will have no falls in the next 90 days .Will receive assist with ADL's as needed to keep res safe and free of falls .Approach .(1) .Assist with daily decision making to keep res safe and free of falls (2) .Provide redirection, reminders cueing as needed (3) .Keep res room and hallways free of clutter (4) .Encourage regular rest periods to prevent fatigue (5) .Monitor room regularly for spills/episodes of incontinence, keep floor clean and dry (6) .Focused fall assessment Q 3 months and PRN (7) .Remind resident to pick feet up when ambulating w/ shuffled gait (8) .Monitor vital signs and blood sugar when c/o feeling dizzy or weak (9) .Assist resident to get things out of her closet when needed (10) .Mobile per w/c self propelled (11) .Bed and personal alarm as needed (12) .Staff to assist with dressing and grooming . A quarterly assessment, dated [DATE], documented resident #5 was severely cognitively impaired, required limited assistance with ambulation in room, corridor and with most ADLs. The assessment documented the resident had two falls with no injury and two falls with injury (except major) since the prior assessment. A physician order [REDACTED]. A nurse's note, dated [DATE] at 4:30 p.m., documented, Resident was found laying on her Back in the lobby, with her wheelchair flipped backwards. Resident said she had stood up to walk, but felt weak, and fell on her Back, hitting her head on the floor. Neuro checks initiated. V/S within normal range .Will continue to monitor. Bed & chair alarms in use . An incident report, dated [DATE] at 4:30 p.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Resident was found laying on her Back in the lobby. Resident said she stood up from wheelchair and felt weak, and fell on her Back, hitting her head on the floor. Resident's wheelchair was flipped backwards .CORRECTIVE ACTION TAKEN (IF NEEDED): 1) Monitor resident frequently 2) Use a bed & chair alarm. 3) Encourage resident to call for assistance . A nurse's note, dated [DATE] at 5:30 p.m., documented, Resident was found laying on the lobby floor on her Back. Resident said she had tried to walk, but felt weak and fell on her buttocks and hit her head on the floor. No s/s of injuries noted on head. Abrasion noted on Left Lower Leg (5.5 cm x 0.5 cm). Neuro checks ongoing. A few abnormal readings noted, like wise increased confusion and a temporary drooling. Balance is poor, gait unsteady. Resident is alert, and speech clear for the most part. Resident was advised to rest in her bed, but she refused. (Physician name deleted) was called, and notified. He said there wasn't much to be done at present .He ordered: CBC, Chem 14, and Urinalysis for the following day .Staff started attending to resident on a one-on-one basis. Chair alarm in use . An incident report, dated [DATE] at 5:30 p.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Resident was found laying on her back on the floor in the lobby. Resident said she had tried to walk, but felt weak and fell on her buttocks and hit her head on the floor. No bruises/wounds/hematomas on head. Abrasion noted to L Lower Leg .CORRECTIVE ACTION TAKEN (IF NEEDED): One-on-one Assistance 2) Monitor resident frequently 3) Bed/chair alarm. 4) Encourage resident to call for assistance . A care plan, dated [DATE], documented, Problem Actual Fall [DATE] 1630 Found laying on her back in the Lobby c w/c flipped backwards. Stated she stood up, felt weak and fell backward - hitting her head on floor 1730 Found laying on lobby floor on her back. Said she tried to walk, felt weak and fell on to her buttocks & hit her head on floor Goal 1. Resident will have no further falls. 2. Resident will have no significant injury related to falls. Approaches Assess for injury, notify physician and responsible party with any fall. Make sure resident area is well lit and free of obstacles or clutter. Make sure call light is placed within easy reach of the resident. Make sure frequently used items are within easy reach of the resident. Discourage reaching, bending, stretching for items .Chair alarm .Encourage us of ambulation aid .wheelchair .Transfer with staff assist .specify: number of staff: (1) .Encourage use of appropriate foot wear. Closely monitor resident when she is up for weakness and un-steadiness Encourage resident to use w/c due to weakness Monitor resident's meds for side effects of dizziness, (increased) weakness [DATE] CT of Head (ordered by PCP) . A physician order [REDACTED]. A doctor's progress note, dated [DATE], documented the resident used a wheelchair now due to being a fall risk. A nurse's note, dated [DATE] at 3:00 p.m., documented, Resident had been sitting in recliner in lobby earlier on shift. Has required assistance for transfer - resident having difficulty standing, weak . A nurse's note, dated [DATE] at 5:15 p.m., documented, Staff checked c resident for supper - noted resident sitting on bathroom/shower room floor by toilet - resident yelling for help - Nurse assessed resident noted no apparent injuries. Staff got resident off floor - sat resident on toilet - Nurse getting v/s equipment returned - resident became unresponsive - limp - staff placed resident in w/c transported res to bed - inc cares provided per staff. V/S 97.0 63 20 ,[DATE] 99% R.A. Resident left to rest in bed . A nurse's note, dated [DATE] at 5:30 p.m., documented, @ 15 min after resident .was left to rest in bed - staff walked by room - noted resident going down to floor - landing on bottom. Resident hit left side head on bed - nurse assessed resident noted no injuries. Neuro checks started. DON notified (physician name deleted) notified per fax. Neuros WNL . An incident report, dated [DATE], documented, .Certain Injuries .She has been identified as high fall risk due to cognition and increased weakness .Investigation reveals a total of 3 falls. Fall #1- [DATE] at 1715 pm: Resident found sitting on BR floor. Assessed by charge nurse (name removed) LPN who stated there were no injuries. Fall #2- [DATE] @ 1730 pm resident was observed by staff member standing in her room. Staff member reports (resident's name deleted) fell to the floor from a standing position and hit her head on the bed Charge nurse assessed resident, found no abrasions, lacerations, swelling or discoloration of head. No c/o pain from resident. No other injuries noted .Fall#3 [DATE] @ 0200 am. staff found (resident name deleted) on the floor of her room. Resident stated she did not hit her head. Assessed by charge nurse who reports no visible injuries. VS and neuro checks ongoing. Dr notified. At approximately 0700 oncoming charge nurse noted (resident name deleted) right foot swollen and (resident name deleted) c/o pain. Neuro checks are WNL. Dr notified and resident sent to ER for eval. Xray revealed fx of right ankle. Right foot splinted and sent back to NH. Appt with surgeon made .Resident admitted to (hospital name deleted) for surgical repair of fx of right ankle on [DATE] at 1400 pm . A nurse's note, dated [DATE] at 2:00 a.m., documented, At @ (sic) 0200 staff heard noise - noted resident laying on right side on floor in room by bed. Right arm under head - unknown if hit head. Resident assessed - No apparent injuries noted. Neuros cont - WNL - resident remains weak . An incident report, dated [DATE] at 2:00 a.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Staff heard noise - noted resident laying on right side on floor - by bed. No apparent injuries. Per resident did not hit head. No redness noted to Right side head .CORRECTIVE ACTION TAKEN (IF NEEDED): Resident assessed returned to bed - safety alarm placed on bed . A care plan documented, Problem Actual Fall [DATE] 1715 Found sitting in bathroom/shower yelling for help. Assisted to toilet - became non-responsive. Assisted to her bed 1730 Noted going down to floor - landed on bottom hit L side head on bed No injuries [DATE] 0200 Found laying on R side on floor in her room next to bed. Arm under head - unknown if she hit head Goal 1. Resident will have no further falls. 2. Resident will have no significant injury related to falls. Approaches Assess for injury, notify physician and responsible party with any fall. Make sure resident area is well lit and free of obstacles or clutter. Make sure call light is placed within easy reach of the resident. Make sure frequently used items are within easy reach of the resident. Discourage reaching, bending, stretching for items .Make sure resident bed is in the lowest possible position .Bed alarm. Chair alarm .Transfer with staff assist .specify: number of staff: (1 - 2) .Encourage use of appropriate foot wear. Closely monitor resident for unsteady gait and/or (increased) weakness Monitor resident's whereabouts when awake and assist, as needed Neuro's/Vital signs as per facility policy - notify PCP as warranted Monitor LOC D/T hitting head on bed R Ankle swollen/painful to touch - unable to bear weight (will request x-ray) . A care plan, dated [DATE] at 2:00 a.m., documented, .Problem or need Swollen, Painful R ankle unable to tolerate ROM, unable to put weight (sic) Goals .1) Will be able to tolerate splint and/or cast to ankle c (No) further injuries Plan of Approach [DATE] 1) Sent Resident to E.R. for x-ray R ankle per PCP - showed fracture [DATE] 2) Splint to R ankle (lower) leg [DATE] 3) Appt. c Orthopedic - admitted to hospital - surgery done * ORIF c plate laterally and cannulated screws medially . A nurse's note, dated [DATE] at 7:00 a.m. (Nurse's note should have been dated [DATE]), documented, Resident sitting on bed. Attempted to get VS. Resident c/o R foot pain upon standing. Swollen/bruised R ankle noted. Res unable to perform ROM c R foot. Unable to bear wt on R foot. (Physician name removed) notified per ADON. Orders rec'd to send to (hospital name deleted) for xray R foot . An incident report, dated [DATE] at 7:30 a.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Upon entering resident's room, resident was sitting on bed. Vital signs taken. Resident c/o R foot pain. ROM unable to be performed due to c/o severe pain. Unable to put weight on it also. R ankle noted to be very swollen and discolored above ankle on R outer (lower) leg .CORRECTIVE ACTION TAKEN (IF NEEDED): Sent to (hospital name removed) for x-Ray per orders PCP. Splint applied at PCP office, going to see (physician name removed) today . A clinic note, dated [DATE], documented .pt is here for evaluation and management of right leg and ankle pain. pt fell 3 times yesterday .assessment: Fracture, ankle . An Xray report, dated [DATE], documented, .minimally displaced fractures at the distal fibular metadiaphysis and at the medial malleolus. There is overlying soft tissue swelling. There is also an acute nondisplaced fracture at the posterior malleolus .Impression:Acute fractures . A physician order [REDACTED]. A nurse's note, dated [DATE] at 8:00 p.m., documented, Resident found lying on the lobby floor on her Back. She denied hitting her head - said she slid off her wheelchair. ROM and skin assessment revealed no s/s of new injury - Brakes on w/c were not locked, and resident said she was trying to self transfer. She was encouraged to lock brakes always before transferring. physician and Sister notified . An incident report, dated [DATE] at 8:00 p.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Resident was found laying on her Back on the lobby floor. She refuses hitting her head. She said she slid off her w/c and fell on her buttocks, and laid back. ROM and skin assessment revealed no new injuries .CORRECTIVE ACTION TAKEN (IF NEEDED): 1) One-on-one attendance/assistance 2) Frequent monitoring 3) Encourage resident to lock w/c before transfer . A nurse's note, dated [DATE] at 2:15 p.m., documented, Res found on floor in her room. VS WNL. No s/s pain or discomfort noted. Denies pain. PCP faxed. No new bruising noted. Good ROM. An incident report, dated [DATE] at 2:15 p.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Was reported to this nurse by PT (name removed) that Res was on floor in her room. Staff responded. VS taken assisted to w/c x3 Res was incont Bowel. Taken to BR & cleaned Body checked for bruising or reddness (sic) none noted except old bruises. Res has good ROM cast intact to RLE denies pain .CORRECTIVE ACTION TAKEN (IF NEEDED): Personal alarm on @ all times or frequent checks by staff et administer pain meds as needed . A nurse's note, dated [DATE] at 2:15 p.m., documented, Resident lowered to floor p attempting to self transfer to recliner. (No) s/s injuries. Dr. faxed & notified. Daughter notified. An incident report, dated [DATE] at 2:15 p.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Resident lowered to floor by staff p resident attempted to self transfer into recliner .CORRECTIVE ACTION TAKEN (IF NEEDED): 1) Monitor closely 2) Keep chair alarm in place 3) Medicate to keep pain level low as possible 4) Frequent monitoring . A care plan documented, Problem Actual fall [DATE] Found laying on her back on lobby floor. Stated she slid off w/c and fell on to buttocks then laid backwards Denied hitting head [DATE] Found in floor next to her bed c legs straight out in front of her, sitting on her bottom. Denies hitting her head, denies c/o pain (no) injuries noted [DATE] Lowered to floor after attempting to self transfer from w/c to recliner and lost her balance Goal 1. Resident will have no further falls. 2. Resident will have no significant injury related to falls. Approaches Assess for injury, notify physician and responsible party with any fall. Make sure resident area is well lit and free of obstacles or clutter. Make sure call light is placed within easy reach of the resident. Make sure frequently used items are within easy reach of the resident. Discourage reaching, bending, stretching for items .Bed alarm - continue use Chair alarm - continue use .Transfer with staff assist . specify number of staff: (2) .Encourage use of appropriate foot wear. Frequent monitoring Provide 1:1 when possible for resident safety Encourage resident to lock breaks before transfers Fall assessment q 3 months and prn Do not leave resident unattended . An admission assessment, dated [DATE], documented the resident was severely impaired cognitively, required limited to extensive assistance with ADLs, and the activity of ambulation in the room and corridor did not occur. The assessment documented the resident had functional limitation in range of motion with impairment on one side of the lower extremities. The assessment documented the resident had experienced two falls with no injury, two falls with injury (except major), and two falls with major injury since the prior assessment. A nurse's note, dated [DATE] at 12:55 p.m., documented, Found in bathroom floor flat on back .c/o side of head hurting. No bruising or knots noted. Dr et POA notified. Neuros initiated. An incident report, dated [DATE], documented, .Description of Incident .Found on floor of bathroom laying in front of wheelchair. Charge nurse assessed resident no visible injuries. Not known if hit head. Will start neuros. Monitor and notify PCP and family .Final report: Neuro checks were WNL for resident. No visible hematoma noted. No discolration (sic), no swelling, and no c/o of head pain per resident. No injuries related to fall noted . A nurse's note, dated [DATE], documented, .Res fell transferring self from w/c to recliner p lunch. No s/s of injury noted. Res fell on her bottom c her back hitting end table. Resting quietly in recliner @ this x. An incident report, dated [DATE] at 12:30 p.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Resident stood up and was transferring from w/c to recliner when she lost her balance and fell backward onto her bottom hitting her back against the end table. Assessment done - (no) injury noted @ this time. Did not hit head. Assisted to recliner .CORRECTIVE ACTION TAKEN (IF NEEDED): Assessment done. (No) injuries noted @ this time . A nurse's note, dated [DATE] at 10:00 p.m., (Nurse's note should have been dated [DATE]), documented, .Resident stood up from w/c attempted to take step- landed on bottom. Upon nurse assessment of resident - nurse noted no injuries. (Physician name deleted) notified per fax - unable to fax D/T fax down - family and ADON to be notified per day shift. No c/o pain or discomfort. Will monitor. An incident report, dated [DATE] at 10:00 p.m., documented, .DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Resident attempting to self transfer from w/c to recliner - took step landed on bottom on floor. Nurse assessment noted no injuries .CORRECTIVE ACTION TAKEN (IF NEEDED): Encourage resident to ask for help . A care plan documented, Problem Actual fall [DATE] Attempting to self transfer from w/c to recliner. Took one step and fell . Landed on her bottom on the floor (no) injuries did not hit head [DATE] Attempting to self transfer. Found sitting on buttocks in her room. States legs felt weak and she fell . Denied hitting her head. (No) s/sx injury Goal 1. Resident will have no further falls. 2. Resident will have no significant injury related to falls. Approaches Assess for injury, notify physician and responsible party with any fall. Make sure resident area is well lit and free of obstacles or clutter. Make sure call light is placed within easy reach of the resident. Make sure frequently used items are within easy reach of the resident. Discourage reaching, bending, stretching for items .Chair alarm. Transfer with staff assist .specify: number of staff: (1 - 2) .Encourage use of appropriate foot wear. Remind resident frequently to ask for help to transfer Monitor resident's whereabouts when she is wandering around facility . An incident report, dated [DATE] at 4:20 a.m., documented, DESCRIPTION OF INCIDENT AND TREATMENT ADMINISTERED Resident found sitting on buttocks on bedroom floor. She said she tried to self transfer from bed onto wheelchair, when she lost grip of wheelchair and fell . Denied hitt

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who was admitted to facility did not develop a reduction in range of motion for 1 (#5) of 5 sampled residents whose records were reviewed for a range of motion. The facility failed to: a. develop and implement interventions to prevent a decline in range of motion for resident #5. b. provide range of motion for resident #5. c. ensure soft hand splints, wash cloths and/or carrots were in the resident's hands. The assistant director of nursing (ADON) identified three residents who had a decline in range of motion. Findings: A facility policy, revised on 07/92, titled "Policy & Procedure on Range of Motion Services" documented, "...Any resident who enters the facility will not experience a reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion was unavoidable. It shall be the policy of this facility to provide active and passive range of motion for residents to promote maximum mobility of extremities nd (sic) prevent deterioration of present range of motion. Any resident with a limited range of motion will be provided such treatment which is appropriate to increase the range of motion and to prevent further decreases in the range of motion...PROCEDURES: Direct care staff will be fully aware of each resident's range of motion and will be assigned specific duties by the D.O.N. (director of nursing) as to what therapeutic and rehabilitative services must be provided and will see that these services are carried out..." Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A significant change assessment, dated 08-15-12, documented resident #5 had no impairment in range of motion. A physicians' telephone order, dated 01-10-13, documented, "...May use soft hand splints bilaterally due to contractures for comfort and (sic) further injury..." A quarterly assessment, dated 01-31-13, documented resident #5 was severely cognitively impaired, required extensive to total assistance with activities of daily living, and had impairment in both upper extremities. A monthly physicians' order, dated March 2013, documented, "...MAY USE SOFT HAND SPLINTS BIL (bilaterally) FOR COMFORT AND TO PREVENT INJURY...QD (every day)..." On 04-02-13 at 4:45 p.m., resident #5 was observed in a recliner with her feet up. Resident #5 had both arms drawn up close to her body and had her hands fisted. There was nothing observed in her hands. On 04-03-13 at 8:50 a.m., resident #5 was observed sitting in a recliner in the common area with her husband at her side. Resident #5 had both arms drawn up close to her body and had her hands fisted. There was nothing observed in her hands. On 04-03-13 resident #5's care plan was reviewed. There was no care plan in place regarding a decrease in range of motion for resident #5. On 04-04-13 at 2:30 p.m., certified nurse assistant (CNA) #2 was asked what interventions had been done regarding resident #5's decline in range of motion. CNA #2 stated, "We use a carrot or wash cloth in both hands unless she is using them to eat." On 04-04-13 at 2:40 p.m., the restorative aide (RA) was asked if resident #5 was receiving restorative care. The RA stated the resident was not receiving restorative. The RA stated the resident had carrots to put in her hands however, the facility had experienced such staff turn over that not every one was aware they were supposed to place the carrots in the resident's hands. On 04-04-13 at 3:30 p.m., resident #5 was observed sitting in a recliner in the common area. Resident #5 had both arms drawn up close to her body and had her hands fisted. There was nothing observed in her hands. On 04-04-13 at 5:45 p.m., the ADON was asked if resident #5 had experienced a decline in range of motion. The ADON stated the resident had become stiffer. The ADON was asked if the resident's decline in range of motion had been care planned. She stated, "I failed. I forgot to care plan it." On 04-04-13 at 5:15 p.m., the ADON was asked if resident #5 had soft hand splints. The ADON stated the resident did not have hand splints. The ADON was asked how physicians' orders were implemented. She stated they would talk to the physical therapist or the occupational therapist to get help picking out the splints. The ADON stated they should have been reviewing the physicians' orders to make sure they were done. On 04-04-13 at 5:55 p.m., the corporate nurse was asked if there was any documentation showing resident #5 had carrots/wash cloths placed in her hands. The corporate nurse stated there wasn't anything in the CNA flow sheets documenting staff were placing anything in the resident's hands.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident did not experience a severe weight loss of one (#8) of three sampled residents who were reviewed for weight loss. The facility failed to: a. provide gastrostomy tube feedings as the physicians had ordered. b. accurately document the intake of residents' gastrostomy feeding tubes. Resident #8 had a severe weight loss of 11.8 pounds in three months from 142.6 pounds in February 2011 to 130.8 pounds in May 2011. Resident #8 had [DIAGNOSES REDACTED]. The resident's current monthly physician's orders [REDACTED]. The current physician's monthly orders for the month of 05-2011 included an order, originally dated 04-27-10, which documented to give 150 cubic centimeters (cc) [MEDICATION NAME] 1.5 [MEDICATION NAME] via peg tube four times per day (QID). A second order, dated 07-13-10, on the current monthly physician's orders [REDACTED]. The resident's care plan, dated 11-30-10, documented the resident had a gastrostomy tube ([DEVICE]). The care plan documented to give tube feeding as ordered, 150 cc [MEDICATION NAME] 1.5 [MEDICATION NAME] via peg tube QID, hold [MEDICATION NAME] 1.5 150 cc overnight, and if he eats more than 50% of meals continue flushing with 120 cc H20 (water) QID. The care plan documented to monitor intake and output every shift. The resident's quarterly assessment, dated 12-01-10, documented the resident was severely impaired related to cognitive skills for daily decision-making, had memory problems, was totally dependent for activities of daily living (ADL), and had a [DEVICE]. On 05-10-11 at 1:14 p.m., during the initial tour of the facility, resident #8 did not have a dressing around his [DEVICE] site. There was a small amount of dried matter around the [DEVICE] site. The resident's clinical record documented the following weekly weights: 01-03-11 weight was 140.8 pounds (lbs.) 01-16-11 weight was 144.2 lbs. 01-21-11 weight was 144.6 lbs. 01-28-11 weight was 141.8 lbs. 02-04-11 weight was 142.6 lbs. 02-11-11 weight was 138.4 lbs. 02-18-11 weight was 136.8 lbs. 02-23-11 weight was 135.8 lbs. 02-28-11 weight was 132.8 lbs. 03-07-11 weight was 135.8 lbs. 03-14-11 weight was 134.2 lbs. 03-21-11 weight was 135.4 lbs. 03-28-11 weight was 134.4 lbs. 04-04-11 weight was 133.6 lbs. 04-11-11 weight was 133.8 lbs. 04-18-11 weight was 133.2 lbs. 04-25-11 weight was 133.6 lbs. 05-02-11 weight was 130.8 lbs. 05-11-11 weight documented in dietary notes was 127.8 lbs. The resident's clinical record documented the resident's weights in the physician's progress notes as follows: 01-13-11 weight was 140.8 lbs. 03-31-11 weight was 134.4 lbs. 04-21-11 weight was 133.2 lbs. The resident's dietary monthly progress notes, dated 01-31-11, documented by the dietary manager, stated, "Residents Wt (weight) is 144.6 # some meals he eats 75-100% some meals he refuses to eat." The resident's dietary monthly progress notes, dated 02-20-11, documented by the dietary manager, stated, "Residents wt is 138#." The resident's dietary monthly progress notes, dated 03-03-11, documented by the registered dietician (RD), stated, "R (resident) weight 136#. (Down) 8 # past month. R eats well TF (tube feeding) & po (by mouth) intake adequate to meet est. (established) needs. (No) current labs. (No) skin breakdown. Continue (with) current nutrition care plan." The resident's dietary monthly progress notes, dated 03-29-11, documented by the RD, stated, "March wt 135.4# (down) 0.6 # past month. Pt received [MEDICATION NAME] 1.5 150 cc if po (less than) 50%. TF & po adequate to meet est. (No) current labs. (No) skin breakdown. Will continue to monitor." The resident's treatment administration record (TAR) for 03-2011, documented 120 cc in 42 spaces out of a possible 124 entries for the resident's 150 cc tube feeding [MEDICATION NAME]. The remainder of the 124 possible entries was blank. The 150 cc [MEDICATION NAME] was documented as not given on one occasion after a meal where it was documented the resident ate 0 percent. The resident's intake and output sheet (I&O) for 03-2011 had 111 undocumented spaces out of the possible 250 entries for intake of fluids for the month. The I&O sheets for 03-01-11 through 03-06-11 were missing. The resident's dietary monthly progress notes, dated 04-20-11, documented by the RD, stated, "Wt 133.2 (down) 2.2 # past month. Resident TF regimen continues if PO (less than) 50%. TF & PO adequate to meet est. needs. (No) changes noted today. Continue (with) current POC (plan of care)." The 04-2011 TAR documented the 150 cc tube feeding [MEDICATION NAME] as not being given 3 times out of a possible 120 entries when the resident ate less than 50%. The I&O sheet for 04-2011 had 141 undocumented spaces out of a possible 300 entries for intake of fluids for the month. The I&O sheet for 05-01-11 through 05-10-11 had 65 undocumented spaces out of a possible 100 entries for intake of fluids for those days. On 05-11-11 at 9:20 a.m., the resident was observed in his geri chair in the lobby. At 12:12 p.m., certified medication aide (CMA) #1 stated that the resident had eaten 100 percent of his lunch and did not need a tube feeding [MEDICATION NAME]. She stated that she had just finished giving the resident a 300 cc H20 flush. On 05-12-11 at 12:15 p.m., the resident was observed in the lobby in his geri-chair on his back watching television with other residents. On 05-12-11 at 12:32 p.m., licensed practical nurse (LPN) #3 was observed giving the resident a [MEDICATION NAME] 1.5 tube feeding [MEDICATION NAME]. LPN #3 assembled her supplies on the resident's bedside table on top of a paper towel. She had a 240 cc can of [MEDICATION NAME] 1.5 sitting on the bedside table. LPN #3 had the [MEDICATION NAME] 1.5 tube feeding and H20 pre-measured in Styrofoam cups. She stated she used Styrofoam cups to measure the fluids due to the disappearance of the plastic cannisters that were normally used. When asked, she stated the amount of water was 120 cc and the [MEDICATION NAME] 1.5 was 240 cc. On 05-12-11 at 4:50 p.m., the director of nursing (DON) was shown the I&O records with 124 opportunities for the resident to receive feedings and flushes. The DON stated she did not know how anyone could tell whether the resident had been fed or not by looking at the many blanks noted on the I&O record. The DON stated she did not have any idea where the staff had come up with the amounts recorded on the I&O records. On 05-12-11 at 5:41 p.m., the resident was in his room in bed. His lips were moist and mucous membranes were moist even though he was breathing through his mouth. His skin did not appear to be dry. On 05-13-11 at 10:43 a.m., the DON was asked about resident missing tube feedings on the TAR. She stated when she heard that residents were not being given their tube feeding, she did not come in and look. She questioned staff and monitored resident #8's weights through quality assurance. She stated that no aides went in during the tube feeding and she felt she could only check weights. She stated resident #8's only form of control was his eating and he may use that for getting attention. The DON stated the resident had a couple of infections since 01-2011 which could cause weight loss. The DON stated the resident's weights fluctuated. The DON stated she had spoken with the facility's registered dietitian that morning and orders would be changed to never hold tube feeding for resident #8. The DON stated the resident's new physician's orders [REDACTED]. On 05-13-11 at 11:35 a.m., the resident was observed in the dining room being given a drink and assisted with the meal by a staff member. On 05-13-11 at 12:46 p.m., LPN #3 was observed giving resident #8 his [MEDICATION NAME] 1.5 tube feeding. Supplies were on the bedside table and the water and [MEDICATION NAME] 1.5 were pre-measured in Styrofoam cups. When asked how much [MEDICATION NAME] 1.5 she had measured out, she stated 150 cc. In an interview on 05-13-11 at 3:15 p.m., LPN #3 was asked about the difference in [MEDICATION NAME] 1.5 tube feeding amounts, LPN #3 said she followed the doctor's orders. She stated she did not know why she gave the 240 cc. LPN #3 stated she thought the resident received one full can of [MEDICATION NAME] which was 240 cc. She stated she checked the doctor orders that day and saw he had 150 cc of [MEDICATION NAME] ordered and gave the 150 cc. LPN #3 stated she rarely gave the feeding herself because when qualified CMAs were working they administered the tube feedings. She stated she received no training on [DEVICE] feeding when she began working in the facility. The DON on 05-13-11 at 3:34 p.m., was asked which of the two [DEVICE] orders the staff should have been following. She stated the 07-13-10 physician's orders [REDACTED]. On 05-17-11 at 4:00 p.m., the physician for resident #8 was called. The physician, when asked, stated he was aware of the resident's weight loss and that was why the resident had the feeding tube. The physician was asked if the resident's weight loss was avoidable or unavoidable. The physician stated he did not know. The physician stated the resident had been a difficult case and that was a difficult question. The physician stated he was pleased with how the resident was doing. On 05-17-11 at 4:25 p.m., the DON was asked about the documentation of the resident's [MEDICATION NAME] 1.5 [MEDICATION NAME] being charted at 120 cc when the resident's order documented 150 cc was to be given. The DON stated she did not know why. Resident #8 had severe weight loss of 11.8 pounds in three months from 02-04-11 (142.6 pounds) to 05-02-11 (130.8 lbs).

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had gastrostomy feeding tubes received the proper treatment and care for 3 (#7, #8, and #9) of 3 sampled residents who had gastrostomy feeding tubes. The facility failed to: a. provide gastrostomy tube feedings and/or water flushes as the physicians had ordered. b. check placement of the tubes and to provide a [MEDICATION NAME] feeding as the facility policy directed. c. change gastrostomy feeding tube dressings as ordered. d. accurately document the intake of residents' gastrostomy feeding tubes. Resident #8 had a severe weight loss of 11.8 pounds in three months from 142.6 pounds in February 2011 to 130.8 pounds in May 2011. The facility identified 3 residents who had gastrostomy tubes. Findings: The facility's policy and procedure related to gastrostomy tubes for [MEDICATION NAME] feeding documented, "...Confirm placement by auscultation and check residual. . . .Flush tube with the prescribed amount of water. . . .Administer prescribed feeding. Pour slowly. The height of the syringe adjusts the speed of the flow. . . .Flush tube with the prescribed amount of water." 1. Resident #8 had [DIAGNOSES REDACTED]. The resident's current monthly physician's orders [REDACTED]. The current physician's monthly orders for the month of 05-2011 included an order, originally dated 04-27-10, which documented to give 150 cubic centimeters (cc) [MEDICATION NAME] 1.5 [MEDICATION NAME] via peg tube four times per day (QID). A second order, dated 07-13-10, on the current monthly physician's orders [REDACTED]. The resident's care plan, dated 11-30-10, documented the resident had a gastrostomy tube ([DEVICE]). The care plan documented to give tube feeding as ordered, 150 cc [MEDICATION NAME] 1.5 [MEDICATION NAME] via peg tube QID, hold [MEDICATION NAME] 1.5 150 cc overnight, and if he eats more than 50% of meals continue flushing with 120 cc H20 (water) QID. The care plan documented to monitor intake and output every shift. The resident's quarterly assessment, dated 12-01-10, documented the resident was severely impaired related to cognitive skills for daily decision-making, had memory problems, was totally dependent for activities of daily living (ADL), and had a [DEVICE]. On 05-10-11 at 1:14 p.m., during the initial tour of the facility, resident #8 did not have a dressing around his [DEVICE] site. There was a small amount of dried matter around the [DEVICE] site. The resident's clinical record documented the following weekly weights: 01-03-11 weight was 140.8 pounds (lbs.) 01-16-11 weight was 144.2 lbs. 01-21-11 weight was 144.6 lbs. 01-28-11 weight was 141.8 lbs. 02-04-11 weight was 142.6 lbs. 02-11-11 weight was 138.4 lbs. 02-18-11 weight was 136.8 lbs. 02-23-11 weight was 135.8 lbs. 02-28-11 weight was 132.8 lbs. 03-07-11 weight was 135.8 lbs. 03-14-11 weight was 134.2 lbs. 03-21-11 weight was 135.4 lbs. 03-28-11 weight was 134.4 lbs. 04-04-11 weight was 133.6 lbs. 04-11-11 weight was 133.8 lbs. 04-18-11 weight was 133.2 lbs. 04-25-11 weight was 133.6 lbs. 05-02-11 weight was 130.8 lbs. 05-11-11 weight documented in dietary notes was 127.8 lbs. The resident's clinical record documented the resident's weights in the physician's progress notes as follows: 01-13-11 weight was 140.8 lbs. 03-31-11 weight was 134.4 lbs. 04-21-11 weight was 133.2 lbs. The resident's dietary monthly progress notes, dated 01-31-11, documented by the dietary manager, stated, "Residents Wt (weight) is 144.6 # some meals he eats 75-100% some meals he refuses to eat." The resident's dietary monthly progress notes, dated 02-20-11, documented by the dietary manager, stated, "Residents wt is 138#." The resident's dietary monthly progress notes, dated 03-03-11, documented by the registered dietician (RD), stated, "R (resident) weight 136#. (Down) 8 # past month. R eats well TF (tube feeding) & po (by mouth) intake adequate to meet est. (established) needs. (No) current labs. (No) skin breakdown. Continue (with) current nutrition care plan." The resident's dietary monthly progress notes, dated 03-29-11, documented by the RD, stated, "March wt 135.4# (down) 0.6 # past month. Pt received [MEDICATION NAME] 1.5 150 cc if po (less than) 50%. TF & po adequate to meet est. (No) current labs. (No) skin breakdown. Will continue to monitor." The resident's treatment administration record (TAR) for 03-2011, documented 120 cc in 42 spaces out of a possible 124 entries for the resident's 150 cc tube feeding [MEDICATION NAME]. The remainder of the 124 possible entries was blank. The 150 cc [MEDICATION NAME] was documented as not given on one occasion after a meal where it was documented the resident ate 0 percent. The resident's intake and output sheet (I&O) for 03-2011 had 111 undocumented spaces out of the possible 250 entries for intake of fluids for the month. The I&O sheets for 03-01-11 through 03-06-11 were missing. The resident's dietary monthly progress notes, dated 04-20-11, documented by the RD, stated, "Wt 133.2 (down) 2.2 # past month. Resident TF regimen continues if PO (less than) 50%. TF & PO adequate to meet est. needs. (No) changes noted today. Continue (with) current POC (plan of care)." The 04-2011 TAR documented the 150 cc tube feeding [MEDICATION NAME] as not being given 3 times out of a possible 120 entries when the resident ate less than 50%. The I&O sheet for 04-2011 had 141 undocumented spaces out of a possible 300 entries for intake of fluids for the month. The I&O sheet for 05-01-11 through 05-10-11 had 65 undocumented spaces out of a possible 100 entries for intake of fluids for those days. On 05-11-11 at 9:20 a.m., the resident was observed in his geri chair in the lobby. At 12:12 p.m., certified medication aide (CMA) #1 stated that the resident had eaten 100 percent of his lunch and did not need a tube feeding [MEDICATION NAME]. She stated that she had just finished giving the resident a 300 cc H20 flush. On 05-12-11 at 12:15 p.m., the resident was observed in the lobby in his geri-chair on his back watching television with other residents. On 05-12-11 at 12:32 p.m., licensed practical nurse (LPN) #3 was observed giving the resident a [MEDICATION NAME] 1.5 tube feeding [MEDICATION NAME]. LPN #3 assembled her supplies on the resident's bedside table on top of a paper towel. She had a 240 cc can of [MEDICATION NAME] 1.5 sitting on the bedside table. After telling the resident what she was about to do, she put gloves on. She listened to the stomach area around the [DEVICE] site. The [DEVICE] site did not have a dressing on as was ordered. She stated that she had put a dressing on that morning (05-12-11) and usually checked the [DEVICE] before she ended her shift because it came off occasionally. She then checked for residual stomach contents by using the syringe and trying to pull off excess stomach fluids. There was no residual. LPN #3 had the [MEDICATION NAME] 1.5 tube feeding and H20 pre-measured in Styrofoam cups. She stated she used Styrofoam cups to measure the fluids due to the disappearance of the plastic cannisters that were normally used. When asked, she stated the amount of water was 120 cc and the [MEDICATION NAME] 1.5 was 240 cc. She poured half of the water into the syringe that was connected to the [DEVICE]. She then began pouring the [MEDICATION NAME] 1.5 into the syringe. She allowed the fluid to drain into the [DEVICE] by gravity. The remainder of the water was poured in after the tube feeding. After she removed the syringe and closed the cap of the [DEVICE], she listened with her stethoscope around the [DEVICE] a second time. On 05-12-11 at 4:50 p.m., the director of nursing (DON) was shown the I&O records with 124 opportunities for the resident to receive feedings and flushes. The DON stated she did not know how anyone could tell whether the resident had been fed or not by looking at the many blanks noted on the I&O record. The DON stated she did not have any idea where the staff had come up with the amounts recorded on the I&O records. On 05-12-11 at 5:41 p.m., the resident was in his room in bed. His lips were moist and mucous membranes were moist even though he was breathing through his mouth. His skin did not appear to be dry. On 05-13-11 at 10:43 a.m., the DON was asked about resident missing tube feedings on the TAR. She stated when she heard that residents were not being given their tube feeding, she did not come in and look. She questioned staff and monitored resident #8's weights through quality assurance. She stated that no aides went in during the tube feeding and she felt she could only check weights. She stated resident #8's only form of control was his eating and he may use that for getting attention. The DON stated the resident had a couple of infections since 01-2011 which could cause weight loss. The DON stated the resident's weights fluctuated. The DON stated she had spoken with the facility's registered dietitian that morning and orders would be changed to never hold tube feeding for resident #8. The DON stated the resident's new physician's orders [REDACTED]. On 05-13-11 at 11:35 a.m., the resident was observed in the dining room being given a drink and assisted with the meal by a staff member. On 05-13-11 at 12:46 p.m., LPN #3 was observed giving resident #8 his [MEDICATION NAME] 1.5 tube feeding. Supplies were on the bedside table and the water and [MEDICATION NAME] 1.5 were pre-measured in Styrofoam cups. When asked how much [MEDICATION NAME] 1.5 she had measured out, she stated 150 cc. The LPN followed the same procedure of listening with her stethoscope around the [DEVICE] site and then listened to his lungs. She said his lungs were clear. A dressing was around the [DEVICE] site. The LPN gave half of the water first, tube feeding second, and then followed with water. She removed the syringe and closed the [DEVICE] cap. In an interview on 05-13-11 at 3:15 p.m., LPN #3 was asked how she checked for placement of the [DEVICE]. She stated she listened with her stethoscope around the [DEVICE] site for bowel sounds. She stated she listened to the lungs to make sure they were clear. When asked about the difference in [MEDICATION NAME] 1.5 tube feeding amounts, LPN #3 said she followed the doctor's orders. She stated she did not know why she gave the 240 cc. LPN #3 stated she thought the resident received one full can of [MEDICATION NAME] which was 240 cc. She stated she checked the doctor orders that day and saw he had 150 cc of [MEDICATION NAME] ordered and gave the 150 cc. LPN #3 stated she rarely gave the feeding herself because when qualified CMAs were working they administered the tube feedings. She stated she received no training on [DEVICE] feeding when she began working in the facility. The DON on 05-13-11 at 3:34 p.m., was asked about her interpretation of checking for placement of the [DEVICE]. She stated you listen with your stethoscope for the bubbling sound as you insert air into the tube. The DON stated she had not had any inservices on confirming placement of the [DEVICE]. The DON stated when a nurse began working in the facility, the experienced nurses would train the new nurses on [DEVICE]s. The DON was asked which of the two [DEVICE] orders the staff should have been following. She stated the 07-13-10 physician's orders [REDACTED]. On 05-17-11 at 4:00 p.m., the physician for resident #8 was called. The physician, when asked, stated he was aware of the resident's weight loss and that was why the resident had the feeding tube. The physician was asked if the resident's weight loss was avoidable or unavoidable. The physician stated he did not know. The physician stated the resident had been a difficult case and that was a difficult question. The physician stated he was pleased with how the resident was doing. On 05-17-11 at 4:25 p.m., the DON was asked about the documentation of the resident's [MEDICATION NAME] 1.5 [MEDICATION NAME] being charted at 120 cc when the resident's order documented 150 cc was to be given. The DON stated she did not know why. Resident #8 had severe weight loss of 11.8 pounds in three months from 02-04-11 (142.6 pounds) to 05-02-11 (130.8 lbs). 2. Resident #9 had [DIAGNOSES REDACTED]. The resident's quarterly assessment, dated 03-02-11, documented the resident needed extensive assistance for transfers and totally dependent for all other ADLs. The assessment documented the resident had a [DEVICE]. The monthly physician's orders [REDACTED]. documented a daily dressing change to the [DEVICE] site. The order stated to clean the area with water and cover with 4 x 4 every day. The monthly physician's orders [REDACTED]. documented if the resident did not eat 50% or more of a meal, give a [MEDICATION NAME] of [MEDICATION NAME] 1.5 with 120 cc flush H20. The resident's treatment administration record (TAR) documented to give [MEDICATION NAME] 1.5 120 cc if the resident did not eat 50% or more of meal. The I & O sheets for 03-2011 had 140 undocumented spaces out of a possible 310 entries for intake for the month. The I & O sheets for 04-2011 had 88 undocumented spaces out of a possible 170 entries for intake for the month. The I & O sheets for 04-11-11 through 04-23-11 were missing. On 05-10-11 at 1:23 p.m., resident #9 did not have a dressing around her gastrostomy tube site. The area around the tube was clean. The I & O sheets for 05-01-11 through 05-11-11 had 61 undocumented spaces out of a possible 110 entries for intake for the month. On 05-11-11 at 12:13 p.m., the resident was observed in her wheelchair being wheeled out of the dining room and taken to her room. At 12:33 p.m., CMA #1 stated she had just given the resident one-half of her tube feeding and 180 cc of water as the resident had eaten 40% of her meal. At 3:30 p.m., the resident was observed in her wheelchair in the lobby watching television. On 05-12-11 at 11:20 a.m., the resident was observed sitting in a wheel chair in the dining room at the table waiting for the lunch meal. The resident's lips were moist. On 05-13-11 at 11:37 a.m., the resident was observed in the dining room being assisted with the meal by a staff member. The resident's skin appeared adequately hydrated and clean. On 05-14-11 at 10:00 a.m., registered nurse (RN) #1 was observed doing resident #9's gastrostomy tube ([DEVICE]) feeding and [DEVICE] dressing change. RN #1 used hand cleanser, put on her gloves, gathered her supplies, and entered the resident's room. RN #1 placed the supplies on the resident's beside table. RN #1 put her stethoscope in her ears and picked up the resident's [DEVICE]. After RN #1 opened the [DEVICE], she put in the syringe and withdrew a small amount of stomach contents. She then replaced the stomach contents, removed the syringe, and clamped the [DEVICE]. She removed the stethoscope from her ears and placed it on the resident's bed. She then took the syringe to the resident's bathroom and rinsed it out. RN #1 did not check for placement by auscultation per the facility policy. RN #1 proceeded by pulling up 50 milliliters (ml) of water and pushing it through the resident's [DEVICE]. She pulled up a syringe full of formula and pushed it through the [DEVICE]. RN #1 repeated this process a second time with the formula and the water, pushing both through the [DEVICE]. After RN #1 finished the [DEVICE] feeding, she removed the supplies from the room. She removed her gloves and used a hand cleanser to clean her hands. RN #1 was asked how much water she had used to flush the [DEVICE]. She stated 50 ml before and after the feeding. RN #1 was asked how much formula she had given the resident. She stated 120 ml. On 05-16-11 at 2:45 p.m., the DON was asked to clarify resident #9's flush order. She stated the resident should receive 60 ml of water before and after each feeding. On 05-16-11 at 3:30 p.m., the DON was asked how [MEDICATION NAME] [DEVICE] feedings should be administered. She stated the nurse should check for placement by auscultation and by aspirating to check for residual. She stated if there was a residual greater than 100 ml, the feeding should be held. She stated after flushing with water, the nurse should give the feeding by holding up the syringe and pouring the formula into the syringe. The DON stated the syringe should be held up to let the formula go in slowly and follow that with another flush of water. The DON was asked if the water or formula should be pushed through the syringe. She stated no. The resident had not had weight loss. 3. Resident #7 had [DIAGNOSES REDACTED]. The resident's annual assessment, dated 04-24-11, documented the resident's cognition was severely impaired. The assessment documented the resident was totally dependent on staff for all activities of daily living (ADL) and had a gastrostomy tube for delivery of nutrition. The resident's current physician's orders [REDACTED]. . ." The resident's current monthly physician's orders [REDACTED]." On 05-12-11 at 11:46 a.m., certified medication aide (CMA) #1 was observed to check the resident's gastrostomy tube residual. There was no residual. The CMA then flushed the resident's gastrostomy tube with 60 cc of water, then gave 237 cc of [MEDICATION NAME] 1.5, then flushed the tube with 60 cc of water. The CMA did not check the resident's gastrostomy placement as the facility policy documented and did not follow the physician's orders [REDACTED]. On 05-12-11 at 2:35 p.m., the CMA was asked how she checked the resident's gastrostomy tube placement. She stated the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s gastrostomy tube placement at 8:00 a.m. The surveyor read the CMA the physician's orders [REDACTED]. The CMA stated that was her fault. She stated, "I'm sorry." On 05-13-11 at 7:10 p.m., LPN #1 was asked how often the residents' gastrostomy tube dressings were changed. She stated every day. The LPN stated for residents #7 and #8, she cleaned around the gastrostomy tube site and left it open to air. Resident #8 had a physician's orders [REDACTED]. On 05-14-11 at 9:15 a.m., LPN #1 was observed to administer medications for resident #7. The LPN stated she was going to aspirate to make sure she was getting stomach contents. The LPN then stated she was going to give a "little bitty flush." The surveyor asked the LPN how much water was used for the flush. The LPN stated, "I've got 40 cc." After the medication administration the LPN flushed the resident's gastrotomy tube with what the LPN stated was "about 40 (cc)" of water. The LPN did not check the resident's gastrostomy placement as the facility policy documented and did not follow the physician's orders [REDACTED].