Every finding on record at Parkland Manor Living Center

Based on observation, record review, and interview, the facility failed to change oxygen tubing per the facility policy for 1 (#30) of 2 sampled residents reviewed for respiratory care. The DON identified one resident with PRN oxygen therapy. Findings: On 12/02/25 at 11:05 a.m., Resident #30 was observed in their room. The resident was observed to have oxygen per nasal cannula. There was no date on the oxygen tubing to indicate when the tubing had been changed. A Departmental (Respiratory Therapy) - Prevention of Infection policy, dated 11/2011, read in part, Change the oxygen cannulae [sic] and tubing every seven (7) days, or as needed. Medical diagnoses form for Resident #30, dated 05/13/25, showed the resident has diagnoses which included COPD, asthma, and shortness of breath. A care plan for Resident #30, dated 05/26/25, showed the resident has altered respiratory status related to asthma, COPD, and nicotine dependence. The care plan showed the resident received oxygen therapy as ordered. A quarterly MDS assessment for Resident #30, dated 11/05/25, showed the resident has a BIMS score of 10, which indicated the resident was moderately cognitively impaired. The assessment showed the resident received oxygen therapy. A physician order for Resident #30, dated 11/10/25, showed oxygen per nasal canula every eight hours PRN to keep oxygen saturation above 90%. On 12/03/25 at 11:50 a.m., Resident #30 stated they only used their oxygen as needed and did not know when the oxygen tubing had last been changed. On 12/03/25 at 12:11 p.m., LPN #1 stated the oxygen tubing was changed on the night shift once a week. LPN #1 stated residents who wore their oxygen all of the time had their tubing changed weekly. LPN #1 stated some of the residents who wore oxygen PRN just had the tubing changed PRN. LPN #1 reported Resident #30 used oxygen as needed and they only changed the tubing as needed since the resident did not use it all of the time. On 12/04/25 at 8:57 a.m., the DON provided the facility respiratory policy and stated oxygen tubing should be changed every seven days, or once a week. The DON stated Resident #30 should have a physician order to change the oxygen tubing weekly and the tubing should be changed every seven days per the facility policy.

Based on record review and interview, the facility failed to ensure accuracy of a level I PASRR assessment for 1 (#3) of 2 sampled residents reviewed for PASRR assessments.The administrator identified 32 residents resided in the facility. Findings: Resident #3 had a medical diagnosis report, dated 09/05/25, showed Resident #3 was admitted with diagnoses which included schizoaffective disorder- bipolar type and bipolar disorder.Resident #3's level I PASRR screen, dated 09/08/25, showed a primary diagnosis of chronic diastolic congestive heart failure and a secondary diagnosis of atherosclerotic heart disease. The level I PASRR screen showed the resident had no diagnosis of a serious mental illness.On 12/03/25 at 4:25 p.m., the administrator was shown the level I PASSR form and Resident #3's admission diagnoses. The administrator was asked if these diagnoses had been reported to the OHCA to see if a level II PASSR was required.On 12/03/25 at 4:30 p.m., the administrator stated the level I PASSR form was not completed correctly. They stated there was no documentation the OHCA had been notified of the serious mental illness diagnosis.

Based on record review and interview, the facility failed to ensure a resident representative was notified in a timely manner when a resident experienced a change in condition for one (#1) of three sampled residents reviewed for change in condition. The DON identified 17 residents who resided in the facility. Findings: An undated Change in a Resident's Condition or Status policy, read in parts, Our facility shall promptly notify the resident, [their] attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: It is necessary to transfer the resident to a hospital/treatment center .Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status. Res #1 had diagnoses which included pneumonitis and dysphagia. Res #1's admission record, original admitted [DATE], documented resident representative #1 was their legal guardian and first emergency contact. A quarterly assessment, dated 07/25/24, documented Res #1 had moderate cognitive impairment. A nurse note, dated 10/25/24 at 9:58 p.m., documented Res #1 was transferred via emergency services to the hospital. There was no documentation resident representative #1 was contacted regarding Res #1's change in condition and transfer. A nurse note, dated 10/26/24 (no time documented), documented Res #1's representative and legal guardian was contacted via phone call. The note documented a message was left regarding the resident's status and transfer to the hospital. A nurse note, dated 01/16/25 at 1:00 a.m., documented Res #1 was transferred via emergency services to the hospital. There was no documentation resident representative #1 was contacted regarding Res #1's change in condition and transfer. A nurse note, dated 01/16/25 at 10:05 a.m., documented Res #1's representative and legal guardian was contacted via phone call. The note documented resident representative #1 was informed of Res #1's change in condition and transfer to the hospital. On 01/27/25 at 11:25 a.m., the administrator stated the facility contacted Res #1's secondary emergency contact instead of their primary emergency contact and legal guardian upon Res #1's transfer to the hospital on 10/25/24 and 01/16/25. They stated resident representative #1 should have been notified of the change in condition and transfer to the hospital prior to other family members. On 01/27/25 at 11:45 a.m., the DON stated the facility did not contact Res #1's legal guardian immediately upon transfer to the hospital on 10/25/24 and 01/16/25, but should have. They stated staff contacted the secondary emergency contact because that family member lived closer and visited Res #1 daily. The DON stated they contacted resident representative #1 as soon as the errors were observed.

Based on observation, record review, and interview, the facility failed to ensure: a. medications were administered as ordered for one (#2); b. an accurate account of controlled medications was maintained for two (#2 and #4); and c. a physician ordered medication was available to administer for one (#4) of three sampled residents reviewed for pain. The BOM identified 17 residents with orders for pain medication resided in the facility. Findings: An undated Medication Handling Procedure policy, read in part, .The facility staff is responsible for reordering the medication when needed .The Refill Order Form serves as the system's basic form to facilitate the transfer of medication reorders . An undated Storage and Documentation of Controlled Medications policy, read in part, .All controlled medications shall be checked for accountability at each change of shift .In the event that a discrepancy is noted follow the policy with regard to pilferage . An undated Medication Discrepancies policy, read in part, .When a discrepancy is noted in controlled medication during shift count the off going nurse will investigate the possible reason for the discrepancy .If the discrepancy cannot be found the Director of Nurses is to be notified immediately and an incident report will be filled out, stating the facts and signed by both the off going and oncoming nurses. The Director of Nurses will then notify the Administrator and a formal in house investigation initiated. The Director of Nursing is to monitor closely for any forming discrepancy patterns and the consultation pharmacist notified . 1. Resident #2 had diagnoses which included DIC, pneumonia, and sepsis. Physician orders, dated 08/21/24, documented hydromorphone (pain medication) one mg/ml po q four hours prn; and Ativan (lorazepam) (benzodiazepine) 0.5 mg liquid by mouth q four hours prn. A Physician Order, dated 08/22 (the order did not contain the year), documented clarification order hydromorphone one mg/ml give one ml sublingual every four hours routine for pain relief/air hunger. A Physician order, dated 08/22/24, documented change prn lorazepam to routine lorazepam two mg/ml give 0.5 ml sublingual q four hours. It documented may give with the routine hydromorphone. The count sheet for Resident #2's lorazepam two mg/ml documented give 0.5 ml po (the PRN was marked out) q four hours for anxiety and agitation routine every four hours. It documented the last dose was administered on 08/23/24 at 10:00 p.m. with a remaining count of 13.5 ml. Under this it documented, count corrected, dated 08/23/24 at 11:30 p.m. with an 11 written beside it. There was another time entered under that with the time 11:26 p.m. The bottom of the count sheet documented can not count correct without another nurse or DON to witness. The count sheet for Resident #2's hydromorphone one mg/ml give one ml po prn q four hours for pain relief and air hunger. Under this line it documented not a prn order. It documented one dose was administered on 08/23/24 at 8:00 p.m. with a remaining count of 12. Under this it was documented count corrected 08/23/24 at 11:30 p.m. with a count of 15. It documented times of 2:00 a.m. and 6:00 a.m. with no amount administered. It documented the last dose was administered 08/24/24 at 10:00 a.m. with a remaining count of 14 ml. The bottom of the form documented can not count correct without another nurse or DON to witness and cannot scribble on any legal form. The August 2024 medication administration record did not document Resident #2's routine lorazepam or routine hydromorphone was administered on 08/24/24 at 2:00 a.m. or 6:00 a.m. It documented the routine lorazepam was administered on 08/24/24 at 10:00 a.m. and 2:00 p.m. Neither of these administrations were signed out on the count sheet. It documented the routine hydromorphone was administered on 08/24/24 at 2:00 p.m. This administration was not signed out on the count sheet. A Nurse Note, dated 08/24/24 at 3:36 p.m., documented Resident #2 was given the last dose of medications at 2:30 p.m. A Quality Assurance meeting, dated 09/06/24, documented the issues were scribbling on narc count sheet; count correcting; hospice med changes. It documented the following resolutions: a. monitor residents that were pulled by the state during complaint survey over issue; b. switch out bottles to syringes as they needed refilled; and c. DON or assignee to monitor and report findings during monthly QA. An in-service, dated 09/06/24, read in part, .All medications for [unknown resident] and [Resident #4] will be signed out and administered by a nurse & Med Aide and the MAR/TAR & Narcotic Records documented by both . An in-service, dated 09/11/24, documented scribbling-one line errors, no MAR/TAR or narc form would be scribbled on. It documented narcotic forms, a prn order would have its own form separate from a routine form. It documented when nurses began to run low on an item used for treatment or medication administration, they were to inform the CMA or the nurse to notify pharmacy provider. Neither in-service addressed an accurate account of controlled medications or what to do when a count sheet was inaccurate. On 10/30/24 at 11:30 a.m., Family Member #1 stated the facility would not take the pain medications the hospice had for Resident #2. They stated Resident #2 laid in pain for four and a half hours. They stated the facility used a pharmacy out of Ardmore and would not use the pain medicine hospice had. They stated the facility did get the same medication in that hospice had for Resident #2. On 11/01/24 at 10:22 a.m., the DON stated they had in-serviced staff on the need to document everything that happened on a count sheet. They stated staff were in-serviced that they were not permitted to correct a count alone. On 11/01/24 at 10:24 a.m., the DON stated prn medications were to have a separate count sheet than the routine medication. They stated sometimes liquid morphine could leak. They stated staff were to get the DON immediately if this happened. The DON stated the facility had requested for pharmacy to send syringes to better visualize the amount. They stated staff were to verify the label and if there were any discrepancies, they were to go to the DON to review the order and pharmacy label. They stated hospice had also been instructed they were not to make medication changes without speaking to the DON to ensure there was no confusion. On 11/01/24 at 10:25 a.m., the DON stated Resident #2's hydromorphone was not a prn order. They stated the resident had a prn order and then routine. The DON stated on the count sheet where it documented 08/23/24 and 15, LPN #1 was scribbling. The DON stated they had an in-service and went over that it was not legal or appropriate documentation. The DON stated when they went in the count was three ml over. They stated they would say the resident probably did not get their medication as ordered. The DON stated LPN #1 was written up and no longer worked at the facility. They stated the facility implemented two signatures were required when administering these types of medication and LPN #1 still did it alone. On 11/01/24 at 10:30 a.m., the DON stated LPN #1 was the person who documented the count of lorazepam going from 13.5 ml to 11 ml. They stated the count should have been 13. The DON stated the count sheet did not document the medication was administered as ordered. On 11/01/24 at 12:18 p.m., the DON stated Resident #2 was not included on the in-service dated 09/06/24. They stated the count sheets the surveyor had was the end for Resident #2's controlled medications. They stated they would look to see the reason the scheduled lorazepam was not administered. They stated they QA'd after this and they would provide the copies. On 11/01/24 at 1:45 p.m., the DON stated Resident #2's medication was not administered as ordered on 08/24/24 at 2:00 a.m. and 6:00 a.m. 2. Resident #4 had diagnoses which included multiple sclerosis and trigeminal neuralgia. A Physician Order, dated 07/24/24, documented morphine 100 mg/5 ml give 0.5 ml sublingually every two hours prn for pain/shortness of breath. Resident #4's count sheet, date received 08/21/24, documented morphine sulfate 100 mg/5 ml give 0.5 ml by mouth every four hours prn. It documented the count on 10/07/24 at 5:00 a.m. was 4 ml. It documented count correction on the next dose administered on 10/07/24 at 8:00 a.m. with an amount remaining of zero. A Physician Order, dated 08/31/24, documented morphine 100 mg/5 ml place and dissolve 0.5 ml sublingually every four hours for trigeminal neuralgia. Physician Orders, dated 10/08/24, documented clarification on morphine order, continue morphine sulfate 100 mg/5 ml give 0.5 ml sublingual every two hours prn for break through pain individual syringes, and morphine sulfate 100 mg/5 ml give 0.5 ml sublingual every four hours routinely for trigeminal neuralgia individual syringes. Resident #4's count sheet, received 10/21/24, documented morphine 100 mg/5 ml give 0.5 ml every two hours prn. It documented the last dose was administered on 10/25/24 at 6:15 p.m. with zero count remaining. On 11/01/24 at 10:35 a.m., CNA #1 stated if a resident experienced signs and symptoms of pain, they would notify the nurse and medication aide. They stated they would see if there was anything they could do to improve their comfort. On 11/01/24 at 10:40 a.m., LPN #2 stated when a resident experienced pain, they would ask the location and have the resident rate their pain if able. They stated if the pain was high enough, they would ask the resident if they wanted a pain medication and try non pharmacological interventions first to see if it helped. On 11/01/24 at 10:45 a.m., LPN #2 stated staff were to check medications three times before administering and verify all the rights. They stated if a resident refused a medication, they would ask the reason and explain any questions the resident had. On 11/01/24 at 1:30 p.m., LPN #2 was asked to explain Resident #4's morphine count sheet that went from a count of four to zero on 10/07/24. They stated with bottles, when staff tipped it over, it leaked. They stated the facility no longer did bottles only syringes. They stated when it leaked, and the count was off, they had to do a count correction. They stated when staff gave the last dose on 10/07/24 at 8:00 a.m. there was only 0.5 left in the bottle and then the count was zero. On 11/01/24 at 1:33 p.m., LPN #2 was asked to verify Resident #4's morphine count on the medication cart. There was no prn morphine available in the medication cart for Resident #4. The administrator walked by and stated they would look for it. On 11/01/24 at 1:40 p.m., the DON stated Resident #4's morphine that went from a count of four to zero was a bottle with a dropper. They stated it was leaking out because the bottle was sticky. They stated the facility was changing to syringes. The administrator stated, We started in September. The DON stated sometimes they were overfilled. The administrator stated, You can say they are 5 ml, but you look and they are not. On 11/01/24 at 1:50 p.m., the DON stated Resident #4's prn morphine was Not here. On 11/01/24 at 1:51 p.m., CMA #1 stated staff went through medications, if they were not available, staff would go check the medication storage room. They stated if the medication was not available there, they would call pharmacy and make sure they received it in the building the same day. They stated they ordered Mondays, Wednesdays, and Fridays. They stated on Tuesday and Thursday they completed a heavy narcotic order. CMA #1 stated they were not aware of Resident #4's prn morphine being out. They stated they would have called pharmacy and if pharmacy could not get it, they would have notified hospice. On 11/01/24 at 1:55 p.m., LPN #2 stated they believed the policy for ensuring medications were available to administer was to order seven days in advance to ensure there was a week of pills available.

Based on observation, record review, and interview, the facility failed to ensure medications were administered separately and PEG tube placement was verified prior to the administration of medications for one (#17) of one resident reviewed for tube feedings. The DON identified one resident who received medications via PEG tube. Findings: An Administering Medications through an Enteral Tube policy, revised November 2018, read in parts, .Verify placement of feeding tube: if you suspect improper tube positioning, do not administer feeding or medications. Notify the charge nurse or physician .Administer each medication separately and flush between medications .If administering more than one medication, flush with 15 mL warm water (or prescribed amount) between medications . Res #17 had diagnoses which included dementia, cerebral infarction, and gastrostomy. A quarterly assessment, dated 04/27/24, documented Res #17 was severely cognitively impaired, had no swallowing concerns, and received 25% or less proportion of total calories through parenteral or tube feeding. A care plan, revised 05/06/24, documented medication administration through peg tube until further notice. On 05/30/24 at 7:15 a.m., LPN #1 was observed to access Res #17's PEG tube. LPN #1 did not check residual or verify placement of the PEG tube prior to administering 30 mLs of water. LPN #1 then administered 12 routine medications that had been mixed all together in one 30 mL medication cup. On 05/30/24 at 7:20 a.m., LPN #1 was asked how they ensured the PEG tube was in the correct place prior to medication administration and if all the medications should have been given mixed together. LPN #1 stated they had checked residual earlier in the shift but should have checked again using auscultation prior to instilling any water or medications through the PEG tube. LPN #1 stated sometimes they administered each medication separately but felt administering them all at once was appropriate also. On 05/30/24 at 1:32 p.m., the DON was made aware of the medication administration observations. The DON stated the nurse should have verified correct placement of the PEG tube prior to instilling anything through it. They stated auscultation with air should have been used for placement verification. The DON stated each of the 12 medications should have been administered separately per policy.

Based on record review and interview, the facility failed to ensure the residents were free from accident hazards fro one (#8) for two residents sampled for accidents. The administrator reported 21 residents resided in the facility. Findings: On 05/29/24 at 9:55 a.m., Res #8 reported one person uses lift to transfers her most times. A monthly summary, dated 4/2/24, documented mechanical lift with 2 person assist. On 05/29/24 at 1:07 p.m., CNA #1 was asked how the resident is transferred. CNA #1 reported with the mechanical lift. CNA #1 was asked how many people transfer resident and he reported usually 2 but I can do it by myself. CNA #1 was asked if he transferred the resident by himself yesterday morning and he reported yes. On 05/29/24 at 2:03 p.m., the DON reported the mechanical lift should be used by 2 staff members with all transfers.

Based on record review and interview, the facility failed to ensure accuracy of a level I PASARR assessment for three (#8, 10, and #13) of three residents reviewed for PASARR assessments. The administrator identified 21 residents who resided in the facility. Findings: 1. Res #10 had a level I PASARR screen, dated 04/27/23, which documented a primary diagnosis of hypertensive heart disease and chronic kidney disease with heart failure and a secondary diagnosis of hemiparesis and hemiplegia. The level I PASARR screen documented the resident had no diagnoses of a serious mental illness. A medical diagnosis report, dated 05/01/23, documented Res #10 had admission diagnoses which included schizoaffective disorder- bipolar type, delusional disorders, and brief psychotic disorders. On 05/29/24 at 2:00 p.m., the DON was shown the level I PASSAR form and Res #10's admission diagnoses. The DON was asked if these diagnoses had been reported to the OHCA to see if a level II PASSAR was required. On 05/29/24 at 2:15 p.m., the DON stated the level I PASSAR form was not completed correctly. They stated there was no documentation the OHCA had been notified of the serious mental illness diagnoses. 43023 2. Res #8 was admitted to the facility with diagnosis of bipolar disorder. A PASARR Level I, dated 10/28/21, documented the resident did not have a mental health diagnosis. 3. Res #13 was admitted to the facility with diagnoses of schizoaffective disorder and major depressive disorder. A PASARR Level I, dated 10/25/22, documented the resident did not have a mental health diagnosis. On 05/29/22 at 1:55 p.m., the DON reported the PASARs were not filled out correctly and the OHCA was not notified.

Based on observation, record review, and interview, the facility failed to ensure medications were administered according to physician orders for two (#1 and #5) of six residents who were observed for medication administration. The administrator identified 21 residents who resided in the facility. Findings: A Medication Administration policy, undated, read in parts, .Ensure that the six rights of medication administration are followed: Right resident, Right drug, Right dosage, Right route, Right time, Right documentation .Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time . 1. Resident #5 had diagnoses which included type II diabetes mellitus. A physician order, dated 10/02/23, documented Humalog insulin - inject 6 units subcutaneously before meals for type II diabetes mellitus. On 05/29/24 at 12:05 p.m., LPN #2 was observed to administer Novolog insulin 6 units subcutaneously per injection to Res #5. On 05/30/24 at 1:39 p.m., the DON was made aware of the medication administration observations with LPN #2. The DON stated LPN #2 had administered the wrong type of insulin to Res #5. They stated Humalog insulin should have been administered per physician order instead of Novolog because they are not the same insulin. 2. Resident #1 had diagnoses which included chronic pain. A physician order, dated 03/11/24, documented hydrocodone-acetaminophen oral tablet 7.5/325 mg - give one tablet by mouth every 4 hours as needed for pain. On 05/30/24 at 7:50 a.m., CMA #1 was observed to administer hydrocodone-acetaminophen 5/325 mg one tablet by mouth to Res #1. On 05/30/24 at 8:52 a.m., CMA #1 was asked to compare Res #1's MAR with the medication that had been administered. CMA #1 stated the resident was administered the wrong strength of medication. CMA #1 stated Res #1 had received 5/325 mg of the hydrocodone-acetaminophen, but they should have received 7.5/325 mg per physician order. On 05/30/24 at 1:50 p.m., the DON was made aware of the medication administration observations with CMA #1. The DON stated Res #1 had received the wrong strength of medication. They stated CMA #1 should have verified the physician order with the medication prior to administration.

Based on record review and interview, the facility failed to ensure a. a PRN psychotropic medication was limited to 14 days for two (#1 and #17); b. a GDR (gradual dose reduction) was attempted for one (#15); and c. routine/PRN psychotropic medications were not received unless for a specific diagnosis for two (#15 and #17) of five residents reviewed for unnecessary medications. The administrator identified 21 residents who resided in the facility. Findings: A Tapering Medications and Gradual Dose Reduction policy, revised July 2022, read in parts, .Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs .Within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner shall attempt and GDR in two separate quarters (with at least one month between the attempts) , 1. Res #1 was admitted [DATE] with diagnoses which included schizoaffective disorder, paranoid personality disorder, and anxiety. A physician order, dated 03/11/24, documented lorazepam 0.5 mg one tablet every four hours as needed for anxiety. A MAR, dated May 2024, documented Res #1 had received lorazepam 0.5 mg once daily on 29 occasions. On 05/30/24 at 12:05 p.m., the DON stated PRN psychotropic medications should have a 14 day stop date. They stated having not realized Res #1 had received lorazepam since admission. The DON stated this medication should have been discontinued after 14 days and reordered only after the physician had assessed the resident. 2. Res #15 was admitted [DATE] with diagnoses which included dementia, anxiety, and major depressive disorder. A physician order, dated 08/08/23, documented mirtazapine 15 mg by mouth at bedtime for antidepressant. A physician order, dated 08/08/23, documented olanzapine 10 mg by mouth at bedtime for anxiety. A physician order, dated 08/08/23, documented quetiapine 12.5 mg by mouth at bedtime for depression/anxiety. A physician order, dated 08/08/23, documented buspirone 10 mg by mouth two times daily for anxiety. A physician order, dated 08/09/23, documented paroxetine 40 mg by mouth one time a day for depression/anxiety. Monthly medication regimen review reports were reviewed for August 2023 through April 2024. No recommendations for a GDR of the psychotropic medications were documented by the consulting pharmacist during this time frame. No attempts of a GDR or physician's rationale as to why a GDR was not appropriate were documented in the medical record since Res #15 was admitted to the facility. On 05/30/24 at 12:00 p.m., the DON stated no attempt of a GDR had been completed or attempted for Res #15 since admission. They stated the consulting pharmacist had not documented a recommendation of a GDR during the monthly reviews. The DON stated the physician had not documented rationale for the ongoing need for the psychotropic medications per policy. On 05/31/24 at 9:38 a.m., the DON stated anxiety was not an appropriate diagnosis for the use of olanzapine. 43023 3. Res #17 was admitted to the facility with diagnoses of dementia and anxiety. A physician's order, dated 04/08/24, documented Olanzapine 5mg give 1 tablet every 4 hours as needed for agitation. A physician's order, dated 05/06/24, documented Olanzapine 10mg 1 tablet by mouth twice a day for anxiety. On 05/31/24 at 9:35 a.m., the DON reported dementia and anxiety are not an appropriate diagnosis for Seroquel and Olanzapine. The DON reported the PRN Olanzapine should have had a 14 day stop date.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 31 opportunities were observed with two errors. The total medication error rate was 6.45%. The administrator identified 21 residents who received medications in the facility. Findings: 1. Resident #5 had diagnoses which included type II diabetes mellitus. A physician order, dated 10/02/23, documented Humalog insulin - inject 6 units subcutaneously before meals for type II diabetes mellitus. 2. Resident #1 had diagnoses which included chronic pain. A physician order, dated 03/11/24, documented hydrocodone-acetaminophen oral tablet 7.5/325 mg - give one tablet by mouth every 4 hours as needed for pain. On 05/29/24 at 12:05 p.m., LPN #2 was observed to administer Novolog insulin 6 units subcutaneously per injection to Res #5. LPN #2 stated the resident received this insulin due to the before meals physician order. On 05/30/24 at 7:50 a.m., CMA #1 was observed to administer hydrocodone-acetaminophen 5/325 mg one tablet by mouth to Res #1. On 05/30/24 at 8:52 a.m., CMA #1 was asked to compare Res #1's MAR with the medication that had been administered. CMA #1 stated the resident was administered the wrong strength of medication. CMA #1 stated Res #1 had received 5/325 mg of the hydrocodone-acetaminophen, but they should have received 7.5/325 mg. On 05/30/24 at 1:39 p.m., the DON was made aware of the medication administration observations with LPN #2. The DON stated LPN #2 had administered the wrong type of insulin to Res #5. They stated Humalog insulin should have been administered instead of Novolog because they are not the same insulin. On 05/30/24 at 1:50 p.m., the DON was made aware of the medication administration observations with CMA #1. The DON stated Res #1 had received the wrong strength of medication. They stated CMA #1 should have verified the MAR with the medication prior to administration. The DON was informed of the medication error rate of 6.45%.

Based on observation and interview, the facility failed to ensure the removal of expired/use by date medications/supplies from the medication storage room, medication cart, and treatment cart. The administrator reported 21 residents resided in the facility. Findings: On [DATE] 09:30 AM Review of the medication cart 1 bottle of house stock ibuprofen, sue by date [DATE] 1 card of vitamin C 500mg--, 7 pills, use by date [DATE] 1 card Probiotic 3 with 6 capsules, use by date [DATE] 1 card Metoprolol 25mg with 12 pills, use by date [DATE] 1 card Clonidine 0.1mg with 28 tablets, use by date [DATE] 1 card Loratadine 10mg with 20 tablets, use by date [DATE] 1 card Senna 8.6mg with 56 pills, use by date [DATE] 1 card Aspirin 81mg with 11 pills, use by date [DATE] 1 card Ibuprofen 800mg with 12 pills, use by date [DATE] 1 card Vitamin D3 2000IU with 25 tablets, use by date [DATE]. On [DATE] 09:48 AM CMA #1 reported medications should have been removed from the cart. On [DATE] 09:53 AM Review of the medication/storage room with CMA #1. 2 injections of Hepatitis B Vaccine with a use by date of [DATE] 1 vial Tubersol 5TU/0.1ml with a use by date of [DATE] 2 Bottles of Miralax Powder with a use by date of [DATE] 1 card of Clonidine 0.1mg with 31 tablets with a use by date of [DATE] 1 card of Acetaminophen 500mg with 30 tablets with a use by date of [DATE] On [DATE] 10:05 AM CMA #1 reported all medications should have been removed from the med room. [DATE] 10:06 AM Review of the treatment cart with LPN #2 2 pair 7 ,d+[DATE] sterile latex gloves with an expiration date of ,d+[DATE] 2 bottles Novolog 100u/ml with an open date of [DATE] 1 Humalog Kwickpen with an open date of [DATE] [DATE] 10:15 a.m., LPN #2 reported these items should have been removed from the cart already. 46582 Resident #5 had diagnoses which included type II diabetes mellitus. A physician order, dated [DATE], documented Humalog insulin - inject 6 units subcutaneously before meals for type II diabetes mellitus. On [DATE] at 12:05 p.m., LPN #2 was observed administering medication. LPN #2 obtained a box containing a vial of Novolog insulin from the medication cart. The box was dated [DATE]. LPN #2 obtained 6 units of insulin from the vial and administered the insulin subcutaneously to Res #5. On [DATE] at 12:10 p.m., LPN #2 was asked what the date on the insulin box indicated. LPN #2 stated the date indicated when the vial was first opened for use. They stated they did not know how long the insulin could be used after the open date. LPN #2 stated they thought the insulin could be administered up until the expiration date on the insulin vial itself. On [DATE] at 1:39 p.m., the DON was made aware of the medication administration observation. The DON stated the insulin should not have been administered. They stated the vial should have been disposed of after 30 days from the opening date on the box.

Based on record review and interview, the facility failed to ensure care plans were developed/implemented for four (#9, 19, 11, and #13,) of 14 residents sampled for care plans. The Administrator reported 21 residents resided in the facility. Findings: 1. Res #9 admitted to the facility with diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder. A care plan revised on 02/09/24, documented AIMS (abnormal involuntary movement scale) completed quarterly and PRN. A review of the resident's record documented the last AIMS was completed on 01/27/24. On 05/30/24 at 11:47 a.m., the DON reported the AIMS assessment should have been completed quarterly. 2. Res #19 was admitted to the facility with diagnoses of displaced intertrochanteric fracture of right femur and displaced fracture of base of neck of left femur. A care plan revised on 04/10/24 documented pressure censor applied to alert staff when movement is detected. A care plan revised on 04/14/24 documented assure security mat in placed at all times. On 05/30/24 at 11:37 a.m., the DON was asked about the security mat and pressure censor that is documented on the resident's care plan. She stated the pressure censor should be on his bed and the security mat was used to keep the cool air off the resident since he is in the low bed. On 05/30/24 at 11:39 a.m., the DON and this surveyor went to the resident's room to check for the pressure censor and security mat. Neither one was observed in place. The DON was asked if the care plan was being followed and she reported no it is not. 3. Res #11 was admitted to the facility with diagnoses of bipolar disorder, major depressive disorder, and anxiety. A care plan, dated 04/24/24, contained no documentation of bipolar disorder. On 05/30/24 at 11:45 a.m., the DON reported the resident's diagnosis of bipolar disorder should have been care planned. 4. Res #13 was admitted to the facility with diagnoses of schizoaffective disorder and major depressive disorder. A care planned revised on 05/22/24 contained no documentation of schizoaffective disorder. On 05/30/24 at 11:46 a.m., the DON reported the resident diagnosis of schizoaffective disorder should have been care planned.

Based on record review and interview, the facility failed to ensure the consulting pharmacist identified irregularities and/or clinically significant risks which may result or be associated with psychotropic medications for two (#1 and #15) of five residents reviewed for unnecessary medications. The administrator identified 21 residents who resided in the facility. Findings: A Tapering Medications and Gradual Dose Reduction policy, revised July 2022, read in parts, .Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs .Within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner shall attempt and GDR in two separate quarters (with at least one month between the attempts) , 1. Res #1 was admitted [DATE] with diagnoses which included schizoaffective disorder, paranoid personality disorder, and anxiety. A physician order, dated 03/11/24, documented lorazepam 0.5 mg one tablet every four hours as needed for anxiety. A MAR, dated May 2024, documented Res #1 had received lorazepam 0.5 mg once daily on 29 occasions. Monthly medication regimen review reports were reviewed for March 2024 and April 2024. No recommendations were documented that lorazepam should be limited to 14 days unless the physician documented in the medical record the rationale for extending beyond 14 days and indicated the duration for the prn order. On 05/30/24 at 12:05 p.m., the DON stated PRN psychotropic medications should have a 14 day stop date. They stated having not realized Res #1 had received lorazepam since admission. The DON stated this medication should have been discontinued after 14 days and reordered only after the physician had assessed the resident. The DON stated the consulting pharmacist had missed this in the monthly medication reviews. 2. Res #15 was admitted [DATE] with diagnoses which included dementia, anxiety, and major depressive disorder. A physician order, dated 08/08/23, documented mirtazapine 15 mg by mouth at bedtime for antidepressant. A physician order, dated 08/08/23, documented olanzapine 10 mg by mouth at bedtime for anxiety. A physician order, dated 08/08/23, documented quetiapine 12.5 mg by mouth at bedtime for depression/anxiety. A physician order, dated 08/08/23, documented buspirone 10 mg by mouth two times daily for anxiety. A physician order, dated 08/09/23, documented paroxetine 40 mg by mouth one time a day for depression/anxiety. Monthly medication regimen review reports were reviewed for August 2023 through April 2024. No recommendations for a GDR of the psychotropic medications were documented by the consulting pharmacist during this time frame. No attempts of a GDR or physician's rationale as to why a GDR was not appropriate were documented in the medical record since Res #15 was admitted to the facility. On 05/30/24 at 12:00 p.m., the DON stated no attempt of a GDR had been completed or attempted for Res #15 since admission. They stated the consulting pharmacist had not documented a recommendation of a GDR during the monthly reviews. The DON stated the physician had not documented rationale for the ongoing need for the psychotropic medications per policy.

Based on observation, record review, and interview, the facility failed to ensure physician's orders were followed for leg rest to wheelchair and pressure offload boots when out of bed for one (#19) of one resident sampled for physician's orders. The Administrator reported 21 residents resided in the facility. Findings: Res #19 was admitted with diagnoses of displaced intertrochanteric fracture of right femur, displaced fracture of base of neck of left femur, and history of falling. A physician's order, dated 5/23/24, documented add elevating leg rests to w/c d/t edema when out of bed and pressure off load boots when out of bed. On 05/29/24 at 8:38 a.m., Res #19 was observed up in w/c in dining room. The resident's legs were not elevated, and no pressure offload boots were observed. On 05/30/24 at 10:41 a.m., the resident was observed up in w/c in lobby, legs were not elevated, and no offload boots were in place. On 05/30/24 at 11:40 a.m., the resident's leg rest were observed sitting on the resident's bedside table in room and offload boots were observed under the resident's bed. The DON was asked if the staff are following physician's order and she reported no they are not.

Based on record review and interview, the facility failed to ensure accurate coding of a MDS assessment for an indwelling catheter for one (#5) of 12 residents whose MDS assessments were reviewed. The administrator identified 21 residents who resided in the facility. Findings: Res #5 had diagnoses which included cerebral infarction and hypertensive heart disease with heart failure. An annual MDS assessment, dated 01/22/24, documented the resident was cognitively intact, required maximum assistance with toileting, and had an indwelling catheter. A physician order, dated 02/26/24, documented to discontinue the foley catheter. A quarterly MDS assessment, dated 04/18/24, documented the resident was cognitively intact, dependent with toileting, and had an indwelling catheter. Res #5's records were reviewed and did not document an order for an indwelling catheter during the review period of the quarterly assessment. On 05/29/24 at 1:55 p.m., the DON stated Res #5's indwelling catheter was discontinued in February. They stated the MDS assessment was documented in error.

Based on record review and interview, the facility failed to electronically submit quarterly direct care staffing information as required by the Centers for Medicare Services (CMS). The Resident Census and Conditions of Residents form, dated 06/20/23 documented 20 residents resided in the facility. Findings: A facility policy, Reporting Direct-Care Staffing Information (Payroll-Based Journal), not dated, documented in part, .Staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act .Staffing information will be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter .Census data will be reported each fiscal quarter and will include resident census on the last day of each month of the quarter . On 06/19/23 at 11:30 a.m., during the entrance conference, the DON was informed the PBJ Staffing Data Report documented the facility had failed to submit data for the FY Quarter 2 2023, January 1 - March 31, 2023. The DON reported the facility was normally over-staffed for the resident census, and stated she thought the Administrator was responsible for reporting this data. On 06/21/23 at 9:15 a.m., the Administrator was asked about the PBJ staffing data report, which documented the facility had failed to submit data as required. The Administrator stated she was responsible for reporting the direct care staffing data and would try to provide documentation to show it had been reported. The Administrator stated she was very familiar with the reporting requirements and wasn't sure why the data was not submitted. On 06/21/23 at 4:20 p.m., the Administrator reported she was unable to gain access to the requested staffing information and could not provide documentation to show the required direct care staffing data had been submitted.

Based on observation, interview, and record review, it was determined the facility failed to thaw foods in a manner to prevent the outbreak of foodborne illness. The facility identified 31 residents who received food from the kitchen. Findings: A facility policy, dated 12/2010, documented foods would not be thawed at room temperature. On 07/30/18 at 5:05 p.m., during the initial kitchen tour, four packages of 10 smoked sausages, one package of deli ham, and one large bag of eggs were observed laying out on the counter next to the sink. Ice crystals were observed on the outside of the food packages. No thaw date was observed on the foods. Cook #1 was asked why the foods were laying on the counter. She stated they had put them out at 3:00 p.m. She stated they usually thawed foods under running water, but they did not have good water pressure today. The DM stated, Normally that is a big no-no. At 5:10 p.m., the kitchen staff was observed to place stickers with a thaw date/time on the food items and place them in the refrigerator. On 08/01/18 at 12:18 p.m., the DM was asked what thaw methods they used. She stated they thawed foods in the refrigerator or they placed the foods in the sink with water running over them. She was asked if thawing foods by laying them out on the counter was an acceptable method. She stated, No. She was asked why they had placed the smoked sausage, deli ham, and bag of eggs on the counter to thaw on 07/30/18. She stated she had placed the items on the counter and she got side tracked. She stated she had planned to put thaw stickers on the items and place them in the refrigerator to thaw.

Based on observation, interview, and record review, it was determined the facility failed to administer nebulizer treatments per current standards of practice for two (#17 and #26) of two residents who were observed to receive a nebulizer treatment. The facility identified three residents with physician orders for nebulizer treatments. Findings: An undated nebulized medication administration procedure guide documented the nurse or CMA would remain with the resident during the nebulizer treatment unless otherwise indicated in the resident's care plan. 1. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order for resident #17, dated 07/02/18, documented the resident was to receive [MEDICATION NAME] sulfate solution 2.5 mg/3 ml, one vial via nebulizer twice daily. Review of the clinical record revealed no physician's order for the self-administration of medications. On 08/01/18 at 9:43 a.m., LPN #1 was observed administering a nebulizer treatment to resident #17. LPN #1 mixed the medication per physician's orders and placed the mask on the resident. He turned the nebulizer machine on, placed the call light within reach of the resident, and left the room. LPN #1 continued administering medications to other residents. On 08/01/18 at 2:10 p.m., LPN #1 was asked who provided nebulizer treatments to the residents. He stated the nurses did. He was asked how the treatments were completed. He stated the resident's oxygen saturation was checked, lung sounds were auscultated, and the medication was administered. He was asked if they were supposed to leave the residents alone while they received a breathing treatment. He stated that he had always thought you should stay with resident only if they were really sick, like had pneumonia or something. LPN #1 was asked if resident #17 was able to administer his own breathing treatments. He stated yes, he always had. He was asked to review the resident's clinical record and tell if it documented anywhere that the resident could administer his own medication. LPN #1 stated he did not know an order was required. LPN #1 was asked what the policy was related to remaining with the resident during administration of a nebulizer treatment. He stated he would need to look at it. He was asked if he was aware that it was current standard of practice to remain with a resident during a nebulizer treatment. He stated no but he would start now. On 08/01/18 at 2:25 p.m., the DON was asked if the staff was supposed to leave a resident alone while they received a breathing treatment. She stated if the resident had been assessed to safely administer the breathing treatment and if it was care planned, they could do it on their own. She was asked if they had any residents that were able to self-administer a breathing treatment. She stated she would have to look at their care plans. She stated it should be on their care plan if they were able to do it. On 08/01/18 at 2:44 p.m., the DON was asked who monitored to ensure nebulizer treatments were completed according to current standards of practice. She stated, The nurse. She was asked why the nurses left residents while nebulizer treatments were going. She stated she could not answer that question. She was asked who monitored the nurses. She stated she did. 2. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Monthly physician orders for resident #26, dated 08/2018, documented the resident was to receive [MEDICATION NAME] sulfate nebulizer solution 2.5 mg/3 ml, one vial via nebulizer three times daily. Review of the clinical record revealed no physician orders for the self-administration of medications. On 08/01/18 at 9:43 a.m., LPN #1 was observed administering a nebulizer treatment to resident #26. LPN #1 mixed the medication per physician's orders and placed the mask on the resident. He turned the nebulizer machine on, placed the call light within reach of the resident, and left the room. On 08/01/18 at 2:10 p.m., LPN #1 was asked who provided nebulizer treatments to the residents. He stated the nurses did. He was asked how the treatments were completed. He stated the resident's oxygen saturation was checked, lung sounds were auscultated, and the medication was administered. He was asked if they were supposed to leave the residents alone while they received a breathing treatment. He stated that he had always thought you should stay with resident only if they were really sick, like had pneumonia or something. LPN #1 was asked if resident #26 was able to administer her own breathing treatments. He stated yes, she always had. He was asked to review the resident's clinical record and tell if it documented anywhere that the resident could administer her own medication. LPN #1 stated he did not know an order was required. LPN #1 was asked what the policy was related to remaining with the resident during administration of a nebulizer treatment. He stated he would need to look at it. He was asked if he was aware that it was current standard of practice to remain with a resident during a nebulizer treatment. He stated no but he would start now. On 08/01/18 at 2:25 p.m., the DON was asked if the staff was supposed to leave a resident alone while they received a breathing treatment. She stated if the resident had been assessed to safely administer the breathing treatment and if it was care planned, they could do it on their own. She was asked if they had any residents that were able to self-administer a breathing treatment. She stated she would have to look at their care plans. She stated it should be on their care plan if they were able to do it. On 08/01/18 at 2:44 p.m., the DON was asked who monitored to ensure nebulizer treatments were completed according to current standards of practice. She stated, The nurse. She was asked why the nurses left residents while nebulizer treatments were going. She stated she could not answer that question. She was asked who monitored the nurses. She stated she did.

Based on interview and record review, it was determined the facility failed to ensure one (#13) of five sampled residents who were reviewed for unnecessary medications had documented rationale for the continued order of an as needed anti-anxiety medication. The facility identified six residents as receiving anti-anxiety medications. Findings: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 05/25/18, documented the resident was severely impaired in cognitive skills for daily decision making and received an antipsychotic, antidepressant, and diuretic medications on seven of the seven preceding days. The resident's care plan, dated 05/25/18, documented a problem related to Alzheimer's dementia with behaviors. It was documented the resident could be combative and physically and verbally aggressive and resistant to care. The goal was to maintain at the resident's current level without further decline. Interventions included to administer medications as currently ordered and monitor for side effects and effectiveness. Physician orders, dated 07/2018, documented orders for [MEDICATION NAME], an anti-anxiety medication, 0.5 mg, one tablet every 24 hours as needed for anxiety. The original order was dated 06/04/18. Review of the clinical record revealed no physician documentation of the rationale for the as needed [MEDICATION NAME] order to be extended beyond 14 days from the original order. On 08/01/18 at 11:57 a.m., the DON was asked why the resident had an order for [REDACTED]. She stated she did not believe the resident was receiving the [MEDICATION NAME] though. The DON was asked if she was aware a resident could not have an order for [REDACTED]. She was asked if the rationale for the order was documented in the clinical record. She stated, I don't see it.

Based on observation, interview, and record review, it was determined the facility failed to ensure expired medications were discarded and controlled medications were properly stored in one of one medication room that was observed. The facility identified 32 residents as receiving medications. Findings: The facility's policy for storage of medication, revised 04/2013, documented, .The facility shall not use discontinued, outdated, or deteriorated drugs or biological's. All such drugs shall be returned to the dispensing pharmacy or destroyed . 1. On 08/02/18 at 11:15 a.m., a vial of influenza vaccine, with an expiration date of 04/2017, was found in the medication storage room in the refrigerator. On 08/02/18 at 11:35 a.m., the DON was asked who was responsible for ensuring there were no expired medications stored with the current stock of medications. She stated the pharmacy consultant should check monthly, and the CMAs were to check daily on every shift. She was informed of the expired influenza found in the medication room in the refrigerator. She stated, I guess that got missed. 2. On 08/02/18 at 11:15 a.m., a toolbox was observed in the refrigerator in the medication room. The toolbox contained one milliliter of topical [MEDICATION NAME], 0.5mg/ml, for resident #18. The tool box was not permanently affixed to the refrigerator. On 08/02/18 at 11:43 a.m., the DON was asked if the toolbox in the medication room refrigerator, containing a schedule II medication, was permanently affixed to the refrigerator. She stated, No.

Based on observation, interview and record review, it was determined the facility failed to ensure a resident who was admitted with no limited range of motion (ROM) did not have a decline in ROM for one (#35) of three residents reviewed for contractures. The facility failed to ensure interventions were implemented to prevent contractures for the resident, who was observed to have contractures of his fingers on both hands, his right elbow, right knee and left ankle. The facility identified four residents who had contractures. The director of nurses (DON) reported 32 residents resided in the facility. Findings: Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An undated interim care plan did not include the resident's range of motion abilities. A physical therapy evaluation, dated 03/05/16, documented the resident's functional mobility with sit to stand was moderate assist of two. The resident's gait, balance and posture was arm-in-arm, and the resident could ambulate 15 feet. A occupational therapy evaluation, dated 03/05/16, documented the resident's passive and active range of motion for both upper and lower extremities was within functional limits. A physician's progress note, dated 03/09/16, documented, The resident's lower extremities had some weakness in his lower extremities and the resident was not able to stand on his own. The resident's upper extremities had decreased range of motion and his arms seemed stiff. A physician's progress note, dated 04/20/16, documented the resident's physical therapy was stopped because of payment problems. The note documented nurses were to work with the resident a couple times a day to see if they could increase the resident's walking and activity level. A physician's progress note, dated 05/18/16, documented the facility would provide restorative care for the resident daily if physical and occupational therapy could not see the resident. A nursing restorative care program, dated 05/27/16, documented the resident would begin the following exercises: ~ parallel bars for standing three times a week for 30 days. ~ forward reaching with both hands, using a reacher three times a week for 30 days. The goal documented was to maintain current level of function for activities of daily living (ADLs) and transfers. A restorative note, dated 05/27/16, documented the resident was started on a restorative program, was to be seen for 30 days, and then re-evaluated. The restorative care record, dated June 2016, documented the resident did not complete the scheduled ROM exercises four times in June. The record documented the resident had met the goal of using parallel bars for strengthening and was discharged from the parallel bars exercise on 06/27/16. A physician's progress note, dated 06/15/16, documented the physician had encouraged the nurses and family to provide upper and lower extremity passive range of motion exercises. The restorative care record, dated 06/27/16, documented a new treatment plan for the resident. The plan documented the resident was to start ambulating more than 200 feet three times weekly for 30 days. The restorative care record, dated July 2016, documented a treatment for [REDACTED]. The record documented the resident was unable to participate with ambulation. The ambulation portion of the program was discontinued on 07/14/16. A significant change assessment, dated 07/20/16, documented the resident had a short and long term memory problem with severe memory impairment. The assessment documented the resident required extensive assistance of two people with ADLs and had no limitations in range of motion. The care plan, updated 07/22/16, did not include the resident had range of motion limitations or contractures. A care plan conference summary, dated 10/20/16, documented the resident had decreased range of motion and mobility. The restorative program continued from June through October 2016. The restorative care record for October 2016 documented the resident had met his goals and restorative services were discontinued on 10/21/16. A quarterly assessment, dated 01/20/17, documented the resident had severe cognitive impairment and required two person extensive assistance with activities of daily living, had no limitations with range of motion and did not receive restorative services. On 03/27/17 at 2:29 p.m., the resident was observed to have a contracture at the right and left hands. There were no observed splint devices in place. On 03/28/17 at 10:07 a.m., licensed practical nurse (LPN) #1 was asked if the resident had a contracture. She stated he did not have a contracture and could move his hands at times. On 03/29/17 at 10:09 a.m. certified nurse aide (CNA) #1 was interviewed regarding any restorative care the resident was receiving. She stated the resident was not receiving restorative services. She stated she was told by the restorative aide (RA) a few months ago the CNAs should perform ROM with the resident since he didn't need to be on the restorative program any more. The CNA was asked if the resident had any contractures. She stated she did not think the resident had any contractures. On 03/29/17 at 11:30 a.m., a family interview was conducted regarding any restorative services the resident was receiving. The family member reported the resident did have both physical therapy and occupational therapy when first admitted to the facility. The family member reported therapy was stopped due to insurance payment problems, and the resident was then started on restorative services shortly after therapy stopped. The family member stated restorative care was stopped sometime in October 2016. The family member stated the resident was unable to walk by the end of July 2016 and unable to use his hands to grasp anything by November 2016. On 03/30/17 at 1:33 p.m., the RA was interviewed regarding restorative care provided for resident. She stated the resident was not currently on a restorative program. She stated the resident had met his goals and was d/cd in October 2016. She was asked if the resident had any contractures. She stated she did not think the resident had any contractures. She was asked if anyone from the nursing staff had asked to have the resident started back on restorative services. She stated no one had said anything about the resident needing services again. She was asked if the resident was on a maintenance program. She stated she did not know what a maintenance program was and did not have any residents on a maintenance program. She was asked to observe the resident for contractures. She attempted to extend the resident's fingers and was unable to extend all finger joints. She reported the resident had contractures of the left pointer finger, left ring finger, right pointer finger and was unable to close or open his right hand. She attempted to extend the resident's right lower extremity and was unable to fully extend it. She stated the resident had a contracture at the right knee joint. She attempted to flex and extend the resident's ankle joints and was unable to flex or extend the left ankle. She stated the resident had a contracture of the left ankle. She was asked how she was informed when a resident needed restorative services. She stated she was informed by therapy staff or the nursing staff. She was asked if residents were re-evaluated after the resident was d/cd from restorative services. She stated she had never been asked to re-evaluate a resident in the past. On 03/30/17 at 1:50 p.m., LPN #1 was asked to observe the resident's extremities. The LPN attempted to move the resident's left fingers and was unable to fully extend the resident's pointer finger. She stated the joint was stiff and had a contracture. She attempted to move the fingers on the resident's right hand and was unable to fully extend the pointer finger. She stated the joint was stiff and had a contracture. She attempted to extend the resident's right upper extremity. She was unable to fully extend the extremity and stated the right elbow had a contracture. She attempted to extend the resident's lower extremities. She was unable to fully extend the resident's right lower extremity and left ankle joint. She stated the right lower extremity had a contracture and the left ankle joint had a contracture. She was asked how often the resident should be assessed for the development of contractures. She stated she was not sure but thought the resident should be assessed since he required the use of a mechanical lift with transfers and did not bear weight. She was asked how long the resident had the contractures. She stated she did not know. On 03/30/17 at 2:52 p.m., the minimum data set (MDS) coordinator was interviewed regarding assessments of residents with range of motion limitations. She was asked how she would be notified of a resident who had ROM limitations. She stated she was notified any time a resident was receiving therapy services, or if a resident was begun on a restorative program. She was asked how often residents should be assessed for ROM limitations. She stated each resident should be assessed for range of motion problems with each MDS assessment. She was asked if she assessed the resident for ROM problems when his last assessment was completed. She stated she had just started in her position and could not recall if she assessed the resident or not. On 03/30/17 at 3:14 p.m., the DON was interviewed regarding what interventions were currently in place to ensure residents at risk for or with ROM limitations did not develop contractures. She stated there was no system in place to identify residents at risk for contractures. She was asked how residents with range of motion problems were identified. She stated they were assessed by the MDS nurse when their assessment was due. The DON was asked about the presence of contractures with resident #35. She stated she was not aware the resident had any contractures and thought the resident looked the same as he did when she started in her position a few months prior.

Based on record review and staff interviews, It was determined the facility failed to ensure interventions were implemented to prevent falls for one (#12) of three sampled residents who were reviewed for accidents/falls. The resident had a fall on 03/03/17, which resulted in a laceration to the forehead requiring seven sutures and a fracture to the left patella. This had the potential to affect all 32 residents residing in the facility. Findings: A facility policy titled, 'Falls and Fall Risk' documented, .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. A fall risk assessment, dated 01/14/17, identified the resident was a high risk for falls with a score of 22. A score of 10 or greater indicated a high fall risk. A quarterly assessment, dated 02/11/17, documented the resident had moderate cognitive impairment, required extensive assistance from two or more staff for bed mobility, transfers, dressing, toileting, hygiene and was at risk for falls. The care plan, last updated 02/16/17, documented the resident had neurological deficits related to Parkinson's disease and weakness, impaired cognitive function and a potential for falls. An incident report, dated 02/19/17 at 12:00 a.m., documented, Res (resident) yelled for help. Upon entry into room, res was laying face down. I asked res how she got on the floor. Res stated 'I fell '. I assessed res and determined she could be moved. A nurse's note, dated 02/19/17 at 3:45 a.m., documented .small bump on left side of head, no redness noted anywhere on body. The incident report documented steps taken to prevent recurrence was to place a fall mat at the bedside. A nurse's note, dated 03/03/17 at 7:45 p.m., documented, .this nurse entered room and resident was lying on left side, head in a pool of blood .laceration noticed to middle of forehead, abrasion noted to left knee, which she complained of pain to knee she complained of pain to knee .No discoloration noted to left knee. The note documented the physician and family were notified of the fall with injury and the resident was transported to an emergency room for evaluation per the physician's orders [REDACTED]. An incident report, dated 03/03/17 at 7:45 p.m., documented, Resident was yelling out help me. This nurse entered room resident was on left side. Laceration noted to middle of forehead. abrasion noted to left knee without any swelling. Cool wash (cloth) placed to forehead, resident made comfortable on floor . The incident report documented the resident was transported to the emergency room via ambulance on 03/03/17 at 8:15 p.m., and a tab alarm was to be placed as a measure to prevent recurrence. There was no documentation in the nurse's notes or on the incident report a fall mat had been in place prior to the fall. An 'Emergency Physician Record', dated 03/03/17 at 8:35 p.m., documented the resident had a four centimeter laceration on the forehead which required seven sutures, and a skinned left knee. A nurse's note, dated 03/03/17 at 11:50 p.m., documented resident, Back in facility. Laceration to forehead received 7 stitches. Abrasion to left knee was noted. A physician order, dated 03/05/17 at 10:00 p.m., documented safety mat at beside bed at all times. A nurse's note, dated 03/06/17 at 12:30 p.m., documented Resident c/o (complained of) left knee pain reported to (name deleted physician). N.O. (new order) for xray to left hip and left knee mobile xray called, family notified. A nurse's note, dated 03/06/17 at 2:30 p.m., documented the x-ray report identified the resident had a transverse fracture to the lower third area of the patella (kneecap). The physician/family were notified of the results and the resident was sent to an emergency room for further evaluation. A nurse's note, dated 03/07/17 at 3:00 a.m., documented the resident returned to facility with splint on the left leg and new orders for pain medication every 6 hours as needed. A nurse's note, dated 03/08/17 at 3:30 a.m., documented. .safety mat and call light in place . On 03/30/2017 at 10:12 a.m., certified nurse aide (CNA) #4 was asked how she knew which residents were at risk for falls and what interventions were being used for those residents. She stated the nurses would tell the aides which resident was at high risk, and what interventions were to be used. She was asked what type of interventions were currently being used for resident #12. She stated, We have a floor mat next to her bed and her bed is kept in the low position. She was asked when the floor mat at the bedside was implemented. She stated, After her last fall. She was asked if there were any other interventions which had been used to ensure the residents safety. She stated, Yes, I check to make sure she is centered in the middle of the bed. If she is too far to the side then I will reposition her. At 1:10 p.m., an interview was conducted with licensed practical nurse (LPN) #1. She was asked how she kept staff informed of the type of interventions currently being used for residents who were at risks for falls. She stated the staff was advised when they come on duty. She further stated, Most of them already know who's at high risk for falls. She was asked what interventions were in place to ensure resident #12's safety. She stated the resident was monitored every two hours. She stated all staff observed her as they went up and down the hall, and stated a fall mat was at her bedside. She was asked how long the fall mat had been at the bedside. She stated since her last fall. She was asked when the fall mat had been ordered. She stated she thought the mat had been ordered after a fall in February. She was asked if she could recall when the mat was placed and she stated After she fell the last time.

Based on record review and interview, it was determined the facility failed to implement interventions to prevent the development of avoidable pressure ulcers for one (#7) of three residents reviewed for pressure ulcers. Within four weeks of admission, the resident, who was admitted to the facility with no pressure ulcers, had developed two stage 2 pressure ulcers, and within five weeks of admission, the resident developed two more stage 2 pressure ulcers, resulting in harm. This had the potential to affect 13 residents the facility identified to be at risk for the development of pressure ulcers. Findings: Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A nursing assessment, dated 10/03/16, documented areas of redness were present beneath the left breast and to the right and left perineal areas. An admission assessment, dated 10/10/16, documented the resident had no cognitive impairment, required extensive assistance with bed mobility, was at risk for the development of pressure ulcers and had no pressure ulcers. The assessment documented moisture associated skin damage was present. The care plan, dated 10/11/16, documented the resident was at risk for altered skin integrity. Interventions included weekly skin assessments were to be performed and the resident was to be turned and repositioned every two hours. There was no documentation the resident's skin had been assessed weekly from 10/03/16 through 10/31/16. The October and November 2016 ADL (Activities of Daily Living) sheets had no documentation the resident had been turned and repositioned every two hours. On 10/31/16, a 'Weekly Pressure Ulcer Report' documented an open area to the resident's left superior buttock measuring 2.5 cm (centimeter) x 1.2 cm x 0.1 cm, (width x length x depth) and an open area to the right superior buttock measuring 4.6 cm x 2.5 cm x 0.1 cm, both pink in color to the wound bed. A physician's telephone order documented, low air loss mattress d/t (due to) skin breakdown . On 11/01/16, a physician's telephone order documented the resident was to begin receiving Vitamin C and Zinc supplements. These supplements are used to increase nutritional status when pressure ulcers are present to assist with the healing process. On 11/03/16, the care plan was updated to include the following additional interventions: ~wheelchair cushion, ~low air loss mattress, ~vitamin c and zinc as ordered and ~Hydrogel treatments to the left and right buttocks daily There was no documentation in the nurse's notes from 10/03/16 through 11/03/16 the resident had been turned and repositioned every two hours. On 11/03/16, a weekly pressure ulcer progress report documented an open area to the right inferior buttock measuring 0.4 cm x 0.5 cm x 0.1 cm and an open area to the left inferior buttock measuring 0.5 cm x 0.2 cm x 0.1 cm, both yellow in color to the wound bed. The pressure ulcers identified on 10/31/16 remained present. On 03/30/17 at 12:45 p.m., the restorative aide was asked how the facility ensured residents did not develop pressure ulcers. She stated residents were to be turned and repositioned every two hours or more often if needed. The restorative aide was asked if she recalled resident #7 and the resident's needs related to pressure ulcer prevention. She stated the resident had needed to be assisted with turning and repositioning every two hours. She was asked how this was documented and she stated it was documented on the ADL sheets. On 03/30/17 at 1:00 p.m., licensed practical nurse (LPN) #1 was asked about the open areas for resident #7 and verified they had been stage 2 pressure ulcers. She was asked how the facility ensured residents did not develop pressure ulcers. She stated skin was assessed weekly and staff were to turn and reposition residents at risk of pressure ulcers every two hours. She was asked how this was documented. She stated turning and repositioning was to be documented on the ADL sheets and/or nurse's notes. She was advised about the lack of documentation to confirm staff had assessed the resident's skin weekly and turned and repositioned the resident. She stated she could not verify the resident had been turned and repositioned every two hours to prevent the pressure ulcers from developing.

On 02/10/14 at 12:30 p.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide an environment free of accident hazards and failure to provide supervision to prevent accidents. The existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 1:00 p.m., the administrator and director of nursing (DON) were notified of the existence of the IJ. At 4:30 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: "The facility will ensure that the resident environment remains as free of accident hazards as possible to the extent that the facility has control. I. Prevention of Accidents & Hazards A. Identify any type of closet's or rooms that could cause or be a hazard to residents and secure all doors of these closet's or rooms that are identified. B. Alarm for Back Rehab (Rehabilitation) Hall installed (that alerts staff members that someone has entered the back rehab hall) whereby they must proceed to search for the reason why the alarm was set off. C. Identify any type of closet's that could be dangerous to residents and ensure they are locked at all times. II. Methods used to show prevention of accident & hazards A. Round tools used daily to document the checking of closet or rooms that should be locked (See attached Maintenance and Administrator round tool) B. In-service all staff members on the operation of the new alarm on the Rehab Back Hall door. (See In-service sign in sheet) C. Floor plan marked to identify closets doors that should be locked (see attached floor plan) D. In-service Department supervisors on floor plan and doors that should be locked at all times to prevent accidents & hazards The facility will (ensure) residents receive adequate supervision and assistance to help prevent accidents. III. Adequate supervision for Wandering Residents (reacess (sic) these residents) A. Identify wandering residents (see elopement notebook) B. Limit the number of staff members that are on break or lunch at the same time to allow adequate supervision C. Identify types of situations that wandering residents could be at risk from (elopement, tail gating a visitor or smoker, visually check exits when alarm sounds) III. (sic) Methods used to show adequate supervision of wandering residents A. In-service staff members on wandering residents & hourly documentation B. In-service staff members on what adequate supervision means & aware of situations that could be harmful to wandering residents C. In-service employees that two care givers cannot go on break at the same (sic); their charge nurse will assign break times; or they will be subject to disciplinary action. D. Staff will not be allowed to come back to work without first receiving in-service's A,B,C listed above to be completed by 2-11-14 by 6pm. E. QA Committee review for the next several months." On 02/12/14 at 9:00 a.m., the director of nursing was asked for the in-services presented for the prevention of accidents/hazards and adequate supervision. She presented copies of the in-services presented to all staff. Topics for the in-services were: 1. Elopement book which identified residents at risk of elopement and residents who wandered, 2. North hall alarm system settings, 3. Adequate supervision of all residents with focus on resident's requiring increased care; identified residents requiring hourly checks/visualization, 4. All staff to notify charge nurse/direct supervisor before taking breaks with no more than two nursing staff, dietary or housekeeping at all times, and 5. Types of situation/incidents wandering residents could get into. The director of nursing also presented a copy of the in-service presented to nursing staff. The topic of the in-service was: all charge nurses to immediately notify administrator, director of nursing and assistant director of nursing of any resident that requires one on one assistance. At 9:30 a.m., staff member #1, a certified medication aide, was interviewed. She stated she had received in-services on 02/10/14, regarding residents who were at risk for elopement and/or wandering, adequate supervision and residents who required increased care/hourly checks/visualization, types of situations/incidents endangering to wandering residents, taking breaks/lunch to ensure adequate supervision, north hall alarm system/procedure and locations of areas that could be dangerous for wandering residents and procedures for residents requiring one on one supervision. At 9:45 a.m., staff member #2, maintenance, was interviewed. He stated he had received in-services on 02/10/14 and 02/11/14, regarding the north hall alarm system/procedure and locations of areas that could be dangerous for wandering residents, taking breaks/lunch to ensure adequate supervision, adequate supervision and residents who required increased care/hourly checks/visualization, types of situations/incidents endangering to wandering residents, and residents who were at risk for elopement and/or wandering. He identified areas that were unsafe for wandering residents. He identified areas he was to check daily to ensure doors were locked, thermostats were checked and alarm on back hall functioning. At 10:00 a.m., staff member #3, housekeeping, was interviewed. He stated he had received in-services on 02/10/14, regarding residents who were at risk for elopement and/or wandering, adequate supervision and residents who required increased care/hourly checks/visualization, types of situations/incidents endangering to wandering residents, taking breaks/lunch to ensure adequate supervision, north hall alarm system/procedure and locations of areas that could be dangerous for wandering residents. At 10:15 a.m., staff member #4, a certified nurse aide, was interviewed. She stated she had received in-services on 02/10/14, regarding residents who were at risk for elopement and/or wandering, adequate supervision and residents who required increased care/hourly checks/visualization, types of situations/incidents endangering to wandering residents, taking breaks/lunch to ensure adequate supervision, north hall alarm system/procedure and locations of areas that could be dangerous for wandering residents and procedures for residents requiring one on one supervision. At 10:30 a.m., staff member #5, a certified medication aide/medical records, was interviewed. She stated she had received in-services on 02/10/14, regarding residents who were at risk for elopement and/or wandering, adequate supervision and residents who required increased care/hourly checks/visualization, types of situations/incidents endangering to wandering residents, taking breaks/lunch to ensure adequate supervision, north hall alarm system/procedure and locations of areas that could be dangerous for wandering residents and procedures for residents requiring one on one supervision. At 10:45 a.m., staff member #6, a licensed practical nurse, was interviewed. She stated she had received in-services on 02/10/14, regarding residents who were at risk for elopement and/or wandering, adequate supervision and residents who required increased care/hourly checks/visualization, types of situations/incidents endangering to wandering residents, taking breaks/lunch to ensure adequate supervision, north hall alarm system/procedure, locations of areas that could be dangerous for wandering residents and procedures for residents requiring one on one supervision. At 11:00 a.m., staff member #7, a certified nurse aide, was interviewed. She stated she had received in-services on 02/10/14, regarding residents who were at risk for elopement and/or wandering, adequate supervision and residents who required increased care/hourly checks/visualization, types of situations/incidents endangering to wandering residents, taking breaks/lunch to ensure adequate supervision, north hall alarm system/procedure, locations of areas that could be dangerous for wandering residents and procedures for residents requiring one on one supervision. At 11:15 a.m., the director of nursing and assistant director of nursing were asked when the last staff member had been in-serviced. They stated the last staff member had been in-serviced on 02/11/14 at 4:30 p.m. The IJ was removed on 02/11/14 at 4:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with potential for more than minimal harm. Based on observation, record review and interviews, it was determined the facility failed to provide an environment free of accident hazards and failed to provide supervision to prevent an accident resulting in hypothermia for one (#1) of four sampled residents who wandered, resulting in actual harm. The facility identified five residents who wandered and were at risk for harm from environmental hazards. Findings: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A fall risk assessment completed on 01/08/14, documented the resident was at risk for falls. An 'Elopement Risk Assessment' dated 01/08/14, documented the resident was an elopement risk and often searched for his wife. Physical and occupational therapies for weakness were initiated on 01/09/14, and treatments were received five times per week. The weekly notes dated 01/13/14 through 01/17/14, and 01/31/14 through 02/07/14, documented the resident was pleasantly confused. The admission assessment, dated 01/21/14, documented the resident scored three on the brief interview for mental status, indicating severe cognitive impairment. The assessment documented the resident had impaired vision, saw large print but not regular newspaper/book print. The assessment documented the resident displayed fluctuating inattention and wandering behavior which occurred four to six days but less than daily. The assessment documented the resident was ambulatory with supervision/oversight and his balance was steady. The care plan, dated 01/22/14, documented a problem with cognitive loss/dementia and elopement risk due to searching for his wife. Interventions included all staff were to frequently observe room, to give immediate response as needed, and ensure he did not leave the front door. The care plan documented a problem with wandering in hallways and into other residents' rooms, uninvited at times, and often looked for his wife. The care plan documented the resident was moved from room #8 to room #29 due to wandering. The goal documented the resident was to be maintained in a safe environment. Interventions included all staff were to supervise closely to prevent elopement, keep resident close to area that was supervised, redirect when wandering was observed, check for whereabouts every one to two hours and ensure alarmed exits were functional at all times. The care plan documented the resident was at risk for falls due to poor vision and documented the resident ambulated unassisted in hallways. The goal documented the resident was to move about the facility without any injury from falls. Interventions included all staff were to encourage and allow the resident to walk to activities and dining room daily, and the environment was to be free from obstruction. The history and physical from (name deleted hospital) just prior to the resident's admission to the facility on [DATE], documented the resident had become more difficult to deal with and had more spells with agitation and dementia, was very emotional and temper flared. The history and physical documented the resident had been diagnosed with [REDACTED]. A nurse's note, dated 01/12/14 at 5:00 p.m., documented the resident was confused in the evening, ambulatory and frequent redirection out of other rooms was provided. Nurses' notes, dated 01/13/14, documented the resident required frequent redirection. A nurse's note, dated 01/14/14 at 3:00 a.m., documented the resident required frequent redirection back to his room. A nurse's note, dated 01/15/14 at 2:00 a.m., documented the resident was up and out of bed six times, removed clothing, went in other rooms, was confused and gait was unsteady. Nurses' notes, dated 01/16/14 at 1:00 a.m. and 01/18/14 at 4:00 a.m., documented the resident got up and removed clothing, went into other rooms and required one on one supervision full time. A nurse's note, dated 01/19/14 at 10:40 a.m., documented the resident required frequent redirection. A nurse's note, dated 01/20/14 at 1:00 a.m., documented the resident was frequently in other rooms and frequent redirection was required. A nurse's note, dated 01/21/14 at 10:30 a.m., documented the resident remained confused, wandered at times and frequent redirection was required. The family was consulted and permission was obtained for a change in rooms to another hall. A nurse's note, dated 01/22/14 at 12:45 a.m., documented the resident wandered in other rooms, removed clothing and one on one supervision was required. A nurse's note, dated 01/24/14 at 12:45 a.m., documented the resident was confused. A nurse's note, dated 01/26/14 at 10:45 a.m., documented the resident wandered, was very confused and became agitated with wife/family while they visiting, yelling and shaking his fist at them. The notes documented the resident was redirected, and one on one care was provided until the resident calmed down. The February 2014, monthly physician's orders [REDACTED]. A nurse's note, dated 02/01/14 at 2:00 a.m., documented the resident required frequent redirection. Nurses' notes, dated 02/02/14 at 10:00 a.m. and 02/06/14 at 10:00 a.m., documented the resident remained confused, ambulated unassisted in hallways and required frequent redirection. A nurses note, dated 02/07/14 at 1:00 a.m., documented the resident required frequent redirection. At 3:30 a.m., the nurse's note documented, "Summoned to res (resident) room by wife, wife states "he was getting up to use the bathroom and slid off the bed on his bottom..." The note documented the resident was assessed and no injuries were obtained. The resident was assisted to the the bathroom and back into bed. Vital signs were obtained and were within normal limits. Temperature was 98.6 degrees Fahrenheit. A nurse's note, dated 02/08/14 at 7:30 a.m., documented the resident was confused, required one on one care all day, and was trying to leave the facility. Nurses' notes dated 01/31/14 through 02/09/14, documented the resident's average temperature was 97.9 degrees Fahrenheit. A nurse's note, dated 02/09/14 at 12:00 a.m., documented the resident was lying in bed. At 3:00 a.m., the nurse notes documented, "During 0300 (3:00 a.m.) round CNA (certified nurse aide) reported to this nurse that res was not in his room. CNA states res was in bed c (with) eyes closed, @ (at) 0100 (1:00 a.m.) rounds Staff searched facility for res, this writer entered Rehab hall noted urine on floor and water down hallway, upon investigation heard water coming from hopper room, This writer tried to open hopper room door noted it was blocked able to crack door and observed res lying in floor supine position head under sink L (left) arm behind back, noted water pouring over Res coming from spout on wall, called for CNAs x 2 (two CNAs) for assist (assistance). CNA was able to push door open enough to reach hand in and move equipment Res noted unresponsive to verbal & tactile stimuli, Res noted to be breathing eyes open skin pale in color cold to touch, moved Res out to hallway Res noted c (with) soaked clothing c water, CNAs and this writer removed clothing and applied blankets to res, Res able to follow c eyes to verbal stimuli @ this time, placed call to (name deleted emergency transport service) for transport to ER (emergency room ) passive ROM (range of motion) performed s (without) difficulty or c/o (complaint of) pain (no) rotations noted (no) abnormalities (no) visible knots redness or open areas to head PERL (pupils equal reacting to light) assisted to sitting position color improving skin slightly pink, (no) visible injury noted assisted to w/c (wheelchair) able to bear wt (weight) balance impaired transferred (sic) to front lobby via w/c..." At 3:35 a.m., a nurse's note documented, "EMS (emergency medical services) in facility Res awake (no) c/o, EMS transferred (sic) to strecher (sic) and in route to (name deleted hospital) ER (emergency room )..." Records from the (name deleted receiving hospital) were reviewed. A '(name deleted hospital) Registration' documented the resident arrived at the facility on 02/09/14 at 3:45 a.m. An 'Emergency Admission Assessment' from the receiving hospital dated 02/09/14 at 4:32 a.m. documented, "...Upon arrival, pt (patient) was nonverbal, had cyanotic lower extremities, and his body temp was too low for thermometer to register...Neurologic Level of consciousness is confused. Orientation: Unable to assess...Patient is drowsy. Patient does not respond to commands...Eyes open to sound. Patient does not respond verbally. Left eye: Pupil is non reactive...Right eye: Pupil is non reactive...upper extremities are clenched tightly to body and trembling..." A NUR (Nurse) Note dated 02/09/14 at 4:00 a.m., by (name deleted) RN (registered nurse), documented, "...Pt's arms and jaws are rigid and locked tight. Skin is cold to the touch. Cyanosis noted on feet. Pt is trembling. Warm blanket and oxygen 2L (liters) NC (nasal canula) placed on pt. Pt placed on cardiac monitor. 20g (gauge) IV (intravenous) to R (right) AC (antecubital) x 4 attempts. 1L LR (Lactated Ringers solution) running wide open. Manual palpable BP (blood pressure) of 78/52, HR (heart rate) 72, RR (respiratory rate) 14, pulse ox 96%. EKG (electrocardiogram) performed (difficult to determine-pt trembling) and shown to provider..Skin tear noted to left elbow..." Vital signs were documented as following: 02/09/14 at 4:20 a.m. - Temperature was too low to register on thermometer, blood pressure was 78/52, pulse was 72, respirations were 14 and oxygen saturation was 96% with oxygen at 2 liter/minute per nasal cannula. 02/09/14 at 4:40 a.m., which was 55 minutes after arrival at the emergency room - Temperature was 95.7 degrees Fahrenheit temporal. A NUR Note dated 02/09/14 at 4:50 a.m., by (name deleted) RN, documented, "...becoming more verbally responsive. Responds to command." A 'Physician History and Physical' dated 02/09/14 at 6:54 a.m., documented [DIAGNOSES REDACTED]. Vital signs were documented as following: 02/09/14 at 6:37 a.m. - Temperature 97 Fahrenheit temporal, blood pressure was 86/58, pulse was 76, respirations were 15 and oxygen saturation was 96% with oxygen at 2 liter/minute per nasal cannula. An 'Admission Assessment' performed on 02/09/14 at 7:05 a.m. by (name deleted) RN documented, "...Level on consciousness is lethargic...responds to commands...becoming more alert since ER arrival...Patient is on cardiac monitor. Heart Rate Range: 72...Disrhythmia noted-unable to clearly interpret reading due to pt's tremors...upper extremities clenched tightly to his body...Unable to assess patient's pain level because pt still nonverbal..." A 'Provider Note' dated 09/09/14 at 11:31 a.m., documented, "Serial cardiac enzymes are elevated on 2nd draw. Spoke with pt's cardiologist (name deleted) and advised inpatient transfer to ICU (intensive coronary unit) at (name deleted hospital). A NUR Note performed on 09/09/14 at 12:00 p.m., by name deleted RN documented, "Pt transferred to (name deleted hospital) ICU..." On 02/09/14 at 9:00 a.m., an environmental tour was conducted. The door to the maintenance room was unlocked and easily opened. The room was cluttered with numerous and various tools and chemicals for cleaning. The tools were accessible, but the chemicals were behind much clutter of benches, stools, tools, and could not be accessed easily. A set of double doors, which were fire doors, was located on one of the three halls with residents' rooms. The rehab department was located by passing through these double doors. The double doors were observed with a Velcro attached cloth sign across the doors with an emblem of a stop sign and the word "STOP" inside the emblem. The doors were easily opened for access to the rehab area. There was an alarm which sounded when doors were opened but automatically stopped when the doors shut. There were also cowbells attached to the door which sounded when the door opened. The rehab hall was observed. There were no residents residing in the resident rooms located in the rehabilitation area. The hopper room, located on the east hall in the rehab area, was observed. The room was on the far end of the hall closest to an exit door. The room contained a hopper, located on the west side of the room by the north wall, stainless steel sink, located on the center of the north wall, and numerous wheelchairs and wheelchair parts, which were piled up and located on the east side of the room. There was a pipe coming out of the north wall approximately four feet from the floor between the hopper and the sink. The pipe was capped so it was nonoperational. There were two pedals near the floor beneath the pipe from the wall. The sink was connected to the wall. The hopper contained water. On 02/10/14 at 11:00 a.m., staff member #10 was interviewed. She stated she was working the hall the resident resided on the night of the incident. She stated she was aware the resident wandered into other rooms. She was asked how she ensured residents who wandered remained safe. She stated staff checked all residents every two hours on the odd hours. She was asked if this was often enough for residents who wandered and she stated most of the time. She stated she was aware the double doors to the rehab area were not locked and could be easily opened. She was asked if the unlocked doors could be a hazard to wandering residents and she stated yes. At 1:00 p.m., staff member #11 was interviewed. She stated she was aware the resident wandered into other rooms. She was asked how she ensured residents who wandered remained safe. She stated staff checked all residents every two hours on the odd hours. She was asked if checking resident #1 every two hours was adequate to ensure his safety. She stated she thought it had been often enough. She stated she was aware the double doors to the rehab area were not locked and could be easily opened. She was asked if the unlocked doors could be a hazard to wandering residents and she stated yes. She stated there had been cow bells on the door to alert staff when the door opened, but could not always be heard if staff were not near. At 1:15 p.m., staff member #12 was interviewed. She stated she was aware the resident wandered into other rooms. She was asked how she ensured residents who wandered remained safe. She stated staff checked all residents every two hours on the odd hours. She stated some residents, including resident #1, needed to be checked more often, because he usually got up from bed during the night more often and wandered unaware of his surroundings into other rooms, usually around 3:00 a.m. to 5:00 a.m. She stated she was aware the double doors to the rehab area were not locked and could be easily opened. She was asked if the unlocked doors could be a hazard to wandering residents. She stated yes. She stated there had been cow bells on the door to alert staff when the door opened, but could not always be heard if staff were not near. On 02/12/14 at 9:30 a.m., staff member #2 was interviewed. The staff member was asked how he ensured the facility was free of accident hazards. He stated doors in the facility that residents should not have free access to, such as rooms with chemicals and equipment, were to be locked at all times. He stated he was to check those doors three times weekly to ensure they remained locked. He stated all the doors in the rehab area were to remain locked at all times, including the door where resident #1 had been found. He stated the door to the rehab room located in the rehab area was unlocked only when staff was working with residents. On 02/12/14 at 9:10 a.m., staff member #2 was asked about the air temperature and cold water temperature of the rehab area. He stated the thermostat was set at 72 degrees Fahrenheit during the week and 70 degree Fahrenheit for the weekend. He was asked about the temperature of the water from the pipe in the hopper room that had run onto the resident. He stated the pipe was cold water only. The temperature of the cold water was obtained at that time and observed to be 47.7 degrees Fahrenheit. The staff member was asked about the door to the hopper room where the resident had been found. He stated he had unlocked the door the week prior on 01/30/14, and did not realize the door did not lock when it closed as the room was exited. He stated he has a checklist that he checks every Monday, Wednesday and Friday that includes checking all doors that are to be locked. He stated the hopper room should have been locked. He provided the surveyor with a checklist dated 01/29/14, and stated that date was when all doors had last been checked. The staff member was asked if he performed any maintenance to the rehab hall and/or hopper room after the resident was found in the hopper room. He stated he came to the facility that day, mopped the water from the floor and used fans to help dry the floor. He was asked how much water was on the floor. He stated the water had run out from the hopper room into the hallway and then down the north side of the hallway approximately 35 feet into three unoccupied resident rooms to the bathroom doors in those resident rooms.

Based on record review and interview, it was determined the facility failed to maintain the highest practicable well being of a resident who had intractable diarrhea for one (#30) of 24 sampled residents. This resulted in actual harm to the resident. This had the potential to affect all 35 residents who resided in the facility. Findings: Resident #30 had [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident had severe cognitive impairment, was frequently incontinent of bladder and bowel, and was on a toileting program to manage her bowel continence. Nurse's notes documented the following: ~ on 11/27/13 at 5:00 p.m., the resident had a temp of 102.3 degrees Fahrenheit, ~ on 11/30/13 at 5:00 a.m., the resident had two loose stools, ~ at 7:35 a.m., the resident was incontinent of loose stools, ~ on 12/01/13 at 2:00 a.m., the resident had two loose stools, ~ at 2:00 p.m., the resident had two loose stools and had poor food and fluid intake, ~ on 12/02/13 at 12:30 a.m., the resident had loose stools, ~ at 10:45 a.m., the resident continued to have loose stools, and ~ on 12/03/13 at 7:45 a.m., "...Res (resident) in dining room for breakfast @ this time. Not eating or drinking...Lethargic, not responding to verbal stimuli, sliding down in w/c (wheelchair), skin color pale/ashen color. Skin turgor sluggish...res to (Hospital name deleted) ER (emergency room )..." A history and physical dated 12/03/13, documented the resident was hospitalized for [REDACTED]. She received intravenous antibiotics while in the hospital. On 01/31/14 at 2:22 p.m., staff member #1 was asked about the resident having the loose stools . She stated the resident did have diarrhea and there was [MEDICAL CONDITION] going around the facility at the time. On 02/04/14 at 10:31 a.m., staff member #7 was asked what should be done for a resident with a temperature and/or loose stools that would not subside. She stated if you had a resident with loose stools, you would notify the physician. If they had three loose stools you would call the attending physician and notify him. She stated if a resident had a temperature she would take a full set of vital signs and notify the attending physician. She stated if a resident did not have an order for [REDACTED].

Based on observation, record review, and interview, it was determined the facility failed to: a. ensure one (#30) of four sampled residents reviewed for falls, were free from falls and injury. This resulted in actual harm to the resident. The facility identified 18 residents as being at risk for falls, and b. ensure bathroom call lights were accessible for two (#5 and #37) of 27 residents, who utilized the bathroom, whose bathrooms were observed. This had the potential to affect 32 residents identified by the facility as utilizing the bathrooms. Findings: 1. Resident #30 had [DIAGNOSES REDACTED]. On [DATE], a fall risk assessment was completed. The resident's score was 15, which indicated she was a high risk for falls. The facility's incident reports documented the resident had the following falls: ~ on [DATE] at 9:40 a.m., she fell in the hallway with no apparent injury. An intervention to prevent reoccurrence was for physical therapy (PT) to evaluate and treat, and ~ on [DATE] at 1:45 p.m., she fell in her room beside her bed while putting her panties on. There was no apparent injury. An intervention to prevent reoccurrence was that staff oriented the resident to her walker. A telephone order, dated [DATE], documented the resident was to have a PT/OT (occupational therapy) evaluation for therapy. An incident report, dated [DATE] at 5:00 p.m., documented the resident had an observed fall without injury in another resident's room while attempting to sit on the edge of the bed. An intervention to prevent reoccurrence was to ensure the resident had non skid footwear on at all times. A PT plan of treatment documented the resident began PT services on [DATE], five days after therapy was ordered. An OT plan of treatment documented the resident began OT services on [DATE], six days after therapy was ordered. An admission assessment, dated [DATE], documented the resident had severe cognitive impairment and was frequently incontinent of urine and bowel. She required supervision/set-up assistance only with bed mobility, transfers and ambulation. Her balance during transitions and walking was steady at all times. She had no functional limitations in range of motion and required no mobility devices. Her fall history prior to admission to the facility was undetermined, however, she had no fractures related to a fall in the six months prior to admission. The resident had two falls without injury since her admission. The resident had exhibited wandering behavior on a daily basis which significantly intruded on the privacy and/or activities of other residents. A care plan, dated [DATE], and last updated on [DATE], documented: .Problems.has a potential for falls related to generalized weakness and dementia .XXX[DATE] - Res. (resident) remains @ (at) risk for falls, cont (continue) current POC (plan of care). .Goals.will have no injuries from falls through next review .Interventions.encourage and allow independence .keep corridors, rooms well lighted .keep call light within easy reach and answer promptly .XXX[DATE] - PT to eval (evaluate) & tx (treat) .XXX[DATE] - Ensure non-skid footwear on @ all times .XXX[DATE] - Assist res c (with) ambulating as needed to prevent future falls. make sure res wears non skid socks or/and shoes. .XXX[DATE] - Make sure spills are cleaned up to avoid falls. make sure res wearing non-skid sock (sic) and/or shoes @ all (times). Enc. (Encourage) res. to ask for assist if feeling weak or help is needed. Freq. (Frequent) reminders from staff for res to (change) positions slowly .XXX[DATE] - Encourage resident not to sit on stools but in regular chairs d/t (due to) the wheels on the stools .XXX[DATE] - Encourage res to use w/c (wheelchair) instead of walking around s (without) assistance esp (especially) when weak. Enc. Res to wear non-skid shoes & socks at all (times) .XXX[DATE] - tab alarm - cont B&B (Bowel & Bladder) program q (every) 2 (hours) prn cont restorative therapy .XXX[DATE] - Utilize tab alarm at all times to alert staff of resident attempting to transfer self d/t hx (history) of falls .XXX[DATE] - Reinforced c CNA B/B program & res has to be assisted c toileting q 2 (hours) & prn (as needed). Especially p (after) meals. Tab alarm @ all times .XXX[DATE] - Enc. res to ask for assistance. Also enc. use of w/c & make sure tab alarm in place .XXX[DATE] - make sure bed alarm/chair is on and (in) working condition. Enc. res to use call light. Ensure call light is in reach of res @ all times .XXX[DATE] - ensure tab alarms are functioning & in place @ all (times) staff to freq. remind & redirect res. while (up) in w/c .XXX[DATE] - .safety mat & low bed. The facility's incident reports documented the resident had the following falls: ~ on [DATE] at 7:15 a.m., she fell with no apparent injury. Interventions to prevent reoccurrence were to assist the resident with ambulation as needed and to make sure the resident wears non skid socks and/or shoes, ~ on [DATE] at 9:40 a.m., she fell while getting up from a dining room table with no apparent injury. Coffee was observed on the floor beside the resident. Interventions to prevent reoccurrence were to make sure spills were cleaned up, encourage the resident to ask for assistance and for frequent reminders from staff for resident to change position slowly, ~ on [DATE] at 7:35 a.m., she was found on the couch in her room with blood observed on the bathroom floor and on the back of her head. She was sent to the ER (emergency room ) for evaluation and treatment. Interventions to prevent reoccurrence were to cont (continue) on bowel and bladder program, cont PT, non skid footwear and change her Xanax (anti-anxiety medication) administration time from a.m. to bedtime, ~ on [DATE] at 4:35 p.m., she fell while trying to sit on a rolling stool in the dining room and it slid out from under her. There was no apparent injury. An intervention to prevent reoccurrence was to encourage res not to sit on stools but in regular chairs, ~ on [DATE] at 8:15 a.m., she fell with no apparent injury. She was wearing shoes which were too small with slick soles. An intervention to prevent reoccurrence was her shoes were changed to a pair that fit with non slick soles, ~ on [DATE] at 1:00 p.m., she fell after standing up from dining room table. She stumbled over her house shoe and had no apparent injury. Staff changed her house shoes to more steady shoes. An intervention to prevent reoccurrence was for staff to ensure proper footwear, non skid footwear was on at all times, and ~ on [DATE] at 5:30 p.m., resident slid off of couch in her room with no apparent injury. An intervention to prevent reoccurrence was, res has been known to sit in floor purposefully in past. A telephone order, dated [DATE], documented, .D/C (discontinue) PT/OT services on [DATE] (secondary) to pt (patient) reaching max (maximum) rehab (rehabilitation) potential @ this time. Restorative recommended to maintain.strength, ADL's (activities of daily living) & transfers. A RESTORATIVE NURSING SCREEN, completed on [DATE], documented the resident had falls during the past 30 days and during the past 31 to 180 days. She was a fall risk and had memory problems and dementia. She was independently ambulatory. The facility's incident reports documented the resident had the following falls: ~ on [DATE] at 10:30 a.m., she fell in the front lobby with no apparent injury. Interventions to prevent reoccurrence were to encourage the resident to use wheelchair instead of walking around without assist especially when weak and to encourage nonskid footwear, ~ on [DATE] at 12:45 p.m., she fell in the dining room with no apparent injury. Interventions to prevent reoccurrence were to encourage the resident to ask staff for assist when feeling weak or dizzy and to ensure she was wearing non skid footwear, ~ on [DATE] at 1:45 p.m., she fell in the lobby by a recliner. She had a laceration to her left eyebrow area. First aide was administered. She appeared to be getting out of the recliner and slipped in the house shoes she was wearing. Interventions to prevent reoccurrence were to encourage the resident to stay seated and ask for assistance, to have a tab alarm on at all times, to cont with bowel and bladder program every two hours and as needed and to cont restorative therapy, and ~ on [DATE] at 1:45 p.m., she fell with no apparent injury. Interventions to prevent reoccurrence were to reinforce with CNA (certified nursing assistant) that the resident was on a bowel and bladder program which required her to be assisted with toileting every two hrs and as needed especially after meals and for a tab alarm to be on her at all times. A nurse's note dated [DATE] at 1:45 p.m., documented, .W/C utilized for long distances to & from dining. A restorative care flow record documented the resident began to receive restorative services on [DATE], 14 days after the order for restorative was received. A quarterly assessment, dated [DATE], documented the resident had severe cognitive impairment and was frequently incontinent of urine and bowel. She required supervision/set-up assistance only with bed mobility, transfers and ambulation. Her balance during transitions and walking was steady at all times. She had no functional limitations in range of motion and required no mobility devices. The resident had two falls without injury and two falls with minor injury since the prior assessment. The resident continued to exhibit wandering behavior on a daily basis. A monthly nursing summary dated [DATE], documented the resident was to be in a wheelchair at all times when up. An incident report dated [DATE] at 8:10 a.m., documented the resident had a fall with no injury. Interventions to prevent reoccurrence were to encourage the resident to ask for assistance, use wheelchair and make sure the tab alarm was in place. The clinical record documented the resident was in the hospital from [DATE] to [DATE], for severe dehydration, urinary tract infection and sepsis. The resident returned to the facility on [DATE], with physician's orders [REDACTED]. Therefore, on [DATE], restorative nursing services were discontinued. The facility's incident reports documented the resident had the following falls: ~ on [DATE] at 2:10 p.m., she fell in her room by her bed with no injury. Interventions to prevent reoccurrence were to make sure bed and chair alarms were on and in working condition, to encourage resident to use her call light and to make sure call light was in reach at all times, ~ on [DATE] at 10:45 a.m., she had a witnessed fall in the front lobby with no apparent injuries. Interventions to prevent reoccurrence were to ensure tab alarms were functioning and in place at all times and for staff to frequently remind and redirect the resident while in her wheelchair, and ~ on [DATE] at 7:20 a.m., she fell in her room beside her bed. A laceration was observed to her right eye. She was sent to the ER for evaluation. Interventions to prevent reoccurrence were to ensure the bed and chair alarm were on the resident and in working condition, received a new order for a low bed with safety mat, to make sure call light was in reach and to continue restorative therapy and bowel & bladder program. On [DATE], a fall risk assessment was completed. The resident's score was 25 which indicated a high risk for falls. The resident expired on [DATE]. On [DATE] at 1:55 p.m., staff member #10 was asked about the functional status of the resident. She stated the resident was ambulatory when she was admitted . The staff member stated, She (the resident) was a fall risk so we encouraged her to use a wheelchair. At 2:22 p.m., staff member #1 was asked about the resident's functional status. She stated the resident was ambulatory when admitted to the facility. The staff member stated, She told me straight up when she first got here she was a fall risk. The staff member was asked if the resident could remember things like being told to ask for assistance when getting up. She stated, No, she couldn't remember anything. On [DATE] at 10:31 a.m., staff member #7 was asked about the resident's functional status. She stated when first admitted , the resident could ambulate, but she fell a lot. She stated the resident was placed in a wheelchair about three weeks into her stay. The staff member was asked about the resident's cognitive status. She stated the resident could not carry on a conversation. She stated the resident was not be able to use a call light. The staff member was asked if the resident could remember to wear non skid footwear. She stated no. She stated the resident had a whole slew of shoes and would wander into other resident's rooms and put on their shoes. She was asked who was responsible for making sure the resident wore proper shoes. She stated, The direct care staff. At 11:00 a.m., staff member #4 was asked about the OT evaluation taking six days from the date ordered to be completed. She stated evaluations for therapy should be done within 24 to 48 hours after ordered. On [DATE] at 11:50 a.m., staff member #4 was asked if the interventions put in place to prevent reoccurrence of falls for the resident were appropriate. After looking at the care plan, she stated, No, they used the same interventions over and over again. She also stated with her impaired cognitive status the resident could not remember to use her call light or put on non-skid shoes and/or socks. The staff member was asked why the resident was placed in a wheelchair while still ambulatory. She stated it was so staff did not have to watch her as closely. At 2:00 p.m., staff member #11 was asked about the PT evaluation not being done for five days after therapy was ordered. She was unable to give a reason for why the therapy was not started sooner. She stated the nurses did not always let the therapists know about the orders for therapy right away. 2. Resident #5 had [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident had severe cognitive impairment and required limited assistance of one person with transfers and toilet use. Balance during moving from seated to standing position and when moving on and off the toilet was not steady, but she was able to stabilize herself without human assistance. She utilized a wheelchair for mobility and was independent in locomotion. She had no falls since the prior assessment. A care plan, last updated on [DATE], documented the resident had a potential for falls related to her impaired mobility and [DIAGNOSES REDACTED]. The resident's clinical record and the facility's incident reports documented the resident had falls on [DATE] and [DATE]. Neither fall occurred in the bathroom. On [DATE] at 11:21 a.m., an observation was made of the call light in the bathroom of resident #5. The call light was observed to have no cord attached to the call light that reached the floor, to use in an emergency. At 4:40 p.m., staff member #7 was asked if the resident was able to toilet herself. She stated the resident required some toileting assistance however, the resident toileted herself. The staff member was asked how the resident would notify staff if she were to fall in the bathroom. She stated the resident was able to and had pulled the call cord for assistance. The surveyor and staff member went to the resident's room. The resident was in the bathroom transferring herself from the toilet to her wheelchair without difficulty. The surveyor then showed the staff member the call light in the bathroom with no cord attached. The staff member stated, I don't know what happened to the cord. It was there Sunday. The staff member stated the call light would be inaccessible to the resident should she fall. At 5:00 p.m., staff member #3 was asked if the resident was able to toilet herself. She stated the resident was able to toilet herself sometimes but also required assistance at times. She stated the staff encouraged the resident to ask for assistance but the resident frequently forgot to ask for assistance. Staff member #3 was asked if the resident was able to use the call light in the bathroom. The staff member stated the resident was able to and did use the call light in her bathroom when assistance was needed. 3. An observation was made on [DATE] at 11:04 a.m., of the call light cord in the bathroom of resident #37. The cord was approximately 5 inches long. At 4:40 p.m., staff member #4 was asked if the resident used her call light. She stated not very often. She stated the resident was in the front lobby most of the time. She was asked if the resident had ever fallen in the bathroom. She stated yes. She was asked how the resident called for assistance when in the bathroom. She stated the resident would use the call light to call for help. The staff member was shown the call light cord in the bathroom. She stated, Oh, that's a problem.

Based on record review and interview, it was determined the facility failed to ensure an avoidable pressure ulcer did not develop for one (#30) of three sampled residents who currently or previously had pressure ulcers. This resulted in actual harm to the resident. The facility identified two residents who currently had pressure ulcers. Findings: Resident #30 had [DIAGNOSES REDACTED]. An admission assessment, dated 08/20/13, documented the resident had severe cognitive impairment. She required supervision/set-up assistance only with bed mobility, transfers and ambulation. Her balance during transitions and walking was steady at all times. She had no functional limitations in range of motion and required no mobility devices. She was frequently incontinent of urine and bowel. She was at risk for pressure ulcers, however, she had no pressure ulcers or other ulcers, wounds or skin problems. A care plan dated 08/21/13, documented the resident had the potential for impaired skin integrity related to her being incontinent of bowel and bladder. An incident report, dated 11/15/13, documented the resident had a fall. One of the interventions to prevent reoccurrence was to encourage the resident to use a wheelchair instead of walking around without assistance. A nurse's note dated 11/17/13 at 1:45 p.m., documented, "...W/C (wheelchair) utilized for long distances..." A quarterly assessment, dated 11/20/13, documented the resident had severe cognitive impairment. She required supervision/set-up assistance only with bed mobility, transfers and ambulation. Her balance during transitions and walking was steady at all times. She had no functional limitations in range of motion and required no mobility devices. She was frequently incontinent of urine and bowel. She was at risk for pressure ulcers, however, she had no pressure ulcers or other ulcers, wounds or skin problems. A monthly nursing summary dated 11/20/13, documented the resident was to be in a wheelchair at all times when up. The resident's care plan, updated on 11/20/13, documented, "...remains incontinent c (with) potential for impaired skin integrity. Cont (continue) current POC (plan of care)..." No new interventions for the prevention of pressure ulcers were implemented when the resident was placed in a wheelchair. An incident report dated 11/23/13, documented the resident had a fall. One of the interventions to prevent reoccurrence was to encourage the resident to use a wheelchair. A nurse's note, dated 11/25/13 at 3:00 p.m., documented the resident had an open area to the coccyx which measured 1 cm (centimeters) by 0.2 cm and new orders were received for a treatment. This was ten days following the initiation of a fall intervention for the resident to use a wheelchair instead of walking around without assistance. On 02/04/14 at 10:31 a.m., staff member #7 was asked about the resident's pressure ulcers. She stated she had seen one on the resident's buttocks that was half dollar in size. It was a stage II or stage III, with a lot of white slough. The staff member stated when the resident was up in the wheelchair she was constantly moving and the staff was constantly pulling her up in her wheelchair. She stated that constant motion could have been indicative of potential shearing of the resident's skin. She stated the facility staff placed the resident in a wheelchair for about three weeks. She stated the staff would put her in the wheelchair and if she wasn't doing well they would put her in a recliner. On 02/05/14 at 11:50 a.m., staff member #4 was asked why the resident was placed in a wheelchair while still ambulatory. She stated so staff did not have to watch her as closely.

Based on record review and interview, it was determined the facility failed to ensure one (#30) of one sampled resident with intractable diarrhea received adequate fluids to prevent dehydration. This resulted in actual harm. This had the potential to affect all 35 residents who resided in the facility. Findings: Resident #30 had [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident had severe cognitive impairment, was frequently incontinent of bladder and bowel, and was on a toileting program to manage her bowel continence. Nurse's notes documented the following: ~ on 11/27/13 at 5:00 p.m., the resident had a temp of 102.3 degrees Fahrenheit, ~ on 11/30/13 at 5:00 a.m., the resident had two loose stools, ~ at 7:35 a.m., the resident was incontinent of loose stools, ~ on 12/01/13 at 2:00 a.m., the resident had two loose stools, ~ at 2:00 p.m., the resident had two loose stools and had poor food and fluid intake, ~ on 12/02/13 at 12:30 a.m., the resident had loose stools, ~ at 10:45 a.m., the resident continued to have loose stools, and ~ on 12/03/13 at 7:45 a.m., "...Res (resident) in dining room for breakfast @ this time. Not eating or drinking...Lethargic, not responding to verbal stimuli, sliding down in w/c (wheelchair), skin color pale/ashen color. Skin turgor sluggish...res to (Hospital name deleted) ER (emergency room )..." A history and physical dated 12/03/13, documented the resident was hospitalized for [REDACTED]. She received intravenous antibiotics while in the hospital. A nurse's note, dated 12/16/13, documented the resident returned to the facility. A nurse's note, dated 12/19/13 at 12:30 a.m., documented the resident required assistance for nutrition, hydration, toileting, transferring, and adls (activities of daily living). A care plan, last updated on 12/23/13, did not address the resident's increased risk for dehydration during the time frame of the resident's diarrhea and urinary tract infection. No plan was implemented to address how each shift was going to ensure the resident received the required fluids necessary to prevention dehydration during this time period. A nurse's note, dated 12/28/13 at 11:55 a.m., documented the resident returned to the facility from the ER (emergency room ). The note documented the resident's daughter told staff the hospital told her the resident had an UTI. A nurse's note dated 12/30/13 at 9:00 a.m., documented, "...New order for [MEDICATION NAME] (antibiotic)...for UTI..." The clinical record contained no documentation of amounts of fluids given and taken by the resident. On 02/05/14 at 3:13 p.m., staff member #4 was asked whether a plan to prevent dehydration should have been initiated. She stated a temporary care plan should have been developed to include the amount of fluids to be given each shift and the amount taken should have been documented.

Based on record review and interview, it was determined the facility failed to notify the attending physician of a resident developing diarrhea and an elevated temperature (temp) for one (#30) of 20 sampled residents. This resulted in actual harm to the resident. This had the potential to affect 35 residents who resided in the facility. Findings: Resident #30 had [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident had severe cognitive impairment, was frequently incontinent of bladder and bowel, and was on a toileting program to manage her bowel continence. Nurse's notes documented the following: ~ on 11/27/13 at 5:00 p.m., the resident had a temp of 102.3 degrees Fahrenheit, ~ on 11/30/13 at 5:00 a.m., the resident had two loose stools, ~ at 7:35 a.m., the resident was incontinent of loose stools, ~ on 12/01/13 at 2:00 a.m., the resident had two loose stools, ~ at 2:00 p.m., the resident had two loose stools and had poor food and fluid intake, ~ on 12/02/13 at 12:30 a.m., the resident had loose stools, ~ at 10:45 a.m., the resident continued to have loose stools, and ~ on 12/03/13 at 7:45 a.m., "...Res (resident) in dining room for breakfast @ this time. Not eating or drinking...Lethargic, not responding to verbal stimuli, sliding down in w/c (wheelchair), skin color pale/ashen color. Skin turgor sluggish...res to (Hospital name deleted) ER (emergency room )..." A history and physical dated 12/03/13, documented the resident was hospitalized for [REDACTED]. She received intravenous antibiotics while in the hospital. On 01/31/14 at 2:22 p.m., staff member #1 was asked about the resident having loose stools. She stated the resident did have diarrhea and there was [MEDICAL CONDITION] going around the facility at the time. On 02/04/13 at 10:31 a.m., staff member #7 was asked what she would do if a resident had a temperature or loose stools. She stated if a resident had an elevated temperature, she would take a complete set of vital signs and if the resident did not have anything ordered for the temp she would call the physician. The staff member stated if a resident had three loose stools, she would notify the physician. She stated the resident's primary care physician did not have standing orders for diarrhea.