Every finding on record at Rainbow Health Care Community and Rainbow Assisted

Based on observation, record review, and interview, the facility failed to ensure food was not served beyond their expiration date. The administrator identified 84 residents received nourishment from the kitchen. Findings: On 06/15/26 at 12:38 p.m., the following observations were made during the tour of the kitchen:a. in the refrigerator, an opened one-gallon container of tartar sauce was observed to be dated 01/20/26, handwritten on the lid. The container had a manufacture date of 12/06/25, and b. in the walk-in cold storage, an unopened half-gallon container of buttermilk was observed with a best-by of 06/01/26. An unopened gallon container of whole milk was observed with a best-by date of 06/11/26. A policy titled Refrigeration, revised 08/21/24, read in part, Ensure food storage and safety practices are maintained and monitored and comply with Federal and State regulations governing food storage and safety. On 06/15/26 at 12:52 p.m., the dietary manager stated the tartar sauce should have been disposed of long ago. The dietary manager stated expired milk products were to be placed in a crate with tape over it to indicate they were expired. The dietary manager stated the expired milk products were not in a crate with tape over it to indicate they were expired.

Based on observation and interview, the facility failed to ensure the most recent survey results of the facility were posted in a place readily accessible to residents, family members and legal representatives of residents.The DON reported 75 residents resided at the facility.Findings:On 07/23/25 at 10:52 a.m., the survey results binder was observed to be sitting on the ledge of a half wall between the receptionist's desk and the common room used for activities. A small end table, a soda machine, and a large circular dinner table were blocking access to the binder on one side, and the other side was only accessible from behind the receptionist's desk. On 07/23/25 at 10:46 a.m., all four residents that attended the resident council meeting stated they did not know anything about the survey results binder, nor did they know where to find it, but they would be interested in reading the results. On 07/23/25 at 10:54 a.m., the administrator stated someone had not moved the table back to its correct position after the residents completed their exercise activity at 10 a.m. The administrator stated most activities were done in that area and the large circular table would need to be moved against the wall to provide enough space. The administrator stated residents could go behind the receptionist's desk to gain access to the binder.

Based on observation, record review, and interview, the facility failed to ensure a controlled medication was secured in a locked container that was permanently affixed to the building for 1 (#14) of 1 sampled resident reviewed for medication storage.The DON reported 75 residents at the facility were administered medications at the facility.Findings:On 07/23/25 at 1:00 p.m., CMA #3 was observed entering the facility medication storage room while the surveyor was conducting their inspection inside the room. CMA #3 was observed opening a refrigerator unit. A small black lock box approximately 7 inches square and 2 inches deep was observed inside the unit. The refrigerator door did not have a lock on it.On 07/24/25 at 12:00 p.m., CMA #1 was observed to enter the facility medication storage room, opened the refrigerator which contained the small black lockbox. The CMA was observed to be able to remove the lockbox from the refrigerator as the lockbox was not secured to the refrigerator by any means.A facility policy titled Medication Storage in the Facility, dated 2024, read in part, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier.A facility document titled Individual Patients Narcotic Record, showed Resident #14 had a supply of 10 Lorazepam concentrate 2mg per milliliter syringes available at the facility. The document also had the handwritten word, Fridge, located in the upper right corner of the document.On 07/24/25 at 12:30 p.m., LPN #1 was asked to open the small black lockbox stored in the refrigerator located in the facility medication storage room. LPN #1 obtained the lockbox and opened it. They stated the lockbox contained 10 prefilled Lorazepam (a benzodiazepine) syringes that belonged to Resident #14. LPN #1 was asked who had keys to the lockbox. They stated the charge nurse on duty had keys to the lockbox. They were asked who had access to the medication room and the contents of the refrigerator. LPN #1 stated the nurses and CMAs on duty had access to the medication room and the refrigerator.On 07/24/25 at 3:00 p.m., the DON was asked to explain the system in place to secure Resident #14's Lorazepam supply located in the medication room. They stated the medication room was locked and they believed either the refrigerator, or the small lockbox had a lock on them but were not sure which. The DON stated they were unaware of the necessity of container which held controlled medications needed to be permanently affixed. The DON stated they agreed the black lockbox that contained the Lorazepam was small and easy to conceal and carried away.

On 11/07/24, an IJ situation was determined to exist related to the facilities failure to ensure staff were aware of proper transportation after a resident slid out of a wheelchair during a transport. On 10/29/24, Resident #3 came out of their wheelchair during a transport from the hospital to the facility when the facility driver had to slam on the brakes. CNA #1 and transport driver #1 where unable to lift Resident #3 back into the wheelchair. This resulted in Resident #3 riding approximately 30 miles on the floor of the transport van. On 11/07/24 at 1:20 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 11/07/24 at 1:30 p.m., the administrator was notified of the IJ situation and the IJ template was provided. On 11/08/24 at 10:29 a.m., an acceptable plan of removal was provided. The plan of removal documented: There is the potential for serious harm, impairment, or death if the transportation vehicle is involved in an accident. Current driver training acknowledgment will be updated to include 'van will not operate unless resident is safely secured according to the proper van seatbelt instructions.' Current staff members assigned as van drivers and CNAs to accompany residents while being transported were educated on 11.7.24 by administration r/t actions to be taken in the event of a resident incident or van incident. In the event of a resident incident, get to a safe place and immediately call 911.Stay in place until 911 arrives. Do not operate the van until resident has been assessed by 911 with no injuries noted and can continue with transport after properly secured. If resident requires first aide, treat with supplies in first aide kit until 911 arrives. Ensure administrator is contacted or DON if admin not available. Also included in education if van breaks down, proceed to a safe place, ensure resident is safe and immediately reach out to facility administrator who will provide direction. DON was educated on 11.7.2024 by the Regional Director of Operations on the same as above. Any new employees hired for van driver or transport assist will be provided this education along with van competencies before first transport. Training will occur annually and as needed. All the education was completed yesterday by 5pm. Emps not in the building were called by admin and educated over the phone. [NAME] was educated by me yesterday around 4pm. We have a monthly checklist for our vans in TELS [communication system], we will be moving this to a weekly checklist. We also have a pre-trip checklist that is used prior to a transport taking place. On 11/08/24, interviews were conducted with multiple staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided pertaining to the plan of removal. On 11/07/24 at 5:00 p.m the immediacy was lifted. The deficient practice remained at an isolated potential for harm. Based on observation, record review, and interview, the facility failed to ensure staff were aware of proper transportation after a resident slid out of a wheelchair during a transport for one (#3) of three sampled residents reviewed for accident hazards. The charge nurse identified 70 residents resided in the facility. Findings: A Safely Loading and Securing Wheelchairs in Shuttle Buses form, undated, read in part, Both a lap belt and shoulder strap are needed to secure the passenger in the vehicle. Resident #3 had diagnoses which included hemiplegia, hemiparesis, cerebral infarction, and cardiomyopathy. A progress note, dated 10/29/24 at 10:38 p.m., documented Resident #3 slid out of a wheelchair during a facility transport. It documented the resident sustained a 3.5 cm skin tear to their left elbow. On 11/06/24 at 12:29 p.m., the AD stated they could transport residents in the facility van if a CNA went with them. The AD stated they had to watch a video, take a quiz, and do a return demonstration with the maintenance supervisor. They stated they would load a resident in the van in their wheelchair, buckle them in with a lap belt, shoulder belt, and four straps to secure the wheelchair to the van. The AD was asked who transported Resident #3 from the hospital. They stated they and CNA #1 had. The AD stated CNA #1 had loaded the resident in the van, secured the wheelchair with four straps, and placed the lap belt on the resident. They stated the shoulder strap did not work. The AD stated when they were getting on the on ramp to the turnpike, a few vehicles in front of them hit their brakes and they had to do the same. The AD stated when they hit the brakes Resident #3 slid out of their wheelchair onto the van floor. They stated they drove to the service road and found a place to park. The AD stated Resident #3 sustained a skin tear to their left elbow. The AD stated they and CNA #1 were unable to get the resident off of the floor and back into the wheelchair. The AD stated they spoke to the DON on the phone and were instructed to make Resident #3 comfortable and to drive back to the facility as carefully as they could. The AD stated the ride was around 25 to 30 minutes on the turnpike. They stated they thought they should have called 911 to see if they could help get Resident #3 back in their wheelchair. The AD stated they thought the shoulder strap may have helped keep the resident in the wheelchair. On 11/06/24 at 12:40 p.m., an observation of the facility transport van was made with the AD. There was no shoulder strap located in the vehicle. The AD stated it was not there during the transport for Resident #3. On 11/06/24 at 1:17 p.m., CNA #1 stated they there was no shoulder strap in the facility transport van when Resident #3 had been transported. CNA #1 stated they had asked the DON if they should call 911 for help after Resident #1 slid out of their wheelchair. They stated the DON instructed them to make the resident as comfortable as possible, since they were not injured, and to bring the resident to the facility. On 11/06/24 at 1:36 p.m., the DON stated all staff who go on transports have had to watch a video, take a quiz, and do a return demonstration to ensure they know how to secure a resident sitting in a wheelchair in the transport vans. The DON was asked how they ensured safe transports. They stated with a lap belt and shoulder straps. The DON was asked how Resident #3 was kept safe during the transport when they rode approximately 30 miles on the van floor. The DON stated they instructed the staff to make Resident #3 as comfortable as possible and return to the facility.

Based on observation, record review, and interview, the facility failed to ensure proper handwashing was conducted during incontinent care, between residents, and/or a roll gauze that was dropped on the floor was not used to perform a treatment for seven (#1, 2, 5, 6, 7, 8, and #9) of seven sampled residents observed for infection control. The charge nurse identified 70 residents resided in the facility. Findings: A Hand Hygiene policy, dated 04/28/22, documented hand hygiene should be performed before and after providing care, before and after applying and removing gloves, and after handling soiled linens. It documented staff could use alcohol based hand rub if their hands were not visibly soiled. An Incontinent Care policy, dated 07/21/22, read in part, Perform Hand Hygiene and Apply Gloves .Remove Soiled Brief .Cleanse Perineal Area .Remove Soiled Gloves, Perform Hand Hygiene & Apply Clean Gloves .Apply Clean Brief & Clothing .Discard Contaminated Items .Remove Gloves & Perform Hand Hygiene On 11/05/24 at 10:11 p.m., CNA #2 was observed touching Resident #5's incontinent brief with bare hands to determine if it was soiled. They did not wash their hands or use alcohol rub. On 11/05/24 at 10:15 p.m., CNA #2 was observed to apply gloves and provide incontinent care to Resident #6. They did not wash hands or use alcohol rub prior to or after providing incontinent care. They did not remove their soiled gloves prior to touching the bed control and repositioning the resident. On 11/05/24 at 10:24 p.m., CNA #2 was observed taking Resident #7's head phones to adjust the volume with soiled hands. On 11/05/24 at 10:30 p.m., CNA #2 was observed to touch Resident #9's incontinent brief with their bare hands to determine if it was soiled. They did not wash their hands or use alcohol rub. On 11/05/24 at 10:32 p.m., CNA #2 was observed to touch Resident #8's incontinent brief with their bare hands to determine if it was soiled. They did not wash their hands or use alcohol rub. On 11/05/24 at 10:33 p.m., Resident #2 asked CNA #2 for denture tablets. CNA #2 went to the supply room, picked up a packet of denture tablets, and then gave them to Resident #2. On 11/05/24 at 10:44 p.m., LPN #1 was observed providing wound care to Resident #1's right lower leg while CNA #2 held the leg up. LPN #1 was wrapping the leg with roll gauze, dropped it on the floor, CNA #2 picked the roll gauze up, handed it to the LPN, and LPN #2 continued wrapping the leg with the soiled roll gauze. On 11/06/24 at 8:50 p.m., CNA #2 was asked what the policy was for providing perineal care and handwashing. They stated to gather supplies, provide care, and remove gloves. CNA #2 stated they did not use alcohol rub because it made their hands too dry. They stated they wash their hands after removing gloves. CNA #2 stated they wash their hands when they get to work, before they leave work, prior to feeding a resident, after they used the restroom, and between residents. They stated they would wash their hands after picking up trash or soiled linens. CNA #2 was asked if they would perform handwashing when checking briefs. They stated they'd wash before and after, or use hand sanitizer. CNA #2 was asked if they would wash their hands prior to touching residents' personal items or bed controls after providing perineal care. They stated, Yes.

Based on observation and interview, the facility failed to ensure a sanitary environment in the shower rooms. The DON identified 76 residents who reside at the facility. Findings: A Quality of Life-Homelike Environment policy, dated 02/01/16, read in part, .2. The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .a. Cleanliness and order . A Resident Council Meeting form, dated 02/13/24 documented the residents stated that the shower rooms were not cleaned up after the previous shower. On 02/26/24 at 10:52 a.m., the shower room located on Park Place Hall was observed to have hard water/lime/calcium deposits on the faucet. There was also a thick black substance in the corners of the shower stall and between the floor tile grout lines. The silicone caulking was coming loose from the corners of the shower stall walls and between the floor tiles and had a thick black substance underneath it. On 02/27/24 at 8:16 a.m., the shower room located on Hummingbird Hall was observed to have hard water/lime/calcium deposits on the shower wall and the faucet of the shower stall. The floor tiles were missing, exposing concrete, and the other floor tiles had deep cracks and divots. On 02/27/24 at 8:34 a.m., the shower room located on Southwest Hall was observed to have hard water/lime/calcium deposits on the faucet. There was also a thick black substance in the corners of the shower stall and on the baseboards in the shower room. All three shower rooms had an abundance of dirt and debris in the floors and behind the toilets. On 02/27/2 at 9:05 a.m., the housekeeping supervisor was made aware of the above findings. They stated they had been unable to get the showers clean because there was no drain for the water to drain, resulting in the thick black substance building up in the shower rooms.

Based on record review and interview, the facility failed to ensure ongoing assessment including pre/post assessments were completed for two (#129 and #25) of two residents who were reviewed for dialysis. The DON identified four residents who received dialysis services. Findings: The Dialysis Communication policy, dated 09/27/23, read in part, .The top section of the Dialysis Communication Transfer From is completed by the Nurse responsible for sending the resident to the Dialysis Unit/Facility .The bottom section of the form is completed by personnel responsible for the resident at the Dialysis Facility and returned to the nursing home with the Resident .Once the form is completed, the most recent form should be stored in the medical record . 1. Resident #129 had diagnoses which included dependence on renal dialysis. The Baseline Care Plan, dated 02/21/24, documented the resident required dialysis. The Long Term Care Evaluation, dated 02/21/24, documented the resident was scheduled for dialysis Monday, Wednesday, and Friday and the location of the dialysis access was the left forearm. The undated, top portion, of the, Dialysis Communication Form, read in parts, .To be completed by Licensed Nurse for dialysis resident prior to dialysis treatment . The bottom portion of the form, read in parts, .To be completed by Dialysis Center following dialysis treatment, and to accompany resident on return to center . The top portion of the form was blank for current treatment/time, date, access site, and access condition. The bottom portion had been filled out by the dialysis nurse. The Dialysis Communication Form, dated 02/26/24, did not document the access site, access condition, weight, medications administered before dialysis, or the assessment prior to dialysis. Those sections of the form were left blank. On 02/26/24 at 11:19 a.m., LPN #6 reviewed the electronic clinical record and stated Resident #129 did not have orders for dialysis or monitoring. LPN #6 stated they did not perform any assessments when residents returned from dialysis. On 02/27/24 at 11:19 a.m., the DON stated the charge nurses obtained vital signs or would check on residents when they returned from dialysis. They stated the charge nurses did not complete an assessment but they reviewed vital signs on the communication form and would observe any dressings. The DON stated they missed putting orders in for dialysis and monitoring upon admission for Resident #129. They stated there was no documentation of the facility monitoring Resident #129 after dialysis or any other documented information before dialysis. 47751 2. Res #25 had diagnoses that included end-stage renal disease, dependence on renal dialysis, and hypertension. A physician order, dated 11/26/22, documented remove dressing to fistula to LUE six hours after the resident returns from dialysis daily every Monday, Wednesday, and Friday. A physician order, dated 10/05/23, documented dialysis every Monday, Wednesday, and Friday at 10:30 a.m. at the dialysis center. Dialysis communication forms, dated 01/03/24 through 02/23/24, a total of 20 opportunities failed to document the nurse's name, current treatment time, access site, access condition, time of last meal, medication given pre-dialysis in addition to obtaining a pre-dialysis weight. The document had spaces to record the bruit/thrill, status of access graft/catheter, and skin issues with the access site. The pre-dialysis part of the form the nurse was responsible for completing was blank except for the vital signs. A care plan revised 01/14/24, documented: Assess my dialysis port/shunt for signs and symptoms of bleeding every shift and when I return from dialysis. Ensure that the dressing is dry, intact, and free from signs and symptoms of infection. Assess my vital signs and investigate abnormal findings. Monitor me for signs and symptoms of complications. A quarterly assessment, dated 02/07/24, documented the resident's cognition is moderately impaired and received renal dialysis. On 02/26/24, at 8:28 a.m., Res #25 was asked if the nurses were assessing his dialysis port when they returned from dialysis. They stated they were not. On 02/27/23 at 11:22 a.m., LPN # 1 was asked what the process was for completing dialysis pre- and post-communication forms. They stated they had not been completing them. They were shown resident #25's dialysis communication forms. They were asked why the form was blank except for the pre-dialysis vital signs. They stated they were unaware they were required to complete the form other than the vitals. On 02/27/24 at 1:19 p.m., the DON was asked what the process was for completing the dialysis pre and post-communication form. The DON stated the form was to be completed on the resident's dialysis days prior to departing from the facility and upon return to the facility.

Based on observation, interview, and record review, the facility failed to offer the residents an HS snack and ensure snacks were served to the residents in accordance with the facility policy, for three (#11, 16, and #25) of three sampled residents reviewed for food and nutrition services. The DON identified 76 residents resided in the facility. Findings: A facility policy titled, Meals & Snacks, dated 11/27/23, documented, .3. An evening snack shall be provided by Nutritional Services and offered to the residents by Nursing . On 2/26/24 at 11:43 a.m., the dietary manager was asked about the resident snack schedule. They stated dietary prepares snacks for the residents at 10 a.m., 2 p.m., and a bedtime snack around 7 p.m. They stated the snacks are placed at the nurse station. 1. Res #11 had diagnoses which included diabetes, protein-calorie malnutrition, and muscle wasting. On 02/25/24 11:52 a.m., Res #11 was asked if they were being offered a snack at bedtime. They stated they have never been offered a snack at bedtime. On 02/27/24 10:36 a.m., Res #11 was asked if they were offered a snack at bedtime last night. They stated they were not. 2. Res # 16 had diagnoses which included diabetes, muscle wasting, and anemia. On 2/25/24 Res #16 was asked if they were being offered a snack at bedtime. They stated they were not being offered a snack at bedtime. They stated if they wanted a snack they had to transfer to their wheelchair and propel themselves up the hall to the nurse station. They stated the bananas are black and over ripe and that dietary never offers apples or oranges and that they wished they would. On 02/27/24 10:42 a.m., Res #16 was asked if they were offered a snack at bedtime last night. They stated they were not. 3. Res #25 had diagnoses which included end stage renal disease and hyperlipidemia. On 02/25/24 1:22 p.m., Res #11 was asked if they were being offered a snack at bedtime. They stated they were not. They stated they got hungry at bedtime and would like a snack. On 02/27/24 10:56 a.m., LPN #1 was asked if the 10 a.m. snacks were brought to the nurse station. They stated they were not. On 02/27/24 at 11:05 a.m. the dietary manager was asked if the 10 a.m. snacks were brought to the nurse station. They stated they forgot and the snacks were not brought to the nurse station. On 02/27/24 at 1:14 p.m. the DON was made aware of the above stated. They stated they were not aware snacks were not being offered to the residents.

Based on observation, record review and interview, the facility failed to ensure the ice machine was clean. The DON identified # residents ate from the kitchen. Findings: A Nutritional Services Sanitation policy, reviewed 11/27/23, read in parts, .Nutritional Services shall ensure a clean and sanitary work environment; to promote to promote and protect food safety; and, to maintain compliance with Federal, State, and Local regulations governing food sanitation and safety .Cleaning of equipment .ice machines, etc shall be completed by the maintenance department .Equipment shall be cleaned, sanitized, delimed .in accordance with manufacturer recommendations . On 02/25/24 at 11:22 a.m., the ice machine was observed to have black and pink substances on the deflector plate in the bin of the ice machine. Ice was observed to be touching the deflector plate. On 02/25/24 at 11:23 a.m., Cook #1 stated they did not know what the substance was but it was disgusting. They stated it should not be served. On 02/25/24 at 1:30 p.m., the dietary supervisor stated the ice should not be used and the machine should be cleaned more frequently. The maintenance supervisor stated the ice machine was last cleaned on 02/20/24 when the filters were changed.

Based on observation and interview, the facility failed to ensure staff followed infection control protocols while delivering meals to residents in the dining room. The administrator identified 76 residents who resided in the facility. Findings: On 02/25/24 at 12:41 p.m., the noon meal was observed in the dining room. DA #1 was observed to not sanitize their hands between plates. DA #1 was observed to touch their pants and facial hair net between delivering resident plates. DA #2 was observed to not sanitize their hands between resident plates while touching the rim of a cup of cobbler and touching their pants. On 02/25/24 at 12:49 p.m., DA #2 was observed to sanitize their hands, but continued to touch their pants. On 02/26/24 at 9:08 a.m., the Dietary Supervisor stated they expected staff to use hand sanitizer only if they cannot get to the sink and between plates.

Based on record review and interview, the facility failed to ensure residents were offered the opportunity to formulate an advance directive for one (#31) of three sampled residents who were reviewed for advance directives. The DON identified 76 residents who resided in the facility. Findings: The Advanced Directives policy, dated 04/26/23, read in part, .Upon Admission the Facility will provide Resident who is Medically Deemed Competent or Resident Representative, who does not have an existing Advance Directive, with written information and instructions regarding the Right to make Advance Directives prior to the initiation of Care or at any requested time . Resident #31 had diagnoses which included unspecified dementia. The face sheet for Resident #31 documented the resident was a full code. Review of the electronic clinical record did not reveal the resident had been offered the option to formulate an advance directive. On 02/27/24 at 3:10 p.m., the social services director stated they would review the clinical record for documentation related to the advance directive. On 02/27/24 at 3:51 p.m., the social services director stated they did not have information regarding formulating an advance directive for Resident #31.

Based on observation, record review and interview, the facility failed to ensure care plans were reviewed and revised for two (#16 and #43) of nine residents who were reviewed for care plans. The DON identified 76 residents who reside at the facility. Findings: The Care Plan for Resident #43, initiated 11/03/23, documented a fall risk focus for mobility. The care plan documented the resident was a fall risk due to weakness affecting the left dominant side. Last revised 02/28/24. The care plan documented Resident #43 would not sustain serious injury through the review date, and to notify the physician of fall with recent medication changes. The care plan documented to ensure proper body alignment/position while in bed, ensure the call light was within reach and encourage use for assistance as needed. There was no mention of a fall mat placed next to the bed of Resident #43. 1. Resident #43 admitted with diagnoses which included hemiplegia, hemiparesis, and muscle weakness. The Care Plan for Resident #43, initiated 11/03/23, documented a fall risk focus for mobility. The care plan documented the resident was a fall risk due to weakness affecting the left dominant side. Last revised 02/28/24. The care plan documented Resident #43 would not sustain serious injury through the review date, and to notify the physician of fall with recent medication changes. The care plan documented to ensure proper body alignment/position while in bed, ensure the call light was within reach and encourage use for assistance as needed. There was no mention of a fall mat placed next to the bed of Resident #43. A Fall Incident report, dated 02/20/24, read in parts, Resident #43, .laying on floor parallel to bed on her back .rolled out of bed, change in condition compared to before hospitalization , bed in low position, fall mat in place . A Fall Incident report, dated 02/21/23, read in part, [Resident #43 was in the floor .I slid off the bed and hit my head and back .fall matt placed by bed . A fall risk evaluation completed 2/21/24 documented one to two falls in the last 3 months, with a fall risk score of 19. On 02/25/24 at 4:11 p.m., a fall mat was observed on the floor not next the bed, but in the middle of the room. An Incident Note, dated 02/25/24, read in part, .Resting quietly in bed w/ eyes closed .Cont [continue] on FFU [fall follow up] w/o [without] injury. Bed in lowest position w [with]fall mat in place. Call light and personal items in reach. Will cont to observe for changes. On 02/29/24 at 9:33 a.m., Resident #43 was observed in bed, with their bedside table over them. No fall mat was observed in the room. On 02/29/24 at 9:45 a.m., CNA #8 stated the interventions in place to prevent injury from fall were a lowered bed. They stated they were not aware of any other interventions. CNA #8 stated they were made aware of interventions through report from the nurse or shift report. On 02/29/24 at 10:43 am, LPN #6 stated the interventions in place to prevent injury from fall were proper body alignment while bed, call light in reach, prompt response to requests, education on safety reminders and what to do if a fall occurs. LPN #6 was asked if a fall mat was in place. LPN #6 went to speak with the MDS coordinator and stated they thought there was an intervention for a fall mat. On 02/29/24 at 10:49 a.m., LPN #6 returned, stated no fall intervention for a fall mat was included on the care plan. On 02/29/24 at 10:56 a.m., the DON stated there was a fall mat, but it was removed because the resident was able to push it away. They stated they were having someone put a beveled fall mat next to the bed right now, they then nodded to a staff in the office, who left the room. The DON was asked why the care plan was not updated. The MDS coordinator stated the care plan should have been updated. 47751 2. Res #16 had diagnoses that included abnormalities of gait and mobility, muscle wasting, lack of coordination, generalized weakness, HTN, seizures, and Parkinson's Disease. An ADL and mobility care plan, dated 03/05/23, included bed mobility that did not reflect the resident s use of their two quarter rails. A significant change assessment dated [DATE] documented that the resident's cognition was intact, they required extensive assistance with most ADLs, and they had no impairment to their extremities. A quarterly assessment, dated 12/27/23, documented that the resident's cognition was intact, required moderate assistance with most ADLs and had impairment to one side of their upper extremities. On 02/25/24 at 10:59 a.m., the resident was observed in their bed with two-quarter rails, one to each side of the top of their bed. Both quarter rails were pulled up. The resident was awake and alert in their room and watching television. The resident was asked what they used the bed rails for. They stated to pull myself up in bed. On 02/27/24 at 2:37 p.m., the ADON reviewed the resident's care plan and confirmed it needed to be updated to reflect the use of the quarter bedrails. They stated that the care plan should have been updated to reflect the current resident's status and needs.

Based on observation, record review and interview, the facility failed to ensure fall mats were properly placed for two (#43 and #10) of two resident who were reviewed for accident hazards. The DON identified # residents who were at risk for falls. Findings: An Accident & Incident Documentation & Investigation policy, revised 04/26/23, read in parts, .The Licensed Nurse shall document the Incident and notify the supervisor and Director of Nursing for follow through as needed .The licensed Nurse may complete a Nurses' Note and update the Resident Care Plan as needed . 1. Resident #43 admitted with diagnoses which included hemiplegia, hemiparesis, and muscle weakness. A Fall Incident report, dated 02/20/24, read in parts, Resident #43, .laying on floor parallel to bed on her back .rolled out of bed, change in condition compared to before hospitalization , bed in low position, fall mat in place . A Fall Incident report, dated 02/21/23, read in parts, [Resident #43 was in the floor .I slid off the bed and hit my head and back .fall matt placed by bed . A fall risk evaluation completed 2/21/24 documented one to two falls in the last 3 months, with a fall risk score of 19. On 02/25/24 at 00:00 p.m., a fall mat was observed on the floor not next to the bed, but in the middle of the room. An Incident Note, dated 02/25/24, read in part, .Resting quietly in bed w/ eyes closed .Cont [continue] on FFU [fall follow up] w/o [without] injury. Bed in lowest position w [with]fall mat in place. Call light and personal items in reach. Will cont to observe for changes. On 02/29/24 at 9:33 a.m., Resident #43 was observed in bed, with their bedside table over them. No fall mat was observed in the room. On 02/29/24 at 9:45 a.m., CNA #8 stated the interventions in place to prevent injury from fall were a lowered bed. They stated they were not aware of any other interventions. CNA #8 stated they were made aware of interventions through report from the nurse or shift report. On 02/29/24 at 10:43 am, LPN #6 stated the interventions in place to prevent injury from fall were proper body alignment while bed, call light in reach, prompt response to requests, education on safety reminders and what to do if a fall occurs. LPN #6 was asked if a fall mat was in place. LPN #6 went to speak with the MDS coordinator and stated they thought there was an intervention for a fall mat. On 02/29/24 at 10:49 a.m., LPN #6 returned, stated no fall intervention for a fall mat was included on the care plan. On 02/29/24 at 10:56 a.m., the DON stated there was a fall mat, but it was removed because the resident was able to push it away. They stated they were having someone put a beveled fall mat next to the bed right now, they then nodded to a staff in the office, who left the room. The DON was asked why the care plan was not updated. The MDS coordinator stated the care plan should have been updated. 2. Resident #10 was admitted with diagnoses which included, hemiplegia, hemiparesis, history of falls, muscle wasting and atrophy. A review of falls revealed Resident #10 had fallen on the following dates 12/25/23, 12/23/23, 12/17/23, 10/20/23, 10/15/23, 10/11/23, 10/2/23, 9/16/23 x 3. A Care Plan, revised 08/09/20, documented a fall risk related to balance and a history of falls, with interventions which included staff to perform more frequent checks on Resident #10 in early morning hours, and remind Resident #10 to ask for assistance with transfers and to not lean forward in their wheelchair. The care plan documented a beveled fall mat was to be placed by the bed of Resident #10 to reduce risk of injury and to ensure the fall mat was at bedside while the resident was in bed. On 02/29/24 at 11:30 a.m., an observation of a blue unbeveled fall mat was underneath the bed of Resident #10. Resident #10 was observed to be in the bed with eyes closed. On 02/29/24 at 12:48 p.m., an observation of a fall mat was underneath the bed of Resident #10 and the resident was in bed with their eyes closed. On 02/29/24 at 1:00 p.m., CNA #9 stated a fall mat was one of the interventions in place to prevent injury due to falls. They stated the fall mat was to be place in front of the bed. They stated the fall mat was currently under the bed. CNA #9 reached under the bed and pulled a blue unbeveled fall mat out from under the bed. They stated Resident #10 gets up and down on their own and sometimes pushes the fall mat under the bed. They stated the hospice for Resident #10 brought the fall mat. CNA #8 stated the aides were responsible to ensure the fall mat was in place. On 02/29/24 at 12:52 p.m., LPN #6 stated the resident should have a beveled fall mat. LPN #6 observed the fall mat and stated the fall mat was not beveled. They stated nursing was responsible to ensure the proper mat was in place. On 02/29/24 at 2:30 p.m., the DON stated nursing was responsible to ensure the proper fall mat was used and appropriately placed. The DON stated they did not know why a beveled mat was not supplied by the hospice.

Based on record review and interview the facility failed to ensure nutritional supplements were provided as ordered for one (#73) of seven residents who were reviewed for nutrition. The DON identified 19 residents who were ordered nutritional supplements. Findings: The Nutritional Supplements policy, dated 12/01/22, read in part, .The Facility will have a formulary of Nutritional Supplements to be utilized as interventions to help ensure nutritional needs are met. Supplements may be available through the Nutritional Services or Nursing Department . Resident #73 had diagnoses which included chronic obstructive pulmonary disease. An admission assessment, dated 01/05/24, documented the resident was cognitively intact for daily decision making. A physician order, dated 02/15/24, documented the resident was ordered a house shake twice daily for weight support. On 02/25/24 at 11:43 a.m., the resident stated they had not been receiving a nutritional supplement. The Care Plan, updated 02/27/24, documented the resident had weight loss related to diuretic use and had house shakes twice daily for nutritional/weight support. Review of the February 2024 MARs and TARs did not reveal documentation the resident was receiving the house shake twice daily. On 02/29/24 at 12:33 p.m., LPN #6 stated Resident #73 had an order for a house shake twice daily. They stated the nursing department had not been administering the nutritional supplement and the dietary department had not been made aware of the order. On 02/29/24 at 12:36 p.m., the ADON stated the resident had been ordered a nutritional supplement on 02/15/24 but it had not been put on the MAR or TAR but it was to be sent on the meal tray by the dietary department. On 02/29/24 at 12:49 p.m., the dietary manager stated they had not been sending the nutritional supplement on the meal tray for Resident #73.

Based on record review, observation, and interview, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain an informed consent prior to installation for two (#11 and #16) of two sampled resident reviewed for side rails. The ADON identified four residents had grab bars/u-rails attached to their beds. Findings: 1. Res #11 had diagnoses which included diabetes, unsteadiness of feet, lack of coordination, anxiety, osteoporosis cerebral infarct, HTN, and CHF. A quarterly assessment, dated 01/17/24, documented the resident's cognition was intact, required substantial assistance with most ADLs, had impairment on one side of their upper and lower extremities, and was always incontinent of bowel and bladder. On 02/25/24 at 10:21 a.m., the resident was observed in their bed with one-quarter rail to the upper right side of the bed. The quarter rail was pulled up. The resident was awake and alert in their bed. The resident was asked what the bed rail was for. They stated they did not know. There was no evidence in EHR the resident had been assessed for risk of entrapment from bed rails prior to installation, review of the risks and benefits of bed rails with the resident or resident representative, and obtain an informed consent prior to installation. 2. Res #16 had diagnosis which included diabetes, COPD, abnormalities of gait and mobility, unsteadiness on feet, Parkinson's disease, anxiety, dementia, CHF, and insomnia. An ADL and mobility care plan, dated 03/05/23, included bed mobility that did not reflect the resident s use of their two quarter rails. A significant change assessment dated [DATE] documented that the resident's cognition was intact, they required extensive assistance with most ADLs, and they had no impairment to their extremities. A quarterly assessment, dated 12/27/23, documented that the resident ' s cognition was intact, required moderate assistance with most ADLs, and had impairment to one side of their upper extremities. There was no evidence in EHR the resident had been assessed for risk of entrapment from bed rails prior to installation, review of the risks and benefits of bed rails with the resident or resident representative, and obtain an informed consent prior to installation. On 02/25/24 at 10:59 a.m., the resident was observed in their bed with two-quarter rails, one to each side of the top of their bed. Both quarter rails were pulled up. The resident was awake and alert in their room and watching television. The resident was asked what they used the bed rails for. They stated to pull myself up in bed. On 02/27/24 at 2:37 p.m., the ADON reviewed the residents' EHRs and confirmed there was no assessment conducted or informed consent obtained prior to the bed rail installation for resident's #11 and #16.

Based on record review and interview, the facility failed to ensure side effect monitoring was implemented for anticoagulant medications for two (#3 and #129) of six sampled residents whose medications were reviewed. The DON identified 12 residents who were ordered anticoagulant medications. Findings: 1. Resident #3 had diagnoses which included atrial fibrillation. The care plan, dated 10/10/23, documented the resident received Coumadin and had an increased risk of bleeding. The care plan documented to monitor for side effects. The MAR/TAR, dated December 2023, documented the resident received Coumadin (an anticoagulant/blood thinner) 2mg once daily. The MAR and TAR did not document side effect monitoring for the Coumadin. The MAR/TAR, dated January 2024, documented the resident received Coumadin 2mg once daily. The MAR and TAR did not document side effect monitoring for the Coumadin. The quarterly assessment, dated 01/17/24, documented the resident had received an anticoagulant medication during the look back period. The MAR/TAR, dated 02/01/24 through 02/27/24, documented the resident received Coumadin 2mg once daily from 02/01/24 through 02/25/24 and Coumadin 1.5mg once daily from 02/26/24 through 02/27/24. The MAR and TAR did not document side effect monitoring for the Coumadin from 02/01/24 through 02/27/24. On 02/28/24 at 2:02 p.m., LPN #6 stated side effect monitoring was documented on the TAR. They stated side effect monitoring for Resident #3 was not documented on the TAR. They reviewed the electronic health record for Resident #3 and stated the intervention to monitor for side effects related to anticoagulant use was missed upon readmission to the facility. On 02/29/24 at 11:53 a.m., the DON stated they did not have documentation side effects were monitored for Resident #3. On 02/29/24 at 12:45 p.m., the ADON stated charge nurses were to monitor for side effects of anticoagulant medications and document on the TAR. They stated the intervention to monitor for side effects of Coumadin for Resident #3 had not been put into the computer so it had not generated onto the TAR. 2. Resident #129 had diagnoses which included dependence on renal dialysis. The Order Summary Report, dated 02/26/24, documented an order for heparin (an anticoagulant/blood thinner) 5000units/ml inject one milliliter subcutaneously three times daily to start on 02/21/24. The MAR/TAR, dated 02/21/24 through 02/26/24, documented the resident received heparin 5000units/ml as ordered. The MAR and TAR did not document side effect monitoring for the heparin. On 02/29/24 at 12:47 p.m., the DON stated side effect monitoring had not been put into the electronic clinical record so it had not generated onto the TAR.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was below five percent. A total of 28 opportunities were observed with two medication errors. Total medication error rate was 7.14%. The DON identified 76 residents resided in the facility. Findings: 1. Res #3 had diagnoses which included cellulitis, low protein, and low albumin levels. A physician order, dated 10/10/23, documented to administer Arginaid two times daily for wound support and low protein and albumin. On 02/26/24 at 7:32 a.m., CMA #2 was observed during medication pass and did not administer the Arginaid. The CMA was asked why they did not administer it. They stated because Res #3 always refuses it. They were asked if they offered the Arginaid to Res #3. They stated they did not and that the Arginaid needed to be discontinued from the MAR. The February 2024 MAR, documented the Res #3 had not taken the Arginaid 51 times for the month. 2. Res #40 had diagnoses which included constipation. A physician order, dated 03/13/23, documented to administer Miralax oral packet 17 GM in the morning and to mix with four to eight ounces of water/juice. On 02/26/23 at 7:45 a.m., CMA #2 was observed during medication pass and did not administer the Miralax. The CMA was asked why they did not administer it. They stated because Res #40 always refuses it. They were asked if they offered the Miralax to Res #40. They stated they did not and that the Miralax needed to be discontinued from the MAR. A medication administration record, dated February 2024, documented the resident had not taken the Miralax 26 times for the month. On 02/26/24 at 10:59 a.m., the cooperate nurse was made aware of the 7.14% med error rate. They asked what the errors were. They were informed the Arginaid was not offered to Res #3 and the Miralax was not offered to Res #40 and that both were marked as refused. They stated the CMA should have offered the medications to the residents.

Based on record review and interview, the facility failed to ensure arbitration agreements provided for the selection of a neutral arbitrator and a neutral venue agreed upon by both parties for one (#129) of two sampled residents who were reviewed for arbitration agreements. The administrator identified 76 residents who resided in the facility. Findings: A copy of the Agreement to Arbitration, provided by the administrator, read in part, .The Agreement .The parties choose to settle any future claims or controversies through binding arbitration administered by the American Health Lawyers Association (AHLA) .the arbitration will be at the Facility and conducted in accordance with the AHLA Rules . Resident #129 was admitted to the facility on [DATE]. Review of the clinical record revealed an Agreement to Arbitration, had been signed by the resident's representative on 02/22/24. The signature page of the agreement had been scanned into the electronic clinical record. On 02/27/24 at 11:27 a.m., the administrator was asked where in the arbitration agreement it was documented a neutral arbitrator agreed upon by both parties. The administrator reviewed the arbitration agreement and stated they did not find that verbiage in the document. The administrator was asked where in the arbitration agreement it was documented a convenient venue for both parties would be selected. The administrator stated they were not familiar with arbitration agreements.

Based on observation, record review, and interview, the facility failed to ensure residents were free from physical restraints which were not required to treat the resident's medical symptoms for one (#1) of two residents reviewed for restraints. The administrator identified 78 residents resided in the facility. Findings: A facility policy titled Physical Restraint , dated 07/26/23, read in part, .Policy: Physical Restraints are not to be used to limit Resident mobility for the convenience of staff .Procedure . Prior to using a Restraint, an evaluation of the Resident should be completed .A Physician's Order for a Restraint includes the type of least restrictive Restraint .The Restraint-Physical Restraint UDA and Restraint Consent UDA is completed prior to implementing a Restraint .The IDT Team evaluates continued need and use of the Restraint quarterly and as needed . Res #1 had diagnoses which included difficulty in walking, other abnormalities in gait and mobility, lack of coordination, mild intellectual disability, and arthropathy. An incident report, dated 03/03/23 at 3:24 a.m., documented Res #1 fell in the shower while undressing and sustained a five cm laceration to their left palm and thumb, and a abrasion to their left great toe. An annual assessment, dated 04/12/23, documented the resident's cognition was intact, had impaired speech, no presence of rejection of care was displayed, and required limited assistance with mobility and most ADLs. The assessment doumented balance and transition was not steady, only able to stabilize with staff assistance, and frequently incontinent of both bowel and bladder. A nursing note, dated 06/02/23 at 8:58 p.m., documented staff were called to the room by the roommate stating they saw Res #1 fall. Res#1 was observed in the floor on his buttocks and the resident's right arm was scraped required first aid. A quarterly assessment, dated 12/06/23, documented the resident's cognition was intact, had impaired speech, no presence of rejection of care was displayed, required supervision with toileting and most all ADLs, and was frequently incontinent of both bowel and bladder. On 01/16/24 at 10:45 a.m., observed Res #1 resting with eyes closed lying back in their recliner with a rollator walker seat underneath the recliner's leg rest. On 01/16/24 at 11:03 a.m., CNA #1 was asked how often the rollator walker seat was placed underneath the recliner's foot rest. They stated they were told to place the rollator walker there any time the resident was seated in their recliner. While the CNA was in the resident's room, the resident was asked to demonstrate lowering the leg rest of the recliner. Res #1 was unable to lower the recliner. CNA #1 was asked if they considered the recliner to restrict the resident's movement. They stated, Yes. CNA #1 stated the resident turns on their call light and to ask staff to lower the foot of the recliner for them. 01/16/24 at 11:32 a.m., CNA#2 was asked if the rollator walker was always kept at the end of the resident's recliner. They stated it was. They were asked if the resident was able to lower their recliner. CNA #2 stated No. They were asked if they considered the recliner to restrict the resident's movement. They stated they did. There was no documentation in the resident's clinical record of an evaluation for the restraint, physician order, or restraint consent form. 01/16/24 at 1:15 p.m., the DON stated they assessed Res #1 and the resident was able to lower the recliner part of the way down. They stated the resident told them they climb over the recliner arm rest to go to the restroom.

Based on record review, observation, and interview, the facility failed to ensure a medication administration error rate was less than five percent for two (#13 and #70) of five sampled residents observed during the medication pass. There were four medication errors out of 27 opportunities, which made the error percentage rate 14.81 percent. The Resident Census and Conditions of Residents form documented 76 residents resided in the facility. Findings: Review of the facility policy titled, Medication Administration and General Guidelines read in part .Medications are administered as prescribed, and in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so .Medications are administered within one hour of the scheduled time .Adheres to the 6 rights of Medication Administration .Right Time . 1. Resident #13 had diagnoses which included dependence on renal dialysis and chronic obstructive pulmonary disease. Review of Physician orders, dated active as of 01/24/23, documented atorvastatin calcium tab 10 Milligram (MG) give 1 tablet by mouth at bedtime, melatonin tablet 5 MG give 1 tablet by mouth at bedtime, and there was no order for arginaid powder (a supplement used for wound healing). Review of the MAR, dated January 2023, documented an order for atorvastatin calcium tablet 10 MG to be given at 8:00 p.m., melatonin tab 5 MG to be administered at 8:00 p.m., and there was no order for arginaid powder. On 01/24/23 at 4:40 p.m., CMA #1 was observed administering medications for resident #13. CMA #1 administered atorvastatin 10 MG by mouth, Melatonin 5 MG, and arginaid 4.5 grams 1 packet with 8 ounces of water. During medication reconciliation, the MAR dated January 2023, revealed atorvastatin 10 MG was to be administered at 8:00 p.m., Melatonin 5 MG was to be administered at 8:00 p.m., and there were no orders for arginaid. On 01/25/23 at 2:02 p.m., CMA #1 reported resident #13 was given arginaid because she just knew the resident took the medication. The CMA reviewed the MAR and physician orders for resident #13 and stated she did not see arginaid orders. The CMA further stated she gave the atorvastatin calcium tablet and the melatonin, which were ordered for 8:00 p.m., because that was what the resident had requested. CMA #1 stated, I go by what the resident wants. On 01/26/23 at 8:42 a.m., during an interview with resident #13, the resident stated he had not requested to receive his medications all at the same time and would not refuse to take a medication at 8:00 p.m. if that was the scheduled time. The resident reported he usually did not go to bed until 10:30 p.m. On 01/26/23 at 8:52 a.m., RN #1 reported there must be an order for arginaid before the medication could be administered. The RN reported the order was discontinued on 11/08/22. She further reported no one had reported to her that resident #13 wanted all of his medications changed to the same time. The RN reported residents could request their medications be changed to a different time. The RN stated the process to change medication times would be to call the physician and get an order for the medication time change. On 01/26/23 at 9:58 a.m., the pharmacist reported a physician order was required to administer arginaid powder. The pharmacist stated when staff are administering mediations, the physician orders should be followed. 2. Resident #70 was admitted with congestive heart failure and essential hypertension. Review of physician orders, dated 01/16/23, documented sacubitril-valsartan oral tablet 24-26 MG give one tablet by mouth two times a day for heart failure. Review of the MAR, dated January 2023, documented an order for sucubitril-valsartan oral tablet 24-26 MG give 1 tablet by mouth two times a day for heart failure at 8:00 a.m. and 5:00 p.m. On 01/24/23 at 4:20 p.m., CMA #1 was observed administering medications for resident #70. During medication reconciliation, an order for sacubitril-valsartan tab 24-26 milligram (MG), give one tab by mouth two times a day for heart failure at 5:00 p.m., was identifed and the MAR documented the medication was to be administered at 5:00 p.m. The medication was not administered during the medication observation. On 01/25/23 at 2:02 p.m., CMA #1 reported resident #70's sacubitril-valsartan was not administered during the medication pass observation because the medication was reordered by the nurse that morning and was waiting on arrival of the medication from the pharmacy. The CMA stated the medication was delivered between 7 and 8 o'clock and she administered the medication upon arrival. On 01/26/23 at 8:15 a.m., RN #1 reported, once the medication gets down to the last row, the medication reorder should be sent to the pharmacy. The RN reported when she went to give the 8:00 a.m. dose of medication, there was no medication on the cart. The RN reported she had reordered the medication. She further reported the medication should be on the cart and ready to administer at the ordered time. On 01/26/23 at 9:58 a.m., the pharmacist reported the medication should be available and ready for administration at the ordered time. On 01/26/23 at 10:20 a.m., the DON reported the staff should follow physician orders and use the punch-initial-give technique. The DON was made aware of the medications given without an order, as well as medications given outside of the required administration time frames. The DON stated she understood the medication error rate of 14.81 percent. On 01/26/23 at 10:29 a.m., the Administrator reported, I expect staff to follow physician orders and follow the orders as written. She stated she understood the medication error rate of 14.81 percent and would in-service staff on the errors.

Based on record review and interview, the facility failed to assess and monitor a surgical site and failed to follow physician's orders for surgical site treatments for one (#5) of three sampled resident who were reviewed for wounds. Resident #5 was admitted to the hospital for [CONDITION(S)] related to surgical site infection. The DON identified 11 residents who had wounds. Findings: Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated [DATE], documented Resident #5's cognition was intact, had no behaviors of rejection of care, required supervision with ADLs, had impairment of lower extremity on one side, and had no skin breakdown, open [CONDITION(S)], or surgical wounds. A Wound care plan, dated [DATE], documented Resident #5 had a post-surgical wound to the left groin. The care plan documented to administer treatments as ordered and monitor for effectiveness date initiated was [DATE]. Resident #5 did not have the left groin surgical incision wound on [DATE]. Resident #5 was admitted to the hospital on [DATE] for a left common femoral artery endarterectomy with retrograde and external iliac stents on the left side. (Removal of plaque build-up in the femoral artery with stent placement to increase blood flow.) Resident #5 was readmitted to the facility's Park Place hall on [DATE] after the left common femoral artery endarterectomy procedure. The hospital discharge instructions, dated [DATE], read in parts, .Call provider for: redness, tenderness, or signs of infection (pain swelling, redness, odor or green/yellow discharge around incision site) .Prevena wound system to left groin should remain in place until batteries die which is usually around post op day 7 (,d+[DATE]) and then can be removed and discarded. [Incision management system used to protect the incision from external contamination, holds incision edges together and delivers negative pressure at 125 mm hg for up to seven days.] Then shower daily and was [sic] incision with soap and water, pat surgical incisions dry . A nurse's progress note, dated [DATE] at 5:51 p.m., read in parts, .Res returned from .medical center .Call .provider if redness, tenderness, or s/s of infection occur .Wound care orders: Bed baths until wound vac removed, then can resume showers. Wash .groin daily w/soap and water then pat dry- Prevena wound vac system to remain in place until batteries die, usually post op day 7 (,d+[DATE]) then discard. Then to shower daily and wash L groin incision w/soap and water, pat dry . A skin observation tool assessment, dated [DATE] documented to see wound care physician's notes for orders. The assessment was signed on [DATE]. Review of the TAR, dated [DATE] through [DATE], revealed there was no documentation the wound management system had been assessed or monitored. The TAR did not document when or if the initial wound vac management system had been removed on [DATE] and when or if the battery had died . A nurse's note, dated [DATE], read in parts, .wound vac intact and maintaining pressure . A social services note, dated [DATE], read in parts, .resident going back to old room [Southwest hall] .no concerns at this time . A skin observation assessment tool, dated [DATE], documented Resident #5's skin was warm, dry, and intact. The assessment did not document the left groin surgical site. A NP progress note, dated [DATE], revealed there was no assessment of the surgical site documented. A nurse's skin/wound note, dated [DATE], read in parts .Surgical wound to R groin, clean daily w/soap and water. OTA .res to shower daily . The nurse's note documented the right groin was the surgical site. The discharge hospital paper work documented the surgical site was on the left groin. A review of the TAR, dated [DATE] through [DATE] revealed there was no documentation the surgical site to the left groin had been washed with soap and water daily after the wound management system was supposed to be removed, or when the wound vac management system was removed. A nurse's infection note, dated [DATE] at 10:29 a.m., read in parts, .Surgical incision to left groin showing signs of infection with inflammation and scant amount of discharge, top of incision aprox 3 cm is dehiscing. Cleaned area with wound cleaner, applied 3 steri strips and placed gauze in the groin to absorb moisture. Notified [physician] received order for [MEDICATION(S)] . A nurse's infection note, dated [DATE] at 1:44 p.m., documented the social worker called the vascular surgeon for an earlier appointment. The note documented the vascular surgeon's office advised the social worker to send Resident #5 to the Emergency Department for evaluation. A nurse's note, dated [DATE] at 2:35 p.m., documented Resident #5 was transferred to the hospital via ambulance. A hospital ED provider note, dated [DATE], read in parts, .ED Course and Impression .Clinical Impressions as of [DATE] .Surgical wound infection .There is a large left inguinal wound that appears poorly healing .Will treat with broad spectrum abx . The hospital progress note, dated [DATE], revealed a picture of the left groin. The picture revealed redness surrounding the wound, off white and blackened areas in the wound bed and three steri strips on the wound. A hospitalist progress note, dated [DATE], read in parts, .[CONDITION(S)] .present on admission .Left groin .infection with foul-smelling drainage .Wound cultures [DATE] growing many bacteria .plan to take patient for washout . A hospital cardiovascular note, dated [DATE], read in parts, .Assessment/Plan .Left groin infection. Aerobic culture showed few staphylococcus coagulate negative and few streptococcus gamma [CONDITION(S)] (bacteria) .On [MEDICATION(S)] and [MEDICATION(S)] (antibiotics) . Hospital wound progress note, dated [DATE], read in parts, .Wound Bed Assessment .Eschar; Slough [dead tissue] .Surround Skin Assessment .Erythematous [abnormal redness of the skin due to inflammation] . On [DATE] at 10:47 a.m., a confidential employee interview was conducted. The employee stated Resident #5's orders were not put on the TAR when they came back from the hospital. When RN #1 discovered the wound it was in bad shape. On [DATE] at 2:11 p.m., LPN #2 was asked for documentation the wound vac management system was removed on [DATE]. They stated they would have to look on the TAR. LPN #2 was asked who the nurses were who were responsible for Resident #5's wound care in [DATE]. LPN #2 identified RN #1 and LPN #3. LPN #2 stated the left groin surgical site should have been assessed on every shift. LPN #2 was asked for the left groin surgical site assessments done on [DATE] through [DATE], and [DATE] through [DATE]. There was no documentation provided the surgical site had been assessed. On [DATE] at 10:45 a.m., the vascular surgeon's RN stated the vascular surgeon stated based on the appearance of the wound on [DATE] in the emergency room , it was apparent the nursing home had not been taking care of the surgical incision. The vascular surgeon's RN stated they had taken pictures of the surgical site on [DATE], and the left groin surgical site had slough, purulent drainage, eschar in the wound bed, and had redness around the site with dark purple areas and three steri strips had been placed on the wound by the nursing home staff and were in place in the pictures. The vascular surgeon's RN stated the surgical incision site should have been almost healed when the wound vac was removed. They stated the wound vac management system should have been removed on [DATE]. The vascular surgeon's RN was asked if they expected the surgical site to have complications due to Resident #5's comorbidities. They stated no, the vascular surgeon performed this procedure often. The vascular surgeon's RN stated if the nursing home would have followed the discharge orders the surgical site would not have looked like it had looked on admission to the ED on [DATE]. The vascular surgeon's RN stated they had not received any communication from the nursing home concerning Resident #5's surgical site until [DATE] when Resident #5 had been taken to the ED. On [DATE] at 11:11 a.m., CNA #1 stated they remembered Resident #5, but had never given Resident #5 a shower and did not remember seeing the wound vac dressing to the left groin surgical site. On [DATE] at 11:22 a.m., CNA #2 who had worked on the hall where Resident #5's room was located stated they did not remember the surgical site, or what wound care was being done in [DATE]. They stated they had given Resident #5 a shower a few times before the resident was put on hospice in [DATE]. On [DATE] at 11:47 a.m., LPN #1 stated they remembered Resident #5. LPN #1 stated they had been Resident #5's nurse when Resident #5 had been on Park Place after returning from the procedure on [DATE]. LPN #1 was asked if they had removed the wound vac management system on [DATE]. LPN #1 reviewed the TAR for [DATE], and stated they did not see the wound vac on the TAR. LPN #1 stated if they had removed the wound vac they would have initialed the TAR to indicate the wound vac had been removed. LPN #1 stated they had not removed the wound vac on [DATE], but had done Resident #5's wound care to the left knee on [DATE]. LPN #1 stated the day shift nurses were responsible for the wound care unless it was ordered more than one time a day. LPN #1 was asked if they had documented the assessment of the wound vac. LPN #1 stated skin assessments were usually done weekly. LPN #1 stated they did not remember the appearance of the surgical site, dressing, or wound vac drainage. LPN #1 reviewed Resident #5's surgical site discharge instructions. LPN #1 was asked who would be responsible for cleaning the surgical site with soap and water. They stated the nurses. On [DATE] at 12:18 p.m., CMA #1 stated they remembered Resident #5 had a wound on the left groin. They stated they did not recall giving Resident #5 a shower after Resident #5 had the procedure in [DATE]. On [DATE] at 3:24 p.m., RN #1 was asked if they had removed the wound vac management system when Resident #5 came back from the hospital in May. They stated yes. RN #1 was asked if they remembered when they removed it. They stated no, they thought it was when the battery died a day or two after Resident #5 came back from the hospital in May. RN #1 was asked what the left groin surgical site looked like when the wound vac management system was removed. RN #1 stated the site looked good was open and beefy red. RN #1 was asked if that was after Resident #5 had the procedure done on the left leg in May. They stated yes. RN #1 stated they documented the assessment on the TAR. RN #1 was asked if they had notified the physician of the left groin surgical site when the wound vac was removed. They stated they called one time when the wound was showing signs of infection. RN #1 stated they could not remember what wound care was being performed on the surgical site after the wound vac was removed. RN #1 stated it would have been documented on the TAR. There was no documentation RN #1 provided wound care to the left groin surgical site in [DATE]. On [DATE] at 6:22 p.m., LPN #3 stated they remembered Resident #5 but could not recall the wound care orders for Resident #5 in [DATE]. LPN #3 stated Resident #5 had a wound vac on for a short time. LPN #3 was asked if they had removed the wound vac. They stated no. LPN #3 was asked if they had showered Resident #5. They stated no, the CNAs performed the showers. LPN #3 was asked if they documented the wound care performed. They stated yes. There was no documentation LPN #3 provided wound care to the left groin surgical site in [DATE] . On [DATE] at 6:09 p.m., the DON was asked if they had found any documentation concerning the wound care treatments and surgical site assessments for Resident #5. They stated no, they would have to check with LPN #2. The DON was asked if any of the nurses had notified them they removed the initial wound vac system on or around [DATE]. They stated no. On [DATE] at 6:21 p.m., LPN #2 was asked if they had found documentation when or if the initial wound vac system was removed, surgical site assessments, or documentation the site was washed with soap and water daily per the hospital discharge instructions. They stated no. LPN #2 stated the left groin surgical incision had scabbing and red streaking when Resident #5 went to the hospital on [DATE].

Based on observation, interview, and record review, it was determined the facility failed to: ~ prevent significant weight loss for one (#72) of three sampled residents whose records were reviewed for nutrition. Resident #72 experienced a significant weight loss of 10.4% x 3 months and 14.5% x 6 months from Februalry (YEAR) and (MONTH) (YEAR) (with previous significant weight loss prior to (MONTH) (YEAR) of 12.5% in six months). The facility identified eight residents who had significant weight loss; and ~assess, monitor, and intervene on the nutritional status of a resident who received enteral feeding via peg tube by not infusing the feeding at the correct rate and/or obtaining daily weights per physician orders [REDACTED].#39) of one sampled residents whose records were reviewed for nutritional status via peg tube. The facility identified two residents who received nutrition via peg tube feeding. Findings: A policy titled, Weight and Hydration Management Overview, dated (MONTH) (YEAR), documented, .Resident's nutritional status will be monitored on a regular basis .Significant unintended changes in weight (loss of gain) (sic) or insidious weight loss may indicate a nutritional problem . A policy titled, Tube Feeding: Continuous Tube Feeding, dated (MONTH) (YEAR), documented, .Purpose: To provide nourishment to the resident who is unable to obtain nourishment orally .Procedure: Verify physician order [REDACTED].Connect the infusion pump, set the rate and start the continuous feedings . 1. Resident #72 had [DIAGNOSES REDACTED]. A weight entry, dated 01/01/18, documented the resident's weight as 126 Lbs. A dietician note, dated 01/10/18 documented, (MONTH) wt: 126#. BMI: 23.0. Sig wt loss of 12.5% x 6 months. Wt also noted down 3.1% x 1 month. Will notify MD .Meal intake: 47% x 15 meals. Resident continues to receive Medpass 2.0 60cc TID, 120kcal/5gm protein per serving. Skin intact, Rec increase Medpass 2.0 to 90cc TID, 180kcal/7.5gm protein per serving . A consultant dietician recommendation, dated 01/10/18, documented the resident had a weight loss of 3.1% in one month and 12.5% in six months. It documented the resident received Medpass 2.0 60cc TID with the recommendation to increase the Medpass 2.0 to 90cc TID with meals. The physician accepted the recommendation. Documentation of the resident's weights were as follows: ~02/05/18 - 131 Lbs; ~02/13/18 - 130 Lbs; ~03/07/18 - 127 Lbs; ~04/03/18 - 125 Lbs; ~04/04/18 - 126 Lbs; ~05/02/18 - 125 Lbs; ~06/07/18 - 121 Lbs; ~07/04/18 - 114 Lbs; ~08/03/18 - 112 Lbs. and ~08/22/18 - 119 Lbs The dietary manager's nutritional note, dated 02/27/18, documented, resident appetite good weight up 5#. The dietary manager's nutritional note, dated 03/16/18, documented, resident weight is down 4#. The dietary manager's nutritional note, dated 04/19/18, documented, resident appetite good weight up 1#eats (sic) her meal in dining room. A quarterly assessment, dated 05/04/18, documented the resident was severely impaired in cognition for daily decision making and required supervision and set up help only for eating. A dietician note, dated 05/15/18, documented, (MONTH) wt: 125#. BMI: 22.9. No sig wt change x 1, 3, 6 months .Meal intake: 100% x 15 meals. Resident continues to receive Medpass 2.0 90cc TID with meals, 180kcal/7.5gm protein per serving .Continue current interventions . A consultant dietician recommendation report to the physician was not available in the clinical record for this dietician note. A care plan, revised 06/18/18, documented the resident had a nutritional problem related to being on a pureed diet and history of weight loss. Interventions included to assist the resident with meals, received 90cc of Medpass three times a day, and to make diet change recommendations as needed. The dietary manager's nutritional note, dated 06/27/18, documented, resident weight down 4#. A dietician note, dated 07/25/18, documented, (MONTH) wt: 114#. BMI: 20.8. Sig wt loss of 5.8% x 1 month, loss of 9.5% x 3 months. Will notify MD .Meal intake: 67% x 15 meals. Nursing reports resident is fed by staff as needed. Resident also receives Medpass 2.0 90cc TID, 180kcal/7.5gm protein per serving .Rec weekly wt monitoring x 4 weeks. No documentation of a consultant dietician recommendation report to the physician was found in the clinical record. A quarterly assessment, dated 08/04/18, documented the resident was severely impaired in cognition for daily decision making, required extensive assistance of one person for eating, and had experienced a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician prescribed weight loss regimen. A dietician note, dated 08/14/18, documented, (MONTH) wt: 112#. BMI 20.5. Sig wt loss of 10.4% x 3 months, loss of 14.5% x 6 months. Will notify MD .Meal intake 85% average. Resident continues to receive Medpass 2.0 90cc TID .Continue current interventions. Review of the clinical record did not reveal physician progress notes [REDACTED]. On 08/22/18 at 10:52 a.m., the DON provided physician progress notes [REDACTED]. She stated she did not find documentation from the physician regarding the resident's significant weight loss. On 08/22/18 at 2:39 p.m., the DON stated she had obtained an order from the physician for weekly weights for four weeks. She stated she obtained a weight at 122 pounds. The DON did not provide documentation of when this weight was obtained. No documentation regarding this weight was provided. She was asked what the process was for consultant dietician recommendations. She stated the medical records staff member delivered them to the physician's office. She was asked what the time frame was for the physician to address the recommendation and return them to the facility. She stated it depended on if the physician was on vacation but it usually did not take more than a couple of weeks. She was asked where the consultant dietician recommendations were for dates 05/15/18, 07/25/18, and 08/14/18. She stated they were with the physician. At 2:45 p.m., the surveyor asked staff to obtain the resident's weight by use of the sitting scale as obtained with previous weights. The resident's weight was 119 pounds. On 08/22/18 at 3:55 p.m., the resident's physician was informed of the surveyor's finding that the resident had experienced a significant weight loss since (MONTH) (YEAR). He was asked if he was aware the resident had experienced a significant weight loss. He stated he was aware and Medpass had been ordered. He stated he was not sure he knew exactly how much weight the resident had lost. He was asked who had notified him of the significant weight loss. He stated he did not remember who had notified him. He was asked if the facility had kept in contact with him regarding the residents nutritional status and significant weight loss. He stated he knew about the resident's weight loss but would have to review his records for specific information. He was asked where his documentation was kept regarding resident #72's weight loss. He stated it should be at the facility. He was informed of no documentation in the clinical record regarding significant weight was found. He stated he would need to inquire about the records when he returned to his office. By the end of survey he had not provided further information. On 08/23/18 at 11:06 a.m., the restorative aide was asked how she was made aware of which residents were ordered weekly weights. She stated the DON provided a list. She was asked to whom she provided weekly and monthly weight. She stated the DON, ADON, the charge nurses, and the dietary manager. She was asked how often she received an updated list of residents who were ordered weekly weights. She stated when the dietician, physician, or nurses noticed a change in the residents' weight. She was asked if resident #72 was on weekly weights. She stated the DON informed her today (08/23/18) the resident was to be weighed weekly. She was asked if the resident had been on weekly weights prior to 08/23/18. She stated she would have to check in the clinical record. She was asked where weekly weights were documented. She stated in the electronic record under the weights option. Review of the clinical record did not reveal the resident had been weighed weekly per the dietician's recommendation on 07/25/18. On 08/23/18 at 11:17 a.m., the ADON was asked what the process was for the consultant dietician's recommendations. She stated the dietician gave them to the dietary manager and the dietary manager gave them to the DON. She stated the DON gave them to the medical records staff member who delivered to the physicians. She was asked what the time frame was for the physicians to return the signed consultant dietician recommendations to the facility. She stated it could be one day to a couple of weeks. She was asked why the consultant dietician recommendations were not available from the physician for the nutrition notes dated 05/15/18, 07/25/18, and 08/14/18. She stated if she had received them from the physician they would have been placed in a binder in her office. She was asked how the physician had been involved in the resident's significant weight loss. She stated, I can't give you an answer for that. I didn't know until yesterday when they said she had a significant weight loss. She was asked if she received a copy of the monthly weights. She stated yes. She was asked what her process was when she received the monthly weights. She stated they were reviewed for changes and placed in a binder. She was asked who was responsible to communicate with the physician regarding residents with significant weight loss. She stated the DON. On 08/23/18 at 1:51 p.m., the DON was asked what the process was for consultant dietician recommendations. She stated she would make a copy of the recommendations and would then give them to the medical records staff member who delivered to the physician. She was asked what the time frame was for the physicians to return the signed consultant dietician recommendation to the facility. She stated it could be anywhere from one day to a couple of weeks. She stated once she made a copy of the recommendation she would call the physician and obtain verbal orders from him. She was asked about resident #72's significant weight loss. She stated the resident had gone from feeding herself to requiring assistance with dining. She stated the resident had been ordered Medpass and they reviewed her weights. She was asked the process of reviewing the weights. She stated they would compare the current to the previous month's weight to determine if there had been a change. She was asked when she had become aware of the resident's significant weight loss. She stated she did not know. She was asked how she identified residents who had a significant weight loss. She stated, We look at what the dietician writes. 2. Resident #39 had [DIAGNOSES REDACTED]. The care plan, dated 06/25/18, documented, .currently on a regular diet with mechanical soft texture and an order for [REDACTED].will maintain adequate nutritional status .Interventions: order for daily weights every morning. If I gain or loss (sic) 2 pounds in 24 hours or 5 pounds in 1 week, notify my physician .provide and serve diet as ordered .RD to evaluate and make diet change recommendations PRN . An admission assessment, dated 06/27/18, documented the resident was moderately impaired in cognition for daily decision making and was totally dependent on staff for bed mobility, transfers, and eating. She had an indwelling urinary catheter, a [MEDICAL CONDITION], and during the seven day look back she had a feeding tube and a mechanically altered diet. The proportion of total calories the resident received through tube feeding was 51% or more. The average fluid intake the resident received per day by tube feeding was 501 cc or more. A Weights and Vitals Summary documented: ~07/03/18 - 180 Lbs (Sitting); ~07/10/18 - 169 Lbs (Sitting); ~07/17/18 - 167 Lbs (Mechanical Lift); and ~08/03/18 - 172 Lbs (Sitting) A physician order, dated 07/20/18, documented, .Daily weight: If resident gains or loses 2 pounds in 24 hours or 5 pounds in 1 week notify Physician .Status .Active. A physician order, dated 07/20/18, documented, .Regular diet, Mechanical Soft texture, Thin consistency .Status .Active . A physician order, dated 07/31/18, documented, .Decrease cont feeding from 60 to 50 ml/hr .Discontinued . The Treatment Administration Record (TAR), dated 08/18, documented, Daily weight: If resident gains or loses 2 pounds in 24 hours or 5 pounds in 1 week notify Physician . The TAR did not document that daily weights had been obtained. A physician order, dated 08/17/18, documented, .Glucerna 1.5 cont feed at 50ml/hr .Discontinued . A physician order, dated 08/17/18, documented, .glucerna 1.5 cont feed at 60 ml/hr .Status: Active . The Treatment Administration Record (TAR), dated 08/18, documented, Glucerna 1.5 cont feed at 60 ml/hr. A dietician note, dated 08/17/18, documented, .August wt: 172# .No sig wt change x 1 month .Wt is noted down 4.4% x 1 month .Daily wt monitoring continues .Diet order: Regular MS .Records indicate resident declines most meals .Encouragement at meals continues .TF order: Glucerna 1.5 60 cc/hour continues . Continuous tube feedings infusing via pump at 50 ml/hour were observed the following date and times: ~08/21/18 at 8:50 a.m.; ~08/21/18 at 2:15 p.m.; and ~08/22/18 at 8:30 a.m. A review of the TAR revealed no documentation that the tube feeding had infused at the rate of 60 ml/hour. The TAR indicated the order for the tube feeding at 50 ml/hour that had been discontinued was administered on: ~08/06; ~08/07; and ~08/13. On 08/23/2018 at 10:40 a.m., LPN #1 was asked who was responsible for hanging enteral feedings. She stated the LPN. She was asked who was responsible for programming the pump for a continuous tube feeding. She stated the LPN. She was asked how the nurses knew what rate to set the pump. She stated the nurses would check the physician order [REDACTED]. LPN #1 was asked who was responsible for taking the physician orders [REDACTED]. She stated whoever takes the verbal or telephone order is responsible for entering the information into the electronic health record. She stated that information is printed out and placed in the chart, the MAR and TAR, and the original was sent to the physician for signature. She was asked who was responsible for ensuring the tube feeding pump was set at the rate ordered by the physician. She stated whoever took the order should set the rate. On 08/23/18 at 11:06 a.m., the restorative aide was asked who was responsible for weighing and documenting weights on residents. She stated she was whether it was daily, weekly, or monthly. She was asked how she received her orders to obtain certain resident weights. She stated from a physician order, the dietician, the DON, or nursing. She stated other than a nurse requesting a resident be weighed, the information came from the DON. She was asked what the process was after receiving a request to weigh a resident. She stated she placed it in the weights logbook. She was asked where the weights were documented. She stated in the weights logbook and in the electronic health record. She was asked how the physician and the dietician received information regarding weights she obtained. She stated monthly she gave a weight report to the DON, ADON, MDS coordinator, and nursing. She stated weekly she gave a weight report to the DON, ADON, and nursing. She was asked if every resident was weighed routinely. She stated yes, monthly. She stated every new resident was weighed weekly times four. She was asked how often she received an updated list of residents who need to be weighed. She stated there was no set time, just whenever there was a change. She was asked if there were residents currently being weighed daily. She stated not now, but we did have. She named the residents but made no mention of resident #39. On 08/23/18 at 11:17 a.m., the ADON was asked what the process was for taking physician orders. She stated whoever took the orders would place them in the electronic health record. She stated the orders are printed and the original was sent to the physician, a copy was placed in the chart, and a copy was sent to the pharmacy if needed. She was asked who was responsible for monitoring tube feedings and rates. She stated the charge nurses. She was asked who was responsible for physician order [REDACTED]. She stated the nurse taking the order. She was asked who was responsible for reviewing physician orders. She stated the DON and MDS coordinator reviewed orders daily. She was asked who was responsible for notifying the restorative aide of a resident who needed to be weighed. She stated whoever took the order. She was asked who was responsible for ensuring the physician orders [REDACTED]. She stated the DON and the MDS coordinator on the daily review. On 08/23/18 at 1:45 p.m., the DON was asked who was responsible for physician orders [REDACTED]. She stated depends on who took the order. She was asked who was responsible for ensuring physician orders [REDACTED]. She stated whoever took the order. She was asked who was responsible for reviewing the clinical record for completeness. She stated she did not know. She was asked who was responsible for hanging enteral feedings and setting the pump. She stated the charge nurse at the time. She was asked who was responsible to ensure the accurate tube feeding was being administered to the resident. She stated the charge nurse. She was asked who was responsible for monitoring the nursing staff to ensure the physician orders [REDACTED]. She was asked who was responsible for monitoring the nursing staff to ensure the physician orders [REDACTED]. She stated the charge nurse and ultimately she was responsible. She was asked if she knew why daily weights were not obtained on resident #39 as ordered by the physician on 07/20/18. She stated no. She stated that should have been documented. She was asked if she knew why the continuous tube feeding was set at 50 ml/hour instead of 60 ml/hour as ordered by the physician on 08/17/18. She stated no.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to notify the physician when a resident began showing signs and symptoms of increased intracranial pressure. At 4:00 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 4:02 p.m., the administrator was notified of the IJ situation related to the facility's failure to notify the physician when a resident began showing signs and symptoms of increased intracranial pressure. On [DATE] at 4:45 p.m., an acceptable plan of removal was provided. The plan of removal documented, .All nurses will be in-serviced on signs and symptoms of intercranial (sic) hemorrhage, monitoring for head injuries related to fall, notification of physician in change of condition post fall. Nurses will also be inserviced on completing documentation as required. No nurses will be scheduled or allow (sic) to work until education has be (sic) completed. Staff inservice will be completed by 1800 [DATE]. Director of Nursing or Designees will monitor the implementation of the plan and if need to make changes. Daily audits of falls to be done daily for 4 weeks, then if compliance noted, then random audits done weekly for 90 days,until substantial compliance noted. The quality assurance committee will review IDT findings monthly for a period of 3 months then quarterly for 9 months to ensure continued compliance with state and federal regulations The immediate jeopardy was removed on [DATE] at 10:36 a.m., when all components of the plan of removal were carried out. The deficient practice remained at an isolated level of actual harm. Based on interview and record review, it was determined the facility failed to notify the physician for a resident when she began showing signs and symptoms of increased intracranial pressure after a fall for one (#4) of six sampled residents who were reviewed for changes in condition. The resident fell and hit her head on [DATE] at 10:30 a.m. The resident begain exhibiting signs and symptoms of increased intracranial pressure at 3:00 p.m. The resident's physician was not notified of the symptoms of increased intracranial pressure until 6:00 p.m., when the resident was transfered by ambulance to the hospital. The resident expired on [DATE] due to a subdural hematoma from [MEDICATION NAME] force trauma of the head. The facility identified 70 residents who resided at the facility. Findings: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident was cognitively intact for daily decision making; was dependent on staff for bed mobility and transfers; and had limitations in range of motion on one upper and one lower extremity. The care plan, dated [DATE], documented the resident was at high risk for falls related to a fall before admission that resulted in three fractures. The goal was the resident would have minimal risk of injury from falls through the next review date. Interventions included to keep the call light within reach; encourage to participate in activities that promote exercise and physical activity for strengthening and improved mobility; encourage to participate with therapies as ordered; and to maintain a safe environment. Monthly physician orders, dated ,[DATE], documented the resident was to receive apixaban (Eliquis), an anti-coagulant, 2.5 mg twice daily for blood clot prevention. A progress note, dated [DATE] at 8:03 p.m., documented, .resident up to w/c with c/o headache that rates ,[DATE]. Medicated with prn pain meds .Currently resting in bed without s/s of obvious distress . A progress note, dated [DATE] at 1:30 a.m., documented, .resting in bed easily awaken alert oriented x 3 .no (complaints of) pain or discomfort at this time . A skilled daily nurse's note, dated [DATE] at 10:30 a.m., documented, .Resident was ambulating s walker et stated she got dizzy and lost her balance and slid down onto floor. States she hit the right side of her head on wall. Head to toe assessment completed c no R/E observed. No redness observed to any skin. PERL. Alert O x 3. Speech clear. Able to stand c assist. Assisted into w/c. Vital signs taken. Denies Pain. Neuro checks initiated. (Physician name withheld) notified of fall c no new orders .(blood pressure) ,[DATE] (pulse) 96 (respirations) 20. (oxygen) sat 99% on room air .resident c/o of dizziness c ear ache instructed to call for assist before getting up. Verbalizes understanding . Review of the resident's neurological flow sheet, dated [DATE] from 10:35 a.m. until 1:40 p.m. revealed the resident's blood pressure ranged from ,[DATE] to ,[DATE]; her pulse ranged from 53 to 64; and her pupil size and reaction remained at 1 mm and brisk. It was documented the resident was fully conscious and had equal and strong hand grasps during this period. The neurological flow sheet documented, .Notify MD IMMEDIATELY of signs and symptoms of Intracranial Pressure!!! . An internet website, http://www.healthline.com/health/increased-intracranial-pressure, documented: .The signs of increased ICP include: * headache * nausea * vomiting * increased blood pressure * decreased mental abilities * confusion about time, and then location and people as the pressure worsens * double vision * pupils that don't respond to changes in light * shallow breathing * [MEDICAL CONDITION] * loss of consciousness * coma . An internet website, https://medlineplus.gov/ency/article/ 3.htm, documented: .Increased intracranial pressure .Symptoms .adults: * Behavior changes * Decreased consciousness * Headache * Lethargy * Neurological symptoms, including weakness, numbness, eye movement problems, and double vision * [MEDICAL CONDITION] * Vomiting . Medication administration records, dated [DATE] at 3:00 p.m., documented, .[MEDICATION NAME] ,[DATE] mg (one) c/o head/shoulder pain (eight) per nurse . This entry was signed by CMA #1. The neurological flow sheet, dated [DATE] at 3:40 p.m., documented the resident's blood pressure had increased to ,[DATE], her pulse rate was 64, and she remained fully conscious with equal and strong hand grasps and pupil sizes of three with a brisk reaction. A progress note, dated [DATE] at 3:44 p.m., documented, .Resident remains on neuro checks for previous fall without further incident. resident does c/o headache that rates ,[DATE], and medicated with prn [MEDICATION NAME]. See MAR. Resident educated on fall prevention per facility policy, and procedure. resident able to use call light button appropriately. Will c/t monitor . Medication administration records, dated [DATE] at 4:00 p.m., documented, .[MEDICATION NAME] 25 mg (one) p/o c/o N/V per nurse . This entry was signed by CMA #1. The neurological flow sheet, dated [DATE] at 4:40 p.m., documented the resident's blood pressure had increased to ,[DATE] and her pulse rate had increased to 90. It was documented there was no change to her level of consciousness, hand grasps, pupil size, or pupil reaction. A progress note, dated [DATE] at 5:32 p.m., documented, .resident in room with c/o 'not feeling well.' refused evening meal d/t nausea without emesis. Medicated for nausea. See MAR. Will c/t to monitor . Review of the clinical record revealed no documentation the facility intervened or that they notified the physician when the resident first began showing signs of increasing intracranial pressure at 3:00 p.m. through 5:32 p.m. The resident had developed a headache, had an increasing blood pressure, and had developed nausea, all symptoms of increased intracranial pressure. The neurological flow sheet, dated [DATE] at 5:40 p.m., documented the resident's blood pressure had increased to ,[DATE] and her heart rate was 92. It was documented the resident had snoring respirations at 14 to 16 per minute. It was also documented the resident was in a stupor, had no movement, had pupil sizes at 2 mm and fixed, and her speech was slurred. A progress note, dated [DATE] at 5:50 p.m., documented, .Resident in room laid back onto bed with increased s/s of decreased loc. resident responded with sub sternal rub, and answered: 'what.' VS: ,[DATE], 70, 98% RA with intermittent snoring respirations. Resident c/t have increased s/s of decreased loc. This nurse had another nurse call 911 while this nurse stayed with resident. Resident awakened intermittently, and palpable pulses to radial, and apical heart. Oxygen applied at 2L/NC/O2 while awaiting transport to (hospital name withheld) . A progress note, dated [DATE] at 6:00 p.m., documented, .ambulance arrival and resident condition stable upon departure . A hospital computerized tomography scan result, dated [DATE], documented, .Findings: There is an extensive right-sided subdural hemorrhage which measures 2.7 cm in thickness .This causes significant midline shift to the left by at least 2.4 cm .Impression: Significant right subdural hematoma casing mass effect and midline shift to the left. Possible small associated subarachnoid hemorrhage in right sylvian fissure . A hospital discharge summary, dated [DATE], documented, .Primary cause of death: [MEDICAL CONDITION]. Contributing cause bilateral subdural hematoma status [REDACTED]. A progress note, dated [DATE] at 12:41 p.m., documented, .I called to check on the resident today and the (family member) informed me that the resident had passed away this morning . A State of Oklahoma Certificate of Death, certified on [DATE], documented, date of death .[DATE] .Time of Death 04:50 .Cause of Death .Immediate Cause .Subdural Hemorrhage .Sequentially list conditions, if any, leading to the cause listed .[MEDICATION NAME] Force Trauma Of The Head .Date of Injury XXX[DATE] .Place of Injury .Nursing Home .Describe How Injury Occurred: Fall . On [DATE] at 2:39 p.m., CMA #1 was asked to describe the process for documenting when as needed medications were given. She stated as needed medications were given only after approval from the resident's nurse. She stated the time documented was the time the medication was given. On [DATE] at 2:49 p.m., LPN #1 was asked what was monitored for if a resident had a fall and hit their head or if a fall was unwitnessed. She stated neurological checks were started, and she monitored for changes in mental status. She was asked what the signs and symptoms of increased intracranial pressure were. She stated confusion, one-sided weakness, and changes in the pupils. On [DATE] at 2:51 p.m., LPN #2 was asked what was monitored for if a resident had a fall and hit their head or if a fall was unwitnessed. She stated she would complete neurological checks, watch for slurred speech, and monitor their hand grasps. She was asked what the signs and symptoms of increased intracranial pressure were. She stated the resident's orientation would be off kilter, the vital signs could be different, their eyes might hurt, and loud noises and lights would bother them. On [DATE] at 2:55 p.m., LPN #3 was asked what the signs and symptoms of increased intracranial pressure were. She stated a change in level of consciousness, vital signs might change a little, and the pupils might change. On [DATE] at 3:30 p.m., the DON was asked what staff was expected to do if a resident had a fall and hit their head or had an unwitnessed fall. She stated staff was to monitor the resident and notify the doctor to see if they wanted to send the resident out for a scan. She was asked if staff was supposed to monitor for increased intracranial pressure. She stated, Yes. The DON was asked what the signs and symptoms of increased intracranial pressure were. She stated a change in the level of condition, change in the reaction to light, change in the consciousness level. She stated any definite change in the normal for the resident. She was asked if headaches, nausea, and vomiting were signs of increased intracranial pressure. She stated, Absolutely. On [DATE] at 4:31 p.m., the DON was asked if there was documentation the physician was notified the resident was showing signs and symptoms of increased intracranial pressure. She reviewed the clinical record and stated, No, there is not. She was asked what the facility's expectation of staff was if a resident began to show those signs and symptoms. She stated staff was expected to notify the physician of any change in condition. On [DATE] at 12:00 p.m., the resident's physician was asked if staff notified him when the resident began showing signs and symptoms of increased intracranial pressure. He stated, I don't have a record one way or another. He was asked what his action would have been if he had been in the building at the time the changes started and he had been notified. He stated he would have evaluated the resident immediately, especially since he knew she had a previous history of an [MEDICAL CONDITION].

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to intervene when a resident began showing signs and symptoms of increased intracranial pressure. The resident fell and hit her head on [DATE]. The resident expired on [DATE] due to a subdural hematoma from [MEDICATION NAME] force trauma of the head. At 4:00 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 4:02 p.m., the administrator was notified of the IJ situation related to the facility's failure to intervene when a resident began showing signs and symptoms of increased intracranial pressure. On [DATE] at 4:45 p.m., an acceptable plan of removal was provided. The plan of removal documented, .All nurses will be in-serviced on signs and symptoms of intercranial (sic) hemorrhage, monitoring for head injuries related to fall, notification of physician in change of condition post fall. Nurses will also be inserviced on completing documentation as required. No nurses will be scheduled or allow (sic) to work until education has be (sic) completed. Staff inservice will be completed by 1800 [DATE]. Director of Nursing or Designees will monitor the implementation of the plan and if need to make changes. Daily audits of falls to be done daily for 4 weeks, then if compliance noted, then random audits done weekly for 90 days,until substantial compliance noted. The quality assurance committee will review IDT findings monthly for a period of 3 months then quarterly for 9 months to ensure continued compliance with state and federal regulations The immediate jeopardy was removed on [DATE] at 10:36 a.m., when all components of the plan of removal were carried out. The deficient practice remained at an isolated level of actual harm. Based on interview and record review, it was determined the facility failed to intervene for a resident when they began showing signs and symptoms of increased intracranial pressure after a fall for one (#4) of six sampled residents who were reviewed for changes in condition. The resident fell and hit her head on [DATE] at 10:30 a.m. The resident begain exhibiting signs and symptoms of increased intracranial pressure at 3:00 p.m. 911 was called at 5:50 p.m. The resident's physician was not notified of the symptoms of increased intracranial pressure until 6:00 p.m., when the resident was transfered by ambulance to the hospital. The resident expired on [DATE] due to a subdural hematoma from [MEDICATION NAME] force trauma of the head. The facility identified 70 residents who resided at the facility. Findings: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident was cognitively intact for daily decision making; was dependent on staff for bed mobility and transfers; and had limitations in range of motion on one upper and one lower extremity. The care plan, dated [DATE], documented the resident was at high risk for falls related to a fall before admission that resulted in three fractures. The goal was the resident would have minimal risk of injury from falls through the next review date. Interventions included to keep the call light within reach; encourage to participate in activities that promote exercise and physical activity for strengthening and improved mobility; encourage to participate with therapies as ordered; and to maintain a safe environment. Monthly physician orders, dated ,[DATE], documented the resident was to receive apixaban (Eliquis), an anti-coagulant, 2.5 mg twice daily for blood clot prevention. A progress note, dated [DATE] at 8:03 p.m., documented, .resident up to w/c with c/o headache that rates ,[DATE]. Medicated with prn pain meds .Currently resting in bed without s/s of obvious distress . A progress note, dated [DATE] at 1:30 a.m., documented, .resting in bed easily awaken alert oriented x 3 .no (complaints of) pain or discomfort at this time . A skilled daily nurse's note, dated [DATE] at 10:30 a.m., documented, .Resident was ambulating s walker et stated she got dizzy and lost her balance and slid down onto floor. States she hit the right side of her head on wall. Head to toe assessment completed c no R/E observed. No redness observed to any skin. PERL. Alert O x 3. Speech clear. Able to stand c assist. Assisted into w/c. Vital signs taken. Denies Pain. Neuro checks initiated. (Physician name withheld) notified of fall c no new orders .(blood pressure) ,[DATE] (pulse) 96 (respirations) 20. (oxygen) sat 99% on room air .resident c/o of dizziness c ear ache instructed to call for assist before getting up. Verbalizes understanding . Review of the resident's neurological flow sheet, dated [DATE] from 10:35 a.m. until 1:40 p.m. revealed the resident's blood pressure ranged from ,[DATE] to ,[DATE]; her pulse ranged from 53 to 64; and her pupil size and reaction remained at 1 mm and brisk. It was documented the resident was fully conscious and had equal and strong hand grasps during this period. The neurological flow sheet documented, .Notify MD IMMEDIATELY of signs and symptoms of Intracranial Pressure!!! . An internet website, http://www.healthline.com/health/increased-intracranial-pressure, documented: .The signs of increased ICP include: * headache * nausea * vomiting * increased blood pressure * decreased mental abilities * confusion about time, and then location and people as the pressure worsens * double vision * pupils that don't respond to changes in light * shallow breathing * [MEDICAL CONDITION] * loss of consciousness * coma . An internet website, https://medlineplus.gov/ency/article/ 3.htm, documented: .Increased intracranial pressure .Symptoms .adults: * Behavior changes * Decreased consciousness * Headache * Lethargy * Neurological symptoms, including weakness, numbness, eye movement problems, and double vision * [MEDICAL CONDITION] * Vomiting . Medication administration records, dated [DATE] at 3:00 p.m., documented, .[MEDICATION NAME] ,[DATE] mg (one) c/o head/shoulder pain (eight) per nurse . This entry was signed by CMA #1. The neurological flow sheet, dated [DATE] at 3:40 p.m., documented the resident's blood pressure had increased to ,[DATE], her pulse rate was 64, and she remained fully conscious with equal and strong hand grasps and pupil sizes of three with a brisk reaction. A progress note, dated [DATE] at 3:44 p.m., documented, .Resident remains on neuro checks for previous fall without further incident. resident does c/o headache that rates ,[DATE], and medicated with prn [MEDICATION NAME]. See MAR. Resident educated on fall prevention per facility policy, and procedure. resident able to use call light button appropriately. Will c/t monitor . Medication administration records, dated [DATE] at 4:00 p.m., documented, .[MEDICATION NAME] 25 mg (one) p/o c/o N/V per nurse . This entry was signed by CMA #1. The neurological flow sheet, dated [DATE] at 4:40 p.m., documented the resident's blood pressure had increased to ,[DATE] and her pulse rate had increased to 90. It was documented there was no change to her level of consciousness, hand grasps, pupil size, or pupil reaction. A progress note, dated [DATE] at 5:32 p.m., documented, .resident in room with c/o 'not feeling well.' refused evening meal d/t nausea without emesis. Medicated for nausea. See MAR. Will c/t to monitor . Review of the clinical record revealed no documentation the facility intervened or that they notified the physician when the resident first began showing signs of increasing intracranial pressure at 3:00 p.m. through 5:32 p.m. The resident had developed a headache, had an increasing blood pressure, and had developed nausea, all symptoms of increased intracranial pressure. The neurological flow sheet, dated [DATE] at 5:40 p.m., documented the resident's blood pressure had increased to ,[DATE] and her heart rate was 92. It was documented the resident had snoring respirations at 14 to 16 per minute. It was also documented the resident was in a stupor, had no movement, had pupil sizes at 2 mm and fixed, and her speech was slurred. A progress note, dated [DATE] at 5:50 p.m., documented, .Resident in room laid back onto bed with increased s/s of decreased loc. resident responded with sub sternal rub, and answered: 'what.' VS: ,[DATE], 70, 98% RA with intermittent snoring respirations. Resident c/t have increased s/s of decreased loc. This nurse had another nurse call 911 while this nurse stayed with resident. Resident awakened intermittently, and palpable pulses to radial, and apical heart. Oxygen applied at 2L/NC/O2 while awaiting transport to (hospital name withheld) . A progress note, dated [DATE] at 6:00 p.m., documented, .ambulance arrival and resident condition stable upon departure . A hospital computerized tomography scan result, dated [DATE], documented, .Findings: There is an extensive right-sided subdural hemorrhage which measures 2.7 cm in thickness .This causes significant midline shift to the left by at least 2.4 cm .Impression: Significant right subdural hematoma casing mass effect and midline shift to the left. Possible small associated subarachnoid hemorrhage in right sylvian fissure . A hospital discharge summary, dated [DATE], documented, .Primary cause of death: [MEDICAL CONDITION]. Contributing cause bilateral subdural hematoma status [REDACTED]. A progress note, dated [DATE] at 12:41 p.m., documented, .I called to check on the resident today and the (family member) informed me that the resident had passed away this morning . A State of Oklahoma Certificate of Death, certified on [DATE], documented, date of death .[DATE] .Time of Death 04:50 .Cause of Death .Immediate Cause .Subdural Hemorrhage .Sequentially list conditions, if any, leading to the cause listed .[MEDICATION NAME] Force Trauma Of The Head .Date of Injury XXX[DATE] .Place of Injury .Nursing Home .Describe How Injury Occurred: Fall . On [DATE] at 2:39 p.m., CMA #1 was asked to describe the process for documenting when as needed medications were given. She stated as needed medications were given only after approval from the resident's nurse. She stated the time documented was the time the medication was given. On [DATE] at 2:49 p.m., LPN #1 was asked what was monitored for if a resident had a fall and hit their head or if a fall was unwitnessed. She stated neurological checks were started, and she monitored for changes in mental status. She was asked what the signs and symptoms of increased intracranial pressure were. She stated confusion, one-sided weakness, and changes in the pupils. On [DATE] at 2:51 p.m., LPN #2 was asked what was monitored for if a resident had a fall and hit their head or if a fall was unwitnessed. She stated she would complete neurological checks, watch for slurred speech, and monitor their hand grasps. She was asked what the signs and symptoms of increased intracranial pressure were. She stated the resident's orientation would be off kilter, the vital signs could be different, their eyes might hurt, and loud noises and lights would bother them. On [DATE] at 2:55 p.m., LPN #3 was asked what the signs and symptoms of increased intracranial pressure were. She stated a change in level of consciousness, vital signs might change a little, and the pupils might change. On [DATE] at 3:30 p.m., the DON was asked what staff was expected to do if a resident had a fall and hit their head or had an unwitnessed fall. She stated staff was to monitor the resident and notify the doctor to see if they wanted to send the resident out for a scan. She was asked if staff was supposed to monitor for increased intracranial pressure. She stated, Yes. The DON was asked what the signs and symptoms of increased intracranial pressure were. She stated a change in the level of condition, change in the reaction to light, change in the consciousness level. She stated any definite change in the normal for the resident. She was asked if headaches, nausea, and vomiting were signs of increased intracranial pressure. She stated, Absolutely. On [DATE] at 4:31 p.m., the DON was asked if there was documentation the physician was notified the resident was showing signs and symptoms of increased intracranial pressure. She reviewed the clinical record and stated, No, there is not. She was asked what the facility's expectation of staff was if a resident began to show those signs and symptoms. She stated staff was expected to notify the physician of any change in condition. On [DATE] at 12:00 p.m., the resident's physician was asked if staff notified him when the resident began showing signs and symptoms of increased intracranial pressure. He stated, I don't have a record one way or another. He was asked what his action would have been if he had been in the building at the time the changes started and he had been notified. He stated he would have evaluated the resident immediately, especially since he knew she had a previous history of an [MEDICAL CONDITION].

Based on interview and record review, it was determined the facility failed to prevent and report neglect for one (#6) of six sampled residents whose medications were reviewed. The facility obtained physician orders [REDACTED]. The facility did not attempt to find an alternate source for the medication, and they did not report the family's neglect to the proper authorities. Resident #6; who had [DIAGNOSES REDACTED]. This had the potential to affect nine residents who received medications and whose stay at the facility was paid for privately. Findings: The facility's policy on abuse and neglect prevention, dated 01/2016, documented, .To establish guidelines that prevents (sic), identifies, and report resident abuse and neglect .It is the policy of the facility, to ensure that each resident is treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect .it is the facility's responsibilities to prevent not only abuse, but also those practices and omissions, neglect and misappropriation of property, that if left unchecked, lead to abuse .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff .family members or legal guardians .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident does receive a lack of care in one or more areas .It is the responsibility of the Administrator and Nursing Services to identify events such as suspicious bruising of residents; occurrences, patterns, and trends that may constitute abuse/neglect and to determine the direction of the investigation .Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury .be reported, the Administrator will appoint a member of management to investigate the alleged incident. The Administrator will file an initial report .Alleged incidents include occurrences between staff/resident, resident/resident, family .Once the facility administration becomes aware of any of these alleged violations, the home must report immediately to the designated state agency .It is required each employee to be knowledgeable of current abuse and neglect laws and be familiar with procedures for reporting suspected abuse or neglect . The Food and Drug Administration's undated medication guide for [MEDICATION NAME] documented, .To prevent serious side effects, do not stop taking [MEDICATION NAME] suddenly . Drugsdb.com's [MEDICATION NAME] withdrawal webpage, dated 06/28/12, documented, .Stopping [MEDICATION NAME] suddenly can cause withdrawal symptoms that include: [MEDICAL CONDITION] or difficulty sleeping, Recurrence of schizohrenia symptoms (delusions or hallucinations), Recurrence of [MEDICAL CONDITION] disorder symptoms (depression or mania). Some patients may also report nonspecific symptoms such as: Anxiety, Nausea and Vomiting, Sweating, Tremor. Usually, the withdrawal symptoms present as recurrence of the underlying disorder ([MEDICAL CONDITION] disorder, depression, or [MEDICAL CONDITION]) for which the patient is being treated for [REDACTED]. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, initiated 10/22/14, documented a problem related to impaired cognitive function/dementia with behavioral disturbances. The goal was the resident would be oriented to self and have her needs met through the next review date. Interventions included to administer medications as ordered. A psychiatric progress note, dated 10/03/16, documented the resident was receiving [MEDICATION NAME] 7.5 mg at bedtime. It was documented the resident sometimes thought her family member was present when they were not, but no other behavioral problems were reported. The resident's [DIAGNOSES REDACTED]. It was documented, .no suggested medication change . An annual assessment, dated 10/15/16, documented the resident was severely impaired in cognitive skills for daily decision making, had no behaviors, and received antipsychotic and antidepressant medications on seven of the preceding seven days. A progress note, dated 11/30/16 at 12:34 p.m., documented, .still resides on Hummingbird hall with a roommate . Behavior monitoring sheets, dated 11/2016, revealed documentation the resident had no episodes of behaviors for the month. Physician orders, dated 12/2016, documented the resident was to receive [MEDICATION NAME] 7.5 mg by mouth at bedtime for delusional disorder related other persistent mental disorders. It was documented the resident began receiving the medication in this dose on 05/24/16. Medication administration records, dated 12/04/16, documented, .[MEDICATION NAME] 7.5 mg not administered awaiting pharmacy . A progress note, dated 12/05/16 at 1:36 p.m., documented, .PCP notified that pharmacy is unable to fill meds due to non payment. resident is out of [MEDICATION NAME] 7.5 mg. Asked if med needs to be dc'd. No new order at this time. (Family member) does not return calls . Medication administration records, dated 12/05/16, documented, .[MEDICATION NAME] 7.5 mg not given awaiting fufillment . A progress note, dated 12/06/16 at 9:38 a.m., documented, .DON .notified that at this time med is still not in facility per (pharmacy name withheld) due to non payment by (family member) .instructed to DC med . A note to the physician, dated 12/06/16, documented, .(resident #6) is out of [MEDICATION NAME] 7.5 mg (one) po at HS, (pharmacy name withheld) is unable to fill anymore meds until (family member) pays them, do you want this dc'd? (Family member) will not return calls . The note was signed OK by the physician and dated 12/06/16. A progress note, dated 12/08/16 at 12:12 p.m., documented, .she was moved off of the secured unit due to not being a flight risk anymore . A progress note, dated 12/25/16 at 5:21 p.m., documented, .refusing meals and health shake po fluids encouraged with minimal po intake or fluid intake .Dr office notified . A progress note, dated 01/03/17 at 9:02 p.m., documented, .Resident hollers constantly Redirection unsuccessful Repositioned 1:1 unsuccessful Disruptive to other residents Incont care provided as needed . A progress note, dated 01/04/17 at 4:40 a.m., documented, .resident cont on and off through out night to call out for different things resident was given drinks, changed and repositioned, and given snacks. None of these actions was successful in reducing the calling out . A progress note, dated 01/05/17 at 5:37 a.m., documented, .called out all shift and was unconsoleable (sic). Snacks, drinks, repositioning, incont care offered and taken with no help in resident's calling out . A progress note, dated 01/06/17 at 5:40 a.m., documented, .Resident did not call out as much this 10-6 shift . A progress note, dated 01/06/17 at 6:12 p.m., documented, .resident refused dinner meal this shift . A progress note, dated 01/09/176 at 9:46 p.m., documented, .refused meds. Continuously hollering out Redirection/positioning unsuccessful. (Family member) to nurses station with concerns resident yelling will keep her awake all night . A progress note, dated 01/12/17 at 2:32 p.m., documented, .January wt: 160# .sig wt loss of 6.4% x 1 month. Will notify MD .Meal intake: 63% average. [MEDICATION NAME] in place as appetite stimulant. Encouragement ongoing .rec weekly wt monitoring x 4 weeks. Should wt fail to stabilize consider additional interventions . A progress note, dated 01/30/17 at 1:18 a.m., documented, .laying in bed yelling out different needs, at times wants her knees readjusted, at times her neck, at times c/o feeling like she choking (sic), at times just yelling help, each time these things are done for her she yells out again within minutes of leaving room, res doesn't comprehend or else remember to use her call light, res has been readjusted in bed, checked for incont. and incont care given when needed and flds offered and she takes flds at times, when go to leave room res. voices at times she doesn't want you to leave room and has advised her that we cannot stay in room c her at all times and she will say 'why', situation is explained to her, but res cont to yell out, res does yell out the whole 8 hr shift at times if not the whole 8 hrs then its close to it at other times, res appetite has decreased during day, and fld intake in decreased, cont to check for incont and reposition q 2 hour and offer flds. and snacks. Res did yell out whole 8 hours last night and was reported in report that she did yell out alday (sic) today, call light, flds and personal items . Behavior monitoring sheets, dated 01/2017, documented the resident had behaviors of yelling out, restlessness, or uncooperativeness on 19 out of 31 days. A progress note, dated 02/02/17 at 4:31 a.m., documented, .Resident has continued to call out. CNAs reposition, offer fluids and snacks, change resident and resident cont to call out. Resident denies pain. Resident clean dry and fluids and call light in reach . A progress note, dated 02/03/17 at 4:49 a.m., documented, .Resident has continued to call out all night. All interventions unsuccessful . A progress note, dated 02/04/17 at 6:31 a.m., documented, .Resident called out all night long. Unable to redirect with snacks, drinks, re-positioning or one on one. Resident called out so much that her voice is extremely hoarse . A progress note, dated 02/06/17 at 1:16 a.m., documented, .resident yelling out continuously Redirection unsuccessful Incont care provided Offered snacks/fluids Denies pain or discomfort No distress noted . A progress note, dated 02/08/17 at 1:51 p.m., documented, .February wt: 148# .Sig wt loss of 7.5% x 1 month, 11.9% x 3 months, loss of 14% x 6 months. Will notify MD .Meal intake: 18% average . A progress note, dated 02/13/17 at 7:38 p.m., documented, .Resident continues to decline no po intake this shift. (Physician name withheld) assessed resident .advised resident hosipce (sic) appropriate . A progress note, dated 02/14/17 at 8:48 a.m., documented, .resident seems very lethargic this am and will not eat or drink .(physician name withheld) notified . Behavior monitoring sheets, dated 02/01/17 through 02/14/17, documented the resident had behaviors of yelling out, restless, and uncooperativeness on 12 of 14 days. There was no behavior documentation on two of the 14 days. A progress note, dated 02/14/17 at 1:00 p.m., documented, .resident trying to yell after oral care done unable to form words .orders received (sic) to transfer to .hospital . A progress note, dated 02/17/17 at 3:38 p.m., documented, .Today the family called to let me know that the resident had passed away the night before . Review of the clinical record revealed no documentation the facility contacted Adult Protective Services regarding the family not providing payment for the resident's medication. There was no documentation the facility attempted to find an alternate source for the resident's medication. There was no documentation the facility attempted to assist the resident in any way to obtain the medication. On 03/15/17 at 4:14 p.m., the administrator, social services director, and business office manager were interviewed. The administrator was asked if he had knowledge the resident's antipsychotic medication had been discontinued because the pharmacy would not refill the prescription due to lack of payment on the family's part. He stated, No. He stated this had occurred before he came to the facility. He stated the DON at the time was now at a different facility. The social services director was asked if she had been aware of the situation. She stated, No. She stated, If they had brought it to my attention, we could have looked at different avenues. She stated they had never had this type situation before. The social services director was asked if Adult Protective Services had been notified the family was not paying for the resident's medications. She stated, Not on my part. She was asked whose role it would have been to notify Adult Protective Services. She stated, More than likely mine. The business office manager was asked if she had notified Adult Protective Services regarding the family not paying for the resident's medications. She stated, No. She stated the family and OSDH had been notified the family was not paying the bill at the facility, but she had not contacted Adult Protective Services. On 03/20/17 at 12:50 p.m., LPN #4 was asked if she had knowledge of resident #6's medication. She stated she remembered faxing, calling, and speaking with one of the physician's nurses. She was asked to explain what had occurred with the resident's Olanzipine. She stated she had ordered the medication but was informed by the pharmacy they would not deliver it until the resident's charge account had been brought current. She stated she reported the situation to the DON. LPN #4 stated the DON informed her she would speak with the administrator. LPN #4 stated she waited a few more days, and the resident ran out of Olanzipine. She stated she asked the DON what she was to do, and the DON informed her to get an order from the physician to discontinue the medication. LPN #4 stated the DON made a comment at the time that the family member was not paying her bill at the facility either. LPN #4 stated she had made multiple attempts to communicate with the family member over the phone, and the pharmacy consultant had provided information related to medication assistance to the family member in the past. She stated the family member would never complete the paperwork for assistance. LPN #4 stated the pharmacy consultant had not been involved in this particular situation. LPN #4 was asked if the facility contacted Adult Protective Services related to the family member not paying the resident's pharmacy bill. She stated, Not that I am aware of.

Based on interview and record review, it was determined the facility failed to implement their abuse and neglect policy and procedure to prevent and report neglect for one (#6) of six sampled residents whose medications were reviewed. The facility obtained physician orders [REDACTED]. to the proper authorities. Resident #6; who had [DIAGNOSES REDACTED]. This had the potential to affect nine residents who received medications and whose stay at the facility was paid for privately. Findings: The facility's policy on abuse and neglect prevention, dated 01/2016, documented, .To establish guidelines that prevents (sic), identifies, and report resident abuse and neglect .It is the policy of the facility, to ensure that each resident is treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect .it is the facility's responsibilities to prevent not only abuse, but also those practices and omissions, neglect and misappropriation of property, that if left unchecked, lead to abuse .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff .family members or legal guardians .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident does receive a lack of care in one or more areas .It is the responsibility of the Administrator and Nursing Services to identify events such as suspicious bruising of residents; occurrences, patterns, and trends that may constitute abuse/neglect and to determine the direction of the investigation .Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury .be reported, the Administrator will appoint a member of management to investigate the alleged incident. The Administrator will file an initial report .Alleged incidents include occurrences between staff/resident, resident/resident, family .Once the facility administration becomes aware of any of these alleged violations, the home must report immediately to the designated state agency .It is required each employee to be knowledgeable of current abuse and neglect laws and be familiar with procedures for reporting suspected abuse or neglect . The Food and Drug Administration's undated medication guide for [MEDICATION NAME] documented, .To prevent serious side effects, do not stop taking [MEDICATION NAME] suddenly . Drugsdb.com's [MEDICATION NAME] withdrawal webpage, dated 06/28/12, documented, .Stopping [MEDICATION NAME] suddenly can cause withdrawal symptoms that include: [MEDICAL CONDITION] or difficulty sleeping, Recurrence of schizohrenia symptoms (delusions or hallucinations), Recurrence of [MEDICAL CONDITION] disorder symptoms (depression or mania). Some patients may also report nonspecific symptoms such as: Anxiety, Nausea and Vomiting, Sweating, Tremor. Usually, the withdrawal symptoms present as recurrence of the underlying disorder ([MEDICAL CONDITION] disorder, depression, or [MEDICAL CONDITION]) for which the patient is being treated for [REDACTED]. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, initiated 10/22/14, documented a problem related to impaired cognitive function/dementia with behavioral disturbances. The goal was the resident would be oriented to self and have her needs met through the next review date. Interventions included to administer medications as ordered. A psychiatric progress note, dated 10/03/16, documented the resident was receiving [MEDICATION NAME] 7.5 mg at bedtime. It was documented the resident sometimes thought her family member was present when they were not, but no other behavioral problems were reported. The resident's [DIAGNOSES REDACTED]. It was documented, .no suggested medication change . An annual assessment, dated 10/15/16, documented the resident was severely impaired in cognitive skills for daily decision making, had no behaviors, and received antipsychotic and antidepressant medications on seven of the preceding seven days. A progress note, dated 11/30/16 at 12:34 p.m., documented, .still resides on Hummingbird hall with a roommate . Behavior monitoring sheets, dated 11/2016, revealed documentation the resident had no episodes of behaviors for the month. Physician orders, dated 12/2016, documented the resident was to receive [MEDICATION NAME] 7.5 mg by mouth at bedtime for delusional disorder related other persistent mental disorders. It was documented the resident began receiving the medication in this dose on 05/24/16. Medication administration records, dated 12/04/16, documented, .[MEDICATION NAME] 7.5 mg not administered awaiting pharmacy . A progress note, dated 12/05/16 at 1:36 p.m., documented, .PCP notified that pharmacy is unable to fill meds due to non payment. resident is out of [MEDICATION NAME] 7.5 mg. Asked if med needs to be dc'd. No new order at this time. (Family member) does not return calls . Medication administration records, dated 12/05/16, documented, .[MEDICATION NAME] 7.5 mg not given awaiting fufillment . A progress note, dated 12/06/16 at 9:38 a.m., documented, .DON .notified that at this time med is still not in facility per (pharmacy name withheld) due to non payment by (family member) .instructed to DC med . A note to the physician, dated 12/06/16, documented, .(resident #6) is out of [MEDICATION NAME] 7.5 mg (one) po at HS, (pharmacy name withheld) is unable to fill anymore meds until (family member) pays them, do you want this dc'd? (Family member) will not return calls . The note was signed OK by the physician and dated 12/06/16. A progress note, dated 12/08/16 at 12:12 p.m., documented, .she was moved off of the secured unit due to not being a flight risk anymore . A progress note, dated 12/25/16 at 5:21 p.m., documented, .refusing meals and health shake po fluids encouraged with minimal po intake or fluid intake .Dr office notified . A progress note, dated 01/03/17 at 9:02 p.m., documented, .Resident hollers constantly Redirection unsuccessful Repositioned 1:1 unsuccessful Disruptive to other residents Incont care provided as needed . A progress note, dated 01/04/17 at 4:40 a.m., documented, .resident cont on and off through out night to call out for different things resident was given drinks, changed and repositioned, and given snacks. None of these actions was successful in reducing the calling out . A progress note, dated 01/05/17 at 5:37 a.m., documented, .called out all shift and was unconsoleable (sic). Snacks, drinks, repositioning, incont care offered and taken with no help in resident's calling out . A progress note, dated 01/06/17 at 5:40 a.m., documented, .Resident did not call out as much this 10-6 shift . A progress note, dated 01/06/17 at 6:12 p.m., documented, .resident refused dinner meal this shift . A progress note, dated 01/09/176 at 9:46 p.m., documented, .refused meds. Continuously hollering out Redirection/positioning unsuccessful. (Family member) to nurses station with concerns resident yelling will keep her awake all night . A progress note, dated 01/12/17 at 2:32 p.m., documented, .January wt: 160# .sig wt loss of 6.4% x 1 month. Will notify MD .Meal intake: 63% average. [MEDICATION NAME] in place as appetite stimulant. Encouragement ongoing .rec weekly wt monitoring x 4 weeks. Should wt fail to stabilize consider additional interventions . A progress note, dated 01/30/17 at 1:18 a.m., documented, .laying in bed yelling out different needs, at times wants her knees readjusted, at times her neck, at times c/o feeling like she choking (sic), at times just yelling help, each time these things are done for her she yells out again within minutes of leaving room, res doesn't comprehend or else remember to use her call light, res has been readjusted in bed, checked for incont. and incont care given when needed and flds offered and she takes flds at times, when go to leave room res. voices at times she doesn't want you to leave room and has advised her that we cannot stay in room c her at all times and she will say 'why', situation is explained to her, but res cont to yell out, res does yell out the whole 8 hr shift at times if not the whole 8 hrs then its close to it at other times, res appetite has decreased during day, and fld intake in decreased, cont to check for incont and reposition q 2 hour and offer flds. and snacks. Res did yell out whole 8 hours last night and was reported in report that she did yell out alday (sic) today, call light, flds and personal items . Behavior monitoring sheets, dated 01/2017, documented the resident had behaviors of yelling out, restlessness, or uncooperativeness on 19 out of 31 days. A progress note, dated 02/02/17 at 4:31 a.m., documented, .Resident has continued to call out. CNAs reposition, offer fluids and snacks, change resident and resident cont to call out. Resident denies pain. Resident clean dry and fluids and call light in reach . A progress note, dated 02/03/17 at 4:49 a.m., documented, .Resident has continued to call out all night. All interventions unsuccessful . A progress note, dated 02/04/17 at 6:31 a.m., documented, .Resident called out all night long. Unable to redirect with snacks, drinks, re-positioning or one on one. Resident called out so much that her voice is extremely hoarse . A progress note, dated 02/06/17 at 1:16 a.m., documented, .resident yelling out continuously Redirection unsuccessful Incont care provided Offered snacks/fluids Denies pain or discomfort No distress noted . A progress note, dated 02/08/17 at 1:51 p.m., documented, .February wt: 148# .Sig wt loss of 7.5% x 1 month, 11.9% x 3 months, loss of 14% x 6 months. Will notify MD .Meal intake: 18% average . A progress note, dated 02/13/17 at 7:38 p.m., documented, .Resident continues to decline no po intake this shift. (Physician name withheld) assessed resident .advised resident hosipce (sic) appropriate . A progress note, dated 02/14/17 at 8:48 a.m., documented, .resident seems very lethargic this am and will not eat or drink .(physician name withheld) notified . Behavior monitoring sheets, dated 02/01/17 through 02/14/17, documented the resident had behaviors of yelling out, restless, and uncooperativeness on 12 of 14 days. There was no behavior documentation on two of the 14 days. A progress note, dated 02/14/17 at 1:00 p.m., documented, .resident trying to yell after oral care done unable to form words .orders received (sic) to transfer to .hospital . A progress note, dated 02/17/17 at 3:38 p.m., documented, .Today the family called to let me know that the resident had passed away the night before . Review of the clinical record revealed no documentation the facility contacted Adult Protective Services regarding the family not providing payment for the resident's medication. There was no documentation the facility attempted to find an alternate source for the resident's medication. There was no documentation the facility attempted to assist the resident in any way to obtain the medication. On 03/15/17 at 4:14 p.m., the administrator, social services director, and business office manager were interviewed. The administrator was asked if he had knowledge the resident's antipsychotic medication had been discontinued because the pharmacy would not refill the prescription due to lack of payment on the family's part. He stated, No. He stated this had occurred before he came to the facility. He stated the DON at the time was now at a different facility. The social services director was asked if she had been aware of the situation. She stated, No. She stated, If they had brought it to my attention, we could have looked at different avenues. She stated they had never had this type situation before. The social services director was asked if Adult Protective Services had been notified the family was not paying for the resident's medications. She stated, Not on my part. She was asked whose role it would have been to notify Adult Protective Services. She stated, More than likely mine. The business office manager was asked if she had notified Adult Protective Services regarding the family not paying for the resident's medications. She stated, No. She stated the family and OSDH had been notified the family was not paying the bill at the facility, but she had not contacted Adult Protective Services. On 03/20/17 at 12:50 p.m., LPN #4 was asked if she had knowledge of resident #6's medication. She stated she remembered faxing, calling, and speaking with one of the physician's nurses. She was asked to explain what had occurred with the resident's Olanzipine. She stated she had ordered the medication but was informed by the pharmacy they would not deliver it until the resident's charge account had been brought current. She stated she reported the situation to the DON. LPN #4 stated the DON informed her she would speak with the administrator. LPN #4 stated she waited a few more days, and the resident ran out of Olanzipine. She stated she asked the DON what she was to do, and the DON informed her to get an order from the physician to discontinue the medication. LPN #4 stated the DON made a comment at the time that the family member was not paying her bill at the facility either. LPN #4 stated she had made multiple attempts to communicate with the family member over the phone, and the pharmacy consultant had provided information related to medication assistance to the family member in the past. She stated the family member would never complete the paperwork for assistance. LPN #4 stated the pharmacy consultant had not been involved in this particular situation. LPN #4 was asked if the facility contacted Adult Protective Services related to the family member not paying the resident's pharmacy bill. She stated, Not that I am aware of.

Based on interview and record review, it was determined the facility failed to attempt to find an alternate source for medications necessary to meet the needs of one (#6) of six sampled residents whose medications were reviewed. The facility obtained physician orders [REDACTED]. The facility did not attempt to find an alternate source for the medication. Resident #6; who had [DIAGNOSES REDACTED]. This had the potential to affect nine residents who received medications and whose stay at the facility was paid for privately. Findings: The Food and Drug Administration's undated medication guide for Zyprexa documented, .To prevent serious side effects, do not stop taking Zyprexa suddenly . Drugsdb.com's Zyprexa withdrawal webpage, dated 06/28/12, documented, .Stopping Zyprexa suddenly can cause withdrawal symptoms that include: Insomnia or difficulty sleeping, Recurrence of schizohrenia symptoms (delusions or hallucinations), Recurrence of bipolar disorder symptoms (depression or mania). Some patients may also report nonspecific symptoms such as: Anxiety, Nausea and Vomiting, Sweating, Tremor. Usually, the withdrawal symptoms present as recurrence of the underlying disorder (bipolar disorder, depression, or schizophrenia) for which the patient is being treated for [REDACTED]. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, initiated 10/22/14, documented a problem related to impaired cognitive function/dementia with behavioral disturbances. The goal was the resident would be oriented to self and have her needs met through the next review date. Interventions included to administer medications as ordered. A psychiatric progress note, dated 10/03/16, documented the resident was receiving Zyprexa 7.5 mg at bedtime. It was documented the resident sometimes thought her family member was present when they were not, but no other behavioral problems were reported. The resident's [DIAGNOSES REDACTED]. It was documented, .no suggested medication change . An annual assessment, dated 10/15/16, documented the resident was severely impaired in cognitive skills for daily decision making, had no behaviors, and received antipsychotic and antidepressant medications on seven of the preceding seven days. A progress note, dated 11/30/16 at 12:34 p.m., documented, .still resides on Hummingbird hall with a roommate . Behavior monitoring sheets, dated 11/2016, revealed documentation the resident had no episodes of behaviors for the month. Physician orders, dated 12/2016, documented the resident was to receive Olanzapine 7.5 mg by mouth at bedtime for delusional disorder related other persistent mental disorders. It was documented the resident began receiving the medication in this dose on 05/24/16. Medication administration records, dated 12/04/16, documented, .Olanzapine 7.5 mg not administered awaiting pharmacy . A progress note, dated 12/05/16 at 1:36 p.m., documented, .PCP notified that pharmacy is unable to fill meds due to non payment. resident is out of Olanzapine 7.5 mg. Asked if med needs to be dc'd. No new order at this time. (Family member) does not return calls . Medication administration records, dated 12/05/16, documented, .Olanzapine 7.5 mg not given awaiting fufillment . A progress note, dated 12/06/16 at 9:38 a.m., documented, .DON .notified that at this time med is still not in facility per (pharmacy name withheld) due to non payment by (family member) .instructed to DC med . A note to the physician, dated 12/06/16, documented, .(resident #6) is out of Olanzapine 7.5 mg (one) po at HS, (pharmacy name withheld) is unable to fill anymore meds until (family member) pays them, do you want this dc'd? (Family member) will not return calls . The note was signed OK by the physician and dated 12/06/16. A progress note, dated 12/08/16 at 12:12 p.m., documented, .she was moved off of the secured unit due to not being a flight risk anymore . A progress note, dated 12/25/16 at 5:21 p.m., documented, .refusing meals and health shake po fluids encouraged with minimal po intake or fluid intake .Dr office notified . A progress note, dated 01/03/17 at 9:02 p.m., documented, .Resident hollers constantly Redirection unsuccessful Repositioned 1:1 unsuccessful Disruptive to other residents Incont care provided as needed . A progress note, dated 01/04/17 at 4:40 a.m., documented, .resident cont on and off through out night to call out for different things resident was given drinks, changed and repositioned, and given snacks. None of these actions was successful in reducing the calling out . A progress note, dated 01/05/17 at 5:37 a.m., documented, .called out all shift and was unconsoleable (sic). Snacks, drinks, repositioning, incont care offered and taken with no help in resident's calling out . A progress note, dated 01/06/17 at 5:40 a.m., documented, .Resident did not call out as much this 10-6 shift . A progress note, dated 01/06/17 at 6:12 p.m., documented, .resident refused dinner meal this shift . A progress note, dated 01/09/176 at 9:46 p.m., documented, .refused meds. Continuously hollering out Redirection/positioning unsuccessful. (Family member) to nurses station with concerns resident yelling will keep her awake all night . A progress note, dated 01/12/17 at 2:32 p.m., documented, .January wt: 160# .sig wt loss of 6.4% x 1 month. Will notify MD .Meal intake: 63% average. Megace in place as appetite stimulant. Encouragement ongoing .rec weekly wt monitoring x 4 weeks. Should wt fail to stabilize consider additional interventions . A progress note, dated 01/30/17 at 1:18 a.m., documented, .laying in bed yelling out different needs, at times wants her knees readjusted, at times her neck, at times c/o feeling like she choking (sic), at times just yelling help, each time these things are done for her she yells out again within minutes of leaving room, res doesn't comprehend or else remember to use her call light, res has been readjusted in bed, checked for incont. and incont care given when needed and flds offered and she takes flds at times, when go to leave room res. voices at times she doesn't want you to leave room and has advised her that we cannot stay in room c her at all times and she will say 'why', situation is explained to her, but res cont to yell out, res does yell out the whole 8 hr shift at times if not the whole 8 hrs then its close to it at other times, res appetite has decreased during day, and fld intake in decreased, cont to check for incont and reposition q 2 hour and offer flds. and snacks. Res did yell out whole 8 hours last night and was reported in report that she did yell out alday (sic) today, call light, flds and personal items . Behavior monitoring sheets, dated 01/2017, documented the resident had behaviors of yelling out, restlessness, or uncooperativeness on 19 out of 31 days. A progress note, dated 02/02/17 at 4:31 a.m., documented, .Resident has continued to call out. CNAs reposition, offer fluids and snacks, change resident and resident cont to call out. Resident denies pain. Resident clean dry and fluids and call light in reach . A progress note, dated 02/03/17 at 4:49 a.m., documented, .Resident has continued to call out all night. All interventions unsuccessful . A progress note, dated 02/04/17 at 6:31 a.m., documented, .Resident called out all night long. Unable to redirect with snacks, drinks, re-positioning or one on one. Resident called out so much that her voice is extremely hoarse . A progress note, dated 02/06/17 at 1:16 a.m., documented, .resident yelling out continuously Redirection unsuccessful Incont care provided Offered snacks/fluids Denies pain or discomfort No distress noted . A progress note, dated 02/08/17 at 1:51 p.m., documented, .February wt: 148# .Sig wt loss of 7.5% x 1 month, 11.9% x 3 months, loss of 14% x 6 months. Will notify MD .Meal intake: 18% average . A progress note, dated 02/13/17 at 7:38 p.m., documented, .Resident continues to decline no po intake this shift. (Physician name withheld) assessed resident .advised resident hosipce (sic) appropriate . A progress note, dated 02/14/17 at 8:48 a.m., documented, .resident seems very lethargic this am and will not eat or drink .(physician name withheld) notified . Behavior monitoring sheets, dated 02/01/17 through 02/14/17, documented the resident had behaviors of yelling out, restless, and uncooperativeness on 12 of 14 days. There was no behavior documentation on two of the 14 days. A progress note, dated 02/14/17 at 1:00 p.m., documented, .resident trying to yell after oral care done unable to form words .orders received (sic) to transfer to .hospital . A progress note, dated 02/17/17 at 3:38 p.m., documented, .Today the family called to let me know that the resident had passed away the night before . Review of the clinical record revealed no documentation the facility attempted to find an alternate source for the resident's medication. There was no documentation the facility attempted to assist the resident in any way to obtain the medication. On 03/15/17 at 4:14 p.m., the administrator, social services director, and business office manager were interviewed. The administrator was asked if he had knowledge the resident's antipsychotic medication had been discontinued because the pharmacy would not refill the prescription due to lack of payment on the family's part. He stated, No. He stated this had occurred before he came to the facility. He stated the DON at the time was now at a different facility. The social services director was asked if she had been aware of the situation. She stated, No. She stated, If they had brought it to my attention, we could have looked at different avenues. She stated they had never had this type situation before. The social services director was asked if Adult Protective Services had been notified the family was not paying for the resident's medications. She stated, Not on my part. She was asked whose role it would have been to notify Adult Protective Services. She stated, More than likely mine. The business office manager was asked if she had notified Adult Protective Services regarding the family not paying for the resident's medications. She stated, No. She stated the family and OSDH had been notified the family was not paying the bill at the facility, but she had not contacted Adult Protective Services. On 03/20/17 at 12:50 p.m., LPN #4 was asked if she had knowledge of resident #6's medication. She stated she remembered faxing, calling, and speaking with one of the physician's nurses. She was asked to explain what had occurred with the resident's Olanzipine. She stated she had ordered the medication but was informed by the pharmacy they would not deliver it until the resident's charge account had been brought current. She stated she reported the situation to the DON. LPN #4 stated the DON informed her she would speak with the administrator. LPN #4 stated she waited a few more days, and the resident ran out of Olanzipine. She stated she asked the DON what she was to do, and the DON informed her to get an order from the physician to discontinue the medication. LPN #4 stated the DON made a comment at the time that the family member was not paying her bill at the facility either. LPN #4 stated she had made multiple attempts to communicate with the family member over the phone, and the pharmacy consultant had provided information related to medication assistance to the family member in the past in the past. She stated the family member would never complete the paperwork for assistance. LPN #4 stated the pharmacy consultant had not been involved in this particular situation. LPN #4 was asked if the facility contacted Adult Protective Services related to the family member not paying the resident's pharmacy bill. She stated, Not that I am aware of.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to aid in the prevention of falls for two (#1 and #2) of three sampled residents who were reviewed for falls. This resulted in actual harm for resident #1 when he fell and sustained a fractured right femur and when he fell and required eight staples for a head laceration. The facility identified 28 residents as having falls in the last three months. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A telephone order, dated 03/06/15, documented to transport the resident to the hospital due to a recent fall, hypotension, and high fever. It was documented the resident returned to the facility on [DATE]. A nurse's note, dated 03/10/15 at 2:00 a.m., documented the resident was awake and ambulating into the hall. A nurse's note, dated 03/10/15 at 3:50 p.m., documented, .bed alarm in place, pt high fall risk, pt tries several times a day to get up unassisted. cont. to redirect pt reorient pt to call light, pt requires close monitoring to avoid fall . A nurse's note, dated 03/11/15 and untimed, documented the resident was at high risk for falls. It was documented full precautions; a bed alarm, tab alarm, and fall mat; were in place. A nurse's note, dated 03/11/15 at 7:45 p.m., documented, .pt pleasant (and) cooperative, easily re-directed although he cont to get up on his own without using call light . A nurse's note, dated 03/12/15 at 12:15 a.m., documented the resident continued to get up without calling for assistance. A nurse's note, dated 03/13/15 at 4:30 a.m., documented the resident frequently tried to stand up from his wheelchair without assist. It was documented a personal alarm was in place. The resident was sent to the hospital on [DATE] due to the urge to urinate frequently. He returned to the facility on [DATE]. admission orders [REDACTED]. A nurse's note, dated 03/23/15 at 10:40 a.m., documented fall precautions were in place. It was documented the resident was highly confused and constantly attempted to get out of the bed or chair. It was documented staff was sitting with the resident. A nurse's note, dated 03/23/15 at 6:30 p.m., documented, .Res refuses to stay in bed (and) refuses to stay in w/c. Constantly transferring. When staff tries to help him he is squeezing their hands very hard (and) becoming combative. He has also torn staff's uniforms while he has been grabbing (at) q thing. Call to (physician name withheld) c N.O. to (increase) Ativan to 0.5 mg q 4 (hours) routine (and) give 1 mg now, Also to put res on mattress on floor . There was no documentation the staff attempted to determine why the resident was continually transferring. A nurse's note, dated 03/24/15 at 7:00 a.m., documented the physician was called due to the resident having increased agitation and not being able to rest. An order was received to obtain a psychiatric consult for the resident. A nurse's note, dated 03/28/15 at 1:15 p.m., documented the resident was transferred to an in-patient psychiatric hospital. A nurse's note, dated 03/31/15 at 11:00 a.m., documented the resident returned to the facility. It was documented the resident was very agitated. The resident was provided one on one care. It was documented the resident required constant redirection and was very confused. It was documented bed and tag alarms were in place. A nurse's note, dated 04/01/15 at 2:15 a.m., documented the resident was alert and confused. It was documented he kept getting up and pulling on everything. It was documented it took one on one constantly to keep the resident in bed. A nurse's note, dated 04/01/15 at 7:58 a.m., documented an order had been received for the resident to have a seat belt on while in the wheelchair. The clinical record documented the resident was able to remove the seat belt at will. A nurse's note, dated 04/01/15 at 6:30 p.m., documented the resident continued to benefit from one on one care. A nurse's note, dated 04/03/15 at 12:15 a.m., documented the resident required one on one care due to he frequently leaned forward in his wheelchair. An admission assessment, dated 04/06/15, documented the resident had long and short-term memory problems; inattention and disorganized thinking; and rejected care at times. It was documented the resident required limited assistance with bed mobility, transfers, walking, and locomotion. It was also documented the resident required staff assistance for balance during transitions and walking. It was documented the resident had two or more non-injury falls since admission. The resident's care plan, dated 04/10/15, documented a problem related to actual falls. The goal was the resident would resume usual activities without further incident through the review date. Interventions included to continue interventions on the at-risk plan and to provide activities that promote exercise and strength building where possible. A nurse's note, dated 05/03/15 at 6:00 a.m., documented, .Resident was found on his back on floor c his head on cushion area of geri chair . Review of the clinical record revealed no documentation the facility attempted to determine the cause of the resident's fall or identified any intervention to aid in the prevention of falls. A nurse's note, dated 05/14/15 at 10:30 a.m., documented, .client sitting on his buttocks on the floor, client received (sic) s/t to (right) arm (and) (left) arm . Review of the clinical record revealed no documentation the facility attempted to determine the cause of the resident's fall or identified any intervention to aid in the prevention of falls. A nurse's note, dated 05/25/15 at 7:20 a.m., documented, .very anxious, trying to get (up) (and) walk, not listening to staff, unable to redirect . A nurse's note, dated 05/31/15 at 11:00 a.m., documented, .resident was sitting at dining room table in w/c when he suddenly flipped w/c backward, head hit floor . Review of the clinical record revealed no documentation the facility attempted to determine the cause of the resident's fall or identified any intervention to aid in the prevention of falls. A nurse's note, dated 06/24/15 at 6:50 a.m., documented, .CMA heard tab alarm found client in the floor on his (right) side, (small) laceration to (right) eyebrow, s/t to (right upper) arm, c/o (right) hip pain, holding area c his (right) hand, client positioned on his back, ref to straightened legs, continues to guard (right) hip . It was documented the resident was transferred to the hospital, and the seat belt was discontinued. A nurse's note, dated 06/24/15 at 9:30 a.m., documented the resident had been diagnosed with [REDACTED]. A hospital discharge instruction sheet, dated 06/30/15, documented, .Complete Discharge Diagnosis .Fracture of femoral neck; S/P .open reduction internal fixation .fracture .right femur fracture . Review of the clinical record revealed no documentation the facility attempted to determine the cause of the resident's fall or identified any intervention to aid in the prevention of falls. It was documented the resident returned to the facility on [DATE]. A nurse's note, dated 07/08/15 at 7:15 a.m., documented the resident kept standing up without assistance from staff. It was documented, .Sets alarm off but he is too fast for them to keep him from standing . A nurse's note, dated 07/10/15 and untimed, documented the resident was found sitting on his bed with skin tears to both elbows. It was not noted how the resident received the skin tears. A nurse's note, dated 07/11/15 at 2:45 p.m., documented the resident continued trying to get up and was very restless. A nurse's note, dated 07/12/15 at 7:15 a.m., documented, .Resident was found in his room on safety mat on hands (and) knees, there was a small amt of bleeding from back of head (secondary) to a skin tear and large hematoma . Review of the clinical record revealed no documentation the facility attempted to determine the cause of the resident's fall or identified any intervention to aid in the prevention of falls. A nurse's note, dated 07/13/15 at 8:45 p.m., documented, .Res very restless entire shift. Would (not) lay (down) (and) sleep earlier. Kept getting (up) . A nurse's note, dated 07/15/15 at midnight, documented the resident was medicated for pain but continued to try to stand numerous times. It was documented a tab alarm and fall mat were in place. It was also documented the bed was in the low position. A nurse's note, dated 07/27/15 at 10:15 a.m., documented the resident was very anxious, pulling on tables, and trying to walk. A nurse's note, dated 07/27/15 at 9:30 p.m., documented the resident had been trying to get up and stand up over and over. It was documented the resident had appeared to be in pain and was medicated. It was documented there had been good results. A nurse's note, dated 07/31/15 at 10:50 p.m., documented, .Resd attempted to get out of bed et fell on to floor. CNA heard tab alarm found resd laying on floor resd had hematoma to forehead, et s/t to (right) elbow . Review of the clinical record revealed no documentation the facility attempted to determine the cause of the resident's fall or identified any intervention to aid in the prevention of falls. A nurse's note, dated 08/03/15 at 1:30 p.m., documented, .Tab alarm sounded, client in the floor on his (right) side, (right) arm (and) head against the wall- s/t to (right) elbow .Tab alarm intact, mat next to (low) bed . Review of the clinical record revealed no documentation the facility attempted to determine the cause of the resident's fall or identified any intervention to aid in the prevention of falls. A nurse's note, dated 08/03/15 at 9:30 p.m., documented, .Tag alarm was heard. Staff went in room (and) res was standing straight up beside bed. Res had taken gown off c tag alarm . A nurse's note, dated as a late entry for 08/03/15, documented an order for [REDACTED]. It was documented the seat belt was for increased security for prevention of falls due to dementia with poor safety awareness. It was documented the resident could remove the seat belt. A nurse's note, dated 08/04/15 at 8:00 p.m., documented the resident was sitting at the nurses' station for one on one care due to him standing up over and over. It was documented the resident had a protective helmet and seat belt in place. It was documented the resident frequently removed the seat belt. A nurse's note, dated 08/12/15 at 1:55 p.m., documented, .Pressure alarm sounded, found client in the floor in D.R. on his (right) side, client had removed soft helmet (and) seat belt, nonskid socks on , sleeve guards in place . Review of the clinical record revealed no documentation the facility attempted to determine the cause of the resident's fall or identified any intervention to aid in the prevention of falls. A nurse's note, dated 08/13/15 at 11:44 p.m., documented, .this nurse was called to unit by CNA where she found resd laying on (right) side c face downward. There was blood by wall et dresser. Resd had a silver dollar sized raised area to back of head c laceration et bruising noted . Review of the clinical record revealed no documentation the facility attempted to determine the cause of the resident's fall or identified any intervention to aid in the prevention of falls. A nurse's note, dated 08/14/15 at 2:15 a.m., documented, .resd returned via ambulance c orders for repeat CT scan of head w/in 24 (hours). Staple removal in 7 days . It was documented the resident had eight staples. A nurse's note, dated 08/16/15 at 2:35 p.m., documented, .resident was found in his room on his (left) back side c his head raised (up) in the air, safety mat under his legs, no apparent injury, no red or bruised areas . The resident's care plan, updated 08/19/15, documented a problem related to an actual fall with injury. The goal was the resident would be free from further incident through the review date. Interventions included to assess for pain, continue interventions on the at-risk plan, make sure helmet was on head at all times, make sure mats were in place when the resident was in bed, and the use of a seat belt when the resident was up in the wheelchair. The interventions listed were to help prevent injury with falls. There were no interventions listed to help prevent falls except for the seat belt. A nurse's note, dated 08/29/15 at 12:20 p.m., documented, .CNA saw resident stand up, then took one step loosing balance falling backward hitting back of head on door, abrasion c swelling noted to area . Review of the clinical record revealed no documentation the facility attempted to determine the cause of the resident's fall or identified any intervention to aid in the prevention of falls. On 09/24/15 at 9:37 a.m. and 11:02 a.m., the resident was observed sitting in his wheelchair in the dining room. He had a soft helmet on, and a tab alarm was in use. He did not have a seat belt on. At 1:10 p.m., the resident was observed lying in bed. The bed was in the low position, and a fall mat was on the floor beside the bed. The resident had a soft helmet on. A bed alarm was in place. CNA #1 stated the resident's door was to remain open so that staff could hear if the resident got out of bed. On 10/01/15 at 3:23 p.m., CNA #2 was asked if the resident was at risk for falls. She stated, Yes. She was asked what caused the resident's falls. She stated, He would just try to get up. CNA #2 was asked what she was supposed to do to help prevent falls with the resident. She stated the staff did one on one at times. She stated alarms and a fall mat were in use, and the resident wore a protective helmet. On 10/01/15 at 3:33 p.m., LPN #1 was asked if the resident was at risk for falls. She stated, Yes. She was asked what interventions were to be implemented to aid in the prevention of falls. She stated the resident wore a soft helmet, alarms were used, and mats were in place when the resident was in bed. She stated trying to stand was a behavior the resident exhibited. She stated even one on one didn't work for a multiple of reasons, including we don't have enough staff to do one on one all the time. On 10/01/15 at 3:52 p.m., the DON was asked if the resident was at risk for falls. She stated, Yes. She was asked what the root cause was of the resident's falls. She stated, I think it comes from dementia. He has to be busy. The DON was asked what interventions had been put in place to aid in the prevention of falls. She stated staff was supposed to use activities to keep him busy. She also stated that one on one care was provided at times. She was asked if one on one care was provided at all times. She stated, Not all the time. The DON was asked if the interventions of alarms, mats, a helmet, and seat belt were interventions to help prevent falls or minimize injury. She stated they did not prevent falls. 2. Resident #1 was admitted to the facility on [DATE], after falling and suffering a subdural hematoma. The resident had [DIAGNOSES REDACTED]. A nurse's note, dated 04/24/15 at 8:05 p.m., documented the resident was alert and oriented to person and place. A nurse's note, dated 04/26/15 at 2:15 a.m., documented, .Resd found in floor laying face down c (right) arm underneath her. Resd stated she was trying to get out of bed to void (and) fell out of her bed (and) that she think her arm is broken . It was documented the resident was transferred to the hospital. Hospital discharge instructions, dated 04/28/15, documented, .Fracture dislocation of (right) shoulder joint .High fall risk .Keep Immobilizer on at all time accept (sic) bathing . A nurse's note, dated 04/28/15 at 6:30 p.m., documented .Resident lethargic, unable to answer questions appropriately . The resident's admission assessment, dated 05/08/15, documented the resident had long and short term memory problems and required extensive assistance with transfers and bed mobility. It was documented she had experienced two or more non-injury falls since admission. The resident's care plan, dated 05/18/15, documented the resident was at moderate risk for falls related to confusion and weakness. The goal was the resident would be free of falls through the review date. Interventions included to anticipate her needs and to be sure the call light was within reach. A nurse's note, dated 07/07/15 at 4:30 p.m., documented, .Resident wormed her way off the side of the bed ended up on her knees beside bed, torso still on bed. (No) injuries . A nurse's note, dated 07/08/15 at 9:55 p.m., documented, .Resident in bed but continues to try to get out whistling off and on all evening. Confused, thinks she is riding in a truck .Repeatedly having to put her legs/feet back on bed . A nurse's note, dated 07/18/15 at 10:00 p.m., documented, .Resd found lying on (left) side on pad beside her bed .(no) injury .close monitoring started . A nurse's note, dated 07/23/15 at 4:20 p.m., documented .continues to .try to get out of bed/chair. Continue to try to redirect with no avail . A nurse's note, dated 07/23/15 at 4:50 p.m., documented, .found on floor on fall mat back against bed legs extended (no) injuries . A nurse's note, dated 07/24/15 at 4:15 p.m., documented, .found on floor beside bed on fall mat . A nurse's note, dated 07/27/15 at 10:05 p.m., documented, .trying to get (up) (without) assistance all shift . A nurse's note, dated 07/28/15 at 11:10 p.m., documented, .continues to get feet off side of bed and try to get out of bed . A nurse's note, dated 08/29/15 at 9:25 a.m., documented, .resident was found on her back on safety mat c her head against bed, no injury . A nurse's note, dated 09/16/15 at 2:30 p.m., documented, .res on floor beside bed on fall mat .res laying on stomach . On 09/24/15 at 9:40 a.m., 12:00 p.m., and 1:20 p.m., the resident was observed seated in her geriatric chair in her room. The resident was moving about in her chair. No staff was present. On 09/24/15 at 2:13 p.m., the resident was observed lying in bed. She was attempting to get her legs off the bed. No staff was present. At 2:14 p.m., LPN #1 walked by the room but did not look in or stop. On 09/24/15 at 2:17 p.m., CNA #1 was asked which residents were at risk for falls. She identified resident #1 as being at risk. She was asked what interventions were in place to help prevent falls for resident #1. She stated tag alarms were used to let the staff know when residents were trying to get up,. She stated that additional staff was used to sit with some residents in the dining room who were at risk for falls. CNA #1 was asked what interventions were in place to help prevent falls for resident #1. She stated they kept the resident turned, a fall mat was in place, and her bed was in the low position. She stated the resident wiggled. She stated, We watch her a lot. CNA #1 was asked how those interventions helped prevent falls for the resident. She stated, They won't prevent her from falling. She stated, They are to help her stay safe if she does. CNA #1 was asked why the resident was left alone in her room on this day. She stated, I don't know. On 09/24/15 at 2:24 p.m., LPN #1 was asked if the resident was at risk for falls. She stated, Yes, if we don't watch her real close. She was asked what caused the resident to fall, She stated, Dementia. She was asked what the facility did to help prevent the resident from falling. She stated they would see if the resident needed to eat or drink. She stated if the resident was awake, they would sit her in the geriatric chair. She stated if the resident was brought out to the public areas, she would get agitated. On 09/24/15 at 2:32 p.m., the DON was asked if the resident had experienced falls. She stated, Yes. The DON was asked what the facility had done to determine the root cause of her falls. She stated they previously had used a form but that was not available to them now that they tracked falls on the computer. The DON was asked how staff determined what interventions to put into place if they did not determine the root cause of the falls. She stated they started with tab alarms and would work their way up from there. At 3:00 p.m., the DON was asked how the interventions listed on the care plan helped prevent falls for the resident. She stated, They don't.