Every finding on record at Sand Springs Nursing and Rehabilitation

A past noncompliance immediate Jeopardy situation was determined to exist effective 12/01/25 related to the facility's failure to ensure residents were free from abuse by facility staff. Based on record review and interview, the facility failed to protect the resident's right to be free from sexual abuse by staff for 1 (#29) of 2 sampled residents reviewed for allegations of abuse. The administrator identified 59 residents resided in the facility. Findings: A care plan with an imitated date of 11/21/23, and last reviewed on 12/02/25, showed Resident #29 had self-care performance deficit related to decreased mobility. Interventions included Resident #29 was able to dress independently and could do up buttons, tie shoes, do zippers, put on shirts, pull up pants, put on socks, and put on coats. The interventions for transfers and toilet use included Resident #29 required zero staff participation with transfers and to use the toilet. Resident #29 required no assistance with toileting. An annual assessment for Resident #29, dated 11/21/25, showed a BIMS of 15 which indicated Resident #29 was cognitively intact for daily decision making. The assessment showed diagnoses which included heart failure, DVT, HTN, depression, and bipolar disorder. There was no documentation to show Resident #29 had a previous history of seeking out sexual encounters with care givers. Resident #29 hand written statement, dated 11/27/25, read in part, I am [Resident #29] I took a shower about 12:30 am and 1:00 am then I went to my room to get dress and [CNA #1]come in the room and me if I need help with getting dressed I said no and then started with a blow job and then turned over then we had sex. I was not forced A typed statement, dated 11/27/25, signed by the DON, read in part, On November 27, 2025, I Was informed that [Resident #29] had oral sex with one of the CNA's on duty the night before. I spoke with [Resident #29] who told me yes [they] had participated in oral sex with a CAN [sic] during [their] shower and again in [their] room later. [Resident #29] stated multiple times that she was not forced. That it was more out of curiosity. [Resident #29] stated that after the 2nd episode or oral sex they attempted to have intercourse, but [they] was unable to penetrate.A typed statement, dated 11/27/25, signed by the administrator, read in part, On November 27, 2025, I was present when the resident [Resident #29] spoke with police about the abuse allegation. The resident stated that the incident was not forced and was consensual. She also stated that she was touching the CAN [sic] as well. A handwritten statement, from CNA #4, dated 11/27/25, read in part, [Resident #29] told me that after [their] shower [CNA #1] came to her about 12:30 a.m. and tried to have sex but told [them] [they] was to tight so proceeded to do oral sex. A handwritten statement, from CMA #1, dated 12/02/25, read in part, I let [Resident #29] in when [Resident #29] got back from being out with [their] family. [Resident #29] said you have a boyfriend and I said yes why? [Resident #29] said I do too, well we just mess around and I asked who It was and [Resident #29] said [CNA #1], [they] gave me a shower las night and I sucked his [explicit] and [they] liked it. And [Resident #29] said yea, and later on we was in my room and we done it again, but [name deleted] came in and asked what I needed because my call light went off and [CNA #1] hid behind the curtain. Later on I stopped [name deleted] and asked if seen anything and he said no. And then I went to the med [medications] room to help [name deleted] and I reported it to [LPN #1, Business office manager, CNA #4].An investigation for an allegation of sexual abuse, dated 11/27/25, showed an investigation began on 11/27/25 when the facility learned of the allegation of an oral sex interaction with a staff member and Resident #29. The investigation showed CNA #1 was suspended pending the investigation. The facility investigation showed the administrator discovered CNA #1 was unable to be located for 45 minutes during their shift and had been providing care to Resident #29 on a hall they were not assigned to. The investigation showed the facility substantiated the allegation of sexual abuse and provided in-service to all staff for sexual abuse, appropriate/inappropriate relationships with residents, conducted safe surveys with all residents and began same sex only care with two staff for Resident #29. An in-service, dated 11/28/25, showed staff were educated on appropriate/inappropriate relationships with residents. A handwritten statement, from CNA #2, dated 12/02/25, read in part, I [CNA #2] was here on the night this occurred. I was working with [CNA #1] for a 16-hour shift and what I saw was [CNA #]1 changing [Resident #29] [they] started changing her around 1:30 a.m. or so. I wasn't aware of the exact time, but I was going to check on [Resident #29] to make sure [they] was well. I opened the door and [CNA #1] said [they] was changing her or helping her. I came back 10-12 minutes later because another resident had fell and me and [CNA #3] needed help so I looked around and couldn't find [CNA #1], so I checked the last place I seen [them] and [they] was sure enough still in there which was odd. So, I walked in the room and all I saw was him just finishing changing her. A QA/QAPI was completed on 12/02/25 with follow up QAPIs on 12/03/25, 12/10/25, 12/11/25 and 12/17/25. Resident safe surveys were completed, Interviews were conducted with staff and showed they had knowledge of the facility abuse policy and confirmed they had in-service on abuse. Resident interviews revealed no concerns with abuse, felt safe and reported anything to nursing staff. A care plan for Resident #29, initiated on 12/02/25, showed a focus for resident relationships related to seeking out sexual relationships with caregivers of the opposite sex. The care plan showed interventions which included, administer medications as ordered, monitor/document for side effects and effectiveness, caregivers to provide opportunity for positive interaction, education for successful coping and interaction strategies, intervene as necessary to protect the rights and safety of others and same sex caregivers for personal care/showers. Prior to the care plan dated 12/02/25, the care plan did not address any behaviors of Resident #29 seeking out sexual relationships with staff. An APS-Report, dated 12/12/25, page 4, read in part, [Resident #29], stated that [CNA #1] came back into [Resident #29] room and was standing by the bed. [Resident 29], stated that [CNA #1] started rubbing on [Resident #29] indicating her chest area, and then put [Resident #29] hand on [their] private parts outside of [CNA #1] pants. [Resident #29], stated that [CNA #1] then took it out and I put it in my mouth, . [Resident #29], stated that when [CNA #1] came back 'We had sex. [Resident #29], stated that [CNA #1] kept saying you are tight. [Resident #29] stated [they] had done this before at another facility with diet. [[[ staff 2 1/2 years ago.An APS-Report, dated 12/12/25, page 5, read in part, On December 2, 2025, at 9:33 AM, I interviewed [Administrator]. [Administrator] stated that [they] verified with [Resident #29] who reported that [they] had given a 'blow job' to staff in the shower and in her room. [Administrator] stated that [Resident #29] told her that it was consensual.On 12/16/25 at 2:00 p.m., the administrator stated they were aware of the sexual abuse allegation against a staff member, and the DON conducted an interview with Resident #29. The administrator stated they had issues in the past with Resident #29 seeking out sexual relationships, with caregivers. The administrator stated Resident #29 had been moved closer to the nurse's desk to observe and the care plan had been updated to address the resident seeking out sexual relationships. On 12/15/25 at 12:10 p.m., Resident #29 stated they and an employee had a sexual relation. Resident #29 stated they were not forced and it was consensual. Resident #29 stated the employee was no longer allowed to come back into the facility. On 02/13/29 at 12:30 p.m., the corporate nurse stated the facility should not have substantiated the allegation because there was no way to prove oral sex took place. On 02/13/26 at 12:47 p.m., the DON stated on 11/27/25 they received a call from the facility stating Resident #29 had performed oral sex on a male staff member. The DON stated they immediately came to the facility and spoke with Resident #29. The DON stated Resident #29 told them the CNA was their boyfriend and they had performed oral sex on them. The DON stated the allegation was substantiated because the timeline matched up with the interviews of staff and Resident #29 never changed how they described the incident. On 02/13/26 at 3:45 p.m., CNA #1 stated they assisted Resident #29 in the shower because they were going out with family the next day. CNA #1 stated in no way did anything sexual happen between them and they were taken aback by the accusations. CNA #1 denied the resident was ever their girlfriend.

Based on record review and interview, the facility failed to ensure assessments were accurate for 1 (#28) of 17 sampled residents reviewed for falls.The administrator identified 59 residents resided in the facility. Findings: A quarterly assessment for Resident #28, dated 11/25/25, showed a BIMS of 03 which indicated the resident was severely impaired for daily decision making. The assessment showed diagnoses which included hypertension, non-Alzheimer's disease, anxiety disorder, depression and psychotic disorder. Section J of the assessment showed Resident #28 had no falls since admission/entry, reentry, or prior assessment. On 12/17/25 at 3:36 p.m., the MDS coordinator stated they ensured the accuracy of the MDS by looking at the provided documentation and doing the assessment themself. They stated when a resident had a fall, they added the falls to the assessment and the care plan. The MDS coordinator reviewed the quarterly assessment dated [DATE] for Resident #28 and stated they had not accurately coded the assessment related to falls.

Based on observation, record review, and interview, the facililty failed to maintain an infection control program for enhanced barrier precautions for three (#29, 46, and #51) of three reviewed for infection control. The DON identified eight residents who currently had EBP. Findings: A policy titled Enhanced Barrier Precautions documented in parts .EBPs employ targeted gown and glove use during high contact resident care activitites when contact precautions do not otherwise apply .Examples of high-contact resident care activitites requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing) . 1. Res #29 had diagnoses which included obstructive and reflux uropathy, diabetes mellitus, atrial fibrillation, polyneuropathy, and depressive disorder. On 06/17/24 at 10:20 a.m., signage was noted at the door for Res #29 and documented enhanced barrier precautions gown and gloves required. On 06/17/24 at 10:24 a.m., LPN #2 stated they were unsure what the signage on the door meant. The LPN #2 stated they were not aware of the resident requiring special precautions with care at this time. On 06/21/24 at 8:50 a.m., the DON stated an in-serviced regarding enhanced barrier precautions had been provided for staff. The DON stated the signage on the door documented staff were to wear a gown and gloves when providing resident personal care. 2. Res #51 had diagnoses which included neuromuscular dysfunction of bladder, vesical tenesmus, tubuloinerstitial nephritis, and left nondominant hemiplegia. On 06/17/24 at 10:46 a.m., the Res #51 was lying in bed with a catheter hanging from the bedside. A sign posted at the resident's door documented enhanced barrier precautions. On 06/17/24 at 10:54 a.m., LPN #2 stated the resident had ESBL in the urine and staff must wear gown, gloves, mask, and shoe protectors with resident care. PPE was available at door entrance. On 06/20/24 at 9:35 a.m., Res #51's door was observed with signage indicating the resident required enhanced barrier precautions. On 06/20/24 at 9:37 a.m., Res #51 was observed during foley catheter care. On 06/20/24 at 9:40 a.m., CNA #1 was observed donning gloves and pulling back the covering of Res #51. Res #51 stopped the CNA and asked if the CNA #1 should be wearing a gown. On 06/20/24 at 10:17 a.m., CNA #1 was observed emptying the resident's foley catheter drainage bag, and placing a new brief and gown without wearing PPE. On 06/20/24 at 10:33 a.m., CNA #1 stated they should have donned a gown to empty the foley catheter and assist the resident with dressing. On 06/20/24 at 11:01 a.m., the DON stated the CNA should have been wearing PPE during care for the resident as part of enhanced barrier precautions. 3. 42171 3. Res #46 had diagnoses which included a stage four pressure ulcer and diabetes mellitus. A sign on Res #46's door documented they required EBP. On 06/19/2024 at 12:13 p.m., LPN #1 and the ADON were observed providing ordered wound care to Res #46, they were not wearing gowns. On 06/20/24 at 8:25 a.m., LPN #1 stated they should have been wearing a gown because Res #46 required EBP. On 06/20/24 at 9:00 a.m., the ADON stated they should have been wearing a gown while providing direct patient care for Res #46.

Based on observation, record review, and interview, the facility failed to: a. assess the resident for the use of side rails, b. ensure to mattress fit correctly for the bed frame and use of side rails, c. monitor for safety and maintenance for the use of side rails, d. obtain an informed consent prior to the use of side rails, for one (#27) of one sampled residents reviewed for side rails. The DON identified eight residents who used side rails. Findings: The policy for Bed Safety and Bed Rails documented use of bed rails were prohibited unless the criteria for use had been met. The policy documented bed frames, mattress and bed rails were checked for compatibility and size prior to use. The policy documented regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. The policy documented the maintenance staff was to routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. Resident #27 had diagnoses which included diabetes mellitus, morbid obesity, and hypertension. The care plan, dated 06/13/19, documented the resident had an ADL self care deficit. The care plan documented the resident used a halo rail/Ubar on their bed to assist with turning and/or repositioning. A physician order, dated 07/18/22, documented the resident may use bilateral m-bars to aide with turning and repositioning. A quarterly assessment, dated 03/18/24, documented bed rails were not used. On 06/17/24 at 2:50 p.m., the Resident #27 was lying in bed on their left side. The resident's bed frame was visible three to five inches from mid mattress down. There were rolled blankets from the top of the bed to the middle positioned between the bed rail and the mattress. On 06/19/24 at 10:49 a.m., LPN #2 stated the resident's bed had quarter rails to each side. The LPN stated the mattress did not cover the metal frame of the bed from midway down and rolled blankets were used between the mattress and quarter rail. The LPN stated the mattress did not fit the resident's bed. On 06/19/24 at 11:14 a.m., the DON accompanied the survey to the resident's room. The DON stated they were unaware the resident had quarter rails. The DON stated the mattress did not fit the bed frame. The DON was unsure who was responsible for assessing and monitoring beds for safety and the use of rails. The DON stated the bed frame and rails should be assessed at least monthly. The DON stated to their knowledge the resident had the current bed since 2019. On 06/19/24 at 2:41 p.m., the DON provided a side rail consent form and a restraints: side rail utilization assessment for the resident that was completed but not dated. The DON stated to documents were most likely completed today. The DON stated at this time they could not provide assessments or monitoring for the use of bed rails for the resident.

Based on record review and interview, the facility failed to provide enough staff to ensure assistance with ADL's and a clean environment was provided for one (#33) of three residents reviewed for ADL's The administrator reported the census was 52. Findings: An undated facility policy titled Staffing, Sufficient and Competent Nursing, read in part, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment Res #33 had diagnoses including paraplegia and diabetes mellitus. An admission assessment, dated 05/14/24, indicated the Res #33 was independent with daily decision making and was dependent on staff for transfers. A physician order, dated 06/17/24, documented Per resident request: up to chair daily as tolerated to facilitate wound healing On 06/17/24 at 11:00 a.m., Res #33 stated that he wanted to get out of bed more often, but staff didn't always help him. Res #33 also stated they had not been out of bed since the end of last week. The trash can in the resident's room was observed to be full and soiled linens were piled in two separate areas of the floor. The floor was discolored in areas and sticky to the touch. Two pairs of soiled gloves were observed near the wall by the bathroom. Food debris was observed near the resident's bed. Res #33 stated housekeeping did not do a good job cleaning the room. On 06/18/24 at 10:00 a.m., Res #33 stated they still have not been out of bed. Food debris was observed near the resident's bed, one pair of soiled gloves were observed near the wall by the bathroom. The floor was sticky to the touch. On 06/19/24 at 10:10 a.m., Res #33 stated they had an order from the doctor, and they still had not been out of bed. On 06/19/24 at 10:36 a.m., the Housekeeping supervisor stated the CNA's were responsible to ensure that dirty linens were not in the floor, but housekeeping should ensure the room is clean. On 06/20/24 at 9:28 a.m., CNA #3 stated that they try to get Res #33 up, but they are pulled away a lot of times and they are unable to get the resident up. They also stated they are usually the only aide on the hall, and they had not seen Res #33 out of bed since last week. On 06/20/24 at 9:30 am, LPN #1 stated they had not seen Res #33 out of bed since late last week, they also stated staffing was an issue at times and required tasks were not always completed. On 06/21/24 at 8:30 a.m., Res #33 reported they have not been out of bed since last week. On 06/21/24 at 8:42 a.m., Housekeeper #1 stated they do not have enough housekeeping staff to clean the rooms like they should be cleaned. On 06/21/24 at 8:46 a.m., the Housekeeping supervisor stated that the rooms are not getting deep cleaned appropriately because of lack of staff. On 06/21/24 at 8:53 a.m., LPN #2 stated staff were not always available to ensure resident needs were met in a timely fashion.

Based on observation and interview, the facility failed to ensure nurse staffing information was posted on a daily basis. The administrator identified 52 residents resided in the facility. Findings: On 06/17/24 at 10:35 a.m., the nurse staffing board was not observed as posted in any high visibility area. On 06/19/24 at 12:44 p.m., a staffing board was observed posted at the nurses station near the front door. The staffing data on the posting was dated 06/18/24. On 06/20/24 at 9:36 a.m., a staffing board was observed posted at the nurses station near the front door. The staffing data on the posting was dated 06/18/24. On 06/21/24 at 8:22 a.m., a staffing board was observed posted at the nurses station near the front door. The staffing data on the posting was dated 06/18/24. On 06/21/24 at 8:26 a.m., the DON stated the staffing data was posted right up front. They pointed to the staffing data observed at the nurses station near the front door. The DON stated the staffing data was supposed to be update daily but was not.

Based on record review and interview , the facility failed to administer medication as ordered by the physician for one (#51) of five sampled residents who were reviewed for unnecessary medication. The administrator identified 52 residents resided in the facility. Findings: Resident #51 had diagnoses which included acute embolism and thrombosis of unspecified deep veins of the lower extremity, cardiomyopathy, chronic systolic heart failure, hemiplegia to left nondominant side, and anemia. A five day assessment, dated 05/24/24, documented the resident was cognitively intact and was receiving an anticoagulant medication. A hospital discharge order, dated 06/12/24, documented the resident was to receive Eliquis (a anticoagulant medication) 10mg by mouth twice a day for six days then decrease to 5mg by mouth twice a day. The Resident #51's MAR for June 2024 did not document the resident received Eliquis as ordered by the physician. On 06/19/24 at 2:15 p.m., LPN #2 stated they admitted the resident to the facility on [DATE] from the hospital. The LPN #2 stated physician orders were put in the computer and a copy was faxed to the pharmacy. The LPN #2 was unsure why the medication was not on the MAR or why the Eliquis had not been given. On 06/20/24 at 2:06 p.m., the DON reviewed the resident's hospital physician orders. The DON stated the resident had not received the Eliquis as ordered by the physician. The DON stated some education needed to be given.

Based on observation, record review, and interview, the facility failed to complete weekly skin assessments as ordered to identify impaired skin integrity for one (#27) of three residents reviewed for pressure ulcers. The DON identified two residents with pressure ulcers. Findings: Res #27 had diagnoses which included diabetes mellitus, morbid obesity, and hypertension. A care plan, dated 07/19/20, documented the resident had potential for impaired skin integrity related to fragile skin, incontinence, and/or impaired mobility. A physician order, dated 08/21/23, documented the facility was supposed to do weekly skin assessments. The staff was to examine the resident's skin from head to toe and document any new abnormalities and notify the physician for treatment every evening shift on Mondays. A weekly skin assessment, dated 05/13/24, documented the resident had redness and moisture to the groin area. A weekly skin assessment, dated 05/27/24, documented the resident had moisture associated redness to the left iliac crest and a treatment was in place. On 06/17/24 at 2:51 p.m., the Res #27 stated they had discomfort and had a wound to the right hip from lying on that side. On 06/19/24 at 10:49 a.m., LPN #2 completed a skin assessment for the resident. The LPN #2 stated the Res #27 had pressure areas to both hip areas. The LPN #2 stated the areas were discolored and could open if left untreated. On 06/20/24 at 9:54 a.m., the DON stated weekly skin assessment had not been completed the month of June 2024 to identify new skin concerns for the resident.

Based on observation, record review, and interview, the facility failed to maintain a clean comfortable environment for one (#33) of three residents sampled for environment. The administrator reported the census was 52. Findings: An undated facility policy titled Cleaning and Disinfecting Residents' Rooms, read in part, Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled Res #33 had diagnoses including paraplegia and diabetes mellitus. An admission assessment, dated 05/14/24, documented the resident was independent with daily decision making and was dependent on staff for transfers. On 06/17/24 at 11:00 a.m., Res #33's room was observed. The trash can was observed to be full and soiled linens were piled in two separate areas of the floor. The floor was discolored in areas and sticky to the touch. Two pairs of soiled gloves were observed near the wall by the bathroom. Food debris was observed near the resident's bed. On 06/17/24 at 11:05 a.m., Res #33 stated housekeeping came in every day but did not do a good job. On 06/18/24 at 10:00 a.m., Res #33's room was observed. Food debris was observed near the resident's bed, one pair of soiled gloves were observed near the wall by the bathroom. The floor was sticky to the touch. On 06/19/24 at 10:10 a.m., Res #33's room was observed. Food debris was observed near the resident's bed, one pair of soiled gloves were observed near the wall by the bathroom. On 06/19/24 at 10:36 a.m., the housekeeping supervisor stated the CNA's were responsible to ensure that dirty linens were not in the floor, but housekeeping should ensure the room is clean. On 06/21/24 at 8:42 a.m., housekeeper #1 stated they do not have enough housekeeping staff to clean the rooms like they should be cleaned. On 06/21/24 at 8:46 a.m., the housekeeping supervisor stated that the rooms are not getting deep cleaned appropriately because of lack of staff.

Based on record review and interview, the facility failed to ensure a PRN order for an antianxiety had a 14 day stop date and an antipsychotic had an appropriate diagnosis for one (#53) of five sampled residents reviewed for unnecessary medications. The administrator identified 52 residents resided in the facility. Findings: Res #53 had diagnoses which included dementia. A physician order, dated 04/04/24, documented to administer Seroquel (an antipsychotic) 200 mg at bedtime for dementia. A MAR for April 2024 documented Seroquel was received by the resident 25 times. A physician order, dated 05/05/24, documented to administer Ativan (an anti-anxiety) 0.5 mg every six hours as needed for agitation. A MAR for May 2024 documented Seroquel was received by the resident 31 times, and Ativan was received by the resident 16 times. A MAR through 06/19/24, documented Seroquel was received by the resident 18 times, and Ativan was received by the resident 9 times. On 06/19/24 at 2:41 p.m., the DON stated it was the responsibility of the DON to ensure the end date for the PRN and the diagnosis for the psychotropic medication.

Based on observation, record review, and interview, the facility failed to ensure assistance with ADL's was provided for one (#33) of three residents reviewed for assistance with ADL's. The administrator reported the census was 52. Findings: Res #33 had diagnoses including paraplegia and diabetes mellitus. An admission assessment, dated 05/14/24, indicated the resident was independent with daily decision making and was dependent on staff for transfers. A physician order, dated 06/17/24, documented Per resident request: up to chair daily as tolerated to facilitate wound healing. On 06/17/24 at 11:00 a.m., Res #33 stated that they wanted to get out of bed more often, but staff didn't always help them. Res #33 also stated they had not been out of bed since the end of last week. On 06/18/24 at 10:00 a.m., Res #33 stated they still had not been out of bed. On 06/19/24 at 10:10 a.m., Res #33 stated they had an order from the doctor to get up, and they still had not been out of bed. On 06/20/24 at 9:28 a.m., CNA #3 stated they try to get Res #33 up, but they are pulled away a lot of times and they are unable to get the resident up. They also stated they are usually the only aide on the hall, and they had not seen Res #33 out of bed since last week. On 06/20/24 at 9:30 a.m., LPN #1 stated they had not seen Res #33 out of bed since late last week. On 06/21/24 at 8:30 am, Resident #1 reported they have not been out of bed since last week.

Based on record review and interview, the facility failed to ensure resident records were accurate for one (#49) of four sampled residents reviewed for accidents. The administrator identified 52 residents resided in the facility. Findings: Res #49 had diagnoses which included dementia. A progress note dated 04/30/24 at 10:08 a.m., documented the resident's hand was deep purple, swollen, and painful. The note documented the physician was notified. On 06/20/24 at 1:51 p.m., the medical director stated the report they received did not include pain or discoloration. An observation of a text message documented the staff reported to the doctor the hand was swollen and not painful. The message to the doctor included a photograph. The photograph did not show the resident's hand was discolored.

Based on observation, record review, and interview, the facility failed to inspect the bed frame, mattress, and bed rails as part of a regular maintenance program for one (#27) of one sampled residents reviewed for side rails. The DON identified eight residents who used side rails. Findings: The policy for Bed Safety and Bed Rails documented use of bed rails were prohibited unless the criteria for use had been met. The policy documented bed frames, mattress and bed rails were checked for compatibility and size prior to use. The policy documented regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. The policy documented the maintenance staff was to routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. Res #27 had diagnoses which included diabetes mellitus, morbid obesity, and hypertension. The care plan, dated 06/13/19, documented the resident had an ADL self care deficit. The care plan documented the resident used a halo rail/Ubar on their bed to assist with turning and/or repositioning. A physician order, dated 07/18/22, documented the resident may use bilateral m-bars to aide with turning and repositioning. A quarterly assessment, dated 03/18/24, documented bed rails were not used. On 06/19/24 at 11:41 a.m., the Res #27 was lying in bed on their left side. The Res #27 bed frame was visible three to five inches from mid mattress down. There were rolled blankets from the top of the bed to the middle positioned between the bed rail and the mattress. On 06/19/24 at 10:49 a.m., LPN #2 stated the resident's bed had quarter rails to each side. The LPN #2 stated the mattress did not cover the metal frame of the bed from midway down and rolled blankets were used between the mattress and quarter rail. The LPN #2 stated the mattress did not fit the resident's bed. On 06/19/24 at 11:14 a.m., the DON accompanied the survey to the resident's room. The DON stated they were unaware the resident had quarter rails. The DON stated the mattress did not fit the bed frame. The DON was unsure who was responsible for assessing and monitoring beds for safety and the use of rails. The DON stated the bed frame and rails should be assessed at least monthly. The DON stated to their knowledge the resident had the current bed since 2019.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than five percent for three (#34, 27, and #31) of 16 residents observed during medication passes. A total of 25 opportunities were observed with three errors and a total error rate of 12%. Findings: 1. Resident #34 had diagnoses which included diabetes. A physician's order, dated 03/13/23, documented the resident was to receive Novolog insulin per sliding scale readings at 150 mg/dL or greater. The resident was to receive six units for a finger stick blood sugar reading between 251 mg/dL and 300 mg/dL. On 05/10/23 at 4:43 p.m., LPN #1 stated the resident's finger stick blood sugar reading was 267 mg/dL. LPN #1 stated the resident was to receive four units of Novolog insulin for every 50 mg/dL above 150 mg/dL. On 05/10/23 at 4:43 p.m., LPN #1 was observed to administer eight units of Novolog insulin for a finger stick blood sugar reading of 267 mg/dL. This is two units more than the Novolog sliding scale insulin (6 units) for a finger stick blood sugar of 267 mg/dL. 2. Resident #27 had diagnoses which included chronic obstructive pulmonary disease. A physician's order, dated 04/14/23, documented the resident was to received Advair diskus 250-50 mcg, one puff inhaled orally two times a day. On 05/11/23 at 11:35 a.m., LPN #2 was observed to administer Advair diskus 250/50 mcg/ACT to resident #27. Resident #27 was sitting in their room. LPN #2 placed the Advair diskus to the resident's lips and pulled the trigger on the diskus, which punctures the capsule inside, allowing the resident to inhale the powder. As the resident began to breath in, the LPN removed the diskus from their lips. Resident #27 informed the LPN they had removed the diskus before the resident had an opportunity to inhale the medication. LPN #2 placed the Advair diskus back to the resident's lips and again pulled the trigger. Just as the resident began to inhale, the LPN removed the diskus from their lips. Resident #27 again informed the LPN they had removed the diskus before they had an opportunity to inhale the medication and stated they would nod their head when they were ready for the LPN to remove the diskus from their lips. LPN #2 again pulled the trigger on the Advair diskus and then placed the diskus to the resident's lips. Resident #27 inhaled a breath and nodded their head in affirmation. The LPN removed the Advair diskus. 3. Resident #31 had diagnoses which included diabetes. A physician's order, dated 07/21/22, documented the resident was to receive five units of Novolog by subcutaneous injection before meals and at bedtime. A physician's order, dated 03/29/23, documented the resident was to receive Novolog insulin per sliding scale readings at 200 mg/dL or greater. The resident was to receive two units for a finger stick blood sugar reading between 200 mg/dL and 250 mg/dL. On 05/11/23 at 4:38 p.m., RN#1 was observed to administer nine units of Novolog insulin for a finger stick blood sugar reading of 213 mg/dL. This is two units more than the routine Novolog insulin (5 units) and the Novolog sliding scale insulin (2 units) for a finger stick blood sugar of 213 mg/dL. On 05/12/23 at 3:45 p.m., the DON was informed of the above observations. The DON stated the facility was always looking for ways to improve the care they provided the residents.

Based on observation and interview, the facility failed to store foods according to professional standards for food service safety. The facility failed to discard left-over refrigerated foods within the timeframe allotted for food service safety and failed to label/date left-over foods stored in the refrigerator according to professional standards for food service safety. The director of nursing identified 56 residents who ate meals prepared in the kitchen. Findings: On 05/11/23 at 7:10 a.m., the following items were observed stored in the walk in refrigerator: - a resealable bag, dated 05/03, of cooked hamburger patties, - an undated container of hand diced tomatoes - a container, dated 05/06, of vanilla pudding, - a covered plate of hashbrowns, dated 05/06, - a pan of mechanically soft sweet and sour chicken, dated 05/08, and - an undated pan of spanish rice. On 05/11/23 at 5:00 p.m., the assistant dietary manager was asked what the facility policy was regarding the storage of left-overs. The ADM stated deserts were stored in the refrigerator for up to 24 hours and everything else was stored in the refrigerator for up to 48 hours. The ADM stated all staff were responsible for ensuring left-overs were either used or thrown away within the proper timeframe. The refrigerator was observed with the assistant dietary manager and the listed items were still present. The ADM stated the items needed to be thrown away. The ADM stated the rice and diced tomatoes were not dated and should be thrown away.

Based on record review and interview, the facility failed to obtain a thyroid stimulating hormone level for one (#1) of four residents sampled for laboratory testing. The director of nursing stated all 52 residents had the potential to receive orders for laboratory testing. Findings: Resident #1 had diagnoses which included hypothyroidism. A physician's progress note, dated 02/22/23, documented resident #1 has an elevated thyroid stimulating hormone level and ordered the hormone level to be checked again in four weeks. A review of the electronic medical record for resident #1 found no laboratory results for a thyroid stimulating hormone level on or around 03/22/23. On 04/28/23 at 3:15 p.m., the MDS coordinator stated the lab was ordered on 02/22/23 under a standard other classification, instead of as a laboratory service and so the program did not trigger for the nurse to make out the requisition forms and draw the specimen. The coordinator stated once the date came around, the order dropped off the system as completed without ever showing on the treatment administration record for the nurse to perform. On 04/28/23 at 4:50 p.m., the corporate quality assurance nurse stated a consulting nurse had recently performed chart reviews and identified a problem with the facility laboratory testing orders.

Based on observation, interview, and record review, it was determined the facility failed to provide care and services to prevent the development or worsening of pressure ulcers for one (#5) of two resident sampled residents reviewed for pressure ulcers. The facility failed to prevent a pressure ulcer from developing on a resident with other identified pressure ulcers; failed to maintain a packed dressing on an unstageable pressure ulcer as ordered by the physician; and failed to cover/apply a packed dressing on an unstageable pressure ulcer as ordered by the physician; on an incontinent resident, potentially allowing for urine and feces to contaminate the wound. The facility identified 30 residents who were incontinent and 6 with pressure ulcers who resided in the facility. Findings: Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admit/readmit screener, dated 07/02/21, documented the resident had a blister on her front right iliac crest; a superficial stage II pressure ulcer measuring 0.5cm by 0.5 cm (centimeter) on her left buttock and another superficial stage II pressure ulcer measuring 2cm by 1cm on her left gluteal fold; a scabbed callous measuring 0.5cm by 0.5cm on the right ball of her foot; and a superficial skin tear measuring 2cm by 0.5cm below her right scapula. The comments section documented, .multiple reddish purple bruising both arms, and bluish green bruising to lower extremities, redness to abd [abdominal] folds, under breast and groin areas . The admission assessment, dated 07/09/21, documented the resident was cognitively intact, was incontinent of bowel, had a urinary catheter, two stage II pressure ulcers, and moisture associated skin damage. The skilled nurse's note, dated 07/14/21, documented the resident was incontinent of bowel and bladder. There was no documentation of the presence of a urinary catheter. The physician's wound order, dated 07/16/21, documented, .Treatment- Wound. Coccyx/sacral region. Cleanse area with soap and warm water. Pat dry. Apply packing strips to tunneling area. Cover with cut to fit algenate to areas of concern or breakdown. Triad as needed to pink areas, cover with abd. secure with tape. Change as needed due to soilage, or moisture in location . On 07/20/21 at 12:30 p.m., the resident was observed laying on her back in bed with her eyes closed. There was body odor present. There was no urinary catheter present. There was a bath blanket (lightweight blanket) that appeared partially folded and wrinkled under the resident's hips. The wound consultant note, dated 07/21/21, documented wound #1 was to the sacrum and was to be cleansed with saline, skin prep applied to periwound, alginate with silver applied to wound bed and an ABD or bordered foam dressing applied to cover the wound daily. The notes documented the plan of care, .Sacral - UPI [unstageable pressure injury or ulcer] - continuing silver alginate. Consider DNA culture, Pre-[MEDICATION(S)]. Acute complicated wounds due to etiology, comorbidities, nutrition, decreased mobility, risk of worsening of wound without proper treatment. Reviewed chart/vitals/meds. Educated on orders. Ensure only 1 flat sheet the length of the bed and 1 disposable pad is used on LAL [low air loss] mattress and avoid cloth pads. Ensure LAL setting is appropriate for weight. Educated on wound care orders, etiology of wound, and importance of keeping patient repositioned every 2 hours. Check patient frequently for incontinent episodes to keep skin clean an dry. Unable to determine true depth of wound. Visible and measurable depth of necrotic tissue in wound bed is noted as depth for measurement purposes to track wound dimensions, wound progress, and response to treatment. There were no wound measurements documented in the wound consultant's progress note. The facility wound tracking sheet, dated 07/21/21, documented the resident had a right gluteal unstageable pressure ulcer measuring 4cm x 3cm x 2.1cm. The tracking sheet also documented the resident had abdominal [MEDICATION(S)] with a fowl odor. The treatment was to cleanse the area daily with soap and water and apply [MEDICATION(S)] powder twice daily. On 07/21/21 at 10:50 a.m., the resident was observed laying on her back in bed with her eyes closed. There was body odor present. There was a bath blanket partially folded and wrinkled under her lower back and hips. At 2:30 p.m., the resident was observed laying on her back in bed with her eyes closed. There was a bath blanket partially folded and wrinkled under her lower back and hips. On 07/26/21 at 9:20 a.m., the resident was observed laying on her back in bed with her eyes closed. There was a poorly folded bath blanket under the resident's hips, buttocks, and legs. At 4:30 p.m., the resident was observed laying on her back in bed with her eyes closed. There was a poorly folded bath blanket under the resident's low back, hips, and buttocks. On 07/27/21 at 5:30 a.m., incontinent care was observed with CNA #3 and the ADON. The resident was turned from her back to her left side and supported by the ADON. The brief was soaked through with urine and feces. There was a bath blanket folded to approximately two feet long by three feet wide and positioned under the resident's hips like a bed pad. The bath blanket was wet and there was a oval shaped brown stain approximately a foot in diameter under the resident and brown stained rings on the fitted sheet, under the bath blanket. The staff were asked why the resident had a bath blanket under her instead of a pad and draw sheet. The CNA stated the pads were not wide enough for the resident's bariatric bed. The CNA removed the right side of the resident's brief. An undated two by three inch occlusive bandage was observed in the brief and the right buttock wound appeared open and exposed with what appeared to be feces covering a portion of the wound bed. There was no packing or calcium alginate present. The CNA removed the brief and performed incontinent care. The CNA was asked when the resident was last changed. She stated she started her shift at 3:00 a.m. and did not know when the resident was last changed. The ADON was asked about the wound dressing. The ADON stated the wound was to have iodaform packing where the wound tunneled and the wound bed covered with calcium alginate and secured with and an ABD (absorbency) pad and tape. She was asked if she saw any of that in the wound or brief. She stated no. She asked the CNA if she seen anything and the CNA stated no. The ADON stated it looked like night shift had just thrown a band-aide over the wound. A new brief was applied and a clean bath blanket placed under the resident. No dressing was applied to the wound. The ADON instructed CNA #3 to inform the resident's nurse to apply a dressing. The two staff members positioned the resident and exited the room. At 4:00 p.m., the ADON was asked to measure the wound for resident #5. The ADON and corporate nurse entered the room and positioned the resident on her right side. The right side of the brief was removed and there was no dressing in place over the wound. There was no sign of a dressing in the soiled brief. The ADON was asked where about the dressing. She stated there was no dressing. The resident's brief was wet and soiled with green feces. The wound bed appeared contaminated with green feces. As the resident was pulled further onto her left side, a large volume of green mucousy fluid discharged from the wound. The discharge was a duller green than the feces or the substance contaminating the wound bed. The ADON was asked if she saw feces in the wound bed. She stated she could not tell if it was feces or the discharge from the wound. The wound was cleaned, measured, packed with a non medicated strip, calcium alginate was applied to the wound bed, and the wound was covered with an ABD pad, and secured with tape. A clean brief and bath blanket was placed under the resident. A yellow and brown stained ring was observed under the area of the bath blanket as they positioned the clean bath blanket under the resident. At 5:30 p.m., LPN #1 was asked if she was the nurse for resident #5. She stated yes. She was asked when her shift started. She stated her shift started at 6:00 a.m. and she was covering a portion of the evening shift. She was asked if she had dressed resident #5's wound. She stated she had not performed the dressing but had it on her list of things to still do. She was asked if she was informed this morning of the wound needing dressed. She stated no. She was asked why she had not dressed the wound earlier. She stated because the nurse aides on the floor had little experience in their duties and were not proficient or certified, she was having to watch as they worked and/or performed more of their duties herself, so she had not had time to complete her assigned work. At 5:40 p.m., the ADON was asked why she had not applied the needed dressing that morning. She stated she should have stayed and dressed the wound but was already late getting to her hall assignments covering one of the day time floor nurse positions. She was asked if she informed the resident's nurse of the wound not being dressed. She stated no. She was asked since the wound was left undressed, what possible contaminates could have potentially entered the wound. She stated because of the location of the wound and the resident's incontinence, the wound could have been contaminated with urine and feces. She was asked what system was in place to monitor a resident's skin condition. She stated weekly skin assessment were performed by the nurse and the CNA was to document on shower sheets any skin issues they observed while assisting the resident with bathing. She was asked where the weekly skin assessment was documented. She stated the nurse marked on the treatment sheet the skin assessment was performed and any irregularities were documented in the progress notes. She stated the nurse aides also monitored skin changes during showers and documented any skin issues on a shower sheet which were turned into the charge nurse for review and signature before being given to the ADON. She stated she reviewed them and placed them in each resident's file. She was asked who was responsible for monitoring to ensure skin assessments were performed and wounds were improving. She stated she was responsible for the monitoring. She stated she relied on her staff to perform their duties as assigned. She stated the facility was short much of their staff and she had been assigned to work the floor most days. She stated working the floor left her little time to complete her assigned duties like monitoring the nursing staff to ensure duties were completed and keeping up with wound orders, treatments, and measurements. She was asked how the facility monitored wounds to ensure they were improving. She stated they kept a wound book which documented relevant information such as wound size and treatment on each wound. She stated the wound consultant measured and assessed the wounds weekly. She stated the wound consultant wrote the measurements down and treatment recommendations and gave the hand written note on a flow sheet to the facility. She stated later, their consultants progress note would be available online but the note did not provide the wound measurements, only the handwritten flowsheet left at the facility provided the wound measurements. She was asked if the wound consultants recommendations were considered orders. She stated no. She stated the recommendations were called to the physician. She stated the physician usually agreed with the orders and they were initiated. She was asked what was the date of the current dressing order. She stated 07/16/21. She was shown the wound consultants progress note dated 07/21/21 which recommended a low air loss mattress with a single flat sheet and disposable blue pad under the resident. She was asked if this was the resident's first time being seen by the wound consultant. She stated yes. She was asked why the resident's wounds were not assessed the previous week by the wound consultant. She stated the consultant was in the facility on 07/14/21 and was not aware of the resident's pressure ulcer. She was asked why the resident was not on a low air loss mattress as recommended. She stated she did not know. She was asked why the resident had a bath blanket under her instead of a single flat sheet and disposable blue pad. She stated she did not know.

Based on observation, interview, and record review, it was determined the facility failed to assess, monitor, and intervene for one (#2) of two residents sampled for wounds. The facility failed to assess and monitor a resident's skin condition who had previously identified skin damage and was incontinent of urine. The facility identified 30 residents who were incontinent. Findings: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admit/readmit screener, dated 06/28/21 (all sections signed completed on 06/29/21 except demographics, skin integrity, respiratory, and admission summary which were signed as completed on 07/14/21), documented the resident had one stage II pressure ulcer on her right lower abdomen. The screener documented the resident was incontinent one or more times per shift, day and night, and urinated a large volume of urine. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment, dated 07/08/21, documented the resident was cognitively intact. The assessment also documented the resident was frequently incontinent of bowel and bladder and was not participating in a toileting program. The assessment documented the resident had moisture associated skin damage and no pressure ulcers. A nurse's progress note, dated 07/13/21 and signed by the ADON (assistant director of nursing), documented, .Treatment continues to ABD (abdominal) folds. Areas showing improvement. No new areas of concern noted at this time . A shower sheet, dated 07/20/21, documented the resident had redness under arms, breasts, legs, and stomach. It also documented the resident had a sore under stomach area. There was an arrow pointing to the right lower pubic area of the illustrated person on the shower sheet. The sheet was initialed by a charge nurse and dated 07/20/21. On 07/20/21 at 2:40 p.m., resident #2 stated she was repeatedly left wet for hours at night. She stated her call light was left unanswered for hours at night while she lay cold and wet. She stated this occurred most every night. On 07/21/21 at 10:25 a.m., the resident was observed up in her chair. The LPN entered the room and asked the resident permission to apply the Triad wound ointment. Resident observed to have a half dollar size wound and a quarter size wound on her lower right pubis where Triad ointment was applied. Both with an irregularly shaped border and a pale pink wound beds. Further wounds appeared closer to her vaginal opening but were not well observed due to positioning. There was no application of a wound ointment to the observed wounds near the vaginal opening. The monthly treatment sheet, dated July 2021, documented a weekly skin observation was to be performed and any irregularities documented every Monday day shift. The treatment sheet documented the weekly skin observation was performed on 07/05/21, 07/12/21, 07/19/21, and 07/26/21. There was no documentation of further skin breakdown, irritation, or irregularities in conjunction with the skin observations. On 07/27/21 at 4:08 a.m., the hall which resident #2 resides on was observed. The resident's call light was already illuminated above her door. The resident was observed to be in bed. The resident appeared wet with top sheet, resident gown, brief, quilted pad, and fitted sheet, soaked from the resident's shoulder's to her knees. The resident stated, .I am so pissed. This is inhumane. I've been soaked since 1:00 [a.m.], trying to get changed . CNA #3 entered the room. She stated she could see the resident had soaked through her brief and pad and the bed was wet from the resident's shoulders to knees. The CNA stated she normally did not work the night shift and was asked to cover a portion of the shift, starting at 3:00 a.m. She stated she was told the resident was last changed at midnight. On 07/27/21 at 2:55 p.m., the ADON was asked to perform a skin assessment on resident #2. The ADON identified four wounds on the on the residents lower abdomen/pubic area and labial folds. She stated some of the wounds appeared moisture related. She was asked if the resident remaining wet from urine for extended periods of time would contribute to some of the open areas she saw on the resident's skin. She stated yes. She was asked what interventions she would recommend to improve skin integrity. She stated the resident needed to be kept clean and dry with timely incontinent care and regularly scheduled bathing. She stated the application of medicated/barrier creams would also aide the healing process. She was asked if she was aware of the resident's wounds prior to the skin assessment. She stated she was only aware of one prior to the skin assessment. The progress note, dated 07/27/21 at 5:08 p.m., documented, .Skin assessment completed. Resident has a large pendulous abdomen with large area firm to touch to left abdominal pannus. Mons pubis area is also significantly enlarged above labial folds. Resident noted to have 4 separate areas with partial thickness skin loss and moisture related maceration: clock face at 11:55 [o'clock] measures 0.8x0.8x0.2; 4:00 [o'clock] measuring 0.2x0.3 non measurable depth, 3:00 [o'clock] measuring 2.6x1.9; anterior L labial fold measuring 0.7x0.6x0.2. No other areas of concern noted at this time. PCP [physician] made aware. [Company name omitted], in house wound nurse with planned eval and tx [treatment] in am . The wound consultant note, dated 07/28/21, documented the resident had four wounds, two related to [CONDITION(S)] and two related to moisture associated skin damage. The consultant documented recommendations for the wounds related to moisture associated skin damage included treating the area with [MEDICATION(S)] three times a day and as needed for soiling. She recommended incontinence checks every two hours to prevent moisture and maceration from setting up in the wounds. She documented there was a risk of worsening without proper treatment. At 5:40 p.m., the ADON stated she was just provided a wound consultant note dated five days prior to admission. The wound consultant note, dated 06/23/21, documented the resident had a superior pubis wound and an inferior pubis wound. No measurements were documented. The wounds were documented as improving and to continue the wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented a medial posterior pubic trauma area as resolved. The note documented, .Chronic complicated wounds due to etiology, comorbidities, nutrition, decreased mobility, incontinence, risk of infection or worsening of wound without proper treatment . She was asked why if the resident was already seen by the same contracted wound consultant company, had the resident not continued to be seen by the consultant. She stated she was not aware the resident was being seen by the wound consultant until now. She stated the nursing home the resident transferred from did not report the resident had any skin issues or breakdown and did not report an order for [MEDICAL RECORD OR PHYSICIAN ORDER] She was asked why the facility was unaware of the resident's needs. She stated the admission should have been coordinated better. She was asked what system was in place to monitor the resident's skin condition. She stated weekly skin assessment were performed by the nurse and the CNA was to document on shower sheets any skin issues they observed while assisting the resident with bathing. She was asked where the weekly skin assessment was documented. She stated the nurse marked on the treatment sheet the skin assessment was performed and any irregularities were documented in the progress notes. She stated the nurse aides also monitored skin changes during showers and documented any skin issues on a shower sheet which were turned into the charge nurse for review and signature before being given to the ADON. She stated she reviewed them and placed them in each resident's file. She was asked for a copy of all shower sheets and skin documentation since admission. By end of survey, only one shower sheet was provided. The resident's clinical record was reviewed with the ADON and there was no documentation in the clinical record of the resident receiving a shower. She was asked who was responsible for monitoring to ensure skin assessments were performed and wounds were improving. She stated she was responsible for the monitoring. She stated she relied on her staff to perform their duties as assigned. She stated the facility was short much of their staff and she had been assigned to work the floor most days. She stated working the floor left her little time to complete her assigned duties like monitoring the nursing staff to ensure duties were completed as assigned and keeping up with wound orders, treatments, and measurements. She was asked how the facility monitored wounds to ensure they were improving. She stated they kept a wound book which documented relevant information such as wound size and treatment on each wound. She was asked if resident #2's wounds were documented in the wound book. She stated no. She stated the wounds documented in the wound book were those seen by the wound consultant and resident #2 had not been seen by the wound consultant since her admission to the facility. She was asked why the progress note, dated 07/13/21, did not provide details of the wound or wounds such as etiology, location, size, or treatment. She stated the note should have provided more relevant wound information. She was asked how the facility assessed and monitored the resident's skin to ensure wounds were healing. She stated they were not assessing and monitoring the resident's skin/wounds.

Based on observation, interview, and record review, it was determined the facility failed to provide assistance with activities of daily living for four (#2, 3, 4, and #5) of four residents observed for assistance with activities of daily living. The facility identified 30 residents who were incontinent and 56 who resided in the facility. Findings: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admit/readmit screener, dated 06/28/21 (all sections signed completed on 06/29/21 except demographics, skin integrity, respiratory, and admission summary which were signed as completed on 07/14/21), documented the resident had a stage two pressure ulcer on her right lower abdomen. The screener documented the resident was incontinent one or more times per shift, day and night, and urinated a large volume of urine. The admission assessment, dated 07/08/21, documented the resident was cognitively intact. The assessment also documented the resident was frequently incontinent of bowel and bladder and was not participating in a toileting program. The assessment documented the resident had moisture associated skin damage and no pressure ulcers. A nurse's progress note, dated 07/13/21 and signed by the ADON (assistant director of nursing), documented, .Treatment continues to ABD (abdominal) folds. Areas showing improvement. No new areas of concern noted at this time . On 07/20/21 at 2:40 p.m., resident #2 stated she was repeatedly left wet for hours at night. She stated her call light was left unanswered for hours at night while she lay cold and wet. She stated this occurred most every night. The monthly treatment sheet, dated July 2021, documented a weekly skin examination was performed on 07/05/21, 07/12/21, 07/19/21, and 07/26/21. There was no documentation of further skin breakdown or irritation in conjunction with the skin examinations. On 07/27/21 at 4:08 a.m., the hall which resident #2 resides on was observed. The resident's call light was already illuminated above her door. The resident was observed to be in bed. The resident appeared wet with top sheet, resident gown, brief, quilted pad, and fitted sheet, soaked from the resident's shoulder's to her knees. The resident stated, .I am so pissed. This is inhumane. I've been soaked since 1:00 [a.m.], trying to get changed . CNA #3 entered the room. She stated she could see the resident had soaked through her brief and pad and the bed was wet from the resident's shoulders to knees. The CNA stated she normally did not work the night shift and was asked to cover a portion of the shift, starting at 3:00 a.m. She stated she was told the resident was last changed at midnight. On 07/27/21 at 2:55 p.m., the ADON was asked to perform a skin assessment on resident #2. The ADON identified four wounds on the on the residents lower abdomen/pubic area and labial folds. She stated some of the wounds appeared moisture related. She was asked if the resident remaining wet from urine for extended periods of time would contribute to some of the open areas she saw on the resident's skin. She stated yes. She was asked what interventions she would recommend to improve skin integrity. She stated the resident needed to be kept clean and dry with timely incontinent care and regularly scheduled bathing. She stated the application of medicated/barrier creams would also aide the healing process. She was asked if she was aware of the resident's wounds prior to the skin assessment. She stated she was only aware of one wound prior to the skin assessment. The progress note, dated 07/27/21 at 5:08 p.m., documented, .Skin assessment completed. Resident has a large pendulous abdomen with large area firm to touch to left abdominal pannus. Mons pubis area is also significantly enlarged above labial folds. Resident noted to have 4 separate areas with partial thickness skin loss and moisture related maceration: clock face at 11:55 [o'clock] measures 0.8x0.8x0.2; 4:00 [o'clock] measuring 0.2x0.3 non measurable depth, 3:00 [o'clock] measuring 2.6x1.9; anterior L labial fold measuring 0.7x0.6x0.2. No other areas of concern noted at this time. PCP [physician] made aware. [Company name omitted], in house wound nurse with planned eval and tx [treatment] in am . The wound consultant note, dated 07/28/21, documented the resident had four wounds, two related to [CONDITION(S)] and two related to moisture associated skin damage. The consultant documented recommendations for the wounds related to moisture associated skin damage included treating the area with [MEDICATION(S)] three times a day and as needed for soiling. She recommended incontinence checks every two hours to prevent moisture and maceration from setting up in the wounds. She documented there was a risk of worsening without proper treatment. 2. Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment, dated 06/02/21, documented the resident was severely impaired in cognition, required extensive one person assistance in toileting and personal hygiene, and was incontinent of bowel and bladder. On 07/21/21 at 10:45 a.m., resident #3 was observed sitting on the side of her bed. The resident's finger nails appeared dirty, long, and irregularly shaped. On 07/26/21 at 11:30 a.m., resident #3 was observed laying in bed without a pillow. She was positioned on her left side in a fetal position with her head toward the foot of the bed. There were brown stains on the fitted sheet just in front of her face. Her right hand was observed cupped near her face. Her fingers and nails were long and irregularly shaped with dried brown feces under the nails and a ball of dried feces resting in the palm of her hand. The resident had on a brief which was saturated with urine and feces. Her back, right hip, buttocks, and pubic/vaginal area was observed to have dried feces. The roommate observed the dried brown feces on the resident's hand and exited the room, stating she was going to find a staff member to assist the resident. NA #2 (nurse aide) returned with the roommate and the NA stated she was going to change the resident. The NA was in the room briefly before exiting and returning with a shower chair. The NA transported the resident to the shower room. The NA was asked if the resident had on a brief. She stated yes. She was asked if in her opinion the brief was soiled more than what one incident of incontinence. She stated yes. She was asked if the feces was dried onto the resident. She stated yes. She was asked why the resident's brief was not changed earlier. She stated she had been busy with other residents and had not had an opportunity to get to her. On 07/27/21 at 1:30 p.m., the clinical record for the resident was reviewed. There was no shower documented for the resident. On 07/27/21 at 4:50 p.m., the resident was observed in bed. Her finger nails appeared long, irregularly shaped, and dirty with a brown substance under her finger nails. Her fingers smelled of feces. On 07/28/21 at 3:30 p.m., CNA #4 (certified nurse aide) was asked what type of personal care the resident received. She stated the resident received routine incontinent care and assistance with bathing. She was asked how often the resident was bathed. She stated showers were scheduled for twice a week. She was asked when nail care was performed. She stated nail care was performed when the resident received her shower. The resident's nails were observed with CNA #4. She was asked what was the condition of the resident's nails. She stated the resident's nails were dirty and needed trimmed. On 08/28/21 at 4:00 p.m., the ADON was asked who was responsible for monitoring to ensure ADL care like showers and nail care were provided. She stated the aides filled out a shower sheet for each shower they provided and those were signed by the charge nurse for the unit and turned into her. She was asked when nail care was performed. She stated nail care was to be performed when the resident received their shower. She was asked how the showers were charted in the resident's record. She stated the aide was suppose to chart them in the electronic medical record. She was shown the electronic medical record for the resident and asked how many showers the resident received in the last 30 days. She stated none were charted. She stated she knew the resident had received a shower earlier in the month because she saw the resident preparing for the shower. She stated the shower sheets were usually kept in each resident's file as a way to monitor resident care but she had been too busy working as a floor nurse to keep up with the shower sheets. The ADON was asked to provide all the shower sheets for the resident for the last 30 days. By end of survey, one shower sheet, dated 07/03/21, was provided. It was signed by CNA #4. There was no charge nurse signature. 3. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 05/14/2021, documented the resident was cognitively intact, and required one person physical assistance for bathing and hygiene. The resident was observed on 07/20/21, 07/21/21, 07/26/21, 07/27/21, and 07/28/21. The resident's nails were observed to be dirty, long, and irregularly shaped. The resident's electronic medical record was reviewed and documented the resident had not received a shower since 07/15/21. On 07/21/21 at 11:28 a.m., the resident stated it was a week since her last bath. On 07/28/21 the ADON was asked to provide all shower sheets for resident #4 for the last 30 days. By end of survey, two shower sheets were provided. One was dated 07/02/21 and the other was dated 07/15/21. 4. Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment, dated 07/09/21, documented the resident was cognitively intact, was incontinent of bowel and had a urinary catheter. The skilled nurse's note, dated 07/14/21, documented the resident was incontinent of bowel and bladder. There was no documentation of the presence of a urinary catheter. On 07/20/21 at 12:30 p.m., the resident was observed asleep in bed. The resident's hair appeared unkept and her nails appeared dirty and irregularly shaped. The resident's gown appeared stained with spilt food and drink and body odor was present. The resident woke and was asked when she last received a shower or bath. She stated she did not recall. The facility wound tracking sheet, dated 07/21/21, documented the resident had abdominal [MEDICATION(S)] with a fowl odor. The treatment was to cleanse the area daily with soap and water and apply [MEDICATION(S)] powder twice daily. The resident's nails appeared dirty and irregularly shaped on 07/21/21, 07/26/21, and 07/27/21. On 07/27/21 at 5:30 a.m., incontinent care was observed with CNA #3 and the ADON. The resident was turned from her back to her left side and supported by the ADON. The brief was soaked through with urine and feces. There was a bath blanket (light blanket) folded to approximately two feet long by three feet wide and positioned under the resident's hips like a bed pad. The bath blanket was wet and there was a oval shaped brown stain approximately a foot in diameter under the resident and brown stained rings on the fitted sheet, under the bath blanket. The staff were asked why the resident had a bath blanket under her instead of a pad and draw sheet. The CNA stated the pads were not wide enough for the resident's bariatric bed. The CNA removed the right side of the resident's brief. An undated two by three inch occlusive bandage was observed in the brief and the right buttock wound appeared exposed with what appeared to be feces covering a portion of the wound bed. There was no packing or calcium alginate present. The CNA removed the brief and performed incontinent care. The CNA was asked when the resident was last changed. She stated she started her shift at 3:00 a.m. and did not know when the resident was last changed. The ADON was asked about the wound dressing. The ADON stated the wound dressing was suppose to have iodaform packing where the wound tunneled and the wound bed covered with calcium alginate. She was asked if she saw any of that in the wound or brief. She stated no. She asked the CNA if she seen anything and the CNA stated no. The ADON stated it looked like night shift had just thrown a band-aide over the wound. A new brief was applied and a clean bath blanket placed under the resident. No dressing was applied to the wound. The ADON instructed CNA #3 to inform the resident's nurse to apply a dressing. The two staff members positioned the resident and exited the room. At 4:00 p.m., the ADON was asked to measure the wound for resident #5. The ADON and corporate nurse positioned the resident on her right side. The right side of the brief was removed and there was no dressing in place. The ADON was asked where about the dressing. She stated there was no dressing. The resident's brief was wet and soiled with green feces. The wound bed appeared contaminated with green feces. As the resident was pulled further onto her left side, a large volume of green mucousy fluid discharged from the wound. The discharge was a duller green than the feces or the substance contaminating the wound bed. The ADON was asked if she saw feces in the wound bed. She stated she could not tell if it was feces or discharge. The wound was cleaned, measured, packed with a non medicated strip, calcium alginate applied, covered with an ABD pad (absorbency pad), and secured with tape. A clean brief and bath blanket was placed under the resident. A yellow and brown stained ring was observed under the area of the bath blanket as they positioned the clean bath blanket under the resident. At 5:30 p.m., LPN #1 was asked if she was the nurse for resident #5. She stated yes. She was asked when her shift started. She stated her shift started at 6:00 a.m. and she was covering a portion of the evening shift. She was asked if she had dressed resident #5's wound. She stated she had not performed the dressing but had it on her list of things to still do. She was asked if she was informed this morning of the wound needing dressed. She stated no. She was asked why she had not dressed the wound earlier. She stated because the nurse aides on the floor had little experience in their duties and were not proficient or certified, she was having to watch as they worked and performed more of the duties herself, so she had not had time to complete her assigned work. At 5:40 p.m., the ADON was asked why she had not applied the needed dressing that morning. She stated she should have stayed and dressed the wound but was already late getting to her hall assignments covering one of the day time floor nurse positions. She was asked who was responsible for monitoring ADL care. She stated she was responsible. She stated she relied on her staff to perform their duties as assigned. She stated the facility was short much of their staff and she had been assigned to work the floor most days. She stated working the floor left her little time to complete her assigned duties like monitoring the resident's ADL's.

Based on observation and interview, it was determined the facility failed to provide adequate clean linen for three (Blue Moon, Dreamsicle, and Serenity) of three halls whose linen carts and closets were observed. The facility census was 56 residents. Findings: On 07/20/21 at 12:30 p.m., an observation of the linen closets and linen carts was conducted for halls Blue Moon (a locked unit), Dreamsicle, and Serenity. There was one flat sheet and no fitted sheets or pillow cases on Blue Moon. There was no flat sheets, fitted sheets, or pillow cases on Dreamsicle. There was one fitted sheet, two flat sheets, and no pillow cases on Serenity. At 4:40 p.m., an observation of the linen closets and linen carts was conducted for halls Blue Moon, Dreamsicle, and Serenity. There was one flat sheet, three fitted sheets, and four pillow cases on Blue Moon. There was three flat sheets, no fitted sheets, and one pillow case on Dreamsicle. There was no fitted sheet, flat sheet, or pillow case on Serenity. On 07/21/21 at 10:15 a.m., resident #3 was observed laying on a mattress with no fitted sheet and one flat sheet covering her. The resident stated she did not know why there was no fitted sheet on the bed. The roommate's fitted sheet was stained yellow and wet with urine. The roommate was not in the room. At 10:25 a.m., resident #2 was observed asleep in her wheelchair. There was no linen on her bed. The resident woke and was asked why her bed had no linen. She stated she was incontinent in the middle of the night and the sheets were removed. She stated she continued to sleep in bed for awhile without the sheets. At 10:40 a.m., an observation of the linen closets and linen carts was conducted for halls Blue Moon, Dreamsicle, and Serenity. There was one flat sheet, two fitted sheets, and no pillow cases on Blue Moon. There was no flat sheets, fitted sheets, or pillow cases on Dreamsicle. There was no fitted sheet, flat sheet, or pillow case on Serenity. At 11:40 a.m., CNA #1 was asked if there was enough available linen to meet the resident's needs. She stated there was usually enough but the last few days the linen had been harder to find. She was asked why resident #3 was laying in bed without a fitted sheet. She stated she did not know. She was asked why resident #2 was without a fitted sheet on her bed. She stated she had not been in the resident's room yet so did not know why the bed was without sheets. The linen closet was observed with CNA #1. She was asked if there were any flat sheets, fitted sheets, draw sheets, or pillow cases. She stated no. She was asked if there was enough linen for her to meet resident needs. She stated not now. At 12:30 p.m., an observation of the linen closets and linen carts of Dreamsicle hall and Serenity hall with the administrator. She stated she was not made aware of the lack of linen. She stated there was soiled linen to wash and more linen in storage. She was asked who was responsible for monitoring the level of clean linen available to residents. She stated she was. On 07/27/21 at 4:25 a.m., CMA #1 stated she usually washed bedding at the beginning of her shift. She was asked if that was part of her assigned duties. She stated if she did not wash the bedding at the beginning of her shift, she would not have the bedding she needed on her shift for the residents.

Based on observation, interview and record review, it was determined the facility failed to provide supervision to prevent falls and implement new interventions to prevent further falls for one (#45) of four sampled residents who were reviewed for falls. This lack of supervision resulted in the resident falling 35 times without injury within six months of admission before falling and sustaining a left wrist fracture and another fall sustaining a laceration to the head and rib fractures. The facility identified 12 residents who resided in the secure dementia unit. Findings: A policy, titled Fall Risk Assessment documented, .The nursing staff, in conjunction with the Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls . The policy continued to document, .The staff will look for evidence of a possible link between the onset of falling (or an increase in falling episodes) and recent changes .The staff .will evaluation functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living .capabilities, activity tolerance, continence, and cognition .The staff and Attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable . A policy titled, Falls and Fall Risk, Managing, documented, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The staff .will identify appropriate interventions to reduce the risk of fall .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped .staff will identify and implement relevant interventions .to try to minimize serious consequences of falling .The staff will monitor and document each resident's response to interventions intended to reduce falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . A clinical protocol for falls, dated as revised on 10/2010, documented, .As part of the initial assessment, the nurse or physician will help identify individuals with a history of falls and risk factors for subsequent falling .The staff will evaluate the resident for risk factors for falling .The staff will evaluate and document falls that occur while the individual is in the facility .For an individual who has fallen, staff will attempt to define possible causes .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .The staff will monitor the individual's response to interventions intended to reduce falling or the consequences of falling .If the individual continues to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions .As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful . Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment, dated 10/14/17, documented the resident was at a moderate risk for falls due to history of multiple falls in the last six months. The assessment documented the resident was taking the following types of medication more than three times a week: antihypertensives, benzodiazepines, narcotics and [MEDICAL CONDITION]. She was frequently incontinent of her bladder, had agitated behavior daily or more in the last seven days, was confined in a wheelchair, was unable to independently come to a standing position, exhibited loss of balance while standing, required hands on assistance to move from place to place, used short discontinuous steps and or shuffling steps, exhibited jerking or instability when making turns, used an assistive device and had a decrease in muscle coordination. An admission assessment, dated 10/20/17, documented the resident was cognitively intact, was independent with bed mobility, required extensive assistance of one staff member for transfers, toileting, bathing, was continent of bowel and bladder and was not able to transfer from a sitting to standing position or transfer from surface to surface without staff assistance and had a history of [REDACTED]. The clinical record documented the resident had six non injury falls from 10/20/17 to 10/25/17. A nurse's note, dated 10/26/17 at 12:54 a.m., documented the resident was on the skilled nursing unit for [MEDICAL CONDITION] humerus and coccyx and required the assistance of one staff member but would not to use the call light to call for assistance. A care plan, dated 10/27/17, documented the resident had an ADL (activities of daily living) self care performance deficit related to muscle weakness and a history of a fracture. Documented interventions included one staff member was to assist the resident with toileting, personal hygiene and extensive physical assistance of one staff member for transferring. The care plan documented to encourage the resident to use the call bell for assistance. A care plan for falls, dated 10/27/17, documented the resident was a high risk for falls related to weakness, [MEDICAL CONDITION] and other past history. The care plan documented the following interventions to prevent falls: ensure the call light is within reach and encourage and re-encourage the resident to use the call light for assistance as needed and respond promptly. A nurse's note, dated 10/28/17 at 4:45 a.m., documented, Upon exiting another residents room, I heard resident calling out .When I arrived resident was noted lying in r (right) side near doorway on floor. obtained neuro check, res (resident) had firm hand grasp, rom (range of motion) in bilat (bilateral) le (lower extremities) and bilat ue (upper extremities). loc (level of consciousness) was consistent with prior days. assessed for skin injury, res had bruise to coccyx area 2 cm (centimeter) x 2 cm. Res. c/o (complained of ) severe pain in coccyx and was unable to come to a sitting position. Notified physician received order to send to hospital for eval. (evaluation) Res left facility with emsa (emergency medical services authority) approx. (approximately) 0435 (4:35 a.m.) en route to (Name-deleted hospital). A nurse's note, dated 10/28/17 at 8:45 a.m., documented, returned from hospital via Ambulance. Confused, agitated by staff. Denies pain @ rest although pain evident with repositioning. Initially refused medications . A nurse's note, dated 10/28/17 at 6:30 p.m., documented, This nurse was passing meds (medications) to another resident. I heard yelling down the hallway, when I got to (Resident # 45) room she was sitting on the floor by the recliner. She told me she fell when trying to see what was in the hallway. When I assessed her for injuries, she indicated pain 10/10 in coccyx area. She told me she thought she broke her back and wanted to go to the hospital. Emsa was contacted and resident immediately upon their arrival was transferred to Hospital for eval and treatment . The care plan for falls, revised on 12/15/17, documented the following interventions: Anticipate and meet the needs of the resident, follow facility fall protocol, review past falls and attempt to determine the cause of the fall, record possible root causes, alter remove any potential causes if possible and educate. A nurse's note, dated 12/16/17 at 9:00 a.m., documented, CNA (certified nurse aide) came and got this nurse to assist her with the Resident. CNA stated that she turned around to move a chair and that when she turned back around the resident was sitting on the floor. Resident was assessed. VS WNL (vital signs within normal limits). No injuries noted. Resident stated that I went to adjust myself in the chair and forgot to lock the wheels and so the wheelchair moved and I sat on the floor. Educated resident on the importance of making sure that her wheelchair is locked before attempting to change positions and also to ask for help if she needs it. A nurse's note, dated 12/17/17 at 8:11 p.m., documented, Resident slipped out of bed and landed on floor at 2000 (8:00 p.m.). Unwitnessed fall. No injuries. Denies pain Resident was attempting to go to the bathroom . A nurse's note, dated 12/18/17 at 11:30 a.m., documented, Called to dining room by CN[NAME] Observed resident sitting on floor next to dining room chair. Resident stated that she was trying to transfer herself from her wheelchair to the dining room chair and fell on her bottom. Denied hitting head and denied pain nor discomfort. No indication of injuries. Assisted resident to wheelchair x's 2 staff members . A nurse's note, dated 12/18/17 at 11:50 p.m., documented, resident was found in another room on the floor in the dark, resident wouldn't (would not) stay there until this nurse got there, she was in the hall, she refused to allow me to take vitals, she refused to let me help her get up, she refused to let the aide help her get up, she denies any pain, denies any injuries, there was however a skin tear on her thumb, she refused to allow me to put a dressing on it . The care plan for falls updated on 12/29/17, documented the following falls and interventions: ~ A non injury fall on 12/29/17 with the following intervention: educated the resident on safety awareness while in the wheelchair, resident voiced understanding was initiated on 02/21/18, ~ A non injury fall on 01/18/18, 01/19/18, 01/30/18, 02/02/18, 02/03/18, 02/10/18 times three, 02/13/18, 02/14/18, 02/15/18 times two, and on 02/16/18 with no new interventions documented as initiated on the care plan. ~ Two non injury falls on 02/20/18 documented the following interventions: call light within reach at all times while the resident is in her room (intervention previously initiated on 10/27/17), staff to assist the resident to the bathroom every two hours and as needed as the resident allows, ensure the resident's wheelchair is locked when transferring or any attempts to rise by the resident, when placing the resident in bed, staff to ensure the resident is in the center of the bed and positioned comfortably with adequate amounts of blankets of her liking, offer to place the resident by the window when she is up in the common area, offer throw blankets to the resident while she is up in the wheelchair. The interventions were documented as initiated on 02/21/18. A fall risk assessment, dated 02/21/18, documented the resident was now a low risk for falls. ~ A non injury fall on 03/04/18 intervention included to involve in activities. An incident report, dated 03/05/18 at 5:00 a.m., documented the resident was found sitting on the floor with no injuries noted. The incident report documented the resident was assisted to her wheelchair with one staff member. The fall care plan did not document the fall or interventions to prevent further falls. The activities of daily living (ADL) task report, dated 03/05/18, did not document initials indicating the resident was toileted on the night shift 10:00 p.m. to 6:00 a.m. An incident report, dated 03/18/18 at 12:36 p.m., documented the resident was found on the floor with her legs crossed, was confused and stated she was trying to get up. The incident report documented the staff was to ensure the resident had non-skid socks on as she allowed. The report documented the resident had the following predisposing physiological factors: confused, gait imbalance, impaired memory and recent change in cognition. The fall care plan did not document the fall or new interventions to prevent further falls. An incident report, dated 03/25/18 at 3:19 p.m., documented the resident was sitting on the floor with her legs straight out in front of her in her room. The incident report documented the resident stated she had gotten up and the wheelchair rolled out from under her and the resident was assessed and did not have an injury. The incident report documented to continue to encourage the resident to lock her wheelchair before rising and CNAs were instructed to ensure the resident had non-skid socks on at all times. (this was initiated on the fall from 02/21/18). The report documented the resident had the following predisposing physiological factors: gait imbalance, impaired memory, recent change in cognition, incontinent, recent change in medications and weakness. The fall care plan did not document the fall or new interventions to prevent further falls. An incident report, dated 03/25/18 at 3:48 p.m., documented the resident was found in the floor sitting in front of her wheelchair. The incident report documented the resident stated she did not know what happened. The report documented the resident had no new bruises, was able to move all extremities, was encouraged to ask for assistance with transfers and the CNAs were instructed to make more frequent checks on the resident as she would allow. The incident report documented the resident had a predisposed factor of confusion. The fall care plan did not document the fall or new interventions to prevent further falls. The ADL task report, dated 03/25/18, did not document initials to indicate the resident was toileted on the evening shift (2:00 p.m. to 10:00 p.m.). A quarterly assessment, dated 03/26/18, documented the resident's cognition was severely impaired, she required limited assistance of one staff member for bed mobility, transferring, toileting, was incontinent of bowel and bladder, was not able to move from a sitting to standing position or transfer from surface to surface without staff assistance and used a wheelchair for mobility. The assessment documented she had two or more non injury falls, two or more injury falls and two or more falls with major injury. A nurse's note, dated 03/26/18 at 11:14 a.m., documented the resident had a fall on 03/25/18, at the time of the fall no obvious injury was noted and the resident did not have any complaints of pain. The note documented this morning the left wrist was swollen, bruised and painful, x-rays were positive for fracture and emergency services were called to transport the resident to the hospital. A nurse's note, dated 03/26/18 at 4:40 p.m., documented the resident returned to the facility via ambulance awake, alert with usual confusion and had a splint on her left arm for stabilization for a closed [MEDICAL CONDITION] end of the left radius (larger bone of the forearm broken near the wrist). There were instructions to schedule an appointment for follow up care for the fracture. An incident report, dated 03/30/18 at 9:35 p.m., documented a nursing description, Resident walking out of room looking for bathroom, lost her balance and she fell hit head on edge of doorway. CNA heard resident fall and saw her laying half in half out of door way. Left side of head has large 3 inch laceration with bleeding. I was going to go to the bathroom and fell . Immediate Action Taken: Resident assessed moves all extremities full range of motion left side of head has 3 inch laceration moderate amount of bleeding transfer to (Name-deleted hospital) to eval and treat . The incident report documented the resident had the following predisposing factors: gait imbalance and impaired memory. The care plan did not document the fall or implement new interventions to prevent further falls. A nurses note, dated 03/31/18 at 9:09 p.m., documented an x-ray was taken and the results documented the resident had a fracture involving the left second through fourth ribs without significant displacement. The nurse's note documented the reason for the exam was pain. The clinical record documented the resident had three non injury falls from 04/01/18 to 05/02/18. A care plan for falls, revised on 05/02/18, documented the resident was a high risk for falls related to weakness, [MEDICAL CONDITION] and other past history. The care plan documented the following falls and interventions: ~ A non injury fall on 05/02/18 with the following intervention: the resident has a [DIAGNOSES REDACTED]. ~ Two non-injury falls on 05/08/18 with the following interventions: pain medication administered and hospice to evaluate and documented the resident continually took her non-skid socks off and became agitated when the staff attempted to put them back on the resident initiated on 02/21/18. ~ A non injury fall on 05/13/18 with no new interventions documented to prevent further falls. ~A non injury fall on 05/18/18 with no new interventions documented to prevent further falls. ~ A non injury fall on 06/20/18 and documented the resident stated she was trying to go to the bathroom. The care plan did not document new interventions to prevent further falls. ~ A non injury fall on 07/05/18 with the following interventions: assisted the resident back to the bed, encourage staff to monitor residents for attempts to self transfer and or ambulate and assist as needed and allowed and the resident was unable to be redirected due to her diagnosis. On 07/10/18 at 9:27 a.m., the resident was observed in her wheelchair in the common area getting coffee. When asked how she was doing, the resident stated she was not sure where she was or what she was doing. At 10:08 a.m., while one CNA was answering a call light and one CNA was participating in a coloring activity with the residents, the resident got out of her bed and into her wheelchair and propelled herself to the common area without staff assistance or intervention. On 07/11/18 at 10:19 a.m., the resident was observed in her bed with her call light out of reach, hanging on the end of the bed. On 07/11/18 at 10:26 a.m., CNA #3 was asked about the residents who required toileting every two hours. The CNA did not identify resident #45 as needing to be toileted every two hours. CNA #3 was asked if she had any residents who required frequent checks. She did not identify resident #45 as requiring frequent monitoring. On 07/12/18 at 8:16 a.m., the resident was observed propelling herself to her bathroom and standing up from the wheelchair without staff assistance. One CNA was in the shower room and one CNA was providing care to another resident. There was no other staff member to supervise the resident. At 3:00 p.m., the resident's wheelchair was observed outside of her bathroom door, the resident's bathroom door was shut. Two staff members walked past the the resident's room and did not respond to the empty wheelchair sitting by the bathroom door. At 3:03 p.m., the resident was observed walking out of the bathroom, the resident did not use her wheelchair, she sat down on her bed and stated she was confused and started cursing. The resident walked from her bed to her wheelchair and sat down in her wheelchair. Two staff members were observed to be in the common area with other residents, they were unaware of the resident self toileting. On 07/15/18 at 5:02 p.m., the resident was observed getting out of her bed without staff assistance. The resident was standing behind the wheelchair and stated she could not figure this out. The resident sat back down on the bed and started talking to herself. At 5:05 p.m., the resident stood up behind her wheelchair and walked around the wheelchair without staff assistance and stated, I hope I don't fall. The resident sat down in her wheelchair and propelled herself around her room. The resident then got out of her wheelchair and self transferred to the bed. There were two staff members in the common area and was not aware of the resident self transferring. At 5:13 p.m., the resident's wheelchair was sitting by the bathroom door, the toilet flushed and the resident propelled herself out of the bathroom and put herself to bed again. At this time CNA #1 was the only staff observed in the common area with other residents and RN #1 was not on the unit, no other staff members were on the unit. On 07/15/18 at 5:15 p.m., CNA #1 was asked who was assigned to work on the unit with her. She stated she was working by herself and the nurse would cover her if she needed a break. The CNA stated she worked by herself on the evening shift. CNA #1 was asked about her job duties. She stated she passed the supper trays, gave showers, assisted the residents with activities, checked and changed the residents every two hours and at 8:30 p.m. she would get the residents ready for bed. She was asked who assisted her with getting the residents ready for bed. The CNA stated she did that by herself. CNA #1 was asked if there were any residents on fall precautions on the unit she was assigned to work. She stated one resident on the unit was on fall precautions but did not identify resident #45 as being the resident on fall precautions. When asked again if anyone else was on fall precautions, CNA #1 stated no. (One CNA was scheduled on the resident's unit. The interim director of nursing (DON) and activities director arrived after the surveyors were on site.) At 5:23 p.m., the resident was up in her room walking behind her wheelchair. The resident put herself back in bed without staff assistance. On 07/16/18 at 5:12 p.m., the interim DON was asked who was on fall precautions on the dementia unit. She stated resident #45 was a fall risk because she had a lot of falls. The interim DON was asked how many falls the resident had in (MONTH) (YEAR). She stated eight. She was asked about the two falls on 10/28/17. She stated the resident was sent to the hospital after each fall and returned the same day according to the incident reports. The interim DON was asked if fall interventions were put in place and the date they were initiated on the care plan. She stated the fall interventions documented the call light was to be within reach, encourage the resident to use the call light and respond promptly to all requests for assistance. She stated those were the standard interventions initiated on the care plan on admission. The interim DON was asked if new interventions were implemented after the falls had occurred in (MONTH) (YEAR). She stated nothing was added to the care plan. The Interim DON was asked how many falls the resident had in (MONTH) (YEAR). She stated none, the resident was sent to the hospital on [DATE] and did not return until 11/28/17. The Interim DON was asked how many falls the resident had in (MONTH) (YEAR). She stated five and refused first aide to her thumb on one of the falls. She was asked if the intervention initiated on 12/29/17 to educate the resident on safety awareness was an appropriate intervention for her. She stated no. The interim DON was asked how many falls the resident had (MONTH) (YEAR). She stated the resident had three falls and was sent out to the hospital due to left shoulder pain and had no injury. She stated the resident's falls were documented on the care plan but no new interventions were documented on the care plan. She was asked what was meant by the intervention to follow the facilities fall protocol. She stated she really did not know but thought it was how the resident was taken care of after a fall. The interim DON was asked how many falls the resident had in (MONTH) (YEAR). She stated thirteen. She stated on 02/16/18 the resident complained of pain to the right leg and had an x-ray done but had no fracture. She was asked what interventions had been put in place for the resident's falls. She stated to ensure the resident had non skid socks on but continually took the socks off, the staff were to reapply as allowed. Also staff were to assist the resident to the bathroom every two hours and as needed or any attempts to rise by the resident, ensure the resident was in the center of the bed and comfortable with adequate amount of blankets to her liking. She further stated when the resident was up in her wheelchair, staff were to offer to place the resident by the window in the common area, ensure resident had a throw blanket in her lap as needed or as she allowed when she was up in her wheelchair and ensure the wheelchair was locked when transferring the resident. She stated the interventions were initiated on 02/21/18. The interim DON was asked about the interventions. She stated the resident liked to sit by the window. The interim DON was asked how many falls the resident had in March. She stated the resident had eight falls. The interim DON stated an x-ray of the left leg was performed on 03/04/18 due to a fall and the incident report documented the resident did not have a fracture. The interim DON was asked about the two falls on 03/25/18 resulting in a [MEDICAL CONDITION] wrist. She stated according to the incident reports and nurse's notes at the time of the fall, there was no obvious injury and the resident could move all of her extremities and did not have any complaints of pain. She stated on 03/26/18 the resident had swelling and bruising to her left wrist. An x-ray was obtained and was positive for a left wrist fracture. The resident was sent to the hospital and returned the same day with a soft splint. The interim DON was asked about the fall on 03/30/18. She stated according to the incident report and the nurse's note, the resident hit her head on the doorway and sustained a three inch laceration on the left side of her head and was sent out to the hospital. She was asked if the resident required sutures for the laceration. She stated there was no documentation to indicate if she did or not. The interim DON was asked about the nurse's note on 03/31/18. She stated the note documented the resident's left second through fourth ribs were fractured without significant displacement and documented the reason for the X-ray was pain. She was asked how the resident sustained [REDACTED]. The interim DON was asked if interventions had been put in place to prevent the resident from falling in (MONTH) (YEAR). She stated on 03/04/18 the intervention was to encourage the resident to participate in activities. She was asked if the falls resulting in fractures had been documented on the care plan with new interventions to prevent falls. She stated no. The interim DON was asked how many falls the resident had in (MONTH) (YEAR). She stated the resident had two non injury falls. The interim DON was asked how many falls the resident had in (MONTH) (YEAR). She stated four with one fall on 05/13/18 indicating the resident complained of pain with no injury. She was asked about the intervention for non-skid socks she stated that intervention was already in place. The interim DON stated the resident had two non injury falls in (MONTH) (YEAR) and one non injury fall in (MONTH) (YEAR). She was asked about the intervention on the care plan for frequent checks dated as initiated on 03/25/18 and 06/30/18. She was asked how often frequent checks were performed. She stated she did not know, there was not a specific time frame documented for frequent checks. The interim DON was asked how often the resident would be checked if she was already being checked every two hours according to the care plan intervention initiated on 02/21/18. She stated she could not determine how often the resident was checked. The interim DON was asked if the unit had sufficient staff to monitor the residents for safety. She stated she did not think one aide could monitor the residents and perform their other assigned duties. She stated she knew the day shift usually had two aides and she felt that was enough staff on the unit. The interim DON was asked how many CNAs were working on the unit on 07/16/18 on the evening shift. She stated one CN[NAME]

Based on observation, record review and interview, it was determined the facility failed to: ~ perform thorough skin and pressure ulcer assessments; and ~ ensure preventive measures to prevent the development of pressure ulcers were implemented for two (#30 and #41) of four sampled residents who were reviewed for pressure ulcers. Resident #30 developed a facility acquired unstageable pressure ulcer to the left hip and sacrum, and Resident #41 developed an unstageable pressure ulcer to the left heel. The facility identified four current residents as having pressure ulcers which three were facility acquired. Findings: A policy titled, Pressure Ulcer Risk Assessment, documented, .Pressure ulcers are usually formed when a resident remains in the same position for and extended period of time .common site of a pressure ulcer is where the bone is near the surface of the skin .including .heels .If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often .become infected .A pressure ulcer risk assessment will be completed upon admission, with each additional assessment .Skin will be assess for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated . A policy titled, Pressure Ulcer Treatment, documented, .The pressure ulcer treatment program should focus on .Assessing the resident and the pressure ulcer(S) .Managing tissue loads .Pressure ulcer care .Managing bacterial colonization and infection .Education and quality improvement .When eschar is present, a pressure ulcer cannot be accurately staged until the eschar is removed .The following information should be recorded in the resident's medical record .They type of treatment and resident response .The date and time the wound care was given .The position in which the resident was placed .The name and title of the individual performing the care .Any change in the resident's condition .All assessment data (i.e., color, size, pain, drainage, etc.) when inspecting the wound .Resident tolerance of the procedure .Any problems or complaints made by the resident related to the procedure .The signature and title of the person recording the data . A policy titled, Prevention of Pressure Ulcers, documented, .Identify risk factors for pressure ulcer development .Change position at least every two hours or more frequently if needed .Determine if resident needs a special mattress .If a special mattress is needed, use one that contains foam, air, gel, or water, as indicated .For a person in a chair .Change position at least every hour .Use foam, gel or air cushions as indicated to relieve pressure .When repositioning, reduce friction and shear by lifting .rather than dragging .Do not use donut-shaped cushions .Refer resident to .restorative nursing .as indicated . 1. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 04/09/18, documented the resident had moderately impaired cognition, required extensive assistance of one staff member for bed mobility, extensive assistance of two staff members for transfers, ambulated via wheelchair, was at risk for pressure ulcers and had the following preventative measures in place: turning/repositioning program and surgical wound care. No baseline care plan was completed on admission to include measurable goals and interventions to prevent the development of pressure ulcers. An activities of daily living (ADL) task sheet, dated 04/2018, did not document initials and codes to indicate the task of assisting the resident with bed mobility had been performed on the following dates: ~ Day shift (6:00 a.m.-2:00 p.m.): 04/12/18, 04/15/18, 04/24/18, 04/28/18 and 04/29/18 and ~ Evening shift (2:00 p.m.-10:00 p.m.): 04/15/18, 04/26/18 through 04/30/18 and ~ Night shift (10:00 p.m.-6:00 a.m.): 04/02/18, 04/04/18 through 04/07/18, 04/11/18 through 04/13/18, 04/18/18, 04/21/18, 04/24/18 and 04/28/18. The ADL task sheet did not document initials and codes to indicate the task of assisting the resident with turning and repositioning every two hours had been performed on the following dates: ~ Day shift: 04/12/18, 04/15/18, 04/24/18, 04/28/18 and 04/29/18 and ~ Evening shift: 04/15/18, 04/26/18 through 04/30/18 and ~ Night shift: 04/02/18, 04/04/18 through 04/06/18, 04/11/18 through 04/13/18, 04/18/18, 04/21/18, 04/25/18 and 04/28/18. A physician's orders [REDACTED]. A weekly wound sheet, dated 04/09/18 and 04/16/18, documented the resident had surgical incisions and had the following risk factors: diabetes mellitus and incontinence and a pressure reduction mattress was in place for a preventive measure. A weekly wound sheet, dated 04/20/18, documented the resident had a facility acquired right heel stage 1 pressure ulcer measuring 2 cm in length x 2 cm in width with no depth and a left heel stage 2 blister measuring 5 cm in length x 5 cm in width and had superficial depth. The weekly skin assessment documented the pressure ulcers were acquired at the facility and documented the wound bed did not have [MEDICATION NAME], granulation, slough or eschar tissue. The assessment documented the resident had risk factors of diabetes and incontinence and the following preventive measures were put in place pressure reduction mattress, chair cushion, float heels, turning and repositioning. A verbal physician's orders [REDACTED]. A nurse's note, dated 04/20/18 at 9:23 a.m., documented an open dried blister area on the left heel measured 5 cm x 5 cm was noted and cleaned, a dry dressing was applied and the right heel red was noted to have a 2 cm x 2 cm area. The heels were floated off of the bed. The nurses note documented the physician was notified and new orders were received to cleanse the area with normal saline, pat dry and apply skin prep every shift and leave open to the air. A weekly wound sheet, dated 04/23/18 at 10:34 a.m., documented the resident had a facility acquired stage 2 dried open blister on left heel and the following preventive measures/interventions were in place: pressure reduction mattress and float heels (position heels so they are not touching the bed surface). A nurse's note dated, 4/25/18 at 2:55 a.m., documented, while cleaning left heel with [MEDICATION NAME] per tx (treatment) blister reopened and began to bleed cleaned res (resident) wrapped with non adhesive bandage and gauze to secure will continue to monitor. (The clinical record did not indicate the physician was notified the blister had reopened.) A nurse's note, dated 04/29/18 at 6:36 p.m., documented [MEDICATION NAME] was applied to both heels. The clinical record did not document the description of the left heel. The clinical record did not document wound measurements or descriptions of the blister/pressure ulcer on the weekly wound sheets for 04/30/18 and 05/07/18. An activities of daily living (ADL) task sheet, dated 05/2018, did not document initials and codes to indicate the task of assisting the resident with bed mobility had been performed on the following dates: ~ Day shift (6:00 a.m.-2:00 p.m.): 05/01/18, 05/03/18, 05/05/18, 05/06/18, 05/12/18, 05/13/18, 05/20/18, 05/26/18 and 05/27/18 ~ Evening shift (2:00 p.m.-10:00 p.m.): 05/01/18, 05/03/18, 05/05/18, 05/06/18, 05/12/18, 05/13/18, 05/14/18, 05/16/18 through 05/21/18, 05/23/18, 05/26/18 through 05/28/18. ~ Night shift (10:00 p.m.-6:00 a.m.): 05/02/18, 05/04/18, 05/10/18, 05/11/18, 05/13/18, 05/16/18, 05/19/18, 05/21/18, 05/27/18, 05/30/18 and 05/31/18. The ADL task sheet did not document initials and codes to indicate the task of assisting the resident with turning and repositioning every two hours had been performed on the following dates: ~ Day shift: 05/01/18, 05/03/18, 05/05/18, 05/06/18, 05/12/18, 05/13/18, 05/20/18, 05/26/18 and 05/27/18 ~ Evening shift: 05/01/18, 05/03/18, 05/05/18, 05/06/18, 05/12/18, 05/13/18, 05/14/18, 05/16/18 through 05/21/18, 05/23/18 and 05/26/18 through 05/28/18. ~ Night shift: 05/02/18, 05/04/18, 05/10/18, 05/11/18, 05/13/18, 05/16/18, 05/19/18, 05/21/18, 05/27/18, 05/30/18 and 05/31/18. A verbal physician's orders [REDACTED]. The verbal order was confirmed by the LPN. (The clinical record did not contain documentation to indicate why the treatment order for the left heel had been changed.) A nurse's note dated, 05/11/18 at 9:30 a.m., documented wound care was changed to daily dressing of santyl to the left heel with calcium alginate. (The clinical record did not document a description of the wound or a reason for the wound care treatment change) A care plan, dated 05/11/18, documented the resident currently had a wound related to immobility, incontinence and confusion. The care plan documented the pressure ulcer was unstageable and had interventions which included to [MEDICATION NAME] for ten days per order related to the resident's wound infection, administer treatments as ordered and monitor for effectiveness, follow the facilities policies/protocols for the prevention and treatment of [REDACTED]. The care plan documented the resident was incontinent of bowel and bladder related to confusion, dementia and impaired mobility and had interventions which included to check the resident every two hours and as required for incontinence, wash, rinse and dry perineum. (The weekly wound sheets documented the resident had risk factors for skin issues related to incontinence) The care plan documented the resident had diabetes mellitus and had interventions which included check all of the body for breaks in the skin and treat promptly as ordered by the doctor and monitor/document/report to the physician as needed signs and symptoms of infection to any open areas, redness, pain, heat, swelling or pus formation. A weekly wound sheet, dated 05/14/18 at 9:42 a.m., documented the resident had a stage 2 left heel treatment in place and the right heel was painted with [MEDICATION NAME] for preventative care. The wound sheet did not document the description or size of the wound or preventative/interventions. A wound care specialist evaluation, dated 05/17/18, documented the resident had an unstageable pressure wound due to necrosis (death of tissue) to the left heel and measured 3.5 cm in length x 5 cm in width and the depth was not measurable. The evaluation documented the pressure ulcer had light serous drainage and had 40%thick adherent black necrotic tissue with 40% slough (yellow devitalized tissue which can be stringy or thick and adherent on the tissue bed) and 20% granulation tissue (new vascular tissue in granular form on the healing surface of a wound). The wound care specialist evaluation documented the devitalized tissue of the pressure ulcer was surgically excised at a depth of 0.15 cm. The report was signed by the physician. A wound culture, dated as collected on 05/12/18 and resulted on 05/18/18, documented the resident had a positive wound culture for proteus mirabilis and escherichia coli. The report documented the resident was [MEDICATION NAME](antibiotic) 500 milligrams (mg) one tablet by mouth twice a day for ten days. A Medication Administration Record [REDACTED]. On 07/10/18 at 9:17 a.m., the resident was observed in her bed with a dressing on her left foot and a pillow under her calves to float heels off of the mattress. The call light was not within reach and was hanging off the foot board of the bed. The resident waved, kept eyes closed and did not answer questions. At 9:22 a.m., the resident was observed being provided incontinent care by one staff member. The staff member was observed to drag the resident to the side with a draw sheet to change the resident's adult brief. At 12:19 p.m., the resident was observed being provided incontinent care. The resident was lying in the same position as she was when observed at 9:22 a.m. The resident was wet and had no odors, no feces, no redness to her bottom. On 07/15/18 the resident was observed continuously from 4:32 p.m. to 6:59 p.m., the resident was sitting in her broda chair in the common area without being repositioned or toileted. At 7:00 p.m. the resident was taken to her room and transferred to her bed via mechanical lift and provided incontinent care. The resident had a small bowel movement in her adult brief. At 7:15 p.m. certified nurse aide (CNA) #1 was asked when the last time the resident had been repositioned and/or provided incontinent care. She stated around 2:00 p.m., when she had gotten back from her lunch. She stated she had also checked the resident in the common area before supper she was not wet. On 07/16/18 at 10:05 a.m., LPN #3 was observed providing wound care to the resident's left heel pressure ulcer. She removed the dressing on the left heel, cleansed the wound with wound cleanser, measured the wound applied crushed [MEDICATION NAME] tablet (antibiotic) and the new dressing. The LPN was asked to describe the wound. She stated it measured 2.4 cm in length x 2.2 cm in width x 0.1 cm in depth and the wound bed was beefy red with no slough with minimal drainage and no odor and the surrounding tissue was intact. LPN #3 was asked about the antibiotic placed in the wound bed. She stated the [MEDICATION NAME] was for the drainage and odor the pressure ulcer had at one point. The LPN stated she was not sure if the pressure ulcer was acquired at the facility. On 07/17/18 at 8:52 a.m., the LPN/clinical compliance coordinator was asked about the resident's care plan on admission. She stated it was never completed on admission. She stated it was opened but no information was on the care plan. At 11:00 a.m., the LPN/assistant director of nursing (ADON) was asked about the pressure ulcer on the resident's left heel. The ADON was asked how the resident developed a blister. She stated it was not documented in the clinical record. The ADON was asked if the resident was at risk for developing a pressure ulcer according to the admission assessment. She stated yes. The ADON was asked what interventions were put in place prior to the resident developing the blister. She stated no interventions were put in place. The ADON was asked what interventions were put in place to prevent the blister from worsening. She stated the notes documented to float heels on 04/20/18 and skin prep was ordered to be applied every shift and to leave the blister open to air. The ADON was asked about the weekly wound sheets. She stated she would look in the clinical record. At 11:13 a.m., LPN #3 was asked if she knew how the resident developed the blister on her left foot. She stated she did not know and the resident may have come from the hospital with the blister. The LPN was asked what interventions were put in place to prevent the blister/pressure ulcer from worsening. She stated the resident had her heels floated off the bed and wound treatments were ordered. LPN #3 was asked if she had performed the wound care on the pressure ulcer. She stated she had done the dressing changes when she worked the day shift. She stated the nurses were putting [MEDICATION NAME] on both of the resident's heels. The LPN was asked if she could describe the progression of the pressure ulcer from 04/23/18 to 05/14/18. She stated on 04/20/18 it was a dried blister on the left heel and we were putting skin prep on it and on 05/18/18 the resident had the pressure ulcer debrided. LPN #3 was asked if she had documented the pressure ulcer measurements and description of the pressure ulcer on 04/30/18 and 05/07/18. She stated no, the previous director of nursing (DON) was staging the pressure ulcer. The LPN was asked if the clinical record contained documentation of the previous DON's notes on the resident's pressure ulcer. She stated no. At 11:36 a.m., LPN #2 was asked about the pressure ulcer. She stated it was a blister when it started out. LPN #2 was asked how the resident developed the blister. She stated, I have no idea. LPN #2 stated the heel that had the blister on it was the leg the resident had broken. She stated the resident crossed her legs all the time. LPN #2 stated she was assisting CNA #4 with getting the resident out of bed and noticed something on the sheet and observed the blister on the resident's heel. LPN #2 was asked if the resident was able to move her left leg. She stated she could move it some but not much. The LPN stated the resident would try to get out of bed on her own but would complain of soreness to her left hip when the staff attempted to get her out of bed. LPN #2 was asked about the appearance of the blister. She stated when the skin came off the blister, the left heel was red. She was asked what interventions had been put in place prior to the blister forming. She stated nothing, the resident did not have any skin problems until the blister formed. LPN #2 stated the resident was getting up and participating in physical therapy. LPN #2 was asked what interventions were put in place after the blister was discovered. She stated on 04/20/18 the resident's heels were floated off the the bed and [MEDICATION NAME] was applied to both of her heels. LPN #2 was asked when the blister was identified. She stated 04/20/18. She stated the blister had popped but the skin was still on the blister. The LPN was asked about the progression of the blister. She stated on 04/23/18 the blister was open and dried out and the edges of the blister were peeling. She stated the weekly wound sheets and nurses notes did not document the description or measurements of the left heel pressure ulcer after 04/23/18 until the wound specialist evaluation was done on 05/17/18. At 4:07 p.m., LPN #2 was asked about the order for santyl for the resident on 05/11/18. She was asked why the pressure ulcer treatment had changed. She stated the previous DON had told her to ask the physician for an order for [REDACTED]. She stated she did not remember. She stated at one time it did have eschar on it. She stated she knew the physician had debrided the pressure ulcer. 2. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A progress note from a specialty hospital the resident was admitted from, dated 12/04/17, documented the resident had a deep tissue injury to the sacrum and the resident was currently on a low air loss mattress. The injury measured 5 centimeters (cm) by 3cm. A nurse's note, dated 12/11/17 at 10:00 p.m., documented the resident had a scar on his coccyx. A Braden scale for predicting pressure sore risk, dated 12/12/18, documented the resident was at a high risk for developing pressure sores. A nurse's note, dated 12/12/17 at 5:37 a.m., 12/14/17 at 4:37 a.m. and on 12/15/17 at 1:45 a.m., documented the resident had a rash like reddened area to his bottom. A Braden scale for predicting pressure sore risk, dated 12/16/17, documented the resident was at a high risk for the development of pressure sores. An admission assessment, dated 12/18/18, documented the residents cognition was severely impaired, required total assistance with activities of daily living, was always incontinent of bowel and bladder and received nutrition via a feeding tube 51% and greater. The assessment documented the resident had a stage one or greater, a scar over a bony prominence, was at risk of developing a pressure ulcer and did not have a pressure ulcer upon admission. The assessment further documented the resident was to have a pressure reducing device for his chair, bed, be on a turning and repositioning program, receive nutrition or hydration intervention to manage skin problems, have an application of ointments and or medications other than to the feet. A nurse's note, dated 12/19/17 at 3:29 a.m., documented [MEDICATION NAME] cream applied to buttocks/coccyx for redness and mild excoriation . A nurse's note, dated 12/21/17 at 4:05 a.m., documented [MEDICATION NAME] cream applied to buttocks/coccyx for redness and mild excoriation . A nurse's note, dated 12/22/17 at 5:41 a.m., documented [MEDICATION NAME] cream applied to buttocks/coccyx for redness and mild excoriation . A skin/wound note, dated 12/22/17 at 10:00 a.m., documented, #1 Right superior buttock open shearing wound 2.0cm x 1.5cm x 0.2cm #2 wound right inferior buttock 0.5cm x 0.3cm x 0.3cm #3 wound left buttock 2.3cm x 1.7cm x 0.2cm. Cleansed area and notified (name-deleted physician) for orders . These wounds was not added to the weekly wound report or documented on for follow up. A physicians order, dated 12/22/17 at 11:49 a.m., documented, Hydrogel Gel (Carbomer Gel Base) Apply to buttock wound bilaterally topically two times a day for impaired skin integrity . The 12/2017 treatment record was reviewed and did not indicate the wound care was performed on 12/24/17 at 8:00 p.m.,12/29/17 at 8:00 p.m. or on 12/30/18 at 8:00 a.m. or 8:00 p.m. A physician progress notes [REDACTED]. The note also documented the resident had [MEDICAL CONDITION] and was on isolation. A care plan, initiated on 12/24/18, documented the resident had the potential for impairment to skin integrity related to due to impaired mobility and sometimes fidgeting around in bed creating friction. Interventions included: ~ Measure wounds weekly and notify physician with any signs and or symptoms of exacerbation such as infection and non-healing issues. Initiated on 12/29/17. ~ [MEDICATION NAME] Skin Protectant Paste four times daily as needed. Imitated on 01/03/18. ~ provide a pressure reducing mattress such as a low air loss mattress, positioning pillows to protect the skin while up in chair. Initiated on 01/05/18. ~ Keep skin clean and dry, use lotion on dry skin. Initiated on 01/05/18. ~ Monitor/document location, size and treatment of [REDACTED]. to physician. Initiated on 01/05/18. A care plan, initiated on 12/24/17, documented the resident had an activities of daily living self care performance deficit related to confusion, disease process and [MEDICAL CONDITION]. Interventions documented the resident required two staff participation to reposition and turn in bed. A weekly wound report, dated 01/02/18, documented the resident had a facility acquired unstageable pressure ulcer to the sacrum which measured 3cm x 6cm x 0.1cm. The pressure ulcer as first observed on 01/02/18. A progress note detail sheet, submitted on 01/02/18, documented, .the wound was limited to skin breakdown. There is a large (67% - 100%) amount of necrotic tissue within the wound bed including Adherent Slough . A physician progress notes [REDACTED]. A nurse's note, dated 12/29/17 at 6:48 a.m., documented, res has excoriation and reddened bottom [MEDICATION NAME] cream applied with pericare . A nurse's note, dated 12/29/17 at 6:54 p.m., documented, .has excoriation to his bottom/sacral area c (with) current TX in place . A weekly wound report, dated 01/09/18, documented the resident had a facility acquired pressure ulcer to the sacrum which measured 2.6cm x 6cm x 0.1cm. The pressure ulcer was first observed on 12/11/17. A progress note, dated 01/09/18, documented, .There is a small amount serosanguineous drainage note. There is small (1-33%) pink granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough .Pressure Relief/Offloading: Follow Facility Pressure Ulcer Prevention Policy/Protocol Wheelchair Pressure Redistribution Cushion per Facility Policy/Protocol . A nurse's note, dated 01/10/18 at 5:15 a.m., documented, res (resident) has maceration of coccyx treated per doctor order area appears to have decreased redness with no s/s (signs/symptoms) of infection present [MEDICATION NAME] applied to buttocks for reddened rash area appears decreased in area . A weekly wound report, dated 01/16/18, documented the resident had a facility acquired unstageable pressure ulcer to the sacrum which measured 4cm x 6cm x 0.1cm. The ulcer was first identified on 01/02/18. Another wound report with a handwritten date of 01/16/18, documented the resident had a unstageable pressure injury which measured 4cm x 6cm x 0.1cm with 25% slough . It documented the previous measurement on 01/09/18 was 2.6cm x 6cm x 0.1cm with 75% slough. A physician progress notes [REDACTED]. The note documented the resident had an unstageable wound to the left hip which measured 0.6cm x 0.5cm x eschar, an unstageable wound to the right buttock which measured 0.5cm x 0.6cm x eschar and an unstageable wound to the sacrum which measured 5cm x 5cm x slough. A Nurse's note, dated 01/22/18 at 4:17 p.m., documented the dietician recommended vitamins for wound healing. The order was written and faxed to the pharmacy. The treatment record documented the order was implemented on 01/26/18. A physician progress notes [REDACTED]. There was no mention of the wounds on the sacrum. A weekly wound report, dated 02/02/18, documented the resident had a facility acquired unstageable pressure ulcer to the left hip which measured 1cm x 1.5cm. This was first observed on 02/02/18 and a facility acquired unstageable pressure ulcer to the sacrum, which measured 4cm x 3cm x 2cm first observed on 01/02/18. A physicians progress note, dated 02/03/18, documented the resident had unstageable wounds to the left hip and sacrum which are showing very little progress. The note documented a new order for a low air loss mattress. There was no documentation or observation this was obtained. A skin/wound note, dated 02/04/18 at 9:15 a.m. documented, Resident has pressure ulcer and discoloration to sacrum, ulcers to L (left) hip, and scabbed ulcers to R (right) medial foot. [MEDICATION NAME] cream was applied to sacrum discoloration, pressure ulcer to sacrum and ulcer to L hip were cleansed with NS (normal saline), santyl applied and covered with bordered gauze dressing. [MEDICATION NAME] was applied to L hip and R medial foot. A physician's progress note, dated 02/05/18, documented the resident had an unstageable wound to the sacrum and left hip. A physician's progress note, dated 02/10/18 documented the resident was still having loose stools due to [MEDICAL CONDITION]. Continues with unstageable wounds to the sacrum and left hip. A new order for a low air loss mattress was written. This was a new order on the progress note for 02/03/18. There was no documentation or observation this order was implemented A weekly wound report, dated 02/16/18, documented the resident had a facility acquired stage III pressure ulcer measuring 4cm x 3cm x 0.1cm to the sacrum. This was first identified on 01/02/18. The report also documented a facility acquired unstageable pressure ulcer to the left hip which measured 0.2cm x 0.2cm. A physicians progress note, dated 02/17/18, did not document the pressure ulcers. A physician's progress note, dated 02/24/18, documented the resident had a stage II wound to the sacrum. A weekly wound report, dated 03/01/18, documented the resident had a facility acquired stage III pressure ulcer to the sacrum which measured 3cm x 3cm. A nurse's note, dated 03/04/18 at 2:23 p.m., documented, resident tx (treatment) to buttocks cleaned with NS (normal saline), santyl, covered with bordered gauze. A skin wound note, dated 03/07/18, documented, Resident has small abrasion on top of gluteal fold on coccyx. cleaned and cream applied. A weekly wound report, dated 03/15/18, documented the resident had a facility acquired Stage II pressure ulcer on the sacrum which observed on 01/02/18. The ulcer measured 1cm x 0.5cm. A nurse's note, dated 03/18/18 at 4:39 p.m., documented, tx to buttocks, cleaned with ns/santyl covered with border gauze . A weekly wound report, dated 03/22/18, documented the resident had a facility acquired stage II pressure ulcer to the sacrum which measured 1cm x 0.5cm x 0.1cm. The ulcer was first identified on 01/02/18. A skin/wound note, dated 03/22/18 at 9:07 p.m., documented, Resident continue to have dressings on buttocks clean and dry and intact . A skin/wound note, dated 03/24/18 at 8:25 p.m., documented, resident tx to coccyx, cleaned with ns, pat dried, applied santyl and covered with border gauze . A physician progress notes [REDACTED]. Also a new order for Zinc and [MEDICATION NAME] for wound healing was to be initiated. A skin/wound note, dated 03/27/18 at 2:59 p.m., documented, residents wound on buttocks is granulating well almost healed A Braden scale for predicting pressure sore risk, dated 03/28/18, documented the resident was at low risk for pressure sore development. A weekly wound report, dated for the week of 03/29/18, documented the resident had a facility acquired stage II pressure ulcer to the sacrum and it was resolved. Another care plan, initiated on 05/11/18, documented the resident had bladder incontinence related to dementia and impaired mobility. Interventions included to check the resident every two hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. The current physician orders [REDACTED]. On 07/10/18 at 11:17 a.m., the resident was observed sitting up in his broda chair in the lobby. There was no cushion observed in the chair. On 07/12/18 at 11:00 a.m., the resident was observed in his bed on his back. The mattress was a foam concave mattress. At 2:00 p.m., the resident was observed in his broda chair in front of the television. The chair was not observed to contain a pressure reducing cushion. At 2:40 p.m., the resident was assisted to his room and left up in the broda chair, which does not contain a cushion (TRUNCATED)

Based on interview, and record review, it was determined the facility failed to treat a resident in a manner to maintain and promote their dignity for one (#1) of six sampled residents who were reviewed for dignity. Resident #1 had been video recorded with a cell phone, by a dietary staff member, while the dietary staff member was addressing the resident using foul language. The video was then posted to a social media site. This had the potential to affect all 45 residents who resided in the facility. Findings: A policy titled, Quality of Life - Dignity, revised August 2009, documented, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .1. Residents shall be treated with dignity and respect at all times. 2. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .7. Staff shall speak respectufully to residents at all times .11. Demeaning practices and standards of care that compromise dignity are prohibited . Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/08/17, documented the resident was moderately impaired in cognition for daily decision making. An incident form documented an incident, dated 03/05/17, for resident #1. The incident type was documented as an allegation of abuse/mistreatment. The reporting party was documented as the DON. The incident form documented the following as a summary of the investigation, .On 03-07-17 at approx (2:40) p.m., (name withheld), Administrator and (name withheld), RN/DON was informed by (name withheld), CDM, that she just observed a video that was posted live on (social media site name withheld) on Sunday 3-5-2017 by (name withheld) dietary aide (#1). Video captured an image of (resident #1) .standing in the kitchen door asking what was for lunch. (Name withheld) Dietary aide (#1) stated to (name withheld) dietary aide (#2) regarding (resident #1) and (name withheld) cook (#1), '(Resident #1) kick her ass. She has (resident #1) f****d up. You hear me. (Resident #1) f****d up. You better tell her what we have for lunch before she jumps across this table.' while resident was still in the kitchen doorway. (Name withheld) Cook (#1) informed (resident #1) what was for lunch and then (resident#1) left the kitchen doorway. (Resident #1's) mother (name withheld), (physician name withheld), Sand Springs Police Department and APS notified on 03-07-2017. On 03-07-2017, Messages were left for (dietary aide #1), (dietary aide #2), and (cook #1) to call the Administrator. On 03-07-2017 at approx (5:30 p.m.), Administrator and DON began re in-servicing all staff on reporting abuse and Sand Springs Nursing and Rehabilitation Social Media policy. All staff not present will receive the in-service prior to working again. Video was no longer on (social media name withheld) upon checking on 03-07-2017 at approx (5:34) pm. On 03-07-2017 at approx (6:35) pm, (name withheld) Police Department was informed of above and report was taken by Officer . On 03-07-2017 at approx (8:38 p.m.), APS was faxed incident report of abuse. On 03-08-2017, (name withheld) cook (#1) spoke with (name withheld) Administrator and (name withheld) RN/DON. (Cook #1) was informed she was terminated from employment for failure to report the abuse to the Administrator, the DON or her immediate supervisor and for violation of Sand Springs Nursing and Rehabilitation social media policy. On 03-08-2017, messages were again left for (dietary aide #2) and (dietary aide #1) to call the administrator. On 03-09-2017, (name withheld) dietary aide (#2) and (name withheld) dietary aide (#1) both refused to come in to the facility to speak with administration. (Name withheld) Administrator, and (name withheld) CDM called (dietary aide #1) and informed her she was terminated from employment due to verbal abuse toward (resident #1) and for violation of Sand Springs Nursing and Rehabilitation social media policy. (Name withheld) Administrator and (name withheld) CDM called (dietary aide #2) and she was informed she was terminated from employment for failure to report the abuse to the Administrator, the DON or her immediate supervisor and for violation of Sand Springs Nursing and Rehabilitation social media policy. (Resident #1) continues to maintain her normal routine. In-services on reporting abuse and social media policy is ongoing to ensure all staff is re in-serviced prior to working with the residents . A handwritten statement by cook #1, dated 03/05/17, documented, .In the mornings and through out (sic) the day residents come to the kitchen asking questions .while I'm cooking lunch she (resident #1) comes by again the girls tell me that she wants to know whats for lunch as I walk up she is talking I am unable to hear her due to the stove vent. I heard one or both girls say no & laugh (as usual they are on their or one of phones video chatting so assumed like usual) When I got to her (resident #1) I listened then told her what we were having . On 03/22/17 at 5:45 p.m., resident #1 was asked if she had ever seen staff use their cell phones to take pictures or videos. She stated, I didn't know cell phones took pictures. She was asked if staff had ever asked to take her picture or video her. She stated yes for holidays and special events but she was fine with that. On 03/23/17 at 10:23 a.m., the CDM was asked what she had observed in the video which was posted on the social media site. She stated dietary aide #1 had been on duty for approximately two hours and began live streaming video footage for about one hour. She stated she recorded cook #1 and dietary aide #2. She stated the video showed resident #1 approached the kitchen doorway and asked what was for dinner. She stated dietary aide #1 asked her co-workers and used foul language in regards to and about resident #1. She was asked what resident #1 did after dietary aide #1 used foul language. She stated the resident continued to stand there and was not sure the resident had heard the dietary aide's statement. The CDM was asked when she first viewed the video. She stated she could not remember the exact date but she thought it was a couple of days after it was originally live streamed onto the social media site. She stated she immediately notified the administrator and they attempted to contact dietary aide #1. She was asked what the facility policy was for abuse allegations. She stated they were to report it to the administrator immediately. On 03/23/17 at 1:24 p.m., the resident stated no one had ever cursed or used foul language towards her or in her presence. On 03/23/17 at 1:45 p.m., the administrator was asked what she had observed on the video which had been live streamed on the social media site. She stated she observed dietary aide #1 using foul language in regards to and in front of resident #1 and immediately began an abuse investigation. She was asked what the investigation entailed. She stated they terminated the three kitchen staff present at the time of the live streamed video, inserviced staff on reporting abuse and the social media policy, notified all responsible parties, and the DON spoke with resident #1. She stated the DON took over the investigation at that point. On 03/23/17 at 3:47 p.m., the DON was asked what her role consisted of for the investigation to the incident with resident #1. She stated she assisted the administrator and completed the final report which was submitted to the Oklahoma State Department of Health. She stated she contacted the responsible parties and provided inservices. She was asked if she had spoken to resident #1 about the incident. She stated yes. She was asked what the facility policy was for completing abuse investigations. She stated she could not answer without looking at the policy. She was asked if she interviewed staff members. She stated no. The DON was asked if she interviewed other residents to ensure others had not been videoed and placed on social media sites. She stated no. She was asked why she had not interviewed other staff and residents to ensure others had not been affected by situations regarding the use of foul language and being recorded on social media sites. She stated she had not thought about interviewing other staff and residents.

Based on interview and record review, it was determined the facility failed to: ~Implement their abuse policy and procedure to prevent mental abuse and to ensure allegations of abuse were thoroughly investigated for one (#1) of six sampled residents who were reviewed for abuse. Resident #1 had been video recorded with a cell phone, by a dietary staff member, while the dietary staff member was addressing the resident using foul language. The video was then posted to a social media website. ~Provide training to educate staff on the facility's policy and procedure for abuse and exploitation for one (Dietary aide #2) of three staff members whose employee records were reviewed. This had the potential to affect all 45 residents. Findings: An undated Abuse Prevention/Reporting policy documented, .residents of this facility will be free of abuse, neglect, mistreatment .TRAINING: Abuse prevention and reporting will be included in the nurse aide training training (sic) curriculum and in the new employee orientation training .INVESTIGATE: Any allegation or suspicion of abuse will be investigated by interviewing all parties involved, including the resident in the allegation, any residents who may have witnessed the incident, staff involved, either as witnesses or named in the incident. A written report will be maintained with all recorded statements .REPORTING: Incidents of abuse, neglect .will be reported immediately to the Oklahoma State Department of Health, the Oklahoma State Department of Human Services, the appropriate State Board Registry, and local law enforcement agency, if appropriate. An undated Social Media Policy documented, .Employees are encouraged to use common sense and exercise good judgement and discretion when using these social media sites .Employees should understand these sites are not private and there is no expectation of privacy in employee's postings .Employee postings could be forwarded and disseminated in a manner that they never anticipated and intended .Employees are prohibited from posting, discussing, disclosing and/or commenting on any information about SSNR operations, personnel, business relationships, or residents .Statements relating to any past/present resident of the facility .Violations of this policy, or any violation of the health Insurance Portability and Accountability Act (HIPPA) and related laws, and any federal or state law or regulation, could be deemed as abuse . An undated form titled, Sand Springs Nursing and Rehab Abuse Definitions, documented, .Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services . A policy, titled SSNR Cell Phone Policy, dated 07/23/15, documented, .CNA's and CMA's are not allowed to use a cell phone for any reason while clocked in. You are allowed to keep it on silent in your pocket for emergency reasons only. Your family or friends in case of an immediate emergency can call the facility at anytime to reach you. If you need to make a call or reply to a text you are to make your charge nurse aware, clock out and step out of the building to return a call or reply to a txt (sic) in a timely manner. If you are caught abusing this policy it will be grounds for termination. RN's and LPN's are only allowed to use their cell phones for facility related issues not personal use. If you need to make a personal call or reply to a personal text you are to make the other charge nurse on your shift aware, clock out and step out of the building to return a call or reply to a txt (sic) in a timely manner. If you are caught abusing this policy in any manner it will be grounds for termination . Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/08/17, documented the resident was moderately impaired in cognition for daily decision making. An incident form documented an incident, dated 03/05/17, for resident #1. The incident type was documented as an allegation of abuse/mistreatment. The reporting party was documented as the DON. The incident form documented the following as a summary of the investigation, .On 03-07-17 at approx (2:40) p.m., (name withheld), Administrator and (name withheld), RN/DON was informed by (name withheld), CDM, that she just observed a video that was posted live on (social media site name withheld) on Sunday 3-5-2017 by (name withheld) dietary aide (#1). Video captured an image of (resident #1) .standing in the kitchen door asking what was for lunch. (Name withheld) Dietary aide (#1) stated to (name withheld) dietary aide (#2) regarding (resident #1) and (name withheld) cook (#1), '(Resident #1) kick her ass. She has (resident #1) f****d up. You hear me. (Resident #1) f****d up. You better tell her what we have for lunch before she jumps across this table.' while resident was still in the kitchen doorway. (Name withheld) Cook (#1) informed (resident #1) what was for lunch and then (resident#1) left the kitchen doorway. (Resident #1's) mother (name withheld), (physician name withheld), Sand Springs Police Department and APS notified on 03-07-2017. On 03-07-2017, Messages were left for (dietary aide #1), (dietary aide #2), and (cook #1) to call the Administrator. On 03-07-2017 at approx (5:30 p.m.), Administrator and DON began re in-servicing all staff on reporting abuse and Sand Springs Nursing and Rehabilitation Social Media policy. All staff not present will receive the in-service prior to working again. Video was no longer on (social media name withheld) upon checking on 03-07-2017 at approx (5:34) pm. On 03-07-2017 at approx (6:35) pm, (name withheld) Police Department was informed of above and report was taken by Officer . On 03-07-2017 at approx (8:38 p.m.), APS was faxed incident report of abuse. On 03-08-2017, (name withheld) cook (#1) spoke with (name withheld) Administrator and (name withheld) RN/DON. (Cook #1) was informed she was terminated from employment for failure to report the abuse to the Administrator, the DON or her immediate supervisor and for violation of Sand Springs Nursing and Rehabilitation social media policy. On 03-08-2017, messages were again left for (dietary aide #2) and (dietary aide #1) to call the administrator. On 03-09-2017, (name withheld) dietary aide (#2) and (name withheld) dietary aide (#1) both refused to come in to the facility to speak with administration. (Name withheld) Administrator, and (name withheld) CDM called (dietary aide #1) and informed her she was terminated from employment due to verbal abuse toward (resident #1) and for violation of Sand Springs Nursing and Rehabilitation social media policy. (Name withheld) Administrator and (name withheld) CDM called (dietary aide #2) and she was informed she was terminated from employment for failure to report the abuse to the Administrator, the DON or her immediate supervisor and for violation of Sand Springs Nursing and Rehabilitation social media policy. (Resident #1) continues to maintain her normal routine. In-services on reporting abuse and social media policy is ongoing to ensure all staff is re in-serviced prior to working with the residents . A handwritten statement by cook #1, dated 03/05/17, documented, .In the mornings and through out (sic) the day residents come to the kitchen asking questions .while I'm cooking lunch she (resident #1) comes by again the girls tell me that she wants to know whats for lunch as I walk up she is talking I am unable to hear her due to the stove vent. I heard one or both girls say no & laugh (as usual they are on their or one of phones video chatting so assumed like usual) When I got to her (resident #1) I listened then told her what we were having . On 03/22/17 at 5:45 p.m., resident #1 was asked if she had ever seen staff use their cell phones to take pictures or videos. She stated, I didn't know cell phones took pictures. She was asked if staff had ever asked to take her picture or video her. She stated yes for holidays and special events but she was fine with that. On 03/23/17 at 10:23 a.m., the CDM was asked what she had observed in the video which was posted on the social media site. She stated dietary aide #1 had been on duty for approximately two hours and began live streaming video footage for about one hour. She stated she recorded cook #1 and dietary aide #2. She stated the video showed resident #1 approached the kitchen doorway and asked what was for dinner. She stated dietary aide #1 asked her co-workers and used foul language in regards to and about resident #1. She was asked what resident #1 did after dietary aide #1 used foul language. She stated the resident continued to stand there and was not sure the resident had heard the dietary aide's statement. The CDM was asked when she first viewed the video. She stated she could not remember the exact date but she thought it was a couple of days after it was originally live streamed onto the social media site. She stated she immediately notified the administrator and they attempted to contact dietary aide #1. She was asked what the facility policy was for abuse allegations. She stated they were to report it to the administrator immediately. On 03/23/17 at 1:24 p.m., the resident stated no one had ever cursed or used foul language towards her or in her presence. On 03/23/17 at 1:45 p.m., the administrator was asked what she had observed on the video which had been live streamed on the social media site. She stated she observed dietary aide #1 using foul language in regards to and in front of resident #1 and immediately began an abuse investigation. She was asked what the investigation entailed. She stated they terminated the three kitchen staff present at the time of the live streamed video, inserviced staff on reporting abuse and the social media policy, notified all responsible parties, and the DON spoke with resident #1. She stated the DON took over the investigation at that point. On 03/23/17 at 3:47 p.m., the DON was asked what her role consisted of for the investigation to the incident with resident #1. She stated she assisted the administrator and completed the final report which was submitted to the Oklahoma State Department of Health. She stated she contacted the responsible parties and provided inservices. She was asked if she had spoken to resident #1 about the incident. She stated yes. She was asked what the facility policy was for completing abuse investigations. She stated she could not answer without looking at the policy. She was asked if she interviewed staff members. She stated no. The DON was asked if she interviewed other residents to ensure others had not been videoed and placed on social media sites. She stated no. She was asked why she had not interviewed other staff and residents to ensure others had not been affected by situations regarding the use of foul language and being recorded on social media sites. She stated she had not thought about interviewing other staff and residents. 2. A payroll change notice in Dietary aide #2's employee file documented a hire date of 02/03/17. Review of the employee file did not reveal dietary aide #2 received training regarding abuse/neglect, social media, or cell phone usage upon hire. On 03/24/17 at 2:15 p.m., the BOM was asked who was responsible to ensure new employees received training regarding policies and procedures for abuse/neglect, social media, and cell phone usage. She stated she was. She was asked where it was documented dietary aide #2 had received these trainings. She stated it was not available. By the end of the survey the training documentation for dietary aide #2 had not been provided to the survey team.

Based on interview and record review, it was determined the facility failed to thoroughly investigate an allegation of abuse for one (#1) of six sampled residents who were reviewed for abuse. Resident #1 had been video recorded with a cell phone, by a dietary staff member, while the dietary staff member was addressing the resident using foul language. The video was then posted to a social media website. This had the potential to affect all 45 residents who resided in the facility. Findings: An undated Abuse Prevention/Reporting policy documented, .residents of this facility will be free of abuse, neglect, mistreatment .TRAINING: Abuse prevention and reporting will be included in the nurse aide training training (sic) curriculum and in the new employee orientation training .INVESTIGATE: Any allegation or suspicion of abuse will be investigated by interviewing all parties involved, including the resident in the allegation, any residents who may have witnessed the incident, staff involved, either as witnesses or named in the incident. A written report will be maintained with all recorded statements .REPORTING: Incidents of abuse, neglect .will be reported immediately to the Oklahoma State Department of Health, the Oklahoma State Department of Human Services, the appropriate State Board Registry, and local law enforcement agency, if appropriate. An undated Social Media Policy documented, .Employees are encouraged to use common sense and exercise good judgement and discretion when using these social media sites .Employees should understand these sites are not private and there is no expectation of privacy in employee's postings .Employee postings could be forwarded and disseminated in a manner that they never anticipated and intended .Employees are prohibited from posting, discussing, disclosing and/or commenting on any information about SSNR operations, personnel, business relationships, or residents .Statements relating to any past/present resident of the facility .Violations of this policy, or any violation of the health Insurance Portability and Accountability Act (HIPPA) and related laws, and any federal or state law or regulation, could be deemed as abuse . An undated form titled, Sand Springs Nursing and Rehab Abuse Definitions, documented, .Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services . A policy, titled SSNR Cell Phone Policy, dated 07/23/15, documented, .CNA's and CMA's are not allowed to use a cell phone for any reason while clocked in. You are allowed to keep it on silent in your pocket for emergency reasons only. Your family or friends in case of an immediate emergency can call the facility at anytime to reach you. If you need to make a call or reply to a text you are to make your charge nurse aware, clock out and step out of the building to return a call or reply to a txt (sic) in a timely manner. If you are caught abusing this policy it will be grounds for termination. RN's and LPN's are only allowed to use their cell phones for facility related issues not personal use. If you need to make a personal call or reply to a personal text you are to make the other charge nurse on your shift aware, clock out and step out of the building to return a call or reply to a txt (sic) in a timely manner. If you are caught abusing this policy in any manner it will be grounds for termination . Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/08/17, documented the resident was moderately impaired in cognition for daily decision making. An incident form documented an incident, dated 03/05/17, for resident #1. The incident type was documented as an allegation of abuse/mistreatment. The reporting party was documented as the DON. The incident form documented the following as a summary of the investigation, .On 03-07-17 at approx (2:40) p.m., (name withheld), Administrator and (name withheld), RN/DON was informed by (name withheld), CDM, that she just observed a video that was posted live on (social media site name withheld) on Sunday 3-5-2017 by (name withheld) dietary aide (#1). Video captured an image of (resident #1) .standing in the kitchen door asking what was for lunch. (Name withheld) Dietary aide (#1) stated to (name withheld) dietary aide (#2) regarding (resident #1) and (name withheld) cook (#1), '(Resident #1) kick her ass. She has (resident #1) f****d up. You hear me. (Resident #1) f****d up. You better tell her what we have for lunch before she jumps across this table.' while resident was still in the kitchen doorway. (Name withheld) Cook (#1) informed (resident #1) what was for lunch and then (resident#1) left the kitchen doorway. (Resident #1's) mother (name withheld), (physician name withheld), Sand Springs Police Department and APS notified on 03-07-2017. On 03-07-2017, Messages were left for (dietary aide #1), (dietary aide #2), and (cook #1) to call the Administrator. On 03-07-2017 at approx (5:30 p.m.), Administrator and DON began re in-servicing all staff on reporting abuse and Sand Springs Nursing and Rehabilitation Social Media policy. All staff not present will receive the in-service prior to working again. Video was no longer on (social media name withheld) upon checking on 03-07-2017 at approx (5:34) pm. On 03-07-2017 at approx (6:35) pm, (name withheld) Police Department was informed of above and report was taken by Officer . On 03-07-2017 at approx (8:38 p.m.), APS was faxed incident report of abuse. On 03-08-2017, (name withheld) cook (#1) spoke with (name withheld) Administrator and (name withheld) RN/DON. (Cook #1) was informed she was terminated from employment for failure to report the abuse to the Administrator, the DON or her immediate supervisor and for violation of Sand Springs Nursing and Rehabilitation social media policy. On 03-08-2017, messages were again left for (dietary aide #2) and (dietary aide #1) to call the administrator. On 03-09-2017, (name withheld) dietary aide (#2) and (name withheld) dietary aide (#1) both refused to come in to the facility to speak with administration. (Name withheld) Administrator, and (name withheld) CDM called (dietary aide #1) and informed her she was terminated from employment due to verbal abuse toward (resident #1) and for violation of Sand Springs Nursing and Rehabilitation social media policy. (Name withheld) Administrator and (name withheld) CDM called (dietary aide #2) and she was informed she was terminated from employment for failure to report the abuse to the Administrator, the DON or her immediate supervisor and for violation of Sand Springs Nursing and Rehabilitation social media policy. (Resident #1) continues to maintain her normal routine. In-services on reporting abuse and social media policy is ongoing to ensure all staff is re in-serviced prior to working with the residents . A handwritten statement by cook #1, dated 03/05/17, documented, .In the mornings and through out (sic) the day residents come to the kitchen asking questions .while I'm cooking lunch she (resident #1) comes by again the girls tell me that she wants to know whats for lunch as I walk up she is talking I am unable to hear her due to the stove vent. I heard one or both girls say no & laugh (as usual they are on their or one of phones video chatting so assumed like usual) When I got to her (resident #1) I listened then told her what we were having . On 03/22/17 at 5:45 p.m., resident #1 was asked if she had ever seen staff use their cell phones to take pictures or videos. She stated, I didn't know cell phones took pictures. She was asked if staff had ever asked to take her picture or video her. She stated yes for holidays and special events but she was fine with that. On 03/23/17 at 10:23 a.m., the CDM was asked what she had observed in the video which was posted on the social media site. She stated dietary aide #1 had been on duty for approximately two hours and began live streaming video footage for about one hour. She stated she recorded cook #1 and dietary aide #2. She stated the video showed resident #1 approached the kitchen doorway and asked what was for dinner. She stated dietary aide #1 asked her co-workers and used foul language in regards to and about resident #1. She was asked what resident #1 did after dietary aide #1 used foul language. She stated the resident continued to stand there and was not sure the resident had heard the dietary aide's statement. The CDM was asked when she first viewed the video. She stated she could not remember the exact date but she thought it was a couple of days after it was originally live streamed onto the social media site. She stated she immediately notified the administrator and they attempted to contact dietary aide #1. She was asked what the facility policy was for abuse allegations. She stated they were to report it to the administrator immediately. On 03/23/17 at 1:24 p.m., the resident stated no one had ever cursed or used foul language towards her or in her presence. On 03/23/17 at 1:45 p.m., the administrator was asked what she had observed on the video which had been live streamed on the social media site. She stated she observed dietary aide #1 using foul language in regards to and in front of resident #1 and immediately began an abuse investigation. She was asked what the investigation entailed. She stated they terminated the three kitchen staff present at the time of the live streamed video, inserviced staff on reporting abuse and the social media policy, notified all responsible parties, and the DON spoke with resident #1. She stated the DON took over the investigation at that point. On 03/23/17 at 3:47 p.m., the DON was asked what her role consisted of for the investigation to the incident with resident #1. She stated she assisted the administrator and completed the final report which was submitted to the Oklahoma State Department of Health. She stated she contacted the responsible parties and provided inservices. She was asked if she had spoken to resident #1 about the incident. She stated yes. She was asked what the facility policy was for completing abuse investigations. She stated she could not answer without looking at the policy. She was asked if she interviewed staff members. She stated no. The DON was asked if she interviewed other residents to ensure others had not been videoed and placed on social media sites. She stated no. She was asked why she had not interviewed other staff and residents to ensure others had not been affected by situations regarding the use of foul language and being recorded on social media sites. She stated she had not thought about interviewing other staff and residents.

Based on interview and record review, it was determined the facility failed to ensure residents were free from mental abuse for one (#1) of six sampled residents who were reviewed for abuse. Resident #1 had been video recorded with a cell phone, by a dietary staff member, while the dietary staff member was addressing the resident using foul language. The video was then posted to a social media website. This had the potential to affect all 45 residents who resided in the facility. Findings: An undated policy and procedure, titled Abuse Prevention/Reporting, documented, .residents of this facility will be free of abuse, neglect, mistreatment . An undated Social Media Policy documented, .Employees are encouraged to use common sense and exercise good judgement and discretion when using these social media sites .Employees should understand these sites are not private and there is no expectation of privacy in employee's postings .Employee postings could be forwarded and disseminated in a manner that they never anticipated and intended .Employees are prohibited from posting, discussing, disclosing and/or commenting on any information about SSNR operations, personnel, business relationships, or residents .Statements relating to any past/present resident of the facility .Violations of this policy, or any violation of the health Insurance Portability and Accountability Act (HIPPA) and related laws, and any federal or state law or regulation, could be deemed as abuse . An undated form titled, Sand Springs Nursing and Rehab Abuse Definitions, documented, .Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services . A policy, titled SSNR Cell Phone Policy, dated 07/23/15, documented, .CNA's and CMA's are not allowed to use a cell phone for any reason while clocked in. You are allowed to keep it on silent in your pocket for emergency reasons only. Your family or friends in case of an immediate emergency can call the facility at anytime to reach you. If you need to make a call or reply to a text you are to make your charge nurse aware, clock out and step out of the building to return a call or reply to a txt (sic) in a timely manner. If you are caught abusing this policy it will be grounds for termination. RN's and LPN's are only allowed to use their cell phones for facility related issues not personal use. If you need to make a personal call or reply to a personal text you are to make the other charge nurse on your shift aware, clock out and step out of the building to return a call or reply to a txt (sic) in a timely manner. If you are caught abusing this policy in any manner it will be grounds for termination . Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/08/17, documented the resident was moderately impaired in cognition for daily decision making. An incident form documented an incident, dated 03/05/17, for resident #1. The incident type was documented as an allegation of abuse/mistreatment. The reporting party was documented as the DON. The incident form documented the following as a summary of the investigation, .On 03-07-17 at approx (2:40) p.m., (name withheld), Administrator and (name withheld), RN/DON was informed by (name withheld), CDM, that she just observed a video that was posted live on (social media site name withheld) on Sunday 3-5-2017 by (name withheld) dietary aide (#1). Video captured an image of (resident #1) .standing in the kitchen door asking what was for lunch. (Name withheld) Dietary aide (#1) stated to (name withheld) dietary aide (#2) regarding (resident #1) and (name withheld) cook (#1), '(Resident #1) kick her ass. She has (resident #1) f****d up. You hear me. (Resident #1) f****d up. You better tell her what we have for lunch before she jumps across this table.' while resident was still in the kitchen doorway. (Name withheld) Cook (#1) informed (resident #1) what was for lunch and then (resident#1) left the kitchen doorway. (Resident #1's) mother (name withheld), (physician name withheld), Sand Springs Police Department and APS notified on 03-07-2017. On 03-07-2017, Messages were left for (dietary aide #1), (dietary aide #2), and (cook #1) to call the Administrator. On 03-07-2017 at approx (5:30 p.m.), Administrator and DON began re in-servicing all staff on reporting abuse and Sand Springs Nursing and Rehabilitation Social Media policy. All staff not present will receive the in-service prior to working again. Video was no longer on (social media name withheld) upon checking on 03-07-2017 at approx (5:34) pm. On 03-07-2017 at approx (6:35) pm, (name withheld) Police Department was informed of above and report was taken by Officer . On 03-07-2017 at approx (8:38 p.m.), APS was faxed incident report of abuse. On 03-08-2017, (name withheld) cook (#1) spoke with (name withheld) Administrator and (name withheld) RN/DON. (Cook #1) was informed she was terminated from employment for failure to report the abuse to the Administrator, the DON or her immediate supervisor and for violation of Sand Springs Nursing and Rehabilitation social media policy. On 03-08-2017, messages were again left for (dietary aide #2) and (dietary aide #1) to call the administrator. On 03-09-2017, (name withheld) dietary aide (#2) and (name withheld) dietary aide (#1) both refused to come in to the facility to speak with administration. (Name withheld) Administrator, and (name withheld) CDM called (dietary aide #1) and informed her she was terminated from employment due to verbal abuse toward (resident #1) and for violation of Sand Springs Nursing and Rehabilitation social media policy. (Name withheld) Administrator and (name withheld) CDM called (dietary aide #2) and she was informed she was terminated from employment for failure to report the abuse to the Administrator, the DON or her immediate supervisor and for violation of Sand Springs Nursing and Rehabilitation social media policy. (Resident #1) continues to maintain her normal routine. In-services on reporting abuse and social media policy is ongoing to ensure all staff is re in-serviced prior to working with the residents . A handwritten statement by cook #1, dated 03/05/17, documented, .In the mornings and through out (sic) the day residents come to the kitchen asking questions .while I'm cooking lunch she (resident #1) comes by again the girls tell me that she wants to know whats for lunch as I walk up she is talking I am unable to hear her due to the stove vent. I heard one or both girls say no & laugh (as usual they are on their or one of phones video chatting so assumed like usual) When I got to her (resident #1) I listened then told her what we were having . On 03/22/17 at 5:45 p.m., resident #1 was asked if she had ever seen staff use their cell phones to take pictures or videos. She stated, I didn't know cell phones took pictures. She was asked if staff had ever asked to take her picture or video her. She stated yes for holidays and special events but she was fine with that. On 03/23/17 at 10:23 a.m., the CDM was asked what she had observed in the video which was posted on the social media site. She stated dietary aide #1 had been on duty for approximately two hours and began live streaming video footage for about one hour. She stated she recorded cook #1 and dietary aide #2. She stated the video showed resident #1 approached the kitchen doorway and asked what was for dinner. She stated dietary aide #1 asked her co-workers and used foul language in regards to and about resident #1. She was asked what resident #1 did after dietary aide #1 used foul language. She stated the resident continued to stand there and was not sure the resident had heard the dietary aide's statement. The CDM was asked when she first viewed the video. She stated she could not remember the exact date but she thought it was a couple of days after it was originally live streamed onto the social media site. She stated she immediately notified the administrator and they attempted to contact dietary aide #1. She was asked what the facility policy was for abuse allegations. She stated they were to report it to the administrator immediately. On 03/23/17 at 1:24 p.m., the resident stated no one had ever cursed or used foul language towards her or in her presence. On 03/23/17 at 1:45 p.m., the administrator was asked what she had observed on the video which had been live streamed on the social media site. She stated she observed dietary aide #1 using foul language in regards to and in front of resident #1 and immediately began an abuse investigation. She was asked what the investigation entailed. She stated they terminated the three kitchen staff present at the time of the live streamed video, inserviced staff on reporting abuse and the social media policy, notified all responsible parties, and the DON spoke with resident #1. She stated the DON took over the investigation at that point. On 03/23/17 at 3:47 p.m., the DON was asked what her role consisted of for the investigation to the incident with resident #1. She stated she assisted the administrator and completed the final report which was submitted to the Oklahoma State Department of Health. She stated she contacted the responsible parties and provided inservices. She was asked if she had spoken to resident #1 about the incident. She stated yes. She was asked what the facility policy was for completing abuse investigations. She stated she could not answer without looking at the policy. She was asked if she interviewed staff members. She stated no. The DON was asked if she interviewed other residents to ensure others had not been videoed and placed on social media sites. She stated no. She was asked why she had not interviewed other staff and residents to ensure others had not been affected by situations regarding the use of foul language and being recorded on social media sites. She stated she had not thought about interviewing other staff and residents.

Based on interview, and record review, it was determined the facility failed to ensure a resident's privacy was not violated for one (#1) of six sampled residents who were reviewed for privacy. Resident #1 had been video recorded with a cell phone, by a dietary staff member, while the dietary staff member was addressing the resident using foul language. The video was then posted to a social media website. This had the potential to affect all 45 residents who resided in the facility. Findings: A policy titled, Confidentiality of Information, revised December 2006, documented, .Our facility shall treat all resident information confidentially .Release of resident information, including video, audio, or computer stored information, will be handled in a manner to protect resident rights . Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/08/17, documented the resident was moderately impaired in cognition for daily decision making. An incident form documented an incident, dated 03/05/17, for resident #1. The incident type was documented as an allegation of abuse/mistreatment. The reporting party was documented as the DON. The incident form documented the following as a summary of the investigation, .On 03-07-17 at approx (2:40) p.m., (name withheld), Administrator and (name withheld), RN/DON was informed by (name withheld), CDM, that she just observed a video that was posted live on (social media site name withheld) on Sunday 3-5-2017 by (name withheld) dietary aide (#1). Video captured an image of (resident #1) .standing in the kitchen door asking what was for lunch. (Name withheld) Dietary aide (#1) stated to (name withheld) dietary aide (#2) regarding (resident #1) and (name withheld) cook (#1), '(Resident #1) kick her ass. She has (resident #1) f****d up. You hear me. (Resident #1) f****d up. You better tell her what we have for lunch before she jumps across this table.' while resident was still in the kitchen doorway. (Name withheld) Cook (#1) informed (resident #1) what was for lunch and then (resident#1) left the kitchen doorway. (Resident #1's) mother (name withheld), (physician name withheld), Sand Springs Police Department and APS notified on 03-07-2017. On 03-07-2017, Messages were left for (dietary aide #1), (dietary aide #2), and (cook #1) to call the Administrator. On 03-07-2017 at approx (5:30 p.m.), Administrator and DON began re in-servicing all staff on reporting abuse and Sand Springs Nursing and Rehabilitation Social Media policy. All staff not present will receive the in-service prior to working again. Video was no longer on (social media name withheld) upon checking on 03-07-2017 at approx (5:34) pm. On 03-07-2017 at approx (6:35) pm, (name withheld) Police Department was informed of above and report was taken by Officer . On 03-07-2017 at approx (8:38 p.m.), APS was faxed incident report of abuse. On 03-08-2017, (name withheld) cook (#1) spoke with (name withheld) Administrator and (name withheld) RN/DON. (Cook #1) was informed she was terminated from employment for failure to report the abuse to the Administrator, the DON or her immediate supervisor and for violation of Sand Springs Nursing and Rehabilitation social media policy. On 03-08-2017, messages were again left for (dietary aide #2) and (dietary aide #1) to call the administrator. On 03-09-2017, (name withheld) dietary aide (#2) and (name withheld) dietary aide (#1) both refused to come in to the facility to speak with administration. (Name withheld) Administrator, and (name withheld) CDM called (dietary aide #1) and informed her she was terminated from employment due to verbal abuse toward (resident #1) and for violation of Sand Springs Nursing and Rehabilitation social media policy. (Name withheld) Administrator and (name withheld) CDM called (dietary aide #2) and she was informed she was terminated from employment for failure to report the abuse to the Administrator, the DON or her immediate supervisor and for violation of Sand Springs Nursing and Rehabilitation social media policy. (Resident #1) continues to maintain her normal routine. In-services on reporting abuse and social media policy is ongoing to ensure all staff is re in-serviced prior to working with the residents . A handwritten statement by cook #1, dated 03/05/17, documented, .In the mornings and through out (sic) the day residents come to the kitchen asking questions .while I'm cooking lunch she (resident #1) comes by again the girls tell me that she wants to know whats for lunch as I walk up she is talking I am unable to hear her due to the stove vent. I heard one or both girls say no & laugh (as usual they are on their or one of phones video chatting so assumed like usual) When I got to her (resident #1) I listened then told her what we were having . On 03/22/17 at 5:45 p.m., resident #1 was asked if she had ever seen staff use their cell phones to take pictures or videos. She stated, I didn't know cell phones took pictures. She was asked if staff had ever asked to take her picture or video her. She stated yes for holidays and special events but she was fine with that. On 03/23/17 at 10:23 a.m., the CDM was asked what she had observed in the video which was posted on the social media site. She stated dietary aide #1 had been on duty for approximately two hours and began live streaming video footage for about one hour. She stated she recorded cook #1 and dietary aide #2. She stated the video showed resident #1 approached the kitchen doorway and asked what was for dinner. She stated dietary aide #1 asked her co-workers and used foul language in regards to and about resident #1. She was asked what resident #1 did after dietary aide #1 used foul language. She stated the resident continued to stand there and was not sure the resident had heard the dietary aide's statement. The CDM was asked when she first viewed the video. She stated she could not remember the exact date but she thought it was a couple of days after it was originally live streamed onto the social media site. She stated she immediately notified the administrator and they attempted to contact dietary aide #1. She was asked what the facility policy was for abuse allegations. She stated they were to report it to the administrator immediately. On 03/23/17 at 1:24 p.m., the resident stated no one had ever cursed or used foul language towards her or in her presence. On 03/23/17 at 1:45 p.m., the administrator was asked what she had observed on the video which had been live streamed on the social media site. She stated she observed dietary aide #1 using foul language in regards to and in front of resident #1 and immediately began an abuse investigation. She was asked what the investigation entailed. She stated they terminated the three kitchen staff present at the time of the live streamed video, inserviced staff on reporting abuse and the social media policy, notified all responsible parties, and the DON spoke with resident #1. She stated the DON took over the investigation at that point. On 03/23/17 at 3:47 p.m., the DON was asked what her role consisted of for the investigation to the incident with resident #1. She stated she assisted the administrator and completed the final report which was submitted to the Oklahoma State Department of Health. She stated she contacted the responsible parties and provided inservices. She was asked if she had spoken to resident #1 about the incident. She stated yes. She was asked what the facility policy was for completing abuse investigations. She stated she could not answer without looking at the policy. She was asked if she interviewed staff members. She stated no. The DON was asked if she interviewed other residents to ensure others had not been videoed and placed on social media sites. She stated no. She was asked why she had not interviewed other staff and residents to ensure others had not been affected by situations regarding the use of foul language and being recorded on social media sites. She stated she had not thought about interviewing other staff and residents.

Based on observation, interview, and record review, it was determined the facility failed to thoroughly assess pain for two (#11 and #21) of three sampled residents who had pain. The facility failed to conduct a comprehensive pain assessment when there was evidence of worsening pain and a significant change in the level of pain for Resident #11 after a hip replacement surgery. The day after an increase in pain, the resident was found to have a dislocation of the femoral prosthesis out of the joint space. The Census and conditions report, identified 22 residents on a pain regimen. Findings: A facility policy, titled Pain assessment and management, dated October 2010, documented, .The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . The pain management program is based on a facility-wide commitment to resident comfort . 'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident . Pain management is a multidisciplinary care process that includes the following: .Effectively recognizing the presence of pain .Identifying the characteristics of pain .Addressing the underlying causes of pain .Developing and implementing approaches to pain management .Identifying and using specific strategies for different levels and sources of pain .Modifying approaches as necessary . Conduct a comprehensive pain assessment .whenever there is onset of new pain or worsening of existing pain . Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain . Ask the resident if he/she is experiencing pain . Review the Medication Administration Record [REDACTED]. Re-assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain . 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital document, titled history and physical, dated 02/07/16, documented, .Assessment .Impacted intertrochanteric [MEDICAL CONDITION] hip . A care plan, dated 02/12/16, documented, .Focus .chronic paint r/t muscle wasting and atrophy Recent left [MEDICAL CONDITION] 02/15/16 .Interventions .Monitor/record pain characteristics every shift and PRN: Quality (e.g. sharp,burning); Severity (0 to 10 scale); Onset; Duration (e.g., continuous, intermittent); Aggravating factors; relieving factors . Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain . An eMar - Medication Administration note, dated 02/22/16 at 7:30 a.m., documented, [MEDICATION NAME]-[MEDICATION NAME] Tablet 7.5-325MG Give 1 tablet by mouth every 6 hours as needed for pain res c/o hip pain rates pain at 7 at this time. A significant change assessment, dated 02/22/16, documented the resident was severely impaired in cognition for daily decision making, needed extensive assistance with ADLs, had a functional limitation in range of motion on one lower extremity, and had not experienced a fall since admission or re-entry to the facility. He received PRN pain medication in the previous five days, pain was frequent, and the worst pain in the previous five days was eight on a 0 to 10 scale. A MAR, dated February 2016, documented the resident received prn pain medication two times on 02/22/16 and four times on 02/23/16. The MAR indicated [REDACTED]. A nurse's note, dated 02/23/16 at 3:01 a.m., documented, .Resident awoke, yelling for a pain med and [MEDICATION NAME]. Admin PRN pain med [MEDICATION NAME] with PRN anxiety med [MEDICATION NAME] . The nurse's note did not document the quality, onset, aggravating factors, severity of the pain, and location of the pain. An eMar - Medication Administration note, dated 02/23/16 at 9:14 a.m., documented, [MEDICATION NAME]-[MEDICATION NAME] Tablet 7.5-325 MG Give 1 tablet by mouth every 6 hours as needed for pain res c/o gen body pain rates pain at a 6 at this time. A facility document, titled Weights and vitals summary, documented on 02/23/16 at 3:18 p.m., the resident's pain level was eight. A facility document, titled Weights and vitals summary, documented on 02/23/16 at 9:30 p.m., the resident's pain level was eight. A nurse's note, dated 02/23/16 at 9:31 p.m., documented, .c/o of hip pain .the resident requested [MEDICATION NAME] . The nurse's note did not document the quality, onset, and aggravating factors. A facility document, titled Weights and vitals summary, documented on 02/24/16 at 3:31 a.m. his pain level was an eight. A nurse's note, dated 02/24/16 at 3:31 a.m., documented, .requested [MEDICATION NAME] nervous .c/o hip pain . The nurse's note did not document the quality, onset, and aggravating factors. A nurse's note, dated 02/24/16 at 10:21 a.m., documented, .resident c/o pain in left hip area, area appears more [MEDICAL CONDITION] this am. order received to x-ray left hip . A facility document, titled Weights and vitals summary, documented on 02/24/16 at 10:22 a.m. his pain level was a seven. A document titled, Weights and vitals summary, documented the following information regarding the resident's pain history: ~from 02/22/16 at 3:30 a.m. through 02/23/16 at 2:14 p.m. the resident had a pain level of 0 or 3; ~from 02/23/16 at 3:18 p.m. through 02/24/16 at 3:31 a.m., the resident had a pain level of 8; and ~at 02/24/16 at 10:22 a.m., his pain level was 7. There was no assessment found regarding the resident's increase in level of pain. A mobile x-ray report, dated 02/24/16, documented, .FINDINGS .The patient is status [REDACTED].Dislocated left femoral prosthesis . On 02/29/16 at 2:38 p.m., LPN #1 was asked what happened with resident #1 on the morning of 2/24/16. She stated, The resident was hollering to go the the bathroom between 7:15 to 8:00 a.m. His leg was swollen. He had been using a walker to go to the bathroom. I got him to sit on the side of the bed but he could not stand. I placed him back in the bed and observed a rotation inward on his left hip. I asked physical therapy to assess the resident and they stated there definitely was something wrong. I tried to call the physician but knew he would be at the facility that day and received an order for [REDACTED].>She was asked if she questioned the resident if he had a fall. She stated, No. He was really confused at times. On 02/29/16 at 3:32 p.m., LPN #1 was asked what had been reported to her during the shift report on the morning of 02/24/16 regarding resident #11. She stated, the nurse told her the resident got up, went to the bathroom, had diarrhea, and had jarred loose the seat lift on the toilet. She stated she had cleaned the resident and assisted him back to bed. She was asked what time he was assisted from the bathroom to bed. She stated, She didn't say. She was asked if the report which was given was documented. She stated it was on the 24 hour report. The shift report, dated 02/24/16, for the 2 - 10 shift was blank and the 10 - 6 shift documented abd (abduction pillow) and PRN [MEDICATION NAME] and [MEDICATION NAME] at 2:45 a.m. The shift report contained no documentation of the resdient's increased pain. On 02/29/16 at 3:40 p.m., the DON was asked what the facility's policy was regarding pain assessment. She stated the following: ~ Initially assess; ~ Administer pain medication and assess for a decrease in pain; ~ Re-position, distraction techniques; ~ Depends on the pain and diagnoses; ~ Assessment for location of pain; and ~ Document in the medication administration and treatment administration record. She was asked who was responsible for completing the pain assessment. She stated the nurse on that shift was responsible for the assessment of pain. She was asked why a pain assessment had not been completed when the resident had complaints of hip pain on the evening and night shift of 02/23/16. She stated the resident was probably still experiencing pain from his hip surgery. She was asked what she would expect the nurse to report, regarding pain, when they were relieved by the following shift. She stated the nurse would report what had been documented in the 24 hour report log, if the resident's pain had increased, and if there had been a change in condition. She was asked if a resident complained of post operative hip pain would a visual assessment of the site be expected. She stated, I absolutely think there should be a visual check with complaint of pain. She was asked what was included in the documentation when a pain assessment was completed. She stated the level of pain, intensity the resident reported, location, and anything else. She was asked why resident #11's pain continued to increase over a two day period when he had been receiving his pain medication as well as requesting his antianxiety medication. She stated, He was continuing to work with therapy more and more. On 02/29/16 at 5:00 p.m., the DON was asked if she was aware the staff had not assessed and documented the quality, onset, and aggravating factors when the resident had a significant increase in his pain level. She stated she was not aware of any problems regarding staffs' lack of assessment and or documentation of pain. 2. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A pain assessment, dated 12/19/15, documented, the resident's pain was occasional and the resident had satisfactory pain management. A significant change assessment, dated 01/20/16, documented the resident was severely impaired in cognition for daily decision making, needed extensive assistance with ADLs, had functional limitation in range of motion on the upper and lower extremity on one side, received scheduled and PRN pain medication, frequently had pain which affected her function, and the resident rated her worst pain in the previous five days as an 8 on a 0-10 pain scale. A pain assessment, dated 01/31/16, documented the resident had not exhibited any behaviors of pain, could not indicate the location and frequency of pain, and the plan of care was satisfactory pain management. A care plan, dated 02/02/16, documented, .Focus .I have a terminal prognosis r/t dx of renal cell [MEDICAL CONDITION] . Goal .My comfort will be maintained . Interventions .Hospice services d/t terminal diagnosis .Medication for symptom management and comfort .Work with nursing staff to provide maximum comfort for the resident . Focus .I have chronic pain . Goal .I will verbalize adequate relief of pain or ability to cope with incompletely relieved pain . Interventions .Anticipate my need for pain relief and respond immediately to any complaint of pain .Assess my characteristics of pain such as: location, type, severity, onset, duration, aggravating factors and relieving factors . Monitor pain characteristics Q shift and PRN: Quality . Severity .Anatomical location .Onset .Duration . A physician order, dated 02/17/16, documented, .[MEDICATION NAME] Tablet 7.5-325 MG .Give 2 tablet by mouth every 4 hours as needed for breakthrough pain . A pain assessment, dated 02/27/16, documented the resident frequently had pain, could indicate location and frequency of pain, stated the pain hurts even more, and the plan of care was satisfactory pain management. An EMAR (electronic medication administration record), dated 02/29/16, documented the resident was administered two tablets of [MEDICATION NAME] 7.5-325 mg at 12:20 p.m. On 02/29/16 at 4:37 p.m., the resident was asked how she felt. She stated, Not good. She was asked if she had pain. She stated, Yes, I'm on hospice. She was asked where the pain was. She stated, All over. She was asked if she informed staff of her pain. She stated, Yes. She was asked if she was administered a pain medication. She stated, Yes. She was asked if the pain medication had helped her pain. She stated, Yes, a little. She was asked what her pain level was now on a 0 - 10 pain scale. She stated, Nine. On 02/29/16 at 5:08 p.m., the resdient was asked if she had informed staff of her pain. She stated, Not yet. I'm going to. She was asked if she was still hurting and what her pain level was. She stated she still hurt and it was a nine and pointed to her abdomen At 5:09 p.m., LPN #5 entered the residents room and asked the resident if she was hurting. The resident nodded her head yes and pointed to her abdomen. She asked the resident her pain level. She stated, Nine. An EMAR, dated 02/29/16 at 5:11 p.m., documented [MEDICATION NAME] two tabs PO Q 4 (hours) PRN for breakthrough pain, abdomen. At 5:13 p.m., LPN #5 was observed as she administered a medication to the resident. A nurse's note, dated 02/29/16 at 5:33 p.m., documented the resident complained of a pain level of 10 and [MEDICATION NAME] was given per order, reassessed pain level and resident stated it was an eight. On 02/29/16 at 3:40 p.m., the DON was asked what the facility's policy was regarding pain assessment. She stated the following: ~ Initially assess; ~ Administer pain medication and assess for a decrease in pain; ~ Re-position, distraction techniques; ~ Depends on the pain and diagnoses; ~ Assessment for location of pain; and ~ Document in the medication administration and treatment administration record. She was asked who was responsible for completing the pain assessment. She stated the nurse on that shift was responsible for the assessment of pain. She was asked what was included in the documention when a pain assessment was completed. She stated the level of pain, intensity the resident reported, location, and anything else. She was asked after a pain medication was administered when would the resident be re-assessed for the effectiveness of the medication. She stated approximately 30 minutes. She was asked how a resident was assessed for the effectiveness of pain medication. She stated by asking the resident their pain level, depending on the resident's cognition.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide cardiopulmonary resuscitation for a resident who had requested life saving measures to be performed. The Oklahoma State Department of Health verified the existence of the IJ related to the facility's failure to provide cardiopulmonary resuscitation. At 2:40 p.m., the administrator and DON were informed of the IJ situation related to the facility's failure to perform cardiopulmonary resuscitation. At 6:49 p.m., an acceptable plan of removal was provided. The plan of removal documented: "...1. All resident charts were reconciled on this date, [DATE] and have accurate Code Status' in place @ 4:45 p.m. 2. All residents Code Status' are displayed on the residents homepage in Point Click Care, and on the inside cover of their paper chart. These will be the only two locations for this information. 3. The DCO in-serviced the DON on appropriate use and location of the code status at 1751. In-servicing will include where to obtain the code status; PCC and paper charts. How to determine the need for CPR, apical pulse for one minute and listening for breath sounds for one minute. Starting and initiating CPR. When and where to document the focal assessment completed to determine the CPR need. When and where to document if DNR or clinically dead. 4) The DCO will in-serviced Licensed Nurses [DATE], 1930. In-servicing will include where to obtain the code status; PCC and paper charts. How to determine the need for CPR, apical pulse for one minute and listening for breath sounds for one minute. When and where to document the focal assessment completed to determine the CPR need. When and where to document if DNR or clinically dead. 5) The remaining Licensed Nurses will be in-serviced before the start of their next scheduled shift on the above. This process will concluded by Saturday [DATE] at 0700." On [DATE] at 9:53 a.m., the administrator provided documentation to show the plan of removal had been implemented as described. Staff were interviewed on [DATE] in regards to their knowledge of the inservices; to ensure their understanding of all aspects of the plans of removal. The IJ was removed, effective [DATE] at 2:10 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a level of actual harm at an isolated incident. Based on interview and record review, it was determined the facility failed to: A. Provide cardiopulmonary resuscitation efforts for one (#3) of 16 sampled residents whose clinical records were reviewed. The resident had requested cardiopulmonary resuscitation. This resulted in an Immediate Jeopardy Situation. This had the likelihood to affect 63 residents who resided in the facility; B. Assess, monitor and intervene for a resident with changes in condition for one (#3) of 16 sampled residents whose clinical records were reviewed. The facility identified 26 residents as receiving blood pressure medications and 45 residents as being on a pain management program; and C. Administer ordered pain medication as requested by one (#16) of four sampled residents who were reviewed for pain. The resident's request for the medication went unanswered for over one hour. This resulted in actual harm to resident #16. The facility identified 45 residents as being on a pain management program. Findings: The facility's policy on advance directives, dated ,[DATE], documented, "...Advance directives will be respected in accordance with state law and facility policy...Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan...The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care..." The facility's policy on pain, dated ,[DATE], documented, "...staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain..." 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Oklahoma Do-Not-Resuscitate (DNR) Consent Form, dated [DATE], documented the resident did not want cardiopulmonary resuscitation in the event his heart quit beating or he quit breathing. A pain management consult, dated [DATE], documented, "...I had a very lengthy discussion with the patient as well as his caregiver today about the fact that higher doses of short acting medications are not appropriate. Rapidly elevated blood levels with short acting medications are going to cause him to have sedation episodes. Rather, what needs to be done is converting him to a longer acting opioid in addition to an occasional breakthrough pain medication. Another issue is that he is on [MEDICATION NAME]. I talked with the caregiver about the fact that any signs of sedation need to result in holding his medication and contacting my office..." A hospice Informed Consent/Election of Benefits statement, dated [DATE], documented the resident had elected to receive hospice services. The RN initial assessment for hospice, dated [DATE] at 11:05 a.m., listed the resident's terminal [DIAGNOSES REDACTED]. It was documented, "...Pt wants cardiopulmonary resuscitation at this time 'if there is a chance of quality of life, but not if I am in a vegetative state'..." The summary/comments page of the hospice assessment documented, "...If there is a chance of quality of life he wants everything done. This RN asked pt what his picture of quality of life looked like. Pt stated, 'I don't want a tube shoved down my throat to breathe or be on a machine. I want to be able to live like I do now, go out of the facility once in awhile, have family visit me and know who they are. I don't want to live in a vegetative state'...Explained to pt if it were in writing in an AD (advance directive), son would only be doing what pt had directed as his wishes. Pt requested medical SW (social worker) to assist with completing AD with him..." The comprehensive assessment, dated [DATE], documented the resident was cognitively intact, displayed no behaviors, was independent with activities of daily living, and had a prognosis of life expectancy of less than six months. Physician orders, dated ,[DATE], documented the resident was to receive the following medications: [REDACTED] ~ [MEDICATION NAME], 1 mg twice daily for anxiety (started [DATE]); ~[MEDICATION NAME] mg extended release daily for hypertension (started [DATE]); ~ [MEDICATION NAME] 20 mg daily for hypertension (started [DATE]); ~ [MEDICATION NAME] 150 mg twice daily for pain (started [DATE]); ~ [MEDICATION NAME] 15 mg daily for pain (started [DATE]); ~ [MEDICATION NAME] 10 mg daily for hypertension (started [DATE]); ~ [MEDICATION NAME] 100 mg twice daily for hypertension (started [DATE]); ~ [MEDICATION NAME]/DSS 30mg/50mg twice daily for pain (started [DATE]); and ~ [MEDICATION NAME] 15 mg every four hours as need for pain (started [DATE]). The Medication Administration Record, [REDACTED]. It was documented the resident received seven doses of as needed [MEDICATION NAME] during the two day period. A hospice note, dated [DATE], documented, "...Pt refused any assist offered by this CHHA today. Pt agitated and very drowsy. He fell asleep during conversation several times..." The Medication Administration Record, [REDACTED]. It was documented the resident received six doses of as needed [MEDICATION NAME] during the two day period. The vital signs summary, dated [DATE] at 6:44 a.m., documented the resident's blood pressure was ,[DATE]. The Medication Administration Record, [REDACTED]. It was documented the resident received nine doses of as needed [MEDICATION NAME] during the three day period. The resident's care plan, updated [DATE], documented, "...Focus... I have Oxygen therapy r/t [MEDICAL CONDITION] wish to remain free from s/sx of poor oxygen absorption through the review date...Interventions...Monitor for s/sx of respiratory distress and report to MD PRN:..Respirations, Pulse oximetry...Lethargy, Confusion...Skin color... Focus...PAIN: I have chronic) (sic) pain r/t chronic pai[DIAGNOSES REDACTED]. I have the potential for increased pain and constipation...Interventions...May hold pain medication due to lethargy...Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician... Focus...I use [MEDICAL CONDITION] medications...r/t disease process...Goal...I will be/remain free of drug related complications, including movement [MEDICAL CONDITION]/behavioral impairment...Interventions...Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications: [REDACTED].behavior symptoms not usual to the person... Focus...I have dx of [MEDICAL CONDITION]. I have the potential for exacerbation of [MEDICAL CONDITION] and anxious episodes associated with shortness of breath...Interventions...Monitor vital signs, skin color, pulse oximetry, airway functioning and degree of restlessness which may indicate [MEDICAL CONDITION] Focus...I have a Do Not Resuscitate code status...Goal...I wish for my DNR code status to be honored...Interventions...If I am found without spontaneous heartbeat or respirations, I wish for no rescue breathing nor CPR to be initiated...My yellow copy of my singed (sic) DNR form is in my chart under the Advanced Directive tab..." The Advanced Directive for Health Care, dated [DATE] and signed by resident #3, documented the resident wanted life sustaining treatment, including artificially administered nutrition and hydration if necessary. This form was noted in the resident's clinical record. The Medication Administration Record, [REDACTED]. It was documented the resident received five doses of as needed [MEDICATION NAME] from midnight on [DATE] through 1:03 a.m. on [DATE]. A nurse's note, dated [DATE] at 4:23 a.m., documented, "...res. observed to be having these entire body involuntary muscle movement of his arms and head, can't remember from one minute to the next what he is doing. res. is not staying focus with task at hand. roaming facility with hair in front of his face res. states is hurting and will ask for pain medication, his behavior is unlike what this nurse has seen before..." Review of the clinical record revealed no documentation to show the resident was assessed or monitored for changes. There was no documentation to show the physician was notified of the resident's behaviors. The Medication Administration Record, [REDACTED]. It was documented the resident received an additional three doses of [MEDICATION NAME] on [DATE], as needed for pain. An eMar note, dated [DATE] at 12:40 a.m., documented, "...(An [MEDICATION NAME])...Resident refused, when approached resident, (sic) to take his scheduled meds he was slumped over in wheelchair. Stated he was fine and did not want ([MEDICATION NAME])..." The Medication Administration Record, [REDACTED] A progress note, dated [DATE] at 12:32 p.m., documented, "...(Hospice physician) here to see resident regarding his pain, new orders received to DC routine [MEDICATION NAME], cont Oxy IR ([MEDICATION NAME]) as written, hold if sedated. [MEDICATION NAME] 10 mg po QID routine and [MEDICATION NAME] 10 mg po TID..." The Medication Administration Record, [REDACTED]. The Medication Administration Record, [REDACTED]. It was documented the resident received three doses of as needed [MEDICATION NAME] for pain. The vital signs summary, dated [DATE] at 7:46 a.m., documented the resident's blood pressure was ,[DATE]. The Medication Administration Record, [REDACTED] An eMar note, dated [DATE] at 3:23 p.m., documented, "[MEDICATION NAME] d/t sedative effect, wouldn't wake up to take med chg. nurse aware..." Review of the clinical record revealed no documentation the resident was assessed or monitored after not waking up. An eMar note, dated [DATE] at 5:18 p.m., documented the resident was requesting an as needed pain medication. An eMar note, dated [DATE] at 12:47 p.m., documented, "[MEDICATION NAME] resident lethargic bp ,[DATE] nurse notified..." A priority note, dated [DATE] at 10:12 p.m., documented, "...(hospice) notified d/t [MEDICAL CONDITION]. To hold [MEDICATION NAME] for 24Hrs..." The MAR, dated [DATE], documented the evening dose of [MEDICATION NAME] was held. There was no documentation to show the facility assessed or monitored the resident after a blood pressure of ,[DATE] was obtained. The MAR, dated [DATE], documented the morning dose of [MEDICATION NAME] was held. The MAR, dated [DATE], documented the resident received four doses of as needed pain medication. It was documented the resident complained of pain ranging from a four to a seven on a scale of zero to ten. It was documented the last dose of as needed medication was provided at 6:51 p.m. on [DATE] An activities note, dated [DATE] at 11:08 a.m. and signed by the LPN, documented, "...This nurse was sent to Residents (sic) room by another resident. found resident sitting on floor in front of wheelchair without a shirt. Resident was very lethargic, and kept dozing when inquiries were made. Vital signs were taken, and stable. no Bruising, abrasions, or skin tears were noted upon assessment. resident was jerking/shaking. resident stated he wanted to sit on the floor, so he did. Called for assistance. This nurse and ADON assisted patient to bed. Call light in reach. Informed ADON, Physician, and family..." An eMar note, dated [DATE] at 12:27 p.m., documented, "[MEDICATION NAME] due to resident being lethargic, nurse notified..." Review of the clinical record revealed no documentation to show the resident was assessed or monitored after being found lethargic. The vital signs summary, dated [DATE] at 7:30 p.m., documented the resident's blood pressure was ,[DATE]. An eMar note, dated [DATE] at 1:56 a.m., documented the resident was complaining of pain and requesting an as needed pain medication. It was documented the resident was medicated. A progress note, dated [DATE] at 6:58 a.m., documented, "...Resident on PNE for fall f/u, (no) S/S of distress. Will continue to monitor..." A progress note, dated [DATE] at 10:39 a.m., documented, "...Resident passed at 1000. (Physician name withheld) noted, TOD 1000. (Family member) notified(,) notified (family member)....(Hospice) notified..." There was no documentation in the clinical record to indicate caridiopulmonary resuscitation had been attempted for the resident. There was no documentation that emergency services had been called for the resident. A priority note, dated [DATE] at 10:39 a.m. and signed by the DON, documented, "...Resident passed at 10:00, (primary care physician) notified, TOD (time of death) 10:00...(hospice) notified. A hospice discharge note, dated [DATE] and signed by the DON, documented, "...Confirmed Absence of Vital Signs: Yes...Time of Death: 10:00...Present at Time of Death: Facility staff and hospice nurse...Notification Attending Physician...Date: [DATE]...Time: 11:00...Comments/Summary Patient passed peacefully..." On [DATE] at 6:30 p.m., the Director of Nursing (DON) was asked what she knew of the resident's death. The DON stated the resident was found sitting on the side of the bed with one leg on the floor and the other across the bedside. The DON stated the resident was slumped over with his shirt off and his skin was mottled. The DON stated the resident's code status was a Do Not Resuscitate. On [DATE] at 6:50 p.m., the assistant Director of Nursing (ADON) was asked if she had found the resident at the time of death. The ADON stated she was walking the facility looking for two oxygen concentrators which were missing. She stated, "I went into his room, looking for a concentrator when I saw him. He was sitting on the side of the bed and slumped over at the waist with his head on the mattress. He was mottled on the right side of his head and down his right arm. I checked his pulse and there was nothing so I had another staff member get the DON. We then positioned him on the bed." The ADON was asked if she checked any other vital signs, such as blood pressure or respirations. She stated she had checked the resident's radial pulse only. The ADON was asked what was the code status for resident #3. She stated he had a do not resuscitate order. On [DATE] at 7:10 p.m., the Director of Nursing (DON) was asked if she contacted the physician to report an absence of vital signs. The DON stated, "Yes." The DON was asked if she checked the resident's blood pressure, pulse, and respirations. She stated, "No. They did that before I came in." On [DATE] at 1:00 p.m., CMA #1 was asked to describe how resident #3 was when she obtained the blood pressure reading of ,[DATE] on [DATE]. The CMA stated, "I went into his room. He was sitting in his wheelchair with his head on the bed like he was asleep. He would wake and respond and then go back to sleep. I notified my charge nurse, (LPN #1), I think. He said to get vital signs and report back to him. I checked vital signs and that is what I got. I reported back to my charge nurse and if I remember right, we helped him back into his bed." On [DATE] at 1:20 p.m., CMA #3 was asked if she recalled holding medication for resident #3 on [DATE]. She stated she held the resident's medication because he was lethargic. The CMA was asked if she notified anyone of resident #3 lethargy. She stated she did not recall. On [DATE] at 1:40 p.m., LPN #1 was asked if he was notified of a blood pressure of ,[DATE] on resident #3 on [DATE]. He stated he did not recall. The LPN was asked what he would do if someone notified him of abnormal vital signs such as a blood pressure of ,[DATE] on resident #3. LPN #1 stated he would go and assess the resident himself. He stated he would change the resident's position and lower the head of the bed to increase the blood pressure. He stated he would tell the CMA to hold blood pressure and narcotic medications. He said he would notify the supervisor and encourage the resident to drink fluids. LPN #1 was asked what he would document in such a situation. He stated, "The BP and hold meds would be." He was asked if he would notify anyone of the abnormal vital signs, the interventions he performed, and the outcome to the resident. He stated, "No. No, probably not." LPN #1 was asked which doctor he notified on [DATE] when he found the resident sitting on the floor in his room. He stated the resident's primary care physician. He was asked what he had reported to the resident's primary care physician. He stated he had informed the physician that the resident was found sitting on the floor with no apparent injuries. LPN #1 was asked if the primary care physician gave any verbal orders. He stated, "No orders." LPN #1 was asked if he notified the physician of any other incidents of abnormal vital signs, held medications, or the resident's lethargic behavior in the last week prior to the resident's death. He stated, "No. Probably not." On [DATE] at 1:50 p.m., LPN #5 was asked if she was assigned to resident #3 on [DATE]. The LPN stated, "I called the hospice when he was on the [MEDICATION NAME] because his blood pressure was low. I was upset because they said they did not want his pain out of control so they held his blood pressure medication. I was asking about holding pain medication but they did not want to have his pain out of control so they said to hold the [MEDICATION NAME]." LPN #5 was asked if she had reported to the hospice representative the other blood pressure medications the resident was on. She stated, "No." LPN #5 was asked if she had reported to the hospice representative the resident's routinely ordered muscle relaxer, anti-anxiety medication, and long acting non narcotic pain medication. She stated, "No." LPN #5 was asked if she notified anyone in the facility or the resident's primary physician of the above concerns. She stated, "No." LPN #5 was asked what the code status was for resident #3. She stated the resident had an advanced directive. She was asked what the advanced directive documented for resident #3. She stated she did not know but she recalled seeing a white advanced directive. LPN #5 was shown the advanced directive for resident #3, dated [DATE]. She stated, " Yes. That's the one." She was asked what the facility protocol was when a resident was found with no pulse. She stated, "If not a DNR, I'd be yelling for help and start CPR." The LPN was asked how the facility ensured staff was aware of each resident's code status. The LPN stated the resident's code status was listed in the resident's paper chart or on the electronic record. She stated, "We used to use hearts outside the door for full code but we don't anymore." On [DATE] at 6:12 p.m., the clinical director for the hospice providing services to resident #3 was asked what their policy was regarding a resident's code status. She stated their service did not require an advanced directive. The director was asked what the code status was for resident #3. She stated, "I know he was not ready to sign a Do Not Resuscitate order." The director stated the resident had voiced he wanted CPR as long as there was a chance for quality of life but not if he would be dependent on a breathing machine because to him that was not quality of life. The director was asked if she notified anyone of the resident's wishes. She stated, "I spoke with the DON at the facility at the time of admission. Also, she (the DON) works for our hospice part time and has access to our charting anytime. Plus, by agreement, we have to have our documentation back into the facility within 48 hours. On [DATE] at 1:00 p.m., LPN #1 was asked if he was present when the resident expired. He stated he was working down the hall when the ADON stepped out of the resident's room and called for help. He was asked if he assisted the ADON with the resident when he expired. He stated he assisted the resident into a lying position and cleaned and dressed the resident as instructed by the DON. LPN #1 was asked what the code status was for resident #3. He stated he was not sure what the code status was for resident #3. He was asked where he would have found the code status. He stated it was listed on a sheet at the nurse's desk. LPN #1 was asked why he had not started CPR. He stated he was following the direction of the ADON and DON. On [DATE] at 3:00 p.m., the DON was asked what the facility policy was for assessing and monitoring a resident with a documented episode of [MEDICAL CONDITION]. The DON stated the vital signs were taken as ordered by the physician. She stated some residents have their blood pressure taken daily and recorded prior to receiving their blood pressure medication. The DON stated that others may have their blood pressure taken weekly by the nurse. The DON was asked why the blood pressure for resident #3 was not monitored when there were documented signs of lethargy and a recorded blood pressure of ,[DATE]. The DON stated she was not aware of the low blood pressure because it was not documented with the rest of the resident's vital signs but instead in the nurse's notes and she had not been informed of the resident's lethargy. The DON was asked if the resident should have been monitored with the changes in medication, frequent lethargy, and the blood pressure reading of ,[DATE]. She stated, "Yes." The DON was asked how the facility ensured care was coordinated if a resident was on hospice. The DON stated the MDS coordinator was responsible for monitoring the hospice records, coordinating care, and ensuring the care plan was updated. The DON was asked who was responsible for ensuring the MDS coordinator ensured the coordination of care. She stated she was responsible. The DON was shown the documentation of the hospice admission and asked if she had been notified of the resident's wishes. She stated she did not recall the conversation with the hospice director. The DON was asked what the resident wished for his code status. She stated the resident wanted to be a full code. On [DATE] at 3:30 p.m. the ADON was asked why she had not documented on resident #3 the day he expired. The ADON stated she had been told by the DON not to chart anything. She stated the DON said she would contact everyone and chart everything that was needed. The ADON was asked if anyone checked the resident's chart for his code status. She stated, "No." 2. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment, dated [DATE], documented resident #16 had almost constant pain during the five days previous to the assessment. The pain had limited the resident's day-to-day activities and made it hard for him to sleep at night. A care plan focus for resident #16, dated [DATE], documented, "...I have chronic pain r/t [MEDICAL CONDITION] muscle weakness..." The goal was for the resident to not have interruptions in normal activities due to pain through the target date of [DATE]. Interventions included, "...Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance..." Another intervention, dated [DATE], documented, " ...Administer pain medication ([MEDICATION NAME] DM, [MEDICATION NAME], & Tylenol) per orders..." A comprehensive assessment, dated [DATE], documented that resident #16 made staff aware of his pain through vocal complaints, facial expressions, and protective body movements on three to four days of the five days previous to the assessment. On [DATE] at 3:58 p.m., resident #16 was asked if he had any concerns regarding pain or pain medication. The resident stated," They make me wait all the time, I ache all over right now." The resident then rated his pain at a seven on a zero to ten scale. Resident #16 was asked what he believed to be the average time he waited for medications after making requests for them. The resident stated it averaged one hour. Resident #16 was asked if he had ever requested pain medication and not received it. The resident stated he asked a nurse for pain medications 30 minutes prior to speaking with the surveyor and had not received it yet. Resident #16 was asked to engage his call light if he still required pain medication. The resident pushed his call button at 4:02 p.m. At 4:02 p.m., the resident's call light above his doorway was not on but the resident's call light on the call light board located at the unit nurses station was activated. The call light board was at eye level on the wall facing the entrance to the nurses station. At 4:06 p.m., CMA #2 was observed sitting at the nurses station approximately two feet from the call light board. The light for resident #16 was the only light activated. The CMA did not check on the resident. At 4:12 p.m., LPN #5 was observed entering resident #16's room and administering medication to the other occupant of the room. The LPN did not ask resident #16 about his call light. At 4:20 p.m., LPN #5 departed the room and returned to the medication cart to retrieve more medication. At 4:25 p.m., LPN #5 reentered the room and administered medications to the other resident in the room. The LPN did not ask resident #16 about his call light. At 4:27 p.m., LPN #5 entered the nurses station. The call light for resident #16 was the only light activated. The LPN did not check on the resident. At 4:30 p.m., CMA #2 reentered the nurses' station. Resident #16's call light was on and continued to be the only light activated. The CMA sat approximately two feet from the call light board. The CMA did not check on the resident. At 4:32 p.m., CNA #7 entered the nurses' station and remained there for approximately 5 minutes. Resident #16's call light was on and the only light activated during that time. The CNA did not check on the resident. At 4:35 p.m., CMA #2 reentered the nurses station to speak on the same telephone as before. Resident #16's call light continued to be the only light activated. The CMA did not check on the resident. At 4:38 p.m., CMA #2 reentered the nurses station. Resident #16's call light was turned on and the only light activated. The CMA did not check on the resident. At 4:40 p.m., CNA #7 entered resident #16's room and asked him if he wanted to go to the dining room. The CNA did not ask the resident about his call light or if he was in pain. CNA #7 assisted the resident to the dining room, but left the call light engaged. At 4:43 p.m., LPN #5 was asked why resident #16's call light was turned on. She replied, "I don't know." LPN #5 did not go to the resident to ask why his light was turned on. At 4:48 p.m., both CMA #2 and LPN#5 were standing together at the nurses station and were asked why resident #16's call light was turned on. Both stated they did not know. They were both asked what they do when a call light is turned on. Both stated in that situation they would check on the resident who turned on the light. The resident's call light was still activated. At 4:55 p.m., CMA #2 went to the dining room and asked resident #16 why he had turned on his call light. The resident stated his back hurt and rated the pain as an eight. CMA #2 asked resident #16 if he wanted pain medication. The resident stated he did. At 5:00 p.m., CMA #2 administered resident #16 a single [MEDICATION NAME] 7XXX,[DATE] mg tablet. On [DATE] at 5:50 p.m., resident #16 was asked to rate the least amount of pain he ever had on a scale of zero to ten, with ten being the worst. The resident stated, "Three, if they give me my medicine." Resident #16 was asked to rate the worst his pain he gets. The resident stated, "Nine, why can't they give me my medicine?" Resident #16 was asked how his pain affected his life. The resident stated the pain distracted him when watching television or conversing with others and woke him from sleep six to eight times each week. Resident #16 was asked how many times a week he believed he waited an unacceptable amount of time for his pain medication. He stated,"Four, six, eight, a lot of times." On [DATE] at 6:27 p.m., CMA #2 was asked if she had performed the physician ordered pain assessment on that date. She stated she had not. CMA #2 was then asked if she had charted that she had performed the pain assessment on that date at 2:01 p.m. She stated she had. On [DATE] at 12:52 p.m., the Director of Clinical Operations (DCO) was asked who was responsible to ensure a resident's pain is managed effectively. The DCO stated it is a team effort between the phys

Based on observation, interview, and record review, it was determined the facility failed to answer call lights in a timely manner for one (#16) of 13 sampled residents who were observed. This resulted in actual harm for the resident when his need for pain medication went unmet. The facility identified 50 residents as being able to use the call light. Findings: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment, dated 05/22/14, documented resident #16 had almost constant pain during the five days previous to the assessment. The pain had limited the resident's day-to-day activities and made it hard for him to sleep at night. A care plan focus for resident #16, dated 07/23/14, documented, "...I have chronic pain r/t [MEDICAL CONDITION] muscle weakness..." The goal was for the resident to not have interruptions in normal activities due to pain through the target date of 01/08/15. Interventions included, "...Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance..." Another intervention, dated 09/23/14, documented, " ...Administer pain medication ([MEDICATION NAME] DM, [MEDICATION NAME], & Tylenol) per orders..." A comprehensive assessment, dated 10/10/14, documented that resident #16 made staff aware of his pain through vocal complaints, facial expressions, and protective body movements on three to four days of the five days previous to the assessment. On 11/25/14 at 3:58 p.m., resident #16 was asked if he had any concerns regarding pain or pain medication. The resident stated," They make me wait all the time, I ache all over right now." The resident then rated his pain at a seven on a zero to ten scale. Resident #16 was asked what he believed to be the average time he waited for medications after making requests for them. The resident stated it averaged one hour. Resident #16 was asked if he had ever requested pain medication and not received it. The resident stated he asked a nurse for pain medications 30 minutes prior to speaking with the surveyor and had not received it yet. Resident #16 was asked to engage his call light if he still required pain medication. The resident pushed his call button at 4:02 p.m. At 4:02 p.m., the resident's call light above his doorway was not on but the resident's call light on the call light board located at the unit nurses station was activated. The call light board was at eye level on the wall facing the entrance to the nurses station. At 4:06 p.m., CMA #2 was observed sitting at the nurses station approximately two feet from the call light board. The light for resident #16 was the only light activated. The CMA did not check on the resident. At 4:12 p.m., LPN #5 was observed entering resident #16's room and administering medication to the other occupant of the room. The LPN did not ask resident #16 about his call light. At 4:20 p.m., LPN #5 departed the room and returned to the medication cart to retrieve more medication. At 4:25 p.m., LPN #5 re-entered the room and administered medications to the other resident in the room. The LPN did not ask resident #16 about his call light. At 4:27 p.m., LPN #5 entered the nurses station. The call light for resident #16 was the only light activated. The LPN did not check on the resident. At 4:30 p.m., CMA #2 re-entered the nurses' station. Resident #16's call light was on and continued to be the only light activated. The CMA sat approximately two feet from the call light board. The CMA did not check on the resident. At 4:32 p.m., CNA #7 entered the nurses' station and remained there for approximately 5 minutes. Resident #16's call light was on and the only light activated during that time. The CNA did not check on the resident. At 4:35 p.m., CMA #2 re-entered the nurses station to speak on the same telephone as before. Resident #16's call light continued to be the only light activated. The CMA did not check on the resident. At 4:38 p.m., CMA #2 re-entered the nurses station. Resident #16's call light was turned on and the only light activated. The CMA did not check on the resident. At 4:40 p.m., CNA #7 entered resident #16's room and asked him if he wanted to go to the dining room. The CNA did not ask the resident about his call light or if he was in pain. CNA #7 assisted the resident to the dining room, but left the call light engaged. At 4:43 p.m., LPN #5 was asked why resident #16's call light was turned on. She replied, "I don't know." LPN #5 did not go to the resident to ask why his light was turned on. At 4:48 p.m., both CMA #2 and LPN#5 were standing together at the nurses station and were asked why resident #16's call light was turned on. Both stated they did not know. They were both asked what they do when a call light is turned on. Both stated in that situation they would check on the resident who turned on the light. The resident's call light was still activated. At 4:55 p.m., CMA #2 went to the dining room and asked resident #16 why he had turned on his call light. The resident stated his back hurt and rated the pain as an eight. CMA #2 asked resident #16 if he wanted pain medication. The resident stated he did. At 5:00 p.m., CMA #2 administered resident #16 a single [MEDICATION NAME] 7.5-325 mg tablet. On 11/25/14 at 5:50 p.m., resident #16 was asked to rate the least amount of pain he ever had on a scale of zero to ten, with ten being the worst. The resident stated, "Three, if they give me my medicine." Resident #16 was asked to rate the worst his pain gets. The resident stated, "Nine, why can't they give me my medicine?" Resident #16 was asked how his pain affected his life. The resident stated the pain distracted him when watching television or conversing with others and woke him from sleep six to eight times each week. Resident #16 was asked how many times a week he believed he waited an unacceptable amount of time for his pain medication. He stated,"Four, six, eight, a lot of times." On 12/08/14 at 12:52 p.m., the Director of Clinical Operations (DCO) was asked who was responsible to ensure a resident's pain is managed effectively. The DCO stated it is a team effort between the physician, nursing staff, and hospice. The DCO was asked who was responsible for the day to day management of a resident's pain regimen. She stated that was the nurses' responsibility. The DCO was asked how long it should take for staff to answer a resident's call light. She replied that 15 minutes is long and that it should be sooner. On 12/08/14 at 1:03 p.m., the DCO was asked why staff did not answer the call light for resident #16. She stated she could not answer that question. She was asked why staff did not ask the resident what his needs were when they entered the room. She stated she did not know why. On 12/08/14 at 1:38 p.m., the administrator and DCO were asked if, prior to the survey, they had identified any concerns related to call lights not being answered in a timely manner. The administrator stated yes. He stated the problem had been identified during resident council meetings. They were asked what had been done to correct the problem. The DCO stated inservice training and learning circles had been done. They were asked if anything, other than inservices, had been done to correct the problem. The DCO stated, "No."

Based on observation, interview, and record review, it was determined the facility failed to: A. Ensure one (#24) of eight sampled residents who were reviewed for pain received pain medication as ordered by the physician. This resulted in actual harm for the resident. The facility identified 85 residents as being on a pain regimen. B. Establish, agree upon, and communicate a coordinated plan of care with the facility and hospice agencies for three (#9, #16, and #24) of three sampled residents whose hospice services were reviewed. The facility identified 16 residents as receiving hospice services. C. Provide suprapubic catheter care in a manner that prevented infection for one (#9) of two sampled residents with suprapubic catheters. The facility identified three residents as having suprapubic catheters. Findings: 1. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/24/13, documented the resident was cognitively impaired and had long and short-term memory loss. It was documented the resident exhibited signs of feeling tired or having little energy, a poor appetite or overeating, and trouble concentrating nearly every day during the preceding two weeks. It was also documented the resident was dependent on staff for eating, dressing, bed mobility, and transfers. It was documented the resident had no signs or symptoms of pain. It was also documented the resident coughed or choked during meals or when swallowing medications and received a mechanically altered diet. The resident's care plan, last updated 01/24/13, documented a problem, "...I am on (hospice name withheld) services for [DIAGNOSES REDACTED]." The resident's care plan did not address pain as a problem. There were no goals or interventions identified. Monthly physician orders, dated 03/2013, documented the resident received [MEDICATION NAME], a pain medication, 5/325 mg twice daily by mouth for pain and every six hours as needed for pain. It was documented the orders were effective 11/16/12. A hospice plan of care, dated 03/20/13, documented a problem, "...Alteration in physical comfort/pain..." The expected outcome was, "...Patient will achieve and maintain optimal physical comfort..." Approaches included, "...Assess pain control q visit...Assess pain using FLACC scale if pt unable to report pain...cognitive defect..." A hospice note, dated 03/25/13, documented, "...This nurse arrived to find pt lying in bed coughing, approximately 3-5 areas of of (sic) pureed food (per facility staff statement), this nurse increased HOB...auscultated Rhonchi/inspiratory wheezes in all lobes, SAO2 93% on RA, productive cough clear sputum of thick viscosity...This nurse completed on call visit: (facility employee name withheld) stated pt had congestion and cough and she ordered a CXR (completed at approximately (7:30 p.m.)); assessment completed; this nurse contacted physician and new orders received; encouraged facility staff to observe swallow precautions, (facility employee name withheld) verbalized understanding...Fields taught...Nutrition (swallow precautions, puree diet nectar thickened liquids...encouraged (facility employee name withheld) to call/fax (hospice name withheld) with results of CXR..." A chest x-ray result, dated 03/25/13, documented the resident's lungs were clear. A hospice note, dated 03/26/13, documented, "...encouraged facility staff...to observe swallow precautions..." MARs, dated 03/27/13 at 8:00 a.m., documented, "[MEDICATION NAME] 5/3235 mg not [MEDICATION NAME] 0.25 mg not given..." A nurse's note, dated 03/27/13 on the 6-2 shift, documented, "...@ (9:30 a.m.) resident monitor/decline (and) possible aspiration on 03/26/2013 2-10 nurse report. Resident in bed resting c eyes closed. Lethargic. FSBS 309 B/P 136/57 temp 98.5 O2 sats 92 pulse 87. Resident continues to decline. Pupils fixed. Skin cool touch, resident medication given @ this x c breakfast. Resident monitor frequently during shift. Resident having cough gurler (sic). Resident suction. Hospice called notified approx. (11:00 a.m.) c request for nurse/ decline c resident. Resident nurse here. Assessed @ (sic) (unknown) c meds order per nurse/(Hospice) provide ([MEDICATION NAME]/[MEDICATION NAME]) liquid c [MEDICATION NAME] 1 % solution give 4 gtts under tongue q 4 (hours) prn for secretions/resident (hospice) nurse left approx (2:00 p.m.) c new meds discussed ordered...Resident v/s @ 1230 101/50, pulse 68, rechecked @ 1330 98/47 pulse 74 temp 98.7. continue to monitor resident c pain rate Wong Baker FACES rated 6 on scale 1-10. Resident continues to be monitored @ this x..." A hospice note, dated 03/27/13 at 2:25 p.m., documented, "...Nurse was called out to do an assessment, the facility called and said patient had a change in status of no response, nurse arrived an (sic) patient was sleeping, no response during the first part of assessement (sic), she did respond to some questions at the end of assessment and did not respond again, non [MEDICAL CONDITION] in BLE, rhonchi in all lungs, BP was low, skin was cool to touch, (LPN #3) requested [MEDICATION NAME] gtts and liquid loratab (sic) because she stated the patient was not swallowing very good, (hospice employee name withheld) was notified..." The hospice note documented the nurse began her travel to the facility at 2:00 p.m., arrived at the facility at 2:25 p.m., and left the facility at 2:55 p.m. It was documented the hospice nurse traveled 9 miles. A nurse's note, dated 03/27/13 at 5:15 p.m., documented, "...Resident medication not here. Requested CMA to check med room for meds. Stated there were no meds. None logged in. Request med aid to call (hospice name withheld) @ this x to check on medications. (Hospice name withheld) sent out 2nd nurse @ this time..." A hospice note, dated 03/27/13 at 6:24 p.m., documented, "...(LPN #3) states that after pt had eaten dinner in bed pt was lethargic and had SaO2 84% on RA and that (LPN #3) suctioned her; (LPN #3) then stated that she would like liquid pain medication for pt because pt was no longer swallowing and would be unable to swallow PO but she denied that pt was showing s/s of pain and that her BP was low..." A hospice physician's orders [REDACTED]. Another hospice physician's orders [REDACTED]. A nurse's note, dated 03/27/13 at 7:00 p.m., documented, "...(Hospice name withheld) here...to follow up c pain medications and [MEDICATION NAME] gtts. Nurse request information @ this x on resident request. (Hospice name withheld) to get meds here did not understand why medication were not here in facility @ this x. Nurse stated that they had not even been order @ this x. That she would order them and have them here tonight..." A nurse's note, dated 03/27/13 and untimed, documented, "...Resident medication here approx (8:00 p.m.) Signed in medication per this nurse. Gave initial dose @ (8:30 p.m.) via sublingual dose under tongue..." A nurse's note, dated 03/27/13 at 9:30 p.m., documented, "...Resident re-evaluated. Med effective..." On 03/28/13 at approximately 11:00 a.m., LPN #3 stated resident #24 had been in pain on the previous day (03/27/13) and she had called hospice for liquid pain medication but it was not delivered until approximately 8:00 p.m. that evening. LPN #3 was asked if the resident was able to make her needs known and verbalize complaints of pain. She stated, "No." LPN #3 was asked how she knew the resident was in pain. LPN #3 stated she knew the resident was in pain because she was moaning loudly, unable to eat lunch, and had been without her pain medication. LPN #3 was asked if the resident's pain medication was routine or as needed. She stated the resident had physician orders [REDACTED]. LPN #3 stated the resident had an episode of coughing and choking on 03/25/13. LPN #3 stated the resident had difficulty swallowing. She stated the facility was afraid the resident had aspirated, so they had obtained a chest x-ray. LPN #3 stated on 03/27/13, the resident was moaning loudly, lethargic, and unable to eat her breakfast or lunch. LPN #3 stated she assessed the resident and found her blood pressure to be low. She stated she instructed the medication aide to hold the resident's pain medication because she was afraid the resident would be unable to swallow it and because the blood pressure was low. She stated she contacted the hospice at approximately 11:00 a.m. to come and assess the resident. She stated she requested liquid pain medication for the resident. LPN #3 stated hospice came to the facility at approximately 2:00 p.m. She stated the hospice nurse assessed the resident and they discussed the need for liquid pain. LPN #3 stated the hospice nurse said the medication had been ordered. LPN #3 stated at approximately 5:00 p.m., the medications had not arrived at the facility. She stated the resident had not received any pain medications that day. LPN #3 stated she called the hospice again and they sent another nurse out. She stated the nurse arrived at the facility at approximately 6:00 p.m. LPN #3 stated the hospice nurse informed her at that time the liquid medications had not been ordered. She stated the hospice nurse ordered the medications, and they arrived at the facility at approximately 8:00 p.m. LPN #3 was asked if she had informed the DON about the resident's pain, her decision to hold the pain medication, and the delay in hospice ordering pain medications. She stated, "No." When asked if she had informed the medical director, LPN #3 stated, "No." LPN #3 stated she could have obtained a physician's orders [REDACTED]." At 12:30 p.m., the resident was observed in the dining room being fed the noon meal. The resident was responsive and showed no signs and symptoms of pain. She was not moaning. At 12:47 p.m., CNA #4, who had taken care of resident #24 on 03/27/13, was asked if the resident had been in pain. She stated, "Yes." She stated, "She was out of it so bad I had to get the nurse." At 1:00 p.m., CMA #4 was asked if the resident had been in pain on 03/27/13. She stated, "Yes." She stated the resident was moaning. She stated, "Around 1, she was out of it." CMA #4 stated LPN #3 had instructed her to give the pain medication then, but the resident's blood pressure was too low, so they decided not to give it. At 1:15 p.m., the DON was asked if she had been made aware of staff not administering the resident's routine pain medication and that hospice had not responded in a timely manner to requests for liquid pain medication. She stated, "No." She stated she could have called the medical director and had medications delivered to the resident immediately. At 1:45 p.m., hospice nurses #1, #2, and the hospice director were interviewed. Hospice nurse #1 was asked if she had made the first visit on 03/27/13. She stated, "Yes." When asked if she obtained the order for liquid pain medication for the resident, hospice nurse #1 stated, "No, I did not." Hospice nurse #1 was asked why she did not obtain the order. She said that she called for the order. She stated the hospice office had sent her an email stating she should contact the physician who was the former medical director at the facility for the order, but she did not receive the email because her email was "acting up." Hospice nurse #1 was asked if she followed up on the request for liquid pain medication and if she contacted the facility to see if the pain medication had been delivered. She stated, "No." Hospice nurse #1 was asked if her office was aware her email was not operating correctly. She stated, "Yes." Hospice nurse #2 was asked if she made the second visit on 03/27/13. She stated, "Yes." When asked if she obtained the order for liquid pain medication for the resident, hospice nurse #2 stated, "Yes." Hospice nurse #2 was asked when the medication was ordered. She stated it was at approximately 7:00 p.m. Hospice nurse #2 was asked if the medication had been ordered by hospice nurse #1. She stated, "It had not been ordered." The hospice director was asked when the hospice received the phone call requesting the first visit. She communicated with her office and stated the office did not document what time the call came in. The hospice director stated they had held to the standard of responding within one hour of a call for assistance. The hospice director was asked when the email was sent to hospice nurse #1 instructing her to contact the physician. She stated her office received an email at 1:28 p.m. from hospice nurse #1 and a response was sent back to her at 1:39 p.m. These times were inconsistent with the times documented by hospice nurse #1 as to her arrival and departure from the facility. The hospice director was asked if she was aware the physician her staff had been directed to call was no longer the medical director at the facility. She stated she was unaware the physician was no longer affiliated with the facility. At 2:15 p.m., the corporate RN stated she spoke with the hospice director and hospice nurses #1 and #2 after their interview with the surveyor. The corporate RN stated the hospice employees had informed her there had been no problem with their email system. 2. A quarterly assessment, dated 01/24/13, for resident #24 documented the resident had a life expectancy of less than six months. The resident's care plan, last updated 01/24/13, documented a problem, "...I am on (hospice name withheld) services for [DIAGNOSES REDACTED]." The care plan did not include interventions for managing the resident's pain. It did not identify which services would be provided by the facility and hospice. There was no documentation hospice had been involved in the development of the resident's care plan. Review of the hospice plan of care revealed no documentation the facility had been involved in the development of the resident's hospice care plan. The care plan did not identify which services would be provided by the hospice and which would be provided by the facility. On 03/28/13 at 10:28 a.m., LPN #3 was asked how care was coordinated between the facility and hospices. She stated, "When they come in, they ask what we need. Normally I have to call to figure out the frequency of visits. I call and find out when bath days will be." LPN #3 was asked how residents' preferences were taken into account when developing the plan of care with hospice. She stated she asked the residents what they wanted. When asked if she went to care plan meetings, LPN #3 stated, "No." LPN #3 was asked if the hospices ever asked her what the residents' preferences were. She stated, "Depends on what hospice it is." At 1:15 p.m., the DON was asked how care was coordinated between the facility and hospices. She stated hospices were invited to the care plan meetings, and the hospices and the facility communicated verbally following each visit. On 03/28/13 at 11:23 a.m., the MDS coordinator was asked if hospices were invited to residents' care plan meetings. She stated, "Yes, when (SSD) remembers to call them." The MDS coordinator was asked where the documentation was that hospice had been invited to the care plan meeting for resident #24. She provided the surveyor a book with sign-in sheets for care plan meetings. Review of the sign-in sheets revealed no documentation hospice had attended the care plan meeting for resident #24. At 11:56 a.m., the SSD was asked if hospice had been invited to the care plan meeting for resident #24. She stated she had forgotten to invite the hospice. 3. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 12/21/12, documented the resident did not have a condition or chronic disease that might result in a life expectancy of less than six months. The resident's care plan, dated 12/31/12, documented a problem, "...I am on (hospice name withheld) for my dx of [MEDICAL CONDITION]" The goal was, "...I wish to be kept comfortable while utilizing hospice services over the next 90 days..." Approaches included, "...Ensure hospice services are being provided. Hospice CNAs to shower me twice a week in addition to facility CNAs showering me twice a week...Notify hospice of any changes in my condition...Administer any prn anxiety/pain medication as ordered if/when needed...Encourage my family/friends open invitation day/night..." The care plan did not identify which services would be provided by the facility and hospice. There was no documentation hospice had been involved in the development of the resident's care plan. On 03/28/13 at 10:28 a.m., LPN #3 was asked how care was coordinated between the facility and hospices. She stated, "When they come in, they ask what we need. Normally I have to call to figure out the frequency of visits. I call and find out when bath days will be." LPN #3 was asked how residents' preferences were taken into account when developing the plan of care with hospice. She stated she asked the residents what they wanted. When asked if she went to care plan meetings, LPN #3 stated, "No." LPN #3 was asked if the hospices ever asked her what the residents' preferences were. She stated, "Depends on what hospice it is." At 11:23 a.m., the MDS coordinator was asked if the hospice attended the care plan meeting for resident #16. She stated, "No." When asked why not, the MDS coordinator stated, "I didn't notify them." The MDS coordinator was asked how she was able to communicate the resident's needs, wishes, and preferences. She stated, "I wouldn't. I just went by how we were going to care for him." 4. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/15/12, documented the resident was cognitively impaired and had a long and short-term memory loss. The resident was severely impaired in decisions regarding tasks of daily life. It was also documented the resident was dependent on staff for transfers, bed mobility, dressing, hygiene, and bathing from the staff. The resident had an alteration in elimination by having a suprapubic catheter, maintaining catheter care per physician's orders [REDACTED]. The resident's care plan, last updated 01/07/13, documented a problem, "...I am on (hospice name withheld) services for my dx of [MEDICAL CONDITION]. The goal was, "...I wish to be kept as comfortable as possible while utilizing hospice services over the next 90 days..." Approaches included, "...Keep me as comfortable as possible...Turning and repositioning me at least Q 2 hrs......Ensure hospice CNA's are providing me with a shower twice a week in addition to the facility CNA's providing me with a shower twice a week...Notify hospice of any changes in my condition..." An undated CNA Care Plan Reference Sheet documented the resident was totally dependent on staff. A care plan meeting was conducted on 01/17/2013. Documentation revealed facility staff and family attended the care plan meeting for resident #9. The record documented, "...(No) complaints (at) this time..." There was no documentation hospice attended the care plan meeting. A Social Progress Note, dated 02/20/13, documented, "...Charge nurse and husband visited the SSD office...not happy with the care hospice staff has been providing for his wife...wife has been smelling bad of body odor and she has not been getting showers but only bed baths...Charge nurse informed the SSD that this morning an aid (sic) reported to her that (name withheld) smelled bad and she was supposed to get a shower last night from hospice...Facility aid (sic) changed clothes and cleaned her..." On 03/29/13 at 4:00 p.m., the MDS/Care Plan Coordinator was asked how she coordinated the care plan with hospice. She stated, "I don't, I depend on the charge nurses." She then stated, "I've never got with hospice. I go to the hospice book and look at their care plan." At 4:20 p.m. the SSD was asked if hospice had been invited to the care plan meeting for resident #9. She stated, "She thought she had but there was no documentation." 5. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A facility policy on handwashing/hand hygiene, dated 04/2012, documented, "...When to wash hands...after handling soiled or used linens, dressings...When to use alcohol-based hand rub...If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations...Before handling clean or soiled dressings, gauze pads, etc...Before moving from a contaminated body site to a clean body site during resident care...After handling used dressings..." A quarterly assessment, dated 10/15/12, documented the resident was cognitively impaired and had a long and short-term memory loss. The resident was severely impaired in decisions regarding tasks of daily life. It was also documented the resident was dependent on staff for transfers, bed mobility, dressing, hygiene, and bathing from the staff. The resident's care plan, last updated 03/20/13, documented a problem, "...I have alteration in elimination: I have a suprapubic catheter. I have a hx of UTI's and I have the potential for further UTI's. The goal was, "...I wish to remain free from UTI's over the next 90 days..." Approaches included, "...Manintain (sic) my foley catheter. Change monthly per physicians orders and maintain sterile technique when changing foley...Maintain closed drainage system. Use aseptic technique when emptying bag...Check me for incontinence Q 2 hrs and prn. After incontinent episodes provide me with proper peri-care per facility protocol...Monitor me for s/s of UTI such as: change in mental status, elevated temp, oliguria, dark concentrated urine, foul odor, c/o lower back pain, etc. Notify charge nurse for assessment. Notify physician for potential urinalysis..." On 03/28/13 at 9:45 a.m., LPN #7 was informed that suprapubic catheter care needed to be observed for resident #9 and asked who would do that care. She stated the CNA would be doing the catheter care. She stated she would ask the CNA to gather the supplies to complete the task. At 10:17 a.m., CNA #9 stated she was ready to do catheter care for resident #9. She informed the resident of the procedure, exposed the area, washed her hands, and donned gloves. She applied a no rinse cleansing foam to a warm wet washcloth and proceeded to clean and dry the catheter tubing. She stated, "That's it." The surveyor informed the CNA that the cleansing of the insertion site of the catheter needed to be observed. She took her gloves off, washed her hands and left the room to get a dressing. CNA #9 re-entered the room, donned gloves without washing her hands or using a hand sanitizer, and picked up the dirty linens and placed them in a plastic bag. She loosened the dressing from the site but left it dangling on the tubing slightly above where she would be cleansing the site. Using the same water, she wet a wash cloth and applied a no rinse cleansing foam. She cleansed the site and dried the area. She removed the dangling soiled dressing and applied the clean dressing securing it with tape. The CNA was asked if she should have removed her gloves and washed her hands after handling the dirty linens and soiled dressing. She stated, "Yes." She stated she should have started at the beginning. She also stated she should have changed her water.

Based on observation, interview, and record review, it was determined the facility failed to: A. Provide supervision to prevent falls for one (#7) of one resident who was observed to have a head injury through a random observation. The facility failed to ensure the personal alarm, bed alarm, and fall mat that were ordered as interventions to prevent falls or injury were in operating condition and/or were correctly implemented. The resident sustained [REDACTED]. The facility identified 11 residents who used personal alarms and one resident with a personal alarm and bed alarm; B. Establish a plan to monitor the whereabouts of one (#14) of one sampled resident with cognitive impairment and mental illnesses after another resident with mental illnesses verbalized fear of resident #14 following an incident; and C. Ensure hot water temperatures were maintained below 115 degrees Fahrenheit (F.) to promote safety of the residents on one (Honey Dale) of six halls. The facility identified 17 residents who resided on Honey Dale. No residents were identified by the facility as wanderers who wandered onto the hallway. No residents were identified by the facility as being able to access the hot water and not know to pull their hands back if the water was too hot. Findings: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, dated 08/15/11, documented a problem of falls. The care plan documented, "...has hx of falls potential for further falls d/t impaired decision making, requires assist with transfers d/t poor safety awareness and cognitive decline..." The goal was, "...will be assisted with transfers & free of falls over next 90 days..." Approaches included, "...When assisting (resident #7) to bed ensure (resident #7) is in center of bed, keep call light & H2O within reach at all times, provide assistance to (resident #7) with all transfers using 1-2 person assist, fall risk assessments per facility protocol, keep room free of clutter, ensure personal body alarm is in place at all times, provide signs to remind (resident #7) in room to ask for assistance before performing tasks alone..." A significant change assessment, dated 09/21/11, documented the resident was severely impaired in cognitive skills for daily decision making, required limited assistance of one person for bed mobility, required extensive assistance of two people for transfers, walking, and toilet use, and was always incontinent of bowel and bladder. A fall risk assessment, dated 04/05/12, documented the resident scored a 19. The form documented, "...Total score of 10 or above represents HIGH RISK..." A nurse's note, dated 04/05/12 at 8:00 p.m., documented, "...Rsd was calling out and was found face down on the floor. Her orbits are swollen and puffy. Her nose was flattened and her hip was swollen and bleeding. Her legs are red (knees) and (left) calf. Both arms have scrapes - abrasions from carpet..." A care plan update, dated 04/05/12, documented, "...Fall (8:00 p.m.) - Keep room door open, monitor for fidgeting or bed mobility - assist c positioning as needed..." A nurse's note, dated 04/11/12 at 9:45 p.m., documented, "...This nurse was going down hall heard a moan went into resident's room saw resident in floor. Floor mat in place bed in lowest position alarm on and in place...floor mat in place and call light in place. Bruise old on (right) arm. Goose egg (hematoma) on (right) side of forehead 2 inch length, 1 1/2 inch wide, 3 quarters inch depth at (10:15 p.m.)..." A care plan update, dated 04/11/12, documented, "...Fall, low bed, floor fall mats, pressure alarm to bed..." A quarterly assessment, dated 06/08/12, documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making, required extensive assistance from one person for bed mobility and transfers, did not walk, was totally dependent for toilet use and was always incontinent of bowel and bladder. It was also documented the resident had experienced one fall with injury. A care plan update, dated 06/08/12, documented, "...Goal (not) met. 2 falls this quarter. Cont c interventions..." A nurse's note, dated 06/10/12 at 5:15 a.m., documented, "...On the stated date and approximate time the above stated resident was discovered by (CNA #3) while conducting rounds on the floor. CNA alerted this reporting nurse who went to the resident's room and observed her lying face down with blood around her head. The CNA was instructed to get the other nurse on duty. The patient was rolled on to her back, patient had two cuts one above the brow line and one below the brow and a scrap (sic) below her eye on the cheek bone with swelling and reddish purple colors appearing (sic) the right eye and cheek. The patients shoulder is also a reddish color. First aide was provided...Note: Patients body up to her mid chest was on the floor matt but her head and upper chest was on the floor her personal alarm was still attached and engaged on the floor with her. Her glasses rested on the floor to the left of her head..." An emergency department physician's note, dated 06/10/12 at 11:12 a.m., documented, "...Procedure laceration repair...Laceration 9 cm in length. Face: right, forehead. Shape: three separate lacerations, one is curvilinear at 5 cm. There is another irregular at 2 cm and another irregular at 2 cm for a total of 9 cm. Depth: subcutaneous...Skin closure: with 5-0 Prolene..." An incident report, dated 06/11/12, documented, "...Describe exactly what you observed or heard: Resident found on floor. Fall matt (sic) not placed completely @ top of bed on floor...Recommended steps to prevent recurrence: Lower bed for resident, pull mat up to head of bed c (no) gaps @ top. set alarm on 'hi'....Hospice to provide another bed (and) mat..." A nurse's note, dated 06/11/12 at 9:50 a.m., documented, "...hospice called regarding to replace bed alarm et larger matt (sic)..." A hospice note, dated 06/11/12 at 12:00 p.m., documented, "...Upon arrival, pt sitting up in wheelchair, eating lunch, pt semi alert, speech confused/garbled - pt currently denies pain - requires max assist with all adl's. Uses wheelchair - called to facility d/t pt had fall over weekend, and needed follow up visit - pt with 2 lacerations to right side of face, with stitches in place, and dried blood noted around stitches - Pt with dark purple/black bruising all around right eye and down face to neck...Also DON in to go over preventative measures with family - This nurse ordered new bolster mattress, with a thicker fall mat. Also replaced bed alarm..." A nurse's note, dated 06/10/12 at 2:40 p.m., documented, "...Only order were (sic) suture removal in 5 days and treatment orders on discharge sheets..." On 06/12/12 at 12:40 p.m., resident #7 was observed seated in her wheelchair in the dining room. The resident was observed to have 3 lacerations with sutures to her right forehead. The right side of the resident's face and neck was covered with bruising of various colors and sizes. The resident did not open her eyes. The resident's family member stated the resident had fallen out of bed in the early morning of 06/10/12. At 12:50 p.m., observations of the resident's room were made. The head of the resident's bed was against the north wall of the room. A brownish red stain was observed on the resident's carpet. The stain measured approximately 10.5 inches wide and 7.5 inches long. The stain was located approximately 9 inches from the right side of the resident's bed and 12 to 15 inches from the north wall. A mattress with bolsters was noted on the resident's bed, and three fall mats, stacked on top of one another, were on the floor next to the bed. Signs documenting to keep the resident's door open at all times were observed on all walls in the room and on the bathroom and entry doors. A sign documenting to keep the resident's personal alarm on her at all times was observed hanging above the resident's bed side table. At 2:29 p.m., the resident's family member was asked what happened to the resident. The family member stated, "She tried to get out of bed Sunday morning. This time it's bad. It isn't the first time." The family member stated, "She will try to get up by herself." The family member pointed to the stain on the carpet and stated, "I don't see how the pads were in place." The family member was asked when the mattress with bolsters was brought to the facility. The family member stated, "Yesterday (06/11/12). If the bed alarm wasn't working, why didn't they do something about it?" The family member was asked how they knew the bed alarm wasn't working. They stated, "One of the nurse aides told us. She stated it hasn't been working. We have been told they close the door at night." The family member stated they came to the facility on [DATE] and "there were signs on the door to leave the door open at all times." The family member was asked who placed the signs. They stated, "The DON." On 06/13/12 at 9:50 a.m., LPN #1 was asked what was wrong with the resident's bed alarm. She stated, "I think it wasn't working. She had a personal one on." When asked how long the alarm had not been working, LPN #1 stated, "I don't know how long." LPN #1 was asked what days she worked. She stated Mondays through Fridays. When asked if the alarm was working when she worked her last shift on Friday 06/08/12, LPN #1 stated, "I don't think so. I heard hospice saying they needed to change it out." LPN #1 was asked if the bed alarm was one of the interventions identified to help prevent falls for the resident. She stated, "Yes it was. so was the mat on the floor." When asked if the mats were in use when the resident fell , LPN #1 stated, "Yes." LPN #1 was asked how the aides knew how and where to place the fall mats. She stated, "They know it goes beside the bed." LPN #1 was asked why nothing was done if the facility was aware the resident's bed alarm was not working. She stated, "I heard hospice say they would replace it." When asked how other staff would have known the bed alarm was not working, LPN #1 stated, "I didn't pass it on but she had her personal alarm on and it was working." LPN #1 was asked why the bed alarm was ordered if the personal alarm was enough. She stated, "I'm assuming the personal alarm was for her to use when she was up in the wheelchair." LPN #1 was asked when she first became aware the bed alarm was not working. She stated, "In the middle of the week I heard hospice talking about the alarm not working so I assumed they changed it. I assumed the personal alarm was to back it up." When asked if she verified hospice changed the bed alarm out, LPN #1 stated, "No." On 06/13/12 at 10:06 a.m., the DON was asked what happened when the resident fell . She stated the resident rolled out of bed. She stated the mats were on the floor but the facility thought the mats might have slid with her when she fell . The DON stated they were bringing in thicker mats. The DON was asked if the resident's fall mats were in the proper position when she fell . The DON stated, "From what they told me they were." When asked if the bed alarm was working, the DON stated, "I've heard it was and it wasn't. the family said it wasn't. Hospice checked and it was working but went ahead and put a new system on there." The DON asked who the nurse was on the shift when the resident fell . She stated it was an agency nurse. When asked how an agency nurse would know a resident was at high risk for falls and what interventions were in place, the DON stated, "Report and the care plan." The DON was asked if any one was aware the fall mats would slide. She stated, "Not to my knowledge." The DON was asked why the incident report documented the mats were not located by the head of the bed. She stated, "The incident report was completed from a family interview." When asked if that was the facility's policy, the DON stated, "No She should have interviewed everyone." When asked if the agency nurse had been interviewed, the DON stated, "No." On 06/13/12 at 10:45 a.m., CNA #1 was asked if the resident's bed alarm had been working. She stated, "No." CNA #1 stated she told the nurse and "she was supposed to get it fixed." When asked when she told the nurse, CNA #1 stated, "Tuesday or Wednesday (June 5th or 6th)." CNA #1 was asked what interventions were in place to help prevent falls for the resident. She stated, "Bed low, alarm on, mats in place. Most generally if she gets up she needs to potty." At 10:58 a.m., LPN #1 and the DON were observed in the resident's room looking at her fall mats. LPN #1 stated, "They were already supposed to have gotten thicker mats. At 11:05 a.m., CNA #2 was asked if the resident had many falls. She stated, "She would try to sit up and stuff. She would yell out 'I gotta pee.' She hasn't fell a lot." CNA #2 was asked what interventions were in place to help prevent falls for the resident. She stated the resident had a chair alarm and a bed alarm "when it was working." When asked if the bed alarm was working last week, CNA #2 stated, "I don't think it was. The nurse said she would call hospice." CNA #2 was asked if the resident had her personal alarm on while in bed. She stated, "No, it goes on the chair." CNA #2 showed the surveyor the personal alarm. The personal alarm had a velcro strap that went around a support bar on the wheelchair and a string with a clip attached to it that was to be attached to the resident's clothes. CNA #2 pointed to the velcro strap and stated, "See how this has to fasten around something. There's nowhere in the bed to fasten this to. She could just take it with her." At 11:15 a.m., LPN #1 was asked when the resident received the bed with the bolsters. She stated, "Since she fell . She had a low air loss mattress." On 06/13/12 at 12:29 p.m., LPN #5 was asked if she had worked at the facility prior to 06/09/12. She stated, "No." When asked if she had received report from the off-going nurse, LPN #5 stated, "I got report from the report book, and she told me the people with problems." LPN #5 was asked if she had experienced any problems at the facility. She stated a lady had fell out of bed and "busted her head really bad." LPN #5 was asked if she was aware the resident was at risk for falls. She stated, "Not really." LPN #5 was asked how she knew the resident had fallen. She stated, "The aide said she was on the floor." She stated, "She (the resident) was face down with blood around her head." LPN #5 stated the resident's fall mat was not positioned correctly by the bed. She stated the mat was right by the bed but was not up by the head of the bed. LPN #5 was asked if she heard the resident's bed alarm or personal alarm sounding. She stated, "The alarm was still attached to her and on the floor." LPN #5 stated the alarm should have been attached better and the "alarm wasn't secured." LPN #5 was asked if the personal alarm was attached to the bed. She stated the alarm was not attached to the bed and it was on the floor with the resident. When asked if the bed alarm sounded, LPN #5 stated the bed alarm did not go off. LPN #5 was asked if she had been notified the resident was at high risk for falls. She stated, "No." When asked if she had been informed the resident's bed alarm was not working, LPN #5 stated, "No." On 06/14/12 at 9:00 a.m., CNA #3 was asked if she had been taking care of the resident when she fell . The CNA stated yes. CNA #3 was asked to describe what happened when the resident fell . She stated she had been completing her rounds and was in the room adjacent to the resident's room. She stated she heard the resident crying, looked in on the resident, and found her on the floor with her glasses on and her alarm still with her. When asked if the personal or bed alarm was sounding, CNA #3 stated, "No." CNA #3 was asked if the personal alarm was attached to the bed. She stated, "No. It was attached to the resident." CNA #3 stated the alarm was laying on the bed. CNA #3 was asked where the fall mats were located. She stated, "They were lower or out more. They were stuck to the ground but were a little bit lower." CNA #3 was asked if the resident's bed alarm was working. She stated she was "pretty sure" it was. When asked if she had been informed it wasn't, CNA #3 stated, "The aide before me never said anything." CNA #3 was asked if the resident was at high risk for falls. She stated, "Yes." When asked if she had received any training regarding how to use a personal alarm, CNA #3 stated the only thing that had to been done was use the button to turn it on or off. CNA #3 was asked if the personal alarm needed to be attached to the bed. She stated, "It has to fall off. The top piece for it has to fall off." At 9:16 a.m., The DON was asked how the personal alarm worked. She stated the alarm had to be connected to a wheelchair or bed. She stated the distance of the cord had to be measured to ensure when the resident pulled away from the alarm it sounded. The DON was asked what training the aides received on personal and bed alarms. She stated, "At this point, they receive training from the other CNAs and one on one training when we go to place a new alarm." 2. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/11/12, documented the resident was moderately impaired in cognitive skills for daily decision making. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incident report for resident #15, dated 06/01/12, documented, "...resident was pushed from front of w/c by another resident fell backwards out of chair and hit back of head on floor..." An incident report for resident #14, dated 06/01/12, documented, "...resident was in smoke room and stated 'get out of my way' and pushed resident from front of w/c resulting in resident hitting back of head police notified...recommended steps to prevent recurrence: keep residents away from each other. Monitor fore behaviors. Any further issues involving police will result in resident being sent to another facility..." A social progress note, dated 06/01/12, documented, "...the SSD was called to immediately come to the Administrator Office. When she arrived (resident #14) was sitting in a chair...The door was shut and the Administrator informed (resident #14) that he assaulted a female resident and he must make a choice on what to do. Either the police can be notified or he can go to a place and have a psych eval for treatment. The Administrator explained to (resident #14) that right now nurses were looking at the female resident because he pushed her so hard that her wheelchair fell over and her head hit the cement floor. (Resident #14) got upset and started saying that he did not assault anyone. Then he stated that the person assaulted him by pinning his leg in a door or up against a wall and now his leg was shaped funny because of it...A mental health officer arrived and spoke with (resident #14) asking him what happened. He stated similar to the above. The officer then asked for the female resident to come in so he could speak with her...The female stated that (resident #14) pushed her when she didn't move quick enough out of his way because he kept telling her to move. She also stated that he has kicked her before. The Administrator and SSD were shocked to hear the news. She was asked why but she really didn't have an answer. She stated that it didn't leave any marks on her. She stated that he is always bothering her for money. The police asked her if she wanted to press charges and she said, 'Yes, I want to press charges.' After the female resident left the room the officer stated that he cannot arrest (resident #14) because of his cognitive condition and he really did not have any proof of intent. The officer called COPES to come and evaluate (resident #14). After they assessed him they stated that they found him coherent. There was no reason for an EOD to be done or to send him to any place for a psych evaluation. (Resident #14) handled himself well and was polite with all of the questions saying that he had no intentions of hurting the female resident..." Intent of the incident could not be established by either the police or mental health officials. On 06/13/12 at approximately 2:00 p.m., resident #15 stated she was afraid of resident #14. Resident #15 told the surveyor about the incident described in the incident reports. Resident #15 was asked if she had told anyone she was afraid of resident #14. She stated she had informed the SSD and administrator. At approximately 3:00 p.m., resident #14 was interviewed regarding the incident. Resident #14 maintained that resident #15 had pinned his leg with his wheelchair in an attempt to prevent him from entering the building. At 4:14 p.m., the SSD was asked if there had ever been other altercations between the two residents. She stated, "Just borrowing money. She sends him to the store." The SSD denied there had been any other physical altercations between the two. The SSD was asked if resident #15 had informed her she was afraid of resident #14. The SSD stated, "Yes." The SSD was asked how the facility was protecting resident #15. She stated, "We have asked (resident #14) not to go into the smoking room when she is there." The SSD was asked if resident #15 had told her she was afraid of resident #14. She stated, "Yes." At 5:12 p.m., CNA #6 was asked if resident #15 exhibited behaviors that showed she was afraid of resident #14. She stated, "She told me she told him to stay away from her." When asked if resident #14 was going around #15 now, CNA #6 stated, "No." At 5:15 p.m., CNA #7 was asked how staff monitored the whereabouts of resident #14. She stated the staff kept watch over him as much as possible. CNA #7 stated resident #15 "goes out of her way" to avoid resident #14. At 5:18 p.m., LPN #2 was asked if resident #15 exhibited behaviors that showed she was afraid of resident #14. She stated, "She says she doesn't want to be around him." At 5:30 p.m., the administrator was asked if resident #15 had expressed she was afraid of resident #14. The administrator stated, "Not until today." The administrator stated, "According to (resident #14), (resident #15) kicked him first." The administrator stated the police and mental health officials had not been able to determine the intent of the incident. On 06/14/12 at 11:40 a.m., the SSD was asked why the administrator had not been notified of resident #15's expression of fear of resident #14 when it was first verbalized. The SSD stated she thought the administrator had been present when she verbalized it, but it could have been later in the evening on 06/01/12, and no one had been with her. The SSD stated some staff had reported to her resident #15 was continuing to visit resident #14 at times. At 2:54 p.m., the administrator was asked what plans had been put into place to monitor the whereabouts of resident #14 after resident #15 had verbalized fear of him. The administrator stated no formal plan had been put into place. 3. On 06/12/12 at 10:10 a.m., the following hot water temperatures were obtained on Honey Dale hall: Room 11 - 121.4 degrees F. - The resident was unable to get to the sink without assistance. Room 7 - 121.0 degrees F. - The resident was not in the room at the time the hot water temperature was discovered. Room 5 - 118.9 degrees F. - The resident was unable to get out of bed without assistance. Water temperatures on the other five halls were within regulatory limits. On 06/12/12 at 10:15 a.m., LPN #1, the charge nurse for the hall, was asked if there were any residents who wandered on Honey Dale hall. She stated, "No." LPN #1 was asked if resident #38, who resided in room 11, was capable of getting to the sink. She stated the resident was unable to get up with the assistance of two people. LPN #1 was asked if resident #37, who resided in room 7, was capable of getting to the sink. She stated the resident was alert and oriented but could only get up with the assistance of one person. LPN #1 was asked if resident #7, who resided in room 5, was capable of getting to the sink. She stated the resident was unable to get up without the assistance of two people. At 10:40 a.m., the administrator and maintenance man were told of the hot water temperatures being above acceptable levels. A monitoring system was in place to ensure residents did not have access to the hot water. At 11:00 a.m., the maintenance man stated he was adjusting the hot water and monitoring the temperatures. On 06/12/12 at 3:45 p.m., the following hot water temperatures for random rooms on Honey Dale hall were obtained. Room 3 - 104.8 degrees F. Room 13 - 102.5 degrees F. North bath - 103.9 degrees F. Room 5 - 105.7 degrees F. The maintenance man stated the water temperatures had been adjusted down and the temperatures were holding below 115 degrees F.