Every finding on record at Seiling Nursing Center

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week.The administrator identified 20 residents resided in the facility.Findings:A PBJ Staffing Data Report, dated 07/01/25 through 09/30/25, showed the metric was suppressed as the PBJ had not been submitted for the required quarter.A review of the direct care staff schedule was conducted from 07/01/25 to 01/21/26. On the schedule the administrator documented on the paper what the letters and colors meant on the schedule:a. A - 6a-6p,b. N - 6p - 6a,c. red ink - request off, andd. highlights red - call out.There were seven days without 8 hours of RN coverage: 10/19/25, 11/08/25, 11/09/25, 11/29/25, 11/30/25, 01/17/26, and 01/18/26. On 01/21/26 at 10:58 a.m., the administrator stated the DON was salary and was not counted on the schedule. On 01/21/26 at 12:08 p.m., the DON stated, Call ins were handled by the nurse trying to get their shift covered, then if not they call and let me know. If the nurse does not find someone, then I find someone, and if not find someone then I come and work it. On 01/21/26 at 12:10 p.m., the DON was asked to verify RN coverage for 10/19/25, 11/08/25, 11/09/25, 11/29/25, 11/30/25, 01/17/26, and 01/18/26. They pulled up all the schedules on their computer and stated they covered on 10/19/25, 11/08/25, 11/09/25, 11/29/25, and 11/30/25 with no timecard to show they worked. The DON stated on 01/17/26 there were only 6 RN hours for that day. The DON stated on 01/18/26 they did not come in and cover, so there were no RN hours. On 01/21/26 at 1:26 p.m., the administrator provided a handwritten piece of paper that showed, DON only clocks in when working on floor, otherwise here for 8 hours/shift when on call and no coverage. The facility did not provide timecards to verify RN hours for the above dates.

Based on record review, and interview, the facility failed to ensure licensed nursing staff were working with a current valid license for 1 (LPN #1) of 4 employees files who required a licenses or certification. The administrator identified 20 residents resided in the facility. Findings:An undated policy titled Nursing Services Staffing, read in part, Shall have and maintain an organized nursing services for its residents which is under the direction of a professional licensed nurse.To provide adequate and properly supervised nursing services for each resident for 24 hours, 7 days a week.Review of the personnel file for LPN #1 did not show any current license verification.On [DATE] at 8:16 a.m., the Oklahoma Board of Nursing website was used to verify the license for LPN #1. LPN #1's license showed an expiration date of [DATE].A review of the clinical staff schedules from [DATE] through [DATE] showed 18 dates LPN #1 worked with an expired license on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].On [DATE] at 2:13 p.m., the DON looked up LPN #1 on the Board of Nursing website and showed the expiration date for LPN #1 was [DATE]. The DON stated they had helped LPN #1 renew on their computer and did not know why it showed lapsed.On [DATE] at 11:35 a.m., the DON stated LPN #1 had been removed from the schedule as they needed to get fingerprinted before they could renew. The DON stated the process for monitoring license expiration dates was to check on hire and periodically. The DON stated LPN #1 had worked approximately 18 days with an expired license. They stated there was not a licensed nurse in the facility on most days LPN #1 worked from [DATE] to the last shift worked on [DATE].

Based on record review and interview, the facility failed to ensure the required PBJ staffing data was submitted to CMS within the mandated timeframe for the FY Quarter 4 2025. The administrator identified 20 residents resided in the facility. Findings:A PBJ Staffing Data Report, dated FY Quarter 4 2025 (07/01/25 through 09/30/25), showed the facility had not provided staffing data to CMS for the PBJ staffing data report for FY Quarter 2 2025. On 01/21/26 at 11:30 a.m., the administrator stated the PBJ was not submitted. They stated they attempted to submit it on the 16th of January, and it was not accepted. The administrator stated it showed it was late and was due on the 15th. They stated customer service was contacted, and the facility was told they missed the deadline and to try next month.

Based on record review and interview, the facility failed to ensure a resident receiving dialysis services had pre-assessments, post assessments, and ongoing communication with the dialysis center for 1 (#12) of 1 sampled resident reviewed for dialysis. The administrator identified 20 residents resided in the facility and one resident received dialysis. Findings:A review of the facility policy book contained no policy for dialysis services. Undated dialysis center forms, Your Medication List and Nutrition and Blood Test Results showed the facility received a copy of Resident #12's tests results and medication from the dialysis center on 01/15/26 via fax. A baseline care plan, dated 01/15/26, showed Resident #12 was admitted to the facility on [DATE] and received dialysis services Tuesdays, Thursdays, and Saturdays.Nursing progress notes, dated 01/17/26, 01/20/26, and 01/22/26, showed Resident #12 was transported to and from dialysis via public transport. There was no documentation in Resident #12's clinical record of communication between the facility and the dialysis center. There was no documentation in the clinical record to show the facility completed Resident #12's dialysis pre and post assessments. On 01/22/26 at 10:10 a.m., the DON stated there were no communication forms or documentation between the facility and the dialysis center. The DON stated the facility was not completing pre and post assessments for Resident #12.

Based on observation and interview, the facility failed to post nurse staffing information included all the required components. The administrator identified 17 residents resided in the facility. Findings: On 06/13/23 at 12:20 p.m., a staffing board was observed in the hallway, outside the med room. It was not observed to contain the facility name, total number and actual hours worked by following the categories of licensed and unlicensed nursing staff, or the resident census. On 06/13/24 at 12:25 p.m., the DON reported she was not aware of all the components required.

Based on observation and interview, the facility failed to ensure the ice machine was clean. The administrator identified 17 residents who resided at the facility. Findings: A weekly cleaning schedule, undated, documented the ice machine was to be cleaned. There was no documentation the ice and water dispenser was cleaned. A blank cleaning schedule, dated June 2024, documented the ice machine (outside and tray) was to be cleaned daily. There was no documentation the ice and water dispenser was cleaned. On 06/10/24 at 9:10 a.m., the ice machine was observed in the dining room. It was observed to have a separate ice and water dispenser. A paper towel was wiped on the inside water dispenser. Black residue was observed on the paper towel. A paper towel was wiped on the inside of the water dispenser. Orange/pink residue was observed on the paper towel. On 06/15/24 at 9:12 a.m., the CDM stated the ice and water dispensers were cleaned weekly. She was unable to provide documentation.

Based on record review and interview, the facility failed to monitor for side effects related to the use of Xarelto for two (#2 and #8) of five sampled residents reviewed unnecessary medications. The DON identified five residents received anticoagulants. Findings: An Unnecessary Drugs policy, dated 06/01/17, documented an unnecessary drug was any drug used without adequate monitoring. 1. Resident #2 had diagnoses which included paroxysmal atrial fibrillation. A Physician's order, dated 01/25/24, documented the resident received Xarelto twice a day. There was no documentation in the resident's clinical record the resident had been monitored for side effects of Xarelto. 2. Resident #8 had diagnoses which included unspecified atrial fibrillation. A Physician's order, dated 07/07/21, documented the resident received Xarelto once a day. There was no documentation in the resident's clinical record the resident had been monitored for side effects of Xarelto. On 06/13/24 at 12:22 p.m., the DON stated side effect monitoring was completed on the TAR. She stated they weren't aware they should be monitoring side effects for Xarelto.

Based on observation, record review, and interviews, the facility failed to ensure enhanced barrier precautions were implemented for a resident with an indwelling catheter for one (#1) of one sampled resident reviewed for infection control with a catheter. The DON identified one resident had an indwelling with a catheter. Findings: Resident #1 had diagnoses which included retention of urine. A Physician's order, dated 09/29/23, documented foley catheter to bedside drainage. A Quarterly assessment, dated 05/25/24, documented Resident #1 had moderately impaired cognition. It documented the resident had a urinary catheter. Resident #1's care plan did not contain documentation of enhanced barrier precautions. On 06/10/24 and 06/12/24 Resident #1 was observed with a catheter bag attached to their wheelchair. There was no signage observed on Resident #1's door indicating the resident was on enhanced barrier precautions. On 6/12/24 at 11:02 a.m., CNA #1 and CNA #4 was observed providing catheter care to Resident #1. They were not observed to wear any PPE other than gloves. Staff were asked if they had been provided education regarding enhanced barrier precautions. They both stated not regarding catheters. On 06/12/24 at 11:10 a.m., the DON was asked what was the facility's policy they had in place for enhanced barrier precautions. The DON stated they hadn't wrote a policy. The DON stated the policy would address the extra or expanded precautions for the use of PPE. The DON was asked when the enhanced precautions would need to be used during resident care. The DON reviewed a paper they identified as receiving from a seminar. They stated residents with catheters should have enhance barrier precautions. She stated the facility should have already had it in place.

Based on observation, record review, and interview, the facility failed to ensure an insulin pen was discarded and not used after 28 days for one (#14) of one sampled resident observed for insulin administration. The DON identified two resident received insulin. Findings: An Insulin Pens policy, dated [DATE], documented the facility shall ensure insulin pens were used in accordance with manufacture instructions. TheHumalog manufacture instructions, dated ,d+[DATE], documented to discard the Humalog pen after using for 28 days even if insulin is left in the pen. On [DATE] at 11:20 a.m., LPN #1 was observed to prepare the Humalog insulin pen for administration for Resident #2. There was a ,d+[DATE] written on the label of the insulin pen. LPN #1 stated that was the date they first started using the pen. LPN #1 clarified it was ,d+[DATE] of 2024. LPN #1 was observed to administer six units of the insulin to Resident #2. LPN #1 stated the look at the use by date on the insulin pen to determine when the insulin was expired. LPN #1 was asked how they determined how long to use the pen after its first use. They stated they just went by the expiration date on the label. On [DATE] at 11:52 a.m., the DON stated insulin was good for 45 days after first use.

Based on record review and interview, the facility failed to ensure side effects were monitored for an antidepressant for one (#2) of five sampled residents reviewed for unnecessary medications The DON identified nine residents received antidepressants. Findings: Resident #2 had diagnoses which included depression. A Physician's order, dated 07/11/23, documented the resident was to receive citalopram once a day. The resident's clinical record did not contain side effect monitoring for citalopram. On 06/13/24 at 12:22 p.m., the DON stated side effect monitoring was documented on the TAR. She stated she didn't know why Resident #2 didn't have it on their TAR.

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed for the use of bed rails, an order had been obtained, or the care plan had been updated prior to installation for one (#5) of one sampled resident reviewed for bed rails. The DON identified two residents with bedrails. Findings: Resident #5 had diagnoses which included repeated falls and dementia A significant change assessment, dated 03/08/24, documented Resident #5 had severely impaired cognition. It documented Resident #5 required substantial and total assistance for position changes. On 06/10/24 at 10:29 a.m., Resident # 5 was observed resting in bed with half bed rails in up position on either side of the bed. On 06/13/24 at 9:48 a.m., the DON stated Resident #5's bed rails were for positioning. The DON stated during a care plan in March, it was decided bed rails would assist with the resident during care. The DON stated there was no documentation of an assessment, order, nor the care plan had been updated.

Based on observation, record review and interviews, the facility failed to ensure: a. staff sanitized hands between dependent residents when feeding and meal assistance was provided for five (#5, 7, 10, 11, and #17) of six residents observed for meal assistance; and b. a water management program was in place to prevent water born illnesses for 17 residents that resided in the facility. The Resident Census and Condition of Residents, dated 06/20/23, documented one resident was dependent for eating and three residents required meal assistance. The census was 17. The DON identified six residents require cues and assistance for meals. Findings: 1. On 06/22/23 at 4:59 p.m., the Administrator was asked if the facility had a water management program in place that included policies and testing water for potential water born illnesses. The administrator stated they did not know about the requirement and did not have a water management program in place. 2. Resident #5 had diagnosis of dementia. An Annual Assessment, dated 04/05/23, documented Resident #5 had severe cognitive impairment and required limited assistance of staff for meal intake. 3. Resident #7 had diagnosis of dementia. An Admission assessment, dated 05/16/23 documented Resident #7 had severe cognitive impairment and required set up assistance for meals. 4. Resident #10 had a diagnosis of dementia. A Quarterly Assessment, dated 04/28/23 documented Resident #10 had severe cognitive impairment and required one person assistance for meals. 5. Resident #11 had diagnosis to include dementia. A Quarterly Assessment, dated 05/28/23, documented Resident #11 had severe cognitive impairment and required one person assistance for meals. 6. Resident #17 had a diagnosis of dementia. An Annual Assessment, dated 04/12/23, documented Resident #11 had severe cognitive impairment and required one person assistance for meals. On 06/20/23 at 5:32 p.m., CNA #1 and an unidentified staff utilized a two person lift to reposition Resident #17. CNA #1 sat at the table near Resident #10, CNA #1 rubbed their nose and pulled their hair away from their face. On 06/20/23 at 5:36 p.m., CNA #1 removed lids from drinks and placed on napkin for Resident #10. A family member entered and CNA #1 got up to allow family to be seated near Resident #10. On 06/20/23 at 5:37 p.m., Resident #17 returned into the dining area and was positioned at the end of the table. CNA #1 sat next to Resident #17, got up and obtained a glass of ice water for Resident #7, who was seated at different table. CNA #1 returned to the seat next to Resident #17 and assisted with sips of water. CNA #1 got up from their chair, assisted Resident #5 and Resident #11 to remove the paper from the ends of their straws, then adjusted the straws. On 06/20/23 at 5:40 p.m., drinks were served to Resident #17. CNA #1 removed the paper from straws and adjusted the straws for Resident #17. On 06/20/23 at 5:42 p.m., CNA #1 scratched their arm, then provided assistance to Resident #17 to obtain another drink of liquids. On 06/20/23 at 5:44 p.m., CNA #1 assisted Resident #11 to open their utensils from a cloth napkin. CNA #1 returned to Resident #17 to provide drinks of fluids. CNA #1 scratched their nose. On 06/20/23 at 5:46 p.m., food was served to Resident #5. CNA #1 used a spoon to section lasagna for Resident #5, then gave the spoon to the resident. On 06/20/23 at 5:52 p.m., food was served to Resident #17. CNA #1 opened the cloth napkin to obtain utensils and attempted to provide eating assistance to Resident #17. On 06/20/23 at 5:54 p.m., CNA #1 rubbed their eyes, then provided bites of food to Resident #5. CNA #1 had not washed or sanitized their hands at any time during the assistance with meal service. On 06/20/23 at 6:05 p.m., the Administrator was seated next to Resident #10 and CNA #1 remained seated next to Resident #5. The Administrator was asked what the facility's policy was for hand washing/sanitizing during meal assistance. The Administrator stated hands should be washed or sanitized before the meal and between providing assistance with each resident. CNA #1 was asked if she had sanitized or washed her hands. CNA #1 stated they should have sanitized between the residents and did not.

Based on observation and interview, the facility failed to ensure lidocaine multiple dose bottles were labeled and dated. The Resident Census and Conditions of Residents report, dated 06/20/23, documented 17 residents resided in the facility. Findings: A Multiple Dose Vials policy, dated 06/01/17, read in part, .Once a multiple dose vial has been punctured, the staff member shall assign a beyond-use date to the vial and place this date on the vial's label . A facility policy titled, Unusable and Outdated Drugs, dated 06/01/17, read in parts, .All discontinued resident drugs .or missing labels shall be returned to the pharmacy for proper disposal .these drugs shall be stored in an isolated area in the pharmacy or other area that has been designated for the storage of such unusable drugs . On 06/22/23 at 8:25 a.m., a medication cart was observed. There were three 1% lidocaine bottles in the medication cart. All three bottles were opened, unlabeled, and undated. On 06/22/23 at 8:35 a.m., the DON stated the lidocaine bottles should have been labeled and dated when opened. They stated the lidocaine was for a resident who was taking rocephin injections and should have been disposed of when the resident completed treatment. 06/23/23 at 10:51 a.m., the DON stated she does not remember which resident the lidocaine was for and when the lidocaine was initially used.

Based on observation, record review and interviews, the facility failed to provide personal privacy to ensure dignity of a dependent resident for one (#17) of one sample resident reviewed for dignity. The Resident Census and Condition of Residents report, dated 06/20/23, documented seven residents were dependent for dressing and the census was 17. Findings: Resident #17 had diagnoses to include dementia, and personality disorder with behaviors. An Annual Assessment, dated 04/12/23, documented Resident #17 had severe cognitive impairment, was inattentive with disorganized thinking which fluctuated, and required extensive assistance with dressing. On 06/20/23 at 2:15 p.m., Resident #17 was observed in bed and restless. Resident #17 had removed the top linens, was naked from the waist down, and exposed the lower half of their body and legs to the hallway. On 06/22/23 at 8:53 a.m., Resident #17 was observed in bed and had placed their feet over the left side/edge of the bed. Resident #17 had removed their gown and linens, which exposed their upper body to the hall. On 06/22/23 at 8:56 a.m., Resident # 17 remained in bed, positioned side ways over the left edge of the bed, completely nude, and exposed to the hall. On 06/22/23 at 8:58 a.m., the Administrator walked past door but did not look in on the resident. On 06/22/23 at 8:59 a.m., CNA #1 walked past door but did not look in on the resident. On 06/22/23 at 9:00 a.m., housekeeper #1 informed the nursing office that Resident #17 was turned side ways on the bed and was moving all around. On 06/22/23 at 9:02 a.m., CNA #3 enter Resident #17's room and close door to attend to the resident. On 06/22/23 at 9:10 a.m., the DON was asked if Resident #17 is normally restless. The DON stated the resident was restless a lot and frequently wriggles out of bed and disrobed. The DON stated staff usually close the door but night shift leaves it open to hear Resident #17. The DON stated the day shift normally close the door due to the privacy curtain fell and needed to be replaced. The DON was asked how long the privacy curtain had been missing. The DON stated they were not sure. The DON was asked if the facility had attempted other means to ensure privacy for the resident. The DON stated the facility had not attempted other interventions.

Based on record review and interview, the facility failed to ensure a gradual dose reductions were acted upon for two (#9 and #22) of five sampled residents reviewed for unnecessary medication. The Resident Census and Conditions of Residents report, dated 06/21/22, documented 13 residents received antidepressant medication, seven residents received antianxiety medication, and five residents received antipsychotic medication. Findings: 1. Resident #9 had diagnoses that included [CONDITION(S)] and other specified depressive disorder. A Physician's Order, dated 12/05/20, read in part, [MEDICATION(S)] Tablet 50 MG ([MEDICATION(S)]) Give 2 tablet by mouth every evening shift related to OTHER SPECIFIED DEPRESSIVE EPISODES . A Physician's Order, dated 12/29/20, read in part, [MEDICATION(S)] HCl Tablet 100 MG Give 1 tablet by mouth at bedtime related to [CONDITION(S)] . An MRR report, dated 01/31/22, documented a request for a GDR for Trazadone 100 mg at HS. An MRR report, dated 02/25/22 documented a request for a GDR for [MEDICATION(S)] 50 mg every evening. There was no documentation the GDRs had been acted upon. On 06/22/22 at 2:52 p.m., the DON was asked when the MRR recommendations should be acted upon once received by the facility. They stated it should be done fairly quickly and that it doesn't always happen. They were shown the MRR requests for [MEDICATION(S)] and [MEDICATION(S)]. They were asked to provide documentation the [MEDICATION(S)] and [MEDICATION(S)] reduction requests were acted upon. The DON stated they were unable to locate the one for [MEDICATION(S)]. The DON and ADON stated they called the physician a couple of times the other day to clarify the [MEDICATION(S)] and did not receive a return call, but they were going to call again. The DON was asked if there was documentation the [MEDICATION(S)] was acted upon. They stated, No. On 06/22/22 at 3:09 p.m., the ADON was asked where the documentation for staff calling to clarify the [MEDICATION(S)] GDR order was located. They stated there may not be any. The ADON looked in the EMR and stated they don't find any documentation. 2. Resident #22 had diagnoses which included senile dementia and depression. A physician's order, dated 06/18/21, read in part, [MEDICATION(S)] Tablet 1 MG Give 1 tablet by mouth two times a day . A physician's order, dated 06/26/21, read in part, [MEDICATION(S)] HCl Tablet 10 MG Give 1 tablet by mouth one time a day . A physician's order, dated 10/16/21, read in part, [MEDICATION(S)] Tablet 0.5 MG ([MEDICATION(S)]) Give 1 tablet by mouth two times a day . A MRR note to physician, dated 01/31/22, read in part, .GRADUAL DOSE REDUCTION (GDR)/TAPERING CONSIDERATION: YES NO .[MEDICATION(S)] 1 mg BID . A MRR note to physician, dated 01/31/22, read in part, .GRADUAL DOSE REDUCTION (GDR)/TAPERING CONSIDERATION: YES NO .[MEDICATION(S)] [[MEDICATION(S)]] 10mg Qday . A MRR note to physician, dated 01/31/22, read in part, .GRADUAL DOSE REDUCTION (GDR)/TAPERING CONSIDERATION: YES NO .[MEDICATION(S)] 0.5mg BID . There where no physician signatures on the MRRs. There was no documentation the MRRs had been acted upon. On 06/23/22 at 11:09 a.m., the DON was shown the MRRs and asked if they had been acted upon. On 06/23/22 at 11:22 a.m., the DON stated they couldn't find the January MRRs had been done.

Based on observation, record review and interview, it was determined the facility failed to provide catheter care for two (#2 and #12) of two sampled residents who were reviewed for urinary catheters. The facility identified two residents with an indwelling catheters. Findings: 1. Resident #12 had [DIAGNOSES REDACTED]. The significant change of assessment dated [DATE], documented the resident to be cognitively intact, required extensive assistance for toileting, and an indwelling catheter was in place. The physician's orders [REDACTED]. On 09/06/19 at 10:41 a.m., the resident was asked why he had a catheter. He stated the catheter was placed while he was a patient at the hospital and did not know why the catheter was placed. He was asked if the staff assisted to keep the catheter clean. He stated the staff cleaned the catheter when his showers were provided twice a week. Sediment is observed in the tubing. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 08/12/19, documented the resident's cognition was intact, required extensive assistance with toilet use, was frequently incontinent and had and an indwelling catheter. The physician's orders [REDACTED]. On 09/03/19 at 10:06 a.m., during an interview with the resident, she stated her catheter does not get cleaned except when she had a shower. She was asked if she had any urinary tract infections. She stated yes. The treatment record documented the resident was to be provided catheter care every shift and the care provided was to be documented by an LPN. On 09/05/19 at 5:39 p.m., the resident was asked if she had been provided catheter care. She stated she had received a shower that morning and they cleaned it then, but not since then. At 8:36 p.m., LPN #2 who arrived at 6:00 p.m., was asked if she had performed any treatments, or catheter care during her shift or if she was going to perform such tasks. She stated no. The ADON who was assigned as the charge nurse from 2:00 p.m. until 6:00 p.m., was asked if he had performed any catheter care. He stated no. The staff were asked who was responsible for performing catheter care since it was indicated on the treatment record. They stated a certified nurse aide can clean them as well. The ADON was informed of the interview with the two cognitive residents and asked if they would be reliable. He stated yes, they would. He acknowledged that he had not been aware the care was not being performed.

Based on observation and interview it was determined the facility failed to ensure the door to a biohazard storage room remained locked/secured. This had to potential to affect 19 residents who resided in the facility. Findings: From 09/03/19 through 09/06/19, the door to the biohazard room was observed to remain unlocked/unsecured. On the inside of the room, bags and containers labeled as biohazard were overflowing from larger containers/boxes. On 09/06/19 at 1:33 p.m., LPN #1 was asked who was responsible for monitoring the biohazard room. She stated, The nurse aides. She was asked when should the boxes be changed. She stated, When they are full. She was asked if the door to the room should be locked/secured. She stated, Yes. At 1:35 p.m., CNA #4 was asked who is responsible for monitoring the biohazard room. She stated, Everyone. She was asked who is responsible for closing the biohazard boxes when they are full. She stated, The charge nurse. She was asked should the door be locked. She stated, Yes. At 1:38 p.m., The ADON was asked who is responsible for monitoring the biohazard room. He stated, The charge nurse. He was asked who is responsible for closing the biohazard boxes when they are full. He stated, The nurse aides. The ADON was shown the unlocked door and was asked if the door should be locked. He stated, Yes, and the key is above the door. Upon opening the door and observing the contents of the room, the ADON was asked if the boxes should have been closed and changed. He stated, Yes.

Based on observation, record review and interview, it was determined the facility failed to provide peri-neal/incontinent care and/or thorough incontinent care for two (#1 and #11) of two sampled residents who were observed for the provision of peri-neal/incontinent care. The facility's Resident Census and Condition of Residents documented: 15 residents were occasionally/frequently incontinent of bladder; and 18 residents required staff assistance for toileting. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. The annual assessment dated [DATE] documented the resident had severe cognitive impairment; required limited assistance of two staff for toileting; and had a urinary tract infection within 30 days prior to the assessment. On 09/05/19 at 6:13 p.m., CNA #3 was observed to assist the resident to the bathroom. A foul urine odor was detected when the resident's pull-up was removed. The CNA wiped the resident's perineal area with toilet paper After the care was provided, CNA #3 was asked how often is peri-care to be provided. She stated, Every time. She was asked how it would be known which resident would require assistance with peri-care. She stated, We just wipe them after every time we take them to the bathroom. CNA #3 was asked how often resident #1 is to be toileted. She stated every time the resident requested. CNA #3 was asked if the resident is continent of bowel or bladder. She stated, Yes but she leaks. 2. Resident #11 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE], documented the resident had severe cognitive impairment, required limited assistance of one staff for toileting, and is always incontinent of bowel and bladder. The care plan last updated 06/24/19, documented the resident to required assistance for activities of daily living/self care and include toileting related to dementia; and was at risk for impaired skin related to decreased mobility/incontinence. On 09/05/19 at 4:07 p.m., the DON assisted the resident to his room/bathroom. She attempted to remove the residents clothing/briefs from his lower body. The resident had been incontinent of urine. The resident refused to remain in the bathroom and walked to his bed and sat down. The DON and CNA #3 donned gloves and removed the wet brief/pull-up. A clean/dry pull-up was placed on the resident. His clothing was replaced. Incontinent care was not attempted during this interaction between staff and the resident. After the care was completed, The DON was asked if the resident had been incontinent of urine. She stated, Yes. She was asked if incontinent care was provided/attempted prior to placing the clean/dry clothing. She stated, No, but I can.

Based on record review and interview, it was determined the facility failed to ensure the correct code status was identified for one (#2) of one sampled residents who were reviewed for advance directives. The facility identified 19 residents who resided in the facility. Findings: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 09/03/19 the clinical record was reviewed. An initial social history documented the resident had a DNR in place and and advance directive had not been executed. A DNR form was not located in the record nor did the physicians orders document the resident was a DNR. On 09/04/19 at 3:16 p.m., the facility was asked for a list of residents and their current code status. At 3:49 p,m., the list of code status was reviewed and documented the resident was a full code. On 09/05/19 at 1:27 p.m., the ADON was asked to review the clinical record and identify the documented code status. After reviewing the record he stated without a DNR in place, we consider the resident to be a full code. He reviewed the social history document and stated the form documented she had an DNR and he was not finding a DNR. He was asked who was responsible upon admission to obtain the correct code status. He stated usually our activities staff and they had been light in that area, she has been hurt. He stated anyone can identity that code status. He was asked who completed that social history form. He stated the activities staff and she should have let us know. At 2:10 p.m., the ADON stated the resident had a DNR signed. He stated they called the hospital and verified and obtained a copy for their records. He further stated they should have done that when she was admitted .

Based on observation and interview it was determined the facility failed to provide a dining environment that enhanced dignity for four (#3, 9, 17 and #19) of six sampled residents who required assistance with eating. The facility's Resident Census and Conditions of Residents documented eight residents required assistance with eating. Findings: On 09/05/19 at 5:35 p.m., residents #3, 9, 17 and #19 were seated around a dining table. CNA #1 stood and walked from resident to resident as she provided assistance with eating and fluid intake. An empty dining chair was located next to resident #17. At 5:40 p.m., The CNA continued to stand while assisting residents #9 and #19. The administrator provided an additional chair to allow the CNA to be seated. The administrator leaned over the back of resident #17 to provide cues/encouragement to eat. The administrator continued to stand between residents #3 and #17, as she provided encouragement and assistance with eating. On 09/06/19 at 3:00 p.m., the administrator was asked what the facility policy was for residents who required staff assistance for eating. She stated, We are supposed to sit next to the residents. She was asked if she recalled the assistance she and CNA #1 had provided while standing during the evening meal on 09/05/19. She stated, We should have been seated.

Based on observation, record review and interview, the facility failed to treat pain for 1 (#1) of 8 sampled residents reviewed for pain management. This deficient practice resulted in actual harm for resident #1 when the facility did not assess, evaluate and treat for continued pain related to right foot wounds from 01/19/11 to 04/19/11. The resident census and condition of residents identified 14 residents who were on a pain management program. Findings: Resident #1 had [DIAGNOSES REDACTED]. A nurse's note dated 01/16/11 documented, "...Res (resident) has sore on (R) (right) heel outer aspect that is 1.5 (by) 1.25 cm (centimeters). Area is scabbed over, surrounding edges (without) redness. Tender to touch. Heels floated off bed (with) pillows...Fax to (physician's name deleted)." A physician's progress note dated 01/17/11 documented, "Painful infected contusion (with) avulsion of nail." The drawing of the foot on the progress note indicated the right great toe was affected. The note documented 10 toenails were trimmed and an ulcer to the right heel with a loose dressing was observed. A nurse's note dated 01/19/11 documented, "...Floated heels, keeps pushing pillow out of way...c/o (complains of) heel hurting, repositioned..." A nurse's note dated 01/22/11 at 3:00 a.m. documented, "Hollering out about foot hurting (and) lifts (R) leg up in (air) - feet afloat (with) pillow but resident pushes pillow away...repositioned (every) 2 (hours) - position changed (frequently) to provide comfort (with) no relief." At 11:00 p.m. a nurse's note documented, "Hollers out several (times) with c/o (R) foot hurting - repositioned (and) feet afloat (with) pillows - (continues) to holler (with) pain Repositioned on (R) side (and) pillows used to position feet - (1:00 a.m.) quieter - resting (with) eyes closed..." There was no documentation of the effectiveness of the intervention for pain between 11:00 p.m. and 1:00 a.m. An "Evaluation of Pain" dated 01/22/11, documented the resident had pain related to arthritis and a right heel decubitus. The evaluation documented she had physician's orders [REDACTED]. The evaluation documented the resident had not requested as-needed (PRN) pain medication in the 30 days prior to the assessment due to "None (available)." The evaluation documented possible indicators of pain exhibited by the resident as yelling out and grimacing. A nurse's note dated 01/28/11 at 9:00 a.m. documented the dressing was changed to the right heel and the resident complained of pain during the treatment. A nurse's note dated 02/01/11 at 9:00 a.m. documented a dressing change was provided for the right foot and the resident kicked, tried to pull the right foot away and "screamed" during the treatment. A nurse's note dated 02/02/11 at 8:30 a.m. documented a dressing change to the heel. The note documented the resident kicked with both legs and yelled during the treatment. The quarterly assessment dated [DATE] documented she was moderately impaired in cognition, required extensive assistance with transfers, dressing and hygiene. She did not ambulate, required supervision for eating and was totally dependent for bathing. She was frequently incontinent of bowel and always incontinent of bladder. The resident had experienced occasional, moderate pain in the 5 days prior to the assessment. The care plan last reviewed/revised on 02/04/11 documented a problem of pain related to arthritis. Further documentation included, "...I want to have any episodes of pain documented so that the (medical doctor) can be notified so he can adjust my medications..." The 02/2011 physician's orders [REDACTED]. There was no other routine or PRN pain medication ordered. A nurse's note dated 02/07/11 at 9:00 a.m. documented the resident kicked with both legs and screamed during the dressing change to the right heel. A nurse's note dated 02/08/11 at 8:30 p.m. documented, "resident screaming out off (and) on, talking loudly c/o (complains of) Right foot pain, (tried) to rearrange feet on pillows, repositioned on Right side. (Continues) to holler off (and) on..." A nurse's note dated 02/09/11 at 9:00 a.m. documented the resident kicked with both legs and screamed during the dressing change to the right heel. A nurse's note dated 02/10/11 at 11:00 p.m. documented, "Yelling out 'my foot hurts' - repositioned..." A nurse's note dated 02/11/11 at 1:30 a.m. documented, "(Continued to yell till (1:00 a.m.) then quiet...Fax sent to (physician's name deleted) about discomfort." There was no further documentation of foot pain that day. A nurse's note dated 02/11/11 (unable to determine the time) documented the facility received a physician's orders [REDACTED]. There was no documentation to indicate the physician was notified of the resident's pain from 01/19/11 to 02/11/11. A nurse's note dated 02/15/11 documented a dressing change to the right heel. The note documented the resident verbalized pain during the treatment. A nurse's note dated 02/16/11 at 10:00 a.m. documented a dressing change to the right heel. The note documented the resident verbalized pain during the treatment. A nurse's note dated 02/17/11 at 9:30 a.m. documented a dressing change to the right heel. The note documented the resident verbalized pain during the dressing change by yelling and pulling her foot away. A nurse's note dated 02/18/11 at 9:00 a.m. documented a dressing change. The note documented the resident verbalized pain by yelling and kicking. Nurses' notes dated 02/21/11, 02/22/11, 02/24/11, 02/25/11, 02/27/11, 02/28/11, and 03/1/11 documented dressing changes to the right foot at which time the resident verbalized pain by yelling and kicking. An "Evaluation of Pain" dated 02/26/11 documented the resident was administered [MEDICATION NAME] 5 mg 3 times per day and did not complain of pain. The nurses' notes prior to the evaluation documented the resident did experience pain. Nurses' notes dated 03/03/11 and 03/04/11 documented dressing changes to the right heel with pain verbalized by kicking and screaming. A nurse's note dated 03/06/11 at 10:30 a.m., documented, "...(Resident continues) to have pain when (treatment) to heel done. Kicks (and) screams during (treatment)..." A nurse's note dated 03/07/11 (no time) documented, "...(Resident continues) to verbalize pain during (treatment right) heel by yelling, Kicking..." A nurse's note dated 03/08/11 at 9:00 a.m. documented a dressing change to the right heel with pain exhibited by kicking and screaming. A nurse's note at 10:30 a.m., documented the resident's physician was in the facility for a quality assurance (QA) meeting. The resident's wounds were discussed. There was no documentation the resident's continued pain related to the wounds was discussed. A nurse's note dated 03/09/11 at 9:30 a.m. documented a dressing change to the right heel with pain exhibited by kicking and screaming. A nurse's note dated 03/15/11 at 10:30 a.m. documented the right foot treatment was provided. The resident verbalized pain during the treatment and there were no signs/symptoms of pain except with the treatment. A nurse's note dated 03/18/11 (no time) documented a dressing change to the heel and the resident verbalized pain during the treatment by yelling at staff and kicking. An "Evaluation of Pain" dated 03/19/11 documented the resident had no complaints of pain, even though the nurses' notes documented she experienced pain. Nurses' notes dated 03/24/11, 03/28/11, 04/11/11 and 04/14/11 documented a dressing change to the right heel and the resident experienced pain during the treatment. An "Evaluation of Pain" dated 04/10/11 documented the resident had no complaints of pain, even though the nurses' notes documented she experienced pain. A nurse's note dated 04/17/11 at 10:00 a.m. documented a dressing change with pain verbalized. A nurse's note dated 04/19/11 at 10:15 a.m. documented a dressing change to the right foot. The note documented the resident exhibited signs/symptoms of pain from the treatment. There was no documentation the resident continued to be reassessed for pain between "Evaluations of Pain" and after routine [MEDICATION NAME] and PRN Tylenol were ordered when the resident continued to exhibit pain. On 04/19/11 at 10:10 a.m., licensed practical nurse #1 was observed as she provided the wound treatments for the resident's right great toe and heel wound. The resident raised her foot when the dressing was removed and when the wound was cleansed. She groaned, hollered "Ow" and tried to pull away during the wound treatment to the heel. On 04/19/11 at 3:00 p.m. the director of nurses (DON), assistant director of nurses and administrator were shown the nurses' notes and "Evaluation(s) of Pain" regarding pain for resident #1. They were asked if the physician had been notified of the resident's pain between 01/19/11 and 02/11/11. They were asked if the resident's pain had been reassessed to determine the effectiveness after the [MEDICATION NAME] was ordered on [DATE]. They made no comment at that time. At 3:30 p.m., the DON returned and stated there was no documentation the physician had been notified of the resident's pain or re-evaluated after the [MEDICATION NAME] was ordered on [DATE]. On 04/19/11 at 3:40 p.m., during an attempt to interview the resident, the resident did not speak. She just smiled and closed her eyes. On 04/20/11 at 9:10 a.m., the resident's physician was interviewed by phone. He was informed of the multiple entries in the nurses' notes describing the resident's pain with wound treatments and at night. He was asked if he had been notified of the resident's pain. He stated he did not recall. He was asked if he was the medical director for the facility. He stated he was. He was asked if the resident's pain had been discussed in the QA committee. He stated he did not recall a discussion of the resident's pain in QA. At 11:40 a.m., certified nurse aide #1 was asked what she would do if a resident exhibited pain. She stated she would report to the charge nurse. She was asked if resident #1 exhibited pain during wound treatment on 04/19/11 when she assisted the LPN with the treatment. She stated, "Yes." She was asked how the resident exhibited pain. She stated the resident "hollered a little bit and made a face."

Based on observation, record review and interview, the facility failed to notify the physician of a resident's continued pain for 1 (#1) of 8 sampled residents reviewed for pain. This resulted in actual harm to resident #1 when she continued to have pain from 01/19/11 to 04/19/11. The resident census and condition of residents documented 14 residents were on a pain management program. Findings: Resident #1 had [DIAGNOSES REDACTED]. A nurse's note dated 01/16/11 documented, "...Res (resident) has sore on (R) (right) heel outer aspect that is 1.5 (by) 1.25 cm (centimeters). Area is scabbed over, surrounding edges (without) redness. Tender to touch. Heels floated off bed (with) pillows...Fax to (physician's name deleted)." A physician's progress note dated 01/17/11 documented, "Painful infected contusion (with) avulsion of nail." The drawing of the foot on the progress note indicated the right great toe was affected. The note documented 10 toenails were trimmed and an ulcer to the right heel with a loose dressing was observed. A nurse's note dated 01/19/11 documented, "...Floated heels, keeps pushing pillow out of way...c/o (complains of) heel hurting, repositioned..." A nurse's note dated 01/22/11 at 3:00 a.m. documented, "Hollering out about foot hurting (and) lifts (R) leg up in (air) - feet afloat (with) pillow but resident pushes pillow away...repositioned (every) 2 (hours) - position changed (frequently) to provide comfort (with) no relief." At 11:00 p.m. a nurse's note documented, "Hollers out several (times) with c/o (R) foot hurting - repositioned (and) feet afloat (with) pillows - (continues) to holler (with) pain Repositioned on (R) side (and) pillows used to position feet - (1:00 a.m.) quieter - resting (with) eyes closed..." There was no documentation of the effectiveness of the intervention for pain between 11:00 p.m. and 1:00 a.m. An "Evaluation of Pain" dated 01/22/11, documented the resident had pain related to arthritis and a right heel decubitus. The evaluation documented she had physician's orders [REDACTED]. The evaluation documented the resident had not requested as-needed (PRN) pain medication in the 30 days prior to the assessment due to "None (available)." The evaluation documented possible indicators of pain exhibited by the resident as yelling out and grimacing. A nurse's note dated 01/28/11 at 9:00 a.m. documented the dressing was changed to the right heel and the resident complained of pain during the treatment. A nurse's note dated 02/01/11 at 9:00 a.m. documented a dressing change was provided for the right foot and the resident kicked, tried to pull the right foot away and "screamed" during the treatment. A nurse's note dated 02/02/11 at 8:30 a.m. documented a dressing change to the heel. The note documented the resident kicked with both legs and yelled during the treatment. The quarterly assessment dated [DATE] documented she was moderately impaired in cognition, required extensive assistance with transfers, dressing and hygiene. She did not ambulate, required supervision for eating and was totally dependent for bathing. She was frequently incontinent of bowel and always incontinent of bladder. The resident had experienced occasional, moderate pain in the 5 days prior to the assessment. The care plan last reviewed/revised on 02/04/11 documented a problem of pain related to arthritis. Further documentation included, "...I want to have any episodes of pain documented so that the (medical doctor) can be notified so he can adjust my medications..." The 02/2011 physician's orders [REDACTED]. There was no other routine or PRN pain medication ordered. A nurse's note dated 02/07/11 at 9:00 a.m. documented the resident kicked with both legs and screamed during the dressing change to the right heel. A nurse's note dated 02/08/11 at 8:30 p.m. documented, "resident screaming out off (and) on, talking loudly c/o (complains of) Right foot pain, (tried) to rearrange feet on pillows, repositioned on Right side. (Continues) to holler off (and) on..." A nurse's note dated 02/09/11 at 9:00 a.m. documented the resident kicked with both legs and screamed during the dressing change to the right heel. A nurse's note dated 02/10/11 at 11:00 p.m. documented, "Yelling out 'my foot hurts' - repositioned..." A nurse's note dated 02/11/11 at 1:30 a.m. documented, "(Continued to yell till (1:00 a.m.) then quiet...Fax sent to (physician's name deleted) about discomfort." There was no further documentation of foot pain that day. A nurse's note dated 02/11/11 (unable to determine the time) documented the facility received a physician's orders [REDACTED]. There was no documentation to indicate the physician was notified of the resident's pain from 01/19/11 to 02/11/11. A nurse's note dated 02/15/11 documented a dressing change to the right heel. The note documented the resident verbalized pain during the treatment. A nurse's note dated 02/16/11 at 10:00 a.m. documented a dressing change to the right heel. The note documented the resident verbalized pain during the treatment. A nurse's note dated 02/17/11 at 9:30 a.m. documented a dressing change to the right heel. The note documented the resident verbalized pain during the dressing change by yelling and pulling her foot away. Nurses' notes documented the resident continued to experience pain from 02/15/11 to 04/19/11. On 04/19/11 at 10:10 a.m., licensed practical nurse #1 was observed as she provided the wound treatments for the resident's right great toe and heel wound. The resident raised her foot when the dressing was removed and when the wound was cleansed. She groaned, hollered "Ow" and tried to pull away during the wound treatment to the heel. There was no documentation the physician was notified of the resident's continued pain. On 04/19/11 at 3:00 p.m. the director of nurses (DON), assistant director of nurses and administrator were shown the nurses' notes and "Evaluation(s) of Pain" regarding pain for resident #1. They were asked if the physician had been notified of the resident's pain between 01/19/11 and 02/11/11. They made no comment at that time. At 3:30 p.m., the DON returned and stated there was no documentation the physician had been notified of the resident's pain after the [MEDICATION NAME] was ordered on [DATE]. On 04/19/11 at 3:40 p.m., during an attempt to interview the resident, the resident did not speak. She just smiled and closed her eyes. On 04/20/11 at 9:10 a.m., the resident's physician was interviewed by phone. He was informed of the multiple entries in the nurses' notes describing the resident's pain with wound treatments and at night. He was asked if he had been notified of the resident's pain. He stated he did not recall. He was asked if he was the medical director for the facility. He stated he was. He was asked if the resident's pain had been discussed in the QA committee. He stated he did not recall a discussion of the resident's pain in QA.