Every finding on record at Sequoyah East Nursing Center, LLC

Based on record review and interview, the facility failed to ensure a resident was not physically assaulted by another resident with a history of assaulting others for 1 (#1) of 6 sampled residents reviewed for abuse. The ADON reported 46 residents resided at the facility. Findings: A facility policy titled Abuse Prevention Policy, dated August 2006, read in part, Our facility is committed to protecting our residents from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, and any other individual. 1. A progress note in Res #2's medical record, dated 01/24/25 at 9:34 a.m., showed Res #2 had hit a nurse during a conversation. A progress note in Res #2's medical record, dated 03/03/25 at 9:01 a.m., showed Res #2 had hit and scratched a certified occupation therapy assistant during therapy. A progress note in Res #2's medical record, dated 03/20/25 at 12:47 a.m., showed Res #2 had asked to be cleaned by staff, but then beat the nurse aides assisting them with a clothes hanger. A progress note in Res #2's medical record, dated 03/30/25 at 4:30 a.m., showed Res #2 had been found on the floor and the resident requested to be assisted up. The note further showed Res #2 hit the nurse who was helping them up. A progress note in Res #2's medical record, dated 06/22/25 at 8:00 a.m., showed Res #2 had kicked Res #1 in the lower left leg while they were in the dining area. 2. A quarterly minimum data set assessment for Res #1, dated 06/07/25, showed the resident had a brief interview for mental status score of 10 which indicated a moderate cognitive impairment. A progress note in Res #1's medical record, dated 06/22/25 at 8:00 a.m., showed another resident had kicked Res #1 in their leg while in the dining area. The note further showed Res #1 had not been injured. On 07/02/25 at 12:05 p.m., LPN #1 was asked about Res #2's behavior and if any monitoring had been done. They stated Res #2 had hit several staff members in the past but were unaware if they had ever hurt another resident before Res #1. LPN #1 stated they were not aware of any order to monitor Res #2's behavior, but if they saw anything they would write a note. On 07/02/25 at 12:14 p.m., the ADON was asked about Res #2's behavior and if any monitoring had been done. The ADON stated there was never an order to monitor the resident's behavior except in March of 2025, but that lasted four days then ended. They stated there had been no monitoring of Res #2 outside of those four days, but if someone saw something they would write a progress note. They stated Res #2 was one on one after kicking Res #1 and that lasted until Res #2 was sent out to a hospital on [DATE]. They stated Res #2 remained at the hospital and would go to a new facility after discharging from there. On 07/02/25 at 12:18 p.m., the DON was asked about Res #2's behavior. They stated there had been no behavior monitoring of Res #2, but they did monitor the side effects of their medications. They stated they had always treated abuse towards staff differently than abuse towards a resident and had not considered behavior monitoring based on those incidents. They were asked if Res #2 had ever made statements they would only assault staff and not residents. The DON stated they had not. On 07/02/25 at 1:45 p.m., Res #1 was asked about the incident with Res #2. They stated they had been in the dining area to get a cup of coffee. Res #1 stated when they walked by Res #2, that resident kicked them in the left leg. Res #1 stated Res #2 had not done that before or after that day.

Based on record review and interview, the facility failed to conduct a thorough investigation of a resident-to-resident physical assault for 1 (#1) of 6 sampled residents reviewed for abuse. The ADON reported 46 residents resided at the facility. Findings: A facility policy titled Abuse Investigations, dated April 2014, read in part, All reports of resident abuse, neglect, injuries of unknown source shall be thoroughly and promptly investigated by facility management. 1. A progress note in Res #1's medical record, dated 06/22/25 at 8:00 a.m., showed another resident had kicked Res #1 in their leg while in the dining area. 2. A progress note in Res #2's medical record, dated 06/22/25 at 8:00 a.m., showed Res #2 had kicked Res #1 in the lower left leg while they were in the dining area. The facility investigative material was reviewed. The material did not contain documentation of residents having been interviewed to determine if other residents other than Res #1 had been harmed by Res #2. On 07/02/25 at 1:25 p.m., the DON was asked to describe the investigation they had conducted following the assault by Res #2 on Res #1. They stated they had interviewed the two residents involved and staff on duty at the time. They were asked if they had interviewed any other residents to see if Res #2 had harmed anyone else. They stated they had not thought about doing that. They stated they should have interviewed other residents to determine if Res #2 had harmed any other residents.

Based on record review and interview, the facility failed to ensure the required PBJ staffing data was submitted to CMS within the mandated timeframe. The administrator stated there were 51 residents residing at the facility. Findings: A PBJ Staffing Data Report, dated 10/01/24 through 12/31/24 (Fiscal year Quarter 1 2025), showed the facility had not provided staffing data to CMS for the PBJ staffing data report for that quarter. On 04/14/25 at 3:18 p.m., the administrator stated the staffing data was not submitted for that quarter because the task was just overlooked. They stated it was now their job to submit the data at this time and in the future. On 04/15/25 at 2:01 p.m., corporate nurse consultant #1 stated they did not have a policy or procedure for submitting the PBJ data. The stated the administrator was sent a form this morning (04/15/25) from CMS about the issue and the administrator had signed the document. They stated the administrator would now be responsible for PBJ data being sent in to CMS on a timely basis.

Based on observation, record review, and interview, the facility failed to ensure dignity was maintained when residents were assisted with meals for 3 (#31, 28, and #23) of 8 residents observed during dining. The MDS coordinator identified six residents who were dependent on staff for eating. Findings: On 04/14/25 at 12:27 p.m., CNA #1 was observed to stand while assisting Resident #31, Resident #28, and Resident #23 with the noon meal. On 04/16/25 at 12:44 p.m., CNA #3 was observed to stand while assisting Resident #31, Resident #28, and Resident #23 with the noon meal. The policy titled, Assistance with Meals, dated March 2022, read in parts, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals. A quarterly assessment, dated 02/08/25, showed Resident #31 had a diagnosis of dementia, was severely impaired in cognition for daily decision making through a staff assessment of mental status, and required substantial/maximum assistance from staff for eating. A quarterly assessment, dated 03/10/25, showed Resident #23 had a diagnosis of dementia, was severely impaired in cognition for daily decision making through a staff assessment of mental status, and was dependent on staff for eating. A quarterly assessment, dated 03/22/25, showed Resident #28 had a diagnosis of dementia, had a BIMS score of 00 which indicated the resident was severely impaired in cognition for daily decision making, and was dependent on staff for eating. On 04/16/25 at 12:46 p.m., LPN #4 stated staff should sit while assisting residents with eating to maintain dignity when dining. On 04/16/25 at 12:48 p.m., the DON stated they provided inservice to staff regarding dignity. They stated staff stood while assisting residents in the main dining room and on the memory care unit. They stated they would need to inform the staff to sit while assisting residents with their meals to maintain dignity with dining.

Based on record review and interview, the facility failed to ensure a resident was provided with a written notice of transfer prior to being transferred to an acute care hospital for 1 (#40) of 2 sampled residents reviewed for discharges. The DON stated 49 residents had transferred to a hospital from [DATE] through 04/14/25. Findings: A facility policy titled Discharging the Resident, dated December 2016, read in part, If the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed, and a telephone report is called to the receiving facility. A progress note, dated 06/20/24 at 3:30 p.m., showed Resident #40 was transferred to an emergency room related to shortness of breath. A progress note, dated 02/11/25 at 3:07 p.m., showed Resident #40 was transferred to a hospital related to abnormal vital signs. On 04/15/25 at 1:31 p.m., LPN #1 stated when they had sent Resident #40 to a hospital they had sent the resident's face sheet and physician orders with the resident. They stated they had not heard of a written notice of transfer and had never sent one with any resident they had sent out to a hospital. On 04/15/25 at 1:36 p.m., the DON stated when they transferred residents to a hospital the nurses would send a resident's CCD ( continuity of care document / a document that summarizes a resident's current condition and treatment at the nursing facility). The DON stated the nurses inform the EMT's (emergency medical technician) of the situation with the resident and then they call the resident's family and physician. They stated they did not know a written notice of transfer was required to be given to the resident prior to leaving for the hospital.

Based on record review and interview, the facility failed to ensure assessments were accurately coded for 1 (#26) of 17 sampled residents whose assessments were reviewed. Findings: The DON identified 51 residents who resided in the facility. Findings: A review of the Resident Census form in the electronic clinical record, dated 08/22/22 through 02/17/25, showed Resident #26 had discharged from the facility-return anticipated on 02/05/25 and was readmitted on [DATE]. A quarterly assessment, dated 02/12/25, showed a completion date of 02/13/25. A 5-day assessment, dated 02/24/25, showed Resident #26 had a BIMS score of 00, which indicated the resident was severely impaired in cognition, and had received an antipsychotic medication. A medication administration record, dated February 2025, did not show Resident #26 had received an antipsychotic medication. On 04/16/25 at 9:01 a.m., the MDS coordinator reviewed the assessment dated [DATE] and the electronic clinical record and stated they had inaccurately coded Resident #26 had received an antipsychotic medication. The MDS coordinator reviewed the assessment dated [DATE] and the census for Resident #26. The MDS coordinator stated the quarterly assessment, dated 02/12/25, was not accurately completed because Resident #26 was discharged from the facility at the time of the completion of the assessment.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed for 2 (#22 and #45) of 9 sampled residents whose baseline care plans were reviewed. The DON identified 51 residents who resided in the facility. Findings: A policy titled Care Plans - Baseline, dated March 2022, read in part, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight [48] hours of admission. 1. An undated face sheet showed Resident #22 was admitted to the facility on [DATE] and had a diagnosis of congestive heart failure. An admission assessment, dated 11/05/24, showed Resident #22 had a BIMS score of 08, which indicated the resident was moderately impaired in cognition for daily decision making. A review of the electronic clinical record and the baseline care plan binder, provided by corporate nurse consultant #1, did not show a baseline care plan had been completed for Resident #22. 2. An undated face sheet showed Resident #45 was admitted to the facility on [DATE] and had a diagnosis of vascular dementia. An admission assessment, dated 12/05/24, showed Resident #45 had a BIMS score of 02, which indicated the resident was moderately impaired in cognition for daily decision making. A review of the electronic clinical record and the baseline care plan binder, provided by corporate nurse consultant #1, did not show a baseline care plan had been completed for Resident #45. On 04/15/25 at 12:25 p.m., the MDS coordinator stated they had recently been informed baseline care plans were to be completed within 48 hours of admission to the facility. On 04/15/25 at 1:00 p.m., the DON stated the baseline care plan for Resident #22 and Resident #45 had not been completed.

2. A physician order, dated 10/23/24, showed Resident #22 was ordered escitalopram oxalate (an antidepressant medication) 10 mg daily. A physician order, dated 01/16/25, showed Resident #22 was ordered quetiapine (an antipsychotic medication) 50 mg daily. A physician order, dated 01/16/25, showed Resident #22 was ordered quetiapine 100 mg at bedtime. A quarterly assessment, dated 02/05/25, showed Resident #22 had a diagnosis of schizophrenia and a BIMS score of 08, which indicated the resident was moderately impaired in cognition for daily decision making. The electronic clinical record, including the medication and treatment administration records, did not show Resident #22 had been monitored for side effects of psychotropic medications. On 04/15/25 at 3:30 p.m., LPN#1 stated nurses should chart psychotropic medication side effects every shift in the electronic health record. On 04/16/25 at 11:22 a.m., the DON stated dementia was not an appropriate diagnosis for an antipsychotic medication and they did not have psychotropic side effect monitoring in place for Resident #17 or #22. Based on record review and interview, the facility failed to ensure an antipsychotic medication had: a. an appropriate diagnosis for 1 (#17); and b. side effect monitoring was in place for 2 (#17 and #22) of 5 sampled residents reviewed for unnecessary medications. The DON reported 42 residents received psychotropic medications. Findings: An undated facility policy titled Psychotropic Medication Use, read in part, Residents will not receive medications that are not clinically indicated to treat a specific condition .Residents receiving psychotropic medications are monitored for adverse consequences. 1. Resident #17's physician order, dated 09/10/24, showed an order for olanzapine (an antipsychotic medication) 2.5 mg three times a day for unspecified dementia. A quarterly assessment, dated 01/15/25, showed Resident #17 had a staff assessment of mental status and was moderately impaired for daily decision making. The assessment also showed Resident #17 received an antidepressant and an antianxiety medication. A treatment administration record, dated 04/2025, did not show Resident #17 was being monitored for side effects of psychotropic medications.

Based on record review and interview, the facility failed to ensure residents who wanted a pneumococcal vaccination received the vaccination for 2 (#3 and #14) of 5 sampled residents reviewed for immunizations. The DON stated 21 residents had been admitted to the facility in the past six months and had been assessed for the need and desire to receive pneumococcal immunizations. Findings: A facility policy titled Pneumococcal Vaccine, dated October 2023, read in part, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 1. A Pneumococcal Immunization Informed Consent form, dated 05/28/24, showed Resident #3 had given consent to receive a pneumococcal vaccination. 2. A Pneumococcal Immunization Informed Consent form, dated 03/31/25, showed Resident #14 had given consent to receive a pneumococcal vaccination. On 04/16/25 at 7:34 a.m., the MDS coordinator stated the process for collecting immunization consents happened during the admission process. They stated the social services director would facilitate that process and once completed they (the MDS coordinator) would check the influenza and pneumococcal consent forms to see who wanted an immunization and who declined. When asked about Residents #3 and #14's pneumococcal immunization forms the MDS coordinator stated they were aware those residents requested pneumococcal vaccines, but they had been busy with influenza and COVID-19 immunizations. They stated they had not gotten around to administering the pneumococcal vaccines to those two residents. On 04/16/25 at 7:47 a.m., the DON stated regarding the pneumococcal vaccinations for Residents #3 and #14, the facility had some recent staff changes that had caused some oversite issues which contributed to those two residents not getting their immunizations. They stated they would become the person who would assist the IP to ensure all vaccinations are carried out.

Based on record review and interview, the facility failed to complete a significant change assessment for 1 (#36) of 1 resident reviewed for hospice. The DON reported 51 residents resided in the facility. Findings: An undated facility policy Comprehensive Assessments, read in part, A significant change is a major decline or improvement in a resident status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The decline is not considered 'self-limiting', b. impacts more than one area of the resident's health status; and c. requires interdisciplinary review and/or revision of the care plan. A care plan, initiated on 05/01/23, showed Resident #36 had diagnoses which included malignant neoplasm of prostate (prostate cancer) and depression. A quarterly assessment, dated 02/14/25, showed Resident #36 had a BIMS score (a test for cognitive functioning) of 11, which was indicative of moderate impairment for daily decision making. A physician's order, dated 02/28/25, showed Resident #36 was admitted to hospice services for liver cell carcinoma. Resident #36's electronic health record was reviewed. A significant change assessment was not located in the resident's electronic health record. On 04/16/25 at 11:17 a.m., the MDS coordinator stated they were unaware a significant change assessment was required when a resident was admitted to hospice services.

Based on record review and interview, the facility failed to ensure hospice services were included on the care plan for 1 (#36) of 1 sampled resident reviewed for hospice. The DON reported 51 residents resided in the facility. Findings: An undated facility policy titled Care Plans, Comprehensive Person-Centered, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. A care plan, initiated 05/01/23, showed Resident #36 had diagnoses which included malignant neoplasm of prostate (prostate cancer) and depression. A quarterly assessment, dated 02/14/25, showed Resident #36 had a BIMS score (a test for cognitive functioning) of 11, which was indicative of moderate impairment for daily decision making. A physician's order, dated 02/28/25, showed Resident #36 was admitted to hospice services for liver cell carcinoma. A care plan, edited 01/01/25, was reviewed and did not include hospice services. On 04/16/25 at 11:17 a.m., the MDS coordinator stated Resident #36 was on hospice and their comprehensive care plan should have included hospice services. On 04/16/25 at 11:30 a.m., the DON stated hospice care should have been included in the care plan for Resident #36.

Based on observation, record review, and interview, the facility failed to assess a resident for smoking safety prior to a resident smoking at the facility for 1 (#103) of 5 sampled residents reviewed for accident hazards. The DON identified 10 residents who smoked at the facility. Findings: On 04/14/25 at 1:01 p.m., Resident #103 was observed in their room lying in bed watching television. Two packs of cigarettes were observed on the resident's bedside table. On 04/15/25 at 2:39 p.m., Resident #103 was observed smoking in an indoor smoking room while supervised by a staff member. A facility policy titled Smoking Policy - Residents, dated October 2023, read in part, Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of smoking consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc. [further/similar things]); c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). A facility document titled Sequoyah East Nursing Center LLC Continuity of Care Document, dated 04/15/25, showed it was unknown if the resident was a smoker. On 04/14/25 at 1:22 p.m., Resident #103's electronic health record was reviewed for the presence of a smoking safety assessment. No assessment was found. On 04/15/25 at 8:18 a.m., Resident #103 stated they had smoked at the facility since they were admitted . They stated a staff member would take them out and sit with them while they smoked. They had no recollection of a safety assessment having been done. On 04/15/25 at 8:31 a.m., the activities director stated they took residents to smoke during smoking times. They stated they knew which residents needed what particular assistance with smoking from the smoking safety assessment. They stated the nurses had the assessments and let them know who needed assistance. They stated Resident #103 did smoke. On 04/15/25 at 11:06 a.m., corporate nurse consultant #1 stated residents who smoked were assessed for safety when they first arrived at the facility and prior to them smoking. They were asked to look at the resident's health record and identify Resident #103's smoking safety assessment. After reviewing the records corporate nurse consultant #1 stated the resident did not have a smoking safety assessment. They stated the safety assessment was required and was stated so in the facility smoking policy. They presented a copy of the smoking policy. They stated staff had not followed policy with Resident #103.

Based on observation, record review, and interview, the facilty failed to ensure a resident with bed rails was assessed for the use of the bed rail for 1 (#45) of 1 sampled resident who was reviewed for bed rails. Corporate Nurse Consultant #1 identified eight residents who utilized bed rails in the facility. Findings: On 04/14/25 at 2:12 p.m., an enabler/assist bed rail was observed on the left side of Resident #45's bed. Resident #45 was observed to pace in the in the hallway. On 04/15/25 at 7:49 a.m., Resident #45 was observed in bed with an enabler/assist bed rail, on the left side of the bed, in the up position. On 04/15/25 at 11:45 a.m., Resident #45 was observed in bed with an enabler/assist bed rail, on the left side of the bed, in the up position. A policy titled Bed Safety and Bed Rails, dated August 2022, read in part, Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted.If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. The interdisciplinary evaluation includes: a. an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs; b. the resident's risk associated with the use of bed rails. An admission assessment, dated 03/07/25, showed Resident #45 had a BIMS score of 02, which indicated the resident was severely impaired in cognition for daily decision making, and had a diagnosis of vascular dementia. A physician order, dated 03/28/25, showed an order for an assist bar for turning and repositioning. A care plan, dated 03/28/25, read in part, Resident requires uni-rail x1 to assist w/ bed mobility Resident will use s/r [side rails] to assist w/ bed mobility through next review date. A review of the electronic clinical record did not show an assessment for the use of the bed rails had been completed or alternatives to bed rails that had been attempted. On 04/15/25 at 11:45 a.m., the DON stated assessments for bed rails were completed when bed rails were initiated and then quarterly. They stated they did not know why an assessment had not been completed and why alternatives utilized prior to the installation had not been documented. On 04/15/25 at 11:50 a.m., the assistant director of nursing stated the bed rail was requested by a family member, but an assessment for the bed rail for Resident #45 should have been completed prior to the placement.

Based on record review and interview, the facility failed to ensure a urine sample was successfully cultured prior to the use of an antibiotic medication for a suspected urinary tract infection for 1 (#40) of 2 sampled residents reviewed for antibiotic use. The IP reported there were six residents prescribed antibiotics at the facility. Findings: A facility policy titled Surveillance for Infections, dated September 2017, read in part, When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation. Cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures. A facility document titled Individual Resident Infection Report, dated 04/07/25, showed Resident #40 had hematuria (blood in the urine), the resident had a possible UTI, the resident had not had a urine culture done, and showed the medication order for Bactrim DS (an antibiotic medication) twice daily for 10 days. A physician's medication order, dated 04/08/25, showed Resident #40 had been prescribed Bactrim DS 800-160 mg one tablet twice daily starting on 04/08/25 and ending on 04/18/25. A hospital urinalysis report, dated 04/09/25, showed a urine sample from Resident #40 had been collected on 04/09/25 at 1:49 p.m. The report further showed the sampled was contaminated and it was not possible to culture the sample to identify any bacteria that may have been present. A hospital urinalysis report, dated 04/10/25, showed a urine sample from Resident #40 had been collected on 04/10/25 at 1:49 p.m. The report further showed the sampled was contaminated and it was not possible to culture the sample to identify any bacteria that may have been present. A facility document titled Sequoyah East Nursing Center LLC Continuity of Care Document, dated 04/04/25, showed Resident #40 was administered a dose of Bactrim DS on 04/15/25 at 7:48 a.m. On 04/15/25 at 7:42 a.m., LPN #1 stated they had reviewed the two lab reports associated with Resident #40's current use of the antibiotic Bactrim DS. They stated the lab reports had shown the samples had both been contaminated and the cultures were not performed. On 04/15/25 at 11:42 a.m., the MDS coordinator/IP stated the antibiotic that had been prescribed, or Res #40 was ordered for hematuria. They stated antibiotics were not generally prescribed for hematuria at the facility. They stated a culture should be done which would show them what bacteria is present in the urine. They stated the urine culture had not been done so they could not know the bacteria or what medication would be needed to stop the infection. They stated when the staff first notices symptoms of an infection they inform the physician, and they wait for the culture to return before ordering an antibiotic. They stated in this case the urine culture should have been attempted again to ensure the proper antibiotic was used. They stated they had not followed their procedures in this case. On 04/15/25 at 1:13 p.m., the DON stated regarding Resident #40's antibiotic use when the staff had found out the urine samples had been contaminated a new urine sample should have been collected and the physician informed of the issue. They stated the antibiotics for UTI's should be prescribed after the bacteria in the urine had been identified and an appropriate antibiotic selected for use. They stated that was the facility policy.

Based on record review and interview, the facility failed to ensure resident medical records were safeguarded against unauthorized use. The administrator stated 48 residents resided in the facility. Findings: A facility document titled Notice of Privacy Practice's Acknowledgement documented newly hired staff members signed they had received a copy of Sequoyah Manor's Notice of Privacy Practices. A facility document titled HIPPA Residents Rights Implementation read in parts, .Sequoyah Manor will take reasonable steps to limit the use or disclosure of and requests for protected health information to the minimum necessary to accomplish the intended purpose . 1. A list of terminated employees documented LPN #1 had left the employment of the facility on 03/01/24. A PHI audit log documented LPN #1 had accessed 11 different areas in the EHR charting system including five areas of Res #5's documentation. On 04/10/24 at 3:30 p.m., the administrator stated this employee's last date to work was 02/27/24. The administrator stated they had been told by other employees LPN #1 was in an office and had been using a computer in an office. They stated they thought LPN #1 was in the facility to speak with a survey team who was at the facility at that time. The administrator stated the LPN had resigned on that day. They stated they turned off their access to the EHR system after they resigned. 2. A list of terminated employees documented LPN #2 had left the employment of the facility on 03/21/24. A PHI audit log documented LPN #2 had accessed the EHR system on 04/01/24 and viewed 16 pages in the EHR including five residents' MARs. The audit log did not document the residents' names who were accessed by LPN #2. The PHI audit log for LPN #2 documented they access the EHR system on 04/02/24 and viewed 9 pages of the facility's EHR system. On 04/10/23 at 4:03 p.m., the administrator stated the EHR system the facility had allowed for staff members to access the system off site which was a draw back for this system. They stated other EHR systems the administrator had worked with did not allow for offsite access. The administrator stated they did not do regular checks to ensure unauthorized access had happened. They stated they only looked to see if unauthorized access had happened if there was a suspicion or complaint.

Based on record review and interview, the facility failed to provide supervision to prevent falls for two (#1 and #5) of seven sampled residents reviewed for abuse. A facility resident roster, dated [DATE], documented 45 residents resided in the facility. Findings: A Falls and Fall Risk, Managing policy, revised date [DATE], read in part, .Based on previous information 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 .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 of the category of falling, until falling is reduced or stopped, or until the reason for the continuation of falling is identified as unavoidable . 1. Resident #1 had diagnoses which included dementia, anxiety, and heart failure. A facility face sheet documented Resident #1 was admitted to the facility on [DATE] and discharged [DATE]. A care plan problem for falls, located in Resident #1's care plan, had a start date of [DATE]. It documented the care plan problem had an edit date of [DATE]. The problem listed falls on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The goal start date was documented as [DATE] and the goal target date was [DATE]. The problem for falls had 11 approaches (interventions) documented. The approaches listed were: a. OT/PT to evaluate and treat, dated [DATE]; b. Avoid use of restraints, dated [DATE]; c. Encourage resident to use environmental devices such as hand grips, handrails, etc., dated [DATE]; d. Check every hour for 30 days, dated [DATE]; e. CNA to offer and assist with toileting every two hours when awake, dated [DATE]; f. Provide the resident a reach extender and teach/encourage use, dated [DATE]; g. Keep call lights in reach at all times, dated [DATE]; h. Keep personal and frequently used items within reach, dated [DATE]; i. Provide the resident a clutter free environment, dated [DATE]; and j. Provide toileting assistance rounds as part of bedtime preparation, date [DATE]. A review of Resident #1's progress notes from [DATE] through [DATE] found the resident had eight falls during that period. A progress note, dated [DATE] at 5:44 a.m., documented Resident #1 had slid from a bed onto the floor. It documented the resident received a skin tear to the right arm because of the fall. A progress note, dated [DATE] at 1:21 p.m., documented Resident #1 fell from their wheelchair and received a skin tear to their right arm. A progress note, dated [DATE] at 4:28 a.m., stated Resident #1 had been sitting in a wheelchair next to the nurse station. LPN #5 documented they had heard a noise and when looking in their direction found the resident had fallen forward from their wheelchair. The resident was bleeding from the forehead and there was bruising and swelling around the right eye. The resident was transferred to a local hospital. A hospital record, dated [DATE] at 4:46 a.m., documented Resident #1 had been sent to the hospital after a fall from a wheelchair. The resident was documented as having a large laceration with significant swelling to the right forehead, eye, and cheek. It further documented a CT scan of the head without contrast found the resident had suffered a right orbital floor fracture (fracture of the eye socket). A progress note, dated [DATE] at 9:19 a.m., documented the resident had returned to the facility. Resident was documented as sitting in a wheelchair by the nurse's station, having sutures on the right forehead, and was tearful and in pain. The note stated the resident's aspirin and blood thinner were ordered held for 14 days. The note documented the resident was placed by the nurse's station for observation purposes. A physician's note, dated [DATE] at 9:39 p.m., documented Resident #1 had died at 9:30 p.m. 2. Resident #5 had diagnoses which included hypertension and emphysema. A Medicare 5-day assessment, dated [DATE], documents the resident was severely impaired for daily decision making. And required moderate assistance with ADL's. A fall care plan, edited [DATE], documented no new fall interventions had been added to the care plan since [DATE]. A review of Resident #5's medical record documented the resident had falls on [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 10:35 a.m., the MDS coordinator stated Resident #1's care plan had not been updated regarding falls since July of 2022. They stated they did not know why the falls section of the care plan had not been updated. At 11:08 a.m., the DON stated after review, Resident #1's care plan had not been updated for falls since 2022. They stated the care plan did not reflect Resident #1's condition on or prior to their death on [DATE]. At 11:20 a.m., the administrator stated their expectations for the care plans were that they would be updated regularly and accurately reflect the residents' conditions and treatments. They stated Resident #1's care plan problem of falls had not been updated since July of 2022. On [DATE] at 8:15 a.m., the MDS coordinator stated that even though Resident #6 had recent falls no new care plan interventions related to falls had been added to the resident's plan of care since [DATE]. They also stated interventions should have been added and they were not sure why they hadn't been. On [DATE] at 10:20 a.m., the DON stated, the facility care planning is awful and the MDS coordinator was not following the care planning policy and procedures.

Based on record review and interview, the facility failed to implement facility policy and procedures to ensure that applicants employment history and references were checked; and ensure that applicants registry checks were completed prior to employment. The administrator reported the census was 45. Findings: A facility policy titled Background Check Policy, read in part, The background checks of new employees will be completed prior to the first day of assigned work. The background check results will be documented in the employee file and kept confidential .Following the application, interview, and decision to hire, an offer of employment will be made pending a background check consisting of at least the following: prior employment verification, reference check, license verification and criminal background check . If all background checks meet the facility standards, the applicant will be offered the position . On 03/04/24 at 10:23 a.m., the buisiness office manager stated that they were responsible for checking applicants employment history and references. They also stated that they did not typically document checking the references or employment history. The buisiness office manager stated they were trained to complete the registry checks after the first day of employment. On 03/05/24 at 9:00 a.m., the buisiness office manager was asked for documentation that reference and employment history checks had been completed for CNA's #1, #9 and #10. No documentation was provided. Nineteen staff employment records were reviewed. One record had no documentation of registry checks. Seven records did not have OSDH background check letters. None of the 19 records had documentation that the facility verified previous employment or contacted references. A review of CNA #1's employment file documented the first day of employment was 02/16/24 and the registry checks were completed on 2/18/24. On 03/07/24 at 10:00 a.m., the administrator stated the BOM was responsible for completing and documenting employment history checks and reference checks, and ensuring the registry checks were completed prior to employment.

Based on record review and interview the facility staff failed to report allegations of abuse to their administrator within the timeframe indicated in state regulations for four (#1, 2, 3, and #7) seven sampled residents reviewed for abuse. A facility resident roster, dated 02/29/24, documented 45 residents resided in the facility. Findings: A facility abuse reporting and investigation policy, dated September 2022, read in part, .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of an unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury . 1. Resident #1 had diagnoses which included dementia, anxiety, and heart failure. An annual assessment, dated 12/21/23, documented the resident's cognition was intact. An incident report, incident date 02/08/24, documented an allegation of abuse which involved Resident #1 and CNA #2. It further documented the facility's social services director had been informed of the incident on 02/09/24 at 8:30 a.m. 2. Resident #2 had diagnoses which included vascular dementia and cerebrovascular disease. A quarterly assessment, dated 12/16/23, documented Resident #2's cognition was severely impaired. An incident report, incident date 02/17/24, documented an allegation of abuse which involved Resident #2 and CNA #1. It further documented the facilities social services director had informed local law enforcement on 02/17/24 at 9:30 p.m. 3. Resident #3 had diagnoses which included neurocognitive disorder with Lewy bodies and chronic obstructive pulmonary disease. A quarterly assessment, dated 12/08/23, documented Resident #3's cognition was severely impaired. An incident report, incident date 02/17/24, documented an allegation of abuse which involved Resident #3 and CNA #1. It further documented the facilities social services director had informed local law enforcement on 02/17/24 at 9:30 p.m. 4. Resident #7 had diagnoses which included dementia and psychosis. A quarterly assessment, dated 02/07/24, documented Resident #7's cognition was moderately impaired. An incident report, incident date 02/12/24, documented an allegation of abuse which involved Resident #7 and CNA #13. It further documented the incident actually occurred on 02/06/24 and was reported to the administrator on 02/12/24. On 03/04/24 at 10:05 a.m., the administrator stated they found out about the allegation of abuse regarding Resident #1 at approximately 9:30 a.m. the day after the alleged incident [02/09/24]. On 03/06/24 at 8:29 a.m., the administrator stated that on 02/12/24, CNA #14 and CNA #15 had informed them of the incident between Resident #7 and CNA #13 that had occurred on 02/06/24. At 8:40 a.m., the administrator stated the incident regarding Resident #2 and Resident #3 had occurred on 02/17/24 at 12:30 p.m., and reported to them at 8:00 p.m. that evening. On 03/07/24 at 10:30 a.m., the DON stated the staff had not been following policy regarding the reporting of abuse allegations.

Based on record review and interview the facility failed to revise resident care plans related to falls for three (#1, 5, and #6) of seven sampled residents reviewed for abuse and neglect. A facility resident roster, dated [DATE], documented 45 residents resided in the facility. Findings: A Goals and Objectives, Care Plan policy, dated [DATE], read in part, .Goals and Objectives are reviewed and/or revised: a. when there has been a significant change in the resident condition; b. when the desired outcome has not been reached; c. when the resident has been readmitted to the facility from a hospital /rehabilitation stay; and d. at least quarterly . 1. Resident #1 had diagnoses which included dementia, anxiety, and heart failure. A facility face sheet documented Resident #1 was admitted to the facility on [DATE] and discharged [DATE]. A review of Resident #1's progress notes from [DATE] through [DATE] found the resident had eight falls during that period. Three of the falls resulted in injury. On [DATE] the resident suffered a skin tear to their right arm, on [DATE] the resident suffered a skin tear to their right arm, and on [DATE] the resident suffered a fracture of their right orbital floor (a fracture of the bones of the right eye socket). 2. Resident #5 had diagnoses which included hypertension and emphysema. A Medicare 5-day assessment, dated [DATE], documents the resident was severely impaired for daily decision making. And required moderate assistance with ADL's. A fall care plan, edited [DATE], documented no new fall interventions had been added to the care plan since [DATE]. A review of Resident #5's medical record documented the resident had falls on [DATE], [DATE], [DATE], and [DATE]. 3. Resident #6 had diagnoses which included mild intellectual disabilities and anxiety. A quarterly assessment, dated [DATE], documented the resident was moderately impaired for daily decision making and required partial assistance from staff. A fall care plan, edited [DATE], documented no new fall interventions had been added to the care plan since [DATE]. A review of Resident #6's medical record documented the resident had a fall on [DATE] and a fall resulting in a broken left femur on [DATE]. On [DATE] at 10:35 a.m., the MDS coordinator stated Resident #1's care plan had not been updated regarding falls since July of 2022. They stated the resident had falls since that time including falls with injuries, but they had not added any new interventions since 2022. They stated they did not know why the falls section of the care plan had not been updated. They stated new interventions were given to them when nurses fill out forms in the fall packet or when they have care plan meetings. They stated the families, and they usually attend the care plan meetings. They stated they send invitations for the meetings to the department heads each week. They stated the department leaders usually do not attend the meeting, but they believe they are required to attend. They stated the medical director had not participated in the care plan meetings. They stated Resident #1 had an annual assessment in December of 2023 but for some reason they did not update the care plan. At 11:08 a.m., the DON stated after review, Resident #1's care plan had not been updated for falls since 2022. They stated the care plan did not reflect Resident #1's condition prior to their death on [DATE]. They stated they had not attended any care plan meetings. They stated they were unaware they were supposed to attend care plan meetings. They stated all departments and staff utilize the care plans. They stated that they honestly did not know much about the care plan process, and it was just their job to assure the MDS coordinator was doing their job. At 11:20 a.m., the administrator stated their expectations for the care plans were that they would be updated regularly and accurately reflect the residents' conditions and treatments. She stated the department heads attend the care plan meetings. They stated they were unaware if the medical director had attended any care plan meetings. They stated Resident #1 had falls since [DATE] including those with injuries. They stated Resident #1 had a fall with a fracture on [DATE]. They stated it was the DON's responsibility to supervise the MDS coordinator to ensure accuracy of their work. On [DATE] at 8:15 a.m., the MDS coordinator stated that even though Residents' #5 and #6 both had recent falls no new care plan interventions had been added since [DATE] for Resident #5 and [DATE] for Resident #6. They also stated that interventions should have been added and they were not sure why they hadn't been. On [DATE] at 10:20 a.m., the DON stated, the facility care planning is awful and the MDS coordinator was not following the care planning policy and procedures.

Based on Interview and record review it was determined the facility failed to ensure showers were given as ordered for two (#5 and #6) of three residents reviewed for bathing. The administrator reported the census was 45. Findings: 1. Resident #5 had diagnoses which included hypertension and emphysema. A Medicare 5-day assessment, dated 11/15/23, documented the resident was severely impaired for daily decision making and required moderate assistance with ADL's. A point of care history sheet, dated February 2024, documented the resident had received two showers and refused two showers during the month of February 2024. 2. Resident #6 had diagnoses which included mild intellectual disabilities and anxiety. A quarterly assessment, dated 02/10/24, documented the resident was moderately impaired for daily decision making and required partial assistance from staff. A point of care history sheet, Dated February 2024, documented Resident #6 had received two showers and refused three showers during the month of February 2024. On 03/05/24 at 8:50 a.m., CNA #8 was asked to review the February shower documentation for Resident's #5 and #6. CNA #8 stated both residents were on the Tuesday, Thursday, and Saturday shower schedule, they also stated Resident #5 had received two showers and refused two showers and that Resident #6 had received two showers and refused three showers in February. CNA #8 further stated that on the nine other scheduled shower days for Resident #5 and the eight other scheduled shower days for Resident #6 either the resident did not get a shower, or the shower was given and not documented. On 03/07/24 at 10:00 a.m., the administrator stated the charge nurse should ensure that showers were administered as ordered, but ultimately the DON and administrator were responsible.

Based on interview and record review, the facility failed to provide effective pain management for one (#46) of one sampled resident reviewed for pain. The facility failed to obtain and administer pain medications in a timely manner and per current standards of practice. Rsident #46 suffered pain at level of nine out of 10, with 10 being severe,disabling pain. The Resident Census and Conditions of Residents report identified there were no residents on a pain management program. Findings: Resident (Res) #46 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A progress note, dated 09/01/21 at 7:22 p.m., read in parts, .new admit to skilled services for dx of right femoral fx with recent ORIF .Resident admits to mild pain, no pain medication orders received from previous facility. Physician notified with n/o for Apap [acetaminophen]. Pharmacy notified and given out of house stock . Review of the resident's clinical record revealed no documentation of discharge orders from the hospital. There were no physician orders for acetaminophen for pain. There was no documentation showing the resident received acetaminophen. A progress note, dated 09/03/21 at 11:33 a.m., read in parts, .Resident C/O pain 9/10 on her R. hip. This nurse reviewed orders and realized she didn't have anything ordered for pain. I then contacted [physician name withheld] and informed him what was going on and he gave resident a new order for 100 mg [MEDICATION(S)] [a narcotic pain medication] Q6H PRN for pain. This nurse entered the order and am now awaiting to receive medication for resident. Will continue to monitor resident . A progress note, dated 09/03/21 at 1:26 p.m., read in parts, .Resident C/O pain 9/10, [physician name withheld] notified and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Order is put in and we are awaiting pharmacy delivery . A progress note, dated 09/03/21 at 7:53 p.m., read in parts, .Resident states pain level is 5/10 at this time, Order is put in for [MEDICATION(S)] and we are still awaiting pharmacy delivery . An undated electronic pharmacy fulfillment record documented the pharmacy received the order for the pain medication at 9/03/21 at 1:13 p.m. This was approximately one hour and 45 minutes after the order was received. It was documented the medication was filled at 5:00 p.m., shipped at 5:46 p.m., and arrived at the facility at 8:43 p.m. This was 50 minutes after it was documented the resident had complained of pain of five out of 10. There was no documentation to show the resident was medicated after the pain medication arrived at the facility. Review of medication administration records showed the resident first received the pain medication on 09/06/21 at 2:26 a.m. The resident's admission Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs), dated 09/08/21, documented the resident was moderately impaired in cognitive skills, received scheduled and as needed pain medications, had pain at the time, and had moderate pain. It was no documented what the resident's pain rated on the zero to 10 scale. The resident's Care Plan, dated 09/13/21, did not address pain. There were no goals or interventions identified. On 10/05/21 at 1:39 p.m., the ADON was asked to provide the discharge orders. She stated the facility did not have the orders, but she had contacted the hospital to have them send the orders over. She was asked how she would write admitting orders without having the discharge orders from the hospital. She stated the physician would give them. She stated they did have the referral documents from the hospital. The ADON stated the family had brought Res #46 to the facility and had already filled her medications before they arrived. On 10/06/21 at 8:27 a.m., LPN #1 stated when an order was received from a physician, the order was documented in the electronic health record, and it was automatically sent to the pharmacy. She stated there had been an error with the system a few times. LPN #1 stated she usually called the pharmacy and verified the order had been received. She stated if an order was received after hours, they were supposed to call the pharmacy. LPN #1 stated the facility had a local pharmacy that was used as an emergency pharmacy. She stated with their normal pharmacy, if something was needed pretty quick, they could usually get it within three to four hours. On 10/06/21 at 11:47 a.m., the DON stated the ADON had completed the resident's admission to the facility. The DON stated the resident did not have any pain medication ordered when she arrived at the facility, so the ADON had contacted the physician and received orders for acetaminophen. She stated the ADON would have used house stock of acetaminophen to medication the resident with. The DON was asked what the staff did when the resident complained of pain of a nine out of 10. She stated the nurse contacted the physician, got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked if the staff offered the resident any acetaminophen at that time. She reviewed the clinical record and stated she did not see where any was given. The DON was asked what staff did on 09/03/21 at 7:53 p.m., when the resident was still complaining of pain of a five out of 10. She reviewed the clinical record and stated it looked like they were still waiting for the pharmacy to fill the pain medication order. She was asked if the staff offered any acetaminophen at that time. She stated no. She stated she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was asked when the pain medication arrived at the facility. She stated it was checked in on 09/03/21 at 8:43 p.m. The DON stated the resident should have been medicated when the pain medication arrived at the facility. She stated the staff should have verified if the resident could have acetaminophen while waiting on the pain medication. The DON stated the situation qualified for utilizing the emergency pharmacy so the resident could have had the pain medication quicker. The DON stated, in her professional opinion, a resident who was having pain of a nine out of 10 would be showing signs of pain such as crying, grimacing, rocking back and forth, and rubbing at the site of pain. She stated a resident who had pain of a five out of 10 would probably be grimacing and have a look of pain. She stated she did not know why the staff had no accessed the emergency pharmacy.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were supervised and free of accidents for one (#16) of three sampled residents who had experienced falls. The facility failed to implement interventions and/or reassess interventions put in place to prevent recurrence. The resident sustained [REDACTED]. The facility identified 34 residents who had falls in the last nine months. Findings: The facility policy on fall risk assessment documented the facility would assess the resident after a fall and identify the causes of the falls. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incident report, dated 01/09/16, documented the resident had a non injury fall. The report documented interventions were to continue including hourly visual checks, toilet the resident, bed change, alarm in place, to monitor every 30 minutes, and one on one until the resident was asleep. A resident specific fall tracking sheet, dated 01/22/16, documented the pharmacist would review the resident's medications. A review of the resident's clinical record did not contain documentation of a pharmacy review of the resident's medications. An incident report, dated 01/23/16, documented the resident had a non injury fall. The incident report documented the resident's alarm went off and staff was unable to get to the resident before she fell . The report documented interventions were to place a bed alarm, hourly and as needed checks, to offer fluids, and toilet every 1-2 hours. An incident report, dated 02/24/16, documented the resident was found on the floor on her right side. The incident report documented the resident was observed to have a hematoma on the right side of her temple measuring 3 centimeters (cm) by 3 cm. The incident report documented the resident had bruising to her face, cheek, jaw, and middle forehead measuring 12 cm by 10 cm. The incident report documented the resident's night stand was moved to prevent further injuries. An incident report, dated 02/29/16, documented the resident attempted to get out of her wheelchair and fell . No injuries were documented. The documented interventions were an activities consult and a restorative consult. A review of the resident's clinical record did not contain an activities consult. An incident report, dated 03/19/16, documented the resident had a non injury fall. The report documented interventions were to get the resident up in the wheelchair and place the pull string on the alarm. An incident report, dated 03/22/16, documented the resident had a fall in her room. The incident report documented the resident complained of pain to her right side. The incident report documented the resident had an x-ray and was found to have four fractured ribs. The documented intervention was to change the resident's toileting schedule from every two hours to every one hour. An incident report, dated 04/13/16, documented the staff responded to the resident's body alarm. The incident report documented as staff entered the resident's room the resident was standing and the resident fell hitting the nape of her neck. The report documented interventions were to readjust the pressure pad under the resident and to educate the staff to monitor the resident frequently. An incident report, dated 04/16/16, documented the resident was found in the floor of her room with the back of her head against the door facing. The incident report documented the bed alarm did not activate. The incident report documented the resident sustained [REDACTED]. The incident report documented the resident was provided a helmet. An incident report, dated 05/07/16, documented the resident was found sitting on the floor of another resident's room. The incident report documented a skin tear to the right elbow. The report documented the intervention was to place the fall alarm where the resident could not remove it before standing. An incident report, dated 05/11/16, documented the resident was found lying beside her bed. The incident report documented the resident sustained [REDACTED]. The report documented interventions were to continue with one hour toileting and one hour visual checks. An incident report, dated 05/18/16, documented the resident attempted to lean over the side of the wheelchair causing the wheelchair to tip over with the resident still in the chair. The incident report documented the resident had removed her protective helmet prior to the fall. The incident report documented the resident sustained [REDACTED]. The incident report documented an activity consult as the intervention to prevent recurrence for falls. A review of the resident's clinical record did not contain documentation of an activity consult. The incident report documented the facility would analyze the resident's falls to determine the pattern and trend. The facility did not provide documentation of investigations to determine the root cause of the resident's falls. An incident report, dated 05/31/16, documented the resident was found lying on the floor of another resident's room. No injuries were documented. The report documented an intervention of one on one care while up in the wheelchair until the resident was resting in bed. An incident report, dated 06/09/16, documented the resident was propelling herself in her wheelchair and started to ambulate, lost her balance, and fell . No injuries were documented. The interventions documented were the staff was instructed on close monitoring at all times and to make sure the resident had slip free shoes and socks. A resident specific fall tracking sheet, dated 06/10/16, documented the facility was to provide the resident with hip protectors. A review of the resident's clinical record did not contain documentation of a physician's orders [REDACTED]. An incident report, dated 06/20/16, documented the resident slid down onto the floor. No injuries were documented on the incident report. The report documented an intervention to place the resident one on one with a staff member. A quarterly assessment, dated 07/06/16, documented the resident was not understood and sometimes understood others. The assessment documented the resident was severely impaired with cognition. The assessment documented the resident required limited to extensive assistance with activities of daily living. The assessment documented the resident was not steady and only able to stabilize with staff assistance with moving from seated to standing positions, walking, turning around, and moving on and off a toilet. The assessment documented the resident had no impairment with range of motion. The assessment documented the resident was continent with bowel and bladder. The assessment documented the resident had two or more falls in the last assessment period. The assessment documented the resident had two or more falls without an injury and two or more falls with non major injuries. An incident report, dated 07/11/16, documented the resident was found on the floor in another resident's room. The incident report documented there were no apparent injuries. The report documented an intervention for one on one supervision for the resident. An incident report, dated 08/11/16, documented the resident's alarm was sounding. The incident report documented the resident was leaning on the bed side commode and urine was noted in the floor. No injuries were documented. The report documented interventions were to move the bed side commode out of site when not in use, continue with the protective helmet, and to toilet the resident every two hours. An incident report, dated 08/18/16, documented the resident was found on the floor of her room with the personal alarm sounding. The incident report documented the resident stated, She was going to the bathroom. The incident report documented the resident had skin tears to her right elbow, finger, wrist, and hand. The incident report documented bruising and swelling to her right eye. The interventions documented were the bed side commode was removed from the room, the pressure alarm was checked, and the resident was moved closer to the nurse station. An incident report, dated 09/04/16, documented the resident stated she was trying to scratch her ankle and fell out of bed onto the floor. The incident report documented the resident sustained [REDACTED]. The incident report documented the resident's right cheek was noticeably swollen. The incident report documented the resident was placed in a low bed with a fall mat. The incident report documented a physician's orders [REDACTED]. An incident report, dated 09/09/16, documented the resident attempted to stand unassisted from the wheelchair and fell to the floor. The incident report documented the resident sustained [REDACTED]. The incident report documented the resident's protective helmet was in place. The report documented an intervention for the resident to be assisted to bed 30 minutes after meals. A quarterly assessment, dated 10/4/16, documented the resident was not understood and sometimes understood others. The assessment documented the resident was severely impaired with cognition. The assessment documented the resident required extensive assistance with activities of daily living needs. The assessment documented the resident was not steady and only able to stabilize with staff assistance moving from seated to a standing position, walking, and moving on and of the toilet. The assessment documented the resident had no impairment with range of motion. The assessment documented the resident was occasionally incontinent of bowel and bladder. The assessment documented the resident had two or more falls during the last assessment period. The assessment documented the resident had two or more falls without an injury and two or more falls with a non major injury. A care plan, updated 10/07/16, documented the resident had cognitive loss and dementia, memory problems, and impaired decision to make daily decisions. The care plan documented the resident had falls and was at risk for additional falls related to impaired balance and being unaware of safety needs. The care plan documented the facility would analyze the resident's falls to determine the trend and pattern. The care plan documented the resident needed assitance with activities of daily living. An incident report, dated 10/07/16, documented the resident stood up to give her husband something and fell to the floor. The incident report documented the resident sustained [REDACTED]. The incident report documented the staff was educated to monitor the resident frequently. An incident report, dated 11/04/16, documented the resident was found lying on the floor in the dining room on her left hip. No injuries were documented on the incident report. The report documented an intervention for the resident to be assisted to bed in between meals. An incident report, dated 11/06/16, documented the resident was attempting to stand and the staff was alerted by the chair alarm. No injuries were documented on the incident report. The report documented the resident was assisted back into the wheelchair with the safety alarm in place. The report documented the resident wore a protective helmet and was placed near the nurses' station for monitoring. The report documented to monitor and assess the resident for pain. On 11/07/16 at 11:12 a.m., the resident was observed in her room. The resident was in her wheelchair with her protective helmet in place. A personal alarm was attached to the resident's wheelchair. The resident was not interviewable. The resident was observed attempting to stand from the wheelchair several times. An incident report, dated 11/09/16, documented the resident was up in her wheelchair for lunch and staff heard the pressure alarm sounding. The incident report documented as staff rounded the corner the resident was observed sitting on the floor. No injuries were documented on the incident report. The report documented interventions were to educate the staff to be aware of the resident, to monitor frequently for drowsiness, and assist the resident to bed. On 11/09/16 at 10:20 a.m., the resident was observed sleeping in her room in a low bed. A fall mat was observed beside the resident's bed. On 11/09/16 at 11:25 a.m., licensed practical nurse (LPN) #1 was interviewed regarding the interventions put in place to prevent recurrence of falls for the resident. The LPN reported the resident had a pressure alarm. The LPN reported the staff kept the resident in sight when she was up. The LPN reported the resident was toileted hourly and taken to activities. On 11/09/16 at 11:30 a.m., certified nurse aide (CNA) #1 was interviewed regarding the resident's care needs. The CNA reported the resident fell often due to the fact she tried to get up unassisted. The CNA reported the staff tried to redirect the resident. The CNA reported the staff took the resident to activities and the resident liked to go outside. The CNA reported the resident was toileted, she was on a low bed with a pressure alarm, and she had a fall mat. On 11/09/16 at 3:15 p.m., the DON was interviewed regarding the interventions put in place to prevent recurrence of falls for the resident. The DON was asked if the facility conducted investigations to determine the root cause of the resident's falls. The DON reported the facility conducted fall meetings every Friday. The DON was asked if she had documentation of the fall meetings. The DON reported the fall meetings were not documented. On 11/14/16 at 9:30 a.m., the DON provided documentation of every one hour visual checks and toileting for the resident. On 11/14/16 at 10:01 a.m., the resident was observed in her wheelchair in the hallway. The resident was observed with a protective helmet, a personal alarm attached to the wheelchair, and tip protectors were observed on the back of the wheelchair. The resident was observed with a staff member sitting in a chair in the hallway. On 11/14/16 at 11:23 a.m., the resident was observed in a low bed. The bed alarm was attached to the bed and a fall mat was observed beside the bed. The resident's husband was observed in the room. On 11/14/16 at 12:57 p.m., the resident was observed up in her wheelchair propelling herself with her feet up and down hallway. The resident was observed with a protective helmet in place. The resident's personal alarm was observed attached to the wheelchair and tip protectors were observed on the back of the wheelchair. Facility staff members were observed in the hallway. On 11/14/16 at 2:43 p.m., the resident was observed in her wheelchair in the hallway visiting with other residents. The resident was observed with a protective helmet in place. The resident's personal alarm was attached to her wheelchair. Tip protectors were observed on the back of the resident's wheelchair. On 11/14/16 at 4:30 p.m, the resident was observed in the hallway up in her wheelchair with protective helmet in place. The resident was visiting with her husband. On 11/15/16 at 9:03 a.m., an interview was conducted with the assistant director of nursing (ADON) regarding the specific fall tracking sheet. The ADON was asked why the interventions to prevent recurrence of falls were documented days later after the falls occurred. The ADON reported the date on the specific fall tracking sheet was when the fall meetings were held. The ADON was asked if she was able to find an activity consult for the resident. The ADON reported she had not been able to find an activity consult. On 11/15/16 at 9:10 a.m., the ADON was asked who was responsible for activities in the locked unit. The ADON reported the activity person for the unit was off at that time. The ADON reported a CNA who was also the facility's restorative aide (RA) was conducting the activities. The ADON was asked if she thought the RA was able to conduct the restorative and the activities on the unit as well. The ADON stated, Probably not. On 11/15/16 at 10:49 a.m., the resident was observed resting in her low bed. Facility staff was observed assisting the resident to get up for lunch. On 11/15/16 at 12:20 p.m., the director of nursing (DON) was interviewed regarding the interventions put in place to prevent recurrence of falls for the resident. The DON was asked for documentation of pharmacy reviews for the interventions of medication reviews for the month of January 2016. The DON reported she had lost some of her information on her computer during an update. The DON reported she did not have a pharmacy review on the resident for the month of January 2016. The DON was asked for documentation of hip protectors used for the resident as documented as an intervention for the month of June 2016. The DON reported she had looked and was unable to find the documentation for the hip protectors. On 11/15/16 at 2:18 p.m., an interview was conducted with LPN #2 regarding the resident's falls. The LPN reported, I usually have the resident to sit with me or another staff when she is up in her wheelchair due to the resident tries to stand up. The LPN reported she didn't believe the resident was able to walk on her own anymore. The LPN reported the facility used a low bed, a fall mat, and a protective helmet. The LPN stated, Sometimes we just have to put her one on one with a staff member.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent accidents for two (#2 and #3) of two sampled residents reviewed for incidents/accidents. The facility failed to provide supervision and effective interventions to prevent burns from hot coffee for the two residents. The facility identified 33 residents who had experienced incidents and/or accidents in the past 90 days. Findings: The facility policy on accident and incident investigation stated staff would identify any injuries after a resident sustained [REDACTED]. The facility policy on condition change of the resident documented staff would develop a plan of preventive measures, safety measures, and resident education. The policy documented staff would notify the resident's responsible party. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/06/14, documented the resident had severely impaired cognition. The assessment documented the resident required extensive assistance with activity of daily living needs. The assessment documented the resident required supervision when eating with one person physical assist. An annual assessment, dated 01/05/15, documented the resident had severely impaired cognition. The assessment documented the resident required extensive assistance with activity of daily living needs. The assessment documented the resident required limited assistance when eating with one person physical assist. A care plan, dated 01/19/15, was reviewed. The care plan did not document an update related to a coffee burn. An incident report, dated 03/10/15, documented the resident had experienced a burn from hot coffee. Nurse notes, dated 03/10/15 at 8:30 p.m., documented the resident was sitting at the dining room table with another resident who was drinking coffee. Resident #2 grabbed the other resident's cup and pulled it into her lap. The resident was taken from the dining room to her room and found to have reddened areas to the top and inner thighs. The nurse notes documented the physician had been notified and orders received. The physician orders, dated 03/10/15, ordered burn treatments twice a day. The orders documented to cleanse redness/blistered areas with normal saline, pat dry, and apply silver sulfadiazine twice a day for 7 days then reevaluate. Nurse notes, dated 03/11/15 at 6:22 p.m., documented the resident had two fluid-filled blisters on the right leg, a blister to the left leg, and an area on the inner left leg where a blister "had popped". On 03/25/15 at 11:50 a.m., residents were observed in the dining room. Several residents were drinking coffee and two were noted to have hot chocolate. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment, dated 10/16/14, documented the resident had severely impaired cognition. The assessment documented the resident required extensive assistance with activity of daily living needs. The assessment documented the resident was on a pureed diet with nectar thickened liquids. The assessment documented the resident required set up assistance with eating. A nursing progress note, dated 02/26/15 at 6:20 a.m., documented the resident was sitting at a table in the dining room when he pulled a cup of coffee onto his lap. The note stated the resident was taken from the dining room to his room and found to have redness to the right thigh and groin area. The note documented the physician had been notified and orders received. An incident report, dated 02/26/15, documented the resident had experienced a burn from hot coffee. A nursing progress note, dated 03/01/15 at 5:54 p.m., documented the resident was found to have [DIAGNOSES REDACTED] to the right thigh and groin area with a blister to the groin. A physician order, dated 03/01/15, documented orders to cleanse the reddened area and blistered areas, pat dry, then apply silvadene until resolved. A care plan, dated 03/19/15, was reviewed. The care plan did not document a problem related to burns. The care plan was not updated to reflect the coffee burns documented on the incident report. On 03/25/15 at 3:46 p.m., the resident was observed to be lying in bed. On 03/26/15 at 9:12 a.m., licensed practical nurse (LPN) #1 was interviewed regarding resident safety and the prevention of recurrence of coffee burns. The LPN stated there was no formal assessment in place to evaluate resident safety. The LPN stated staff should use their judgement in providing coffee to the residents. The LPN stated maintenance had been checking the temperature of the coffee in the dining room since the incidents occurred. On 03/26/15 at 9:21 a.m., licensed practical nurse (LPN) #2 reported most staff members knew the residents and understood their needs. The LPN stated there was no assessment in place to determine safety related to hot liquids. On 03/26/15 at 9:36 a.m., the director of nursing (DON) was interviewed regarding the prevention of recurrence of coffee burns. The DON stated staff kept residents who drink coffee separate from residents who should not have it. The DON stated kitchen staff checked the temperature of the coffee on a more regular basis since the incidents occurred. On 03/26/15 at 11:45 a.m., kitchen staff #1 obtained coffee from the dispenser in the dining room. The staff member checked the temperature of the coffee and the coffee temperature registered 125 degrees Fahrenheit. The kitchen staff stated there was not a log for coffee temperatures and thought maintenance was obtaining the temperatures. On 03/26/15 at 11:50 a.m., certified nurse aide (CNA) #1 reported residents did not have assigned seats in the dining room. The aide stated staff tried to keep residents who should not have hot drinks separate from other residents who might have hot drinks at the table. The aide stated there had not been a formal inservice related to coffee burns. On 03/26/15 at 12:00 p.m., the assistant director of nursing (ADON) reported staff had not been inserviced regarding seating of residents in the dining room related to coffee burns. The ADON reported there had not been resident specific interventions implemented for resident #2 or #3 following the coffee burns. On 03/26/15 at 12:12 p.m., the director of nursing (DON) was interviewed regarding inservicing of staff related to coffee burns and seating of the residents during meals. The DON stated staff had been educated on a shift to shift basis but a formal inservice with documentation had not been done. On 03/26/15 at 1:04 p.m., maintenance reported a temperature log was not maintained for the coffee dispenser in the dining room. He stated he had turned the temperature down on the coffee dispenser after the burns occurred. Maintenance stated the dispenser was currently set at 135.6 degrees Fahrenheit. Maintenance reported there was no documentation for exactly when the temperature was adjusted and he could not be certain of the date. On 03/26/15 at 2:09 p.m., the facility administrator reported the coffee dispenser had initially been turned down to 125 degrees Fahrenheit after the incident. The administrator stated there was no documentation of the previous temperature prior to the incident. The administrator reported residents complained the coffee was too cold and maintenance turned the temperature up to 135 degrees Fahrenheit. The administrator was asked when the temperature was initially adjusted. The administrator stated it would have been after the first burn incident. The administrator stated there was no documentation of the temperature adjustment. The administrator was interviewed regarding the incident report. The administrator reported the adjustment of the coffee temperature was not included on the incident report as an intervention.

Based on record review, observation, and interview, it was determined the facility failed to provide necessary services to prevent and/or promote healing of pressure ulcers for three (#1, #4 and #7) of three sampled residents who were reviewed for pressure ulcers. Resident #4 developed three stage II and two unstageable pressure ulcers. Resident #1 experienced a recurring stage II pressure ulcer. The facility failed to: a. identify; thoroughly assess, evaluate, and monitor existing pressure ulcers in a timely manner; and failed to ensure effective treatment measures were implemented to prevent the development of new pressure ulcers for resident #4. b. identify, thoroughly assess and evaluate, monitor, and ensure effective treatment measures were implemented to prevent the recurrence of a pressure ulcer for resident #1. c. consistently and thoroughly assess, monitor, and document skin condition for resident #7 who was identified at high risk for the development of pressure ulcers. The facility identified 28 residents who were at risk for developing pressure ulcers. Findings: The facility policy for preventative protocols for skin care documented residents who were at moderate to high risk for developing pressure ulcers were to have their skin assessed daily. The facility skin assessment and documentation policy documented nursing service would assess all residents' skin upon admission to the facility, daily during routine care, and weekly for documentation if pressure sores were present. The policy documented all pressure areas and decubitus ulcers would be graded as stage I to stage IV. The policy stated documentation in the medical record would be completed weekly by the charge nurse or the treatment nurse, as well as, a separate weekly entry by the director of nursing service for all residents who fell within the above categories. The policy stated documentation would include specific location, grade, measurement in centimeters for each occurrence, surrounding skin condition, color, drainage, color of drainage, consistency, and odor and drainage, appropriate care and treatment, resident's condition and response to treatment, and specific physician's orders [REDACTED]. 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A skin assessment, dated 08/09/13, documented the resident had a surgical site from hip surgery on the right hip, bruises to bilateral arms, and [MEDICAL CONDITION] to bilateral lower extremities. A nurse's note, dated 08/13/13, documented a new treatment order for a Podus boot to the resident's right lower extremity. The nurse's note did not document an indication for the use of the Podus boot. A treatment flowsheet, dated August 2013, documented to apply [MEDICATION NAME] spray to the right heel two times a day for 14 days then to re-evaluate. The treatment began on 08/13/13 and was discontinued on 08/15/13. The treatment flowsheet did not document measurement, staging, odor or a description of the surrounding tissue. A nurse's note, dated 08/14/13, documented the resident stated her foot had been burning the previous day but was not burning at the present. The note documented the resident was wearing the Podus boot to the right foot. A nurse's note, dated 08/15/13 at 12:07 a.m., documented [MEDICATION NAME] spray was applied to the resident's right heel. A description of the resident's right foot was not documented. A nurse's note, dated 08/15/13 at 6:24 p.m., documented the dressing was applied to a blister to the right heel. The nurse's note documented serosanguinous drainage was noted. The nurse's note documented a new treatment order to clean the wound with normal saline and pat dry. The nurse's note documented to apply triple antibiotic ointment, a foam dressing, and to secure with tape. The nurse's note did not document measurement, staging, odor or a description of the surrounding tissue. A nurse's note, dated 08/16/13 at 10:05 a.m., documented a head to toe assessment was completed. The note documented a wound to the right heel with serous drainage noted. The nurse's note did not document measurement, staging, odor or a description of the surrounding tissue. The admission assessment, dated 08/16/13, documented the resident's cognition was intact. The assessment documented the resident required extensive assistance with transfers, hygiene, and bathing. The assessment documented the resident required limited assistance with bed mobility. The assessment documented the resident was at risk for developing pressure ulcers and had one stage II pressure ulcer. A nurse's note, dated 08/17/13 at 10:14 p.m., documented the treatment was provided per physician orders. The nurse's note documented the resident's left heel had formed a blister and a new order was obtained for the treatment. The nurse's note did not document measurement, staging, odor or a description of the surrounding tissue. A weekly skin assessment, dated 08/20/13, documented a wound to the right heel which measured 3.5 x 3.0, stage II with a pink wound bed and a small amount of pink tinged drainage. The skin assessment documented a wound to the right ankle that measured 5 centimeters (cm) x 0.4 cm, stage II, with a red peri wound and a small amount of pink tinged drainage. The assessment documented a wound to the left ankle which measured 3.5 cm x 1.2 cm, with a pink wound bed and peri wound and a small amount of drainage. The assessment documented a wound to the left heel which measured 3.5 cm x 3.5 cm with a pink wound bed and peri wound and a small amount of drainage. The skin assessment for the wounds to the left ankle and heel did not identify a stage. The assessment did not document staging, odor or a description of the surrounding tissue. There was no documentation of measurements of the wounds on the resident's left or right ankle in the residents medical record prior to 08/20/13. The care plan, dated 08/20/13, documented the resident had three pressure ulcers related to decreased mobility. The care plan for the resident's pressure ulcers had a start date of 08/28/13. The care plan documented the staff were to assess the pressure ulcers for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization weekly. The care plan documented the staff were to conduct a systematic skin inspection weekly and report any signs of further skin breakdown. The care plan documented the staff was to apply Podus boots to the resident to relieve pressure on the heels. A treatment flowsheet, dated 08/21/13, documented to cleanse the resident's left heel with wound cleanser, pat dry, apply [MEDICATION NAME] liberally, cover with foam, use barrier wipes, and secure with tape. The flowsheet also documented to clean the resident's right heel with wound cleaner, pat dry, apply [MEDICATION NAME] to the heel, cover with foam, secure with tape, and use a barrier wipe before taping. Both treatments were initiated on 08/21/13. The flowsheet failed to document a treatment was provided on 08/22/13 for the right heel. A weekly skin assessment, dated 08/26/13, documented a wound to the resident's right heel which measured 3.5 cm x 3.5 cm, stage II with a pink wound bed, red peri wound, and moderate amount of pink tinged drainage. The skin assessment documented a wound to the back of the right ankle which measured 5 cm x 0.2 cm, stage II with a pink wound, and red peri-wound with a moderate amount of pink tinged drainage. The assessment documented a wound to the left heel which measured 4.5 cm x 6 cm, unstageable with a pink peri-wound, and a scant amount of clear drainage. The skin assessment documented a wound to the back of the left ankle which measured 4 cm x 0.2 cm unstageable with a pink peri-wound, and a scant amount of clear drainage. A medication flowsheet, dated August 2013, documented to cleanse the side of the left foot with wound cleanser, pat dry, apply [MEDICATION NAME] liberally, cover with foam, use barrier wipes, and secure with tape. The treatment began 8/27/13. The wound was identified on 08/26/13. A nurse's note, dated 08/27/13 at 9:49 p.m., documented the staff provided a treatment to the bilateral heels and the left side of the foot. The nurse's note documented the wounds were healing well with no drainage. A nurse's note, dated 09/01/13, documented treatments were completed to the resident's bilateral lower extremities. The nurse's note documented the right heel measured 3.5 x 3.5 cm. The nurse's note documented the back of the right ankle measured 5 x 0.2 cm. The nurse's note documented the left heel measured 4.5 x 6 cm. The nurse's note documented the back of the left ankle measured 4 x 0.2 cm. The nurse's note documented the side of the left foot measured 1 x 1.75 cm. The nurses's note documented all wounds were healing well. A treatment flowsheet, dated September 2013, documented to clean the right heel and back of the right ankle with wound cleaner, pat dry, apply [MEDICATION NAME] to the heel, cover with tape. This wound was identified on 08/20/13. The treatment flowsheet start date was 09/01/13. The flowsheet documented to cleanse the back of the left ankle and heel with wound cleanser, pat dry, apply [MEDICATION NAME] liberally, cover with foam, and secure with tape. The wound to the back of the left ankle was identified on 08/20/13. The start date of the treatment was documented as 09/01/13. The treatment record failed to document a treatment on 09/07/13. The treatment flowsheet documented to cleanse the side of the left foot with cleanser, pat dry, apply a liberal amount of [MEDICATION NAME], wipe surrounding area with barrier wipe, put foam and secure with tape. This treatment began on 09/01/13. A weekly skin assessment, dated 09/08/13, documented the wound to the resident's right heel was 4.2 x 3.3 cm, stage II and scabbed with a small amount of yellow drainage. The wound to the right ankle was 1 x 3 cm, no stage was described, with white slough bordered by pink and a small amount of yellow drainage. A nurse's note, dated 09/09/13 at 5:24 p.m., documented a scabbed 3.5 x 3.5 area to the left heel surrounded by peeling skin and a pink border. The nurse's note documented a wound to the side of the left foot. The nurse's note documented a 2.5 x 3 area was noted with white slough surrounded by peeling skin. The nurse's note documented a wound to the ankle which measured 1 x 3 cm with white slough to the wound bed surrounded by a pink border. On 09/10/13 at 10:13 a.m., the director of nurses (DON) was interviewed regarding skin assessments. The DON reported skin assessments were conducted monthly unless the resident had issues then they would be conducted weekly. The DON stated the certified nurse aides (CNA) reported constantly. The DON reported this procedure was followed even if a resident was at risk for skin breakdown. On 09/10/13 at 4:50 p.m., licensed practical nurse (LPN) #4 was observed providing wound care for the resident. The wounds on the resident's bilateral heels were observed unstageable. While cleaning the wounds, the LPN was observed using 4 x 4s and using a back and forth wiping motion while using the same areas of the 4 x 4. The LPN was not observed to change gloves following cleaning the wound and before applying the medication and the dressings. The resident was not observed to have a pressure relieving mattress. On 09/11/13 at 12:05 p.m., LPN #2 was interviewed regarding interventions for pressure ulcers or speciality mattresses. The LPN reported the facility did not have air mattresses. The LPN reported the regular mattresses were supposed to be pressure relieving. On 09/11/13 at 12:09 p.m., LPN #2 was interviewed regarding pressure ulcer/skin assessments. The LPN reported after a pressure ulcer was resolved the resident would go back to monthly assessments. The LPN reported if the area was just a shear, the facility would do a monthly assessment. The LPN reported all residents were to be turned every two hours. The LPN reported the certified nurse aides (CNAs) knew if there was a skin problem when they provided care. The LPN was asked if there were specific days the skin assessments were completed. The LPN reported there were not specific days to assess the residents. The LPN stated each charge nurse was assigned a list of residents and the LPN was responsible for the residents assigned to her for that month. The LPN reported a skin assessment could be conducted on Monday one week and and on Friday the following week so the resident could potentially not be assessed for almost two weeks. The LPN was asked if the facility had provided training on skin assessments. The LPN reported the facility had not provided training on skin assessments. The LPN reported the facility had conducted weekly skin assessments on all residents until a few months ago. The LPN stated the facility probably needed to conduct weekly assessments for residents who were bedbound. On 09/11/13 at 1:05 p.m., the DON was asked when a new wound should have been assessed and staged. The DON reported the wound should have been assessed and staged immediately. On 09/11/13 at 4:05 p.m., the medical director was interviewed regarding the facility's protocol for wound care. The medical director reported he did not know the facility's protocol for assessing wounds but the facility always notified him regarding new wounds. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A significant change assessment, dated 02/27/13, documented the resident was at risk for pressure ulcers and had an unhealed stage II pressure ulcer that had worsened since the prior assessment. The assessment documented the resident had no healed pressure ulcers. The assessment documented the resident received pressure ulcer care. A quarterly assessment, dated 05/28/13, documented the resident was at risk for pressure ulcers. The assessment documented the resident had no pressure ulcers and had no healed pressure ulcers. A skin assessment sheet, dated 07/07/13, documented the resident had a pressure sore to the coccyx that measured 2 x 0.5 centimeters. A skin assessment sheet, dated 07/11/13, documented the resident had a pressure sore to the coccyx that measured 1 x 0.3. A skin assessment sheet, dated 07/20/13, documented no problems were noted. A skin assessment sheet, dated 07/31/13, documented no problems were noted. A monthly skin assessment, dated 08/22/13, documented the resident had no problems. A quarterly assessment, dated 08/27/13, documented the resident was severely impaired with skills for daily decision making ability. The assessment documented the resident had short and long term memory problems. The assessment documented the resident required total assistance for all activity of daily living (ADL) needs. The assessment documented the resident received hospice services. The assessment documented the resident was at risk for pressure ulcers and was provided ointments or medications other than to feet. The assessment documented the resident had no pressure ulcers on the prior assessment. The care plan, dated 05/28/13 and 08/27/13, documented the resident required assistance with ADLs. The care plan documented the staff would anticipate and meet all the needs of the resident because the resident was not able to communicate. The care plan documented the resident required hospice as evidenced by a terminal illness. The care plan documented the hospice staff was to assist the resident with showers three times weekly as well as provide any ADL assistance needed while the hospice aide was in the facility. The care plan documented the resident was at risk for skin breakdown related to being incontinent. The care plan documented the resident would be kept clean and dry as possible. The care plan documented the facility was to minimize skin exposure to moisture. The care plan documented the facility would conduct a systematic skin inspection monthly. The care plan documented if any problems were noted, weekly skin assessments would be conducted until the area was resolved. On 09/10/13 at 10:13 a.m., the director of nurses (DON) was interviewed regarding skin assessments. The DON reported skin assessments were conducted monthly unless the resident had issues then they would be conducted weekly. The DON stated the certified nurse aides (CNA) reported constantly. The DON reported this procedure was followed even if a resident was at risk for skin breakdown. On 09/10/13 at 10:40 a.m., hospice aide #1 was observed to provide personal care for the resident. The resident was observed to have an open area on her buttocks. The hospice aide reported the area had been present for approximately one to one and a half weeks. The resident was not observed to have a pressure relieving mattress. On 09/10/13 at 4:05 p.m., the DON was interviewed regarding the facility policy for skin assessments. The DON was asked when monthly skin assessments were completed. The DON reported nurses were assigned a list of residents to be assessed monthly. The DON reported the residents could be assessed at any time during the month. The DON reported the residents could potentially be assessed at the beginning of the month one month and the next month they could be assessed at the end of the month. The DON reported the residents could potentially have a two month span without having a skin assessment. The DON stated, "We probably need to change that." On 09/11/13 at 10:45 a.m., hospice aide #1 was asked what she would do if she observed anything abnormal with the resident. The hospice aide reported she would notify her hospice nurse and the charge nurse of any abnormal issues. The hospice aide reported the facility was aware of the open area because, "They were putting cream on it." On 09/11/13 at 11:00 a.m., certified nurse aide (CNA) #6 and hospice aide #1 were observed to transfer the resident from a shower chair to the bed following the resident's shower. The sling used under the resident to transfer had a hole that the resident's buttocks slipped through. The resident was observed to have water dripping from her buttocks as she was lifted over the bed. The resident's hair was observed to be wet. The resident was placed in the bed without the staff drying the resident's buttocks or her hair. Hospice aide #1 was asked if she had notified anyone about the open area when she first observed it. The hospice aide reported she had told the facility charge nurse and the charge nurse had provided some cream for the resident. The hospice aide reported she did not know if she had documented the observation of the open area in her hospice notes. On 09/11/13 at 11:30 a.m., LPN #2 was interviewed regarding the resident and the open area observed. The LPN reported she thought the area was a shear. The LPN reported the facility used [MEDICATION NAME] and [MEDICATION NAME] and the area would clear up in about a week. The LPN reported a skin assessment should have been completed when the area was observed. The LPN reported she had put the [MEDICATION NAME] on the resident earlier in the day but not the day before. The LPN reported she was not positive when the area had opened. The treatment sheets, dated August and September 2013, were reviewed. The only documentation of the [MEDICATION NAME] and [MEDICATION NAME] applied was 09/11/13. There were no other skin assessments in the clinical record until 09/11/13 at 2:07 p.m. On 09/11/13 at 11:59 a.m., licensed practical nurse (LPN) #2 was interviewed regarding communication with hospice. The LPN reported the hospice aides did not leave their notes in the building following their visit. The LPN stated, "We read and sign them." On 09/11/13 at 12:05 p.m., LPN #2 was interviewed regarding interventions for pressure ulcers or speciality mattresses. The LPN reported the facility did not have air mattresses. The LPN reported the regular mattresses were supposed to be pressure relieving. On 09/11/13 at 12:09 p.m., LPN #2 was interviewed regarding pressure ulcer/skin assessments. The LPN reported after a pressure ulcer was resolved the resident would go back to monthly assessments. The LPN reported if the area was just a shear the facility would do a monthly assessment. The LPN reported all residents were to be turned every two hours. The LPN reported the certified nurse aides (CNAs) knew if there was a skin problem when they provided care. The LPN reported the open area on the resident had not been present the previous day. The LPN reported the resident would now be placed on weekly skin assessments. The LPN was asked if there were specific days the skin assessments were completed. The LPN reported there were not specific days to assess the residents. The LPN stated each charge nurse was assigned a list of residents and the LPN was responsible for the residents assigned to her for that month. The LPN reported a skin assessment could be conducted on Monday one week and and on Friday the following week so the resident could potentially not be assessed for almost two weeks. The LPN was asked if the facility had provided training on skin assessments. The LPN reported the facility had not provided training on skin assessments. The LPN reported the facility had conducted weekly skin assessments on all residents until a few months ago. The LPN stated the facility probably needed to conduct weekly assessments for residents who were bedbound. On 09/11/13 at 4:15 p.m., the medical director was interviewed regarding problems identified with wounds and assessments. The medical director reported he could not say what the protocol was for assessing a pressure ulcer but the facility did notify him when they found a pressure ulcer. A nurse's note, dated 09/12/13 at 6:00 a.m., documented it was brought to nursing attention at that time the patient had a stage 2 open pressure ulcer to the right buttocks. The nurse's note documented the resident's skin was assessed. The nurse note documented an open area approximately 1 centimeter (cm) x 1cm with no drainage noted. On 09/12/13 at 9:50 a.m., the DON was interviewed regarding the communication between the hospice aides and the facility. The DON reported the hospice aides didn't leave their notes in the facility for their visits. The DON had several hospice aide notes she presented to the surveyor. The DON stated, "They brought them by last night at 9:00 p.m. They've never left notes." The hospice notes presented by the DON were reviewed. The most recent note was dated 09/09/13. There was no documentation during the month of August or September of any skin problems. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Braden scale for prediction for pressure ulcer risk, dated 08/08/13, documented the resident was a high risk for pressure ulcers. A quarterly assessment, dated 08/12/13, documented the resident was severely impaired with cognition. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident was at risk for a pressure ulcer. An admission skin assessment, dated 08/26/13, documented the resident had an excoriation on her buttocks. The measurement of the excoriation was documented as scattered. The skin assessment documented the staff was to use [MEDICATION NAME] skin barrier to the buttocks. A physician's orders [REDACTED]. A significant change assessment, dated 09/03/13, documented the resident was intact with cognition. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident was at risk for a pressure ulcer. The assessment documented the resident had moisture associated skin damage. An updated care plan, dated 09/03/13, documented the resident had cognitive loss and dementia. The care plan documented the resident required assistance with activities of daily living. The care plan documented the resident required extensive assistance of one staff member with bed mobility. The care plan documented the resident was incontinent with bowel and bladder. The care plan documented the resident had a rash related to moisture associated skin damage. The care plan documented the staff would conduct a systematic skin inspection every week until the area was resolved. On 09/10/13 at 4:50 p.m., the resident was observed during wound care. The resident's buttocks were observed red/purple in color. The charge nurse was asked what type of skin issue the resident had. The charge nurse reported the resident had an excoriation. The charge nurse reported the resident returned from the hospital with the excoriation. The resident was observed to be lying on a regular mattress. On 09/11/13 at 12:10 p.m., licensed practical nurse (LPN) #2 was interviewed regarding the facility's policy on skin assessments. The LPN reported any resident with a skin issue would have a weekly skin assessment. The LPN reported the resident was readmitted from the hospital with the excoriation to her buttocks. The LPN was asked if the resident's skin was assessed weekly. The LPN reported the resident should have a weekly skin assessment. On 09/11/13 at 12:45 p.m., the director of nurses (DON) was interviewed regarding the facility's policy for weekly skin assessments. The DON reported if a resident had a pressure ulcer or a skin problem they should be followed up and assessed every week. The DON was asked if the resident had a skin condition that warranted a weekly skin assessment. The DON reported the resident should have had a weekly skin assessment. The DON was asked if the resident had a skin assessment since 08/26/13. The DON reported the resident's last documented skin assessment was 08/26/13.

Based on record review, observation, and interview, it was determined the facility failed to: a) assess and provide interventions to alleviate pain and to decrease pain before daily care and treatments for one (#3) of five residents sampled for pain. The resident experienced excruciating pain during daily care and treatments which resulted in actual harm. The facility identified twenty three residents who received pain medications. b) follow a physician's orders [REDACTED]. The facility identified one resident who was on an ordered water protocol in the facility. c) follow a physicians order for pudding thick liquids and ensure staff was educated in the preparation of pudding thick liquids for one (#8) of nine residents sampled for potential swallowing hazards. The facility identified seven residents with orders for thickened liquids. Findings: The facility policy on pain documented the facility was committed to pain management for all residents. The policy documented if a resident had a change of condition that could result in pain such as new or worsening wound the nurse was to contact the doctor for a pain medication order. The facility policy documented a registered nurse was to do a pain assessment on admission and quarterly. 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A facility pain assessment, dated 08/25/12, documented the resident was currently in pain, at risk for pain, and experienced pain. The assessment documented the resident was cognitively impaired and had communication difficulties. The resident's care plan, dated 09/06/12, documented the resident was at risk for pain. The care plan documented the staff would assist the resident with comfort measures as needed. The resident's fourteen day assessment, dated 09/25/12, documented the resident was severely impaired with cognitive skills. The assessment documented the resident required extensive assistance with bed mobility and transfers. The assessment documented the resident had one Stage III pressure ulcer. The resident's Medication Administration Record, [REDACTED]. The medication record did not document any pain medication had been administered to the resident during the first fourteen days of October 2012. A nurse's note, dated 10/03/12, documented the resident had a Stage III pressure wound to the coccyx. The nurse's note documented the resident was turned and repositioned every hour. A weekly skin assessment, dated 10/08/12, documented the resident had a Stage III pressure ulcer to the coccyx. The weekly skin assessment documented the pressure ulcer measured 4.5 centimeters (cm) x 1.4 cm x .2 cm depth. On 10/15/12 at 9:45 a.m., the resident's wound care treatment was observed. Before the treatment was initiated LPN #1 stated to CNA #1 and CNA #2, "Tell the med-aide when we are done to give him a pain pill." CNA #1 stated the resident hurt all the time when he was moved. LPN #1 cleaned the resident's wound and the resident yelled out loudly and kicked his legs. During observation of the pressure ulcer treatment the resident continued to yell out and cuss. On 10/15/12 at 4:00 p.m., the director of nurses was interviewed regarding the resident's pain regimen with his Stage III pressure ulcer. The director of nurses stated the resident should have pain medication before the pressure ulcer treatments. The director of nurses stated she did not know if the resident had an order for [REDACTED]. 2. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A significant change assessment, dated 10/05/12, documented the resident was severely impaired with cognitive skills. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident required extensive assistance with eating. A functional maintenance plan, dated 10/05/12, documented the resident was to be placed on a Frazier water protocol. The resident was to receive 16 ounces of water with a straw 3 to 4 times daily in between meals. A care plan, dated 10/08/12, documented the resident had cognitive impairment. The care plan documented the resident required assistance with activities of daily living. The care plan documented the resident had a swallowing problem and a potential for aspiration. The care plan documented the facility was to follow a Frazier water protocol. A maintenance program for the Frazier water protocol documented the resident was to receive two cups of thin water with a straw 3 to 4 times a day between meals. The maintenance program sheet, dated 10/2012, documented blanks for the days 10/05/12, 10/06/12, 10/07/12, 10/08/12, 10/09/12, 10/10/12, 10/13/12, and 10/14/12. On 10/17/12 at 2:30 p.m., the resident was observed during personal care. On 10/18/12 at 2:00 p.m., an interview was conducted with the restorative aide regarding the resident receiving the two cups of water three times a day. The restorative aide reported she gave the resident her water after breakfast and lunch. The restorative aide reported the certified nurses aides were supposed to give the resident the water when she was not there. On 10/18/12 at 3:10 p.m., an interview was conducted with the DON regarding the resident receiving her water per the Frazier water protocol. The DON reported the CNAs were supposed to give the residents her water when the restorative aide was not here. 3. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 09/25/12, documented the resident had long and short term memory problems and was severely impaired with decision making skills. The care plan, updated on 09/13/12, documented the resident's diet was to be served per physician's orders [REDACTED]. A physician's orders [REDACTED]. On 10/14/12 at 5:25 p.m., the resident was observed being assisted with her evening meal by certified nurse aide (CNA) #6. The CNA was observed to add two spoonfuls of thickener to the resident's water. The CNA was then observed to pour the thickener out of a bowl into the resident's water without using any kind of measurement. CNA #7 was present in the room and asked the dietary manager if there was a chart to go by to measure the thickener into the liquid. The dietary manager answered yes. The chart for correct thickening measurements was not provided. On 10/15/12 at 5:45 p.m., the resident was observed being assisted with her evening meal by and unidentified staff member. The dietary manager was asked to look at the thickened cranberry juice on the resident's tray. The dietary manager was asked what was the consistency of the cranberry juice. The dietary manager reported the cranberry juice was honey thick. The dietary manager reported the cranberry juice was too thin to be pudding thick.