Every finding on record at Sequoyah Pointe Living Center

Based on interview, record review, and facility document and policy review, the facility failed to protect 1 (Resident #16) of 2 residents sampled for abuse, from further potential abuse after an allegation of abuse was made. On 08/06/2025 at 7:50 PM, Resident #16 alleged that Certified Nursing Assistant (CNA) #1 was rough while providing bed mobility assistance. CNA #1 continued to provide resident care to residents other than Resident #16 until 8:48 PM on 08/06/2025, when the CNA was suspended.Findings included: A facility policy titled, Abuse and Neglect-Administrative Protocol, effective 10/05/2022, revealed, 6. Protect - The facility will act immediately to protect the resident when being notified of an allegation. a. Any staff member (s) that is part of the allegation will be immediately suspended and remain suspended throughout the investigation. An admission Record revealed the facility admitted Resident #16 on 03/23/2022 with a recent readmission on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of pain in the left hip, manic episode - severe with psychotic symptoms, anxiety disorder, insomnia, bipolar disorder, cognitive communication deficits, schizoaffective disorder, mild cognitive impairments of uncertain or unknown etiology, chronic pain, spondylosis without myelopathy or radiculopathy, spinal stenosis, and age-related osteoporosis without current pathological fracture. A quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/19/2025, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #16's Care Plan Report, included a focus area initiated on 03/25/2022 and revised on 01/27/2024, that indicated the resident had an activity of daily living (ADL) self-care deficit related to acute and/or chronic illness resulting in deconditioning. Interventions directed staff to provide assistance with bed mobility (undated). An Oklahoma State Department of Health Initial Incident Report Form dated 08/06/2025 at 10:09 PM revealed Resident #16 alleged that CNA #1 was rough while rolling the resident side to side in bed. The form revealed the resident asked the CNA to go slower but the CNA continued to be rough. Per the form, the facility suspended CNA #1 pending an investigation. A typed statement dated 08/07/2025 at 8:35 PM, signed by Licensed Practical Nurse (LPN) #8, revealed that at approximately 7:50 PM, Resident #16 reported to Certified Medication Aide (CMA) #7 that CNA #1 was too rough. CNA #1's Employee Timesheet dated 08/06/2025 revealed the CNA was clocked in from 2:00 PM until 5:26 PM and from 5:57 PM to 8:48 PM. The Employee Timesheet revealed CNA #1 did not work after 08/06/2025. During an interview on 07/22/2026 at 7:11 AM, CNA #1 revealed after the nurse was notified of the allegation, he was allowed to continue to assist other residents at the facility until the ADM and DON arrived. He stated after the Administrator (ADM) and Director of Nursing (DON) arrived he was taken into an office, notified of the allegation, and placed on suspension. During an interview on 07/22/2026 at 7:46 AM, LPN #8 stated he recalled that Resident #16 told him that CNA #1 had provided care in a rough manner while rolling the resident from side to side during incontinence care. LPN #8 stated he notified the DON immediately of Resident #16's allegation. LPN #8 stated he did not have the authority to suspend CNA #1 and told the CNA to go to the nurse's station to write his witness statement. LPN #8 stated he was unsure whether CNA #1 provided any additional care to any resident prior to the DON and ADM's arrival to the facility on the day of the allegation. He stated that he recalled CNA #1 leaving the facility after the DON and ADM arrived. During an interview on 07/24/2026 at 2:42 PM, the DON reviewed the facility's reportable investigation file and stated she expected the nurse on duty to send home any staff member named in an abuse allegation, immediately. The DON stated that once the facility became aware of the allegation made by Resident #16 on 08/06/2025 at 7:50 PM, she would have expected CNA #1 to be removed from the facility. The DON stated she could not recall whether CNA #1 had been sent home prior to her arrival at the facility on 08/06/2025. During an interview on 07/24/2026 at 3:45 PM, the ADM stated she expected staff to escort the alleged perpetrator out of the facility immediately upon knowledge of an allegation of abuse.

Based on interview, record review, and facility document and policy review, the facility failed to report an allegation of abuse to the state survey agency within two hours after the allegation was made for 1 (Resident #16) of 2 residents reviewed for abuse. Specifically, on 08/06/2025 at 7:50 PM, Resident #16 reported that a staff member was rough with them during care. The facility failed to report the abuse allegation to the state agency until 08/06/2025 at 10:06 PM.Findings included: A facility policy titled, Abuse and Neglect-Administrative Protocol, effective 10/05/2022, revealed, 7. Reporting-The facility will send a report to all reporting agencies as required by OSDH [Oklahoma State Department of Health] guidelines. a. The facility will send a report to the Oklahoma State Department of Health and adult protective services immediately, but not later than 2 hours of being notified of the allegation, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. An admission Record revealed the facility admitted Resident #16 on 03/23/2022 with a recent readmission on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of pain in the left hip, manic episode - severe with psychotic symptoms, anxiety disorder, insomnia, bipolar disorder, cognitive communication deficits, schizoaffective disorder, mild cognitive impairments of uncertain or unknown etiology, chronic pain, spondylosis without myelopathy or radiculopathy, spinal stenosis, and age-related osteoporosis without current pathological fracture. A quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/19/2025, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. A typed statement dated 08/07/2025 at 8:35 PM, signed by Licensed Practical Nurse (LPN) #8, revealed that at approximately 7:50 PM (on 08/06/2025), Resident #16 reported to Certified Medication Aide (CMA) #7 that Certified Nursing Assistant (CNA) #1 was too rough with them. According to the statement, upon assessment, Resident #16 told LPN #8 that CNA #1 threw them from side to side instead of counting down before providing care. Resident #16 told LPN #8 that CNA #1 was too rough and that the resident did not want him back in the room. An Oklahoma State Department of Health Initial Incident Report Form dated 08/06/2025 at 10:09 PM, signed by the Director of Nursing (DON), revealed the facility reported to the state agency that Resident #16 made an allegation of abuse against CNA #1. During an interview on 07/24/2026 at 2:42 PM, the DON stated that once an allegation was made, it should be reported to the nurse who then reports to the Administrator or Director of Nursing. The DON stated that the Administrator and/or DON then went to the facility immediately to submit initial reports within two hours of staff knowledge of the allegation. Per the DON, the facility became aware of Resident #16's allegation on 08/06/2025 at 7:50 PM, and staff notified her at 8:35 PM on 08/06/2025. The DON reviewed the facility initial reportable incident and stated the report was submitted to the state survey agency on 08/06/2025 at 10:06 PM. She stated she expected the facility to report an allegation of abuse to the state survey agency within two hours of staff knowledge of an allegation. During an interview on 07/24/2026 at 3:45 PM, the Administrator stated she expected all allegations of abuse to be reported to the state survey agency within two hours of the facility's knowledge of the allegation.

Based on observation and interview, the facility failed to ensure food served from the kitchen was palatable and served at an appetizing temperature. The DON identified 36 residents who ate from the kitchen. Findings: On 04/08/25 at 12:40 p.m., Residents #10 and #31 were observed sitting together in the dining room with their food uneaten. On 04/08/25 at 1:32 p.m., a test tray was delivered. The food was observed to not be hot, the cake was dry and crumbling off the fork, and the steak finger breading was observed to be white in color and to touch was gooey and not thoroughly cooked. On 04/08/25 at 11:10 a.m., Resident #9 stated the food was lousy, everything from seasoning to how it was prepared. They stated the facility served noodles and rice often and the chicken fried steak fingers were too tough and they could not cut or eat it. On 04/08/25 at 11:16 a.m., Resident #90 stated the food was always cold and bland. They stated they always eat in their room. On 04/08/25 at 12:40 p.m., Residents #10 and #31 were sitting together in the dining room. They stated the food was tough and not seasoned and just did not taste right. On 04/08/25 at 1:06 p.m., Resident #9 received their afternoon meal and stated the food was not hot and never was hot. They stated they always eat in their room due to personal issues. On 04/08/25 at 2:31 p.m., Resident #31 stated the food was terrible a lot of the time. They stated the food today was bad and they did not eat most of it but had eaten the peas, roll and mashed potatoes and gravy. On 04/09/25 at 8:49 a.m., Resident #92 stated the food was not very good, not cooked well and not seasoned. They stated they wished the facility had butter not margarine. On 04/09/25 at 9:13 a.m., Resident #93 stated the food was not very good and did not have much flavor. On 04/10/25 at 11:50 a.m., the dietary manager stated they knew food was thoroughly cooked by the temperature.

Based on record review and interview, the facility failed to ensure laboratory services were provided for 1 (#92) of 1 sampled resident who was reviewed for laboratory services. The administrator identified 38 residents who resided at the facility. Findings: Resident #92's admission assessment, dated 04/05/25, showed they resident had a BIMS of 13 which indicated their cognition was intact. The assessment listed diagnosis which included end stage renal disease. Resident #92's care plan, dated 04/05/25, showed a concern for dialysis related to end stage renal disease. The care plan interventions were to obtain and monitor lab/diagnostic work as ordered and to report significant results to the physician. A physician's order, dated 04/05/25, showed to obtain a CBC (complete blood count), CMP (comprehensive metabolic panel), TSH (thyroid stimulating hormone), BNP (B-type natriuretic peptide), and pre-albumin one time only for monitoring. No lab results were recorded in the clinical record. No lab results were provided by the end of the survey. Review of an April 2025 lab administration report showed the labs had not been completed as ordered. On 04/15/25 at 11:04 a.m., the DON stated they did not know why the labs ordered had not been completed. The DON stated when the order was entered, the lab center should have collected them the next morning.

Based on record review and interview, the facility failed to ensure weights were completed as ordered for 1 (#92) of 1 resident sampled who was reviewed for weights. The administrator identified 38 residents who resided at the facility. Findings: Resident #92's admission assessment, dated 04/05/25, showed the resident had a BIMS of 13 which indicated their cognition was intact. The assessment listed diagnoses which included acute on chronic congestive heart failure and end stage renal disease. Resident #92's care plan, dated 04/05/25, showed a concern for decreased cardiac output but did not have an intervention for the monitoring of weight. A physician's order, dated 04/06/25, showed to obtain daily weight one time a day. Review of the treatment administration record, dated April 2025, showed weights were obtained three times out of ten opportunities. The record showed four dates were documented with NA (not applicable) and one blank. Review of progress notes did not show an explanation was provided for why the weights were not obtained. Review of the weights for Resident #92 showed weights were completed on three dates, 04/05/25, 04/06/25, and 04/13/25. No other weights were documented in the clinical record. On 04/15/25 at 11:04 a.m., the DON stated they did not know Resident #92 was ordered daily weights.

Based on record review and interview, the facility failed to ensure bathing was provided to 1 (#33) of 3 sampled residents who were reviewed for activities of daily living. The DON identified 38 residents resided at the facility. Findings: Resident #33's significant change assessment, dated 03/13/25, showed the resident had a BIMS of 15 which indicated they were cognitively intact for daily decision making. The assessment showed Resident #33 was dependent for showers. The assessment listed diagnoses which included periprosthetic fracture around internal prosthetic left knee joint and abnormalities of gait and mobility. Review of the bathing task for March showed Resident #33 had received one shower out of 13 opportunities in March on 03/26/25. A task flow sheet for showers, dated April 2025, showed Resident #33 was to receive showers Monday, Wednesday and Friday. The flow sheet showed one shower in the month of April on 04/04/25 out of five opportunities. On 04/09/25 at 9:32 a.m., Resident #33 stated they had previously been showered three times a week, but would prefer a shower/bath twice a week. They stated they had only been offered a shower/bath once a week in the last month or so. Resident #33 stated they last showered on 04/04/25. On 04/15/25 at 12:39 p.m., CNA #1 stated they did not know why Resident #33 had not received more than two showers in the last two months. They stated any CNA could give showers, but with two CNAs on the floor, they needed a shower aide. On 04/15/25 at 12:43 p.m., the DON stated the shower aide provided showers, but they were on leave. The DON stated the facility was in the process of hiring another shower aide. They stated they did not have an answer to why Resident #33 had only received two showers since 03/26/25.

Based on record review and interview, the facility failed to ensure the residents' right to be free of abuse for two (#1 and #2) of three residents reviewed for abuse. The facility's Resident List Report documented 44 residents lived in the facility. Findings: A resident abuse, neglect, exploitation, and misappropriation prevention program policy, revised April 2021, documented the policy's objectives were: - to protect residents from abuse by anyone, including facility staff and other residents; - to establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems; and -to protect residents from any further harm during the investigations. 1. Resident #2 had diagnoses which included encephalopathy, dementia, and stroke. The quarterly assessment, dated 06/03/24, documented Resident #2 was severely impaired in cognition and utilized a wheelchair for mobility. A State Reportable Incident Report, dated 07/28/24, read in part the facility staff observed Resident #1 had their hand down the pants of Resident #2. The report documented both residents were severely impaired in cognition and utilized a wheelchair for mobility. The report documented the two residents were seperated, Resident #2 was assessed for injury/distress, and a staff member was assigned to stay with Resident #1 until the resident was transported from the facility. The report documented the investigation included interviews with staff and review of video surveillance which showed Resident #1 had their hand on the thigh of Resident #2. The report documented the facility staff were in-serviced on the facility abuse protocol/policy/procedure and identifying sexual abuse. The report documented the staff were given a multiple choice testing tool to ensure understanding of the information provided in the in-service. The report documented the facility staff were to be in-serviced on abuse on hire and quarterly thereafter. The report documented the facility staff would routinely interview residents to ensure they were comfortable with reporting concerns or issues with staff. 2. Resident #1 had diagnoses which included cognitive social and emotional deficit following a stroke, impulsiveness, dysphagia, hydrocephalus, depression, disorientation, and dementia with behaviors. A second State Reportable Incident Report, dated 07/28/24, documented the charge nurse alerted administration a CNA had observed LPN #1 smack the chest of Resident #1 while they were in the common room. The report documented the LPN was suspended and the resident was assessed for injury/distress. The report documented an investigation was initiated. The report documented interviews were conducted with staff and residents. The report documented CNA #1 observed LPN #1 tell Resident #1 not to touch them and then slapped Resident #1 in the chest pretty hard. The report documented video surveillance showed Resident #1 pinching LPN #1 on the buttocks at which time LPN #1 turned and made contact with Resident #1's chest with their open hand thus pushing him away. The report documented LPN #1 was terminated and the appropriate agencies notified of the allegation and the results of the investigation. The report documented the facility staff were in-serviced on the facility abuse protocol/policy/procedure and identifying staff on resident abuse. The report documented the staff were given a multiple choice testing tool to ensure understanding of the information provided in the in-service. The report documented the facility staff were to be in-serviced on abuse on hire and quarterly thereafter. The report documented another intervention to abuse was the facility staff would routinely interview residents to ensure they were comfortable with reporting concerns or issues with staff. On 07/31/24 at 1:30 p.m., the administrator stated the two State Reportable Incident Reports documented related incidents which quickly happened one after the other. The administrator stated the allegation was Resident #1 was overheard making inappropriate comments to Resident #2 and then Resident #1 was observed with their hand down the pants of Resident #2. The administrator stated LPN #1 was observed to start to remove Resident #2 from the area when Resident #1 pinched LPN #1 on their buttocks who then turned and, with an open hand, made contact with the chest of Resident #1, pushing them backward in their wheelchair. The administrator stated through review of surveillance and interviews, the facility was able to substantiate that Resident #1 had their hand on the thigh of Resident #2 and that LPN #1 had made willful contact with Resident #1. The administrator stated the allegations of abuse were substantiated but the facility staff followed their facility abuse protocol after the two events occurred by protecting both residents from further abuse, investigating the two allegations and providing in-services/training. The administrator stated abuse was added to their quality assurance program and would be routinely monitored through the education of staff, testing the staff knowledge of the abuse protocols/procedures, interviewing residents, and vigilant monitoring.

Based on record review and interview, the facility failed to have the participation of the resident or the resident representative in the development of the resident's person centered care plan for three (#1, 2, and #3) of three residents whose care plans were reviewed. The facility's Resident List Report documented 46 residents. Findings: 1. Resident #1 was admitted [DATE] and had diagnoses which included aphasia and psychotic disorder with delusions. On 06/03/24 at 4:25 p.m., a family member was interviewed and stated they were not notified of or offered an opportunity to participate in the resident's care plan meetings. On 06/04/24, the resident's clinical record was reviewed. There was no documentation the resident or resident's representative participated in the care planning process for the resident's admission assessment (11/27/23) or quarterly assessment (02/27/24). 2. Resident #2 was admitted [DATE] with diagnoses which included Alzheimer's dementia and dementia with behaviors. On 06/04/24, the resident's clinical record was reviewed. There was no documentation the resident or resident's representative participated in the care planning process for the resident's admission assessment (05/20/24). 3. Resident #3 was admitted [DATE] with diagnoses which included stroke, dysphagia, disorientation, and dementia. On 06/04/24, the resident's clinical record was reviewed. There was no documentation the resident or resident's representative participated in the care planning process for the resident's admission assessment (01/31/24). On 06/04/24 at 4:25 p.m., the administrator and DON stated they were aware the facility had conducted care plan meetings without resident representation for Resident #1, Resident #2, and Resident #3. The administrator stated there was a delay in resuming resident/representative involvement in the care plan process due to the loss of facility staff in key positions. The administrator stated it was the responsibility of the social service department to notify the resident and resident representative of care plan meetings and coordinate their participation. The DON stated they were ultimately responsible for ensuring the resident had adequate representation during care plan meetings.

Based on record review and interview, the facility failed to have a program designed to help prevent the development of Legionellosis and Pontiac fever caused by Legionella Bacteria. The administrator reported the census was 42. Findings: An undated facility policy, titled Legionella Surveillance and Detection, read in part, .The water management program includes the following elements .A detailed description and diagram of the water system in the facility .The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria . On 12/08/23 at 8:18 a.m., the maintenance supervisor stated the facility did not have a detailed description and diagram of the facility water supply and had not identified areas in the water system that could encourage the growth of Legionella. They also stated that no water management team had been assembled.

Based on record review and interview, the facility failed to ensure showers were provided for two (#7 and #11) of three residents reviewed for bathing. The administrator reported the census was 42. Findings: 1. Resident #7 had diagnoses which included chronic obstructive pulmonary disease and anemia. An admission assessment, dated 06/02/23, documented Resident #7 was moderately impaired in cognition and required assistance with bathing. A review of Resident #7's shower documentation sheets did not document the resident had been offered a shower between 10/2/23 and 10/26/23 or between 11/10/23 and 12/07/23. On 10/06/23 at 10:30 a.m., Resident #7 stated if a shower aide was not working, they usually did not get a shower. 2. Resident #11 had diagnoses which included diabetes mellitus and chronic obstructive pulmonary disease. An annual assessment, dated 10/05/23, documented Resident #11 was intact in cognition. A review of Resident #11's shower documentation sheets did not document the resident had been offered a shower between 09/12/23 and 09/25/23 or between 11/09/23 and 11/27/23. On 10/06/23 at 10:00 a.m., Resident #11 stated that he had gone as long as three weeks without being offered a shower. On 12/12/23 at 930 a.m. the DON was asked for additional documentation of showers for Resident's #7 and #11, none was provided.

Based on record review and interview, the facility failed to ensure a record of controlled medication destruction for the medication Xanax 0.25 mg was completed for one (#38) of twelve sampled residents reviewed for medication diversion. The DON reported 42 resident resided in the facility. Findings: Resident #38 had diagnoses which included dementia and anxiety disorder. A facility policy titled Disposal of Medications And Medication-Related Supplies, dated November 2018, read in part .All controlled substances remaining in the facility after a resident had been discharged , or the order is discontinued, are disposed of: 1) In the facility by the a[sic] registered nurse, director of nursing and/or consultant pharmacist (or other allowed by state law) .Disposition is documented on the individual controlled substance accountability record/book . The facility controlled medication destruction log was reviewed. A controlled medication destruction log sheet, dated 06/17/23, documented prescription #3276468, Xanax 0.25 mg, count of 20 tablets belonging to Resident #38. The form was not signed by a pharmacist or registered nurse. A controlled drug count sheet with a received date of 06/13/23, documented 90 doses of Xanax 0.25 mg tablets had been delivered for Resident #38's use. The form documented on 06/17/23 that 80 doses of the medication remained. Next to that number three signatures were hand written on the document along with the date of 07/28/23 and the number 20. A hand written sentence stating the medication had been discontinued was also on the document. The section of the form for documenting the deposition of remaining doses was blank. On 12/11/23 at 9:12 the DON was alerted to the incomplete controlled medication destruction form for Resident #38's Xanax 0.25 mg prescription number 3276468. On 12/11/23 at 9:19 a.m., the DON stated they could not find the medication in question or other documentation of the medication having been destroyed. On 12/11/23 at 9:32 a.m., the DON stated it was their expectation that the destruction of medication would follow the policy and procedures of the facility. They stated they expect documentation to be timely and accurate.

Based on observation, record review, and interview, the facility failed to ensure: a. residents were assessed for entrapment risk prior to the use of side rails for two (#18 and #95) of two sampled resident reviewed for accident hazards; b. interventions in lieu of the use of bed rails were attempted prior to their use for on (#95) of two sampled residents reviewed for accident hazards; c. residents or resident representatives were informed of the risk and benefits of using side rails and obtained signed consent prior to their use for two (#18 and #95) of two sampled resident reviewed for accident hazards; and d. resident beds were inspected for proper fit to each resident and the bed rails were of appropriate for the size and weight of each resident for one (#95) of two sampled resident reviewed for accident hazards. The CMS-671 form, dated 12/07/23, documented 43 residents resided in the facility. Findings: A facility policy titled Bed Rail and Bed Safety, revision date August 2022, read in part .Before using bed rails for any reason, the staff shall inform the resident or resident representative about the benefits and potential hazards associated with bed rails and obtain informed consent . The policy also documented the requirement for the resident to be assessed for the use of bed rails prior to use and the bed would be inspected for its appropriateness and functionality for each specific resident. It also documented alternative interventions were to be attempted prior to the use of bed rails. 1. Resident #18 had diagnoses which included dementia with behavioral disturbances and generalized muscle weakness. A review of Resident #18's care plan, dated 04/11/23, documented a focus, goal, and interventions related to safety including the use of bed rails. It documented the resident and resident representatives would be educated on the use of side rails. A review of the resident's medical record did not result in the locating of a consent for the use of bed rails. A Side Rail/Bed Maintenance Inspection Worksheet form, dated 05/30/23, documented the residents height and weight, bed frame and matress dimensions, the type of side rail to be used, and that the bed, mattress, and bed rail were in a safe condition. The form did not indicate if the bed frame manufacturers specifications for matress and bed rails had been reviewed as part of the process. On 12/07/23 at 8:44 a.m., the resident was observed sitting in their room. The resident identified a bed next to them as their's. The bed had small bed rails attached to each side of the bed frame. 2. Resident #95 had diagnoses which included dementia and generalized muscle weakness. A review of Resident #95's care plan, dated 11/29/23, did not contain documentation of the use of bed rails or interventions that would preclude the use of bed rails. On 12/06/23 at 1:21 p.m., the resident was observed laying in bed. Two small side rails were attached to each side of the bed. On 12/06/23 at 1:45 p.m., a resident representative stated the had not known they needed to sign a consent for the bed rail and had not been spoken to about bed rail use of safety. On 12/11/23 at 7:58 a.m., the DON stated the education for the resident and representative should have been done for each resident with a bed rail prior to use but was not sure if they had been done. They stated they believed the use of bed rails by the residents were assessed every quarter. They stated other interventions were used prior to bed rails. On 12/11/23 at 10:19 a.m., the maintenance supervisor stated they had not been inspecting the beds of resident prior to the use of side rails. They stated they had been doing bed inspections starting in May of 2023 and presented a copy of Resident #18's bed and bed rail inspection form, dated 05/30/23. They stated they had not performed the inspection on the bed and bed rail of Resident #95. On 12/11/23 at 11:37 a.m., the DON stated they were still looking for the consents and bed rail inspection forms for the two residents. On 12/11/23 at 11:52 a.m., the DON stated they did not find any consents and only one of the bed rail inspections. They stated it was their expectation that the policy regarding the use of bed rails would be followed.

Based on observation, record review, and interview, the facility failed to ensure resident who received dialysis treatment were routinely assessed after dialysis treatments for one (#12) of two sampled resident reviewed for dialysis care. The DON reported two resident at the facility received dialysis treatments. Findings: A facility policy titled, End-Stage Renal Disease, Care of a Resident with [title ends abruptly], read in part, .Residents with end-stage renal disease (ESRD) will be care for according to currently recognized standards of care . Resident #12 had diagnoses which included chronic kidney disease, end stage renal disease, and dependence on renal dialysis. Sixteen documents titled Pre/Post Dialysis Communication Report, dated on and between 10/17/23 and 12/07/22 were reviewed. Ten of those forms, dated 10/17/23, 10/21/23, 11/09/23, 11/18/23, 11/20/23, 11/25/23, 11/30/23, 12/02/23, 12/05/23, and 12/07/23, did not include a completed post dialysis treatment assessment of Resident #12. On 12/08/23 at 9:06 a.m., Resident #12 was observed watching televisions in their assigned room. They stated the staff checked on her before she left and after returning from dialysis treatments. They were unable to state the assessments were done routinely. On 12/08/23 at 9:19 a.m., LPN #1 stated the assessments of the residents were to be done prior to leaving, while at the dialysis center, and again when the resident returned to the facility. On 12/11/23 at 11:03 a.m., LPN #2 stated the dialysis assessment form was to be filled out when at the facilty when the resident was assessed prior to departure for the treatment and upon return after the treatment. They stated many of the post assessment sections of the form for Resident #12 were not done. On 12/11/23 at 11:07 a.m., LPN #1 stated the dialysis assessments needed to be done before and after the treatments and the assessment forms must be completed. They stated many of the forms for Resident #12 did not have completed post assessments documented. On 12/11/23 at 11:10 a.m., the DON stated they had reviewed the dialysis assessment forms for resident #12 and found the post assessments had not been documented. They stated the assessments and form must be completed when the residents returned from treatment and that was their expectation. They stated the nurses would be receiving inservices on the subject.

Based on record review and interview, the facility failed to ensure indwelling catheters were changed according to the physician's orders for one (#1) of one resident reviewed for catheter care. The DON reported three residents in the facility had indwelling urinary catheters. Findings: Resident #1 had diagnoses which included multiple sclerosis and neuromuscular dysfunction of bladder. A physician order, dated 10/01/23, documented to change Resident #1's catheter every month on the 2nd and as needed. Review of the TAR and nurse notes did not document the catheter was changed on 10/02/23, 11/02/23 or 12/02/23. On 12/11/23 at 9:40 a.m., LPN #2 stated catheters should be changed according to physician orders.

Based on record review, observation, and interview, the facility failed to maintain sanitation in the kitchen. The facility failed to ensure: a. The dish machine reached manufacturer's specifications for wash and rinse temperatures and monitor the dish machine temperature log; b. Dry goods were not stored on the floor; c. Left-over food was discarded by their storage date; d. The back door to the kitchen sealed in a manner to deter pests/vermin; and e. Food was served in a manner which minimized the risk of cross contamination. The DON identified 43 residents who received nourishment from the kitchen. Findings: The Dish Machine Temperature Record, dated October 2022, documented 22 of 31 days the wash cycle water temperature was under the manufacturer's specification of 120 degrees Fahrenheit for the breakfast column. The record documented eight of 31 days the rinse cycle water temperature was under the manufacturer's specification of 120 degrees Fahrenheit for the breakfast column. The record did not reveal documentation the water temperatures had been obtained on 10/26/22 for the breakfast column. The Dish Machine Temperature Record, dated October 2022, documented ten days the wash cycle water temperature was under the manufacturer's specification of 120 degrees Fahrenheit. The record documented six of 31 days the rinse cycle water temperature was under the the manufacturer's specification of 120 degrees Fahrenheit for the lunch column. There was no documentation for 10/10/22 lunch wash/rinse water temperatures. The Dish Machine Temperature Record, dated October 2022, documented four days the wash cycle water temperature was under the manufacturer's specification of 120 degrees Fahrenheit. There was no documentation for 10/31/22 lunch wash/rinse water temperatures. The Dish Machine Temperature Record for November 2022 was not provided. On 11/02/22 at 10:15 a.m., dietary aide #1 was observed to run the dish machine. The dish machine temperature gauge read below the manufacturer's specification of 120 degrees Fahrenheit for the wash and rinse cycle. The dietary aide stated they had worked in the kitchen for the past week and did not know what the minimum water temperature was for the dish machine cycles. The dietary aide stated they had not been instructed on how to monitor the level of sanitizing agent during the rinse cycle. On 11/02/22 at 10:30 a.m., the dry goods storage room was observed to have boxes of food stored on the floor. On 11/02/22 at 10:38 a.m., daylight was observed around the left and right edges of the back door. The door was opened and the large trash container behind the kitchen was observed to have one lid closed and the other open. On 11/02/22 at 10:40 a.m., the ice machine was observed to have a pink and black substance on the inner compartment door and along the interior edges of the drip pan. On 11/02/22 at 10:45 a.m., the large three door refrigerator was observed. A pan labeled burgers and sauce for sloppy joes, dated 10/26/22, was observed in the refrigerator. A pan of cut melon and a pan of sausage links, both dated 10/31/22, were observed in the refrigerator. A frozen ham was observed in the refrigerator on top of a box of sausage and a box bacon. Cook #1 stated the kitchen staff thawed meat on the bottom shelf of the refrigerator and pointed to where the frozen ham was located. They stated the boxes of bacon and sausage were there because of limited space in the refrigerators. On 11/02/22 at 1:00 p.m., the dish machine was observed with the maintenance supervisor from a sister facility. The dish machine was dismantled for cleaning. The maintenance supervisor stated there was further black and pink substance found behind the censor plate and on the underside of the drip pan. The maintenance supervisor stated the machine needed to be cleaned. On 11/03/22 at 5:00 p.m., the dietary manager was observed serving food from the steam table. The dietary manager was observed to use their bare hands to open two cut baked potatoes. On 11/07/22 at 4:26 p.m., the dietary manager was asked why the dish machine had low water temperatures. The dietary manager stated after the dish machine company and the plumber came to look at the problem, they still had no idea. The dietary manager was asked who was responsible to clean the ice machine. They stated they were instructed the ice machine was cleaned by maintenance. The dietary manager stated all kitchen staff were responsible for ensuring the food stored in the refrigerators was stored properly and discarded when past their storage dates. The dietary manager stated the burgers and sloppy [NAME] sauce should have been discarded after three days and the cut melon after 24 hours. The dietary manager stated they had noticed the surveyor had taken note of their use of their hands when preparing the baked potatoes for two residents. The dietary manager stated for the other baked potatoes ordered, the foil was on the outside of the potato and they touched the foil to squeeze the baked potato open. The dietary manager stated the two baked potatoes they touched with their bare hands were for two residents with limited dexterity. The dietary manager stated to touch the residents' food with their bare hands did not meet food safety requirements.

Based on record review and interview, it was determined the facility failed to ensure a clinical rationale was provided when a gradual dose reduction from the pharmacist was declined by the physician for three (#24, 15, and #10) of five sampled residents who were reviewed for unnecessary medications. The DON identified 46 residents who received medications. Findings: A Tapering Medications and Gradual Drug Dose Reduction policy, dated July 2022, read in parts, .During the first year in which a resident is admitted on a [CONDITION(S)] medication [other than an antipsychotic or a sedative/hypnotic], or after the facility has initiated such medication, the facility will attempt to taper the medication during at least two separate quarters .The tapering may be considered clinically contraindicated, if: the continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder . 1. Res #24 had diagnoses which included [CONDITION(S)] and [CONDITION(S)]. A physician order, dated 08/02/22, documented the resident was ordered [MEDICATION(S)] (a muscle relaxer) 4mg every eight hours for [CONDITION(S)] and [CONDITION(S)]. The Pharmaceutical Consultant Report Muscle Relaxants, dated 10/07/22, read in parts, .Please evaluate and verify the desire to utilize [MEDICATION(S)]. According to CMS, this medication is considered inappropriate for use .Physician Response To Review [Please check appropriate line & write needed comments] .Report Reviewed - No Changes. Rationale for Continuance . The physician placed a check mark to indicate the report had been reviewed and no changes were desired. The area for documentation of the physician's rationale for continuance was left blank. Review of the clinical record did not reveal a rationale for the continuance of the [MEDICATION(S)]. 2. Res #15 had diagnoses which included [CONDITION(S)] disorder and [CONDITION(S)] disorder. A physician's order, dated 04/15/22, documented the resident was ordered [MEDICATION(S)] (an antipsychotic medication) 300mg at bedtime for [CONDITION(S)] disorder. The Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction, dated 05/30/22, read in parts, .Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rationale for the continued use. The resident is prescribed the following psychoactive medications: 1. [MEDICATION(S)] 300 mg QHS .NOTE TO PHYSICIAN: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for NOT reducing a Psychoactive must have a Hand Written, Valid Clinical Rationale as to why the reduction is not desired at this time . The report documented a check mark which indicated a dose reduction was not appropriate and the minimal effective dose was in use. The area for documentation of the physician's rationale for declining the gradual dose reduction was left blank. 3. Res #10 had diagnoses which included psychotic disorder with delusions, anxiety, and depression. A Physician's Order, dated 08/05/22, documented to administer [MEDICATION(S)] (a muscle relaxer) 10mg three times a day for chronic pain. A Physician's Order, dated 08/05/22, documented to administer [MEDICATION(S)] 800mg (an anticonvulsant) three times a day for [CONDITION(S)]. A Pharmaceutical Consultant Report Muscle Relaxants, dated 10/07/22, read in part, .Please evaluate and verify the desire to utilize [MEDICATION(S)]. According to CMS, this medication is considered inappropriate for use . A check mark was placed indicating the physician reviewed the form with no changes made to the order. The hand written rationale documented, Will eval . A Pharmaceutical Consultant Report Opioid with Gabapentinoids, dated 10/07/22, read in parts, .Please evaluate the routine use of Opioid with a Gabapentinoid. This combination has been deemed by CMS as inappropriate due to the potential adverse drug reactions (ADR) . A check mark was placed indicating the physician reviewed the form with no changes. The hand written rationale documented, continue all . On 11/08/22 at 12:45 p.m., the DON was asked what the facility's process was for GDRs or recommendations from the pharmacist. The DON stated they received an email from the pharmacist, the recommendations were provided to the physician, and after the physician addressed the recommendation they returned them to the facility. The DON was asked how recommendations from the pharmacist were monitored to ensure a rationale was provided. They stated they had not monitored the recommendations. The DON was asked if the response from the physician will eval was a rationale to decline the pharmacist's recommendation for the [MEDICATION(S)] for Resident #10. The DON reviewed the pharmacist's report and stated they thought it was a rationale. The DON was asked if the response from the physician continue all was a rationale for declining the pharmacist's recommendation for the [MEDICATION(S)]. They reviewed the pharmacist's report and stated no. The DON was asked why a rationale had not been documented when the physician had declined the recommendation from the pharmacist regarding [MEDICATION(S)] for Res #15. They reviewed the pharmacist's report and stated they did not know. The DON was asked why a rationale had not been provided when the physician had declined the recommendation from the pharmacist regarding [MEDICATION(S)] for Res #24. They reviewed the pharmacist's report and stated they would need to check with the physician.

Based on record review and interview, the facility failed to respond and provide rationale of the facility's response to Resident Council recommendations and grievances for four (March 2022, April 2022, June 2022, and July 2022) of four months of Resident Council meeting minutes reviewed. The Resident Census and Conditions of Residents form documented 46 residents resided in the facility. Findings: On 11/04/22, the Resident Council meeting minutes for 2022 were requested from the DON. Resident Council meeting minutes for March 2022, April 2022, June 2022, and July 2022 were provided. Review of the provided Resident Council meeting minutes did not reveal the facility had responded to the concerns of the Resident Council. On 11/06/22 at 12:30 p.m., the DON stated the facility was unable to find any other documentation of Resident Council meeting minutes. On 11/06/22 at 1:40 p.m., the DON stated a former activities director would perform two Resident Council meetings per month. The DON stated the first Resident Council meeting was to document the Resident Council's recommendations and grievances. The second Resident Council meeting of the month was held to address and respond to the Resident Council's recommendations and grievances. The DON stated the facility was unable to find documentation of the meeting minutes addressing the council's concerns. The DON stated since that activities director separated from the facility, they were not aware of the Resident Council recommendations and grievances being addressed. On 11/08/22 at 2:27 p.m., Res #15 stated they had resided in the facility for almost three years and the facility had never responded to Resident Council recommendations and grievances.

Based on record review, observation, and interview the facility failed to ensure chemicals were secured to prevent accident hazards for two of three housekeeping carts observed. The DON identified two residents who wandered in the facility. Findings: The MSDS, dated 03/12/19, for Comet with Bleach read in part, .Keep out of reach of children . The MSDS, dated 05/15/20, for Citrace Hospital Disinfectant and Deodorizer read in part, .Keep out of reach of children . The undated MSDS for Airworks Air Freshener read in part, .Store locked up . The undated MSDS for Mild Abrasive Cream Cleanser read in part, .Store locked up . The undated MSDS for Micro-Kill Q10 read in part, .Keep out of reach of children . The undated MSDS for Glass Cleaner read in part, .Keep out of reach of children . The undated MSDS for Micro-Kill Foaming Disinfectant read in part, .Keep unnecessary personnel away . On 11/07/22 from 2:57 p.m. to 3:52 p.m., observations were made of housekeeping cart #1 to be unlocked and unattended on Hall F during a continuous observation. Housekeeping cart #1 was observed to be in the hall with the door unlocked and accessible from the center of the hall. A surveyor was able to open and close the door. On 11/07/22 at 3:05 p.m., a second housekeeping cart was observed to be unlocked on Hall F. Housekeeper #2 repeatedly left the cart unattended and were observed to have their back to the cart leaving the carts unobserved. On 11/07/22 at 3:52 p.m., housekeeper #1 was observed to lock both carts in the housekeeping closet. On 11/07/22 at 3:57 p.m., housekeeper #1 was asked what the facility protocol was for housekeeping carts. They stated they did not leave the carts unattended. Housekeeper #1 was asked how the cart was kept secured when they were in resident rooms cleaning and the cart was unattended in the hall. They stated the cart is kept near the wall so they could hear if someone opened it. The contents of housekeeping cart #1 included: 1-7 ounce full can of airworks air freshener 1-40 ounce bottle of Cream cleanser for toilets and sinks 1-21 ounce can of Comet with bleach 1-unmarked open tub contained a blue liquid. The contents of housekeeping cart #2 included: 3-14 ounce full cans of Citrace hospital disinfectant and sanitizer 1-32 ounce bottle of micro kill 10 Q 1-32 ounce bottle of glass cleaner 1-1/2 full 1 lb can of foaming micro kill disinfectant 2-40 ounce bottle of creme cleanser for toilets and sinks On 11/07/22 at 4:01 p.m., the housekeeping supervisor was asked what the protocol was for housekeeping carts. They stated the carts were to be locked and no chemical accessible. On 11/07/22 at 4:18 p.m., the DON was asked what the protocol was for housekeeping carts to ensure chemicals were secured. They stated the carts were to be locked when staff were not present.

Based on record review, observation, and interview, the facility failed to maintain sufficient dietary staff with the necessary competencies and skills to carry out the functions of the food and nutrition service. The DON identified 43 residents who received nourishment from the kitchen. Findings: A review of the employee file for cook #1 revealed their food handler's permit had expired on [DATE]. On [DATE] at 10:15 a.m., dietary aide #1 was observed to run the dish machine. The dish machine temperature gauge read below the manufacturer's specification of 120 degrees Fahrenheit for the wash and rinse cycles. The dietary aide stated they had worked in the kitchen for the past week and did not know what the minimum water temperature was for the dish machine cycles. The dietary aide stated they had not been instructed on how to monitor the level of sanitizing agent during the rinse cycle. On [DATE] at 4:20 p.m., the dietary manager stated the kitchen staff consisted of one cook, two dietary aides, and themselves. The dietary manager stated cook #1 cooked all three meals a day for half of the week and the dietary manager cooked all three meals a day for the other days of the week. The dietary manager stated one dietary aide was scheduled per day. The dietary manager stated both dietary aides recently started working in the kitchen. On [DATE] at 4:26 p.m., the dietary manager was asked who was responsible to ensure food handler's permits had not expired. The dietary manager stated they thought it was the responsibility of human resources. The dietary manager stated there had been dietary staff who had quit when they became the dietary manager a little over a month ago. The dietary manager stated they wanted to hire two more cooks and one more aide. The dietary manager stated they were ultimately responsible for training the newly hired dietary staff. The dietary manager was asked if there were enough dietary staff to meet resident needs. The dietary manager stated it was manageable. The dietary manager was asked why dietary aide #1 had not received training on the use of the dish machine. The dietary manager stated they had been off work and had not had an opportunity to provide much training to dietary aide #1. The dietary manager stated they did not have enough staff in the kitchen to allow the dietary manager to train new dietary employees.

Based on observation and interview, the facility failed to prepare food in a form which met the individual needs of residents who received a pureed meal. The DON identified two residents who received pureed meals. Findings: On 11/03/22 at 4:20 p.m., the dietary manager was observed to prepare pureed ham and potato casserole and place it on the steam table. The ham and potato casserole was observed to contain pieces of ham. The dietary manager stated there were still pieces of ham present even after processing the casserole for an extended period of time. The dietary manager provided the surveyor a sample of the pureed ham and potato casserole. The ham and potato casserole was not observed to be smooth and contained pieces of ham which required chewing. The dietary manager placed the pureed ham and potato casserole on the steam table. On 11/03/22 at 5:15 p.m., the dietary manager plated the pureed ham and potato casserole into a styrofoam container and placed it in the service window to be served to Resident #39. The service was stopped and the facility administrator was shown the texture of the pureed ham and potato casserole. The administrator stated they were able to see pieces of ham in the pureed casserole. On 11/07/22 at 4:26 p.m., the dietary manager was asked how they ensured pureed foods were of the proper consistency. The dietary manager stated they tasted it or observed the food. The dietary manager was asked why they served the ham and potato casserole after stating there were still visible pieces of ham in the pureed casserole. The dietary manager stated the pureed casserole did not look that bad. The dietary manager was asked if they tasted the pureed casserole. The dietary manager stated no. The dietary manager was asked if the pureed ham and potato casserole was the proper texture. They stated no, the consistency was good but there were chunks.

Based on observation, interview, and record review, it was determined the facility failed to prevent accident hazards for one (#6) of three sampled residents reviewed for falls. On 03/19/21 one staff member was transferring resident #6 with the use of a Hoyer lift. The resident fell and broke her hip. The facility failed to ensure proper technique was used to transfer a resident by Hoyer lift. The facility identified 29 residents had fallen in the past six months and 13 residents required the use of a Hoyer lift. Findings: A facility policy for using a portable lifting machine, revised December 2013, documented two nursing assistants were required to perform this procedure. Resident #6 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included [CONDITION(S)], history of a traumatic fracture, and severe protein calorie malnutrition. An admission assessment, dated 12/28/20, documented the resident was independent for daily decision making and required extensive assistance of two staff members with transfers and most activities of daily living (ADLs). A care plan, dated 01/01/21, documented the resident was at risk for falls. The care plan documented the staff was to assist the resident with bed mobility. The care plan did not document the resident required a Hoyer lift for transfers. An incident report, dated 03/19/21, documented the resident fell during transfer with the use of a Hoyer lift. The report documented the staff did not follow facility policy when using the Hoyer lift. The report documented the resident was sent to the hospital for evaluation and treatment. The report documented an investigation was completed and the staff was terminated for not following facility policy. An emergency department note, dated 03/19/21, documented the resident was seen for a contusion of the left hip. An x-ray report, dated 03/19/21, documented a concern for a femoral neck fracture for the resident. A hospitalist discharge summary, dated 03/24/21, documented the resident was non-ambulatory and had [CONDITION(S)]. The discharge summary documented the resident had poor bone status and pins had been placed to her left hip. Inservice records, dated 03/20/21 to 03/26/21, documented the staff was inserviced on the lift machine policy. A quality assurance meeting report, dated 03/25/21, documented nursing issues related to falls, policy changes, and monitoring was discussed. On 08/04/21 at 1:30 p.m., a Hoyer lift transfer was observed. Two staff members transferred a resident using correct technique. On 08/05/21 at 2:10 p.m., the resident was sitting in a recliner in her room. The resident stated she could not ambulate and required the staff to use the Hoyer lift for transfers. The resident stated she had fallen out of the Hoyer lift during transfer in the past. The resident stated since her fall there has always been two staff present when using the Hoyer lift. On 08/10/21 at 1:00 p.m., the administrator stated all staff was inserviced on the mechanical lift policy prior to working their next shift. The administrator stated the education regarding the mechanical lift policy had been added to the new employee hire packet as of 03/20/21. Staff members were interviewed during the survey and were able to verbalize which residents required a two person assist with a transfer. Staff members were also able to verbalize how to appropriately and safely use a hoyer lift, including the use of two staff members at all times.

Based on observation, interview, and record review, it was determined the facility failed to promptly assess, monitor and intervene for one (#3) of six sampled residents who had falls. This resulted in actual harm for the resident, who had a fall and complained of severe pain in her hip and buttocks and was unable to walk or bear weight. The resident was not assessed for three hours, the physician was not notified for three hours and the resident was not sent to the hospital until four hours later. The resident was found to have a [MEDICAL CONDITION]. The facility identified 28 residents with falls in the last ninety days. Findings: The facility's policy on assessing falls and their causes documented, "...1. After a Fall: a. If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. b. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. c. Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. d. Nursing staff will notify the resident's Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone...." Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/13/14, documented the resident was cognitively intact; was independent with transfers, ambulation, and dressing; required supervision with eating; was independent with hygiene; required moderate assistance of one person with bathing; was occasionally incontinent of bladder; and was continent of bowel. It was documented the resident had no deficits with range of motion. The resident's care plan documented a focus for falls. It was documented the resident was at high risk for falls related to the use of pain, allergy, and hypertensive medications. Interventions included to remind the resident to not bend over too far because she might lose her balance and to use the call light for assistance. An incident report, dated 08/24/14 at 8:11 a.m., documented: "...Fall Resident: (#3)... Incident Location: Resident's Room Person Preparing Report: (LPN #2) Incident Description Nursing Description: Res fell trying to transfer to bathroom for urination. Res has left elbow with open area, left middle finger on knuckle with sm open area, res complained very loudly with left hip hurting and not being able to walk. Resident Description: Res stated she was sorry she couldn't help herself, was hurting with hip. Immediate Action Taken Description: Res had v/s taken: 120/70 80 20 97.5 ROM on upper ad (sic) lower extremities left side was unable to move with hip area, res complained of buttocks hurting. Spoke with son, (physician) res transfered to (hospital)... Mental Status...Res complaining of left hip with tears..." The report indicated the physician was notified at 8:32 a.m. A nurse's note, dated 08/24/14 at 8:37 a.m., documented, "...Res fell in room transferring to bathroom. Left side elbow with skin tear and left middle finger with open area on knukle (sic). Res complained of left hip hurting badly..." A nurse's note, dated 08/24/14 at 9:44 a.m., documented, "...Resin (sic) room this morning early at 0545 (5:45 a.m.) and fell transferring to bathroom and urinated on self before falling. Left middle finger and left elbow with skin tear and complaining of left hip pain. Res complained of buttocks hurting. Spoke to (physician name withheld) and (family member) res transferred to (hospital name withheld) via ambulance..." Review of the clinical record revealed no documentation to show the resident was assessed for injury at the time of the incident or that any monitoring had occurred until the day shift nurse completed the incident report at 8:11 a.m. A state reportabe incident report for resident #3, dated 08/24/14, documented, "...Resident was trying to transfer self to toilet for urination. Apparently lost balance in process and fell to floor. She has an open area on her left elbow, small open area on knuckle of left middle finger and complained of pain to left hip. On taking ROM on left side lower extremity, resident unable to move leg and complained of hip pain, also said left buttock hurt. Resident was transported to (hospital name withheld)...Resident is oriented to person, place and time. Resident able to ambulate all over building with walker...Resident did break her left hip. She has had surgery and will return as a skilled patient..." A nurse's note, dated 08/27/14, documented, "...readmitted to facility from hospital on [DATE] S/P (status [REDACTED]. On 11/17/14 at 9:30 a.m., during the initial tour of the facility, the resident was observed in her room. The resident's CNA reported the resident required assistance of staff for transfers and ambulation from the bathroom to the chair or bed. On 11/19/14 at 10:30 a.m., LPN #2, who had worked the day shift on 08/24/14, was interviewed via telephone. LPN #2 was asked what had happened with resident #3. She reported the resident had fallen before she had arrived at the facility to start her shift. She was asked what time she had arrived. She stated she had arrived around 5:15 a.m. LPN #2 reported the night LPN, who no longer worked at the facility, and CNA #3 had gone to the resident's room when the resident fell . LPN #2 stated after she arrived at the facility, the resident continued complaining of hip and buttock pain. She stated she went to the resident's room later and observed the resident could not stand up. She stated, "I thought the hip was broken." LPN #2 reported she called the physician and the family and sent the resident to the hospital around 9:30 a.m. She stated the night nurse had not completed an incident report for the fall so she had made one later. On 11/19/14 at 12:30 p.m., CNA #3 was interviewed via telephone. CNA #3 was asked what had happened when Resident #3 fell . She stated she heard screaming from the resident's room, and she and the night LPN found the resident on the floor. She stated the night nurse looked the resident over and then they lifted the resident up and placed her back in bed. CNA #3 was asked how they had transferred the resident. She stated they lifted the resident under her arms and placed her back in bed. She stated the resident could not bear weight. She stated the nurse had cleaned the wounds on the resident's arms. CNA #3 stated the resident continued to complain of her leg really hurting bad. CNA #3 stated she and another CNA had gone back into the resident's room around 6:00 a.m., to take the resident to the bathroom. She stated the resident could not bear weight. When asked how they transferred the resident, CNA #3 stated they used a wheelchair. On 11/19/14 at 2:30 p.m., the DON was interviewed regarding the lack of assessment and monitoring after resident #3 had the fall that resulted in a [MEDICAL CONDITION]. The DON was notified of the resident falling at approximately 5:45 a.m., and not being assessed at the time of the fall. The DON stated the night nurse should have assessed the resident to rule out any injuries, made out an incident report, notified the DON, and notified the physician at the time of the fall.

Based on interview, and record review, it was determined the facility failed to assess, monitor, and intervene for one resident who had a [DIAGNOSES REDACTED]. This resulted in an actual harm for one (#3) of three sampled residents whose records were reviewed for respiratory issues. This had the potential to affect 13 residents who had a [DIAGNOSES REDACTED]. Findings: A facility policy, titled, [MEDICAL CONDITIONS]- Clinical Protocol, documented, "...the nurse shall assess and document/report...Vital signs...including detailed description of respirations...Full lung assessment...including sounds of wheezing, sputum production...Level of consciousness... Pulse oximetry results...Onset, duration, frequency, severity...What has been done so far to manage the situation...current medications, any changes...Precipitating and relieving factors...staff and physician will identify the impact of existing [MEDICAL CONDITION] and physician will address...the physician will identify situations where hospitalization may be indicated...staff and physician will also encourage advance care planning in individuals with less severe [MEDICAL CONDITION], as for anyone with significant irreversible or progressive chronic conditions..." A facility policy, titled, Change in a Resident's Condition or Status, documented, "Our facility shall promptly notify ...attending physician...of changes in the resident's medical/mental condition and/or status...changes in level of care...a significant change in the resident's physical/emotional/mental condition..." Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 07/23/14, documented the resident had a BIMS score of 13. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident required limited assistance with transfers, extensive assistance with dressing, toileting, and personal hygiene, experienced shortness of breath with exertion, when sitting at rest, and when lying flat, and received oxygen therapy and [MEDICAL CONDITION]. A cardiac/respiratory care plan, dated 08/04/14, documented, "Focus: ...potential for acute respiratory distress due to Diagnosis' of [MEDICAL CONDITION], OBSTRUCTVE SLEEP APNEA, ASTHMA, and End Stage [MEDICAL CONDITION]. Recent hx of hypercapnia, and Pneumonia...Goals: ...will have episodes of acute SOB addressed promptly and comfort maintained and O2 sats>90% through next review date. Interventions: ...Give nebulizer treatments and oxygen therapy as ordered. Observe changes in heart rate and complaints of increased nervousness. Report to Dr. as needed. Monitor s/sx of impending respiratory distress; coughing spells, decreased energy, rapid breathing, complaint of chest tightness or hurting, wheezing, shortness of breath...Monitor vital signs, skin color, pulse biometry, airway functioning and degree of restlessness which may indicate [MEDICAL CONDITION]" A monthly physician's orders [REDACTED]. An assessment, dated 09/06/14 at 10:41 a.m., by RN #1, documented, "...Respiratory: SOB...Yes...On exertion...Yes...Lung sounds...lungs CTA (clear to auscultation)...No...Wheezing...Yes..." A nurse's note, dated 09/06/14 at 4:31 p.m., by RN #2, documented, "...Resident upset with aide at lunch time today and started asking to be sent to hospital. She was assessed by her nurse (RN #1) and had no indications of needing to be sent to the hospital. I myself checked her pulse ox at about 1:15 and it was 99% with temp of 97.2 (tympanic), her O2 was in place via n/c and her only c/o at that time to me, was, "they said I ate breakfast but I don't remember that". She was sitting in her w/c at nurses station without any s/s of resp insufficiencies at that time. At about 4:00 emsa pulls up at door and daughter stated to nurse (RN #3), "I called emsa because you all haven't done anything for her all day, no one has even checked her pulse ox today...She needs to go to hospital and she is going to go. Her nurse (RN #3) gave copy of appropriate paperwork to paramedics at which time they commented they didn't see any reason for her to go either but family said she's going. She left facility via EMSA at about 4:30 pm accompanied by family. FYI. Her aide (name deleted) had answered her light at about 3:30 and resident asked to have her brief changed. At that time there were no family present. Doctor...notified of todays activities and family's actions and informed him that they had taken her to (hospital, name deleted) Also notified DON...at this time..." An ambulance report, dated 09/06/14 at 4:06 p.m., documented, "...Chief complaint Respiratory distress...breathing problem...Oxygen...indication...low SPO2...nasal...1-[MEDICATION NAME] 2.5mg...inhalation...breathing difficulty...Atrovent .5...inhalation. Response: Improved...Impression: Difficulty breathing... ...Narrative report: ...complaining of difficulty breathing...Daughter of pt called 911 stating that pt was "not responsive" and having trouble breathing. Pt states that she has been having trouble breathing today. (Facility, name deleted) staff states that the pts "family wants her to go to the hospital". Pt is on continuous 2 lpm of O2...Upon arrival pt is...in bed. Pt is alert and oriented to person, place, time and event...Pt is placed on cot and O2 was transferred to our portable O2...attached to cardiac monitor with pulse oximetry...pt was administered a nebulized breathing treatment of [REDACTED]. In response to breathing treatment pts pulse oximetry increased and Co2 levels decreased...remained stable with improvements in pt status...Upon arrival care was transferred to (hospital, name deleted)...staff." A hospital emergency room note, dated 09/06/14 at 4:36 p.m., documented, "Physical examination: ...SPO2 87%...Respirations: very diminished BS, bilat rales...XR Chest portable...Final report...suspicious for areas of pneumonia..." The resident received oxygen, respiratory treatments, fluids and three antibiotic medications intervenously, was placed on a [MEDICAL CONDITION] machine in the emergency room . She was transferred by ambulance to another facility for acute care. There was no documentation the facility had followed and implemented the respiratory care plan interventions, notified the physician, monitored the resident's condition, and addressed her request to go to the hospital. There was no documentation the physician was notified or consulted regarding the resident's condition until after the resident had left the facility by ambulance. On 09/10/14 at 1:45 p.m., the DON was asked what had occurred regarding the resident being transferred out to the hospital. She stated they had some staffing issues that day and there were three registered nurses working because some aides had called in. She stated the nurses had said the resident had been anxious and the daughter wanted her to go to the hospital. She was asked for the assessments of the resident's condition at that time. She stated, "They should be in the nurses' notes." On 09/11/14 at 11:05 a.m., the DON was shown the one nurse's note documented by RN #2 that did not address the resident's mental status, respiratory status, lung sounds, physician notification, or pulse oximetry readings from 1:15 p.m. until she was transferred out of the facility. She was asked to speak with the staff that had provided care to the resident. At 2:30 p.m., she stated she had talked to RN #2, who was working at another facility in another town, and she had said that RN #1 was the charge nurse. She stated, "She (RN #1) did 99 percent of the work and she's not taking our calls and has accepted another position." The DON was asked why no one had notified the physician to consult on the resident and monitored the resident. She stated they should have monitored and documented in the clinical record and notified the physician. She stated, "As the DON, I'm responsible and I've communicated that to staff. That nurse totally failed, obviously." She was asked why they had not followed the care plan interventions. She stated, "I can't answer that. I don't know why." She was asked if they should have. She stated, "Yes."

Based on interview and record review, it was determined the facility failed to provide supervision and failed to identify and implement interventions to prevent falls for 1 (#2) of 6 sampled residents who had experienced falls. This resulted in actual harm for resident #2 when she suffered a nose bleed and bruising to her nose after a fall. The facility identified 29 residents who had experienced falls within the last six months. Findings: The facility's undated clinical protocol for falls documented, "...For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall...Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling...If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions...until falling reduces or stops or until a reason is identified for its continuation..." Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 05/21/10, documented a problem of, "...has hx of fall d/t weakness and unsteady on her feet. She is at risk for potential (sic) for injury..." The goal was, "...will be free of self-injury r/t falls qd..." Approaches included, "...Remind/encourage...to ask for or wait for assistance with transfer...Keep call light in reach at all times when in room...Keep adaptive device: wheelchair in reach at all times when in bed. Place wheelchair at side of bed with brakes locked...Observe...at frequent intervals for safety and comfort..." A nurse's note, dated 06/04/10 at 2:30 a.m., documented, "...resident was setting in the floor with urine all over floor..." The care plan, updated on 06/09/10, documented, "...Res fell on floor while attempting to put on shoes, urine noted on floor...Cont goal and approach..." There was no documentation to show the facility identified or implemented any new interventions to aid in the prevention of falls. A quarterly assessment, dated 08/16/10, documented the resident had long and short term memory problems, had moderately impaired cognitive skills for daily decision making, required limited assistance with transfers and personal hygiene, and had fallen within the past 31 to 180 days. A nurse's note, dated 09/04/10 at 4:35 p.m., documented, "...Pt was in room attempted to transfer self from bed to w/c c (no) assist..." An incident report, dated 09/04/10, documented, "...frequent bed checks (and) frequent toileting..." A nurse's note, dated 09/06/10 at 5:30 a.m., documented, "...Res was found sitting in bedroom floor, 2 in laceration on (left) side of head..." An undated fall care plan documented, "...Potential for Injury...Fall risk related to...cognitive deficits...impaired safety awareness...as evidenced by...history of falls...unable to ambulate without assistance...forgets to use assistive devices...unable to transfer without assistance..." The goals were, "...Resident will remain free from injuries...Will receive assist as needed for all ADLs..." Interventions were, "...Maintain record of falls, and evaluate for patterns...Check q 2 (hours) toileting needs..." There was no documentation to show the facility identified or implemented any new interventions to aid in the prevention of falls. A quarterly assessment, dated 02/09/11, did not document the resident's cognitive status. It was documented the resident required limited assistance from one person for transfers and had one fall with injury since her previous assessment. The resident's care plan, dated 02/09/11, documented a problem, "...I am very high risk for falls (and) have had multiple falls recently due to my dementia (and) weakness. I tend to forget I am unable to do things I was capable of previously..." The goal was, "...I will have fewer episodes of falls..." Approaches included, "...Remind me to ask or call for help frequently...Assess me thoroughly when I fall for bruising discoloration - redness...Neuro (checks) if I hit my head...Assure my path is obstacle free...Keep my call light in reach at all times when I am in my room...Keep wheelchair in reach at all times when in bed. Place @ side of bed c brakes locked..." The care plan did not address any new interventions to aid in the prevention of falls. A nurse's note, dated 02/23/11 at 6:00 p.m., documented, "...at 1600 (4:00 p.m.) res was found sitting in floor next to closet with all her clothes pulled out..." The resident's care plan was not updated to include any new interventions to aid in the prevention of falls. A nurse's note, dated 02/24/11 at 2:50 a.m., documented, "...Res noted sitting on buttocks in room across hallway from res room. Blood noted coming from res nose. Res alert et oriented x 2 person et situation. Res stated she fell out of bed onto her face. Nose noted to be swollen...will cont c neuro checks..." An incident report, dated 02/24/11, documented, "...Alert et oriented x 1 person et x situation...Advised res to utilize call light for assist c transfers..." A nurse's note, dated 02/24/11 at 11:00 a.m., documented, "...res cont on neuro (checks) d/t recent fall. res has slight bruising on nose..." The resident's care plan was not updated to include any new interventions to aid in the prevention of falls. On 04/21/11 at 7:19 p.m., the DON was asked what interventions were put into place after each fall to help prevent additional falls. She stated that after the fall on 09/04/10, frequent bed checks and frequent toileting were put into place, after the fall on 09/06/10 no new interventions were put into place, and after the fall on 02/23/11, the resident was re-educated to use the call light. When asked if these were new interventions, the DON stated, "No."