Every finding on record at South Park East

Based on record review and interview, the facility failed to have a water management program to prevent the growth and detection of Legionella. The DON identified 38 residents resided in the facility. Findings:A facility policy titled Legionella Surveillance and Detection, revised July 2017, read in part, Our facility is committed to the prevention, detection and control of water borne contaminants, including Legionella. A facility policy titled Legionella Water Management Program, revised July 2017, read in part, The purpose of the water management program are to identify areas in water system where Legionella bacteria can grow and spread and to reduce the risk of Legionnaire's disease.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.Specific measures used to control the introduction and/or spread of legionella.The water management program will be reviewed at least once a year or sooner. A review of the infection control records, dated 12/01/25 through 05/07/26, did not show any residents were diagnosed with Legionella. On 05/07/26 at 3:30 p.m., the maintenance director was asked for their documentation relating to the water management program to prevent Legionella. They stated they would look and provide all information they had. On 05/08/26 at 9:25 a.m., the maintenance director stated they had no map or drawing of the facility, a system in place that assessed the water system, or had measures in place to monitor to ensure they were free of Legionella. The maintenance director then stated they were not aware they needed to have an assessment of the water system or monitoring in place

Based on observation, record review, and interview, the facility failed to follow menus and provide bread for 1 of 1 meal observation. The dietary manager identified 38 residents in the facility received nutrition from the kitchen. Findings:On 05/04/26 at 12:00 p.m., cook #1 was observed serving the noon meal. [NAME] #1 was observed serving 38 out of 38 trays without any bread or bread sticks. On 05/04/26, the facility menu for the noon meal showed residents were to have the following items served: Ravioli, Italian blend vegetables, bread sticks, and desert. On 05/04/26 at 12:35 p.m., the dietary manager stated no bread had been served, but the cook was supposed to provide plain bread because the stove and oven was not working. On 05/06/26 at 11:15 a.m., cook #1 stated they did not serve bread because there was no way to toast it. They stated they had never had the stove break, so they did not know.

Based on record review and interview, the facility failed to:a. report an allegation of abuse within 2 hours to the OSDH for 1 (#22); andb. complete a final report for an allegation of abuse within 5-days to the OSDH for 1 (#30) of 2 sampled residents reviewed for abuse.The DON identified 38 residents resided in the facility.Findings: 1.An undated face sheet showed Resident #22 was admitted to the facility on [DATE] with diagnoses which included dementia, depression, and psychosis. A Form 283 showed an initial/final incident report for an incident, dated 04/23/26, for Resident #22. The form narrative identified Resident #30. The optional page, read in part, Staff and other residents were interviewed with one further complaint of rape attempt from [Resident #22]. The report's fax transmittal showed the report was sent to OSDH on 04/27/26 at 2:31 p.m., three days after Resident #30 made the allegation. There was no documentation to show the allegation from Resident #22 was reported within two hours to the OSDH. An undated statement, signed by CMA #2, showed Resident #22 approached them and requested a medication to assist with sleep because someone of the opposite sex had just tried to rape them. The undated statement by CMA #2 showed they immediately reported the allegation to the nurse and administrator. On 05/06/26 at 11:21 a.m., CMA #2 stated they were working on April 24th when Resident #22 came out of their room and stated they needed a sleeping pill and someone of the opposite sex had just tried to rape them. CMA #2 stated they reported it to the nurse and the administrator and their statement was taken. CMA #2 stated after writing the statement they turned it in to the administrator and continued to work. They stated Resident #22 reported the allegation to them around 3:30 p.m., when their shift first started. On 05/06/26 at 1:51 p.m., the DON stated they assisted with the investigation after the administrator notified them. The DON stated all allegations needed to be reported within two hours. They stated each allegation, even those found during another investigation, must be reported within two hours and fully investigated. The DON stated the allegation made from Resident #22 was investigated with a previous allegation and it was discovered during the investigation of the allegation of abuse for Resident #30. The DON stated Resident #30 allegation was on 04/24/26. The DON stated the allegation of abuse for Resident #22 should have been reported within two hours, but the investigation was included with that of Resident #30. The DON stated the allegation of abuse for Resident #22 should have been handled differently. On 05/06/26 at 4:31 p.m., the administrator stated Resident #22 was reported to the adult protective services within two hours but was not reported to the OSDH within two hours. 2. A quarterly assessment, dated 02/27/26, showed Resident #30 had a BIMS score of six, which indicated the resident was severely impaired in cognition for daily decision making. A Form 283 showed an initial incident report for an incident, dated 04/23/26, for Resident #30. The form, read in part, It was reported to the Adon by the Activities Director that [Resident #30] stated that someone had touched [their] breast. [Resident #30] was immediately assessed with no new skin issues noted. [Resident #30] has a history of redness to the breast. [Resident #30] was also interviewed and stated a white [person] not too old and not too young touched [their] breast. [Resident #30] denied any pain or discomfort. The one white [person] on duty has been suspended pending investigation. Review of the facility's investigation did not show a final report had been submitted to the OSDH for the incident dated 04/23/26. On 05/05/26 at 4:00 p.m., the DON stated they had put the final results of the investigation for the incident dated 04/23/26 on the Form 283 for Resident #22. On 05/06/26 at 9:21 a.m., Resident #30 stated they had not ever been abused or touched inappropriately and felt safe in the facility. On 05/06/26 at 4:55 p.m., the administrator stated final reports were to be sent to the OSDH within five days. They stated they should not have sent the final report for Resident #30 on the report for Resident #22.

Based on observation, record review, and interview, the facility failed to ensure a quarterly assessment accurately reflected wandering behavior for 1 (#30) of 3 sampled residents reviewed for accidents and supervision. The DON identified one resident was coded on assessments as a wanderer in the facility. Findings:On 05/04/26 at 11:50 a.m., Resident #30 was observed to walk out of room [ROOM NUMBER]. The name plate on the door was not the name of Resident #30. On 05/04/26 at 12:20 p.m., Resident #30 was observed to come out room [ROOM NUMBER] with a purse and walk down to room [ROOM NUMBER], their assigned room. As Resident #30 exited room [ROOM NUMBER], they told another resident to get out of their room.On 05/04/26 at 1:56 p.m. Resident #30 was observed to enter room [ROOM NUMBER], got a pillow, and took it down the hall. Resident #30 was heard stating room [ROOM NUMBER] was their room. On 05/04/26 at 3:26 p.m., Resident #30 was observed in room [ROOM NUMBER] and told the resident who resided in the room to leave. The resident who was told to leave their room was observed leaving their room after being told to go.An undated face sheet showed Resident #30 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. An admission assessment, dated 11/28/25, showed Resident #30 wandered one to three days during the seven-day look back period of the assessment. The assessment showed the wandering behavior for Resident #30 would be addressed on the care plan. A quarterly assessment, dated 02/27/26, showed Resident #30 had a BIMS score of six, which indicated they had a severe impairment in their cognition. The assessment showed Resident #30 had no behaviors such as wandering or rummaging.Nurse progress notes, dated 11/21/25 through 05/06/26, did not show wandering behaviors for Resident #30.On 05/07/26 at 9:30 a.m., CNA #1 stated Resident #30 resided in room [ROOM NUMBER], was confused most of the time, and ended up in other residents' rooms. CNA #1 stated Resident #30 wandered into other resident rooms daily since being admitted to the facility.On 05/07/26 at 9:38 a.m., CNA #2 stated Resident #30 believed room [ROOM NUMBER] was theirs and claimed it as their room. CNA #2 stated when they redirected Resident #30 from other residents' rooms, they became upset with them. CNA #2 stated they did not document these behaviors anywhere.On 05/07/26 at 9:44 a.m., CNA #3 stated when Resident #30 was awake they went room to room and laid on other residents' beds. CNA #3 stated Resident #30 had these wandering behaviors daily since admission and they did not document it anywhere.On 05/07/26 at 9:51 a.m., CMA #1 stated Resident #30 resided in room [ROOM NUMBER], would bypass their room, and go to room [ROOM NUMBER]. CMA #1 stated this occurred every day when Resident #30 was awake. CMA #1 stated they did not document the wandering anywhere.On 05/07/26 at 10:01 a.m., LPN #1 stated Resident #30 was ambulatory and would wander into residents' rooms daily. LPN #1 stated they had worked at the facility since January 2026 and Resident #30 had this behavior daily.On 05/07/26 at 10:31 a.m., the MDS coordinator stated Resident #30 did not wander a lot. They stated there were no notes documented so wandering would not have been coded on the quarterly assessment. They stated they would interview staff but would not ask about wandering. They stated they relied on the documentation in the chart.

Based on observation, record review, and interview, the facility failed to ensure comprehensive care plans were developed for 2 (#8 and #30) of 14 sampled residents whose care plans were reviewed.The DON identified 38 residents resided in the facility.Findings: 1.On 05/07/26 at 8:35 a.m., Resident #8 was observed in a Geri-chair with the fingers on their right and left hand curled inward. On 05/07/26 at 10:51 a.m., hospice aide #1 was observed to transport Resident #8 to the shower room. A facility policy titled Care Plans, Comprehensive Person-Centered, revised 2016, 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. An annual assessment, dated 02/26/26, showed a BIMS score of 00, which indicated the resident was severely impaired in cognition for daily decision making. The assessment showed the resident had impairment in range of motion to one side of their upper and lower extremities and received range of motion services during the lookback period. A Physician's Certification for Hospice Benefit form, dated 03/18/26, showed Resident #8 was admitted to hospice services. On 05/05/26 at 11:08 a.m., family member #1 stated Resident #8 had a contracture to the left hand. Family Member #1 stated they had elected the hospice benefit for Resident #8 a couple of months ago. On 05/07/26 at 8:38 a.m., LPN #1 stated Resident #8 had limited range of motion in both hands. On 05/07/26 at 10:52 a.m., LPN #1 stated Resident #8 had received hospice services for several months. On 05/07/26 at 10:54 a.m., the MDS coordinator reviewed the electronic clinical record and stated Resident #8 had elected the hospice benefit in March 2026. They stated they had failed to develop a care plan related to hospice services. On 05/07/26 at 11:02 a.m., the MDS coordinator reviewed the electronic clinical record and stated Resident #8 had a contracture to the left hand. They stated the care plan and interventions for limited range of motion/contracture had been on the previous care plan but it had not carried over when the care plan was revised on 02/26/26. On 05/07/26 at 2:13 p.m., the DON stated they were not sure why the limited range of motion/contracture was not on the current care plan. They stated they would need to monitor care plans. On 05/07/26 at 2:16 p.m., the DON stated the care plan for hospice may have been overlooked but should have been completed. 2. On 05/04/26 at 11:50 a.m., Resident #30 was observed to walk out of room [ROOM NUMBER], the name plate on the door was not the name of Resident #30. On 05/04/26 at 12:20 p.m., Resident #30 was observed coming out room [ROOM NUMBER] with a purse and walk down to their assigned room, room [ROOM NUMBER]. As Resident #30 was exiting room [ROOM NUMBER] they told another resident to get out of their room. On 05/04/26 at 1:56 p.m. Resident #30 once again went into room [ROOM NUMBER], got a pillow, and took it down the hall. Resident #30 was heard stating room [ROOM NUMBER] was their room. On 05/04/26 at 3:26 p.m., Resident #30 was observed in room [ROOM NUMBER] and told the resident who resided in the room to leave. The resident who was told to leave their room was observed leaving. An undated face sheet showed Resident #30 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. An admission assessment, dated 11/28/25, showed Resident #30 wandered one to three days during the seven-day look back period of the assessment. The assessment showed the wandering behavior for Resident #30 would be addressed on the care plan. A care plan, last revised on 12/08/25, did not address Resident #30's wandering, entering into other residents' rooms, or attempting to keep those residents out of their own room. A quarterly assessment, dated 02/27/26, showed Resident #30 had a BIMS score of six, which indicated they had a severe impairment in their cognition. The assessment showed Resident #30 had no behaviors such as wandering or rummaging. Nurse progress notes, dated 11/21/25 through 05/06/26, did not show wandering behaviors of Resident #30. On 05/07/26 at 9:30 a.m., CNA #1 stated Resident #30 resided in room [ROOM NUMBER] and they were confused most of the time and ended up in other residents' rooms. CNA #1 stated Resident #30 wandered into other resident rooms daily since being admitted to the facility. admitted to the facility. On 05/07/26 at 9:38 a.m., CNA #2 stated Resident #30 believed room [ROOM NUMBER] was theirs and claimed it was their room. CNA #2 stated when they redirected Resident #30 from other residents' rooms, they would become upset with them. CNA #2 stated they did not document these behaviors anywhere. On 05/07/26 at 9:44 a.m., CNA #3 stated when Resident #30 was awake they went room to room and laid on other residents' beds. CNA #3 stated Resident #30 had these wandering behaviors daily since admission and they did not document it anywhere. On 05/07/26 at 9:51 a.m., CMA #1 stated Resident #30 resided in room [ROOM NUMBER], but would go right by their room and go to room [ROOM NUMBER], CMA #1 stated this occurred every day when Resident #30 was awake. CMA #1 stated they did not document the wandering behavior anywhere. On 05/07/26 at 10:01 a.m., LPN #1 stated Resident #30 was ambulatory and would wander into residents' rooms daily. LPN #1 stated they had been working at the facility since January 2026 and Resident #30 had wandering behavior daily. On 05/07/26 at 10:31 a.m., the MDS coordinator stated Resident #30 did not wander a lot. The MDS coordinator stated they reviewed documentation to determine if a resident had wandering behaviors to be care planned. They stated there were no notes documented so wandering would not have been coded on the quarterly assessment. They stated they would interview staff but would not ask about wandering and they relied on the documentation in the chart. The MDS coordinator stated they were not aware of the wandering, and the care plan did not address wandering into other residents' rooms, and it should have been care planned.

Based on observation, record review, and interview, the facility failed to ensure inspection of u-bars was part of their regular maintenance program for 1 (#38) of 1 sampled resident reviewed for accident hazards related to bed rails.The DON identified one resident utilized bed rails.Findings: On 05/05/26 at 12:00 p.m., the bed for Resident #38 was observed to have a u-bar (a type of bed side rail) on the right side of their bed. On 05/05/26 at 2:21 p.m., Resident #38 was observed in their bed with their eyes closed with a u-bar on the right side of the bed. A Bed Safety policy, dated December 2007, read in part, Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. A physician order, dated 06/14/25, showed a u-bar may be used to assist with transfers for Resident #38. A quarterly assessment, dated 04/17/26, showed a BIMS score of four, which indicated the resident was severely impaired in cognition for daily decision making and required partial to moderate assistance for transfers from their chair to their bed. A care plan, revised 04/20/26, showed Resident #38 could utilize a u-bar for assistance with bed transfers. A Medical Device Monthly Evaluation, dated 04/21/26, read in part, Device U bar .Promotes safety comfort and positioning. Review of the electronic clinical record did not show the u-bar for Resident #38 had been inspected as part of the maintenance program. On 05/06/26 at 11:17 a.m., the maintenance supervisor stated they did not regularly inspect u-bars as part of their maintenance program. They stated the only thing they did with u-bars was install and remove them when instructed. On 05/06/26 at 12:44 p.m., the administrator stated they did not know why the maintenance supervisor did not conduct regular inspections of u-bars as part of their maintenance program.

Based on record review and interview, the facility failed to complete a thorough investigation of an allegation of sexual abuse for 1 (#22) of 2 sampled residents reviewed for abuse. The DON identified 38 residents resided in the facility. Findings: An undated face sheet showed Resident #22 was admitted to the facility on [DATE] with diagnoses which included dementia, depression, and psychosis.A Form 283 showed an initial/final incident report for an incident, dated 04/23/26, for Resident #22. The form narrative identified Resident #30. The optional page, read in part, Staff and other residents were interviewed with one further complaint of rape attempt from [Resident #22]. The report's fax transmittal showed the report was sent to OSDH on 04/27/26 at 2:31 p.m., three days after Resident #30 made the allegation.An undated statement, signed by CMA #2, showed Resident #22 approached them and requested a medication to assist with sleep because someone of the opposite sex had just tried to rape them. The undated statement by CMA #2 showed they immediately reported the allegation to the nurse and administrator. There was no documentation of an investigation into Resident #22's allegation of attempted rape made on 04/24/26 to CMA #2. On 05/06/26 at 11:21 a.m., CMA #2 stated they were working on April 24th when Resident #22 came out of their room and stated they needed a sleeping pill and someone of the opposite sex had just tried to rape them. CMA #2 stated they reported it to the nurse and the administrator and their statement was taken. CMA #2 stated after writing the statement they turned it in to the administrator and continued to work. They stated Resident #22 reported the allegation to them around 3:30 p.m., when their shift first started.On 05/06/26 at 1:51 p.m., the DON stated they assisted with the investigation after the administrator notified them. The DON stated all allegations needed to be reported within two hours. They stated each allegation, even those found during another investigation, must be fully investigated. The DON stated the allegation made from Resident #22 was investigated with a previous allegation and it was discovered during the investigation of the allegation of abuse for Resident #30. The DON stated the allegation of sexual abuse for Resident #30 was on 04/24/26. The DON stated the allegation of abuse for Resident #22 was investigated and included with that of Resident #30. The DON stated the allegation of abuse for Resident #22 should have been handled differently. On 05/06/26 at 2:33 p.m., the ADON stated CMA #2 and the administrator came to them and reported Resident #22 stated someone of the opposite sex attempted to rape them on 04/24/26. The ADON stated they talked with Resident #22 who stated someone of the opposite sex tried to come into their room. The ADON stated they had not documented the conversation with Resident #22. The ADON stated the investigation for Resident #22 was included with the investigation for Resident #30 and nothing was done separately. The ADON stated the allegation from Resident #22 should have been handled separately and investigated on its own. On 05/06/26 at 4:31 p.m., the administrator stated there was no documentation the allegation of rape from Resident #22 was investigated and it was part of the investigation for Resident #30.

Based on record review and interview, the facility failed to ensure a significant change assessment was completed for 1 (#8) of 1 sampled resident reviewed for hospice services.The DON identified eight residents received hospice services. Findings: A Physician's Certification for Hospice Benefit, dated 03/18/26, showed Resident #8 had been certified for hospice services for a terminal diagnosis of Alzheimer's disease. The form, read in part, It is my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. The form had been signed by the physician. Review of the electronic clinical record did not show a significant change assessment had been completed when the resident elected the hospice benefit. On 05/07/26 at 10:52 a.m., LPN #1 stated Resident #8 had received the hospice benefit for a couple of months. On 05/07/26 at 10:54 a.m., the MDS coordinator stated Resident #8 had received the hospice benefit since March 2026. They stated when a resident elected the hospice benefit a significant change assessment was to be completed. They reviewed the electronic clinical record and stated they had forgotten to complete a significant change assessment when Resident #8 elected the hospice benefit in March 2026. On 05/07/26 at 2:16 p.m., the DON stated they did not know why a significant change assessment had not been completed when Resident #8 elected the hospice benefit in March 2026. They stated, It must have been overlooked.

On 09/09/25, an IJ situation was determined to exist related to the facility's failure to provide protection from sexual abuse/inappropriate touching from two residents towards three residents sampled for abuse.On 09/09/25 at 11:19 a.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 09/09/25 at 11:54 a.m., the administrator and ADON were notified of the IJ situation and the IJ template was provided.On 09/10/25 at 11:53 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Identification of total number of residents at risk for the same failed practice:42Actions taken to remove the immediacy of the alleged failed practice:o There are 3 residents identified as affected by this alleged deficient practice with the potential for 42 residents overall to be affected including the 2 residents alleged to have had the behaviors affecting others. Resident #1 and Resident #4 have dementia related conditions as does the entire population of this Specialized Dementia Care Facilityo Resident #1 was placed on 1:1 supervision on 08-20-2025 for 72 hours and was no longer exhibiting sexuality toward others-[they] was already on medication to curb sexual impulses at that time and had been on it since 06-07-2025 despite having no behaviors at that time due to making comments toward women staff but no behaviors related to sexual contact or attempts for contact at that point. Resident #1 was placed back on 1:1 supervision on 08-26-2025 and his psychoactive medications were increased (and [they] remained on the previous ordered medication to curb sexuality) by the PA when [they] was notified of an episode of sexuality toward another resident and was removed from 1:1 supervision at 72 hours when no further behaviors of increased sexuality noted and a room change put him into less proximity to women in that room change. On 08-31-2025 a [identity withheld] resident entered Resident #1 room when a contact occurred, so we were unable to determine who initiated that contact since both residents have cognitive impairment. Resident #1 was placed on 1:1 supervision on 08-31-2025 at the time of the identified incident affecting other resident. Resident #1 was sent out to the hospital related to behaviors on 08-31-2025 and returned on 09-01-2025 and remained on 1:1 and continues to be on 1:1 supervision. Resident #4 remains on 1:1 supervision as well since his conduct on 08-31-2025.o The PA was notified of the incidents at the time of occurrence of each. The PA did not state to the facility staff at that time or any other time that [they] felt a discharge was in order for either resident. PA had made medication changes each time for resident #1 in addition to facility interventions but did not make any changes to resident #4 medications stating it was because the [other] resident in that situation was in resident #4 room and resident #4 had no increased sexually motivated behaviors noted before.o All residents that were interviewable have been interviewed and those that are non-interviewable were assessed with no evidence of abuse or inappropriate/ nonconsensual contact identified based on assessment/interview/observation.o Training of all staff in the areas of abuse/neglect risk including sexual behaviors and potential for such behaviors, identification of those at risk for neglect/abuse, protection measures to prevent abuse and neglect, and dementia care including documentation of 1:1 when provided and in-service lasted for 30 minutes for all current staff by the Nursing Leadership Team staff at 12:15pm September 9, 2025 and no other staff will be permitted to work until they have been in-serviced before their next scheduled shift by phone contact or in-person. The information for in-service covered is attached.o The facility will monitor residents (current and future) behaviors to observe for potential to administer/receive abuse or neglect, and verbalization of signs of behaviors that could escalate to abuse or neglect including sexual abuse. New admits will be screened through interviews and record reviews for at risk behavior including abuse and neglect potential including sexual abuse or behaviors that have the potential to affect others. If a resident is determined to be at risk, then this information will be care planned with individualized interventions for that resident will be determined and implemented which may include 1:1 supervision and/or safe discharge. This information will be captured on the initial baseline care plan for new admissions and on regular care plans for current residents. Any behaviors exhibited would be captured in behavior notes and screened daily by the DON or designee to identify behaviors that might lead to abuse/neglect including potential/actual sexual behaviors. The staff will also notify the DON or Administrator of residents that are having signs of increased sexuality at the time of the event so an immediate intervention can be placed and remain in-place until the behaviors are no longer putting anyone at risk. Psych plus services were recently added to our service offering at South Park East. Actions taken to prevent recurrence of alleged failed practice: DON or designee will:o Daily review of all incidents and behavior notes to identify residents at risk for behaviors affecting others including abuse/neglect including sexual behaviorso Reviews will include protection of residents from abuse/neglect including sexual abuse and interventions to reduce abuse/neglect while still protecting resident rights including consensual contacto Training for staff will continue re: dementia including protective measures from abuse/neglect as well as dementia care and behaviors prevention/management and including documentation for 1:1 care when provided, on an on-going basis by the DON, ADON, MDS, Corporate staff or Administrator and will include new hires on 09-09-2025 and on-goingo The facility will monitor resident (current and future) behaviors to observe for potential abuse or increasing sexuality towards others that may put others at risk. New admits will be screened through interviews and record review for at risk behavior including potential risk of abuse or neglect toward others. If a resident is determined to be at risk, then this information will be care planned with individualized interventions for that resident will be determined and implemented. This information will be captured on the initial baseline care plan for new admissions and on regular care plans for current residents. Any behavior exhibited would be captured in the behavior notes and screened daily by the DON or designee to identify behaviors that might lead to abuse/neglect including non-consensual sexual contact. The staff will also notify the DON or Administrator for residents that are exhibiting behaviors that put themselves or others at potential/actual risk at the time of the event so an immediate intervention can be placed.Actions will be completed by: 09-09-2025 3:00PM and no staff will be permitted to work until they have completed the training, and this training will be completed before the start of their next worked shift. All current working staff will be in-serviced about this as of 09-09-2025 on 09-09-2025.Monitoring implementation of the plan:o Administrator or designee will monitor abuse/neglect identification, protection from abuse/neglect and dementia care including behaviors that put self or others at risk.o Daily review allegations and incidents, as well as behaviors that put or potentially put self or others at risk as well as documentation for 1:1 when providedo Review of residents with allegations and incidents, and behaviors that put or potentially put self or others at risk as well as documentation for 1;1 when provided will be conducted daily and the information carried through the Quality Assurance Performance Improvement Processo All residents that can be interviewed will be interviewed and those that are noninterviewable (sic) will be assessed for evidence of abuse or inappropriate/ nonconsensual contact based on assessment/interview/observation.o The facility will monitor resident (current and future) behaviors to observe for risk of abuse/neglect including nonconsensual sexual contact. New admits will be screened through interview and record review for at risk behavior including potential risk of putting others at risk of abuse/neglect including but not limited to nonconsensual sexual contact. If a resident is determined to put others at risk , then this information will be care planned with individualized interventions for that resident to be determined and implemented to protect others and self. This information will be captured on the initial baseline care plan for new admissions and on regular care plans for current residents. Any behaviors exhibited would be captured in the behavior notes and screened daily by the DON or designee to identify behaviors that might lead to abuse/neglect of others. The staff will also notify the DON or Administrator for residents that are or potentially at risk of behaviors affecting others at the time of the event so an immediate intervention can be placed and maintained as indicated. Information will be carried through the Quality Assurance Performance Improvement Process. On 09/10/25 at 4:05 p.m., the IJ was lifted after review to ensure all the components of the POR were reviewed which included 1:1 documentation, resident assessments for injury, and staff interviews regarding education for abuse and dementia, The deficient practice remained at an isolated level with the potential for harm. Based on observation, record review and interview, the facility failed to ensure protection from sexual abuse/inappropriate touching was provided for 3 (#2,3, and #5) of 3 sampled residents reviewed for abuse.The operating officer identified 42 residents resided in the facility.Findings:A policy titled Abuse and Neglect - Clinical Protocol, revised July 2017, read in part, 1. Abuse .Includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes . Sexual abuse .non-consensual sexual contact of any type with a resident.1. 1. Resident #1's order summary, dated 09/04/25, showed Resident #1 had diagnoses of sexual dysfunction and dementia.A quarterly assessment, dated 07/25/25, showed the BIMS of 3 which indicated severe cognitive impairment. The assessment showed verbal and other behaviors, rejection of care and independent mobility. A care plan, initiated 06/12/25, showed Resident #1 had times of making sexually inappropriate actions towards themself or others and had a diagnosis of sexual disfunction. An Initial INCIDENT REPORT FORM, dated 08/20/25, showed Resident #1 was witnessed by staff to place their hand down Resident #3's shirt in the hallway. The report showed Resident #1 was to be placed on 1:1.An Initial INCIDENT REPORT FORM, dated 08/26/25, showed Resident #1 was observed touching Resident #2 inappropriately. The report showed Resident #1 was to be placed on 1:1 and was to receive a psychological evaluation related to current behaviors and care plan would be updated to reflect residents' current status.The care plan was not updated timely following the incident.An initial INCIDENT REPORT FORM, dated 08/31/25, showed Resident #1 was observed touching Resident #5's breast. The report showed Resident #1 was sent out to hospital for psychological evaluation and the care plan was to be updated to reflect current status. 2. 2. Resident #4's care plan, dated 06/12/25, showed diagnoses which included unspecified dementia with agitation. A quarterly assessment, dated 06/24/25, showed a BIMS of 3 indicating severe cognitive impairment. The assessment showed rejection of care and wandering, and mobility assistance. AAn Incident Note, dated 08/31/25, showed Resident #4 was observed touching Resident #2 inappropriately. An Alert Note, dated 08/31/25, showed staff observed Resident #4 with hands on top of the resident's (#2) brief and under shirt. An Initial INCIDENT REPORT FORM, dated 08/31/25, showed Resident #4 was observed touching Resident #2's breast. The report showed Resident #4 was placed on 1:1 and the care plan was to be updated to reflect current status.3. 3. Resident #2's care plan, dated, 06/25/25, showed diagnoses which included Alzheimer's disease and unspecified dementia. A significant change assessment, dated 06/04/25, showed Resident #2 had a BIMS of 00 indicating severe cognitive impairment. The assessment showed rejection of care, wandering, and showed the resident required assistance with mobility and used a wheelchair.An Incident Note, dated 08/26/25 at 3:57 p.m., showed Resident #2 was touched inappropriately by Resident #1.An Alert Note, dated 08/31/25 at 8:47 p.m., showed Resident #4 was observed with their hands on top of Resident #2's brief and under their shirt. 4. 4. Resident #3's quarterly assessment, dated 07/04/25 showed Resident #3 had a BIMS of 00 indicating severe cognitive impairment, physical and verbal behaviors, and wandering. It showed they were independent with mobility. It showed a diagnosis of dementia. An Incident Note, dated 08/20/25 at 6:36 p.m., showed Resident #3 was sitting in a chair in the hallway when Resident #1 touched their breast. 5. 5. Resident #5's care plan, dated 01/07/25 showed diagnosis of Alzheimer's disease.A quarterly resident assessment dated , 07/30/25, showed Resident #5 with BIMS of severely impaired cognition, physical and verbal behaviors, wandering and independent with mobility. On 09/02/25 at 2:50 p.m., CNA #1 stated Resident #1 had touched two of the residents of the opposite sex. They stated Resident #1 had their hands down the resident's shirt and Resident #1 spoke sexually to both the staff and the residents. CNA #1 stated when Resident #1 had the behavior, they would redirect them back to their room and was placed on 1:1. CNA #1 stated Resident #1 had been on 1:1 back-to-back and had been sent to the hospital and came back the next day. They were not aware of anything else being done about the incident. CNA #1 stated they were aware of the incidents with Residents #2 and #3 with regarding Resident #1. CNA #1 stated their last abuse education was last week. CNA #1 was not aware of any sexual behaviors regarding Resident #4.On 09/02/25 at 3:06 p.m., CNA #2 stated they had not received any abuse education within the last two weeks with the last one being on 08/20/25. They stated the interventions to prevent other incidents was the 1:1 and to be within arm's length of the residents.On 09/04/25 at 12:50 p.m., LPN #1 stated Resident #1 had sexual behaviors and was aggressive. They stated they had not received any education on abuse at all in the month of August. LPN #1 stated they were aware of the sexual behaviors of Resident #1 with Resident #3 and another unknown resident the past weekend. LPN #1 stated the facility separated the residents, did 1:1 with Resident #1. They stated Resident #1 was monitored and the incident reported. Monitoring through the shift and monitoring for other behaviors. LPN #1 stated Resident #4 had also been inappropriate with another unknown resident as it had taken place at the same time as Resident #1 on 08/31/25. LPN #1 stated the unknown resident wandered into Resident #4's room. LPN #1 stated wandering was the problem with intermingling women and men. LPN #1 stated the process for 1:1 was for 72 hours, but for Residents #1 and #4 it was for a week. LPN #1 stated the incident with Resident #1 and Resident #3 had occurred in the hallway on evening shift. They stated they were not in the facility and did not know what was else had been done. LPN #1 stated the interventions were 1:1 and psychiatric evaluation. LPN #1 was not aware of the victim in the incident with Resident #4 touching another resident but knew the intervention was 1:1. On 09/05/25 at 2:35 p.m., the DON stated they attempted to prevent recurrence by continued monitoring and tried to keep them away from the other residents. There was no documentation to show the family of Resident #5 had been made aware of the incident that involved them. On 09/08/25 at 1:34 p.m., PA #1 stated they were aware of Resident #1's sexual behaviors towards other residents and placed them on estrogen and psychiatric medication. They stated Resident #1 had been sent to the hospital for behaviors and was sent back to the facility on antipsychotic medication. PA #1 stated the behaviors to expect from someone with a diagnosis of sexual dysfunction would be all the behaviors presented by Resident #1, and that there were a lot of residents of the opposite sex in the facility and the other gender does not know any better. The PA stated they could not get the psychiatric units to admit them. They stated the interventions to prevent recurrence was the 1:1, monitoring, keep them separated and to have family to come visit. On 09/08/25 at 2:00 p.m., PA #1 stated there was nothing else medically for them to do and they felt the perpetrators needed to be discharged . They stated the building was not big enough to deal with this population. PA #1 stated they did not feel the facility was able to provide adequate monitoring for a resident with sexual dysfunction who touched other residents when not on 1:1 monitoring with staff. On 09/08/25 at 2:03 p.m., PA #1 stated they were aware of the behavior of Resident #4 and the same interventions applied for them as for Resident #1. The PA stated the building was not big enough to deal with the population as it was all Alzheimer's and dementia related diagnosis.

Based on record review and interview, the facility failed to ensure allegations of abuse were thoroughly investigated for 5 (#1, 2, 3, 4, and #5) of 5 sampled residents reviewed for abuse. The administrator identified 42 residents resided in the facility. Findings:A policy titled Abuse and Neglect - Clinical Protocol, read in part, The nurse will assess the individual and document related findings.An OSDH incident report, dated 08/20/25, showed Resident #1 touched the breast of Resident #3. There were no safe surveys/assessments of other residents to assure safety, and there was no abuse education documented for all staff.An OSDH incident report, dated 08/26/25, showed Resident #1 touched the breast of Resident #2. There were no safe surveys/assessments of other residents to assure safety, and there was no abuse education documented for all staff. An OSDH incident report, dated 08/31/25, showed Resident #1 touched the breast of Resident #5. There were no safe surveys/assessments of other residents to assure safety, and there was no abuse education documented for all staff.An OSDH incident report, dated 08/31/25, showed Resident #4 touched the breast of Resident #2. There were no safe surveys/assessments of other residents to assure safety, and there was no abuse education documented for all staff.On 09/04/25 at 3:07 p.m., the DON stated they were not aware they needed to complete part C (summary of the investigation details) of the incident report.On 09/05/25 at 10:28 a.m., the DON stated they did not do staff education on the incidents regarding sexual abuse/inappropriate touching. The DON stated QA was done monthly and had not had a meeting for this month yet. They stated they do education on abuse often on their training system. On 09/05/25 at 12:33 p.m., the DON stated they did not have documentation of the education but did do verbal education on abuse following each incident and they could write it down now. On 09/05/25 at 2:35 p.m., the DON stated the charge nurse or whoever finds the issue does the incident report. They stated the results of the assessments on the other residents potentially affected was done visually and not documented.

Based on record review and interview, the facility failed to ensure a resident's family was notified of an allegation of abuse for 1 (#5) of 7 sampled residents reviewed for abuse.The administrator identified 42 residents resided in the facility. Findings:A policy titled Change in a Resident's Condition or Status, revised 12/2016, read in part, Our facility shall promptly notify the resident, his or her attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc. A quarterly assessment, dated 07/30/25, showed Resident #5 had a BIMS score of 3, which indicated severe cognitive impairment. The assessment showed they were independent with mobility.An incident report, dated 08/31/25, showed Resident #1 was observed touching Resident #5's breasts. The report showed the family was notified. An order summary, dated 09/04/25, showed Resident #5 had diagnoses which include Alzheimer's disease and dementia. A family representative interview with Resident #5's family stated they were not aware of any incidents with another resident. They stated they were not aware of residents of the opposite sex in the facility and not informed of any incident that occurred over the weekend. On 09/05/25 at 3:00 p.m., the DON stated they were not aware the family had not been contacted. The DON stated the family should have been notified that same night. On 09/08/25 at 10:52 a.m., the DON stated they had looked into the notification for Resident #5 and stated a note showed they attempted to reach but were unable to. They stated there was not a re-attempt noted, and they were to look into that and notify the family today.

Based on record review and interview, the facility failed to revise/update care plan timely following incidents of abuse for 1 (#1) of 2 sampled residents reviewed for abuse allegations.The administrator identified 42 residents resided in the facility.Findings:A policy titled Care Plans, Comprehensive Person-Centered, dated 12/2016, 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.Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. The Interdisciplinary Team must review and update the care plan: . When the desired outcome is not met.A care plan, initiated on 06/12/25, read in part, I do at times make sexually inappropriate actions towards myself or others. I have a dx of sexual disfunction. The care plan showed an incident, dated 06/06/25, of Resident #1 grabbing staff private parts and making sexual comments about staff. The care plan showed a revision on 09/05/25.A quarterly assessment, dated 07/25/25, showed Resident #1 had a BIMS 3, which indicates severe cognitive impairment. The assessment showed they were independent with mobility. Review of the care plan changes since last review per the electronic record showed the incident on 08/31/25 was dated for 09/01/25. The incident on 08/20/25 was dated for 09/02/25. The incident on 08/26/25 was dated for 09/05/25. An order summary, dated 09/04/25, showed Resident #1 had diagnoses which included sexual dysfunction and dementia.On 09/05/25 at 2:06 p.m., the MDS coordinator stated the care plans were updated every three months and as necessary. They stated if a fall or something physical then they had to add something. The MDS coordinator was asked when Resident #1's care plan had been updated. The MDS coordinator stated they were in it on 09/05/25 and had added on 08/31/25. The MDS coordinator stated they added the behaviors on the 31st. They stated the care plan was updated after each incident of abuse on 6/6/25, 8/20/25, 8/26/25, and 8/31/25. After they reviewed the history of the care plan updates in the electronic record, the MDS coordinator acknowledged they were updated on 09/01/25 and not after the 08/20/25 or the 08/26/25 incidents of abuse. The MDS coordinator stated the care plan should have been updated prior 09/01/25 or 09/05/25 for the related incidents and they were the only ones to update the care plans.

Based on observation, record review and interview, the facility failed to ensure staffing information, which included the facility name, date, actual hours worked for RNs, LPNs, CNAs, and the resident census, was posted in a prominent place readily accessible to residents and visitors. The DON identified 30 residents resided in the facility. Findings: On 02/21/24 at 10:17 a.m., a tour of the facility was conducted to locate the posted nursing staffing information. Behind the nurses' station on a dry erase board, there was a list of staff members working for the 7:00 a.m. to 3:00 p.m. shift, 3:00 p.m. to 11:00 p.m. shift, and the 11:00 p.m. to 7:00 a.m. shift. The date 02/21/24 was located on the board. There was no facility name, census, or actual hours worked located on the dry erase board. On 02/21/24 at 10:20 a.m., the DON located a binder at the nurses' station behind the desk. They stated it was the schedule book. The DON provided a copy of the Daily Staffing Assignment Sheet, dated 02/21/24, which documented census 30, DON, Administrator, and the staffing assignments for the 7:00 a.m. to 3:00 p.m. shift, 3:00 p.m. to 11:00 p.m. shift, and the 11:00 p.m. to 7:00 a.m. shift. They stated it was not posted, but was kept in a binder. On 02/21/24 at 10:26 a.m., the DON stated the form did not contain the facility name, or actual hours worked for RNs, LPNs, or CNAs.

Based on observation, record review, and interview, the facility failed to ensure food items were dated, labeled, and not left open to air in the cooler located in the kitchen for one of two kitchen observations. The CDM identified 11 residents with puree diet, 11 residents with mechanical diets, and eight residents with regular diets resided in the facility. Findings: A Date Marking policy, undated, read in part, .All food and supply items in the Dietary Department should be date marked with receive date.Once items are removed from the original packing and placed in alternate storage containers, the alternate storage container must have received date and transfer date .These items require name labeling also if product inside is not easily identifiable .If items are opened but not dished, this product should be placed in a sealed container, labeled with the open date . On 02/20/24 at 9:02 a.m., the CDM stated staff were to date food items when they came in, date after opening, and date when placing in the fridge. They stated everything was to be dated. On 02/20/24 at 9:25 a.m., the following items were observed in the cooler: a. a metal bowel of meat the CDM identified as chicken for that day. They stated there was no date or label; and b. one large tube of a lunch meat product and a small tube of lunch meat product. The CDM identified both as bologna. They stated there was no date or label present. On 02/20/24 at 9:28 a.m., there was a bag of chopped white items in plastic wrap in the cooler. The CDM stated there was not a date or label on it. On 02/20/24 at 9:30 a.m., an open bag of parmesan cheese with, a package date of 11/29/23, was observed in the cooler. The CDM stated everything was supposed to be labeled and dated. They stated there was no open date. There was also an open bag of pork sausage patties located in an open box in the cooler. The CDM stated the bag was open, used this morning, and should have been closed.

Based on record review and interview, the facility failed to accurately code physical therapy minutes on a quarterly resident assessment for one (#16) of 10 sampled residents reviewed for accurate assessments. The DON identified 30 residents resided in the facility. Findings: Resident #16 had diagnoses which included Alzheimer's Disease and osteoarthritis. Physical Therapy Treatment Encounter Notes documented Resident #16 received therapy services on 12/07/23 and 12/12/23. A Quarterly Resident Assessment, dated 12/12/23, documented no physical therapy minutes for Resident #16. It documented the physical therapy start date was 06/04/23. On 02/21/24 at 2:00 p.m., PTA #1 stated Resident #16 started services in June 2023. They stated the resident received therapy services twice a week. On 02/21/24 at 2:55 p.m., MDS Coordinator #1 stated they used resident, family and staff interviews along with the resident's record to ensure the resident assessments were coded accurately. They stated they communicated with therapy and looked in the electronic record to identify how much time was spent on therapy. On 02/21/24 at 2:56 p.m., MDS Coordinator #1 stated Resident #16's quarterly resident assessment dated [DATE] documented the start date of physical therapy was 06/04/23 which was ongoing. They stated there were no minutes for physical therapy documented.

Based on observation, record review, and interview, the facility failed to ensure an oxygen tank was not stored in a resident's room for one (#12) of one sampled resident observed for oxygen tanks. The Administrator identified three residents with orders for oxygen resided in the facility. Findings: A Fire Safety and Prevention policy, revised 05/11, read in part, .Store oxygen in clean, dry locations away from direct sunlight .Do not store oxygen cylinders in any resident room or living area . Resident #12 had diagnoses which included acute respiratory failure with hypoxia and unspecified diastolic heart failure. A Physician Order, dated 02/10/23, documented may administer oxygen two liters per minute as needed for shortness of breath. On 02/21/24 at 11:16 a.m., Resident #12's room was observed to have a portable oxygen tank stored by the end of their dresser which was located in front of the window. The blinds to the window were open. The oxygen tank did not have a regulator present. On 02/21/24 at 11:18 a.m., Resident #12 was observed seated in a wheelchair in the hall. The resident was observed without oxygen in place. On 02/21/24 at 11:20 a.m., CNA #3 stated Resident #12 did not use oxygen, it was just as needed. They stated oxygen canisters were stored in the oxygen room located across the hall from Resident #12's room. On 02/21/24 at 11:23 a.m., LPN #2 stated resident #12 did not use oxygen. LPN #2 observed the oxygen tank in the resident's room. They reviewed the record and identified an as needed oxygen order. On 02/21/24 at 11:28 a.m., LPN #2 showed the closet located across from Resident #12's room where oxygen tanks were to be stored.

Based on record review and interview, the facility failed to ensure laboratory tests were completed as ordered for one (#26) of five sampled residents reviewed for unnecessary medications. The DON identified 30 residents resided in the facility. Findings: A Lab and Diagnostic Test Results policy, revised 09/12, read in part, .The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs .The staff will process test requisitions and arrange for tests . Resident #26 had diagnoses which included Alzheimer's Dementia and atherosclerotic heart disease of native coronary artery with refractory angina pectoris. A Physician Order, dated 11/01/23, documented CBC and CMP one time only. A Progress Note, dated 11/03/23, documented labs from 11/01 CBC and CMP pending. The note was electronically signed by Physician #1. There were no lab results for the 11/01/23 CBC and CMP located in Resident #26's clinical record. On 02/23/24 at 8:49 a.m., the DON stated they had spoken to PA #1 who reported they had canceled the lab. The DON reviewed the note sent over and stated it documented the lab was cancelled in September. They stated, That can't be right. On 02/23/24 at 8:55 a.m., the DON stated the facility had a contracted lab which came out and drew labs as needed. The DON was unable to provide the CBC and CMP lab results ordered 11/01/23 for Resident #26.

Based on record review and interview, the facility failed to complete a nurse aide performance review once every 12 months for one (CNA #2) of five employee files reviewed. The Employee Information Report, dated 02/21/24, documented 33 staff members for the facility. Findings: CNA #2 had a hire date of 08/16/22. There was no CNA annual competency review located in the employee's file. On 02/21/24 at 10:45 a.m., the DON stated employee skills checks were completed annually. On 02/21/24 at 1:09 p.m., the Director of Clinical Services stated CNA competency reviews were completed upon hire and annually. There was no documentation provided of CNA #2 completing an annual competency review prior to survey exit.

Based on observation, record review, and interview, the facility failed to ensure: a. a gait belt was used during a transfer for one (#16); and b. neurological checks were completed after a fall with head injury for one (#13) of two sampled residents reviewed for accident hazards. The DON identified 30 residents resided in the facility. Findings: A Neurological Assessment policy, dated 10/10, read in part, .The purpose of this procedure is to provide guidelines for a neurological assessment .subsequent to a fall with a suspected head injury .Neurological assessments are indicated .Following a fall or other accident/injury involving head trauma unless diagnostics assessment reveals no head injury . A Safe Lifting and Movement of Residents policy, revised 07/17, read in part, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .Manual lifting of residents shall be eliminated when feasible .Staff responsible for direct resident care will be trained in the use of manual .gait/transfer belts .and mechanical lifting devices . 1. Resident #13 had diagnoses which included Alzheimer's Disease. A State Reportable Incident form, dated 12/22/23, documented Resident #13 was being pushed by a staff member in the dining room and fell forward out of their chair onto the floor. It documented the resident sustained a closed head injury, laceration to forehead, abrasion to their nose, and a skin tear to elbow. It documented the resident was sent to the hospital for evaluation. Hospital Records, dated 12/22/23, documented Resident #13 was seen for a closed head injury, nasal abrasion, skin tear, facial laceration, and fall. It documented the resident was diagnosed with a closed head injury without concussion. It documented the computed tomography scan was negative for infection. It documented the resident should return to the emergency room for severe or worsening headaches, worsening confusion, vision changes, or other neurological changes. It documented instructions for suture removal. There were no neurological checks located in the resident's clinical record for the 12/22/23 fall. On 02/20/24 at 2:37 p.m., Family Member #1 stated Resident #13 had fallen out of their wheelchair which resulted in getting 11 staples to their head at the emergency room . On 02/22/24 at 12:51 p.m., LPN #1 stated staff completed neurological checks for 72 hours after a resident experienced a head injury, unwitnessed falls, and noticeable injuries which involved bruising and swelling. They stated they were completed on a paper neurological form. On 02/22/24 at 1:27 p.m., the DON stated due to the computed tomography scan being negative, neurological checks were not needed. On 02/22/24 at 1:35 p.m., the DON stated Resident #13's communication abilities were very limited. They stated sometimes the resident could answer yes or no, but that was the extent. On 02/22/24 at 1:37 p.m., the DON was asked if staff did not complete neurological checks, how would they know if changes were experienced. They stated, That's a good question. They stated based on their policy, if the computed tomography scan was completed and it was negative, then staff would not complete neurological checks. 2. Resident #16 had diagnoses which included Alzheimer's Disease, osteoarthritis and unsteadiness on feet. A Quarterly Resident Assessment, dated 12/12/23, documented Resident #16 was dependent on staff for sit to stand mobility and chair to bed transfer. On 02/20/24 at 10:02 a.m., CNA #3 and CNA #4 entered Resident #16's room. Both CNA's had gait belts around them. On 02/20/24 at 10:10 a.m., CNA #4 locked the resident's wheelchair, which was located next to the bed. CNA #4 held under the resident's left arm while CNA #3 held under the resident's right arm. CNA #4 held onto the back of the resident's black pants and both CNAs hoisted the resident up out of the wheelchair and pivoted them to a seated position on the bed. The CNAs lifted Resident #16's legs onto the bed. On 02/20/24 at 10:23 a.m., CNA #4 stated staff typically used the resident's arms and a gait belt to transfer. They stated they could also use a sit to stand lift. They stated they did not use the gait belt this time and should have. On 02/20/24 at 10:24 a.m., CNA #4 stated they would use a gait belt when a resident was a two person assist, could bear weight, and could pivot a little.

Based on observation, record review, and interview, the facility failed to ensure; A. physician ordered supplements were provided and B. meal and supplement percentages were documented for two (#10 and #12) of four sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 01/25/23, documented 24 residents. Findings: A Food and Nutrition Services policy, revised 10/2017, read in part, .Meals and/or nutritional supplements will be provided with scheduled mealtime or medication pass as indicated, and in accordance with the resident's medication requirements if given with medication pass. The reason for this is to supplement the meal intake and not to make the resident feel so full with between meal supplements that they do not desire their meal . 1. Resident #10 had diagnoses which included Alzheimer's disease, dysphagia, and anxiety disorder. Resident #10's weight on 12/02/22 documented 134.2 pounds. A Quarterly Resident Assessment, dated 12/28/22, documented the resident required supervision oversight, encouragement or cueing setup help only for the task of eating and required a mechanically altered diet. A Physician Order, dated 12/30/22, documented the resident was to receive a regular diet with pureed texture and a magic cup with meals. The December 2022 meal percentage and supplement forms documented blanks for breakfast on 12/24/22, lunch on 12/24/22, and dinner on 12/05/22, 12/06/22, 12/07/22. 12/12/22, 12/13/22, 12/20/22, 12/22/22, 12/24/22, 12/25/22, 12/27/22, 12/29/22, 12/30/22, and 12/31/22. A Care Plan, revised 01/25/23, documented the resident was at risk for malnutrition with interventions which included provide supplements as ordered by the physician, magic cup with meals, and document amount eaten at meals. The January 2023 meal percentage and supplement forms documented blanks for breakfast on 01/01/23 and 01/22/23, lunch on 01/01/23 and 01/22/23, and dinner on 01/01/23, 01/03/23, 01/04/23, 01/05/23, 01/06/23, 01/07/23, 01/10/23, 01/11/23, 01/13/23, 01/15/23, 01/16/23, 01/17/23, 01/18/23 and 01/22/23. On 01/25/23 at 5:55 p.m., Resident #10 received their meal tray. There was no magic cup observed on the tray. On 01/26/23 at 10:18 a.m. Resident #10 was weighed by CNA #4 and CNA #5. The resident weighed 130.6 pounds. On 01/26/23 at 11:39 a.m., the PA for Resident #10 was asked what risk factors the resident had for weight loss. They stated the resident had poor indentation, muscle wasting, a recent case of Covid 19 and a recent fall which all placed her at risk for weight loss. The PA was asked if the resident had experienced any weight loss. They stated, Yes. They stated the resident had lost three and a half pounds since December 2nd. They were asked what interventions were in place to prevent weight loss. They stated the resident had interventions which included house shakes and a magic cup with meals. On 01/26/23 at 11:52 a.m., the DON was asked what interventions were in place to prevent weight loss for Resident #10. They stated the resident had orders for a health shake and magic cup. They stated the house shake was captured on the TAR and the supplements/magic cup were captured on the meal percentage form. The DON was asked to review Resident #10's meal percentage and supplement intake form and identify the reason for all of the blanks. They stated the reason was there were agency staff who worked the 3 p.m. to 11 p.m. shift and they failed to document the information. On 01/26/23 at 1:28 p.m., Cook #1 was asked to explain the reason Resident #10 did not receive a magic cup with their dinner meal on 01/25/23. They stated the facility had ran out of the magic cups. 2. Resident #12 had diagnoses which included dementia, moderate protein-calorie malnutrition and dysphagia. A Quarterly Resident Assessment, dated 10/20/22, documented the resident required limited assistance with one person physical assist for the task of eating. Resident #12's weight on 12/02/22 was 111 pounds. A Physician Order, dated 11/11/22, documented the resident was to receive a mechanical soft regular diet, nectar consistency with meat and other foods cut into bite size pieces and add gravy for easy swallowing. It documented the resident was to receive a magic cup with meals. A Physician Order, dated 12/30/22, documented the resident was to receive four ounces of Med Pass three times a day between meals. The December 2023 meal percentage form and supplement percentage form documented blanks for breakfast on 12/05/22 and 12/24/22, lunch 12/05/22 and 12/24/22, and dinner 12/01/22, 12/05/22, 12/06/22, 12/07/22, 12/12/22, 12/13/22, 12/20/22, 12/22/22, 12/24/22, 12/25/22, 12/27/22, 12/29/22, 12/30/22, and 12/31/22. The December 2022 MAR documented the resident received less than four ounces of Med Pass 20 out of 59 opportunities. A Care Plan, revised 01/25/23, documented the resident required encouragement for adequate nutrition. It documented interventions which included staff were to monitor and record food intake at each meal and provide supplements as ordered by the physician. The January 2023 meal percentage form and supplement percentage form documented blanks for breakfast on 01/09/23 and 01/20/23, lunch on 01/09/23 and 01/20/23, and dinner on 01/01/23, 01/03/23, 01/04/23, 01/05/23, 01/06/23, 01/07/23, 01/10/23, 01/11/23, 01/13/23, 01/15/23, 01//16/23, 01/17/23, 01/18/23, and 01/22/23. The January 2023 MAR documented the resident received less than four ounces of Med Pass 29 out of 76 opportunities. On 01/25/23 at 5:33 p.m., CNA #2 was observed cutting up the meat for Resident #12 during the dinner meal service. There was no magic cup observed with the resident's dinner meal tray. On 01/26/23 at 8:17 a.m., CNA #3 delivered the breakfast meal tray to Resident #12. No magic cup was observed. On 01/26/23 at 9:37 a.m., the Administrator stated she was leaving for a bit to run to a business to get magic cups. On 01/26/23 at 9:39 a.m., CNA #3 was asked what type of assistance Resident #12 required with meals. They stated the resident required total assistance with meals. They were asked what type of supplements the resident received. They stated they believed a shake. They were asked if a magic cup was served with the resident's breakfast today. They stated they didn't see one. They stated they didn't see any resident with one today. On 01/26/23 at 10:19 a.m., LPN #1 was asked what type of supplements Resident #12 received. They stated the resident had orders for four ounces of Med Pass three times a day between meals, received a mechanically soft diet, and a magic cup with meals. LPN #1 was asked to clarify the amount of Med Pass administered to the resident in January 2023 and December 2022. They stated they could not explain the reason less than four ounces were administered. They stated, at times, the resident did not eat or drink everything. They stated the staff may not have been able to get the resident to consume the four ounces. LPN #1 was asked if there was any documentation of the reason less than four ounces was administered. They stated there was not. On 01/26/23 at 9:48 a.m., the PA for Resident #12 was asked if the resident had experienced any recent weight loss. They stated the resident had experienced a gradual weight loss. They stated the weight in December 2022 was 111 pounds. They stated they believed the weight was inaccurate. They were asked what risk factors the resident had for weight loss. They stated the resident was up walking all over the facility until recently. They stated the resident had experienced a recent decline. They stated the resident also had abnormal thyroid labs in December requiring medication adjustments. They stated the thyroid could have a direct impact on weight changes. The PA stated the resident also had muscle wasting which could impact the resident's weight. They were asked what supplements the resident had ordered. They stated the resident had Med Pass three times a day ordered. On 01/26/23 at 9:57 a.m., Cook #1 and the CDM who was present from a sister home, were asked the reason Resident #12 did not receive a magic cup with their dinner meal on 01/25/23 or their breakfast meal on 01/26/23. Cook #1 stated they had ordered them Monday after they did not come in on the food delivery truck. The Cook stated the facility ran out yesterday after lunch. They stated the Administrator was running to pick some up from a supplier. On 01/26/23 at 10:21 a.m., Resident #12 was weighed by CNA #4 and CNA #5. The Resident's current weight was 104 pounds. On 01/26/23 at 11:19 a.m., the DON was asked what interventions were in place related to nutrition for Resident #12. He stated the resident had orders for magic cup with meals. He stated the magic cup supplement was documented on the supplement percentage form. The DON was asked if the resident had lost weight. He stated the resident was trending down, yes. The DON was asked what the policy was for documenting resident meal intake and supplement intake. He stated the staff should be documenting the percentage taken at every meal. He was asked to review Resident #12's January 2023 and December 2022 meal and supplement percentage forms and identify the reason for the blanks. He stated it was most likely due to agency staff on the 3 p.m. to 11 p.m. shift. He stated the facility provided them with the means to log in and chart, however, it was dependent on their work ethics on if it was completed. The DON was asked who was responsible for ensuring the documentation was completed. He stated the charge nurse on the 3 p.m. to 11 p.m. shift would be responsible.

Based on record review and interview, it was determined the facility failed to ensure physician ordered weekly weights were obtained for one (#82) of three sampled residents reviewed for weight loss. This resulted in the resident sustaining a 23.7 (13%) weight loss that was identified when she was sent to the emergency room . The facility census was 30. Findings: The facility's weight policy, revised March 2011, documented, .provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition .note and record the resident's weight .All assessment data obtained during the procedure .Report significant weight loss/weight gain to the nurse supervisor . Resident #82 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ~served a regular diet with mechanical soft texture; Four ounces of a House shakes with meals, and a magic cup with all meals, ~administer four ounces of Med Pass three times a day for supplement with medications, and ~weigh weekly, every Tuesday, to monitor weight loss. A care plan, dated 08/18/20, documented, .I .receive a mechanically altered diet .I require staff set up and cuing [sic] during meals .Document amounts eaten .Weights as my Dr. [doctor] has ordered . The resident's weights were as follows: ~ 184 pounds (lb) on 08/18/20, ~ 181.4 lb on 08/25/20, ~ 179.6 lb on 09/0120, ~ 176.6 lb on 09/08/20, ~ 177.1 on 09/15/20, ~ 178.3 lb on 09/22/20 and ~ 178.2 on 09/29/20. A dietary progress note, dated 09/23/30, documented, .this months weight .178.3 .Weight Review: down 5.1[percent] in one month .Drinking 2-4 Oz of med pass tid [three times daily], consuming approx. 50% of shakes and magic cups and eating 51-75% of mech [mechanical] soft diet .Continue POC [plan of care] . The resident tested positive for COVID-19 on 09/28/20 and was moved to an isolation wing. There were no weights documented after the resident was moved to the isolation wing. A plan of care note, dated 10/01/20, documented, .POOR APPETITE . A plan of care note, dated 10/02/20, documented, .poor appetite . A plan of care note, dated 10/03/20, documented, .POOR APPETITE . A plan of care note, dated 10/04/20, documented, .Appetite fair . A plan of care note, dated 10/05/20, documented, .Appetite fair . A skilled nurse's note, dated 10/13/20, documented the resident required supervision and set up help for meals. A skilled nurse's note, dated 10/13/20, documented, the resident required set up help with meals. An October 2020 meal intake report, documented blanks for eight meals, the resident refused meals twice, the resident's intake was zero to 25 percent (%) for 37 meals, the intake was 26%-50% for nine meals, and 51%-75% for three meals from 10/01/20 through 10/20/20. It documented eight blanks for the supplement, the resident refused the supplement four times, and zero intake seven times. A progress note, dated 10/20/20 at 5:00 p.m., documented, .in chair with eyes closed resident only responding to painful stimuli .notified MD [medical doctor] and family received orders to ER [emergency room ] . An emergency room History and Physical dated 10/20/20, documented patient care timeline started at 6:12 p.m. on 10/20/20. An emergency room note, dated 10/20/20, documented, .female with a history of alzheimer's who presents from NH [nursing home] .Wt [weight] .154 lb 5.2 oz [ounces] . This was a weight loss of 23.7 lb (13 percent) in less than 30 days. On 09/02/21 at 9:27 a.m., licensed practical nurse (LPN) #1 was asked if the resident had experienced weight loss. She stated she looked smaller. She was asked about her appetite while she was in isolation. She stated some days were better than others. She was asked if she was taking fluids. She stated yes, they were able to get her to drink. She was asked what the protocol was for residents in isolation related to obtaining weights. She stated to her knowledge, they didn't have any weights to be obtained while in isolation. She was asked if the resident had been weighed at any time while in the isolation unit. She stated she should have been weighed the first of the month for monthly weights. At 10:12 a.m., the assistant director of nursing (ADON) was shown the October 2020 meal intake report blanks and refusals. She acknowledged the findings. At 11:02 a.m., certified nurse aide (CNA) #2 was asked how the resident's appetite was while she was in isolation. She stated the resident had begun eating and drinking more and that she sometimes needed assistance. She was asked if the resident had experiences any observable weight loss. She stated, Yes. At 11:34 a.m., the director of nursing (DON) was asked what staff were instructed to do if the noticed observable weight loss. She stated, Notify doctor, get supplements, new weight orders. At 11:45 a.m., the ADON was asked what staff were instructed to do if they observed weight loss. She stated, Contact MD, family, monitor weights then weekly weights. She was asked when residents were weighed when they were skilled. She stated monthly unless orders stated otherwise. At 12:13 p.m., the ADON was asked to locate the weekly weights for October. She stated she didn't see any weights documented for October. She was made aware of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She acknowledged the findings.

Based on record review and staff interviews, it was determined the facility failed to ensure a resident's skin was assessed and monitored and an avoidable stage-3 pressure ulcer did not develop for one (#82) of one sampled resident reviewed for pressure ulcers. The resident developed a stage 3 pressure ulcer that was present on admission to the emergency room . The facility census was 30. The Resident Census and Conditions of Residents report, dated 08/31/21, documented no residents had pressure ulcers. Findings: The facility's Pressure Ulcer/Injuries Overview policy documented, .The purpose of this procedure is to provide information regarding clinical identification of pressure ulcers/injuries and associated risk factor .Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or .present as an open ulcer, the appearance of which will vary depending on the stage .occur as a result of intense and/or prolonged pressure or pressure in combination with shear .skin temperature and moisture, nutrition, perfusion, co-morbidities . The facility's Resident Examination and Assessment policy documented, The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan . Skin .intactness .moisture .color .texture .presence of bruises, pressure sores, redness, [CONDITION(S)], rashes .Documentation .should be recorded in the resident's medical record .All assessment data obtained during the procedure .Reporting .Notify the physician of any abnormalities such as, but not limited to .wounds or rashes on the resident's skin . Resident #82 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 08/18/20, documented, .I have the potential for compromised skin integrity .I have bowel and bladder incontinence .Assess my skin with each episode of incontinent care . Weekly skin assessments, dated 09/02/20, 09/09/20, and 09/15/20, documented the resident did not have pressure ulcers/injuries. A pressure ulcer risk assessment tool, dated 09/22/20, documented the resident was a low risk for pressure ulcers. A nurse's note, dated 09/23/2020 at 1:39 a.m., documented a weekly skin check had been completed by a nurse and the skin was clean, dry, and intact; and there were no pressure wounds. A nurse's note, dated 09/28/20 at 5:20 p.m., documented, .COVID 19 and resident positive .Resident moved into isolation room at this time . On 10/05/20, resident #82 was admitted to skilled services due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A skilled nurse's note, dated 10/05/20 at 11:20 p.m., documented the resident required supervision for bed mobility, transfers and had total dependence for toileting and the resident's skin was in normal limits/no skin issues. A skilled nurse's note, dated 10/13/20 at 8:04 p.m., documented the resident required extensive assistance for bed mobility, transfers, and toileting and the resident's skin remained within normal limits/no skin issues. A skilled nurse's note, dated 10/20/20 at 4:00 a.m., documented the resident required extensive assistance for bed mobility, and transfers; required total assistance for toileting and the resident's skin was within normal limits/no skin issues. A nurse's note, dated 10/20/20 at 5:00 p.m., documented, .observed in chair with eyes closed .only responding to painful stimuli .received orders to ER [emergency room ] . The emergency room History and Physical Information report, dated 10/20/20, documented:, The patient care started at 6:12 p.m. on 10/20/20. The emergency room History and Physical Information report, dated 10/20/20 documented, .Skin .Stage III sacral decubitus ulcer . The emergency room History and Physical, dated 10/20/20 at 6:30 p.m., documented, Pressure Injury (Ulcer) 10/20/20 Coccyx/Sacrum placed .Date first Assessed/Time first assessed: 10/20/20 1830 [6:30 p.m.] Present on Hospital Arrival: Yes .Location: Coccyx/Sacrum . The emergency room History and Physical, dated 10/20/20 at 9:10 p.m., documented, .Pressure Injury .Assessment .Bleeding; Dark red; Black. Drainage Description: Red. Drainage Amount: Small. Cleansing/Treatment: Cleansed. site care; Cleansed with sterile water. Dressing: Sacral Border Dressing .State of Healing: chronic; Necrotic tissue [greater than] 50 %. present on Unit admission?: Yes . On 09/02/21 at 927 a.m., licensed practical nurse (LPN) #1 was asked if the resident had any skin issues. She stated, Not that I recall. She was asked how frequently nursing assessments were conducted when a resident was receiving skilled services. She stated every shift. She was asked if the resident was incontinent or required assistance for toileting. She stated the resident was incontinent at times but staff would assist her to the toilet. She was asked what areas of the skin she assessed during a skilled assessment. She stated, We physically see arms and legs. She stated the resident's had assigned weekly skin assessments and that was when the buttocks/periarea would be assessed. LPN #1 was asked if she looked at the residents buttocks/peri area for any breakdown on each assessment she had completed. She stated, No. She was asked if the nurse aides had reported any skin breakdown to her. She stated, No. At 10:12 AM the assistant director of nurses [ADON] was asked what the facilities protocol was for weekly skin assessments when the resident is in isolation. She stated the skin assessment was combined in the skilled nurse's notes. She stated if there were skin issues identified, there would be documentation on a skin progress note. The ADON was asked if the clinical record contained skin progress notes for resident #84 during the month of October, 2020. She reviewed the record and stated, No. At 11:34 a.m., the DON was asked what is the protocol was for checking skin during a skilled nurse observation note. She stated, They would be checking their skin, all their skin. At 11:45 a.m., the ADON was asked if the the nurse would be expected to observe the resident's buttocks during a skilled nurse assessment. She stated, Yes. She was made aware of the above information. She acknowledged the findings.

Based on observation, record review and interviews, it was determined the facility failed to follow a care plan for interventions related to falls and socialization for one (#1) of three sampled residents. This had the potential to affect an additional 41 residents in the facility. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An incident report, dated 07/19/10, documented, "0855 (8:55 a.m.) - Res walking in hallway witnessed triping (sic) on w/c falling hit face down, 1.5 cm laceration to chin. - Alert (and) confused, oriented x 1. Additional comments and/or steps taken to prevent recurrence: see state report." The incident report faxed to the OSDH, dated 01/19/10, documented "...To prevent this from occurring again, staff will monitor for signs of fatigue and provide frequent rest periods. Staff will monitor when resident is ambulating in the hallway to direct her away from tripping hazards such s wheelchairs. Staff will ensure resident is wearing proper fitting footwear to facilitate in ambulation. (name-deleted physician) will review all medications and adjust as necessary." The comprehensive resident assessment, dated 01/24/11, documented the resident was rarely/never understood by others, and rarely/never as able to be understood. It documented she had short and long term memory problems. Her cognitive skills were severely impaired and she never/rarely made decisions. It also documented she had difficulty focusing attention, had disorganized thinking continuously. She wandered throughout the facility daily. She required limited assistance with the assistance of one staff member for transfers, walking in room. She require supervision to walk on and off the unit. She also required extensive assistance with two staff members for dressing. She was totally incontinent of her bowels and bladder. She was totally dependent for bathing and hygiene. It documented the resident had one fall without injury and two falls with injury since 10/28/10. The residents care plan,dated 05/04/2010 and last updated on 10/29/10, documented, "Problem: (Resident #1) has a fall risk score of 17. (Resident #1) has a quick, unsteady gait. (Resident #1) has a decrease safety awareness and is impulsive and doesn't take redirection well. (Resident #1) will walk in hallway with blanket around shoulders or will carry blanket and get blanket wrapped around legs which poses a hazard for resident. (Resident #1) paces and wanders almost continuously through the day and sometimes through the night. (Resident #1) removes shoes and ambulated in hallways in sock feet. Goal: (Resident #1) will be free of injury to self or others related to falls daily during this review period. (Resident #1) will have minimal or minor injuries R/T fall dly during this review period. Approach: 1) Staff to encourage frequent rest periods when excessive pacing is noted. 2) Staff to ensure that pathways are free from clutter and spills. (handwritten) neuro (checks) - enc rest period in recliner. 3) Staff to ensure that rooms and hallways are well lit. 4) Staff to monitor for safety hazzards, such as (Resident #1) carrying blankets, and remove the hazzard. 5) Inform staff of all risk. 6) Staff to notify family and physician of any injury, regardless of cause. 7) Staff to take (Resident #1) to room and attempt to assist her to bed when noted to be unsteady or tired. 8) Staff to provide one on one visitation with (Resident#1) in courtyard when weather permits or at bedside to allow (Resident #1) to rest...10) Attempt to keep shoes or skid free socks on {Resident #1). Take (Resident #1) to room (and) assist to bed or recliner for rest period... Problem 2: (Resident #1) has reduced social interaction with others due to pacing continuously. Goal: (Resident #1) will have short periods of social interactions with staff while pacing, during care, and at meal times daily during this review period. Approach: 1) Provide one on one visits for (Resident #1) during care, while pacing and at meal times. 2) Staff to escort (Resident #1) to activities and encourage to participate, if even for just a short period of time. 3) Family, staff, and other visitors to pace with (Resident #1) during visits or take outside to sit in the sun on nice days." On 03/24/11 at 10:45 a.m., CNA #3, who is also the activities and social service director, was asked what kind of one on one activities she involved resident #1 in. She stated, "I don't like to do one on one with her. It's not fair to keep her in her room by herself, she needs to be with the other resident's. At 11:05 a.m., the resident was in recliner with foot rest up. She was moaning, and grabbing at her feet. She then got up from her recliner, grabbed her blanket and walked into the hallway. The resident didn't have on skid free socks. As she was walking down the hall, CNA #3 took ahold of her arm and assisted her to the dining room. The resident repeatedly moaned, oh, oh, oh. The CNA placed her blanket in the dirty clothes hamper in the dining room. At 11:15, the resident got up off her chair and walked out of the dining room unassisted. As the resident walked by her, CNA#3 stated, "Just a minute (Resident #1). The CNA then turned back around to walk to the other side of the room. The resident walked out of the dining room and down the hall with a fast shuffle gait, and moaning. She walked to the end of the hall at the nurses' station. She began walking back down the hallway when CNA #7 took her hand and walked the resident back to the dining room. At 11:20 a.m., the resident got up again and ambulated to the edge of the dining room. A CNA assisted the resident out of the dining room and walked to the administrator's office and left her in there with the administrator. Resident continues to moan at this time. At 11:25 a.m., the resident left the administrator's office and began walking down the hall. The administrator followed behind her. She stated to the resident that they would go see what was being served for lunch would help. The resident was seated again in the dining room. At 11:28 a.m., the resident got up again, a CNA stated oh she is leaving the dining room again. The administrator then followed her out and stated if they would get her some food then she would sit. The resident then walked up the hall unassisted. At 1:20 p.m., the resident was observed walking up and down the hallway unassisted. She attempted to get into the dining room through the closed doors. She left the dining room doors and continued pacing quickly, carrying a blanket. The resident was not wearing skid free socks.

Based on record review and interviews, it was determined the facility failed to have sufficient staff to follow a resident's fall intervention plan as evidenced by the resident being left unattended in the dining room which resulted in a fall which caused several fractures to the face for one (#3) of three sampled residents. The director of nurses identified three residents who were a high risk for and had frequent reoccurring falls. Findings: 1. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] documented the resident usually understood others and could be understood, was severely impaired with cognitive skills for daily decision making, and the resident had a fall without injury since the last assessment. It also documented the resident needed supervision with transfers and walking in the room and corridor and was not on a restorative program. A 'Fall Risk Assessment' dated 10/27/11 documented the resident was a high risk of falls with a score of 19. A score of ten or greater represents a high risk. An annual assessment dated [DATE] documented the resident usually understood others and could be understood, was severely impaired with cognitive skills for daily decision making, and did not have a fall since the last assessment. It also documented the resident needed supervision with transfers and walking in the room and corridor. A 'Fall Risk Assessment' dated 01/27/11 documented the resident was a high risk of falls with a score of 21. A score of ten or greater represents a high risk. A care plan dated 01/19/11 and last updated 03/10/11 documented, "Problem: (Resident #3) has a fall risk score of 19 and has a history of falls. (Resident #3) has an unsteady gait. (Resident #3) is impulsive at times and has a decreased safety awareness. (Resident #3) will attempt to ambulate unassisted. 03/01/11 (resident #3) slid out of w/c (wheel chair) to floor. No notes injury. 03/03/11 (Resident #3) up amb. (ambulating) in DR (dining room) unassisted. fell to floor no injury noted. 03/10/11 (Resident #3) fell in the DR. Head trauma noted sent to ER (emergency room ) for eval (evaluation) and tx (treatment). Returned w/ (with) report of fx (fractured) eye socket, fx sinus, contusion to left shoulder. Goal: (Resident #3) will be free of injury to self or others related to falls daily during this review period. Approach...staff to assist with transfers and ambulation. Give verbal reminders for (Resident #3) to wait for assistance...keep pathways clean and free of clutter...keep room well lit and environment consistent...staff to ensure that (Resident #3) has on skid proof and proper fitting footwear...alert staff to fall risk...PT (physical therapy) and OT (occupational therapy) to treat as ordered...staff to report any injury regardless of cause to family and physician...call light in reach while in room. Encourage and instruct on use and give frequent reminders for use. Comment: 02/22/11 PT and OT DC'd (discontinued) secondary to hospice services. 03/10/11- out to ER secondary head injuries. NO (new order) ice pack to (L) check; sinus precautions; [MEDICATION NAME] 500 mg PO (by mouth) TID (three times daily); orth consult; F/U (follow up) @ (at) (name deleted) oral surgery clinic on 03/16;[MEDICATION NAME] spray TID X 3 days." Additional hand written approaches on the care plan documented, "ABT (antibiotic) for prevention of infection R/T (related to) injuries; F/U (follow up) with oral surgery clinic on 03/16; Sinus precautions-Afrin spray; ice pack to left cheek; Neuro checks per policy; encourage participation in act. (activities) to decrease impulsive pacing with staff assist; 03/01/11 encourage (Resident #3) to wait for staff assistance for transfers; 03/03/11 (Resident #3) to be monitored for increased restlessness and encourage to ambulate with staff assist when restlessness is noted." An 'Incident/Accident Report' dated 03/01/11 documented, "1745 p.m. (5:45 p.m.) sitting in wc (wheel chair) , at table, in dining room, slipped from wc onto floor checked for injury- none apparent. additional comments and or steps taken to prevent recurrence: do not leave unattended in dining room." The report did not document any witnesses to the fall. A 'Nurse's Note' dated 03/01/11 at 5:45 p.m., documented, "Sitting in WC (wheel chair) at a table in DR (dining room) slipped from WC onto floor, checked for injury- no apparent injury noted..." The resident's care plan had not been up dated to reflect the intervention of not leaving the resident in the dining room unattended. An 'Incident/Accident Report' dated 03/03/11 documented, "0845 a.m. (8:45 a.m.), CNA (certified nurse aide) witness resident fall in Dr (dining room) Res (resident) up onto f (front) of chair moving around and fell over foot rest landing on (R) side No apparent injury...additional comments and or steps taken to prevent recurrence: remind res to use call light for assistance before attempts @ (at) ambulation..." Certified nurse aide #5 was identified on the incident report as a witness to the fall. A 'Nurse's Note' dated 03/03/11 at 8:45 a.m., documented, 'Resident stand up at DR (dining room) table. While moving over w/c(wheel chair) rest legs, res (resident) tripped falling to (R) (right) side, witness by C.N.A. (certified nurse aide) assessed no apparent injury noted. Family called. Dr. (name deleted) called." An 'Incident/Accident Report' dated 03/10/11 documented, "1715 p.m. (5:15 p.m.), called to dining room by dietary manager res lying in prone position, (L) (left) cheek against floor. Note hematoma apx (approximately) 2.5 cm (centimeters) under left eye, removed from DR (dining room) to bed via wc (wheel chair) sent to ER (emergency room ) via EMSA (Emergency Medical Services Authority)...level of consciousness: brief period of unresponsiveness then alert, verbally responsive...additional comments and or steps taken to prevent recurrence: see state report..." There was no documentation to indicate the fall was witnessed. The incident report faxed to the Oklahoma State Department of Health, dated 03/10/11, documented "relevant resident history: Resident (Resident #3) is an advanced staged Alzheimer's patient, on hospice services, who ambulates with the assist of a wheelchair but does attempt to ambulate unassisted with a very unsteady gait. Resident does not respond to verbal cueing or reminders from staff to not attempt ambulation unassisted and to use call light or request assistance before unassisted ambulation attempts. Resident has been identified as at risk for falls and care planned. Care plan will be updated...To prevent this from occurring again, staff will monitor resident closely for any attempts to ambulate unassisted and provide immediate assistance when observed. Staff will continually remind resident to use call light or request assistance before unassisted ambulation attempts. Staff will ensure resident is toileted in advance of need to prevent unassisted ambulation attempts to the restroom. A bed/chair alarm will be placed to alert staff to any attempts to ambulate unassisted by resident and staff will respond to alarm immediately. Physical therapy will be consulted for any additional interventions to prevent falls Dr. (name deleted) will review all medications and adjust as necessary." A 'Nurse's Note' dated 03/10/11 at 5:15 p.m., documented, "Summoned to dining room per dietary manager (name deleted). Resident on floor prone position (L) (left) cheek on floor, Noted blood from nose- Hematoma to (L) lower eye apx (approximately) 2.5 cm (centimeters) in diameter, unresponsive to verbal/ tactile stimuli...T.C (telephone call) to request permission to transfer to ER (emergency room ) from on call. T.C to family to inquire if they wished transfer to ER for evaluation/ poss (possible) TX (treatment) TC to inform hospice of pending transfer- TC to Dr. (name deleted) spoke to (name deleted)- new order to send to (name deleted) hospital for evaluation, TX- T.C to EMSA (Emergency Medical Services Authority) for transportation." There was no documentation in the nurse's note to indicate the fall was witnessed. An emergency room physician's progress note dated 03/10/11, documented, "...female with dementia found on floor by nursing home staff...pt (patient) experienced unwitnessed fall this afternoon. Suffered bruising (L) cheek, taken to ER...face (L) inferior orbital fx (fracture), (L) ant (anterior) lacrimal inferior max (maxillary) sinus wall fx...1) sinus precautions; 2) Ortho consult arranged; 3) F/U at (name deleted) oral surgery clinic Wednesday Am; 4)[MEDICATION NAME] spray for five days TID (three times); 5) ice pack to cheek; 6) RT (return) to ER (emergency room ) if visual disturbance or other symptoms of concern arises." A 'CT (computerized tomography) Maxillofacial wo (without) Infusion' final report dated 03/10/11 documented, "CT Maxillofacial findings: There is comminuted [MEDICAL CONDITION] left orbital wall with hemorrhage in the left maxillary sinus. Enlargement of the left inferior rectus muscle compared to the right likely represents hematoma and [MEDICAL CONDITION] are additional fractures of the posterior, inferior, and medial walls of the maxillary sinus. A linear [MEDICAL CONDITION] left maxillary sinus courses just anterior to the lacrimal duct. There are small amounts of [MEDICAL CONDITION] within the soft tissue just posterior to the left posterior maxillary wall and within the left orbit. There is fracture and mild concave deformity of the left zygoma. There is also a [MEDICATION NAME] oriented [MEDICAL CONDITION] temporal bone involving the temporomandibular joint...There is a large left preorbital hematoma... Impression: 1. Multiple fractures of the left facial bones including the inferior orbital wall with asymmetric enlargement of the left inferior rectus muscle consistent with [MEDICAL CONDITION]/hematoma. 2. Comminuted fractures of the posterior, inferior, and medial walls of the left maxillary sinus with linear fractures occurring just anterior to the left lacrimal duct. 3. [MEDICATION NAME] oriented [MEDICAL CONDITION] temporal bone involving the left temporomandibular joint. 4. Fracture and concave deformity of the left zygoma. 5. Left maxillary pneumo hemo sinus. 6. Large left preorbital hematoma." A telephone order dated 03/10/11, documented, "1. Sinus Precautions 2. [MEDICATION NAME] 500 mg (milligrams) tab (tablet) P.O. (by mouth) TID (three times a day) 3. Ortho Consult (arrange) 4. F/U (follow up) oral surgery clinic Wed (Wednesday) A.M. 5.[MEDICATION NAME] spray for three days TID." A second telephone order dated 03/10/11, documented, "1. Ice pack to cheek (left). 2. Resume previous Nursing home orders." An interview was conducted on 03/23/11 at 10:00 a.m., with the dietary manager regarding the resident's fall on 03/10/11. She was asked what she witnessed. She stated, "I didn't directly witness the fall. An aide (dietary aide #1) notified me of the resident's fall." She then stated she had gone to the serving window and observed the resident in a pool of blood. She was asked who was present in the dining room when she observed the resident in the pool of blood. She stated, "There were several residents and a family member (of another resident) present." She was asked who was present in the dining room from the facility. She stated, "No staff were present at the time of the fall." An interview was conducted on 03/23/11 at 2:50 p.m., with licensed practical nurse #1 regarding the resident's fall on 03/10/11. She was asked who placed the resident in the dining room. She stated, "(certified nurse aide#3) came and took the resident stating she was going to take her outside." She was asked who assisted the resident to the dining room. She stated, "(certified nurse aide #3)." She was asked who was present in the dining room when the resident fell . "I don't know if an aide was in the room." She then stated, "A family member saw the fall. Normally someone is in the dining room. I can not find anyone that saw her fall." She then stated she had asked staff but no one saw her fall. She was asked what interventions are in place to protect the resident from reoccurrence of falls. She stated, "Not to be left alone in the dining room." She then stated, "She should have never been left alone in the dining room." An interview was conducted on 03/23/11 at 3:15 p.m., with the director of nurses. He was asked who witnessed the resident's fall on 03/10/11. He stated, "The dietary manager." He was asked what aides or nursing staff witnessed the resident's fall. He stated, "I don't know. No staff could tell how the fall occurred." An interview was conducted on 03/23/11 at 3:29 p.m., with dietary aide #1, regarding the resident's fall on 03/10/11. He was asked how the resident fell . He stated, "I didn't see it. I was in the back of the dish room and was asked by certified nurse aide #4 to have the dietary manager call a charge nurse." He was asked if he knew if the aide was present in the dining room during the fall. He stated he didn't know who all was in the room. He then said all he had done was tell the dietary manager to call the charge nurse. An interview was conducted on 03/23/11 at 3:35 p.m., with certified nurse aide #4, regarding the resident's fall on 03/10/11. She was asked how the fall occurred. She stated, "I wasn't in there, no one was in there." She was asked how she knew the resident had fallen. She stated, "A family member had to come and get me." She was asked what interventions were in place to prevent falls from reoccurring. She stated, "The resident can't be left alone in the dining room." An interview was conducted with certified nurse aide #3, who is also the activities director. She was asked how the resident's fall occurred. She stated, "I wasn't in there when she fell ." She was asked who was in the dining room with the resident. She stated, 'I called the nurse's station and no one answered so I left to get an aide." She was asked who was in the room with the resident. She stated, "A family member said they would watch her (the resident)." She then stated, "I can not do everything and be everywhere." She was asked if there was an aide in the room with the resident. She stated, "I don't know if there was an aide in there, I was off at 5:00 p.m." She was asked if the resident could be in the dining room. She stated, "No, (resident #3) is not to be left unsupervised." An interview was conducted on 03/23/11 at 4:38 p.m., with certified nurse aide #5. She was asked about the resident's fall in the dining room on 03/03/11. She stated, "I came in after the fall to help the aide in the room." She was asked who was in the room that witnessed the fall. She provided the name of certified nurse aide #1. She was asked if there were any other aides or staff in the dining room at the time of the resident's fall. She stated, "Just (certified nurse aide #1) in the dining room at the time of the fall." She was asked if the resident could be left alone while in the dining room. She stated, "No, she could not be left alone in the dining room, especially the last few weeks because of the falls." An interview was conducted on 03/23/11 at 4:45 p.m., with certified nurse aide #1, regarding the resident's fall on 03/03/11. She was asked what other staff were present in the dining room when the resident fell . She stated, "There was nobody else in the dining room with me." She was asked how the resident fell . She stated, "I was the only person in the room and happened to turn around and see her (resident #3). I didn't have time to get to her before she fell ." She then stated she tried to redirect the resident to sit back down and she still had fallen. She then stated, "If I noticed sooner it might not have happened. You can not be every where at once." She was asked where she was at in the dining room when the resident fell . She stated, "Under the mirror by the entrance to the kitchen and the resident was in the far corner approximately twenty feet away." She was asked if the resident could be left in the dining room without staff present. She stated, "No."