Every finding on record at Southbrook Healthcare, Inc

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on interview, record review, and facility document and policy review, the facility failed to ensure staff provided the required assistance needed to safely transfer a resident according to their assessed needs, which affected 1 (Resident #41) of 4 residents reviewed for accidents. Specifically, on 02/11/2026, Certified Nursing Assistant (CNA) #1 attempted to transfer Resident #41 to the resident's bed on their own, which resulted in the resident being lowered to the ground. Resident #41 was subsequently diagnosed with a left hip fracture.Findings included: A facility policy titled, Safety and Supervision of Residents, revised 07/2017, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. A facility policy titled, Safe Lifting and Movement of Residents, revised 07/2017, indicated, 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. The policy also specified, 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. The policy indicated, 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. The policy also indicated, 12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which, including a. involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies. A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, indicated, 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. The policy also specified, 7. The comprehensive, person-centered care plan, which included a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. A Resident Face Sheet revealed the facility admitted Resident #41 on 04/28/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of brain stem stroke syndrome, other paralytic syndrome following unspecified cerebrovascular disease affecting unspecified side, and unspecified anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/11/2025, revealed Resident #41 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS further indicated that the resident was dependent on staff for rolling left to right, moving from sitting to lying and lying to sitting on the side of bed, moving from sitting to standing, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. Resident #41's Care Plan included a problem statement started 05/08/2024 and edited 06/05/2026, that indicated the resident had a self-care deficit related to a brain stem stroke, other cerebrovascular disease, and a closed fracture of the left femur (thigh bone), and the resident required assistance with activities of daily living (ADLs). Interventions directed staff to transfer the resident with a full body sling lift and indicated that the resident required two staff to assist. (initiated 05/08/2024). An Oklahoma State Department of Health initial Incident Report Form indicated that the facility reported an incident of Certain Injuries that occurred on 02/11/2026 to the state survey agency. The report revealed that during a transfer from a chair to a bed, a staff member assisted Resident #41 to the floor. The report revealed Resident #41 was initially assessed with no visible injuries, but, due to latent signs and symptoms of pain in the hip, a mobile X-ray was obtained, and the results were positive for an acute intertrochanteric (hip) fracture. The report revealed the physician and the resident's family were notified, and orders were received to send Resident #41 to an emergency room (ER) for an evaluation. A facility Event Report, dated 02/12/2026 related to Resident #41's fall on 02/11/2026, indicated that the incident occurred at 8:30 PM. Per the report, the resident was being assisted to bed by one staff member. Per the report, the resident began to fall, and the staff sat the resident on the floor. Per the report, the resident exhibited or complained of pain related to the fall in their left knee, rating the pain at 3, on a scale of 0-10, with 10 being the worst possible pain. The report included a Progress Note dated 02/11/2026 at 8:45 PM that was recorded as a Late Entry on 02/12/2026 at 9:23 AM and electronically signed by Registered Nurse (RN) #2. According to the Progress Note, one staff member attempted to assist Resident #41 into bed, the resident began to slide, and the resident was assisted to the floor. The note indicated that the incident was witnessed by CNA #1. The note indicated that a CNA came out of the resident's room stating that Resident #41 was on the floor, and RN #2, who was standing at a medication cart, entered the room with CNA #5. The note indicated that Resident #41 was lying on the floor, the resident's feet were slightly under the edge of the bed, and the resident's head was toward a big white table in the room. The note indicated RN #2 obtained the resident's vital signs (measurements including heart rate, respiratory rate, and blood pressure that indicate the status of the body's vital functions) and assisted two CNAs with putting Resident #41 in bed. The note indicated Resident #41 stated their left knee was in pain. The progress note indicated when Resident #41 was asked if it was their left knee, the resident was mumbling, and was hard to understand, and said No, no. The report also included a progress note, dated 02/12/2026 at 9:45 AM that revealed on 02/11/2026 at 9:15 AM RN #3 entered Resident #41's room and saw two CNAs and an RN in the room, and the resident was lying on their back in the bed with their head elevated. The note indicated CNA #1 stated that he was attempting to transfer Resident #41 into bed by himself, and the resident began to slide and was assisted to the floor. The note indicated that a head-to-toe assessment was completed; the resident was alert and denied hitting their head, and there was no distress noted. The note indicated Resident #41 complained of having some discomfort in the left lower leg but denied needing anything for pain. The note indicated there was no bruising, edema, skin tears, or abrasions noted anywhere on Resident #41's body. The note indicated that Resident #41 had normal range of motion, and there were no apparent injuries. Resident #41's [mobile X-ray company's name] Patient Report, dated 02/12/2026 at 12:41 PM, revealed an x-ray was taken of the left hip, and the findings revealed an acute intertrochanteric fracture. Resident #41's Resident Progress Notes, included a note, dated 02/12/2026 at 2:07 PM that was edited on 02/12/2026 at 2:35 PM by RN #4. The Resident Progress Notes revealed that during the 7:00 AM to 3:00 PM shift, RN #4 observed bleeding from Resident #41's left elbow, and the resident had a small U-shaped skin tear measuring 0.5 centimeters (cm) by 0.75 cm. The note indicated Resident #41 denied any pain or discomfort to the left elbow; however, the resident reported pain to the left hip. Per the notes, Resident #41 reported pain in the left hip with movement and denied pain with rest. The note indicated RN #4 reported the pain to the Assistant Director of Nursing (ADON), a call was placed to the resident's physician, and an order was received for an x-ray of Resident #41's left hip. The notes indicated Resident #41's Power of Attorney (POA), POA #6, was informed of the resident's change. Per the note, at 9:27 AM (on 02/12/2026), the resident reported that Tylenol that had been administered for pain was effective. The notes also revealed that at 12:51 PM (on 02/12/2026), the facility received Resident #41's x-ray results and notified the physician, who ordered the resident to be sent to an ER. Per the notes, the POA was informed and agreed with the order. The note indicated that after Resident #41's X-ray, results were received, the physician was notified who then ordered the resident to be sent to an ER, and the POA was informed and agreed with the order. Resident #41's hospital CT [computed tomography] Chest Abdomen Pelvis w [with] cont [contrast], dated 02/12/2026 at 3:27 PM, revealed a comminuted (multiple broken pieces) left intertrochanteric femoral fracture. Resident #41's hospital Discharge Summary, dated 02/16/2026, revealed the resident was admitted to the hospital on [DATE] for evaluation and management of left hip pain following a fall during transfer at the nursing home. The Discharge Summary revealed Resident #41 was found to have a closed, mildly displaced intertrochanteric fracture of the left hip confirmed by radiographs. The Discharge Summary revealed that an orthopedic consultation recommended surgery to repair the fracture. The Discharge Summary revealed that on 02/13/2026, Resident #41 underwent open reduction and internal fixation (ORIF) surgery of the left intertrochanteric hip fracture without complications. During an interview on 07/27/2026 at 11:00 AM, POA #6 stated that a staff member was getting Resident #41 ready for bed, decided they could pick the resident up and put the resident into bed by themselves, but instead, dropped the resident. The POA stated Resident #41 called them the following day, stated their hip hurt, and thought it was from the previous night when the resident was dropped. The POA stated they talked to the nurse, and there were no notes from the night before. The POA stated that an x-ray was ordered, and it was discovered that Resident #41 had a broken hip. The POA stated Resident #41 had to have surgery. The POA stated Resident #41 was afraid of being dropped again. During an interview on 07/29/2026 at 3:02 PM, RN #3 stated that at the time of the incident involving Resident #41, she walked past Resident #41's room, and two CNAs and a nurse were in the room, and the resident was in bed. RN #3 stated that the male CNA revealed that he transferred Resident #41 from the wheelchair to the bed and the resident started slipping. RN #3 stated Resident #41 indicated their left knee was hurting, then started laughing and said they did not need medication. RN #3 stated Resident #41 was care-planned for the assistance of two people with transfers. RN #3 stated Resident #41 was to be transferred with a full body lift, and there were supposed to be two people assisting when transferring a resident using the full body lift. During an interview on 07/29/2026 at 3:27 PM, RN #2 stated that the incident involving Resident #41 occurred at around 8:30 PM when she was at the medication cart administering medications. RN #2 stated CNA #1 came out of the room and said he dropped Resident #41. RN #2 stated Resident #41 said their leg was hurting, and when RN #3 came to finish the assessment, RN #2 told RN #3 what was said. RN #2 stated she received a call the next morning at 8:00 AM from the ADON that she needed to come to the facility and document, and that Resident #41 had been sent to a hospital. During an interview 07/29/2026 at 3:48 PM, regarding the incident involving Resident #41, CNA #5 stated that she was at the nurses' station, heard a noise, and CNA #1 came out of a room and stated that he dropped Resident #41 when the resident slipped during a transfer. CNA #5 stated that when she entered the room, Resident #41 was on the floor and complained about pain to their left side. CNA #5 stated she helped get Resident #41 into bed after the nurse assessment. CNA #5 stated that the CNAs had access to the care plans. She stated that if a resident required two staff to assist, it was also indicated on the resident's door. During an interview on 07/30/2026 at 9:54 AM, the ADON stated CNA #1 picked up Resident #41 and dropped them while attempting to transfer the resident. The ADON stated that all staff had access to the care plans, and her expectation was for the staff to access and follow the care plan, especially for residents that used a lift and required two-person assistance. During an interview on 07/30/2026 at 10:34 AM, the Director of Nursing (DON) stated that she was not at the facility when the incident with Resident #41 occurred. She stated that to her knowledge, CNA #1 picked the resident up to transfer them from a wheelchair to the bed and dropped the resident. She stated that CNA #1 did not follow policy or procedure when transferring Resident #41. The DON stated all staff knew Resident #41 used a mechanical lift and required two people for transfers, and the expectation was for all staff to use two-person assistance with all lifts. The DON stated all staff were trained to use two people when transferring residents using mechanical lifts. During an interview on 07/30/2026 at 11:05 AM, the Administrator (ADM) stated CNA #1 attempted to transfer Resident #41 from a chair to the bed without a sling or a lift and dropped the resident, causing a hip fracture. The ADM stated the care plans entailed how a resident was to be transferred and if a mechanical lift was required, and the expectation was for staff to review and follow the care plans, as well as the codes on resident doors that indicate the resident's transfer and care needs. Review of the facility's Performance Improvement Plan dated 02/12/2026 revealed the facility initiated corrective actions on 02/12/2026 to correct the failed practice as follows: 1. Audit of all residents requiring mechanical lift assist. 2. Clinical skills audit/proficiency check off on all direct care staff for mechanical lift. 3. Inservice staff regarding safe use of mechanical list and following plan of care. 4. Weekly monitoring for proper transfer and mech [mechanical] lift use weekly x 4 [for four weeks], monthly x 3 [for three months], then periodically thereafter. 5. Review the findings of audits in monthly QAPI [Quality Assurance Performance Improvement]. After review and verification of the facility's corrective actions, to include the facility's investigation, facility audits, staff education, skills performance checklists, and interviews with facility staff, the survey team determined the facility implemented the above corrective actions beginning on 02/12/2026 and conducted ongoing education and monitoring; therefore, past noncompliance was cited.

Based on interview, record review, and facility policy review, the facility failed to ensure the State Long Term Care Ombudsman (Ombudsman) was notified of transfers to the hospital for 1 (Resident #5) of 2 residents reviewed for hospitalization.Findings included: A facility policy titled, Transfer or Discharge Notices, indicated, Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g.[exempli gratia, for example], in a monthly list of residents that includes all notice content requirements. A Resident Face Sheet revealed the facility admitted Resident #5 on 03/26/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease, diabetes insipidus, dehydration, hypotension, hypoosmolality and hyponatremia, acute respiratory failure, acute kidney failure, and other disorders of electrolyte and fluid balance. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2026, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. A nursing Progress Note, dated 03/08/2026 at 2:23 PM, revealed orders were received to send Resident #5 to an emergency room. A nursing Progress Note, dated 03/10/2026 at 10:20 PM, revealed Resident #5 returned from the hospital. There was no documentation the Ombudsman was notified of the transfer. A registered nurse's (RN) Progress Note, dated 03/24/2026 at 9:29 PM, revealed a family member had requested that Resident #5 be sent to the hospital, and the resident had returned back to the facility. There was no documentation the Ombudsman was notified of the transfer. A RN's Progress Note, dated 03/28/2026 at 9:32 AM, revealed orders were received to send Resident #5 to an emergency room. A licensed practical nurse (LPN) Progress Note, dated 04/01/2026 at 2:45 PM, revealed Resident #5 returned from the hospital. There was no documentation the Ombudsman was notified of the transfer. A RN's Progress Note, dated 04/11/2026 at 1:32 PM, revealed orders were received to send Resident #5 to an emergency room. A RN's Progress Note, dated 04/11/2026 at 7:58 PM, revealed Resident #5 returned to the facility. There was no documentation the Ombudsman was notified of the transfer. A RN's Progress Note, dated 05/16/2026 at 8:24 AM, revealed orders were received to send Resident #5 to an emergency room. A LPN's Progress Note, dated 05/16/2026 at 5:44 PM, revealed Resident #5 had no new orders from the emergency room visit. There was no documentation the Ombudsman was notified of the transfer. A LPN's Progress Note, dated 06/13/2026 12:17 AM, revealed orders were received to send Resident #5 to an emergency room, and the resident was admitted to the hospital. A RN's Progress Note, dated 06/17/2026 at 1:03 AM, revealed that Resident #5 returned to the facility. There was no documentation the Ombudsman was notified of the transfer. A Social Services Director's (SSD) Progress Note, dated 06/30/2026 at 10:09 AM, revealed Resident #5 had been sent to an emergency room. A RN's Progress Note, dated 07/01/2026 at 10:10 PM, revealed Resident #5 returned to the facility. There was no documentation the Ombudsman was notified of the transfer. A LPN's Progress Note, dated 07/23/2026 at 3:10 PM, revealed orders were received to send Resident #5 to an emergency room. A RN's Progress Note, dated 07/23/2026 at 9:07 PM, revealed Resident #5 returned to the facility. There was no documentation the Ombudsman was notified of the transfer. During an interview on 07/28/2026 at 10:47 AM, the Director of Nursing (DON) stated the SSD was responsible for sending the list of residents transferred or discharged to the hospital to the Ombudsman. During an interview via phone on 07/28/2026 at 2:56 PM, the Ombudsman stated transfer and discharge notifications should be sent to the state office. The Ombudsman stated she gave information about the process to the SSD a few months prior, about April or May. The Ombudsman stated she initially spoke with the Assistant Director of Nursing (ADON) and reported to her that they needed to send the notifications. During an interview on 07/29/2026 at 9:45 AM, the Ombudsman stated she told all her facilities to send the notifications once a month if the residents were going home or to the hospital. The Ombudsman stated the conversation with the ADON was prompted a few months prior because their state office wanted them to remind their facilities about sending in the notices. During an interview on 07/29/2026 at 3:47 PM, the ADON stated the Ombudsman was in the facility doing rounding, and she talked to the Ombudsman about the discharge notices. The ADON stated the Ombudsman said they needed to send the notices monthly, and she reported this to the SSD. During an interview on 07/28/2026 at 10:46 AM, the SSD provided a list of the residents she sent to the State Long Term Care Ombudsman for June 2026, and Resident #5 was not on the list. The SSD stated she had just started sending the lists to the Ombudsman last month. During an interview on 07/29/2026 at 3:24 PM, the SSD stated she did not know she was supposed to be notifying the Ombudsman of residents sent to the hospital. The SSD stated, That was totally my bad that I was not sending the notifications. The SSD stated she had not been told or trained on sending the notifications to the Ombudsman. The SSD stated she sent a list of residents that were discharged from the facility in May 2026, and she sent a list of residents that discharged from the facility in June 2026 after the concern of not receiving the notices was brought up by the Ombudsman. The SSD stated Resident #5 was not included in the list for June 2026 because the resident went to the hospital and were expected to return to the facility. The SSD stated Resident #5 was still their resident. During an interview on 07/29/2026 at 3:52 PM, the DON stated she was not aware that the Ombudsman had to be notified of residents discharging to the hospital, and she found out about it that week.

Based on observation, record review, and interview, the facility failed to obtain physician orders and evaluate one (#18) of one sampled resident reviewed for self-administration of medications. Findings: The DON/RN identified 63 residents resided in the facility. An Administering Medications policy, dated [DATE], read in part, Medications are administered in a safe and timely manner, and as prescribed. The policy also read, Residents may self-administer their own medications if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. A physician's order, dated [DATE], documented to apply Lantiseptic ointment to bilateral buttocks every shift. A quarterly assessment, dated [DATE], documented Resident #18 had moderate cognitive impairment and was independent with activities of daily living. A care plan, dated [DATE], documented the resident was at risk for pressure ulcers due to moisture. The plan of care did not include self-administration of medications. On [DATE] at 3:51 p.m., a bottle of clears eyes (expired), nasal spray, and a medication cup with Lantiseptic was observed on Resident #18's bedside table. On [DATE] at 2:26 p.m., a bottle of clear eyes, nasal spray, and a medication cup with Lantiseptic was observed on Resident #18's bedside table. On [DATE] at 8:52 a.m., RN #1 was asked about Resident #18's bedside medications. They reported they did not think the resident had medications at the bedside. They reported the family must have brought the medication into the facility. Resident #18 stated they used the nasal spray only as needed and used the eye drops every morning and every night. On [DATE] at 11:31 a.m., the DON/RN reported they notified the physician to keep the medications at bedside and to monitor it every Thursday.

Based on observation, record review, and interview, the facility failed to follow physician orders for wound care for one (#1) of three sampled residents who were reviewed for wound care. Resident #1 was admitted to the hospital for wound dehiscence, cellulitis, and sepsis. The facility reported seven residents in the facility required wound care. The DON reported 61 residents resided in the facility. Findings: The facility's Wound Care policy, dated 10/01/10, read in part, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .The following information should be recorded in the resident's medical record: All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound . Resident #1 had diagnoses which included diabetes mellitus, atherosclerotic heart disease, and hemiplegia. An admission assessment, dated 03/08/24, documented resident #1's cognition was intact, no behaviors, and was dependent on staff for most activities of daily living. A care plan, dated 04/05/24, read in part, .Surgical incision located to left [error] lower leg related to hematoma .Address c/o pain promptly .Administer medication per physician's orders .Administer wound care per physician's orders .Notify physician of changes in condition .Observe incision site for odor, drainage . A progress note, dated 04/05/24 at 3:45 p.m., documented in part, .readmitted to skilled services status post hospitalization for right lower leg hematoma evacuation .Right lower leg incision covered with a dressing and wrapped with large ace wrap as pressure dressing applied today at the hospital. It is clean, dry, and intact . A physician order, dated 04/05/24, documented, Triad wound dressing paste; apply to affected area three times a day; 8:00 a.m., 12:00 p.m., 5:00 p.m.; Diagnoses: nontraumatic hematoma of soft tissue. A progress note, dated 04/06/24 at 6:21 p.m., documented Resident #3 also had a dressing to their right lower extremity from a hematoma that was evacuated at [name removed] during their recent hospitalization . A progress note, dated 04/07/24 at 3:07 a.m., documented in part, .Hydrocodone-acetaminophen 10-325 mg tablet given at 4:33 p.m. for complaints 8 of 10 right leg pain was effective .Has a dressing to her right lower extremity . A physician order, dated 04/07/24, documented to cleanse the wound on left [error] lower leg with normal saline solution and pat dry. Adaptic touch non-adhering dressing to wound bed, cover with 4x4 gauze and wrap with Kerlix. Apply ace bandage to cover. Elevate leg. Once a day 7:00 a.m. - 3:00 p.m. Diagnoses: Nontraumatic hematoma of soft tissue. A progress note, dated 04/08/24 at 2:59 a.m., documented in part, .Upon chart review, dressing to lower [error] left leg from hematoma evacuation is to be hanged daily .Area is to be cleansed with NSS, pat dry, apply adaptic touch dressing to wound bed, cover with 4x4 gauze, wrap with Kerlix and cover with ace bandage .Leg is to be elevated when possible .Dressing changed this morning .Stitches still in place .Res has small areas of fluid retention under the skin .Moderate amount of serous drainage noted .Res stated that she was having pain the area .PRN Norco given and was effective . A progress note, dated 04/08/24, documented in part, .at 10:12 a.m.I came into room to get bandage off of right lower extremity for a bath .The bandage was stuck to the wound .Applied wound cleaner to soak the bandage .Went to get the resident a pain pill as this was painful .When med aide brought her the pain pill in 2 minutes later, there was a puddle of blood coming out of the right lower extremity .Firm continuous pressure was immediately applied by another nurse .Called Dr. [NAME] and received order to sent to ER to eval and treat .Ambulance called and resident transferred to the hospital . An Administration History report, dated 03/02/24 through 05/02/24, documented the following administration history for wound care: (Cleanse wound on left [error] lower leg with normal saline solution, pat dry. Adaptic touch non-adhering dressing to wound bed, cover with 4x4 gauze and wrap with Kerlix. Apply ace bandage to cover. Elevate leg. Once a day 7:00 a.m. - 3:00 p.m. Diagnoses: Nontraumatic hematoma of soft tissue.) 04/07/24 at 12:06 p.m., 04/08/24 - missed (sent to hospital). An Administration History report, dated 04/02/24 through 05/02/24, documented the following administration history for triad wound dressing ordered three times a day: 04/06/24 at 8:00 a.m. - missed .04/06/24 at 12:00 p.m. - Late, 04/06/24 at 5:00 p.m. - missed .04/07/24 at 8:00 a.m. - Late. The report contained no documentation of wound care on 04/05/24. The report documented three missed wound care administrations if physician's orders would have been followed. A emergency department report, dated 04/08/24 at 10:30 a.m., documented in part, .presents to the ED with chief complaint of wound check .Patient was sent her for further evaluation of the right lower extremity wound .Physical exam - post surgical changes to lower extremity with dry excoriations moderate amount of cellulitis .The patient is pale .Hemoglobin down to 7.9 from the 8.4 she had at hospital discharge several days ago .Given her hypotension with a recent source of bleeding decision was made to transfer as her until 1 unit packed red blood cells .Blood pressure improved .Blood cultures obtained and antibiotics given .Hospital admission warranted, patient admitted in stable condition . An orthopedic consult, dated 04/08/24 at 1:12 p.m., documented in part, .Right lower extremity: large area of necrotic skin over the anterior leg; fluctuance over the lateral aspect of the leg; leg is TTP; grossly NV intact to the foot .Diagnoses of acute kidney injury, sepsis, and cellulitis .Recommendation if for operative treatment for debridement of the skin on the right leg with irrigation/debridement . A hospital discharge summary, dated 04/17/24, documented in part, .Patient was admitted on [DATE] with right lower extremity hematoma status post evacuation that developed wound dehiscence and infection .Patient was treated with broad spectrum antibiotics and underwent excisional debridement on 04/12/24 with orthopedics .Patient was discharged back to [name removed] skilled nursing facility .Discharge instructions: Continue wound vac for an additional 2 weeks .Referred to orthopedic surgery for follow up of cellulitis and wound vac maintenance . A progress note, dated 04/18/24 at 4:35 p.m., documented in part, .Resident readmitted to skilled services status post hospitalization on right lower extremity that developed wound dehiscence and infection and required hospitalization for diagnoses of cellulitis of right lower extremity, wound dehiscence, and bladder mass .Resident was treated with broad spectrum antibiotics and had excisional debridement .Resident has a right lower leg wound vac on at this time due to the dehisced wound . On 05/02/24 at 11:25 a.m., Resident # 1 was observed in bed. The resident reported they had not been getting up for meals or getting physical therapy due to the wound vac to their right leg and it being painful. The resident's right lower extremity was wrapped with ace bandage and had a wound vac present. On 05/03/24 at 11:20 a.m., the DON reported no skin assessments were available in resident #1's medical record from 04/05/24 through 04/08/24. The DON reported no assessment of the right lower extremity wound site was documented until 04/07/24. The DON reported the Triad wound dressing ordered on 04/05/24 for three times a day, should have been for the coccyx. The DON reported the nurse that entered the readmission orders on 04/05/24 should have called to get a clarification order for wound care for the surgical site to the right lower extremity. The DON reported the order should have been checked and the wound site assessed before 04/07/24. The DON reported the resident did not get wound care as it was documented on the physician orders, due to that type of wound would not have Triad ordered three times a day. The DON was asked why wound care was not done on 04/05/24 as scheduled at 5:00 p.m., and the DON reported resident #1 had just left the hospital and they would have done the wound care before discharge, but was unable to provide proof of the time the wound care was last done in the hospital. The DON reported they did not believe the wound dehiscence or cellulitis was caused by Triad not being administered three times a day per the documented physician order. The DON reported the resident had only missed two treatments before the new wound care order was received and started on 04/07/24.

Based on record review and interview, the facility failed to obtain laboratory tests per physician orders for one (#9) of five sampled residents reviewed for laboratory results. The administrator reported 47 residents resided in the facility. Findings: A Lab and Diagnostic Test Results clinical protocol, revised November 2018, read in part, .When test results are reported to the facility, a nurse will first review the results . Resident #9 was admitted with diagnoses which included cerebrovascular disease, bipolar disorder, autism, diabetes mellitus, and long term use of insulin. A physician order, dated 01/23/23, with a start date of 04/23/23, documented to obtain a hemoglobin A1C and lithium level on the 23rd of January, April, July, and October. On 10/31/23 at 2:07 p.m., the DON reported they did not obtain labs for April or July and was still working on getting October labs. The DON stated they just missed them in April and July. The DON provided an action plan regarding labs. On 10/31/23 at 2:25 p.m., the regional nurse consultant was asked about the lithium levels for April and July and reported they could not find the lab results. The resident's clinical record documented lab results were received on 10/31/23 for the hemoglobin A1C and lithium level. No other labs had been obtained for April or July and no results were documented.

Based on observation and interview, the facility failed to ensure staff performed hand hygiene during the meal pass. The DON reported 49 residents received meals from the kitchen. Findings: On 09/12/22 at 11:45 a.m., CNA #1 was observed in the front dining room, they re- positioned a resident's wheelchair, touched the resident's hand, and served the resident's meal tray without performing hand hygiene. CNA #1 continued to serve multiple meal trays without performing hand hygeine. On 09/12/22 at 11:55 a.m., CNA #1 stated they should have performed hand hygiene prior to each meal tray being served. On 09/13/22 at 10:37 a.m., the DON stated all employees had been inserviced on hand hygiene and CNA #1 should have performed hand hygiene during meal service.

Based on observation and interview, the facility failed to prepare pureed food in a sanitary manner by failing to: a. sanitize blender bowl between each food preparation. b. perform hand hygiene. The DON reported three residents received pureed diets. Findings: a. On 09/13/22 at 10:45 a.m., cook #2 was observed preparing pureed meals. Cook #2 placed beans into the blender bowl. On 09/13/22 at 10:48 a.m., cook #2 was observed to rinse the blender bowl with running water. On 09/13/22 at 10:49 a.m., the blender bowl was observed to contain bean juice. Cook #2 proceeded to place okra into the unsanitized blender bowl. On 09/13/22 at 10:53 a.m., cook #2 rinsed the blender bowl with running water and proceeded to place corn bread into the unsanitized blender bowl. Cook #1 informed cook #2 the blender bowl should have been sanitized. b. On 09/13/22 at 10:45 a.m., cook #2 was observed preparing pureed meals without performing hand hygiene. On 09/13/22 at 11:02 a.m., cook #2 stated they should have performed hand hygiene prior to meal preparation, between each dish prepared, and anytime hands were soiled. Cook #2 also reported the blender bowl should have been sanitized between each use. On 09/13/22 at 11:15 a.m., the DM reported the blender bowl should have been sanitized between each use and hand hygiene should have been performed.

Based on observation and interview, the facility failed to ensure narcotics were stored in a permanently affixed compartment. The Resident Census and Conditions of Residents dated 09/12/22, documented 51 residents resided in the facility. Findings: On 09/13/22 at 9:00 a.m., in the medication room refrigerator, narcotic medications were in three plastic sealed bags on refrigerator shelves and inner door shelves. The three plastic sealed bags were not in a locked or secured container, the bags contained: a.16 syringes of [MEDICATION(S)] (an anti-anxiety medication) gel b. 45 syringes of [MEDICATION(S)] (a pain relieving medication) gel c. two vials of [MEDICATION(S)] (an anti-anxiety medication) gel. On 09/13/22 at 9:20 a.m., the administrator, DON and Corporate Nurse Consultant #2 were informed that narcotics were not stored within a secure permanently affixed compartment in the medication room refrigerator. They stated they were unaware the narcotics should have been stored in a permanently affixed compartment.

Based on observation and interview, the facility failed to provide a home like environment by not maintaining floor tiles. The Resident Census and Conditions of Residents, dated 09/12/22, documented a census of 51 residents. Findings: On 09/12/22 at 10:07 a.m., three broken floor tiles were observed in the center hallway. On 09/12/22 at 10:23 a.m., two broken floor tiles were observed in the dining area. On 09/12/22 at 10:32 a.m., four broken floor tiles were observed in resident room #7. On 09/13/22 at 3:29 p.m., the DON reported the broken floor tiles should have been replaced. On 09/13/22 at 3:30 p.m., the administrator reported the broken floor tiles should have been replaced.

Based on observation and interview, the facility failed to ensure a dignity bag was utilized on one (#10) of one resident reviewed with an indwelling urinary catheter. The Resident Census and Conditions of Residents, dated 09/12/22, documented one resident with an indwelling urinary catheter resided in the facility. Findings: Res #10 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/13/22 at 8:30 a.m., Res #10 was observed in the dining room with an indwelling urinary catheter without a dignity bag cover. On 09/13/22 at 12:30 p.m., Res #10 was observed lying in their bed with the door open and an indwelling urinary catheter bag was observed without a dignity bag cover. On 09/14/22 at 3:00 p.m., the DON reported there should have been a dignity bag covering the indwelling urinary catheter for Res #10.

Based on record review and interview, the facility failed to ensure resident assessments were completed accurately for one (#35) of four residents whose assessments were reviewed for accuracy. The Resident Census and Conditions of Residents dated, 09/12/22, documented 51 residents resided in the facility. Findings: Res #34 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Regime Review dated, 11/04/21, documented in part, . on 10/20/21 [MEDICATION(S)] (an anti-depressant), Trazadone (an anti-depressant), [MEDICATION(S)] (an antipsychotic) and [MEDICATION(S)] (an anxiolytic) were discontinued and [MEDICATION(S)] (an antidepressant) 20mg daily and [MEDICATION(S)] (an antipsychotic) 3mg daily were started . An admission MDS dated , 10/30/21, did not document a GDR had been attempted. The MDS should have reflected a GDR date of 10/20/21. A quarterly MDS dated , 01/30/22, documented in error a GDR had been attempted on 11/03/21. The MDS should have reflected a GDR date of 10/20/21. A quarterly MDS dated , 05/02/22, did not document a GDR had been attempted. The MDS should have reflected a GDR date of 10/20/21. A quarterly MDS dated , 05/02/22, showed the physician documented a GDR was clinically contraindicated on 11/03/21. There was no documentation in the EHR of a GDR being clinically contraindicated. An Event Report dated, 07/18/22, documented in part, .decrease [MEDICATION(S)] to 1.5mg Q Day . A quarterly MDS dated , 08/02/22, did not document a GDR had been attempted. The MDS should have reflected a GDR date of 07/18/22. A quarterly MDS dated , 08/02/22, showed the physician documented a GDR was clinically contraindicated on 07/18/22. There was no documentation in the EHR of a GDR being clinically contraindicated. On 9/14/22 at 10:25 a.m., the MDS Coordinator reported the MDS was not coded correctly regarding the GDR. On 09/14/22 at 10:45 a.m., the DON reported the GDR should have been coded properly on the MDS.

Based on observation, record review, and interview, the facility failed to obtain a physician's order for one (#20) of three residents reviewed for oxygen therapy. On 09/12/22, the DON reported there were three residents with oxygen therapy. Findings: Res #20 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Res #20's EHR failed to show a physician's order for oxygen therapy. An admission note, dated 07/07/22, documented in part, . is O2 dependent at 3 lpm via nasal cannula, humidifier in place due to her stating that it felt like the oxygen was burning her nose. A care plan, dated 07/11/22, documented in part, . resident is At Risk for Impaired Respiratory Status AEB: shortness of breath, requires use of O2 per MD orders. A progress note, dated 08/27/22, documented in part, . Resident stated that she had gotten short of breath and panicked while in bathroom, instructed resident not to take off her oxygen when she goes to the restroom or moves about room if she is becoming short of breath like that upon exertion, resident verbalized understanding. A progress note dated 09/12/22 documented in part, . long enough tubing for her to be able to toilet with oxygen on. On 09/12/22 at 10:32 a.m., Res #20 was observed in bed with oxygen at three liters per nasal cannula. On 09/13/22 at 9:59 a.m., Res #20 was observed in bed with oxygen at three liters per nasal cannula. On 09/13/22 at 3:44 p.m., after reviewing Res #20's EHR, the DON reported there were no physician's order for oxygen therapy.

Based on interview and record review, it was determined the facility failed to complete and transmit resident assessments within the time frame required for four (#1, #2, #8, and #163) of four residents reviewed for timely submission of assessments. The facility identified 60 residents who resided in the facility. Findings: 1. Resident #1 had an annual assessment completed on 09/09/19, with a submission date of 10/14/19. 2. Resident #2 had a quarterly assessment completed on 09/10/19, with a submission date of 10/14/19. 3. Resident #8 had an annual assessment completed on 09/12/19, with a submission date of 10/14/19. 4. Resident #163 was admitted to the facility on [DATE]. The facility reported the admission assessment was due on 10/07/19. On 10/15/19 at 3:45 p.m., the DON reported the MDS coordinator would complete the assessment for resident #163 later that day. On 10/16/19 at 9:36 a.m., the MDS coordinator reported the assessments should have been completed and submitted within the 14 day required time frame.

Based on observation, interview, and record review, it was determined the facility failed to provide physical therapy services as ordered by the physician for one (#49) of one resident reviewed for rehabilitation and restorative services. The facility reported seven residents received specialized rehabilitative services. Findings: Resident #49 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/09/19, documented the resident was cognitively intact. The assessment documented the resident required one-person assistance with most activities of daily living. On 10/14/19 at 9:33 a.m., the resident reported a doctor had ordered physical therapy for his pain but it had never been started. The resident reported he had received nerve stimulator treatment, which had helped with the pain, but he would still like to receive physical therapy. A review of the resident's clinical record documented a pain management consult was conducted on 07/31/19. The consult documented an order for [REDACTED].>On 10/17/19 at 9:45 a.m., the DON reported the order for physical therapy had been missed and had not been scheduled. On 10/17/19 at 11:00 a.m., the ADON provided a copy of the physician order, dated 08/19/19. The order documented for physical therapy/occupational therapy to evaluate and treat the resident.

Based on observation, interview, and record review, it was determined the facility failed to treat residents with dignity and respect when requesting food items from the kitchen for one (#13) of one resident reviewed for dignity. The facility reported 59 residents received food from the kitchen. Findings: Resident #13 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/26/19, documented the resident was cognitively intact. The assessment documented the resident ambulated without assistance and was independent with activities of daily living. On 10/14/19 at 3:07 p.m., the resident stated dietary staff #1 and #2 were sometimes hateful when the resident went to the kitchen to ask for food or drinks. The resident reported they would sigh when asked for coffee or say they didn't have time to get coffee and to come back later. The resident reported she was not afraid of the staff. On 10/15/19 at 10:30 a.m., a resident council meeting was conducted. Seven residents reported if they asked for anything from the kitchen, dietary staff #1 would respond in a rude way. Residents reported they were not afraid of the dietary staff but thought they could be more pleasant. On 10/16/19 at 2:43 p.m., CNA #2 reported dietary staff #1 was loud with the residents when speaking to them at times. On 10/16/19 at 2:45 p.m., dietary staff #1 reported she was aware she could be loud at times with residents and staff. On 10/17/19 at 8:36 a.m., CNA #1 reported dietary staff #1 could be rude to residents and staff when food items were requested from the kitchen. On 10/17/19 at 8:38 a.m., LPN #1 reported dietary staff members were hateful to residents and staff when food items were requested from the kitchen. On 10/17/19 at 9:28 a.m., the DON reported she was aware of the conflict between dietary staff and the residents. The DON reported a plan was in place to correct how dietary staff #1 had interacted with residents and staff. On 10/17/19 at 10:44 a.m., dietary staff #1 was interviewed and asked if any resident had complained to her regarding her or other dietary staff being rude to them. She stated, No. When asked if anyone had talked to her about complaints regarding her being rude to residents or other staff, she stated No. She reported when an issue was brought to her attention related to a resident complaint, she would talk to the resident and hug it out. She reported she was always available to residents to talk about any issues they might have related to the kitchen or dietary staff.

Based on observation, interview, and record review, it was determined the facility failed to provide sufficient staff to meet the needs of residents in a timely manner. The facility identified 60 residents who resided in the facility. Findings: On 10/14/19 at 9:30 a.m., during the initial tour of the facility, an anonymous resident reported he waited for long periods of time for his call light to be answered. The resident reported he had waited 30 minutes or longer for his call light to be answered and was forced to clean himself up due to lack of staff. On 10/15/19 at 10:33 a.m., a resident group meeting was conducted. Nine alert and oriented residents reported call lights often stayed on for 30 minutes or longer before being answered by staff. Residents reported staff would forget them after responding to a call light then leaving without providing care. Residents reported there was usually only one aide assigned to the north unit and on occasion there had been no aides. Resident council minutes were reviewed for the months of July, August, and (MONTH) 2019. During the (MONTH) meeting, residents reported they were not getting baths as scheduled. The minutes were signed but did not document a response. The (MONTH) meeting documented a shortage of aides on weekends. The response documented, we are currently running ads to hire more help. The (MONTH) meeting documented the facility still needed more help on the 3 p.m. to 11 p.m. shift and weekends. The response documented, still accepting applications. Staffing records were reviewed for 09/29/19 through 10/12/19. For the 14 days reviewed, nine shifts were documented to have insufficient staff for the resident census reported. On 10/17/19 at 8:56 a.m., sufficient staffing was discussed with the director of nursing. The DON was informed of the numerous complaints expressed by residents throughout the survey and during the group meeting related to insufficient staffing. The DON reported she had recently hired two CNAs for the day shift. The DON reported there was currently two nurses working the night shift and two to three aides as of this week. The DON reported the staffing change had just started this week because, we've known we had a problem. The DON reported there had been aides splitting shifts to cover the nightshift. The DON reported she had heard a resident complained of having to clean himself up. The DON reported if a resident could clean himself up, they would encourage him to do so and encourage independence. The DON agreed a resident's call light should always be answered in a timely manner.

Based on observation, interview, and record review, it was determined the facility failed to implement a personalized care plan to supervise a resident during smoking for one (#7) of 16 residents reviewed for comprehensive care plans. The facility identified 60 residents who resided in the facility. Findings: The resident had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A quarterly assessment, dated 09/11/19, documented the resident's cognition was intact and required extensive assistance with transfers and personal hygiene. A care plan, dated 09/12/19, documented the resident required a smoking apron or supervision while smoking. The care plan did not reflect a smoking assessment had determined the resident was safe to smoke independently. The care plan did not address resident behaviors related to smoking. A smoking assessment, dated 09/16/19, documented the resident was a safe smoker and allowed to keep cigarettes and lighter in her possession. The resident was observed to smoke outside several times throughout the survey, independently, with no apron and no supervision by staff. On 10/16/19 at 10:40 a.m., the resident was observed while smoking outside. The resident was observed without a smoking apron and was not supervised. The resident reported, The staff never come out with me when I smoke. On 10/16/19 at 10:49 a.m., CNA #1 reported there were no residents on the north hall who required smoking supervision. On 10/17/19 at 9:00 a.m., LPN #1 reported she had called the physician in (MONTH) when a smoking assessment was completed. The LPN reported the physician did not want to discontinue the order for the resident to be supervised while smoking. On 10/17/19 at 9:32 a.m., the MDS coordinator reported she did not change the care plan because the physician did not want the order for supervision to be discontinued. On 10/17/19 at 9:45 a.m., the DON reported the resident refused to wear the apron, was safe to smoke, and the supervision should have been removed from the care plan.

Based on observation, interview, and record review, the facility failed to complete a significant change assessment related to hospice care for one (#263) of 16 residents reviewed for assessments. The facility identified 60 residents who resided in the facility. Findings: Resident #263 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/07/19, documented the resident was cognitively intact. The assessment documented the resident required extensive to total assistance with most activities of daily living. On 09/18/19, the resident was readmitted to the facility from the hospital with a physician's orders [REDACTED]. The clinical record was reviewed and contained no significant change assessment for hospice services. The entry assessment, dated 09/18/19, did not document hospice services. 0n 10/14/19 at 11:00 a.m., the resident was observed in her room. PPE supplies were hanging on the resident's door and were observed to be used by staff when entering the resident's room. On 10/16/19 at 3:35 p.m., the MDS coordinator reported she was behind on assessments and the significant change had not been completed to reflect the resident received hospice services.

Based on observation, interview, and record review, it was determined the facility failed to complete an individualized baseline care plan within 48 hours of admission for one (#163) of one resident reviewed for initial care plan. The facility reported one new admission to the facility in the previous 30 days. Findings: Resident #163 was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The clinical record was reviewed and documented the baseline care plan had not been completed within 48 hours. The record documented it was completed on 09/27/19 at 10:58 a.m. The baseline care plan did not document the resident had [MEDICAL CONDITION] and did not address the resident's antipsychotic medications. On 10/15/19 at 9:00 a.m., the resident reported she had not received a copy of the baseline care plan. On 10/16/19 at 9:35 a.m., the DON reviewed the documentation and acknowledged the above findings.

Based on observation, interview, and record review, it was determined the facility failed to revise the care plan to reflect contact isolation for one (#263) of 16 residents reviewed for comprehensive care plans. The facility identified 60 residents who resided in the facility. Findings: Resident #263 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/07/19, documented the resident was cognitively intact. The assessment documented the resident required extensive to total assistance with most activities of daily living. A care plan, dated 08/07/19, had not been updated to reflect the resident required contact isolation due to ESBL in the urine. On 09/18/19, the resident was readmitted to the facility, from the hospital, with a physician's orders [REDACTED]. On 10/14/19 at 11:00 a.m., the resident was observed in her room. PPE supplies were hanging on the resident's door and were observed to be used by staff when entering the resident's room. On 10/16/19 at 3:35 p.m., the MDS coordinator reported she was behind on getting care plans updated and the care plan should have been revised to reflect the contact isolation.

Based on interview and record review, it was determined the facility failed to ensure a resident's condition was assessed, monitored and interventions were provided for his continued complaints of pain to his left lower extremity following an incident for one (#1) of three residents whose records were reviewed for pain management. This had the potential to affect all 60 residents. Findings: Resident #1 had [DIAGNOSES REDACTED]. A Facility Pain management guideline, effective date 10/2018 documented, All residents will be screened by the Charge Nurse using a resident specific screening tool upon admission, at least once every thirty days and with any change of condition. A quarterly assessment, dated 03/14/19, documented the resident had pain, almost constantly, it effected his sleep, and his numeric rating was a 10 (on pain scale of 1 to 10) for the worst pain on a 5 day look back period. The care plan documented, .Problem Start Date: 03/29/19 Category: Pain I have almost daily c/o pain to my L (left) leg and recent L tibial fx (fracture) and have routine and PRN pain medication available. Updated: 05/07/19 .Approach Start Date: 03/29/19 Give medication as ordered .Approach Start Date: 03/29/19 on going assessment of pain status . The clinical record had no documentation of a pain screening for (MONTH) 2019. The resident had orders for [MEDICATION NAME] 7.5/325 mg every 4 hours as needed for pain and [MEDICATION NAME] 100 mg every 6 hours as needed for pain. On 05/07/19 at 11:00 a.m., resident #1 stated that after supper on Saturday (04/27/19) certified nurse aide (CNA) #1 threw me on the couch. My foot got caught under the edge of the couch. I told CNA #1 my foot got caught under the couch and I complained of pain. At 11:05 a.m., family member #1 stated they broke his foot on Saturday and no one did anything until I got here to the facility on Wednesday 05/01/19. At 12:00 p.m., the director of nursing (DON) stated we looked at the camera which showed on Monday 04/29/19, CNA #1 had put the resident on the couch by herself with his paralyzed side up next to the couch. His foot on his paralyzed side must have went up under the couch. CNA #1 should have transferred him with his unparalyzed side next to the couch. I received a call on 05/01/19 from the charge nurse about the incident. We called the doctor to get an x-ray because his sister was insisting we do something. The (MONTH) Medication Administration Record [REDACTED]. An x-ray was obtained on 05/01/19. The findings documented, .Impression: Nondisplaced, mildly comminuted distal tibial diaphyseal fracture with overlying soft tissue swelling . On 05/07/19 4:00 p.m., the DON was asked if they had done a pain assessment since the resident's injury to his foot on Monday 04/29/19. She stated we have not done one since he broke his foot. A facility Pain Management -- Pain Observation for Cognitively Aware was done the evening of 05/07/19 at 7:04 p.m., it documented the resident had severe, frequent pain as high as a 10. Onset of pain was early morning, mid morning, afternoon, evening, late evening and at night. On 05/08/19 at 2:30 p.m., CMA #1 stated last Monday on 04/29/19, CNA #1 was transferring the resident from his wheel chair to the couch. I was standing by him in case he would start to fall. I usually help, but CNA #1 said she could do it by herself. He did complain that his leg hurt as soon as she sat him down. We didn't think anything of it because he always says his leg hurts when we transfer him. He always complains of pain. We don't give him anything for it unless he goes on and on about it. At 3:15 p.m., CNA #1 said I transferred him (on 04/29/19) by myself, I don't know why, we always transfer with two people, but on this day I did it by myself. He did complain of pain at the time and later that evening. At 3:23 p.m., LPN #1 stated, CMA #1 was saying the resident said CNA #1 broke his leg, this was after they came out of the shower on Monday evening (04/29/19). They were all laughing and I thought they were joking. LPN #1 stated I did not give a pain pill Monday or Tuesday he is usually ok after we reposition him. At 3:30 p.m., the resident was interviewed. He stated, I have pain every day. I tell staff and they don't give me any pain pills until I say owie, owie, owie. He was asked if his pain was being controlled. He stated, No. He was asked when staff repositioned his leg did it take the pain away? He nodded, No. He was asked if it relieved any of the pain? He nodded, No. At 4:30 p.m., the DON stated we try not to give him too many pain pills. He had a drug addiction in the past and he could be drug seeking. There was no documentation in the clinical record stating the resident was a drug seeker. The (MONTH) MAR indicated [REDACTED]. Only one [MEDICATION NAME] 7.5/325 was given that day at 9:11 a.m. The (MONTH) 2019 MAR indicated [REDACTED]. On 05/03/19 only one pain pill was administered that day, at 7 p.m. The DON, Administrator and the corporate nurse were all made aware the resident's pain had not been controlled.

Based on interview and record review, it was determined the facility failed to ensure a resident was transferred properly to prevent injury for one (#1) of three residents whose records were reviewed for neglect. The resident sustained [REDACTED]. This had the potential to affect 14 residents who required assistance with transfers. Findings: Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/14/19, documented the resident was totally dependent with transfers and required two + persons physical assist. He had impairment on his left side with both his upper and lower extremities. A care plan dated 03/29/19 documented, .Approach .Assist with transfers if needed . The care plan did not support the quarterly assessment documentation of two + persons being required to assist with transfers. The care plan was updated on 05/06/19 and documented, .Resident is to be a sling lift at all times, he is not to be lifted any other way but by the sling lift . A state incident report, dated 05/01/19, documented the resident was complaining of left leg pain, the physician was called and orders were given to obtain an x-ray of the tibia and fibula. An x-ray report, dated 05/01/19 at 5:50 p.m., documented, .There is a nondisplaced, mildly comminuted distal tibia diaphyseal fracture. There is mild to moderate overlying soft tissue swelling . Certified nurse aide (CNA) #1 documented the incident in a written statement (not dated) as part of the facility's investigation. The statement documented, . On Monday, I was transferring resident (initials deleted) from his chair to the couch. I transferred by myself this day, something I usually dont do. When I sat him on the couch, he then said his leg hurt. I adjusted his legs and he seemed fine. from the couch we transferred him back to his chair. I had help during the rest of the transfers. From his chair we went to the shower chair. From the shower chair we transferred him to bed. At this time he said something else about his leg. this is Normal. He talks about his leg quite often. Certified medication aide (CMA) #1 documented the incident in a written statement (not dated). It documented, . On Monday night (MONTH) 29th, while transferring resident (name deleted), the aide told me she could do it herself from the wheel-chair to the couch. I stood beside her holding the wheel-chair in case she needed help. The resident did not assist during transfer. They both kind of fell into the couch and then resident claimed his leg hurt. I joked saying he was fine and he laughed then did not bring it back up again. When transferred to the shower chair afterwards he didn't complain of any leg pain. When we transferred the resident to bed after the shower he said his leg hurt until the aide and I fixed him in the bed. Then he didn't say anything else about it. Licensed Practical Nurse (LPN) #1 documented the incident in a written statement (not dated). It documented, On Monday 4-29-19 Resident was being taken back to Room from Shower (with) (name deleted) CNA/CMA and (name deleted) CNA. I was coming up the hall (name deleted CMA ) and (name deleted CNA) and Resident (name deleted) was laughing They stop me and (Name deleted CMA) said (name deleted CNA) broke (resident's name deleted) leg. I said your kidding Right and how did this happen (name deleted CNA) said I guess I karate chop him .(name deleted CMA) and (name deleted CNA) and (resident) laughing I said tell me your teasing they said they was I said to (resident) did (name deleted CNA) Break your leg he smile and shook his head no. I told them not to every kid about something like that again. The RN, ADON (Assistant Director of Nursing) documented the incident in a written statement dated 5-1-19. It documented, .This nurse was notified by the charge nurse of the South unit that Resident (name deleted) had told his sister that (name deleted), CNA, had broken his leg. This nurse ask the charge nurse if the resident had c/o (complaints of) pain. No c/o pain had been voiced. This nurse Then instructed the charge nurse to get an xray of his leg . The follow up state incident report, dated 05/06/19, documented . Investigation results were that the resident was being transferred from wheelchair to couch. He was transferred with his affected side to the couch which resulted in leg not being able to turn, causing unintentional injury . On 05/07/19 at 11:00 a.m., resident #1 stated after supper on Saturday (the incident occurred on Monday) CNA #1 threw me on the couch. My foot got caught under the edge of the couch, I told CNA #1 my foot got caught under the couch and I complained of pain. At 12:00 p.m., the director of nursing (DON) stated she looked at the camera video which showed on Monday 04/29/19, CNA #1 had put the resident on the couch by herself with his paralyzed side up next to the couch. His foot on his paralyzed side went up under the couch. CNA #1 should have transferred him with his unparalyzed side next to the couch. I received a call on 05/01/19 from the charge nurse about the incident. We called the doctor to get an x-ray. At 3:15 p.m., CNA #1 stated, I transferred him by myself, I don't know why, we always transfer with two people. He did complain of pain at the time and later that evening. I told LPN #1 the resident said I broke his leg. LPN #1 said to the resident did she do that to you and the resident said yeah. At 3:23 p.m., LPN #1 stated CMA #1 was saying the resident said CNA #1 broke his leg, this was after they came out of the shower on Monday evening. They were all laughing and I thought they were joking. On 05/07/19 at 4:00 p.m., the DON was in agreement the resident had been transferred improperly, which caused his broken ankle.

Based on record review, observation and staff interviews, it was determined the facility failed to assess, monitor, notify the physician and obtain a treatment in order to prevent a decline in condition resulting in an unstageable necrotic pressure ulcer, resulting in harm, for one (#1) of three sampled residents with pressure ulcers. This had the potential to affect four residents identified by the facility with pressure ulcers. Findings: A facility policy for pressure sores documented, "...Physician notification, if appropriate...If pressure sore is present, the licensed nurse is responsible to record condition of the skin, including stage, size, site, depth, color, drainage and odor as well as the treatment provided. Notification of the physician is required when a new pressure sore is identified as well as when treatment is not effective..." Resident #1 was admitted on [DATE], with numerous [DIAGNOSES REDACTED]. A care plan, dated 08/22/11, documented the resident had a stage II pressure ulcer on the coccyx. The care plan goal documented the pressure ulcer would show resolution by the target date of 11/20/11. The pressure ulcer on the coccyx had healed. An intervention listed was to keep the resident dry and check skin for any additional red areas, monitor skin daily for signs of pressure areas, body/skin audit at least weekly, and the use of positioning and pressure relieving devices. A significant change assessment, dated 10/18/2011, documented the resident was moderately impaired and had no mood or behavior problems. The resident required limited assist of one person with bed mobility and extensive assistance with transfers of one person. The resident had no limitation with ROM. The resident was always incontinent of bowel and bladder. The resident had no pressure ulcers, but was identified at risk for pressure ulcer development. A nurses note, 7/3 shift dated 11/02/11, documented new orders for [MEDICATION NAME] spray to both heels... A Physician telephone order, dated 11/02/11, documented "[MEDICATION NAME] spray to B (both) heels q shift for pain and redness." A nurses note, 3/11 shift dated 11/02/11, documented, "Denies c/o pain tx to bilat heel - c/o of them being "sore"- [MEDICATION NAME] spray applied bilat per order." There was no documented skin assessments for the condition of the resident's heels from 11/02/11 through 11/28/11. There was no documentation of the condition of the resident's heels until 11/26/11, when a nurses note at 13:30 (1:30 p.m.) documented, "[MEDICATION NAME] to coccyx ei [MEDICATION NAME] to heels." A nurses note, 3/11 shift, dated 11/26/11, documented, "Tx to bilat heels c [MEDICATION NAME] completed. Open area to L heel 1.5 cm x 1.5 cm. feet elevated on pillows to alleviate pressure from heels." There was no documentation the physician or family was notified of the decline in condition of the pressure ulcer on the L heel. No new treatment orders for the L heel were obtained. The care plan had not been updated to address the condition of the resident's heels. On 11/28/11 at 10:30 a.m., CNA #1 accompanied the surveyor on a tour of North Hall. The CNA reported resident #1 had a sore on his heel. At 10:45 a.m., CNA #1 was asked if the surveyor could observe the resident's skin. The resident was observed lying in bed with a blanket and pillow under his legs. His heels were both touching the mattress. A dark necrotic area was observed on the residents left heel. During the observation of the resident's skin, the resident complained of pain to the left heel by moaning and reaching for his foot. CNA #1 reported the heel had been red for a couple of weeks and then it turned black. CNA #1 was asked if she would turn the resident over on his side to further observe his skin. Two small, open, circular areas were observed on the resident's left buttock area. At that time, CNA #1 reported the open areas on the resident's buttocks had been there a few days. A Weekly Skin Condition Report Non-Pressure, dated 11/28/11, documented, "Date first observed, 10/04/11, Facility Acquired, Site R buttocks, abrasion c pinkness to buttocks, current size in cm, 0.1 x 0.1, treatment [MEDICATION NAME] q shift, progress P (improving), date physician notified 10/04/11." The above skin assessment had not addressed the current open areas to the residents buttocks. A Weekly Skin Condition Report for Pressure, dated 11/28/11, documented, Facility acquired site L heel, stage IV, current size in cm 1.5 cm x 2.0 cm x udt (unable to determine), , no drainage or odor, soft, black, treatment [MEDICATION NAME] for prevention, progress D (decline), date physician notified, (blank)." At 11:15 a.m., the ADON was asked for any skin assessments for the resident's heels. She then presented the skin assessment dated [DATE]. She was asked for any other skin assessments for the resident. She reported the skin assessment dated [DATE], was the only one she could locate. On 11/28/11 at 1:45 p.m., incontinent care was observed for the resident. The ADON was in the room while CNA #1 performed incontinent care. After incontinent care was completed, the ADON was asked to view the resident's buttocks. She was asked if she observed two open areas to the resident's left buttocks. She stated, " Yes." The ADON reported the areas looked like scratches. At that time, the resident looked up at the ADON and complained of his heel hurting. At that time, the ADON was asked about the resident's left heel. She reported the heel was not like that the last time she saw it previously, it was just red. She reported today was the first time she had seen it since she had returned from vacation. At 4:55 p.m., the DON was asked about any skin assessments for the resident. She reported the facility had not been doing the weekly skin assessments.

Based on record review, observation and staff interviews, it was determined the facility failed to: a) Assess, monitor and notify the physician of episodes of pain involving a necrotic pressure ulcer for one (#1) of two sampled residents with pressure sores, which resulted in harm to the resident. b) Administer pain medications for complaints of headaches for one (#1) of one sampled resident reporting headaches. c) Administer pain medications for complaints of hip pain for one (#1) of one sampled resident with complaints of hip pain. d) Administer pain medications for complaints of head pain following a fall for one (#1) of one sampled resident with complaints of head pain. e) Administer pain medications for complaints of shoulder pain following a fall for one (#1) of one sampled resident with complaints of shoulder pain. This had the potential to affect all 56 residents who resided in the facility. Findings: 1. Resident #1 was admitted on [DATE], with numerous [DIAGNOSES REDACTED]. An Initial Pain Assessment Tool, dated 08/10/11, documented the following: Patient or nurse marks drawing. An X was documented on the back and bilateral lower legs. Patient rates the pain. Scale used 0/10, Present: O, Worst pain gets: 4-6, Best pain gets: 1, Acceptable level of pain 1, Quality: (Use patient's own words, e.g., prick, ache, burn, throb, pull sharp) Aches or throbs. Onset, duration, variations, rhythms: Once in a while, Manner of expressing pain? Able to verbalize pain status. What Relieves the pain? Rest, [MEDICATION NAME] 5 mg. q 4 PRN. What causes or increases the pain? disease process, cold. Other comments: States he doesn't hurt very often, Plan: Continue current pain med regimen. A care plan, dated 08/22/11, documented the resident had a stage II pressure ulcer on the coccyx. The goal was the pressure ulcer would show resolution by target date of 11/20/11. The care plan did not address problems with pain. An intervention listed was to keep the resident dry and check skin for any additional red areas, monitor skin daily for sign of pressure areas, body/skin audit at least weekly, use positioning and pressure relieving devices. The pressure ulcer on the coccyx had healed. Physician's orders contained no orders for routine or PRN pain medications for the resident after 10/04/11, after a hospitalization . An Initial Pain Assessment Tool, dated 10/05/11, documented the following: Patient or nurse marks drawing. There were no marks documetned. Patient rates the pain. Scale used Verbalization, facial expressions. Present: O, Worst pain gets: I don't know, Best pain gets: I don't Hurt, Acceptable level of pain: none. Quality: (Use patient's own words, e.g., prick, ache, burn, throb, pull sharp) I don't hurt now. Onset, duration, variations, rhythms: N/A. Manner of expressing pain? Able to verbalize pain status when asked. What Relieves the pain? No pain at present. What causes or increases the pain? N/A. Other comments: Currently no pain meds. Plan: Will monitor pain status & report to physician when indicated. A significant change assessment dated [DATE], documented the resident was moderately impaired cognitively and had no moods or behaviors. The resident required limited assist of one person with bed mobility and extensive assistance with transfers of one person. The resident had no limitation with ROM. The resident was always incontinent of bowel and bladder. The resident had no pressure ulcers but was identified at risk for pressure ulcer development. The assessment documented the resident had not been on a pain medication regimen, received no PRN pain medications, did not receive non-medication intervention for pain and had no pain in the 5 day look back period. The assessment documented two or more falls with no injuries, in the last 30 days. A 7-3 shift nurses note, dated 11/02/11, documented new orders for [MEDICATION NAME] spray to both heels received. A Physician telephone order, dated 11/02/11, documented "[MEDICATION NAME] spray to B (both) heels q shift for pain and redness." A 3-11 shift nurses note, dated 11/02/11, documented, "Denies c/o pain tx to bilat heel - c/o of them being "sore"- [MEDICATION NAME] spray applied bilat per order." The care plan had not been updated to address the condition of the resident's heels. An Initial Pain Assessment Tool, dated 11/10/11, documented the following: Patient or nurse marks drawing. An X was documented on the back and bilateral heels. Patient rates the pain. Scale used Yes or no, a lot or a little. Present: No, Worst pain gets: Not much, Best pain gets: Not any. Acceptable level of pain: None. Quality: (Use patient's own words, e.g., prick, ache, burn, throb, pull sharp) I don't know. Onset, duration, variations, rhythms: At night sometimes. Manner of expressing pain? Able to answer if ask. What Relieves the pain? No pain meds at this time. Lying down to rest. Elevating legs. What causes or increases the pain? Up a while. Effects Of Pain (Note decreased function, decreased quality of life). Physical activity, Does not like to get out of bed. Other comments: Will monitor for signs and symptoms of pain and report to physician if indicated. Plan: Continue current regimen of resting. There was no documentation the physician was notified of the pain identified for the resident's back and heels. There was no documentation of the condition of the resident's heels until 11/26/11, when a nurses note at 13:30 (1:30 p.m.) documented, "[MEDICATION NAME] to coccyx e.g. [MEDICATION NAME] to heels." A nurses note, dated 11/26/11 on 3/11 shift, documented, " Tx to bilat heels c [MEDICATION NAME] completed. Open area to L heel 1.5 cm x 1.5 cm. feet elevated on pillows to alleviate pressure from heels." There was no documentation the physician or family was notified of the decline in condition of the pressure ulcer on the L heel. No new treatment orders for the L heel were obtained. On 11/28/11 at 10:30 a.m., CNA #1 accompanied the surveyor on a tour of North Hall. The CNA reported resident #1 had a sore on his heel. At 10:45 a.m., CNA #1 was asked if the surveyor could observe the resident's skin. The resident was observed lying in bed with a blanket and pillow under his legs, with both his heels touching mattress. A dark necrotic area was observed on the residents left heel. During the observation of the resident's skin, the resident complained of pain to the left heel by moaning and reaching for his foot. CNA #1 reported the heel had been red for a couple of weeks and then it turned black. CNA #1 was asked if she could turn the resident over on his side to observe his skin. Two small, open, circular areas were observed on the resident's left buttock area. At that time, CNA #1 reported the open areas on the resident's buttock had been there a few days. On 11/28/11 at 1:45 p.m., incontinent care was observed for the resident. The ADON was in room while CNA #1 performed incontinent care. After incontinent care was completed, the ADON was asked to view the resident's buttocks. She was asked if she observed two open areas to the resident's left buttocks. She stated, " Yes." The ADON reported the areas looked like scratches. At that time, the resident looked up at the ADON and reported his head was hurting. The resident also complained of his heel hurting. At that time, the ADON was asked about the resident's left heel. She reported the heel was not like that the last time she saw it previously, it was just red. She reported today was the first time she had seen it since she had returned from vacation. The current physician's orders were reviewed. No routine or PRN pain medications were ordered. At 2:35 p.m., the ADON was asked if the resident had received anything for his headache and heel pain. The ADON reported that she had returned to the resident's room and the resident denied having any pain. The ADON was asked if the resident had anything ordered for pain. She reported the resident could not have anything for pain because Tylenol interfered with his new medications that he was placed on in the psych hospital. The ADON was then asked what she did for the resident when he complained of heel pain. She reported she would reposition his heels and would get him up in his wheelchair, which seemed to help. The ADON was then asked if the repositioning for pain was in resident's care plan. She stated "I don't know." She was asked if she had ever called the resident's primary physician to get an order for [REDACTED]." The care plan dated 08/22/11, had not been updated to address repositioning the residents heels or getting him up in a W/C when the resident complained of pain. On 11/28/2011 at 4:10 p.m., LPN #1 was asked if the resident ever had any pain. LPN #1 reported occasionally the resident complained of heel pain. The LPN was asked what do you do when he complains of pain. She reported when the pain was reported to her, then she would go to his room and ask him about his pain and he would no longer complain of pain. The LPN reported they took his pain medication away when he went to the hospital so the facility couldn't give him anything for pain. The LPN was asked if the physician had been notified in an attempt to get an order for [REDACTED]." On 11/28/11 at 4:30 p.m. CNA #2 was asked if the resident ever complained of pain. The CNA reported he complained about his heel hurting and his head hurting at times. The CNA was asked what she did when he complained of pain. The CNA reported she reported it to her charge nurse. She reported the resident had been hurting the past week. On 11/28/11 at 4:35 p.m., CMA #1 was asked if the resident ever complained of pain. The CMA stated, "Yes." The CMA was asked what she did when the resident reported he was in pain. She reported she would tell the charge nurse. On 11/28/11 at 5:00 p.m., the DON reported she was unable to get in touch with the (name deleted hospital) about the resident's pain medication. She reported she received an order from his attending physician for [MEDICATION NAME] and if that didn't relieve the pain the staff could apply a pain relieving gel on the resident's heels. 2. Resident #1 also experienced a fall on 10/25/11 at 7:45 p.m. The nurses notes documented "Summoned to res. room by CNA who states she heard loud noise I res room - Found res. lying on floor at foot of bed and in front of TV stand- Lying on Left side- c/o left hip pain and moans out loud with any movement- no rotation noted or shortening of LLE. 8:00 p.m., 911 notified per order. 2005 (8:05 p.m.) ambulance here left with res on gurney at 2017 (8:17 p.m.). 0010, (12:10 a.m.) Returned from ER via private Auto accompanied by family." There was no documentation the resident's pain level had been addressed when the resident returned to the facility. On 11/28/11 at 5:00 p.m., the DON was interviewed regarding the resident being sent out to the ER for hip pain. She was asked if the resident was given anything for pain upon arrival back to the facility. She reported the ER physician had not ordered anything for pain, therefore nothing was given. 3. Resident #1 experienced a fall on 10/26/11 at 4:30 p.m. The nurses notes documented, "Alarm sounding resident on floor behind closed door. Head resting on bedside table. hematoma 3 cm posterior of head non open. ROM WNL- gait extremely unsteady denies headache at this time. Neuro's started. Assisted to bed "don't know what I was doing." At 7:10 p.m. nurses notes documented, "Administered prn Tylenol for headache. Hematoma intact v/s WNL - No s/s distressed noted." There was no physician order for [REDACTED]. On 10/28/11 at 1300 (1:00 p.m.), nurses notes documented, "Called to resident room due to him being in the floor. Says he hit his head in the same area as last fall. Hematoma noted to back of head in the same spot as last. Neuros restarted every 15 min...Personal alarm in place. Assisted to bed. Resident says he was bending down to get his socks." There was no documentation the resident was assessed for pain at the time of the fall resulting in a head injury. On 11/28/11 at 5:10 p.m., the DON was asked about the two falls with head injuries. She was asked about treating the resident's pain. She reported she did not want to take a chance of the pain medications with Tylenol attributing to further falls. 4. Resident #1 experienced a fall on 10/31/11. The nurses note documented at 2220 (10:20 p.m.), "Resident found in floor in his room by CNA and CMA. He does not recall what he was doing. No head pain. Did c/o right shoulder pain. Assisted up to bed." There was no documentation of a pain assessment for the shoulder pain. No pain medication was administered for the complaints of shoulder pain. On 11/28/11 at 5:15 p.m., the ADON was asked about the resident's pain. She reported when the resident went to the psych hospital, he was taken off his pain medications at the psych hospital, related to interference with his dementia and psych meds. She was asked where that information could be found in the medical record. She reported she remembered she had talked to the physician at the psych hospital, but didn't write down anything he said. She acknowledged there was no documentation of what he had told her in the medical record. At that time, the DON was asked if the physician had been notified of the resident experiencing pain. She reported the physician had not been notified.

Based on observations, record review and staff interviews, it was determined the facility failed to ensure one (#11) of one sampled resident who received restorative services did not experience a decline in function and maintained his or her highest level of function. The decline in function resulted in actual harm to the resident. This had the potential to affect 24 facility identified residents who received restorative services. Findings: Resident #11 had [DIAGNOSES REDACTED]. An annual assessment, dated 10/21/10, documented the resident was cognitively intact in daily decision making skills, required limited assistance of one person with transfers, and ambulation in the room. The resident required supervision with dressing and bathing with set up help only. A quarterly assessment, dated 07/24/11, documented the resident was cognitively intact, required supervision with transfers and ambulation in her room with setup help only. the resident was independent in dressing and required supervision with bathing with no physical help from the staff. The assessment documented no impairment to the upper extremities in functional limitation in range of motion. The assessment documented impairment on both sides to the lower extremities. The resident had bilateral [MEDICAL CONDITION]. The resident had improved between the two above assessments in transfers and ambulation. A care plan, dated 09/27/11, documented a resident problem as mobility impairment r/t bilateral BKA. One intervention listed on the care plan was "restorative nursing program." The September 2011, monthly physician's orders [REDACTED]." The original date of the order was 09/22/10. The September 2011, restorative flow sheet, documented, "Res to ambulate as tolerated with rolling walker and bilat prosthesis. 5 x week 09/22/2010." The restorative flow sheet was blank for September 19-23, 2011. The restorative flow sheet was blank for September 26-28, 2011. On 09/27/11 at 9:30 a.m., the surveyor went to meet the resident since she was the resident council president. During the conversation, the resident reported the restorative program used to do a pretty good job, but the RA had been scheduled to the floor to work. The resident went on to express she felt like she had a loss of function in walking. She reported the staff had been walking her with a rolling walker. She reported it was not the RA's fault, since she was doing what she was told to do. On 09/27/11 at 10:00 a.m., the confidential group resident meeting was held with eight alert and oriented residents. The group was asked, "Is there anything else about life here in the facility that you would like to discuss?" Four residents in the group reported they would like to discuss restorative services. The four residents in the group reported they were to receive restorative services. When asked had they been receiving restorative services. One resident stated, "We was." When asked who provided the restorative exercises, another resident stated, "We don't have no one." Then another resident reported the restorative aide's name. The resident reported there had been a change in staff schedules to four days on and two days off. The resident further reported since the staff schedule changed, the restorative aide did not have time for restorative services. The resident further reported the RA now worked on the South Hall 99% of the time. On 09/29/11, the RA was interviewed and was asked when the resident had been walked last. She reported the resident had been walked this week, but since the staff schedule had changed she had to work the floor. She stated, "It's (restorative services) been neglected in the last four to six weeks due to the work schedule." The RA reported the last time she had walked the resident, she could not ambulate the same distance. She stated she had been walking from her room to the nursing station, but made it only to the fire extinguisher and had to turn around to return to her room. At that time, the RA was asked to walk the resident and report her performance. An observation was made of the resident walking. The resident reported at times her knees had given her problems it the past, but today her knees were in good shape. The resident applied her bilateral prosthesis and stood in the rolling walker. She walked to the fire extinguisher and stated she was shaky and wanted to sit. Her W/C was provided for her to sit down. She rested approximately six to eight minutes, and then returned to her room. The RA reported the resident had not needed to rest before while ambulating. The RA and surveyor stepped off the distance using the one foot floor tiles to determine distance. The resident had walked 45 feet, then rested and returned to her room, another 45 feet. The RA reported the resident had been ambulating the entire 90 feet without resting, during the last restorative session. The RA and surveyor stepped off the additional distance to the nurse's station on North Hall. From the fire extinguisher, it was another 38 feet to the nurse's station. The additional distance was 76 feet to and from the nurse's station. The total distance to and from the nursing station to the resident's room was 166 feet. The resident had been ambulating this distance before without stopping, and now could ambulate 45 feet and needed to rest. There was a decline in function for the resident in ambulation in activity tolerance and distance. At 2:40 p.m., the DON was asked when the staff schedules had changed to four days on and two days off. She reported the schedules changed on July 4th weekend. At 3:15 p.m., the DON was asked about the restorative program. She stated, "We know we have a problem." When asked was the change in distance and tolerance a decline for the resident, she nodded her head, "Yes."