Every finding on record at Southern Hills Rehabilitation Center

Based on interview, record review, and facility document and policy review, the facility failed to provide appropriate care and services to a resident with an indwelling urinary catheter for 1 (Resident #26) of 1 resident reviewed for urinary catheters. Certified Medication Aide (CMA) #2, an unlicensed staff member, replaced Resident #26's indwelling urinary catheter while under the direct supervision of Registered Nurse (RN) #1. CMA #2 inserted the indwelling urinary catheter into Resident #26 and inflated the catheter balloon prior to seeing a return of urine. RN #1 then took over the insertion of Resident #26's indwelling urinary catheter procedure, deflated the balloon, repositioned the catheter, and reinflated the balloon, with no observed return of urine. As a result, Resident #26 experienced pain, bleeding from the insertion site, and bloody urine with clots.Findings included: A facility policy titled, Catheter Care, with a copyright date of 2024, indicated, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The policy revealed the Policy Explanation included 1. Catheter care will be performed every shift and as needed by nursing personnel. A facility policy titled Catheterization of a Male, with a copyright date of 2024, indicated, Urinary catheterizations will be performed in accordance with current standards of practice to minimize risk for bacterial contamination or urethral trauma. The policy revealed, 1. Urinary catheters shall be inserted by licensed nurses under the orders of the attending physician. An admission Record revealed the facility admitted Resident #26 on 02/19/2025 and readmitted the resident on 04/29/2026. According to the admission Record, Resident #26 had a medical history that included diagnoses of adult failure to thrive, bladder-neck obstruction (a condition when urine flow is blocked or restricted at the base of the bladder), neuromuscular dysfunction of bladder (a dysfunction of the bladder due to the brain, spinal cord, or nerves), iron deficiency anemia secondary to blood loss (chronic), unspecified urethral stricture (a narrowing of the urethra, the tube carrying urine form the bladder), and a history of urinary tract infections. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/26/2026, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed Resident #26 had an indwelling catheter. Resident #26's Care Plan Report included a focus area initiated 02/19/2025, that indicated the resident had an indwelling urinary catheter. Interventions directed staff to change the catheter every month and as needed for patency (initiated 05/07/2025); and change the catheter as needed for signs and symptoms of infection, dislodgment, and/or patency (initiated 05/27/2025). Interventions also indicated that an RN allowed a nursing student to insert a catheter, the RN was suspended pending investigation, and two days later after a thorough investigation the RN's employment was terminated (initiated 08/06/2025). Resident #26's Order Summary Recap [Recapitulation] Report, for the timeframe from 02/01/2025 through 07/31/2026, contained the following orders:- Change the resident's catheter as needed for signs or symptoms of infection, dislodgment, and/or patency. The order was dated 05/07/2025 and discontinued on 09/03/2025.- Change the resident's catheter on the seventh of each month related to neuromuscular dysfunction of the bladder. The order started on 07/07/2025 and ended on 09/03/2025. Resident #26's Progress Notes included a note, dated 08/01/2025 at 8:00 AM and electronically signed by RN #1, that indicated Resident #26's bed was wet due to the catheter leaking, and the resident requested it be changed. The note indicated that the night shift CMA was a nursing student who would graduate that November. The note revealed that RN #1 and the CMA asked Resident #26 if it was okay for the CMA to change the catheter. The note revealed that Resident #26 did not say no. The note revealed that CMA #2 changed the catheter using aseptic technique under RN #1's supervision. The note revealed CMA #2 inserted the catheter and inflated the bulb, and there was no urine return. The note revealed RN #1 informed CMA #2 that everyone was different but usually you can feel it and if you keep inserting it, and indicated that the catheter tubing would curl up in the bladder. The note revealed Resident #26 complained of pain, the bulb was deflated, and RN #1 took over. The note revealed RN #1 inserted the catheter the rest of the way in, there was still no urine return, there was some blood from the penis, the site was cleaned, and the catheter bag was hung on the bedside rail with a dignity cover in place. The note revealed Resident #26's bedding was changed, and the resident was left resting quietly in bed with their call light in reach. The note revealed there was no urine in the bag at 8:00 AM, and RN #1 requested the day nurse to irrigate the catheter. The note revealed that on irrigation of the catheter, a blood clot was dislodged, and there was an immediate return of pink tinged blood. Resident #26's Progress Notes included a note, dated 08/01/2025 at 8:12 AM and electronically signed by Licensed Practical Nurse (LPN) #24, that indicated that LPN #24 assisted the night nurse with Resident #26's indwelling catheter, and indicated that there had been no urine in the catheter bag since the catheter change. The note indicated the catheter was flushed with 10 milliliters (ml) of normal saline (NS) and a small amount of red blood and a medium sized clot, that was blocking urine flow, was removed. The note indicated that pink-tinged urine was in the catheter bag, a small amount of red blood was coming from the end of Resident #26's penis, and the catheter was patent [open, unobstructed]. The note indicated Resident #26 reported slight discomfort in the groin area and indicated that a medication aide was made aware. Resident #26's Progress Notes included a note, dated 08/01/2025 at 12:12 PM, that indicated that a head-to-toe skin assessment was complete for Resident #26, and noted that a small amount of clotted blood was noted on the resident's penis and on the outside of the catheter tubing, and indicated that no active bleeding was noted. The note indicated the urine in Resident #26's drainage bag had a slight red tinge, and the urine in the tubing was clear and yellow. Resident #26's Progress Notes included a note, dated 08/01/2025 at 1:26 PM and electronically signed by LPN #24, that indicated that LPN #24 was called to Resident #26's room to assess bleeding of penis. The note indicated that there was a small amount of red blood at the tip of the penis and down the catheter to the penis. The note indicated there was a quarter-size blood stain observed on the sheets and several small clots under the penis at the scrotum. Resident #26's Progress Notes included a note, dated 08/01/2025 at 9:04 PM, indicated Resident #26 still had blood from their penis. The facility's investigation documents included a typed statement from RN #1 that indicated that when CMA #2 changed the Resident #26's catheter under RN #1's supervision, the resident complained of pain, and the resident complained We used [Resident #26] for a guanine [sic] pig. I [RN #1] reminded [Resident #26] that we asked permission first and [Resident #26] did not say no. The statement was signed by RN #1 and dated 08/01/2025. The facility's investigation documents included an undated unsigned facility document titled, Resident Interview of [Resident #26's initials]. The document indicated that the resident stated they had had many catheter changes but this one was a little more painful. During a phone interview on 07/02/2026 at 9:15 AM, CMA #2 stated the night nurse, RN #1, wanted CMA #2's help with changing Resident #26's catheter. CMA #2 stated that, when RN #1 asked Resident #26 if CMA #2 could assist the RN, Resident #26 did not answer. CMA #2 stated that RN #1 asked CMA #2 to try it and learn it. CMA #2 stated she inserted the catheter but did not get any urine return, so she went a little further as she was taught in school, and she inflated the balloon. CMA #2 stated that RN #1 took over after that, and RN #1 pulled the catheter out some to readjust it. CMA #2 stated there was still no urine; RN #1 said she knew the catheter was in the correct place, and RN #1 inflated the balloon. CMA #2 stated Resident #26 complained of pain, and RN #1 deflated the bulb some. CMA #2 stated RN #1 then adjusted the catheter, and that was when Resident #26 started bleeding. CMA #2 stated RN #1 started writing a statement since she thought Resident #26 would complain, and she slid it under the Director of Nursing's (DON) door. CMA #2 stated she was unaware of RN #1 notifying the providers or the NP. CMA #2 stated Resident #26 made the statement that the resident was used like a [NAME] pig. CMA #2 stated she should not have done the catheterization. CMA #2 stated she was just a medication aide, and catheterization was not her job duty. Attempts were made to interview RN #1, but she was unable to be reached. During an interview on 07/01/2026 at 8:01 PM, Nurse Practitioner (NP) #5 stated Resident #26 never really had any complications with the catheter before 08/01/2025, but the resident did have frequent urinary tract infections (UTIs). NP #5 stated the bleeding was probably related to the CMA changing the catheter as she probably inflated the balloon in Resident #26's urethra and that caused the bleeding and trauma. NP #5 stated the facility terminated the employment of the staff involved. During an interview on 07/02/2026 at 10:03 AM, the previous Interim Administrator (ADM), who was the Interim ADM at the time of the incident, stated that when she got to work that morning, she became aware of the incident, and she initiated an investigation, and reported the incident to the state survey agency. The previous Interim ADM stated she also reported both staff members to the Board of Nursing. The previous Interim ADM stated CMA #2 should have been acting in her capacity as a CMA and not be involved in changing catheters. The previous Interim ADM stated they expected the nurse to use better judgement than to try to instruct someone without informed consent from the resident. The previous Interim ADM stated they were unaware of any instructors coming to the facility with students for on-the-job training. During an interview on 07/03/2026 at 12:28 PM, the DON stated her expectations for catheter care and insertion of a catheter would be that a CMA not act out of their scope of practice, as Harm could happen to the resident. During an interview on 07/03/2026 at 12:39 PM, the current ADM stated his expectations for a catheter change would be for someone qualified as a nurse to perform the procedure.

Based on facility policy review, facility document review, record review, and interview, the facility failed to provide adequate supervision and assistance to prevent accidents for 1 (Resident #91) of 7 residents reviewed for accidents. Specifically, on 04/01/2026, Licensed Practical Nurse (LPN) #19 turned Resident #91 in bed by herself instead of utilizing two people as per the resident's care plan, which resulted in Resident #91 hitting their head on the wall, causing injury.Findings included: An undated facility policy titled, Accident Prevention & [and] Hazard Mitigation, indicated, the Purpose & Objective was To establish operational guidelines that maintain a resident environment as free from accident hazards as is reasonably practicable, and to provide individualized supervision and assistive devices to mitigate identified risks, in strict alignment with federal requirement 42 CFR S 483.25(d) (F-tag 689) and Oklahoma State Department of Health regulations under OAC [Oklahoma Administrative Code] 310:675. The policy further indicated, III. INDIVIDUALIZED RESIDENT RISK MANAGEMENT, which included 1. Clinical Assessment: Licensed nursing personnel shall evaluate each resident for accident, safety, and fall risks upon admission, readmission, significant change in clinical status, and at intervals determined appropriate by the clinical leadership team; and 2. Care Planning: Based upon structured clinical assessments, the interdisciplinary team (IDT) will incorporate generalized and individualized interventions into the resident's comprehensive care plan aimed at mitigating known risks. Interventions will consistently balance clinical safety with the resident's right to selfdetermination [sic], choice, and autonomy. An undated facility policy titled, Activities of Daily Living (ADL) Care Policy, revealed the Purpose was, To ensure residents receive assistance with Activities of Daily Living (ADLs) in a timely manner and in accordance with their assessed needs, care plans, and resident rights. This policy supports resident dignity, safety, comfort, and prevention of neglect. The policy revealed, The facility provides ADL care based on each resident's individualized assessment and care plan. Staff must assist residents with ADLs in a timely manner, consistent with resident needs, preferences, and clinical judgement. The policy revealed, ADL assistance include, but is not limited to, which included Mobility and transfers. The policy revealed, ADL Care Expectations, included Staff must, which included Provide ADL care in a timely manner based on resident needs; and Follow the resident's care plan and preferences. An admission Record revealed the facility admitted Resident #91 on 03/04/2026. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (a type of stroke) affecting left non-dominant side, cognitive communication deficit, and other acquired deformity of the head. An admission Minimum Data Set (MDS), with an Assessment Review Date (ARD) of 03/11/2026, revealed Resident #91 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS further indicated that Resident #91 was dependent on staff for activities of daily living (ADLs) and with rolling left and right in bed. Resident #91's Care Plan Report included a focus area initiated 03/04/2026, that indicated the resident had an ADL and mobility deficit due to a cerebral infarction with hemiparesis and hemiplegia. Interventions directed staff to provide two-person assistance with bed mobility, including turning the resident from side to side, and pulling the resident up in bed (initiated 03/04/2026). An Incident Audit Report, dated 04/01/2026, indicated that on 04/01/2026 at 10:30 AM, Resident #91 hit the right side of their head on the wall and was noted to have a bruise to the right side of their head. Resident #91's Progress Notes included a note, dated 04/01/2026 at 10:27 AM, that indicated that in the process of cleaning the resident's colostomy bag that had broke open, the resident hit the right side of their head. The note indicated that the resident had a raised area to the right side of their head and was being sent to the hospital. An Oklahoma State Department of Health Incident Report Form, submitted by the facility as a final report on 04/03/2026, revealed that on 04/01/2026, LPN #19 was providing bedside care and while attempting to turn Resident #91 towards the wall to change bed linens, Resident #91's momentum shifted, causing the resident's face to make contact with the adjacent wall. The report further indicated that the resident stated, Ouch, you hit my head. The report indicated that LPN #19 sought assistance from Certified Medication Aide (CMA) #23 following the incident. Per the report, a golf ball sized hematoma was observed on the resident's right side temple area and blood was coming from the resident's nostril. The report indicated that an immediate physical assessment was performed by the Director of Nursing (DON) and Quality Assurance (QA) Nurse and revealed that Resident #91 had a hematoma and swelling to the right side of their face. Per the report, the resident was sent to a hospital for evaluation and treatment. An undated handwritten facility document related to the 04/01/2026 incident involving Resident #91 indicated that LPN #19 was interviewed and stated that while turning Resident #91 in bed, the resident said that they hit their head on the wall during the process. The document indicated that the nurse stated that the resident was fighting against nurse while turning. The document indicated that a CMA was interviewed and stated that LPN #19 asked them for assistance, and when the CMA entered the room, they observed blood coming out of the resident's nose. Per the document, the resident stated, she slammed my head on the wall. The document indicated that the CMA observed a golf ball size hematoma on the right-side temple area of the resident's head. Resident #91's Progress Notes included a note, dated 04/01/2026 at 11:31 AM, that indicated that a head-to-toe assessment was completed and a bruise to the right side of the resident's head was noted. The note indicated that the resident's family was notified of the resident hitting their head and being sent to the hospital. Resident #91's Progress Notes included a note, dated 04/01/2026 at 12:56 PM, that indicated that upon return from the hospital, Resident #91 was noted to have a slight raised bruise by their right temple. During an interview on 07/01/2026 at 9:32 AM, the DON stated the staff had access to care plans, and mobility was addressed in the resident's care plan. The DON stated that LPN #19 was aware Resident #91 required two-person assistance with bed mobility but started resident care on Resident #91 by herself. During an interview on 07/02/2026 at 9:43 AM, LPN #19 stated that Resident #91 was dirty from a colostomy bag and when she rolled the resident to change the sheets, the resident rolled and their face hit the wall. LPN #19 stated she asked for help from an aide, and the aide could not help at the time. LPN #19 stated she did not want to wait and proceeded to turn and position the resident on her own. She stated she had turned and positioned the resident on her own before with no issues. She stated that she got to know the residents and their care requirements through the assessments she conducted. LPN #19 stated she did not check resident care plans to determine a resident's level of care and care requirements prior to providing care. During an interview on 07/03/2026 at 12:46 PM, the Administrator stated staff were expected to review the residents' care plans to know what a resident's needs were and how to assist the resident.

Based on interview, record review, and facility document and policy review, the facility failed to ensure only licensed qualified staff replaced a resident's indwelling urinary catheter for 1 (Resident #26) of 1 resident reviewed for urinary catheters. Specifically, Certified Medication Aide (CMA) #2, under the direct supervision of Registered Nurse (RN) #1, attempted to replace Resident #26's indwelling urinary catheter. As a result, Resident #26 experienced pain, bleeding from the insertion site, and bloody urine with clots.Findings included: A facility policy titled, Catheter Care, with a copyright date of 2024, indicated, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The policy revealed the Policy Explanation included 1. Catheter care will be performed every shift and as needed by nursing personnel. A facility policy titled Catheterization of a Male, with a copyright date of 2024, indicated, Urinary catheterizations will be performed in accordance with current standards of practice to minimize risk for bacterial contamination or urethral trauma. The policy revealed, 1. Urinary catheters shall be inserted by licensed nurses under the orders of the attending physician. An admission Record revealed the facility admitted Resident #26 on 02/19/2025 and readmitted the resident on 04/29/2026. According to the admission Record, Resident #26 had a medical history that included diagnoses of adult failure to thrive, bladder-neck obstruction (a condition when urine flow is blocked or restricted at the base of the bladder), neuromuscular dysfunction of bladder (a dysfunction of the bladder due to the brain, spinal cord, or nerves), iron deficiency anemia secondary to blood loss (chronic), unspecified urethral stricture (a narrowing of the urethra, the tube carrying urine form the bladder), and a history of urinary tract infections. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/26/2026, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed Resident #26 had an indwelling catheter. Resident #26's Care Plan Report included a focus area initiated 02/19/2025, that indicated the resident had an indwelling urinary catheter. Interventions directed staff to change the catheter every month and as needed for patency (initiated 05/07/2025); and change the catheter as needed for signs and symptoms of infection, dislodgment, and/or patency (initiated 05/27/2025). Interventions also indicated that an RN allowed a nursing student to insert a catheter, the RN was suspended pending investigation, and two days later after a thorough investigation the RN's employment was terminated (initiated 08/06/2025). Resident #26's Order Summary Recap [Recapitulation] Report, for the timeframe from 02/01/2025 through 07/31/2026, contained the following orders:- Change the resident's catheter as needed for signs or symptoms of infection, dislodgment, and/or patency. The order was dated 05/07/2025 and discontinued on 09/03/2025.- Change the resident's catheter on the seventh of each month related to neuromuscular dysfunction of the bladder. The order started on 07/07/2025 and ended on 09/03/2025. Resident #26's Progress Notes included a note, dated 08/01/2025 at 8:00 AM and electronically signed by RN #1, that indicated Resident #26's bed was wet due to the catheter leaking, and the resident requested it be changed. The note indicated that the night shift CMA was a nursing student who would graduate that November. The note revealed that RN #1 and the CMA asked Resident #26 if it was okay for the CMA to change the catheter. The note revealed that Resident #26 did not say no. The note revealed that CMA #2 changed the catheter using aseptic technique under RN #1's supervision. The note revealed CMA #2 inserted the catheter and inflated the bulb, and there was no urine return. The note revealed RN #1 informed CMA #2 that everyone was different but usually you can feel it and if you keep inserting it, and indicated that the catheter tubing would curl up in the bladder. The note revealed Resident #26 complained of pain, the bulb was deflated, and RN #1 took over. The note revealed RN #1 inserted the catheter the rest of the way in, there was still no urine return, there was some blood from the penis, the site was cleaned, and the catheter bag was hung on the bedside rail with a dignity cover in place. The note revealed Resident #26's bedding was changed, and the resident was left resting quietly in bed with their call light in reach. The note revealed there was no urine in the bag at 8:00 AM, and RN #1 requested the day nurse to irrigate the catheter. The note revealed that on irrigation of the catheter, a blood clot was dislodged, and there was an immediate return of pink tinged blood. Resident #26's Progress Notes included a note, dated 08/01/2025 at 8:12 AM and electronically signed by Licensed Practical Nurse (LPN) #24, that indicated that LPN #24 assisted the night nurse with Resident #26's indwelling catheter, and indicated that there had been no urine in the catheter bag since the catheter change. The note indicated the catheter was flushed with 10 milliliters (ml) of normal saline (NS) and a small amount of red blood and a medium sized clot, that was blocking urine flow, was removed. The note indicated that pink-tinged urine was in the catheter bag, a small amount of red blood was coming from the end of Resident #26's penis, and the catheter was patent [open, unobstructed]. The note indicated Resident #26 reported slight discomfort in the groin area and indicated that a medication aide was made aware. Resident #26's Progress Notes included a note, dated 08/01/2025 at 12:12 PM, that indicated that a head-to-toe skin assessment was complete for Resident #26, and noted that a small amount of clotted blood was noted on the resident's penis and on the outside of the catheter tubing, and indicated that no active bleeding was noted. The note indicated the urine in Resident #26's drainage bag had a slight red tinge, and the urine in the tubing was clear and yellow. Resident #26's Progress Notes included a note, dated 08/01/2025 at 1:26 PM and electronically signed by LPN #24, that indicated that LPN #24 was called to Resident #26's room to assess bleeding of penis. The note indicated that there was a small amount of red blood at the tip of the penis and down the catheter to the penis. The note indicated there was a quarter-size blood stain observed on the sheets and several small clots under the penis at the scrotum. Resident #26's Progress Notes included a note, dated 08/01/2025 at 9:04 PM, indicated Resident #26 still had blood from their penis. The facility's investigation documents included a typed statement from RN #1 that indicated that when CMA #2 changed the Resident #26's catheter under RN #1's supervision, the resident complained of pain, and the resident complained We used [Resident #26] for a guanine [sic] pig. I [RN #1] reminded [Resident #26] that we asked permission first and [Resident #26] did not say no. The statement was signed by RN #1 and dated 08/01/2025. The facility's investigation documents included an undated unsigned facility document titled, Resident Interview of [Resident #26's initials]. The document indicated that the resident stated they had had many catheter changes but this one was a little more painful. During a phone interview on 07/02/2026 at 9:15 AM, CMA #2 stated the night nurse, RN #1, wanted CMA #2's help with changing Resident #26's catheter. CMA #2 stated that RN #1 asked CMA #2 to try it and learn it. CMA #2 stated she inserted the catheter but did not get any urine return, so she inserted the catheter a little further as she had been taught in school, and she inflated the balloon. CMA #2 stated that RN #1 took over after that, and RN #1 pulled the catheter out some to readjust it. CMA #2 stated she should not have done the catheterization. CMA #2 stated she was just a medication aide, and catheterization was not her job duty. Attempts were made to interview RN #1, but she was unable to be reached. During an interview on 07/01/2026 at 8:01 PM, Nurse Practitioner (NP) #5 stated Resident #26 never really had any complications with the catheter before 08/01/2025, but the resident did have frequent urinary tract infections (UTIs). NP #5 stated the bleeding was probably related to the CMA changing the catheter as she probably inflated the balloon in Resident #26's urethra and that caused the bleeding and trauma. NP #5 stated the facility terminated the employment of the staff involved. During an interview on 07/02/2026 at 10:03 AM, the previous Interim Administrator (ADM), who was the Interim ADM at the time of the incident stated CMA #2 should have been acting in her capacity as a CMA and not have been involved in changing catheters. She stated they expected the nurse to use better judgement than to try to instruct someone without informed consent from the resident. The previous Interim ADM stated they were unaware of any instructors coming to the facility with students for on-the-job training. The previous Interim ADM stated she also reported both staff members to the Board of Nursing. During an interview on 07/03/2026 at 12:28 PM, the Director of Nursing (DON) stated her expectations for catheter care and insertion of a catheter would be that a CMA not act out of their scope of practice, as Harm could happen to the resident. The DON stated a nurse could not delegate someone to do something out of their scope of practice. During an interview on 07/03/2026 at 12:39 PM, the current ADM stated his expectations for a catheter change would be for someone qualified as a nurse to perform the procedure. The ADM stated it made them shake their head that someone would place a resident in that type of circumstance.

Based on facility policy review, record review, observation, interview, and a review of a Centers for Disease Control and Prevention (CDC) and National Institute for Occupational Safety and Health (NIOSH) publication, the facility failed to ensure all staff were fit tested for N95 respirators. This deficient practice had the potential to affect all the residents in the facility. The facility also failed to ensure they sanitized a blood pressure cuff that was used between 2 (Resident #57 and Resident #59) of 5 residents reviewed for the medication administration task.Findings included: 1. An undated publication by the CDC and the NIOSH titled, Filtering Out Confusion: Frequently Asked Questions about Respiratory Protection, included How Often Must Fit Testing Be Conducted?, which revealed, In addition to fit testing upon initially selecting a model of respirator, OSHA [Occupational Safety and Health Administration] requires that fit testing be conducted annually, and repeated 'whenever an employee reports, or the employer or the physician or other licensed health care professional makes visual observations of changes in the employee's physical condition that could affect respirator fit.' During an interview on 06/30/2026 at 11:35 AM, Certified Medication Aide (CMA) #8 stated he had worked at the facility for eight or nine months and had not been fit tested for an N95 respirator. During an interview on 06/30/2026 at 11:45 AM, Registered Nurse (RN) #9 stated he had been tested for N95 respirator a couple of years prior at a facility he worked at before coming to work at this facility. During an interview on 06/30/2026 at 11:50 AM, CMA #10 stated she was fit tested for an N95 respirator by the facility six years prior. She stated that staff were not currently using N95 respirators. An observation at the time of the interview revealed one box of N95 respirators in the [NAME] medication room. During an interview on 06/30/2026 at 11:57 AM, the CMA #11 stated she had worked at the facility for over a year, and she had never been fit tested for an N95 respirator. She stated that staff were not currently using N95 respirators. An observation at the time of the interview revealed two boxes of two different brands of N95 respirators in the East medication room. During an observation and interview on 06/30/2026 at 12:08 PM, there were two different brands of N95 respirators being stored in the Central Supply room. The Director of Nursing (DON) stated fit testing should be completed upon hire and annually. She stated she had been working in the facility for 96 days. She stated she was tested for N95 masks at a hospital she worked at before coming to work at the facility in November of 2025. During an interview on 06/30/2026 at 2:17 PM, Wound Nurse #18, who was also the Infection Preventionist, stated she had worked at the facility since April of 2026 as the Infection Preventionist. She stated that the facility's last COVID-19 outbreak was in August of 2024. She stated that she did not think they had N95 respirators in the facility and she had not done any fit testing since she took the position. She stated that staff were supposed to be fit tested upon hire and annually. She stated she had not been fit tested for an N95 respirator in about a year or so at a hospital prior to working at the facility. Wound Nurse #18 stated there was no one assigned to or trained to do fit testing. During an interview on 06/30/2026 at 2:40 PM, the DON stated the facility had several types of N95 respirators available in the facility, but they were not current on their N95 fit testing for staff. She stated that they did have the equipment to fit test. She stated that they did not have anyone assigned to do the fit testing. She stated that she expected all staff to be fit tested before they could work the floor, and all staff should be current on their fit testing. She stated she did not know why they were not fit testing since they had respirators and the equipment. The DON stated that she had been trained at her previous job on how to fit test. During an interview on 06/30/2026 at 2:52 PM, Administrator (ADM) stated he had been the Administrator since February of 2026. He stated staff were supposed to be fit tested for N95 respirators before they could use them. He stated that he did not know how often they were supposed to fit test staff. He stated they had not done any fit testing since he had become the Administrator. He stated that he thought they had a few N95 respirators available in the facility; he was not sure if they had the fit testing equipment and could not think of anyone being trained to do the fit testing. He stated that he expected staff to be fit tested properly and up to date on fit testing for N95 respirators. The ADM stated they did not have a facility policy related to fit testing. 2. A facility policy titled, Infection Prevention and Control Program, revised 09/02/2025, revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy revealed, 4. Standard Precautions, which included a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. The policy revealed, 10. Equipment Protocol, which included a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedure governing the cleaning and sterilization of soiled or contaminated equipment. An undated facility policy titled, Standard Operating Procedure: Shared Care Equipment Sanitization, revealed, To mitigate the risk of cross-contamination and permanently prevent the transmission of infectious pathogen between resident by establishing a standard, uniform, and complaint process for cleaning and disinfecting reusable medical and care equipment. The policy revealed, This procedure applies to all facility personnel responsible for utilizing, operating, or maintaining multi-resident care equipment. This equipment included, but is not limited to, which included blood pressure cuffs. The policy revealed, 1. Point-of Use Initiation, which revealed, The cleaning and disinfection process must be initiated immediately after resident care is completed. Reusable equipment must be completely sanitized at the point of use before it is introduced to another resident's environment or returned to a clean storage area. Deferring cleaning to a later time is strictly prohibited. An admission Record revealed the facility admitted Resident #57 on 01/09/2017. According to the admission Record, the resident had a medical history that included a diagnosis of secondary hypertension (high blood pressure). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2026, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. An admission Record revealed the facility admitted Resident #49 on 01/30/2026. According to the admission Record, the resident had a medical history that included a diagnosis of essential hypertension. A quarterly MDS, with an ARD of 05/06/2026, revealed Resident #49 had a BIMS score of 11, which indicated the resident had moderate cognitive impairment. During an observation on 06/30/2026 beginning at 9:22 AM, Certified Medication Aide (CMA) #13 obtained Resident #57's blood pressure with a wrist cuff. CMA #13 left Resident #57's room and placed the used blood pressure cuff on the medication cart. CMA #13 did not clean or disinfect the blood pressure cuff after using the cuff on Resident #57. At 9:26 AM, CMA #13 obtained Resident #49's blood pressure with the same wrist blood pressure cuff that was previously used on Resident #57. The blood pressure cuff was not cleaned or disinfected prior to using it on Resident #49. During an interview on 06/30/2026 at 9:42 AM, CMA #13 stated she cleaned the blood pressure cuff after every two to three residents. She stated she cleaned it with either an alcohol wipe or sanitizer wipe. CMA #13 stated she also cleaned the blood pressure cuff in the morning before she started using it. During an interview on 06/30/2026 at 9:52 AM, the Director of Nursing (DON) stated staff should clean blood pressure cuffs with sanitizing wipes after each use. The DON stated that alcohol wipes should not be used to clean blood pressure cuffs. The DON stated that she expected the CMA to clean the cuff with a sanitizer wipe between residents.

Based on facility policy review, observation, and interview, the facility failed to ensure refuse was properly contained in dumpsters and failed to ensure outside dumpster lids and side accessibility sliders were operational and remained closed to reduce the potential for harboring insects or rodents for 2 of 2 dumpsters observed. The failures had the potential to affect all the residents in the facility.Findings included: A facility policy titled, General Refuse, Trash & Dumpster Management, effective 03/03/2026, revealed, 3. Outside Dumpster Area Operational Standards, which revealed, The physical dumpster containers and surrounding enclosures must be maintained in accordance with the following criteria, which included 1. Lid and Door Closure: All dumpster lids, top covers, and side accessibility sliders must remain tightly closed and latched when not actively in use. An observation of the outside dumpster area on 06/29/2026 at 9:00 AM revealed the area contained two dumpsters. One dumpster's lid was damaged and hung inside the dumpster and could not be closed properly. The side doors (side accessibility sliders) on the dumpster were also open. The dumpster was 50% full of refuse. During an interview at the time of the observation, the Dietary Manager (DM) stated the dumpster lid had been broken for a while, and it could close properly. She stated the side doors had been left open, and the side doors and lids should always remain closed. She acknowledged there was refuse in the dumpster at that time. During an interview on 06/29/2026 at 9:27 AM, the DM stated there was no record of anyone ever requesting the lid to be repaired or replaced. An observation of the outside dumpster area on 07/01/2026 at 7:55 AM revealed one dumpster's lid was still broken, and refuse was thrown on top of it. Both sliding doors were open on both sides of both dumpsters that were in the area, and both dumpsters were approximately 75% full of refuse. Refuse was also observed on the ground around both dumpsters. During an interview on 06/29/2026 at 9:53 AM, the Maintenance Director stated the dumpster lid had been damaged since he came to work there in December of 2025. He stated there was no record of the facility staff requesting the lid to be repaired or replaced prior to the survey. During an interview on 07/02/2026 at 11:20 AM, Director of Nursing (DON) stated she was not involved with the dumpsters in any way. She stated that she expected the dumpster doors and lids to be able to be closed and not left open. She stated it was important for the side doors and lids to remain closed to reduce the number of pests and rodents. During an interview on 07/02/2026 at 11:23 AM, Administrator (ADM) stated maintenance staff maintained the dumpsters. He stated that he expected the doors and lids to work properly. He stated that the broken lid could allow animals and pests to get into the dumpster.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure activities of daily living (ADLs) were provided for 2 (Residents #17 and #60) of 3 residents reviewed for ADL concerns. Specifically, staff did not shave Resident #60 or Resident #17, and did not provide nail care for Residents #17.Findings included: An undated facility policy titled, Activities of Daily Living (ADL) Care Policy, revealed the Purpose was, To ensure residents receive assistance with Activities of Daily Living (ADLs) in a timely manner and in accordance with their assessed needs, care plans, and resident rights. This policy supports resident dignity, safety, comfort, and prevention of neglect. The policy revealed, The facility provides ADL care based on each resident's individualized assessment and care plan. Staff must assist residents with ADLs in a timely manner, consistent with resident needs, preferences, and clinical judgement. ADL care must be delivered in a manner that maintains dignity, privacy, and respect. 1. An admission Record revealed the facility admitted Resident #60 on 04/16/2026. According to the admission Record the resident had a medical history that included diagnoses of spinal stenosis, quadriplegia, right dominant side hemiplegia, other cervical disc degeneration, other lumbar region intervertebral disc degeneration, and chronic pain. An admission Minimum Data Set (MDS), with an Assessment Reference Date of 04/23/2026, revealed that Resident #60 had a Brief Interview of Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #60 had impairments on one side of both the upper and lower extremities and required substantial to maximal assistance with personal hygiene. Resident #60's Care Plan Report included a focus area, initiated on 04/16/2026, that indicated the resident had an ADL and mobility self-care performance deficit related to diagnoses of weakness, hemiplegia affecting the non-dominant side, spinal stenosis of the lumbar region, other injury of the thoracic spinal cord, and comorbid conditions. Interventions directed staff to assist with bathing on shower days. Resident #60's Care Plan Report did not address the need to shave the resident's facial hair or the resident's grooming preferences related to facial hair. Resident #60's bath and shower records for 04/2026, 05/2026, and 06/2026 revealed staff provided showers according to the resident's shower schedule. Resident #60's bath and shower record, dated 05/09/2026, indicated the resident was shaved, but no other bath or shower record for the timeframe from 04/2026 through 06/2026 indicated the resident was shaved. An observation, on 06/29/2026 at 1:36 PM, revealed Resident #60 sat in a wheelchair in the hallway, dressed, ready for the day, with a patch of long, curled hair on their chin which measured about one half inch. During a concurrent interview, Resident #60 stated that they did not like the hair on their chin, and only one person had offered to remove it. During an observation and concurrent interview, on 06/30/2026 at 4:10 PM, Resident #60 stated they received a shower that day, they had asked if the staff could shave the resident, but the staff said they could not. The observation revealed Resident #60's chin hair remained. An observation on 07/01/2026 at 11:35 AM revealed Resident #60 sitting in the west dining room with chin hair on their face. During a concurrent interview, Resident #60 stated staff had still not shaved the resident. During an interview on 07/03/2026 at 10:12 AM, Registered Nurse (RN) #9 stated certified nurse aides (CNAs) had never been told they could not shave a resident. RN #9 stated he had not noticed Resident #60's facial hair. During an interview on 07/03/2026 at 10:32 AM, CNA #15 stated Resident #60 liked to be shaved, and she had not showered the resident that week. CNA #15 stated staff should shave Resident #60, and no one had ever told her that she should could not shave a resident's facial hair. During an interview on 07/03/2026 at 10:44 AM, CNA #14 stated when they provided showers for the residents staff washed and shaved the residents. CNA #14 stated there were a few residents who wanted staff to shave them, and staff routinely shaved Resident #60. An observation on 07/03/2026 at 10:55 AM, revealed Resident #60 still had not been shaved, and the hair on the resident's chin was gray and black, curled, and was approximately one half inch long if pulled straight. During a concurrent interview, Resident #60 stated staff provided a shower the previous day and no one shaved the resident or offered to shave the resident. During an interview on 07/03/2026 at 11:03 AM, CNA #14 stated she understood that it was important to Resident #60 for the resident to be clean shaven. During an interview on 07/03/2026 at 11:28 AM, the Director of Nursing (DON) stated showers should be done with all schedules and as needed on any shift. The DON stated residents should be shaved with every shower unless they refused. The DON stated staff should not tell residents that they were not allowed to shave the residents. During an interview on 07/03/2026 at 12:07 PM, the Administrator (ADM) stated he expected showers and shaving of all residents to be done. The ADM stated he was not aware of the issues with Resident #60. 2. An admission Record revealed the facility admitted Resident #17 on 06/21/2018. According to the admission Record, the resident had a medical history that included a diagnosis of hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following cerebral infarction (a type of stroke), and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2026, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that Resident #17 was dependent on staff for toileting, bathing, and personal hygiene. Resident #17's Care Plan Report included a focus area initiated 06/23/2018, that indicated the resident had an ADL self-care performance deficit related to diagnoses of late effect stroke with right side hemiplegia, generalized weakness, and limitation of Resident #17's right hand. Interventions indicated that the resident wanted a shower once a week and directed staff to assist the resident as needed. Resident #17's shower sheets dated 04/08/2026, 04/15/2026, and 04/22/2026 revealed bed baths were given. The shower sheets indicated that staff did not shave the resident, and the resident's nails were not trimmed. Resident #17's shower sheet dated 05/20/2026 revealed a bed bath was given. The shower sheet indicated that staff did not shave the resident, and the resident's nails were not trimmed. Resident #17's shower sheet dated 06/11/2026 revealed a bed bath was given. The shower sheets indicated that staff did not shave the resident, and the resident's nails were not trimmed. During a concurrent observation and interview on 06/29/2026 at 2:34 PM, Resident #17's nails on their left hand were long, with a brown substance underneath the nails. Resident #17 took their left hand and opened their contracted right hand, which revealed long nails with a brown substance underneath the nails. Resident #17 was unshaven, with hair growing under the chin and neck. Resident #17 stated, It would be my wishes to be shaved daily but I would be okay with getting shaved twice per week. During a concurrent observation and interview on 06/30/2026 at 11:30 AM, Resident #17 was sitting outside in the courtyard. Resident #17 was still unshaven and had long nails on both hands with a brown substance underneath the nails. Resident #17 stated that a bath was usually provided once per week and was scheduled for the following day. The resident stated that the staff might cut their nails and shave them if they were not in a hurry. During an observation and interview on 07/01/2026 at 8:59 AM, Resident #17 was in bed. Resident #17 continued to be unshaven, with long nails on both hands and a brown substance underneath the nails. Resident #17 stated, I am waiting to get my bed bath. During an observation on 07/01/2026 at 9:13 AM and 10:29 AM Resident #17 was still unshaven and their fingernails were long and were dirty underneath them on both hands. During an observation and interview on 07/01/2026 at 2:16 PM, Resident #17 continued to be unshaven and with long nails on both hands and a brown substance underneath the nails. Resident #17 stated, When the staff got me up today, I wanted to see the flower garden before it got too hot. Resident #17 stated, It would have been nice to get shaved and have a bath first. Resident 17 stated that Wednesdays were their (Resident #17's) normal bath days. During an observation and interview on 07/01/2026 at 2:50 PM, the Quality Assurance (QA) Nurse observed Resident #17's nails and facial hair. During the interview, Resident #17 stated that they used to be shaved by the beautician twice weekly, but the beautician stated she could not shave the resident anymore. The resident stated they would like to be shaved, and the staff were not offering to trim the resident's nails. The QA Nurse stated that a shave and nail care should be provided to Resident #17. During an interview on 07/01/2026 at 3:10 PM, the Director of Nursing (DON) stated her expectation for shaving and nail care was for them to be provided on the residents' shower days and as needed. The DON stated her expectation was for a nurse to provide nail care for diabetic residents. During a concurrent observation and interview in Resident #17's room on 07/01/2026 at 3:30 PM, the DON observed the resident's unshaved face and long and dirty fingernails and stated that the resident needed to be shaved and nail care needed to be provided. During an interview on 07/03/2026 at 11:15 AM, the Administrator stated he was aware that the facility had issues with the provision of shaving and nail care. He stated that the shaving and nail care issues were due to the beautician having left the week prior. He stated that she had been providing shaves and nail care for the residents.

Based on facility policy review, facility document review, record review, and interview, the facility failed to ensure the right to privacy for 1 (Resident #90) of 1 resident reviewed for privacy concerns. Specifically, a certified nurse aide (CNA) took a photograph of the resident with their personal phone without the resident's knowledge or permission and shared the photo with a licensed practical nurse (LPN) on their personal device, who then sent the photo to the Administrator (ADM) using a private communication application the facility staff used for communication purposes.Findings included: An undated facility policy titled, Resident Rights, revealed, The Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Facility. A Facility must protect and promote the rights of each Resident, including each of the following rights, which included E. Privacy and confidentiality. The Resident has the right to personal privacy and confidentiality of his or her personal and clinical records. The policy revealed, 1. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings with family and resident groups. The facility's employee handbooks, dated 07/15/2022 and 08/09/2021, revealed, While [the facility's name] permits employees to bring personal cell phones and other mobile devices (i.e. [id est, that is] smart phones, tablets, laptops) into the workplace, you must not allow the use of such devices to interfere with your job duties or impact workplace safety and health. The policy revealed, If you have a device that has a camera and/or audio/video recording capability, you are restricted from using those functions on Company property unless authorized in advance by management or when they are used in a manner consistent with your gith to engage in concerted activity under section 7 of the National Labor Relations Act (NLRA). The policy revealed, At [the facility's name] we recognize the Internet provides unique opportunities to participate in interactive discussions and share information using a wide variety of social media. However, use of social media also presents certain risks and carries with it certain responsibilities. To minimize risks to the Company, you are expected to follow our guidelines for appropriate use of social medical. This policy applies to all employees who work for the Company. The Guidelines revealed, For the purposes of the policy, social media includes all means of communicating or posting information or content of any sort on the Internet, including to your own or someone else's web log, or blog, journal or diary, personal website, social networking or affinity website, web bulletin board or a chat room, whether associated or affiliated with the Company, as well as any other form of electronic communication. The 08/09/2021 handbook was electronically signed by CNA #16 on 07/21/2025 at 4:26 PM. The 07/15/2022 handbook was electronically signed by LPN #17 on 01/08/2026 at 12:52 AM. An admission Record revealed the facility admitted Resident #90 on 05/06/2026. According to the admission Record, Resident #90 had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure, morbid obesity, depression, chronic pain syndrome, encounter for palliative care, and homelessness. The admission Record also indicated that Resident #90 was their own responsible party and had their family member, Family Member #22, listed as an emergency contact. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/13/2026, revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident exhibited verbal behavioral symptoms directed towards others as well as other behavioral symptoms not directed towards others, during the assessment timeframe, which significantly interfered with care. Resident #90's Consent for Use Of Photographs, Audiovisual Recordings, And Newsletter/Newsprint, revealed a typed consent form to give permission to the facility to use the resident's name and photographs or audiovisual recordings of the resident for display, publication, or broadcast with no form compensation. The consent also gave permission that any photographs or recordings of the resident for identification purposes on medical records, employees, or persons outside the corporation for use in the facility and/or in the public media and/or publications used by the facility or its subsidiary. The consent also indicated that the facility had a social media page to share special moments and events with family and friends, posting employment opportunities and in marketing resident life in the facility. The consent revealed, I understand that I may rescind this authorization and any time, and that I am to be consulted with on each occasion. The consent was signed by Family Member #22 and dated 05/06/2026 and the Business Office Manager (BOM). During a record review and concurrent interview on 07/02/2026 at 10:37 AM, the Regional Clinical Consultant (RCC) provided access to the facility's private/encrypted messaging application used for communication needs that revealed a chat communication between LPN #17 and the ADM, dated 05/15/2026 at 5:14 AM, which included a photograph of Resident #90 and their family member lying in bed together. The RCC stated that CNAs were not allowed and did not have access to the communication application.During a telephone interview on 07/02/2026 at 11:04 PM, LPN #17 stated she reached out to the physician using the communication application and also used it to communicate with management staff. She stated that it was not acceptable to send pictures of residents, but she had seen pictures of wounds, and communications with wound care. LPN #17 stated she remembered Resident #90 and that a picture was taken by CNA #16 of the resident and their family member. LPN #17 stated it is not acceptable to take resident pictures without their permission. She stated that there was a better way to communicate with the management team than by posting a picture of them in bed together. She stated that she did not think Resident #90 or their family member were aware the picture was taken. During a telephone interview on 07/03/2026 at 6:40 AM, CNA #16 stated that he did not remember receiving any training on resident privacy rights, other than when he first started working at the facility. He stated that his understanding of privacy was to protect the residents' dignity, with things like pulling the curtain, keeping residents covered, closing the doors when providing care, and not talking about them outside of the staff on the floor. He stated that he did not remember receiving any training related to photographs for resident care. He stated he had taken a photograph of Resident #90 with his personal cell phone and sent it to LPN #17 on her personal cell phone, then immediately deleted it from his device. He stated that he did not ask permission from the resident or their family member before the photograph was taken, but he should have. During an interview on 07/02/2026 at 9:55 AM, the Director of Nursing (DON) stated that use of the communication application was only for department heads, corporate office staff, and the licensed nurses. The DON stated that she was not sure how long the messages stayed active on the application. The DON stated that staff could upload photographs in the application from their personal devices, but it required staff to give the application access and permission to their personal phone's camera.The DON was interviewed on 07/03/2026 at 11:28 AM. In regard to taking photographs of residents without their permission, the DON stated, no one should be photographed without their knowledge. She stated that she did not think photographs of residents should be posted on the communication application the facility used. She stated that she remembered the instance where staff sent the photograph of Resident #90 on the communication application, and the staff were talked to and told not to post photos. She stated that they informed staff that communication about Resident #90 could have been sent without a photo. She stated that no training was provided on the communication application that the facility used, and she was just told that was how they communicated and that she should download the application.During an interview on 07/03/2026 at 12:07 PM, the ADM stated that when it came to residents' privacy, staff had to make sure they followed the Health Insurance Portability and Accountability Act (HIPPA). He stated that staff should not be taking photographs of residents without their knowledge. He stated that he expected the staff to follow the social media policy. During an interview on 07/03/2026 at 1:59 PM, the ADM stated that he did not instruct the staff to take any photographs of Resident #90 or of any resident. He stated that he did comment in the communication application on the photograph, and afterwards, he educated staff verbally to not take any photographs of residents without their consent.

Based on observation, interview, and facility policy review, the facility failed to ensure they posted their daily staffing totals at the beginning of each shift in a prominent location that was readily accessible to residents, staff, and visitors for 3 (06/29/2026, 06/30/2026, and 07/02/2026) of 3 observations made during the survey and failed to accurately calculate and document the number of hours worked for each discipline for 31 (05/12/2026 through 05/26/2026, 06/15/2026, and 06/17/2026 through 07/01/2026) of 31 days reviewed for staffing. Findings included: An undated facility policy titled, [Facility Name] Nursing Staffing Policy, revealed, The purpose of this policy is to ensure the facility maintains sufficient and competent nursing staff at all times to meet the clinical, functional, and psychosocial needs of all residents. This policy outlines staffing expectations, coverage requirements, posting requirements, and staff eligibility standards. The policy further revealed, The facility posts a Nursing Staffing Sheet at the beginning of each shift. The posting includes: - Facility name - Current date - Resident census - Names and titles of all direct-care staff on duty - Actual hours worked for RNs [registered nurses], LPNs/LVNs [licensed practical nurses/licensed vocational nurses], and CNAs [certified nursing aides] - Shift start and end times - Updates reflecting call-outs, absences, or mid-shift changes. The policy revealed, Staffing postings must be clear, readable, accessible, and located in a prominent public area. Records are maintained for at least 18 months. During an observation on 06/29/2026 at 10:32 AM, of the west nursing unit, there was no posting of daily staffing in a prominent public area as required. The facility had a whiteboard at the nurses' station where they wrote the staff's assignments, the census, and staff room assignments but did not include the actual working hours for each discipline. A hallway leading to the west nursing unit revealed a glass cabinet equipped with a lock that contained a copy of the staffing schedule. Review of that schedule revealed no daily nursing hours were documented. An observation on 06/30/2026 at 4:42 PM, of the east hall, revealed a whiteboard at the nurses' station which included the names of staff, room assignments, and the census. The daily staff posting was not displayed in a prominent location that was readily accessible to residents, staff, and visitors. An observation on 07/02/2026 at 8:32 AM, of the east and west nursing units and the facility's main lobby revealed no daily staff postings to reflect the actual hours, separated by shift, for each discipline of front-line caregivers. During an interview on 07/01/2026 at 12:35 PM, the Director of Nursing (DON) stated they did not keep copies of the assignment sheets for each unit; they only wrote the assignments on the whiteboard but not on any document that was maintained. The DON stated that the staff usually did not change their assignments, so they could usually determine who was assigned to each hall. During an interview on 07/02/2026 at 8:21 AM, the Administrator (ADM) was asked about the requirements for displaying the daily staff postings. The ADM stated that he was not sure what was being requested. He stated the facility only had the whiteboards with the assignments but did not maintain the whiteboards or have the information written anywhere other than the board. During an interview on 07/02/2026 at 11:28 AM, with the Business Office Manage (BOM) and the ADM, the BOM stated that the staffing forms were completed by the staffing coordinator. The ADM provided the daily staffing reports and stated that the Staffing Coordinator completed the forms the following day to track staff call-ins. The ADM stated that they previously displayed the staffing forms in a glass cabinet that was in the hallway leading to the west unit, but it was frequently unlocked and staff would go in and scribble on it, so they removed them. Daily staff postings for the timeframe from 05/12/2026 through 05/26/2026, 06/15/2026, and 06/17/2026 through 07/01/2026 revealed that the forms included the date, census, and divided the data up by shift and by discipline. The forms revealed no documentation of the scheduled hours for each shift as well as the actual hours worked. The form revealed the information listed only provided the number of staff in each discipline per shift. During an interview on 07/03/2026 at 11:28 AM, the DON stated she was not aware the daily staff postings were something they were required to complete. She stated that the Staffing Coordinator was responsible for the staff postings, but she was currently on leave and not available during the survey. During an interview on 07/03/2026 at 12:07 PM, the ADM stated that he expected the daily staff postings to be displayed. He stated that he was aware they should have posted the daily staffing information.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported to the state agency within the 2 hour required time frame for 2 (#2 and #5) of 3 sampled residents reviewed for abuse.The DON identified 67 residents resided in the facility.Findings: A facility policy titled ABUSE PREVENTION POLICY & PROCEDURE, revised 05/23/17, read in part, Any allegation of abuse is reported immediately to the state agency and to all other agencies as required, per state and federal guidelines. Immediately means as soon as possible, but should not exceed 24 hours after the discovery of the incident, in absence of a shorter state timeframe requirement. Refer to State, Federal and Elder Justice Act guidelines.1. An undated face sheet showed Res #2 had diagnoses which included multiple sclerosis, age related osteoporosis, contractures, and muscle wasting and atrophy.Res #2's quarterly assessment, dated 04/21/25, showed the residents cognition was intact and a BIM score of 15.An OSDH incident report, with an incident date of 06/06/25, showed on 06/09/25 at 12:45 p.m. the resident reported to the DON, CNA #4 had left them in their room with the door shut. The report showed the resident had been incontinent of bowel and bladder and was uncomfortable to the point of pain. The report showed Res #2 was afraid with the door closed. A fax transmittal page, dated 06/09/25 at 7:05 p.m., showed the state agency was notified of the allegation of abuse regarding Res #2. The facility failed to report to the state agency within the two-hour required time frame.On 07/10/25 at 3:15 p.m., the DON reviewed the investigative documentation regarding the allegation of abuse on 06/06/25 for Res #2. The DON stated the incident was not reported to the state agency within the two-hour required timeframe.2. An undated face sheet showed Res #5 had diagnoses which included acute respiratory failure, seizures, spinal stenosis, and paranoid schizophrenia.An OSDH incident report, dated 06/29/25, showed an allegation of abuse. The report showed the physician, family, and DHS: Adult Protective Services were notified. The report showed on 06/30/25, the family of Res #5 reported to the administrator Res #5 had been spoken harshly to by CNA #5. On 07/10/25 at 3:15 p.m., the DON reviewed the documentation regarding the allegation of abuse for Res #5. The DON stated they could not find documentation the state agency was notified of the incident within the 2-hour required timeframe.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for 2 (#2 and #5) of 3 sampled residents reviewed for abuse.The DON identified 67 residents resided in the facility.Findings: A facility policy titled ABUSE PREVENTION POLICY & PROCEDURE, revised 05/23/17, read in part, Any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, is to be thoroughly reported, investigated and documented in a uniform manner as detailed below. An incident of abuse incident of abuse must be reported to the charge nurse who will examine the resident, document findings in the clinical records an immediately initiate the Investigation protocol.1. An undated face sheet showed Res #2 had diagnoses which included multiple sclerosis, age related osteoporosis, contractures, and muscle wasting and atrophy.Res #2's quarterly assessment, dated 04/21/25, showed the residents cognition was intact with a BIM score of 15.An OSDH incident report, with an incident date of 06/06/25, showed on 06/09/25 at 12:45 p.m. Res #2 reported to the DON that CNA #4 left them in their room with the door shut. The report showed the resident had been incontinent of bowel and bladder and was uncomfortable to the point of pain. The report showed Res #2 was afraid with the door closed. The investigation documentation for the incident on 06/06/25 regarding Res #2 did not contain resident statements or staff statements regarding the allegation of abuse.On 07/10/25 at 3:15 p.m., the DON reviewed the investigative documentation regarding the allegation of abuse on 06/06/25 for Res #2. The DON stated the incident was not thoroughly investigated.2. An undated face sheet showed Res #5 had diagnoses which included acute respiratory failure, seizures, spinal stenosis, and paranoid schizophrenia.An OSDH incident report, with an incident date of 06/29/25, showed an allegation of abuse. The report showed the family of Res #5 reported to the administrator on 06/30/25, CNA #5 was heard speaking harshly to Res #5.The investigation documentation for the incident regarding Res #5 did not contain resident statements or staff statements regarding the allegation of abuse.On 07/10/25 at 3:15 p.m., the DON reviewed the documentation regarding the allegation of abuse for Res #5. The DON stated the incident regarding Res #5 was not thoroughly investigated.

1. On 04/21/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to supervise residents with exit seeking behaviors. On 04/14/25 Resident #14 was observed to leave the courtyard by a resident, from an unlocked gate, staff were notified and were able to redirect Resident #14 back into the building. Based on record review and interview, the facility failed to provide supervision for 1 (#14) of 1 sampled resident reviewed for exit seeking behaviors. The DON identified 66 residents resided at the facility. Findings: An elopement evaluation, dated 03/27/25, showed Resident #14 was at risk for elopement. The evaluation showed Resident #14 wandered aimlessly and the behavior was likely to affect the safety or well-being of self or others. A care plan, dated 03/28/25, showed Resident #14 liked to go to the courtyard and staff were educated to keep an eye as they passed by. An un-witnessed fall incident report, dated 03/29/25, showed Resident #14 had a history of wandering. An elopement evaluation, dated 04/04/25, showed Resident #14 was at risk of elopement. The evaluation showed Resident #14 had a history of elopement or an attempted elopement while at home and the facility without informing staff, but had not verbally expressed the desire to go home or stay near an exit door. A re-admission assessment, dated 04/10/25, showed a BIMS assessment was not completed due to memory problems for both long and short-term memory. The assessment showed Resident #14 had severely impaired cognitive skills for daily decision making. The assessment showed diagnoses which included a history of stroke and traumatic brain injury. A care plan, revised 04/11/25, showed Resident #14 had a concern for wandering/elopement with episodes of wandering on and off the unit. The care plan showed interventions which included to educate staff to redirect and assist Resident #14 to their hall when observed heading to the doors, ensure Resident #14 was inside the premises by checking on them every two hours and as needed, educate staff to be mindful when going out if Resident #14 was close by or following, and engage Resident #14 in purposeful activity. An elopement incident report, dated 04/14/25, showed Resident #14 had exited the courtyard through an unlocked gate that had been propped open by contractors. The report showed Resident #14 had a predisposing situation factor of Active Exit Seeker. The report showed Resident #14 had stated they wanted out of there. A care plan, revised 04/14/25, showed one-on-one observation every shift and to document in the clinical record. In-service documentation and the ad hoc QAPI meeting signature sheet for elopement and resident safety dated 04/18/25 were reviewed. The documents confirmed in-services and the ad hoc QAPI meeting were completed. On 04/17/25 at 2:53 p.m., the DON stated Resident #14 was sent to a psychiatric hospital, then would be going to a locked unit. On 04/21/25 at 10:32 a.m., the administrator stated they placed signs on the doors to not let residents out of the building and spoke with the contractors about not propping doors open. The administrator stated no other residents were at risk for elopement. They stated Resident #14 was placed on one-on-one supervision until Resident #14 was transferred to a psychiatric hospital, then went go to a locked unit. The administrator stated an ad-hoc QAPI meeting took place and a preventative intervention plan was developed which included the one-on-one supervision. The administrator stated they monitored the documentation daily in the electronic clinical record for Resident #14. On 04/21/25 at 11:45 a.m., CNA #1 stated they believed Resident #14 had dementia. They stated they never saw Resident #14 try to get out, but had been informed Resident #14 was a wanderer and exit seeker. CNA #1 stated they were informed to keep an eye out when Resident #14 went to the courtyard. On 04/21/25 at 11:51 a.m., CNA #2 stated Resident #14 had memory issues and would forget things like to lock their wheelchair. They stated staff had to keep watch when Resident #14 went outside the gate by supervising one-on-one. On 04/21/25 at 11:54 a.m., LPN #1 stated Resident #14 was very confused, easily agitated, and a wanderer. LPN #1 stated Resident #14 was an exit seeker and one-on-one supervision was implemented when they eloped. LPN #1 stated the DON told them to after Resident #14 eloped. LPN #1 stated they were not aware of Resident #14 needing one-on-one before they eloped. LPN #1 stated Resident #14 eloped on 04/14/25 around 1:30 p.m. and was sent out on 04/15/25. 2. On 05/14/25 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure the safety of exit seeking residents. An incident report, dated 05/14/25, showed a representative of Resident #15 approached staff on 05/13/25 at 7:30 p.m. and asked where they could find Resident #15. The report showed staff did not know Resident #15 was missing. Facility protocol was followed for missing residents and Resident #15 was found four minutes later in the facility's independent living [NAME] parking lot. The form showed another resident witnessed Resident #15 leave the courtyard through the gate. On 05/14/25 at 2:45 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 05/14/25 at 2:46 p.m., the DON and the corporate regional administrator were notified of the IJ situation and provided the IJ template. On 05/15/25 at 10:22 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Deficiency Summary: Resident #15 was able to elope the courtyard without staff intervening which put Resident #15 at risk of serious harm or death. During a tour of the courtyard on 05/14/25 at 11:02 a.m., the gates on the east and west side of the courtyard were observed to have a key lock on the latches of the gates that were unlocked. The lock was removed and the gate opened, leading to the parking lot on the east side of the building. This continued to be a hazard for all mobile residents in the facility. 1. Immediate Action Taken: a. When resident #15 was reported missing, an elopement drill was implemented and resident was found within [four] minutes. b. Resident #15 was immediately place[sic] on One on One until [Resident #15] was transferred to another lock down facility for [their] safety. c. Staff monitored the courtyard and courtyard was secure at 12:30 pm on 5/14/2025. 2. Systemic Changes Implemented: a. Courtyard gates were secured with combination locks on 5-14-2025 at 1230pm b. Staff have been in-service[sic] not to use gates in courtyard. c. Elopement assessments have been completed on all residents, and the elopement book has been updated. 3. Education and Training a. In-service of all staff on the following: Completed on 5-15-2025 at 6:30am i. No entry or exit out of the courtyard gates. ii. Elopement Book (location) iii. Elopement and wandering residents' policy and procedures iv. Residents & families enter and exit through the main entrance. Facility will be in compliance on 5-15-2025 at 6:30am. The IJ was lifted, effective 05/15/25 at 6:30 a.m., when all components of the plan of removal had been verified as completed. The gates on the East and [NAME] side of the courtyard were observed to be locked with combination locks. In-services regarding resident elopement and safety were reviewed and staff were interviewed to ensure in-service was completed. Elopement assessments were reviewed for residents in the facility to ensure assessments were completed and the elopement book was observed to have been updated. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on observation, record review and interview, the facility failed to ensure the safety for 1 (#15) of 2 sampled residents reviewed for exit seeking residents. The DON identified 66 residents resided at the facility and no current residents were at risk for elopement. Findings: On 05/14/25 at 11:02 a.m., the East and [NAME] gates of the courtyard were observed to have open key locks on the latches of the gates. The key lock was removed from the East gate and the gate opened up to the East parking lot. On 05/14/25 at 11:04 a.m., the west gate was observed to have an open key lock on the gate, the key lock was removed, and the gate required force to be opened. On 05/14/25 at 11:06 a.m., a ramp at the back of the facility courtyard was observed going up to an open patio for assisted living residents. The patio was observed to have an open area to the [NAME] of the patio where a piece of fencing was removed. The area to the [NAME] of the patio was observed to lead to the independent courtyard and at the front of the independent courtyard was an unlocked gate leading out to the independent parking lot. An admission assessment, dated 02/07/25, showed a BIMS of 00 and a staff assessment for mental status was not conducted. The assessment showed diagnoses which included a traumatic brain injury, aphasia (a language disorder that affects a person's ability to communicate) and depression. The assessment showed functional abilities which included no impairment to upper extremities but impairment on both sides of the lower extremities and Resident #15 was dependent for mobility with a wheelchair but could stand with assistance. A progress note, dated 05/12/25 at 3:24 p.m., showed an elopement evaluation was completed. The evaluation note showed Resident #15 had wandering behavior that was a pattern or goal-directed and was likely to affect the safety or well-being of self or others. A progress note, dated 05/12/25 at 10:21 p.m., showed Resident #15 was propelling around the facility and stated they were leaving and attempted to exit the door. The note showed Resident #15 stated people were waiting for them and they needed to leave, multiple redirects and checks for safety followed. An incident report, dated 05/14/25, showed a representative of Resident #15 approached staff on 05/13/25 at 7:30 p.m. and asked where they could find Resident #15. The report showed staff did not know Resident #15 was missing. Facility protocol was followed for missing residents and Resident #15 was found four minutes later in the facility's independent living [NAME] parking lot. The form showed another resident witnessed Resident #15 leave the courtyard through the gate. A care plan, revised 05/14/25, showed Resident #15 was noted to be outside of the facility and an elopement drill was initiated. The care plan showed Resident #15 was placed on one-on-one supervision with staff. On 05/14/25 at 10:11 a.m., the interim administrator was asked if the facility had an incident on 05/13/25. They stated Resident #15 went out to the courtyard and out of the [NAME] gate to the independent living courtyard and into the parking lot. They stated the immediate action was to place Resident #15 on one-on-one with staff. The interim administrator stated the DON called them on the night of 05/13/25 and informed them another resident saw Resident #15 go out the gate. They stated Resident #15 left the courtyard through the gate on the [NAME] side and was aware enough to know how to open the gate. The interim administrator stated they were locking the gates and the keys were on the medication cart and nurses keys until they could have a keypad installed. They stated nobody was going in or out the gates until the facility had the keypad installed. They stated they were in-servicing all staff on 05/14/25 and looking for a lock down facility for Resident #15 following a discussion with the representative of Resident #15. The interim administrator stated Resident #15 did not leave their facility grounds and the gates had dummy locks, locks that were not completely locked, because they were under the impression it would be a life safety issue. On 05/14/25 at 12:57 p.m. the DON stated Resident #15 had eloped from the [NAME] gate and entered the independent courtyard and exited the unlocked gate out into the parking lot. They stated the resident who witnessed the elopement was Resident #16, who was also in the courtyard at the time. On 05/14/25 at 2:39 p.m., Resident #15's representative stated the facility was not holding the nurse accountable. They stated the nurse informed them Resident #15 used a code to exit the facility. They stated they knew Resident #15 could not do that. Resident #15's representative stated they felt like the DON had a problem with them and that was why the facility wanted to transfer Resident #15 to a different facility.

Based on observation and interview, the facility failed to ensure infection control practices were followed during dining services. The administrator identified 62 residents received meals from the kitchen. Findings: On 11/19/24 at 12:00 p.m., rehabilitative service manager #1 and restorative aide #1 were observed passing hall trays. They were not observed to sanitize their hands after delivering resident lunch trays. On 11/19/24 at 12:07 p.m., rehabilitative service manager #1 stated they sanitize their hands after every second tray. On 11/19/24 at 12:10 p.m., restorative aide #1 stated they sanitize their hands after every third tray. On 11/26/24 at 1:30 p.m., the administrator stated they should sanitize their hands after delivering every tray.

Based on record review and interview the facility failed to provide information to formulate an advance directive for three (#33, #38, and #41) of three sampled residents who were reviewed for advance directives. The administrator identified 66 residents resided in the facility. Findings: The undated document, Residents' Rights Regarding Treatment and Advance Directives, read in part, It is the policy of this facility to support and facilitate a residents right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. 1. Resident #33 was admitted to the facility on [DATE]. No acknowledgement for an advance directive was in the resident's medical record. 2. Resident #38 was admitted to the facility on [DATE]. No acknowledgement for an advance directive was in the resident's medical record. 3. Resident #41 was admitted to the facility on [DATE]. No acknowledgement for an advance directive was in the resident's medical record. On 11/20/24 at 3:00 p.m., the social services director stated they discussed advance directives during the admission process and marked it on the admission form, but they do not have a signed form that shows they offered an advance directive.

Based on record review and interview, the facility failed to ensure a facility assessment was completed annually. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility. Findings: The Facility Assessment policy, dated October 2018, read in part, .A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations . On 10/24/23, the administrator provided a copy of the facility assessment dated [DATE] through 09/08/22. They stated they were checking to see if the former administrator had completed a more recent facility assessment. On 10/27/23 at 3:24 p.m., the administrator stated the facility assessment, dated 09/09/21 through 09/08/22, was the most recent assessment they had. They stated the facility assessment should have been completed annually.

Based on record review and interview, the facility failed to ensure behavior and side effect monitoring was conducted for one (#45) of five residents who were reviewed for unnecessary medications. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility. Findings: Resident #45 had diagnoses which included pain, depressive disorder, insomnia, and chronic embolism and thrombosis. The MAR/TAR, dated 08/16/23 through 08/31/23, documented the resident was administered Prozac (an antidepressant) 10mg daily, Ramelteon (a hypnotic medication) 8mg at bedtime, Eliquis (a blood thinner/anticoagulant medication) 2.5mg twice daily, and Oxycodone (an opiate pain medication) 5mg every four hours as needed. The MAR/TAR, dated 08/16/23 through 08/31/23 did not contain documentation of side effect and/or behavior monitoring for Prozac, Ramelteon, Eliquis, or Oxycodone. The quarterly assessment, dated 08/22/23, documented the resident had received an antidepressant, hypnotic, and anticoagulant medication seven of seven days during the look back period and an opioid medication one of seven days during the look back period. The Care Plan, updated 08/23/23, documented behaviors and side effects were to be monitored and documented for Ramelteon, Prozac, Eliquis, and Oxycodone. The MAR/TAR, dated 09/01/23 through 09/30/23, documented the resident was administered Prozac 10mg daily, Ramelteon 8mg at bedtime, Eliquis 2.5mg twice daily, and Oxycodone 5mg every four hours as needed. The MAR/TAR did not contain documentation of side effect and/or behavior monitoring for Prozac, Ramelteon, Eliquis, or Oxycodone. The MAR/TAR, dated 10/01/23 through 10/26/23, documented Prozac 10mg daily, Ramelteon 8mg at bedtime, Eliquis 2.5mg twice daily, and Oxycodone 5mg every four hours as needed. The MAR/TAR did not contain documentation of side effect and/or behavior monitoring for Prozac, Ramelteon, Eliquis, or Oxycodone. On 10/27/23 at 1:47 p.m., the ADON stated the nurses were to monitor and document behaviors and side effects on the MAR/TAR. On 10/27/23 at 2:56 p.m., the ADON stated they were not sure why behaviors and/or side effects were not monitored/documented for Resident #45. They stated upon readmission to the facility in August the behavior/side effect monitoring was overlooked and not added to the MAR/TAR.

Based on record review and interview, the facility failed to ensure the care plan was implemented related to smoking for one (#13) of one sampled residents whose care plans were reviewed for smoking. The DON identified 20 residents who smoked. Findings: The Care Plans, Comprehensive Person Centered policy, dated September 2013, read in parts, .A comprehensive .care plan .is implemented for each resident . The Smoking Policy - Residents, dated July 2017, read in part, .A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change .and as determined by staff . Resident #13 had diagnoses which included hypertension. A Smoking Assessment, dated 02/24/23, documented the resident was safe to smoke with supervision. Review of the clinical record did not reveal any smoking assessments had been completed after 02/24/23. The Care Plan, dated 08/05/23, documented the resident smoked and a smoking evaluation was to be completed per the facility policy. On 10/27/23 at 1:49 p.m., the ADON stated smoking assessments were to be completed quarterly. They stated the previous DON had been completing them. The ADON stated they did not have a process in place to ensure care plans were implemented and smoking assessments were conducted as per the facility policy.

Based on record review and interview, the facility failed to ensure skin assessments were conducted for one (#34) of three sampled residents who were reviewed for pressure ulcers. The Long-Term Care Facility Application for Medicare and Medicaid form, dated 10/24/23, documented 64 residents resided in the facility. Findings: The Prevention of Pressure Injuries policy, dated April 2020, read in parts, .Assess the resident on admission .for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition .Conduct a comprehensive skin assessment .with each risk assessment . Resident #34 had diagnoses which included atrial fibrillation. The Wound - Weekly Observation Tool, dated 04/13/23, documented a stage three pressure ulcer to the sacrum had resolved. The Care Plan, dated 07/25/23, documented the resident had a history of a healed stage four pressure ulcer to the left buttocks with a documented intervention to conduct weekly skin assessments. The significant change assessment, dated 07/25/23, documented the resident was cognitively intact for daily decision making, was at risk for pressure ulcers, and did not have any current pressure ulcers. The Braden Scale for Predicting Pressure Sore Risk, dated 08/30/23, documented the resident was at risk for development of pressure ulcers. The Skin Observation Tool, dated 09/12/23, documented the resident's skin was intact with no current wounds. Review of the assessments in the clinical record, dated 04/14/23 through 10/24/23, revealed weekly skin assessments/wound assessments had been completed on: 04/20/23; 04/27/23; 05/05/23; 08/09/23; 08/30/23; and 09/12/23. On 10/24/23 at 2:35 p.m., the resident stated they had a pressure ulcer on their sacrum that had healed but they felt like it had recently reopened. On 10/27/23 at 10:22 a.m., the resident's skin was observed with the wound care nurse. Resident #34's skin was observed to be intact with no open wounds. On 10/27/23 at 1:55 p.m., the ADON stated the charge nurses were responsible to complete skin assessments weekly. They stated skin assessments were documented in the electronic clinical record. The ADON stated they did not know why skin assessments had not been completed weekly for Resident #34. They stated they may not have populated the skin assessments on the treatment sheet after a readmission from the hospital. The ADON stated they did not have a process in place to ensure weekly skin assessments were completed. On 11/01/23 at 11:09 a.m., the DON stated the MDS coordinator and the ADON were to complete weekly skin assessments but they recently assigned them to the wound care nurse.

Based on record review and interview, the facility failed to have a program designed to help prevent the development of Legionellosis and Pontiac fever caused by Legionella Bacteria and have an effective and consistent infection surveillance program. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility. Findings: An undated facility policy, titled Legionella Surveillance and Detection, read in parts, .The water management program includes the following elements .A detailed description and diagram of the water system in the facility .The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria . On 11/01/23 at 11:35 a.m., the DON stated the facility did not have a detailed description and diagram of the facility water supply and had not identified areas in the water system that could encourage the growth and spread of Legionella. The DON stated that tracking and trending of infectious diseases was not occurring in the facility until they took the DON position on 10/06/23.

Based on record review and interview, the facility failed to implement an antibiotic stewardship program. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility. Findings: An undated facility policy, titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, read in part, .As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee .All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form . On 10/31/23 at 10:40 a.m., the infection preventionist/ADON stated I should ask the DON what criteria the facility used for antibiotic stewardship. On 11/01/23 at 11:35 a.m., the DON stated they were not utilizing a facility approved antibiotic tracking form for antibiotic regimens. The DON stated they were not sure if the infection preventionist/ADON was reviewing antibiotic use.

Based on record review and interview, the facility failed to ensure influenza and pneumococcal vaccines were offered for two (#57 and #58) of five sampled residents reviewed for vaccines. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility. Findings: An undated facility policy, titled Vaccination of Residents, read in part, .If vaccines are refused, the refusal shall be documented in the resident's medical record .If the resident receives a vaccine, at least the following information shall be documented in the resident's chart .Site of administration .Date of administration . 1. Resident #57 had diagnoses which included chronic kidney disease and hypertension. An immunization report, dated 10/31/23, did not document the resident had been offered or received the influenza or pneumococcal vaccinations. 2. Resident #58 had diagnoses which included chronic respiratory failure and hypertension. An immunization report, dated 10/31/23, did not document the resident had been offered or received the influenza or pneumococcal vaccinations. On 11/01/23 at 11:35 a.m., the DON was asked if any additional documentation was available regarding vaccinations for Resident #57 and Resident #58. The DON stated no.

Based on record review, and interview, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for one (#1) of three sampled residents who had experienced falls. The facility identified 84 residents resided at the facility. Findings: A falls and fall risk policy, documented. Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 03/13/18, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with daily decision making. The assessment documented the resident required extensive assistance with one person physical assist with transfers, walking in room and corridor, toilet use, was always continent of bowel and bladder, had a fall in the last month, and had a fracture related to a fall in the six months prior to admission. A care plan, dated 03/13/18, documented, Focus: .is at high, risk for falls r/t Hx of falls with right [MEDICAL CONDITION] and gait/balance problems .Goal: .will not sustain serious injury when fall occur .Interventions: .Assist with toileting, transfers and bed mobility. Encourage to ask for assistance with transfers and toileting as she tries to transfer self without asking for help .Administer pain medications and breathing treatment as ordered prior to initiating ADLs and therapy when c/o pain and shortness of breath .utilizes wheelchair as means of mobility. Wheelchair in locked position for all transfers, she also uses roller walker when ambulating with therapist .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .Ensure (name deleted) has a safe environment with even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, the bed in low position at night, and place personal items within reach .follow facility fall protocol . An incident report, dated 03/16/18 at 2:45 a.m., documented, This nurse heard resident yelling for help, upon entering residents room, resident was noted sitting up on floor next to bed. Resident stated that she got up to use BSC and her legs gave out on her causing her top (sic) fall onto the floor. She denied hitting head .Immediate action taken: .Resident assisted up to standing position by staff x2. Incontinent care provided .Bruising noted to right knee, small ST noted to left inner wrist . An incident report, dated 03/16/18 at 5:39 p.m., documented, .sitting on floor, no injuries noted. Resident description: My legs gave out when I was transferring back from commode . A nurse's note, dated 03/16/18 at 5:49 p.m., documented, .called for help and was found sitting beside the bed. She says her legs gave out. No injuries noted, had a fall about 3:00 am with injury of skin tear wrist, bruise on knee and c/o left rib pain. Xray done of left ribs, this pm. No injuries with this fall. I suggest .put call light on when she needs to toilet and she said NO. We talked about that she has fallen x 2 in 24 hr trying to transfer to bed from toilet . The care plan, updated 03/19/18, documented, Focus: 03/16/2018 Fall noted-therapy and nursing staff to re-educate resident to use the call light when needing assistance to transfer .03/16/18 - Fall noted-resident to be provided a motion activated night light .Interventions: 03/16/18 Educate on using call light .03/16/18 (first fall) Motion activated light in reach . The care plan did not address new fall interventions to prevent further falls when the resident fell twice on the same day going to the bathroom because her legs gave out. An incident report, dated 04/07/18, documented, Resident was observed sitting on the floor in her room facing the door. Resident stated that she was transferring self from her bed to the commode and her legs gave out under her. She did not hit her head . The care plan, updated 04/07/18, documented, Focus: fall in room, therapy re-educated on asking for assistance for transfers, therapy director reports that she verbalized understanding . The care plan did not address new fall interventions to prevent further falls when the resident fell going to the bathroom and her legs gave out. An incident report, dated 04/22/18, documented, Nurse observed resident sitting on the floor in her room next to her bed. She had her legs out in front of her and regular socks on her feet. No injuries noted at this time. Denies hitting head. No c/o pain voiced .Resident takes (sic) that she was moving from the bed to her wheelchair. While transferring her legs gave out from under her and she slid to the floor. States that the wheelchair moved and was to far away from the bed .Nurse reminded resident to ask for help with transfers at all times . The care plan, updated 04/22/18, documented, Focus: Fall noted- educated to use non skid socks and staff educated on offering to assist to bed after smoke breaks . The care plan did not address new fall interventions to prevent further falls when the resident fell getting out of bed when her legs gave out or that the wheelchair had moved when she fell . An incident report, dated 04/23/18 at 12:57 p.m., documented, CNA came to get this nurse due to she was assisting res to go to the bathroom and res leaned on the wall and slid down. CNA states res did not hit her head or any other body part. Res says she was trying to go to the bathroom and missed the toilet and leaned on the wall and slid down to the floor. Denies any pain or discomfort . An incident report, dated 04/23/18 at 2:08 p.m., documented, CNA assisted res to the bathroom and instructed her to turn on call light when she was finished. CNA left the room to go assist another resident and whe (sic) she went back to (name deleted) room res was in sitting position in the bathroom floor .Res does complain of left knee pain. Res states she was trying to get up from toilet and lost balance and fell .Res re educated on use of call light for assistance . A state reportable incident report dated 04/23/18, documented, Charge nurse called to residents room by CNA due to resident falling in the bathroom Resident noted in sitting position in bathroom floor. Resident denies hitting head but complaining of left leg pain. Assist x2 to wheelchair per resident request and medicated for complaint of pain. Xray obtained with results of proximal tibial left knee fracture. Resident and family notified and resident transferred to ER for further treatment .Resident returned from hospital post surgical intervention for tibia/fibula fracture. Nursing staff educated to not leave resident in bathroom unattended and do not leave resident up in wheelchair in room . The care plan, updated 04/26/18, documented, Focus: 04/23/18 - Witness fall-Staff educated to assist resident on toileting positioning .4/23/18 Fall noted-12:57pm, fall noted 14:08 (2:08 p.m.) c/o hitting head, left leg pain, x-ray left leg tibia fracture-transfer to hospital. Staff educated on not leaving her alone in the bathroom . A medicare five day assessment, dated 05/04/18, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with daily decision making. The assessment documented the resident required extensive assistance with one person physical assist with transfers, locomotion on and off the unit, and toilet use, walking in the room and corridor did not occur, had a fall in the last month, had a fall in the last two to six months, and had a fracture related to a fall in the six months prior to admission or reentry. On 06/06/18 at 10:53 a.m., LPN #1 was asked how often staff round on residents. She stated, At least every two hours. She was asked what staff did for the residents who were high risk for falls. She stated, We check on them every hour. At 10:57 a.m., CNA #1 was asked how often she rounded on the residents. She stated, Every two hours. At 11:43 a.m., the DON was asked what type of assistance the resident required with activities of daily living. She stated, One person assist. She was asked if they had put any toileting interventions in place prior to the day the resident fell and broke her leg. She stated, She had a bedside commode. We encouraged her to use it with assistance. She was asked if the resident required extensive assistance with one person assist with toileting, why the CNA left the resident's room and did not stay with the resident the day she fell in the bathroom and broke her leg. She stated, She wanted privacy. It was not unusual for her to be in there alone. She was asked if the resident had used the call light for assistance when she was finished. She stated, I don't think so. At 12:03 p.m., LPN #1 was asked what type of assistance the resident required with activities of daily living. She stated, She required stand by assistance. She could stand and pivot. She was asked if the resident required extensive assistance with one person assist with toileting, why the CNA left the resident's room and did not stay with the resident the day she fell in the bathroom and broke her leg. She stated, Usually she would ask us to step out and she would call when she was finished. She was asked if the resident had called for asssitance when she was finished. She stated, I don't remember the call light being on. The CNA went back in and she was on the floor.

On 11/05/15 an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide supervision with smoking for residents #2 and #12 and to ensure resident #2 was provided with a smoking apron while smoking. Resident #12 was observed to fall asleep while smoking and drop a lit cigarette onto his lap. Multiple burn holes were observed in his clothing. At 1:54 p.m., The Oklahoma State Department of Health (OSDH) was called and verified the existence of the Immediate Jeopardy situation. At 2:01 p.m., the administrator, the DON, the VP of operations, and two of the facility owners were informed of the Immediate Jeopardy regarding a resident falling asleep while smoking and that a plan of removal would be required. They were also informed that this placed the facility in an extended survey. PLAN OF REMOVAL The plan of removal, dated 11/05/15, was received on 11/05/15 at 4:44 p.m., from facility owner #1. The plan of removal documented, Southern Hills (SH) Administrator was notified on 11/5/15 at 2:08 PM that the facility was placed on an Immediate Jeopardy because (resident #12) and (resident #2) were smoking, falling asleep and had evidence of burns in their clothing. At 2:09 PM, (CMA #3) and (RN #1), were placed in the resident smoking area to supervise resident smoking. Once (CMA #3) provided instruction, she exited the area at 2:18 PM. An SH employee is responsible to monitor smoking around the clock so that no resident smokes without supervision. At 2:34 PM, nurses began assessing residents who smoke. The smoking assessments will be completed by 4:37 PM on 11/5/15. (Owner #1) re-educated the Administrator, Director of Nursing (DON) and Admission Coordinator on the new facility smoking policy by 6:00 PM on 11/5/15. The Administrator, DON, Admission Coordinator will in turn train charge nurses and department heads who will serve as trainers. Staff currently working/on the clock will be educated on the smoking policy by 6:00 PM on 11/5/15. Staff have been called and instructed to come to (facility initials deleted) to be educated on the smoking policy. Staff will be educated by 10:00 AM on 11/6/15. Only staff educated will be allowed to work. If an employee does not complete the education, he/she will not be allowed to work. IN-SERVICE: Staff will be educated on the new facility smoking policy entitled Smoking Safety and how the facility operationalizes this policy before starting their shift. Specifically, staff will be given a list of residents who are allowed to smoke supervised and how to supervise these people. Staff will also receive a list of residents who are allowed to smoke unsupervised. All residents will keep their cigarette, lighters, and smoking material under lock and key in the CMA cart. The staff will be educated on how to access the smoking and lighting material, how many cigarettes each resident is allowed to have and how to ensure any unused cigarettes are either discarded or stored under lock and key in the CMA med cart. Each shift, the DON or designee will identify the employee who will provide oversight for the smokers. Changes in staff who provide this supervision must be approved by the DON or designee. The times available to smoke are 9:00 AM, 11:00 AM, 1:30 PM, 3:30 PM, 6:15 PM and 8:00 PM. The Immediate Jeopardy (IJ) was removed on 11/08/15 at 5:00 p.m., after all the components of the plan of removal were completed. The deficient practice remained at a pattern level of no actual harm with potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to: ~ evaluate resident's abilities to smoke independently and determine the resident's safety needs regarding smoking on admission and at least every three months as defined by their smoking policy for three (#2, 12, and #18) of eight sampled residents who smoked. ~ provide supervision while smoking for two (#2 and #12) of eight sampled residents who smoked. Resident #2 had been assessed to require supervision while smoking. Resident #12 had not had a smoking evaluation completed in six months, had multiple burn holes in his clothes and was observed to fall asleep while smoking and drop a lit cigarette in his lap. ~ ensure residents who required a smoking apron for safety were provided with one while smoking for one (#2) of eight sampled residents who smoked. ~ provide supervision to prevent falls and to identify and implement fall interventions for two (#10 and #11) of five sampled residents with falls. Findings: An undated smoking policy, documented, .Smoking tobacco in any form, whether by residents, visitors, or employees, is expressly forbidden on Facility premises, except in designated smoking areas .Residents are not permitted to keep tobacco products, lighters, or matches in their rooms or personal possession. These items must be kept at the nurses' station .In order to have independent smoking privileges, a resident must be classified as responsible. Residents not so classified are prohibited from smoking unless under the direct supervision of Facility personnel or when a visitor of the resident assume responsibility for the resident while smoking .The designated smoking areas of the Facility are indicated as follows: (blank) A Smoking Safety Policy, last revised on 01/25/15, documented: Policy The facility is committed to maintaining a safe resident smoking environment . 1. Prior to, or upon admission, residents shall be informed in writing, that smoking is permitted in designated areas only, and that smoking articles of any kind are to be stored in the nurses' station (or area designated by the facilty) and not permitted to be stored in resident living or sleeping quarers . 2. All residents will: Be evaluated by licensed nursing staff regarding smoking preferences and abilities upon admission, quarterly and with a significant change in resident mental or physical condition . Have a care plan developed related to this activity . 3. Safety Equipment . Smoking blanket will be located in an area easily accessible to the designated smoking area. 4. Smoking Restrictions: Based on the Smoking Safety Evaluation a determiniation will be made regarding whether a resident requires supervision or may smoke independently. Any restrictions placed on smoking privileges shall be noted on the resident's care plan so that all facility employees may be alerted to smoking restrictions. Should a person, who has been classified as an independent smoker, be, at a later date, reclassified as requiring supervision to smoke, the requirements above shall apply. a. The care plan will be updated to note changes. b. Reclassifications deemed necessary for the safety and well-being of the resident may be made at any time . Any resident who has been classified as requiring supervision shall not be permitted to smoke without the direct supervsion of a responsible staff member, visitor, or volunteer worker. Direct supervision must be provided throughout the entire smoking period. 5. Smoking articles: All residents who smoke, regardless of their classification, will not be permitted to keep any smoking articles/paraphernalia in their room . All staff visiting residents should be alert for any smoking materials stored in resident rooms . 6. Purchasing and/or storage of smoking articles: . All smoking articles for residents will be stored at the nurses' station (or facility designated area) in a safe area with restricted access, such as the medication room or locked box. Independent residents: a. Will request their specific smoking materials and will be given appropriate materials/paaphernalia, including lighter. b. Will return lighters to the nursing station/designated area. c. Nurses will check with the resident upon their return from the smoking area to ensure that all smoking materials/paraphernalia are returned to safe storage . Supervised residents will not be given their smoking materials/paraphernalia unless accompanied by the person designated to provide direct supervision. 7. Direct supervision of residents: . The care plan must be reviewed to ascertain if any specific safety devices, like a non-flammable smoking apron, must be used during the smoking period . The person who provides direct supervision of the supervised smoker will obtain smoking materials from the nurse and will be responsible for returning the smoking materials .to the nurse . 1. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 05/13/15, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact. The assessment documented the resident was not steady with ambulation, required a wheelchair for mobility, and used tobacco. A smoking assessment, dated 05/23/15, documented, .shows he is capable of smoking by himself, he does not show any tremors, puts out cigarette in proper receptacle .it is felt (resident's name deleted) is safe to smoke unassisted. There was no quarterly smoking assessment completed for the resident in August 2015. No other smoking assessments were completed after the initial assessment. A care plan, dated 05/26/15, documented, Focus: .is a smoker. Has no desire to quit. Potential for burns/injury related to smoking .Goal: Will remain free from injury related to smoking over the next 90 days .Interventions: May smoke unsupervised. May keep cigarettes and lighting material with him .facility smoking times. Times are posted on door to smoking area. Observe daily for smoking compliance. To smoke in resident smoking area. Observe for any complications such as: burn holes in clothes, burn on fingers, drops cigarettes, etc. Nurse to assess and notify doctor as warranted. Perform smoking assessment at least every three months and PRN to ensure safe smoking abilities. Remind of smoke times as needed. Keep resident updated to any changes in smoking policy. Report non-compliance or viewed unsafe practices to charge nurse. Nurse assess and notify PCP as warranted. A nurse's note, dated 09/22/15, documented, PT was outside in the smoking area was bout (sic) to fall out of it. I tried to arouse him shaking him slightly and saying his name, and he was hard to arouse. An empty bottle of (whiskey) fell on the ground. He said that he felt fine vital signs were WNL A quarterly assessment, dated 10/14/15, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact. The assessment documented the resident was not steady with ambulation and required a walker/wheelchair for mobility. A nurse's note, dated 11/03/15, documented, 2130 (9:30 p.m.) cna came to this nurse states (res) has a bottle of .whiskey in his chair. resident has smelled of alcohol the past two days, but keeps denying that he is or has been drinking, the bottle was almost empty and was confiscated by the nurse. resident was educated on the dangers of mixing alcohol with the medications he takes .DON and administrator notified. On 11/05/15 at 10:16 a.m., the resident was observed in the smoking area seated in his wheelchair alone. He was observed to put his head down and nod his head up and down with a lit cigarette in his right hand. He dropped his hand and cigarette into his lap and right thigh area as he nodded his head. He opened his eyes and brushed his clothing off as he continued to smoke. He removed his lighter from his coat and re-lit his cigarette. No staff were observed in the smoking area. CMA #2 was observed to walk past the door to the smoking area. She looked out the window at the resident and stated, He stays outside all the time, pretty much 24/7. I think he even sleeps out there too. At 11:05 a.m., the resident was asked how often he went out to smoke. He stated, Whenever I want. He was asked if the staff supervised him in the smoking area. He stated, No. He was asked how he received his cigarettes and lighter. He stated that staff would keep them locked up and sometimes he would keep them. He was asked if he ever burned holes in his clothing during smoking. He stated, Once in a while if the wind is up. The resident's clothing was checked. He had a burn hole in the left sleeve of the coat he was wearing. The resident's closet was checked. Several articles of clothing were observed with round burn holes. On 11/10/15 at 5:05 p.m., the DON and ADON were asked why the resident had not been assessed for safety during smoking since 05/23/15. The DON stated, It should have been done. She stated that no one was monitoring and somehow the assessment was not completed. They were asked why the care plan was not followed regarding smoking assessments, observing for safe smoking, and burn holes in clothing. The DON stated, I don't have the answer for that. The ADON stated, I think we were very lax and we were lax on our policy. We need a system in place and it will be now. 2. Resident #2 was admitted with [DIAGNOSES REDACTED]. A care plan, dated 04/02/15, documented, Focus: .is a smoker. Has no desire to quit. Potential for burns/injury related to smoking .Goal: Will remain free from injury related to smoking over the next 90 days Interventions: .is to be supervised by staff when smoking. Encourage use of smoking apron. Observe daily for smoking compliance. To smoke in resident smoking area. Observe for any complications such as: burn holes in clothes, burn on fingers, drops cigarettes, etc. Nurse to assess and notify doctor as warranted. Perform smoking assessment at least every three months and PRN to ensure safe smoking abilities. Remind of smoke times as needed. Keep resident updated to any changes in smoking policy. Report non-compliance or viewed unsafe practices to charge nurse. An admission assessment, dated 08/26/15, documented the resident had a BIMS score of 12. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident was unable to ambulate, required a wheelchair for mobility, and used tobacco. A smoking assessment, dated 10/04/15, documented, .Resident need for adaptive equipment .smoking apron .supervision .Safe to smoke with supervision .Has some vision loss which could put her at risk for injury. Currently able to light own cigarette .Encourage use of smoking apron when smoking . On 11/05/15 at 10:00 a.m., the resident was observed smoking in the smoking area. She was not wearing a smoking apron and there were no staff present while the resident smoked. On 11/10/15 at 5:05 p.m., the DON and the ADON were asked why the resident had been allowed to smoke unsupervised and without a smoking apron. The DON stated, I don't have an answer for that. They were asked why the care plan had not been followed regarding smoking and the smoking assessment. The DON stated, I don't have the answer for that. The ADON stated, I think we were very lax and we were lax on our policy. We need a system in place and it will be now. 3. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interium care plan, dated 10/15/15, documented the resident smokes unsupervised. No admission smoking safety assessment was observed. A five day medicare assessment, dated 10/22/15, documented the resident had a BIMS of 15. This score indicated the resident was cognitively intact for daily decision making. The assessment documented the resident required assistance with activities of daily living and did not use tobacco products. On 11/09/15 at 11:50 a.m., RN #1 was asked if a smoking assessment had been done for the resident upon admission. She stated, No smoking assessment could be found during the resident's admission. On 11/10/15 at 3:30 p.m., the DON was asked when smoking assessments were to be done. She stated, Upon admission and quarterly. The DON was asked who monitors the assessments are done. She stated, MDS and/or the DON. The DON was asked why the resident had not had a smoking assessment done upon admission. She stated, Can't answer that. 4. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 03/17/15, documented, Focus Falls: .Has fall HX. Potential for further falls D/T unsteady gait, decreased vision D/T glaucoma, generalized weakness and SOB R/T COPD .Goal: .Will remain free from further serious injury R/T falls through next review .Interventions: .Be sure (name deleted) has her glasses on .keep frequently used items within easy reach .maintain bed in lowest position .observe O2 tubing to keep from being tangled around furniture and/or feet when walking .verbally remind as needed for me to use call light and not to get up unassisted . An incident/accident report, dated 09/04/15, documented the resident had an injury fall while walking around the bed unassisted. The fall resulted in a hematoma to the left side of the resident's head. The report documented the steps to prevent recurrence of falls was for, .non skid socks, secure O2 tubing . An incident/accident report, dated 10/16/15, documented the resident had an injury fall while transferring herself to the bedside commode. The fall resulted in a small bump to the left side of the resident's head. The report documented the steps to prevent recurrence of falls was to, .Remind Res to call for help . A quarterly assessment, dated 10/28/15, documented the resident had a BIMS score of 13. This score indicated the resident was cognitively intact for daily decision making. The assessment documented the resident was at risk for falls and had no falls since the last assessment. On 11/05/15 at 10:50 a.m., the resident was observed being assisted from the bed to the wheelchair by staff. On 11/10/15 at 3:40 p.m., the DON was asked if the MDS was inaccurate regarding the falls. She stated, Yes. At 5:34 p.m., the DON was asked if the falls should have been updated to the care plan and new interventions put into place to prevent recurrence of falls. She stated, Falls were discussed at morning stand-up and the care plan should have been updated with new interventions. 5. Resident #10 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/01/15, documented, the resident had a BIMS score of zero. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had no falls since the prior assessment. An incident/accident report, dated 09/11/15, documented the resident had experienced a fall from her wheelchair. A quarterly assessment, dated 09/21/15, documented the resident had a BIMS score of zero. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had no falls since the prior assessment. A care plan, updated on 10/12/15, documented, Focus: .risk for falls due to a past fall hx when I was ambulatory .dependent on staff for my mobility needs .am legally blind and have severe cognitive loss D/T Alzheimer's dementia .Goal: .goal remains appropriate. Cont with POC .Interventions: .maintain my call light in easy reach, answer in timely manner .observe me at least 72 hours S/P a fall for any possible delayed injury .notify my family and PCP of any falls .perform fall risk assessment at least quarterly and prn .assist me with all my transfers .assist me to/from meals and activities .keep room/facility free from clutter and obstacles .maintain my bed in lowest position .be sure I am in the middle of my bed .observe frequently. An incident/accident report, dated 10/13/15, documented the resident was observed on the floor next to her bed, laying on her left side. A nurse's note, dated 10/13/15 at 2:28 p.m., documented, Resident was observed on the floor next to her bed laying on her right side. No injury noted, no s/s of pain observed. Resident assessed and then assisted back to bed by CNAX2 and LPN. Immediate intervention: low bed, will suggest a floor mat also. Physician and daughter .notified by this nurse. An incident/accident report, dated 10/16/15, documented the resident rolled off the bed to the floor, and a small bump was noted on her forehead. A nurse's note, late entry, dated 10/17/15, documented, On 10/16/15 approx. 2115 (9:15 p.m.) resident observed in the floor next to her bed, nurse had been in room previously, resident was noted to have her legs off side of bed, cna and nurse moved resident to center of bed, resident had a knot on the top of her head, resident denies pain, is able to move all extremities, vitals are stable neuros are wnl, resident's son was notified, several family members called also, then family arrived at facility, demanding a low bed and a fall matt (sic), cna unable to locate low bed, family then demanded bed be turned back towards the wall, bed was moved and fall matt (sic) in place, report given to oncoming nurse continue to observe for changes. Family did not want resident sent to hospital at this time. On 11/10/15 at 5:30 p.m., the DON was asked why the resident's fall care plan did not include the three falls the resident had experienced since her readmission to the facility, and interventions implemented after each fall. She stated, There should have been, yes. The DON and administrator were asked why a low bed and fall mat had not been put in place after the resident had fallen on 10/13/15. The administrator stated there were no low beds left in the facility, and the company that provided the beds had to be called to bring one in. The DON was asked what interventions were put in place after the fall on 10/16/15 that resulted in a head injury. She stated, We fixed the beds. We put a mat on the floor, but that doesn't prevent falls. She was asked what measures have you put in place to prevent the resident from having further falls. The DON stated, We cannot prevent falling. It's her right to fall. At 5:35.p.m, the ADON stated, We discuss falls every day in clinical meeting.

Based on observation, interview and record review, it was determined the facility failed to recognize pain and implement pain management interventions for one (#16) of one sampled resident who was reviewed for pain. This resulted in actual harm for resident #16 who experienced pain during wound care and no pain intervention was provided. The resident census and condition report identified 21 residents who required pain management and six residents with pressure ulcers. Findings: A facility policy, titled Pain - Clinical Protocol, documented, .Assessment and Recognition .Staff should use a standardized pain assessment instrument appropriate to the resident's cognitive level .The staff and physician will evaluate nonverbal individuals for nonspecific signs and symptoms that could reflect pain; for example, grimacing while being repositioned or having a wound dressing changed . The facility's policy, titled Pain Assessment, General Guidelines, documented .Continuing assessment of the pain management program will occur daily and will focus on the effectiveness of the program and the comfort level of the resident . A facility policy, dated 09/30/15, titled Pain Assessment, documented, .Pain will be evaluated daily by CMA and Charge Nurse . Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 05/25/15, documented, Focus: Pain .Potential risk for undiagnosed pain and or undertreated pain d/t cognitive loss and impaired skin integrity .Goal: Will remain comfortable and as pain free as possible over the next 90 days .08/11/15 .Interventions: If needed, give prn pain medication prior to performing tx to ulcers on feet .Observe for s/s of pain such as: change in behavior/mood, restlessness, facial grimaces, moaning, etc. Give prn pain med as ordered, and observe for effectiveness . A quarterly assessment, dated 10/21/15, documented the resident had a BIMS score of 2. This score indicated the resident was cognitively impaired for daily decision making. The assessment documented the resident required extensive assistance of two persons with activities of daily living and had a stage I or greater pressure ulcer. The current physician's orders [REDACTED].Rate pain on scale from 0-10 on 6-2 and 2-10 shifts two times a day .[MEDICATION NAME] Gel 160 mg/5ml. Give 20.3 ml via PE[DEVICE] every 4 hours as needed for pain .[MEDICATION NAME]-[MEDICATION NAME] Solution 7.5-325 mg/15ml. Give 10 ml via PE[DEVICE] every 6 hours as needed for pain . On 11/04/15 at 3:15 p.m., wound care was observed for resident #16. LPN #4 went into the resident's room, who was laying in his bed on his right side, and informed him she was going to do a dressing change. She asked him if he was hurting. He stated, No. She asked him if he needed anything for pain before the dressing was to be changed. He spoke to the LPN in a loud voice but was not able to communicate his need because of his slurred, unclear speech deficit. She left the resident's room and went to the treatment cart in the hall. She opened the resident's treatment administration record on the treatment cart and read the information provided for the wound care and supplies needed. She obtained the wound care supplies and a permanent marker, placed them on the top of the cart and moved the cart to the doorway of the resident's room. She entered the room with the supplies, set them up for the procedure and donned her gloves. She told him she was going to do the dressing change. He attempted to speak but was unclear and then became distressed when she pulled the covers away from his legs. The resident was laying in a semi-fetal position with his left leg bent at the knee with the left ankle laying on top of his right leg bent at the knee. The dressing on his ankle was observed to be a clean, intact, 4 roll gauze dressing, wrapped from his heel to mid-ankle. She reached toward the wound dressing covering his left ankle/foot. The resident became agitated when he saw her reach and was heard to say in a loud voice, NO!, NO!, NO! He continued to say it repetitively before she touched the dressing. She lifted the resident's left ankle to remove the dressing in place and the resident yelled out, NO! NO! NO! NO! while she unwrapped the gauze from his foot. The gauze that was next to the wounds was dry and was adhered to the edges of 3 wounds on the resident's left lateral foot. The nurse pulled the remaining gauze from the areas it was adhered to while the resident yelled, NO! repetitively during the dressing removal process. Blood drained from the areas of the wound the dressing had been adhered to, onto the sheets and mattress beneath the resident's foot. The nurse was heard to be apologetic to the resident throughout the dressing removal procedure, saying, I'm sorry, I'm sorry, in response to his saying no during the time the care was provided. She proceeded to do the wound care and told him she had to finish cleaning his wounds and put on the new dressing. She rinsed the wounds with saline and used gauze to dab the excess saline and blood from the wounds. The resident became agitated when she did it and he was heard saying NO! NO! NO! during this procedure. The LPN continued to apologize while she explained she had to clean off the wound and the blood before she could finish the dressing change. She applied the honey ointment to the wound with the sterile q-tip, applied a 2 x 2 foam dressing over the two small pressure ulcers near the left heel and a 4 x 4 foam dressing to the larger wound at the lateral side of the left foot. She picked up a permanent marker and labeled the dressings she placed on the wounds. The resident loudly complained, NO! NO! NO! during the entire time the nurse performed the cleaning and dressing of the wounds. The LPN picked up a pillow from the resident's bed after finishing the dressing change and reached for his left foot. The resident started crying out, NO! NO! NO!, before his foot was touched and she stated, He has contractures and he doesn't like us to move his legs. And he doesn't like lying on this (right) side. She stopped with the attempt to position the pillow under his foot and covered him with the sheet and blanket laying on his bed. The nurse did not ask the resident if he needed anything for pain after she completed the procedure. The length of time of the care observed was 35 minutes, from the time the care started until the care was completed. On 11/04/15 at 4:20 p.m., LPN #4 was asked if resident #16 was medicated for pain prior to the dressing change that was done that afternoon. She stated, No. I asked him if he was hurting and if he needed anything for pain before the dressing change and he said no. He is on prn pain meds, so if he is grimacing we ask, but very seldom does he ask. She was asked if he had been given anything for pain at any time on that day. The residents medication administration records were reviewed with LPN # 4. She stated, It shows he's had no pain medication at all for the month of November. She was asked if the dressing change had already been done for that day. The resident's treatment administration record was reviewed with LPN #4. She stated, Yes, it looks like it was done on the 6-2 shift. She was asked why the dressing change was done again if it had already been done that day. She stated, Because I was asked to do it. I did not know it had already been done until I looked at the treatment record just now. She was asked who asked her to do it. She stated, ADON. She was asked why she continued to do the wound care when the resident was saying no, no, no, and she stated, He always does that when he thinks you are going to touch him. He doesn't like to be touched or moved. Because of his contractures. On 11/04/15 at 4:41 p.m., resident #16 was asked if he was offered pain medication before the dressing done this afternoon. He did not answer. He was asked if he was in pain now. He stated, No. He was asked if it hurt when the dressing change was done this afternoon. He stated, Yes. He was asked where it hurt. He was asked if pain when the dressing change was done. He stated, Yes, in my foot.

Based on observation, interview, and record review, it was determined the facility failed to notify the physician of: A. Right toe and foot wounds, significant changes to a left great toe wound, and changes to an incision on a left [MEDICAL CONDITION] stump for 1 (#20) of 9 sampled residents who were at high risk for health status changes. The facility identified 30 residents were at high risk for health status changes. The facility's failure to notify the physician of wounds to the resident's right toe and foot, significant changes to a left great toe wound, and changes to the incision on a left [MEDICAL CONDITION] constituted an Immediate Jeopardy situation for resident #20; B. Second [MEDICAL CONDITION] the upper left arm received from a hot coffee spill for 1 (#16) of 1 sampled resident who had been burned by hot coffee in the facility. The facility identified 53 residents who required supervision when drinking hot liquids; and C. A newly acquired alteration in skin integrity for 1 (#21) of 13 sampled residents at high risk for skin breakdown. The facility's Census and Conditions report identified 83 residents who received preventative skin measures. Findings: 1. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 03/04/11, documented the resident required supervision with transfers and bathing, was not steady with moving, walking, transfers, and turning around but was able to stabilize self, had a [DIAGNOSES REDACTED]. The care plan, dated 03/05/11, documented a problem, "...I am weak and need some assistance with my ADLS..." The goal was, "...I will have assistance from staff completing my ADLS..." Approaches included, "...Assist me with bathing 3 x week..." Another problem was, "...I have [MEDICAL CONDITION], DM...I am at risk for skin breakdown..." The goal was, "...Skin will remain intact thru NRD..." Approaches included, "...Administer meds as ordered by my Dr...Monitor my skin while providing care. Notify nurse of any changes...Nurse to assess skin q week..." A weekly head to toe skin review, dated 04/12/11, documented the resident had a skin issue to his left foot. There was no description or documentation of the skin issue. There was no documentation to show the physician was notified of the skin issue. A physician's progress note, dated 04/14/11 and signed by the nurse practitioner, documented, "...mild (bilateral lower extremity [MEDICAL CONDITION]) (left greater than right). Comp stockings in place...will get podiatrist appointment..." It was documented the resident had erythemia and an area measuring 1 x 0.5 cm on his left foot. A skin/wound QI log, dated 04/18/11, documented, "...10. Diabetic Neuropathic...Skin/wound type...#10...(R) great toe 0.5 x 1 x UTD necrotic edges intact..." A nurse's note, dated 04/18/11 at 3:15 p.m., documented, "...Called dr...talked c his nurse...(increased) swelling in legs want to know if (increase) [MEDICATION NAME] or Ace wraps..." A nurse's note, dated 04/18/11 on the 2 - 10 shift, documented, "...call back (with) a n/o (increase) [MEDICATION NAME] 2+ [MEDICAL CONDITION] in BLE..." This note was signed by RN #1. A review of the clinical record revealed no documentation to show the physician was notified of the wound on the resident's right great toe. A physician's progress note, dated 04/19/11, documented, "...Nsg concerned...redness (left) foot (and) leg...(positive) black esh (left) great toe. (positive) erythemia toe (and) foot. 3+ ([MEDICAL CONDITION])..." There was no documentation to show the physician was notified of the resident's right great toe wound. Physician's telephone orders, dated 04/19/11, documented, "...Multivit daily, zinc daily, vit c [MEDICATION NAME] (an antibiotic) 500 (mg) daily x 10, Santyl to eschar (left) toe daily. Saline moist gauze to toe..." A nurse's note, dated 04/19/11 at 1:20 p.m., documented, "...N/O Zinc q daily, Vit C daily, multi vit q day - x ray (left) great toe, [MEDICATION NAME] 500 q day x 10, santyel (sic) to eschar (left) toe cover c moist saline gauze wrap c [MEDICATION NAME], change qd..." A nurse's note, dated 04/19/11 on the 2 - 10 shift, documented, "...(up) to DR. Big toe (left) foot swelled (and) red. Ordered xray (and) lab ATB to start when it gets in (and) tx to big toe will cont to monitor..." A review of the MARS, dated 04/19/11, revealed no documentation to show the [MEDICATION NAME], vitamin C, zinc, or multivitamin were administered as ordered. A nurse's note, dated 04/20/11 on the 10 - 6 shift, documented, "...Started on ATB therapy...Initial dose given @ 2100 (9:00 p.m.)..." A nurse's note, dated 04/20/11 on the 6 - 2 shift, documented, "...Doctor apt this am about feet. New treatments start today..." A podiatrist progress note, dated 04/20/11, documented, "...new sore top (left) great toe; unknown etiology...ulcer lateral (left) great distal hallux; (+) [MEDICAL CONDITION], erythemia, nail loosening...ulcer (left) great toe c [MEDICAL CONDITION] (left) hallux nail...debridement of ulcer; bandage applied...PO ABX..." There was no documentation concerning the resident's right great toe. A physician's progress note and prescription, dated 04/20/11, documented, "[MEDICATION NAME] (an antibiotic)...400-80 mg tabs...one tab po bid..." A nurse's note, dated 04/20/11 on the 2 - 10 shift, documented, "...Resi back from toe/foot dr. He did minor surgery on (left) large toe. DX as [MEDICAL CONDITION] (and) leaking loose (left) nail. Also x-ray done c results back of (no) acute boney injuries. Remains c swelling (and) redness...Started on ATB..." A review of the MARS, dated 04/20/11, revealed no documentation to show the [MEDICATION NAME], vitamin C, zinc, or multivitamin were given. A physician's telephone order, dated 04/21/11, documented, "...order clarification MVI c minerals (one) po qd, zinc...220 mg (one) po daily, vitamin C 500 mg (one) po...wd healing..." A physician's telephone order, dated 04/21/11, documented, "...(wound clinic name withheld) to eval and tx..." A nurse's note, dated 04/21/11 on the 6 - 2 shift, documented, "...Resident continues ATB therapy...N/O from (Physician name withheld). Ordered from...this am. Will start in afternoon. Resident denies any pain or discomfort, does have c/o great toe not much pain but it is noticeable..." A nurse's note, dated 04/21/11 and untimed, documented, "...N/O received (sic) for debridement of diabetic ulcer on 4/20/2011. N/O received (sic) for eval/tx at wd clinic. Awaiting return call for appointment..." A review of the clinical record revealed no documentation to show the wound clinic made a return call or that facility staff attempted to contact the wound clinic again. A nurse's note, dated 04/21/11 on the 2 - 10 shift, documented, "...Started on ATB for wound of big toe (and) dx of [MEDICAL CONDITION]" MARS, dated 04/21/11, documented, "[MEDICATION NAME]'d..." The MAR indicated [REDACTED]. Review of the clinical record revealed no physician order to discontinue the [MEDICATION NAME]. A review of the MARS, dated 04/21/11, revealed no documentation to show the [MEDICATION NAME], vitamin C, zinc, or multivitamin were given. A nurse's note, dated 04/22/11 on the 2 - 10 shift, documented, "...Resi fell in the shower rm tonight about 445 pm while he took a shower c the CNA's assist. He was in the shower chair when he got up (and) got his walker, he slipped in water (and) CNA saw him fall to the floor where he bent his (left) knee when he fell (and) c/o left knee pain. Now, no noted swelling @ this time, resident did c/o pain later. Son call (and) Dr called for report of fall (and) pain. No new orders @ this time, will cont to monitor..." This note was signed by RN #1. A review of the MARS, dated 04/22/11, revealed no documentation to show the [MEDICATION NAME], vitamin C, zinc, or multivitamin were given. A weekly head to toe skin review, dated 04/23/11 at 9:00 a.m., documented, "...area to (left) great toe. (no) other areas noted. [MEDICAL CONDITION] to LLE. Tx's in place..." There was no documentation regarding the wound to the resident's right great toe. A nurse's note, dated 04/23/11 at 9:10 a.m., documented, "...c/o (left) leg/foot pain. N/O x-ray (left) knee (and (left) ankle..." A review of the MARS, dated 04/23/11, revealed no documentation to show the [MEDICATION NAME], vitamin C, or zinc, were given. A nurse's note, dated 04/23/11 at 12:55 p.m., documented, "...x-ray results...(left) ankle acute nondisplaced fx - distal metaphysis of fibula. (Physician name withheld) notified. N/O send to ER..." admission orders [REDACTED]. An admission assessment, dated 04/28/11, documented the resident had an area to his left great toe. It was documented, "...(left) great..." There was no further description of the area. There was no documentation to show a wound had been identified on the resident's right great toe. A nurse's note, dated 04/28/11 at 12:02 p.m., documented, "...Resident returned to facility...(left) leg cast, (left) great toe exposed...Resident needs help with bathroom x 2. He thinks he can stand on own but most of his weight should be on (right) leg. Need to remind him constantly..." A review of the treatment sheets, dated 04/28/11 and 04/29/11, revealed no documentation to show any type of treatment was completed for the resident's right or left great toe wounds. A nurse's note, dated 04/30/11 on the 6 - 2 shift, documented, "...Lt great toe black eschar noted. Dry and hard to touch - just under toe nail tip of toe..." It was documented the resident's skin was within normal limits. Treatment sheets, dated 04/30/11, documented, "...cleanse (left) great toe pat dry swab c [MEDICATION NAME] wrap c gauze and tape..." It was documented this treatment was completed on 04/30/11. Review of the clinical record revealed no physician's order for this treatment or treatment orders for the right great toe wound. A weekly head to toe skin review, dated 05/01/11, documented, "...eschar (left) great toe. Cast to LLE for ankle..." There was no documentation to show the resident had a wound on his right great toe. A skin/wound QI log, dated 05/03/11, documented, "...10. Diabetic Neuropathic...Skin/wound type...#10...(R) great toe 0.5 x 1 x UTD..." There was no description of the wound on the resident's left great toe. A nurse's note, dated 05/04/11 on the 6 - 2 shift, documented, "...wound to (left) great toe now open c yellow skin surrounding wound. Blue skin on lateral side of great toe. Mod amnt of yellow bloody drainage on old bandage. Cap refill approx 3 sec in toes..." It was documented the resident's skin was within normal limits. A review of the clinical record revealed no documentation to show the facility notified the physician of the change in the resident's left great toe wound. A nurse's note, dated 05/04/11 on the 2 - 10 shift, documented, "...Call to (wound clinic name withheld) (and) set up appt for May 11..." The physician's order for the resident to be evaluated and treated at the wound care clinic was written on 04/19/11. A nurse's note, dated 05/06/11 on the 6 - 2 shift, documented, "...(Left) great toe wound black open c purple area around toe..." Review of the clinical record revealed no documentation to show the physician was notified of the change in the resident's left great toe. A nurse's note, dated 05/06/11 on the 2 - 10 shift, documented, "...has become confuse (and) slightly forgetful lately..." A nurse's note, dated 05/07/11 on the 2 - 10 shift, documented, "...Toes warm, color to toes WNL, except for area where wound is on (left) great toe..." A weekly head to toe skin review, dated 05/08/11, documented, "...bruising to (left) great toe (and) wound to (left) gr toe tx in place..." There was no documentation of the resident's right great toe wound. A nurse's note, dated 05/09/11 on the 10 - 6 shift, documented, "...dressing to great left toes changed @ (9:00 p.m.)...No bleeding nor drainage noted..." An entry in the DON's wound notebook, dated 05/09/11, documented, "...(Resident #20) (wound clinic name withheld) 5/11/11, (right) great toe 0.5 x 0.6 x 0.1 - wd bed brown eschar...(left) great 2.5 x 3 x UTD - tip necrotic dry/ (no) drainage - toe reddened c blue/black discoloration - poor circulation cold touch cap refill > 3 sec turgor [MEDICAL CONDITION] tx [MEDICATION NAME]" There was no documentation to show the physician was notified of the change to the resident's left great toe wound or of the resident's right great toe wound. A nurse's note, dated 05/10/11 on the 6 -2 shift, documented, "...tx to toe complete...cap refill < 3 sec to (left) toes..." A nurse's note, dated 05/10/11 on the 2 - 10 shift, documented, "...out to (wound clinic name withheld) tomorrow..." A nurse's note, dated 05/11/11 on the 10 - 6 shift, documented, "...toes warm to touch.. Good capillary refill of lt toes..." A nurse's note, dated 05/11/11 on the 6 - 2 shift, documented, "...Noted bilat peripheral extremities cool...dressing to (left) great toe in place..." A nurse's note, dated 05/11/11 on the 2 - 10 shift, documented, "...out to (wound clinic name withheld) early pm (and) back after 5 p.m. New orders to be clarified tomorrow..." The note was signed by RN #1. A wound clinic history and physical, dated 05/11/11, documented, "...Wagner grade III (deep ulcer with [MEDICAL CONDITION] or abscess formation, often with osteo[DIAGNOSES REDACTED]) [MEDICAL CONDITION] with dry gangrene noted on the left great toe approximately to the mid joint...Diagnostic recommendations: 1. TCOM (transcutaneous oxygen monitoring), which initially shows less than 10 (values of 40 are a beginning point for predicting wound failure) on the left, but full report is pending...Arterial ultrasound...Repeat TCOM in 1 week...Therapeutic recommendations: [MEDICATION NAME] paint to toes, keep toes clean and dry...He has had a history of [REDACTED]. Before the cast was put on, the son reported that his toe was starting to turn black. We took a look carefully at the cast. He did have some swelling located with the cast, but overall I did not see any pinch points on his cast. The patient stated the great toe has become worse and now he has lost feeling in his great toe...The left leg appears to be swollen, however, I can insert a finger in between the cast on the dorsal aspect and the plantar aspect and I had good capillary refill across all the other toes and surrounding the toes. The toes do not feel warm. The third toe looks gassy. The great toe appears to be black approximately half at its length. There is no pus draining from the wound...Overall, I doubt that the cast is causing the problem at this point...We have talked with the family for a great length of time on the options including [MEDICAL CONDITION] waiting and revascularization procedures, however, we will share more information with the patient and the family once we have the evaluations completed..." A physician's progress note, dated 05/11/11, documented, "...c/o redness (and) (erythemia) of (left) great toe...has been seeing pod...ulcer (left) toe [MEDICAL CONDITION](positive) ulcer (left) great toe - good cap refill...referral to (unknown) (recheck) in am if worse will send to hosp..." A physician's telephone order, dated 05/12/11, documented, "...Order clarification. Apply [MEDICATION NAME] BID to (left) great toe and then apply a dry dressing..." A nurse's note, dated 05/12/11 on the 2 - 10 shift, documented, "...when resident got up out of bed, very confused @ first of shift. Down for therapy (and) (decreased) confusion note. (Nurse practitioner) called about low B/P (and) confusion..." A nurse's note, dated 05/12/11 on the 2 - 10 shift and documented as continued from previous note, documented, "...(Physician #2) did a visit today about 5:30 pm (and) saw the (left) great toe of this resident. Resi had a wound appt @ (wound clinic name withheld) on 05/11/11...I called the POA (and) spoke c (family member) again about (physician #2 name withheld)'s visit, the order to send to (hospital name withheld) for IV-ATB tonight DX of gangrene in (left) great toe (and) removal of toe..." A physician's telephone order, dated 05/12/11 and written by physician #2, documented, "...Transfer to (hospital name withheld) - direct admit (5:30 p.m.)..." A hospital history and physical, dated 05/13/11 and dictated by physician #2, documented, "...patient...was treated here recently for a fracture of his left ankle after he slipped and fell in the shower...At that time, he was noted to have a dry eschar at the tip of his left great toe. I was notified by the nursing home yesterday that he was having increasing gangrene and was going to be transferred to another hospital for further evaluation next week. I visited his nursing home and found him to have gangrene with impending limb loss of the left foot, so I made arrangements for him to have a direct admission to (hospital name withheld)...Left foot has ischemic gangrenous left great toe beyond the IP joint. The left great toe has some ischemia of the distal portion as well. The left foot is cool and dusky. There is no obvious deformity of the ankle. Right foot is [MEDICAL CONDITION]. I cannot feel a pulse in the right foot...Impression...Impending limb loss left foot secondary to [MEDICAL CONDITION] will evaluate him with tissue studies and with arterial Doppler study to see if there is any possibility of limb salvage..." An orthopedic consult, dated 05/12/11, documented, "...The right lower extremity is grossly normal with a couple of small abrasions on the great toe. The pulses are faint on the right. On the left, there is [MEDICAL CONDITION] and redness from about the ankle distally and there are no palpable pulses. The great toe is black. The skin is cool over the dorsum of the foot on the left...I have advised the patient and his (family member) of the findings. They are in agreement with proceeding with left below-the-knee amputation..." The resident returned to the facility on 05/25/11 following a left [MEDICAL CONDITION]. A nurse's note, dated 05/25/11, documented, "...(right) great toe has open unstageable sore approx penny size...(left) BKA wrapped c pressure dressing..." A physician's telephone order, dated 05/25/11, documented, "...Wound care to (left) BKA, clean c N/C (sic), cover c 4x4 wrap c [MEDICATION NAME] wrap c Ace bandage...Wound care apply Betadyne (sic) to (right) great toe wound leave open to air..." On 05/26/11 at 9:50 a.m., LPN #5 was observed completing wound care to the resident's left BKA stump and right foot wounds. Before beginning the wound care, LPN #5 stated the resident had been pre-medicated with Tylenol as all other pain medications had been discontinued "to see if they were causing confusion." LPN #5 removed the soiled dressing from the stump. Dried blood and two areas of bright red blood were observed on the dressing. The stump was observed to be dark red for approximately two inches on each side of the incision line. This circled the entire incision area. LPN #5 held gauze pads under the stump with his right hand and poured normal saline over the wound with his left hand. LPN #5 then wiped the incision line with the contaminated gauze pads. The resident grunted, and LPN #5 asked if he was hurting. The resident stated, "Yes." LPN #5 dressed the stump, washed his hands, and began the wound care to the resident's right foot. LPN #5 removed the resident's sock. A 3 x 3 cm black area was noted on the resident's right bunion area, and a 1 x 1 cm black area was noted on the medial side of the great toe, on the left side of the toe nail base. Each area was swabbed with a [MEDICATION NAME] swab. A nurse's note, dated 05/26/11 on the 6 - 2 shift, documented, "...C/o pain when pressure applied to stump on (left) BKA. Bandage changed to stump. Red orange in old dressing mod amount. Wound edges approximated...(no) s/s of infection...Wound care to (right) toe. [MEDICATION NAME] to wound per orders. A review of the treatment sheets, dated 05/26/11, revealed the treatment was completed to the resident's right great toe. The sheet documented the dressing was discontinued after 05/26/11, but no date was identified. A review of the clinical record revealed no physician's order to discontinue the treatment. There was no documentation to show the treatment was completed after 05/26/11. A review of the clinical record revealed no documentation to show the physician was notified of the resident's pain during the treatment and dressing change. A nurse's note, dated 05/27/11 on the 6 - 2 shift, documented the resident's stump had abnormal turgor, abnormal skin color, and unusual temperature. It was documented the resident had a [MEDICAL CONDITION] to the right great toe and other open [MEDICAL CONDITION] on the right foot. The note was signed by the DON. The note documented, "...Wound care provided per order. (Right) great toe tx c [MEDICATION NAME] and left open to air. (Left) stump incision has sanquinous (sic) drainage c irregular incision line. [MEDICAL CONDITION] 2+ noted to stump c (increased) [MEDICAL CONDITION] to medial edge approximately 3+. Skin feels boggy c slight discoloration noted to medial edge. Bluish purple, cool to touch. On call dr for (surgeon's name withheld) paged to notify of (change) of condition. Awaiting return call. Res medicated for pain prior to drsg (change)...Will schedule f/u c surgeon Tuesday when office reopens p holiday..." It was documented the resident verbalized a moderate pain level with his pain being at a 6 on a scale of 1 to 10. A review of the MAR, dated 05/27/11, revealed no documentation to show the resident was medicated for pain prior to the treatment. A review of the clinical record revealed no documentation to show the physician was notified of the change in the resident's left BKA stump or the wounds on the resident's right foot. There was no documentation to show the DON had made the charge nurse on the 2 - 10 shift for 05/27/11 aware of the changes in the resident's condition. There was no documentation of a return phone call from the surgeon. On 05/27/11 at 3:32 p.m., the resident's right foot was observed. A black area, approximately 1.2 x 1.3 cm, was noted on the medial side of the great toe, on the left side of the toe nail base. A black area, approximately 3 x 3 cm, was noted on the right bunion area. A nurse's note, dated 05/27/11 on the 2 - 10 shift, documented, "...Resident c/o discomfort to buttocks, noted redness...PCP notified. Spoke c nurse practitioner. Received N.O. [MEDICATION NAME] to buttocks/peri area q shift..." There was no documentation to show the nurse practitioner was notified of the changes in the resident's left BKA stump. A nurse's note, dated 05/28/11 on the 6 - 2 shift, documented, "...Drsg intact lt stump area...clean (and) dry c no drainage noted..." A nurse's note, dated 05/28/11 on the 2 - 10 shift, documented, "...changed dressing to (left) BKA stump...Stump site has sanquinous (sic) drainage, slight redness et [MEDICAL CONDITION].Surgeon to be f/u c on Tuesday per D.O.N..." It was documented on all shifts for 05/28/11 the resident had abnormal skin turgor and a [MEDICAL CONDITION]. There was no documentation to show where the abnormal turgor was. A physician's telephone order, dated 05/28/11, documented, "...Clarification order: [MEDICATION NAME] 5/325 mg (one) po q 4 (hours) PRN pain..." A nurse's note, dated 05/29/11 on the 2 - 10 shift, documented, "...dressing changed to (left) stump...drainage continues..." It was documented on all shifts for 05/29/11 the resident had abnormal skin turgor and a [MEDICAL CONDITION]. There was no documentation to show where the abnormal turgor was. A nurse's note, dated 05/30/11 on the 6 - 2 shift, documented, "...(changed) (unknown) to stump of left (lower) ext. Wound closed c scant < 10 cc red drainage from one suture right of front medial side of wound...(No) s/s of infection..." It was documented on the evening and night shifts for 05/30/11 the resident had abnormal skin turgor and 2+ [MEDICAL CONDITION] to the stump. An entry in the DON's wound notebook, dated 05/31/11, documented, "...18 cm incision line c sanquinous (sic) drainage [MEDICAL CONDITION] 1+, surrounding skin pink (no) discoloration, temp warm, stump protector shrinking as expected, min drainage, (no) odor..." A physician's progress note, dated 05/31/11, documented, "...S/P (left) BKA (secondary) to infection (left) foot...Note: nursing reports (left) stump base healing (unknown) (no) drainage..." On 06/01/11 at 9:42 a.m., the DON was asked when the wound to the resident's left foot was first identified. She stated, "I believe it was 4/19." The DON was shown the weekly skin assessment dated [DATE] and was asked what wound the document referred to. She stated, "I would only be able to assume it was the original wound." The DON was asked if the physician had been notified of the wound on 04/12/11. She stated, "Yes, I believe on that day (physician name withheld) looked at it. He though it was [MEDICAL CONDITION]." When asked if there was documentation the physician had been notified, the DON stated, "No there is not." The DON was asked if there was documentation regarding the wound when it was first identified. She stated, "There should be an assessment. We have a physician's order for wound treatments. I believe it's 4/20." The DON was shown the physician orders for [MEDICATION NAME], vitamin C, zinc, and a multivitamin, dated 04/19/11. She was asked when the medications were started. She stated, "On the 29th". When asked why the medications were not started when ordered, the DON stated, "I cannot answer that." The DON was asked why the [MEDICATION NAME] was not started until the evening of 04/20/11. She stated, "It should have been initial dosed the next day. Our policy is to initial dose within 8 hours for antibiotics." The DON was asked if the resident received the initial dose of antibiotics within 8 hours. She stated, "No." The DON was asked why the [MEDICATION NAME] was discontinued. She stated, "Because of an allergy." When asked where the documentation was that showed the resident was allergic to [MEDICATION NAME], the DON reviewed the chart and stated, "There are no drug allergies [REDACTED]. She stated, "There is no order to dc the [MEDICATION NAME]." The DON was asked why a clarification order was written on 04/21/11 for the multivitamin, vitamin C, and zinc. She stated, "They didn't write for milligram doses on the original." The DON was asked if the medications were started after receiving the clarification order. She stated, "No." The DON was asked why it took 2 days to get a clarification order. She stated, "I cannot answer that question. It wasn't reported to me the meds didn't arrive." The DON was asked when the physician's order was received for the wound care treatments to the left great toe. She stated, "4/19." When asked when the wound care started, the DON stated, "I don't believe the Santyl was started. It looks like it (wound care) was given once on 4/23." The DON was asked why the wound care was not started as ordered. She stated, "I cannot answer that question." The DON was shown documentation the resident saw the podiatrist on 04/20/11. She was asked if the resident received new treatment orders for the left great toe at that time. The DON stated, "I do not see any orders to change the treatment." The DON was shown the physician's order for [MEDICATION NAME], dated 04/20/11, and informed the nursing notes stated the [MEDICATION NAME] was started on 04/21/11. The DON was asked why the MAR indicated [REDACTED]. She stated, "I don't know. The CMAs are good at reporting meds not here." The DON was asked why the charge nurse was unaware the medications were not started. She stated, "She should have known." The DON was asked where the documentation was describing the resident's left great toe wound when he was re-admitted to the facility on [DATE]. The DON stated, "I do wound measurements on Monday. If the charge nurse failed to describe the wound, I would have done it on Monday." The DON was asked who gave the orders for the left great toe wound treatments when the resident was readmitted . She stated, "They should have been from the hospital." When asked where the orders were, the DON stated, "I cannot find any orders from the hospital." On 06/01/11 at 10:38 a.m., the DON was shown the nurse's note from 05/04/11 on the 6 - 2 shift that documented the resident's left great toe wound was open with yellow skin, blue skin on the lateral sides, and a moderate amount of yellow bloody drainage. The DON was asked if the physician had been notified of the change in the resident's left great toe. She stated, "There is no nurse's note to support the doctor was notified." The DON was shown the nurse's note from 05/06/11 on the 6 - 2 shift that documented the resident's left great toe wound was now black and open with purple areas around the toe. The DON was asked if the physician had been notified of the change in the resident's left great toe. She stated, "There's no documentation to support that." The DON was shown the documentation from the wound clinic that documented the resident's left great toe was black 1/2 it's length. She was asked if the staff should have been aware of that and documented it. She stated, "Yes." When asked where the documentation was, the DON stated, "I cannot explain why they did not document what they should have." The DON was asked how often the resident's toe should have been assessed. She stated, "The treatment was daily. I reviewed weekly for measurements." The DON was asked when the wounds on the resident's right great toe were first identified. She stated, "4/18 was when it was first reported to me." The DON was asked if the physician was notified of the wound. She stated, "Yes. The charge nurse was supposed to call for treatment orders for [MEDICATION NAME] that day." When asked where the documentation was to show the physician was notified and orders received, the DON stated, "I do not see documentation that we notified him." The DON was asked if there was an order for [REDACTED]. 5/25." When asked why it was documented on the treatment sheet the treatment had been discontinued and only one treatment had been completed on 05/26/11, the DON stated, "I do not know." On 06/01/11 at 11:46 a.m., the surveyor and the DON observed the resident's right foot. The resident stated he had pain "like a grasshopper" in his stump. The DON did not ask the resident if he needed any pain medication. A hardened black area, approximately 3 x 3 cm, was observed on the resident's right bunion area. A pin-head sized red area was observed on the tip of the great toe. A black area, approximately 1.5 x 1.5 cm was observed on the left side of the great toe's nail base. Three open areas with brown wound bases were noted on the top of the foot, below the great toe nail base. The largest of these areas was pea sized. An abrased area was noted near the center of the top of the foot. The heel area appeared mushy and was slow to blanch. At 12:00 p.m., the surveyor and the DON observed the resident's left BKA stump. As the DON pulled the resident's pant leg up, the resident flinched. The DON did not ask the resident if he was in pain. The DON removed the shrinker and the gauze dressing. Bloody dr

Based on observation, interview, and record review, it was determined the facility failed to: A. Assess and monitor a resident with wounds to his right and left great toes; complete treatments to the wounds; administer antibiotics, vitamins and minerals to aid in wound healing; make wound clinic appointments in a timely manner; assess and monitor a left [MEDICAL CONDITION] stump, and provide pain medication prior to treatments for 1 (#20) of 9 sampled residents who were at high risk for health status changes. The facility identified 30 residents were at high risk for health status changes. The facility's failure to assess and monitor the resident's wounds and amputation stump, provide treatments for the wounds, administer medications to aid in the healing of the wounds, and make wound clinic appointments in a timely manner constituted an Immediate Jeopardy situation for resident #20; B. Ensure [MEDICAL TREATMENT] physician orders for 1 (# 11) of 1 sampled resident receiving [MEDICAL TREATMENT] were implemented in a timely manner. The facility identified 1 resident who received [MEDICAL TREATMENT]; and C. Ensure pulse rates were checked prior to the administrator of Amiodorone, a cardiac medication, for 1 (#2) of 3 sampled residents receiving Amiodorone. The facility identified 3 residents who received Amiodorone. Findings: 1. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 03/04/11, documented the resident required supervision with transfers and bathing, was not steady with moving, walking, transfers, and turning around but was able to stabilize self, had a [DIAGNOSES REDACTED]. The care plan, dated 03/05/11, documented a problem, "...I am weak and need some assistance with my ADLS..." The goal was, "...I will have assistance from staff completing my ADLS..." Approaches included, "...Assist me with bathing 3 x week..." Another problem was, "...I have [MEDICAL CONDITION], DM...I am at risk for skin breakdown..." The goal was, "...Skin will remain intact thru NRD..." Approaches included, "...Administer meds as ordered by my Dr...Monitor my skin while providing care. Notify nurse of any changes...Nurse to assess skin q week..." A weekly head to toe skin review, dated 04/12/11, documented the resident had a skin issue to his left foot. There was no description or documentation of the skin issue. A physician's progress note, dated 04/14/11 and signed by the nurse practitioner, documented, "...mild (bilateral lower extremity [MEDICAL CONDITION]) (left greater than right). Comp stockings in place...will get podiatrist appointment..." It was documented the resident had erythemia and an area measuring 1 x 0.5 cm on his left foot. A skin/wound QI log, dated 04/18/11, documented, "...10. Diabetic Neuropathic...Skin/wound type...#10...(R) great toe 0.5 x 1 x UTD necrotic edges intact..." A nurse's note, dated 04/18/11 at 3:15 p.m., documented, "...Called dr...talked c his nurse...(increased) swelling in legs want to know if (increase) [MEDICATION NAME] or Ace wraps..." A nurse's note, dated 04/18/11 on the 2 - 10 shift, documented, "...call back (with) a n/o (increase) [MEDICATION NAME] 2+ [MEDICAL CONDITION] in BLE..." A review of the clinical record revealed no documentation to show the physician was notified of the wound on the resident's right great toe nor were any treatment orders obtained. A physician's progress note, dated 04/19/11, documented, "...Nsg concerned...redness (left) foot (and) leg...(positive) black esh (left) great toe. (positive) erythemia toe (and) foot. 3+ ([MEDICAL CONDITION])..." There was no documentation to show the physician was notified of the resident's right great toe wound. Physician's telephone orders, dated 04/19/11, documented, "...Multivit daily, zinc daily, vit c [MEDICATION NAME] (an antibiotic) 500 (mg) daily x 10, Santyl to eschar (left) toe daily. Saline moist gauze to toe..." A nurse's note, dated 04/19/11 at 1:20 p.m., documented, "...N/O Zinc q daily, Vit C daily, multi vit q day - x ray (left) great toe, [MEDICATION NAME] 500 q day x 10, santyel (sic) to eschar (left) toe cover c moist saline gauze wrap c [MEDICATION NAME], change qd..." A nurse's note, dated 04/19/11 on the 2 - 10 shift, documented, "...(up) to DR. Big toe (left) foot swelled (and) red. Ordered xray (and) lab ATB to start when it gets in (and) tx to big toe will cont to monitor..." A review of the MARS, dated 04/19/11, revealed no documentation to show the [MEDICATION NAME], vitamin C, zinc, or multivitamin were administered as ordered. A review of the treatment sheet, dated 04/19/11, revealed no documentation to show the resident's left great toe treatment was completed as ordered. A nurse's note, dated 04/20/11 on the 10 - 6 shift, documented, "...Started on ATB therapy...Initial dose given @ 2100 (9:00 p.m.)..." A nurse's note, dated 04/20/11 on the 6 - 2 shift, documented, "...Doctor apt this am about feet. New treatments start today..." A dietary progress note, dated 04/20/11 and signed by the RD, documented, "...Has diabetic wound to (right) great toe. Interventions include...MVI, Zinc (and) Vit C..." There was no documentation regarding the resident's left great toe wound. A podiatrist progress note, dated 04/20/11, documented, "...new sore top (left) great toe; unknown etiology...ulcer lateral (left) great distal hallux; (+) [MEDICAL CONDITION], erythemia, nail loosening...ulcer (left) great toe c [MEDICAL CONDITION] (left) hallux nail...debridement of ulcer; bandage applied...PO ABX..." There was no documentation concerning the resident's right great toe. A physician's progress note and prescription, dated 04/20/11, documented, "[MEDICATION NAME] (an antibiotic)...400-80 mg tabs...one tab po bid..." A nurse's note, dated 04/20/11 on the 2 - 10 shift, documented, "...Resi back from toe/foot dr. He did minor surgery on (left) large toe. DX as [MEDICAL CONDITION] (and) leaking loose (left) nail. Also x-ray done c results back of (no) acute boney injuries. Remains c swelling (and) redness...Started on ATB..." A review of the MARS, dated 04/20/11, revealed no documentation to show the [MEDICATION NAME], vitamin C, zinc, or multivitamin were given. A physician's telephone order, dated 04/21/11, documented, "...order clarification MVI c minerals (one) po qd, zinc...220 mg (one) po daily, vitamin C 500 mg (one) po...wd healing..." A physician's telephone order, dated 04/21/11, documented, "...(wound clinic name withheld) to eval and tx..." A nurse's note, dated 04/21/11 on the 6 - 2 shift, documented, "...Resident continues ATB therapy...N/O from (Physician name withheld). Ordered from...this am. Will start in afternoon. Resident denies any pain or discomfort, does have c/o great toe not much pain but it is noticeable..." A nurse's note, dated 04/21/11 and untimed, documented, "...N/O received (sic) for debridement of diabetic ulcer on 4/20/2011. N/O received (sic) for eval/tx at wd clinic. Awaiting return call for appointment..." A review of the clinical record revealed no documentation to show the wound clinic made a return call or that facility staff attempted to contact the wound clinic again. A nurse's note, dated 04/21/11 on the 2 - 10 shift, documented, "...Started on ATB for wound of big toe (and) dx of [MEDICAL CONDITION]" A MAR, dated 04/21/11, documented, "[MEDICATION NAME]'d..." The MAR indicated [REDACTED]. A review of the clinical record revealed no physician order to discontinue the [MEDICATION NAME]. A review of the MARS, dated 04/21/11, revealed no documentation to show the [MEDICATION NAME], vitamin C, zinc, or multivitamin were given. A review of the treatment sheet, dated 04/21/11, revealed no documentation to show the resident's left great toe treatment was completed. A nurse's note, dated 04/22/11 on the 6 - 2 shift, documented, "...Resident cont ATB therapy for wound on (left) great toe..." A nurse's note, dated 04/22/11 on the 2 - 10 shift, documented, "...Resi fell in the shower rm tonight about 445 pm while he took a shower c the CNA's assist. He was in the shower chair when he got up (and) got his walker, he slipped in water (and) CNA saw him fall to the floor where he bent his (left) knee when he fell (and) c/o left knee pain. Now, no noted swelling @ this time, resident did c/o pain later. Son call (and) Dr called for report of fall (and) pain. No new orders @ this time, will cont to monitor..." A review of the MARS, dated 04/22/11, revealed no documentation to show the [MEDICATION NAME], vitamin C, zinc, or multivitamin were given. A review of the treatment sheet, dated 04/22/11, revealed no documentation to show the resident's left great toe treatment was completed. A nurse's note, dated 04/23/11 on the 10 - 6 shift, documented, "...Pt stated my lt knee isn't hurting. Gait steady. Cont on ATB for wound on Lt great toe..." A weekly head to toe skin review, dated 04/23/11 at 9:00 a.m., documented, "...area to (left) great toe. (no) other areas noted. [MEDICAL CONDITION] to LLE. Tx's in place..." There was no documentation regarding the wound to the resident's right great toe. A nurse's note, dated 04/23/11 at 9:10 a.m., documented, "...c/o (left) leg/foot pain. N/O x-ray (left) knee (and (left) ankle..." A review of the MARS, dated 04/23/11, revealed no documentation to show the [MEDICATION NAME], vitamin C, or zinc, were given. A nurse's note, dated 04/23/11 at 12:55 p.m., documented, "...x-ray results...(left) ankle acute nondisplaced fx - distal metaphysis of fibula. (Physician name withheld) notified. N/O send to ER..." A nurse's note, dated 04/26/11 at 2:30 p.m., documented, "...(Family member) called back (and) said this resident had a new cast put on last night..." admission orders [REDACTED]. An admission assessment, dated 04/28/11, documented the resident had an area to his left great toe. It was documented, "...(left) great..." There was no further description of the area. There was no documentation to show a wound had been identified on the resident's right great toe. A nurse's note, dated 04/28/11 at 12:02 p.m., documented, "...Resident returned to facility...(left) leg cast, (left) great toe exposed...Resident needs help with bathroom x 2. He thinks he can stand on own but most of his weight should be on (right) leg. Need to remind him constantly..." A nurse's note, dated 04/29/11 on the 10 - 6 shift, documented, "...(Left) leg cast remain intact w left great toes exposed..." It was documented the resident's skin was within normal limits. A review of the treatment sheets, dated 04/28/11 and 04/29/11, revealed no documentation to show any type of treatment was completed for the resident's right or left great toe wounds. A nurse's note, dated 04/30/11 on the 10 - 6 shift, documented, "...(left) leg cast remain intact with left great toes exposed..." A nurse's note, dated 04/30/11 on the 6 - 2 shift, documented, "...Lt great toe black eschar noted. Dry and hart to touch - just under toe nail tip of toe..." It was documented the resident's skin was within normal limits. Treatment sheets, dated 04/30/11, documented, "...cleanse (left) great toe pat dry swab c [MEDICATION NAME] wrap c gauze and tape..." It was documented this treatment was completed on 04/30/11. A review of the clinical record revealed no physician's order for this treatment or treatment orders for the right great toe wound. A nurse's note, dated 05/01/11 on the 2 - 10 shift, documented, "...Toes warm to touch. Color WNL..." It was documented the resident's skin was within normal limits. A weekly head to toe skin review, dated 05/01/11, documented, "...eschar (left) great toe. Cast to LLE for ankle..." There was no documentation to show the resident had a wound on his right great toe. A nurse's note, dated 05/02/11 on the 10 - 6 shift, documented, "...No discoloration noted on left foot..." A nurse's note, dated 05/02/11 on the 2 - 10 shift, documented, "...Toes warm to touch..." A nurse's note, dated 05/03/11 on the 10 - 6 shift, documented, "...Toes warm to touch..." It was documented the resident's skin was within normal limits. A skin/wound QI log, dated 05/03/11, documented, "...10. Diabetic Neuropathic...Skin/wound type...#10...(R) great toe 0.5 x 1 x UTD..." There was no description of the wound on the resident's left great toe. A nurse's note, dated 05/04/11 on the 6 - 2 shift, documented, "...wound to (left) great toe now open c yellow skin surrounding wound. Blue skin on lateral side of great toe. Mod amnt of yellow bloody drainage on old bandage. Cap refill approx 3 sec in toes..." It was documented the resident's skin was within normal limits. A review of the clinical record revealed no documentation to show the facility notified the physician of the change in the resident's left great toe wound. A nurse's note, dated 05/04/11 on the 2 - 10 shift, documented, "...Call to (wound clinic name withheld) (and) set up appt for May 11..." The physician's order for the resident to be evaluated and treated at the wound care clinic was written on 04/19/11. A nurse's note, dated 05/05/11 on the 10 - 6 shift, documented, "...lt foot toes warm/dry..." A monthly nursing summary, dated 05/05/11, documented, "...skin conditions...none..." A nurse's note, dated 05/06/11 on the 10 - 6 shift, documented, "...No discoloration or [MEDICAL CONDITION] noted..." A nurse's note, dated 05/06/11 on the 6 - 2 shift, documented, "...(Left) great toe wound black open c purple area around toe..." A review of the clinical record revealed no documentation to show the physician was notified of the change in the resident's left great toe wound. A nurse's note, dated 05/06/11 on the 2 - 10 shift, documented, "...has become confuse (and) slightly forgetful lately..." A nurse's note, dated 05/07/11 on the 2 - 10 shift, documented, "...Toes warm, color to toes WNL, except for area where wound is on (left) great toe..." A nurse's note, dated 05/08/11 on the 6 - 2 shift, documented, "...toes warm to touch..." A weekly head to toe skin review, dated 05/08/11, documented, "...bruising to (left) great toe (and) wound to (left) gr toe tx in place..." There was no documentation regarding the right great toe wound. A nurse's note, dated 05/09/11 on the 10 - 6 shift, documented, "...dressing to great left toes changed @ (9:00 p.m.)...No bleeding nor drainage noted..." An entry in the DON's wound notebook, dated 05/09/11, documented, "...(Resident #20) (wound clinic name withheld) 5/11/11, (right) great toe 0.5 x 0.6 x 0.1 - wd bed brown eschar...(left) great 2.5 x 3 x UTD - tip necrotic dry/ (no) drainage - toe reddened c blue/black discoloration - poor circulation cold touch cap refill > 3 sec turgor [MEDICAL CONDITION] tx [MEDICATION NAME]" There was no documentation to show the physician was notified of the change to the resident's left great toe wound or of the resident's right great toe wound. A nurse's note, dated 05/10/11 on the 10 - 6 shift, documented, "...toes on lt foot w/d..." A nurse's note, dated 05/10/11 on the 6 -2 shift, documented, "...tx to toe complete...cap refill < 3 sec to (left) toes..." A nurse's note, dated 05/10/11 on the 2 - 10 shift, documented, "...out to (wound clinic name withheld) tomorrow..." A nurse's note, dated 05/11/11 on the 10 - 6 shift, documented, "...toes warm to touch.. Good capillary refill of lt toes..." A nurse's note, dated 05/11/11 on the 6 - 2 shift, documented, "...Noted bilat peripheral extremities cool...dressing to (left) great toe in place..." A nurse's note, dated 05/11/11 on the 2 - 10 shift, documented, "...out to (wound clinic name withheld) early pm (and) back after 5 p.m. New orders to be clarified tomorrow..." A wound clinic history and physical, dated 05/11/11, documented, "...Wagner grade III (deep ulcer with [MEDICAL CONDITION] or abscess formation, often with osteo[DIAGNOSES REDACTED]) [MEDICAL CONDITION] with dry gangrene noted on the left great toe approximately to the mid joint...Diagnostic recommendations: 1. TCOM (transcutaneous oxygen monitoring), which initially shows less than 10 (values of 40 are a beginning point for predicting wound failure) on the left, but full report is pending...Arterial ultrasound...Repeat TCOM in 1 week...Therapeutic recommendations: [MEDICATION NAME] paint to toes, keep toes clean and dry...He has had a history of [REDACTED]. Before the cast was put on, the son reported that his toe was starting to turn black. We took a look carefully at the cast. He did have some swelling located with the cast, but overall I did not see any pinch points on his cast. The patient stated the great toe has become worse and now he has lost feeling in his great toe...The left leg appears to be swollen, however, I can insert a finger in between the cast on the dorsal aspect and the plantar aspect and I had good capillary refill across all the other toes and surrounding the toes. The toes do not feel warm. The third toe looks gassy. The great toe appears to be black approximately half at its length. There is no pus draining from the wound...Overall, I doubt that the cast is causing the problem at this point...We have talked with the family for a great length of time on the options including [MEDICAL CONDITION] waiting and revascularization procedures, however, we will share more information with the patient and the family once we have the evaluations completed..." A physician's progress note, dated 05/11/11, documented, "...c/o redness (and) (erythemia) of (left) great toe...has been seeing pod...ulcer (left) toe [MEDICAL CONDITION](positive) ulcer (left) great toe - good cap refill...referral to (unknown) (recheck) in am if worse will send to hosp..." A physician's telephone order, dated 05/12/11, documented, "...Order clarification. Apply [MEDICATION NAME] BID to (left) great toe and then apply a dry dressing..." A nurse's note, dated 05/12/11 on the 2 - 10 shift, documented, "...when resident got up out of bed, very confused @ first of shift. Down for therapy (and) (decreased) confusion note. (Nurse practitioner) called about low B/P (and) confusion..." A nurse's note, dated 05/12/11 on the 2 - 10 shift and documented as continued from previous note, documented, "...(Physician #2) did a visit today about 5:30 pm (and) saw the (left) great toe of this resident. Resi had a wound appt @ (wound clinic name withheld) on 05/11/11...I called the POA (and) spoke c (family member) again about (physician name withheld)'s visit, the order to send to (hospital name withheld) for IV-ATB tonight DX of gangrene in (left) great toe (and) removal of toe..." A physician's telephone order, dated 05/12/11 and written by physician #2, documented, "...Transfer to (hospital name withheld) - direct admit (5:30 p.m.)..." An orthopedic consult, dated 05/12/11, documented, "...The right lower extremity is grossly normal with a couple of small abrasions on the great toe. The pulses are faint on the right. On the left, there is [MEDICAL CONDITION] and redness from about the ankle distally and there are no palpable pulses. The great toe is black. The skin is cool over the dorsum of the foot on the left...I have advised the patient and his (family member) of the findings. They are in agreement with proceeding with left below-the-knee amputation..." A hospital history and physical, dated 05/13/11 and dictated by physician #2, documented, "...patient...was treated here recently for a fracture of his left ankle after he slipped and fell in the shower...At that time, he was noted to have a dry eschar at the tip of his left great toe. I was notified by the nursing home yesterday that he was having increasing gangrene and was going to be transferred to another hospital for further evaluation next week. I visited his nursing home and found him to have gangrene with impending limb loss of the left foot, so I made arrangements for him to have a direct admission to (hospital name withheld)...Left foot has ischemic gangrenous left great toe beyond the IP joint. The left great toe has some ischemia of the distal portion as well. The left foot is cool and dusky. There is no obvious deformity of the ankle. Right foot is [MEDICAL CONDITION]. I cannot feel a pulse in the right foot...Impression...Impending limb loss left foot secondary to [MEDICAL CONDITION] will evaluate him with tissue studies and with arterial Doppler study to see if there is any possibility of limb salvage..." The resident returned to the facility on [DATE] following a left [MEDICAL CONDITION]. A nurse's note, dated 05/25/11, documented, "...(right) great toe has open unstageable sore approx penny size...(left) BKA wrapped c pressure dressing..." A physician's telephone order, dated 05/25/11, documented, "...Wound care to (left) BKA, clean c N/C (sic), cover c 4x4 wrap c [MEDICATION NAME] wrap c Ace bandage...Wound care apply Betadyne (sic) to (right) great toe wound leave open to air..." A review of the treatment sheets, dated 05/25/11, revealed no documentation to show the treatment to the resident's right great toe was completed. On 05/26/11 at 9:50 a.m., LPN #5 was observed completing wound care to the resident's left BKA stump and right foot wounds. Before beginning the wound care, LPN #5 stated the resident had been pre-medicated with Tylenol as all other pain medications had been discontinued "to see if they were causing confusion." LPN #5 removed the soiled dressing from the stump. Dried blood and two areas of bright red blood were observed on the dressing. The stump was observed to be dark red for approximately two inches on each side of the incision line. This circled the entire incision area. LPN #5 held gauze pads under the stump with his right hand and poured normal saline over the wound with his left hand. LPN #5 then wiped the incision line with the contaminated gauze pads. The resident grunted, and LPN #5 asked if he was hurting. The resident stated, "Yes." LPN #5 dressed the stump, washed his hands, and began the wound care to the resident's right foot. LPN #5 removed the resident's sock. A 3 x 3 cm black area was noted on the resident's right bunion area, and a 1 x 1 cm black area was noted on the medial side of the great toe, on the left side of the toe nail base. Each area was swabbed with a [MEDICATION NAME] swab. A nurse's note, dated 05/26/11 on the 6 - 2 shift, documented, "...C/o pain when pressure applied to stump on (left) BKA. Bandage changed to stump. Red orange in old dressing mod amount. Wound edges approximated...(no) s/s of infection...Wound care to (right) toe. [MEDICATION NAME] to wound per orders. A review of the treatment sheets, dated 05/26/11, revealed the dressing change was completed to the resident's right great toe. The sheet documented the treatment was discontinued after 05/26/11, but no date was identified. Review of the clinical record revealed no physician's order to discontinue the treatment. There was no documentation to show the treatment change was completed after 05/26/11. A review of the clinical record revealed no documentation to show the physician was notified of the resident's pain during the treatment and dressing change. A nurse's note, dated 05/27/11 on the 6 - 2 shift, documented the resident's stump had abnormal turgor, abnormal skin color, and unusual temperature. It was documented the resident had a [MEDICAL CONDITION] to the right great toe and other open [MEDICAL CONDITION] on the right foot. The note was signed by the DON. The note documented, "...Wound care provided per order. (Right) great toe tx c [MEDICATION NAME] and left open to air. (Left) stump incision has sanquinous (sic) drainage c irregular incision line. [MEDICAL CONDITION] 2+ noted to stump c (increased) [MEDICAL CONDITION] to medial edge approximately 3+. Skin feels boggy c slight discoloration noted to medial edge. Bluish purple, cool to touch. On call dr for (surgeon's name withheld) paged to notify of (change) of condition. Awaiting return call. Res medicated for pain prior to drsg (change)...Will schedule f/u c surgeon Tuesday when office reopens p holiday..." It was documented the resident verbalized a moderate pain level with his pain being at a 6 on a scale of 1 to 10. A review of the MAR, dated 05/27/11, revealed no documentation to show the resident was medicated for pain prior to the treatment. A review of the clinical record revealed no documentation to show the physician was notified of the change in the resident's left BKA stump or the wounds on the resident's right foot. There was no documentation to show the DON had made the charge nurse on the 2 - 10 shift for 05/27/11 aware of the changes in the resident's condition. There was no documentation of a return phone call from the surgeon. On 05/27/11 at 3:32 p.m., the resident's right foot was observed. A black area, approximately 1.2 x 1.3 cm, was noted on the medial side of the great toe, on the left side of the toe nail base. A black area, approximately 3 x 3 cm, was noted on the right bunion area. A nurse's note, dated 05/27/11 on the 2 - 10 shift, documented, "...Resident c/o discomfort to buttocks, noted redness...PCP notified. Spoke c nurse practitioner. Received N.O. [MEDICATION NAME] to buttocks/peri area q shift..." There was no documentation to show the nurse practitioner was notified of the changes in the resident's left BKA stump. A nurse's note, dated 05/28/11 on the 6 - 2 shift, documented, "...Drsg intact lt stump area...clean (and) dry c no drainage noted..." A nurse's note, dated 05/28/11 on the 2 - 10 shift, documented, "...changed dressing to (left) BKA stump...Stump site has sanquinous (sic) drainage, slight redness et [MEDICAL CONDITION].Surgeon to be f/u c on Tuesday per D.O.N..." It was documented on all shifts for 05/28/11 the resident had abnormal skin turgor and a [MEDICAL CONDITION]. There was no documentation to show where the abnormal turgor was. A physician's telephone order, dated 05/28/11, documented, "...Clarification order: [MEDICATION NAME] 5/325 mg (one) po q 4 (hours) PRN pain..." A nurse's note, dated 05/29/11 on the 2 - 10 shift, documented, "...dressing changed to (left) stump...drainage continues..." It was documented on all shifts for 05/29/11 the resident had abnormal skin turgor and a [MEDICAL CONDITION]. There was no documentation to show where the abnormal turgor was. A nurse's note, dated 05/30/11 on the 6 - 2 shift, documented, "...(changed) (unknown) to stump of left (lower) ext. Wound closed c scant < 10 cc red drainage from one suture right of front medial side of wound...(No) s/s of infection..." It was documented on the evening and night shifts for 05/30/11 the resident had abnormal skin turgor and 2+ [MEDICAL CONDITION] to the stump. An entry in the DON's wound notebook, dated 05/31/11, documented, "...18 cm incision line c sanquinous (sic) drainage [MEDICAL CONDITION] 1+, surrounding skin pink (no) discoloration, temp warm, stump protector shrinking as expected, min drainage, (no) odor..." A physician's progress note, dated 05/31/11, documented, "...S/P (left) BKA (secondary) to infection (left) foot...Note: nursing reports (left) stump base healing (unknown) (no) drainage..." On 06/01/11 at 9:42 a.m., the DON was asked when the wound to the resident's left foot was first identified. She stated, "I believe it was 4/19." The DON was shown the weekly skin assessment dated [DATE] and was asked what wound the document referred to. She stated, "I would only be able to assume it was the original wound." The DON was asked if the physician had been notified of the wound on 04/12/11. She stated, "Yes, I believe on that day (physician name withheld) looked at it. He though it was [MEDICAL CONDITION]." When asked if there was documentation the physician had been notified, the DON stated, "No there is not." The DON was asked if there was documentation regarding the wound when it was first identified. She stated, "There should be an assessment. We have a physician's order for wound treatments. I believe it's 4/20." The DON was shown the physician orders for [MEDICATION NAME], vitamin C, zinc, and a multivitamin, dated 04/19/11. She was asked when the medications were started. She stated, "On the 29th". When asked why the medications were not started when ordered, the DON stated, "I cannot answer that." The DON was asked why the [MEDICATION NAME] was not started until the evening of 04/20/11. She stated, "It should have been initial dosed the next day. Our policy is to initial dose within 8 hours for antibiotics." The DON was asked if the resident received the initial dose of antibiotics within 8 hours. She stated, "No." The DON was asked why the [MEDICATION NAME] was discontinued. She stated, "Because of an allergy." When asked where the documentation was that showed the resident was allergic to [MEDICATION NAME], the DON reviewed the chart and stated, "There are no drug allergies [REDACTED]. She stated, "There is no order to dc the [MEDICATION NAME]." The DON was asked why a clarification order was written on 04/21/11 for the multivitamin, vitamin C, and zinc. She stated, "They didn't write for milligram doses on the original." The DON was asked if the medications were started after receiving the clarification order. She stated, "No." The DON was asked why it took 2 days to get a clarification order. She stated, "I cannot answer that question. It wasn't reported to me the meds didn't arrive." The DON was asked when the physician's order was received for the wound care treatments to the left great toe. She stated, "4/19." When asked when the wound care started, the DON stated, "I don't believe the Santyl was started. It looks like it (wound care) was given once on 4/23." The DON was asked why the wound care was not started as ordered. She stated, "I cannot answer that question." The DON was shown documentation the resident saw the podiatrist on 04/20/11. She was asked if the resident received new treatment orders for the left great toe at that time. The DON stated, "I do not see any orders to change the treatment." The DON was shown the physician's order for [MEDICATION NAME], dated 04/20/11, and informed the nursing notes stated the [MEDICATION NAME] was started on 04/21/11. The DON was asked why the MAR indicated [REDACTED]. She stated, "I don't know. The CMAs are good at reporting meds not here." The DON was asked why the charge nurse was unaware the medications were not started. She stated, "She should have known." The DON was asked if the resident received a treatment to the left great toe on 04/28/11 or 04/29/11. She stated, "No." The DON was asked who made the appointment for the resident to go to the wound clinic as ordered by the physician on 04/19/11. She stated, "I believe (LPN #6), the charge nurse." The DON was shown the nurse's note, dated 04/22/11, that documented she called the wound clinic and faxed the resident's information. The DON stated, "I helped her." The DON was asked why it took from 04/19/11 until 05/11/11 for the resident to get into the wound clinic. She stated, "Appointments are pretty backed up. I tried to remind them." The DON was asked why the nursing note, dated 05/04/11, documented the appointment was made then. She stated, "I cannot answer that. Unless they didn't call back that day." When asked who would have followed up to ensure the appointment was made, the DON stated, "The cha

Based on observation, interview, and record review, it was determined the facility failed to provide pain medication prior to a wound treatment for 1 (#38) of 2 sampled residents with wounds. This resulted in actual harm for resident #38, who experienced pain during wound care. The resident was not assessed for pain prior to the treatment. The facility identified 5 residents with wounds. The facility identified only 2 of 5 residents with wounds were to receive pain medication. Findings: Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." A physician's orders [REDACTED]. [MEDICATION NAME]/acetamin 5mg/325mg tab - [MEDICATION NAME] 1 tab by mouth every 4 hrs. as needed for pain." An annual assessment, dated 07/15/11, documented the resident had a BIMS score of 10, did not have any behaviors, was at risk for pressure ulcers, and did not have any skin conditions. The care plan, dated 07/25/11, documented a problem, "I am at risk of developing pressure ulcers and stasis ulcers, I have had stasis ulcers in the past that have resolved...Approaches:...Monitor my legs daily, reporting abnormal findings to my physician..." The care plan did not address pain. The plan of correction, dated 07/20/11, with a completion date of 08/18/11, for the facility's recertification survey conducted from 05/23/11 through 06/03/11, documented, "...All residents with wounds will be pre-medicated before dressing change. Pain will be evaluated before beginning treatment. Physician will be notified for different pain medication before beginning...All residents will be evaluated for pain before treatment and medicated accordingly; they will be re-evaluated for effectiveness before beginning treatments. To be documented in chart and on MAR's..." A MAR, dated August 2011, documented, "08/29/[MEDICATION NAME] 5/325mg 1/1 po bid, given at 8:00 a.m..." The prn pain medication was not documented as given to the resident on 08/29/11 prior to the wound treatment. On 08/29/11 at 10:00 a.m., RN #1 and LPN #1 were observed as they did a dressing change for resident #38. LPN #1 removed the ace bandage on the resident's left leg. The LPN sprayed [MEDICATION NAME] on the bandages stuck on the resident's left leg and pulled them off. The resident reached down with her hands and attempted to stop her from cleaning the wound. LPN #1 asked the resident if it hurt. The resident yelled out, "Yes." The wound was observed as a stage II stasis ulcer approximately 5 cm. in length. The LPN asked the resident how she was feeling. The resident shouted, "Terrible." At 10:13 a.m., the LPN put santyl on the wound and placed a 3X3 gauze pad on the ulcer and wrapped the leg with gauze. The resident yelled out, "Ouch that hurts." The LPN replied to the resident, "Sorry, I didn't want to hurt you." The resident yelled, "Don't do that, you are hurting me." The resident was grimacing and touching her forehead in pain. The LPN asked the resident if she was hurting. The resident yelled, "Yes." RN #1 stated, "We are doing this to help you, it is for your own good." The LPN and RN were asked if the resident had pain medication before the treatment. The LPN stated, "Yes, at 8:00 a.m." The LPN was asked if she had asked the CMA to give the resident a pain medication before the procedure. She stated, "No." The resident was observed shaking her head up and down and grimacing in pain. The LPN wrapped the resident's left and right legs with ace bandages. The RN asked the resident if she felt any better. The resident did not answer. On 08/30/11 at 2:35 p.m., RN #1 was asked if she had assessed the resident for pain before the dressing change. The RN stated, "No, I guess because I was helping and the LPN was doing the procedure. That was her resident and I was coming in to help her." LPN #1 and RN #1 were asked if the resident was in pain during the procedure. The RN stated, "Well, yes. When the LPN took off the adhesives that were directly on the skin." The LPN was asked if she thought the resident was in pain during the procedure. She stated, "When I was putting the wrap on and she hollered it was because it wasn't put on right." The LPN was asked if the resident had showed signs of being in pain. She stated, "Not for her." The LPN and RN were asked if they had given the resident anything for pain after the procedure. The LPN stated, "No, I knew she had the pain pill at 8:00 a.m." The DON was asked what the facility's Plan of Correction, dated 08/18/11, documented the nurses were to do before a resident treatment. She stated, "They will assess for pain and if the resident was having pain, they are to call the physician for an order for [REDACTED]. The LPN stated, "I can't judge her pain." The RN stated, "I should have assessed her pain and called her physician for a one time order for pain." The RN and LPN were asked if they should have stopped the procedure when the resident expressed she was in pain. The RN stated, "Yes, I did think that and I probably should have." The RN was asked if she notified the physician of the resident's pain during the procedure as the Plan Of Correction, dated 08/18/11, documented. The RN stated, "No."

Based on observation, interview, and record review, it was determined the facility failed to: A. Ensure interventions were put in place after a hot coffee burn had occurred, to prevent hot coffee burns from occurring in the future. This resulted in an immediate jeopardy situation for 1 (#16) of 1 sampled residents who had experienced a second degree burn that resulted in actual harm. This had the potential to affect 53 residents who the facility assessed and identified as needing supervision while drinking hot beverages; B. Provide supervision to prevent accidents while bathing for 1 (#20) of 19 sampled residents who required assistance while bathing. The facility's Census and Conditions report identified 62 residents as needing the assistance of at least one staff member while bathing; The facility's failure to provide supervision while bathing resulted in actual harm for resident #20 when he fell while alone in the shower and suffered a fractured left fibula; C. Provide supervision and identify and implement interventions to aid in the prevention of falls for 2 (#2 and #4) of 5 sampled residents who required assistance with transfers and ambulation. The facility's Census and Conditions report identified 23 residents as requiring assistance with ambulation; D. Post no smoking signs on the doors of 8 (Rooms 107, 108, 111, 205, 210, 302, 403, and 414) of 11 resident rooms where oxygen concentrators were located. The facility identified 10 residents who used oxygen via oxygen concentrators; E. Ensure the air vent cover for 1 resident room (#108) of 14 resident rooms on Hall 100 did not have a hole large enough to be an accident hazard; and F. Ensure chemicals were stored in locked cabinets in one (Spa Room on Hall 300) of two Spa rooms. The storage cabinet contained germicidal cleaner for sanitizing the whirlpool. Findings: The facility's policy and procedure titled Safety and Supervision of Residents, dated December 2007, documented "...Facility-Oriented Approach to Safety...2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA&A reviews of safety and incident/accident reports... Resident-Oriented Approach to Safety...2. Staff shall use various sources to identify risk factors for residents, including...observation of the resident...3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to include the potential for accidcents... Systems Approach to Safety...2. Resident supervision is a core component of the stystems approach to safety..." The facility's falling star program, dated January 2009, documented, "...The Falling Star Program is designed to aid our residents who have fallen or have been identified as risk and high risk for falls (any resident scoring a 10 or greater on the fall risk assessment). These residents have been identified and a 'STAR' has been placed by their name plate...also placed at the head of the residents bed...The star outside the resident's door is an easily seen reminder that a resident is at risk for falls...Documentation of 'Falling Star Program' will be addressed in individual resident care plans..." 1. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A reentry assessment, dated 02/28/11, documented the resident had a BIMS score of 15 and her vision was highly impaired. A nurse's note, dated 05/18/11 at 12:40 p.m., documented "CNA came to me stating this resident stated she hit coffee cup c elbow coffee was hot and splashed on L arm. Upon seeing this it was bright pink just above L elbow aprox. 3 inch square. Resident stated she was fine and wanted a cold rag. This nurse got cold wash cloth for arm. Resident stated felt better and was fine. Will monitor." A nurse's note dated, 05/18/11 at 3:15 p.m., documented "Resident daughter here we look at arm she was going to get bandaids for minor burns that are cooling for her mother will cont to monitor." A weekly head to toe skin review had no documentation for 05/18/11. A care plan, dated 05/18/11, documented, "...Problem...I require supervision for safety for showering...Resident bumped cup of coffee c (L) elbow splashing coffee on arm...Approaches...apply Silvadene cream to area Keflex 250 tid." The care plan did not include interventions to prevent the resident from getting another burn. There was no documentation to show the resident had been assessed for safety regarding hot beverages. A nurse's note, dated 05/19/11 at 5:00 p.m., documented, "N.O. cleanse L elbow area c N.S. pat dry, apply Silvadene cream, cover c 4X4, wrap with Kerlix, secure c tape q day until healed per Dr. (name withheld)...." The incident report, dated 05/18/11, documented "...On 05/19/11 it was reported to ADON that resident was burned with hot coffee through her coat in the dining room at approximately 1240 on on 5/18/11. After this was reported to ADON the charge nurse was instructed to notify the Dr, family, and obtain orders for burn to the arm, and complete an incident report, which is not supported by the charge nurse's documentation. The family member of resident reported to DON on 05/24/11 that the nurses had applied mustard to the burn. Upon review of the chart nurses in question, made no notations that mustard was applied and there were no notations that the Dr was notified until the following day on 05/19/11. At that time they obtained orders for Silvadene cream to arm....Daughter of resident complained that there was no action taken by the charge nurses until 24H after the incident occurred. The daughter went on to state her concerns that she was notified on Sunday (05/22/11) by charge nurse (name withheld) that the burn appeared to be infected and an antibiotic was then ordered for resident... ...After investigation the facility determined that charge nurses failed to do what reasonably prudent nurses would do, and put resident at risk for further infection/injury related to delay of action..." A physician's orders [REDACTED].S., pat dry, apply Silvadene cream, cover c 4X4, wrap c Kerlix, secure c tape q day until healed...Diagnosis: [REDACTED]. A weekly head to toe skin review had no documentation for 05/19/11. A nurse's note, dated 05/20/11 at 11:00 a.m., documented "Silvadene ordered..." A weekly head to toe skin review, dated 05/20/11, documented, "...Skin intact c coffee burn L above elbow." The nurse signature line was blank. A physician's orders [REDACTED]. A letter dated 05/24/11, from the resident's daughter, documented "...On May 18, I came to visit my mother...When I went to hug her she stopped me, telling me that she had burned her elbow at about 1 pm. Upon questioning she explained that she had taken her cofffee off of her lunch tray and put it on the table beside her chair. She then bumped it with her elbow and the coffee spilled onto her elbow. She had a jacket on which caused her very hot coffee to stay against her elbow and caused a significant burn. When I looked at it I was shocked when she told me that the yellow 'stuff' on the burn was table mustard. I went and got the nurse who responded as if mustard was a reasonable treatment for [REDACTED]. The first layer of skin was beginning to peel. I questioned the nurse as to what was going to be done. She told me that it would be dressed with antibiotic ointment and a bandage before she went to bed. Mother came to my home on Thursday morning. When I asked her how the burn was treated at bedtime she told me that they had put more mustard on it..." On 05/25/11 at 10:05 a.m., resident #16's left arm was observed. A 3"x2" second degree burn was observed to be dark pink in color and seeping clear fluid. Two lines within the burn approximately 1" and 1/2" were a deeper burn and seeping bright red blood. At 12:55 p.m., the resident was observed with a cup of coffee, covered with plastic wrap, in her room. The temperature of the coffee was 146 degrees F. A Time and Temperature Relationship to Serious Burns table in the Interpretive Guidelines documented the time required for a 3rd degree burn to occur with a 140 degree temperature is 5 seconds and 2 seconds for 148 degrees. (Moritz, A.R., Henriques F.C. Jr. (1947). Studies of Thermal Injury: II. The Relative Importance of Time and Surface Temperatures in the Causation of Cutaneous Burns. Am J Pathology, 23, 695-720.) On 05/26/11 at 4:35 p.m., the resident was asked how her arm had been burned. She stated, "I had a coffee mug with no lid and it was on the table by my recliner. Normally, I put my coffee there after I am seated in the recliner. I did not see it and when I turned to sit down, my elbow hit the cup and it went onto my elbow. I had a jacket on and the hot coffee went onto the jacket and on my arm. I yelled really loud because it really hurt bad." She was asked if she ever eats in the dining room. She said, "No, I always eat in my room." Immediate Jeopardy Identified On 05/26/11 an Immediate Jeopardy (IJ) situation was determined to exist in regard to the facility's failure to ensure accident hazards were identified and interventions were instituted to prevent further accidents after resident #16 received 2nd degree burns to her arm after spilling coffee. At 5:35 p.m., OSDH was notified and verified the existence of the IJ. At 5:45 p.m., the administrator and the DON were informed of the IJ situation and the failure to provide interventions to prevent accidents related to resident #16 and the burn she received. There was no plan or interventions implemented to prevent residents from being burned by hot coffee. They were informed this IJ placed the facility in an extended survey. The administrator and DON were asked if the resident had a vision problem. The administrator stated, "She can see peripherally." Plan of Removal for Immediate Jeopardy On 05/26/11 at 8:10 p.m., the facility submitted an acceptable plan of removal, which documented: "No coffee will be served between 6:30 PM on Thursday, May 26 and 7:00 AM on Friday, May 27, 2011. All residents will be assessed to determine if they can drink coffee safely. Coffee drinking assessment will be implemented immediately for all current residents, and with change of condition, and upon admission/re-admission and assessments will be completed by 6:45 am 5/27/2011. Assessments will be completed by DON, ADON, MDS coordinator, SDC and Social Services Director. All coffee will be served at not more than 120 degrees F. No staff will be able to work floor until in-serviced on coffee protocol, which is: hot beverages will be poured by RNA/charge nurse, hot beverages will be served at 120 degrees and will be checked by dietary prior to sending hot beverages to nursing personnel. Assigned staff will ensure that residents who require the special mugs have them prior to having hot beverages, and assist with pouring the beverages. In-services will begin 5/27/11 at 8 pm for day shift and completed for 6-2 shift no later than 0645am. the remaining employees will be in-serviced Friday 5/28/2011 by 3pm for all staff. Restorative aides, or charge nurse if RNA is available, will be assigned to pour and monitor coffee for residents who are not safe to drink hot beverages by ensuring that residents have spill-proof mug and access to hot beverages will be limited to assigned staff that assist with hot beverages. Hot beverages will be put on separate cart to ensure hot beverages will be monitored closely. Dietary will take temperature prior to sending hot coffee to nursing personnel. Ammended Plan of Removal On 05/27/11 at 1:25 p.m. an ammended plan of removal and an addendum to coffee/hot beverage assessment was received from the administrator. The ammended plan of removal documented: "No coffee will be served between 6:30 PM on Thursday, May 26 and 7:00 AM on Friday, May 27,2011. All residents will be assessed to determine if they can drink coffee safely. Coffee drinking assessment will be implemented immediately for all current residents, and with change of condition, and upon admission/re-admission and assessments will be completed by 6:45 am 5/27/2011. Assessments will be completed by DON, ADON, MDS coordinator, SDC and Social Services Director. Coffee will continue to be prepared by dietary staff at the regular temperature. No staff will be able to work floor until in-serviced on coffee protocol, which is: hot beverages will be poured by RNA/charge nurse, hot beverages will be served at 120 degrees and will be checked by dietary prior to sending hot beverages to nursing personnel. Assigned staff will ensure that residents who require the special mugs have them prior to having hot beverages, and assist with pouring the beverages. In-services will begin 5/27/11 at 8 pm for day shift and completed for 6-2 shift no later than 0645am. The remaining employees will be in-serviced Friday 5/28/2011 by 3pm for all staff. Restorative aides, or charge nurse if RNA is available, will be assigned to pour and monitor coffee for residents who are not safe to drink hot beverages by ensuring that residents have spill-proof mug and access to hot beverages will be limited to assigned staff that assist with hot beverages. Hot beverages will be put on separate cart to ensure hot beverages will be monitored closely. Dietary will take temperature prior to sending hot coffee to nursing personnel." The addendum to coffee/hot beverage assessment, documented: "Any resident who was assessed to need a cup with a lid will be able to use a regular coffee mug only when being suspervised by staff or responisble adult. If they are unsupervised, they will require a mug with a lid." Immediacy Removed The IJ was removed on 05/27/11 at 3:00 p.m., when the last employee inservice was completed and all residents were assessed for hot beverage supervision. The deficiency remained at an isolated level of actual harm. Staff were interviewed on 05/27/11, in regard to their knowledge of the inservice and to ensure their knowledge of residents who were needing supervision with hot beverages. 2. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 03/04/11, documented the resident required supervision with transfers and bathing and was not steady with moving, walking, transfers, and turning around but was able to stabilize self. The care plan, dated 03/05/11, documented a problem, "...I am weak and need some assistance with my ADLS..." The goal was, "...I will have assistance from staff completing my ADLS..." Approaches included, "...Assist me with bathing 3 x week..." Another problem was, "...I use a walker when I am ambulating. I am unsteady at times. I am at risk for falls..." The goal was, "...I will not have any falls with injury thru NRD..." Approaches included, "...Make sure I use my walker at all times when ambulating...Keep my call light in reach in my room. Make sure my room is clean and free of clutter q day..." A fall risk assessment, dated 03/05/11, documented the resident scored a 10. The form documented, "...A resident who scores a 10 or higher is at risk..." A nurse's note, dated 04/22/11 on the 2 - 10 shift, documented, "...Resi fell in the shower rm tonight about 445 pm while he took a shower c the CNA's assist. He was in the shower chair when he got up (and) got his walker, he slipped in water (and) CNA saw him fall to the floor where he bent his (left) knee when he fell (and) c/o left knee pain. Now, no noted swelling @ this time, resident did c/o pain later. Son call (and) Dr called for report of fall (and) pain. No new orders @ this time, will cont to monitor..." This note was signed by RN #1. An incident report, dated 04/22/11, documented, "...Incident: Resi was done c shower (and) CNA went to get him cloths (sic). He got his walker after resi (sic) (and) she came back into shower area (and) he fell ...Injury...Body Part...(left) knee c/o pain (has a total knee there)...What did resident say happened? He got up into walker (and) went to the shower rm door to see where CNA went...what interventions are necessary: Keep floor dry don't leave resi alone in shower..." A nurse's note, dated 04/23/11 on the 10 - 6 shift, documented, "...Pt stated my lt knee isn't hurting. Gait steady..." A nurse's note, dated 04/23/11 at 9:10 a.m., documented, "...c/o (left) leg/foot pain. N/O x-ray (left) knee (and (left) ankle..." A nurse's note, dated 04/23/11 at 12:55 p.m., documented, "...x-ray results...(left) ankle acute nondisplaced fx - distal metaphysis of fibula. (Physician name withheld) notified. N/O send to ER..." A nurse's note, dated 04/24/11 as a late entry for 04/22/11, documented, "...Call to (family member name withheld) POA...He said hold the x-ray for now. Give Tylenol (and) apply ice. I said I've called the dr already. I'm waiting for him to call back then I will ask him if I can do the ice. Tylenol 325 mg (two) tabs po gave c good results. C/o knee pain until 1030 pm then c/o ankle pain then I con't to (check) resident q 1 (hour) for pain or swelling. Ankle was swelled but this resident was already dx c cellulitis in the (left) leg (and) had the same amount of swelling in the ankle as he had in the floor when I went to see him after his fall (or it looked the same as before, 'the swelling of the ankle'). when the LPN came in for 10 - 6 shift, he did c/o his ankle @ this time about 1030 pm after the resident was checked over (and) go up he walked to his rm s complaint of any kind. This was reported to the DON about 5 pm while she was till here, because @ this time he had (no) c/o. His knee bent when he fell (and) the CNA (and) this resident did tell this nurse about that but before he was moved this nurse (and) CNA (checked) him over including pressure to (left) knee (and) (left) ankle s any c/o voiced until later..." This note was signed by RN #1. A final incident report, with a fax date of 05/03/11, documented, "...Resident fell at 4:45 on 4/22/2011 when CNA left resident in shower room unattended to go get him clean clothes. Resident began to follow CNA out of shower room and slipped on the wet tile and fell . On the morning of 4/23/2011, resident c/o throbbing and stiffness. Knee and ankle xrays ordered. Knee xray negative. Left ankle xray positive for nondisplaced fracture of fibula. (Physician name withheld) notified and ordered for the resident to be sent to the ER....Resident was treated at hospital, no surgical interventions were necessary. Cast applied to left fibula...Nurse aide and RN on duty were disciplined for failing to follow facility protocol related to our falls management program. RN was reported to the Board of Nursing for failing to obtain further orders with injury. Facility inservice was held on falls management program to prevent re-occurrence..." A nurse's note, dated 04/25/11 at 8:30 p.m., documented, "...Resi was to come back today to the home, but I've had no word or verbal report..." This note was signed by RN #1. A nurse's note, dated 04/26/11 at 2:30 p.m., documented, "...(Family member) called back (and) said this resident had a new cast put on last night...When I also said (family member) said for me to not order the x-ray yet, but to wait, she said 'Yes, he didn't want to have (resident #20) have to move around a lot just to see if the Tylenol (and) ('ice pack' he ask us to use.) (sic) would help him before we had the x-ray done - or sent him to the hosp for a (check) or x-ray.' She also said his leg was swollen really bad @ the ankle so the (sic) put on a boot, before they did the cast again last night..." This note was signed by RN #1. Review of an inservice on the facility's fall management program, dated 05/02/11, revealed no documentation to show RN #1 attended the inservice. On 06/01/11 at 9:42 a.m., the DON was asked if the resident was left unattended in the shower. She stated, "According to the CNA, she had turned around to get his clothes. He stood and fell ." The DON was asked if the resident was assessed to be at high risk for falls. She stated, "Yes." The DON was asked if the resident's admission assessment documented the resident required supervision while bathing. She stated, "Yes." When asked if the resident should have been left unattended, the DON stated, "No." The DON was asked if the fall was reported to her when it occurred. She stated, "Yes." When asked if she assessed the resident at that time, the DON stated, "I was outside of the door (shower door) as (RN #1) was going in." The DON was asked if RN #1 assessed the resident. She stated, "Yes." The DON was asked why the information in the clinical record was different than the information provided in the incident report submitted to the State Health Department. She stated, "Because after I investigated, it was difficult to read and understand (RN #1)'s note. After I got a verbal from her I went ahead and sent off the report." The DON was asked if there was a facility inservice held regarding falls as stated in the incident report. She stated, "Yes." When asked if RN #1 attended, the DON stated, "Yes." The DON was asked to provide the documentation where RN #1 attended the inservice. None was provided by the end of the survey. The DON was asked how the aide knew the resident was at high risk for falls. She stated, "We have the falling star program. There are stars on the doors and above the bed." The DON was asked if the resident had a star. She stated, "I don't know." On 06/01/11 at 11:46 a.m., the resident was observed as he was transfered from his wheel chair to his bed with a Hoyer lift. The resident told the surveyor that he had broken his leg. He did not provide further details of the fall. 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An undated nursing admission assessment documented the resident scored a 12 on the fall risk assessment. The form documented, "...Total score above 10 represents high risk..." An activity assessment, dated 03/21/11, documented the resident enjoyed arts and crafts and walking as past activities, but it was not important now. The form documented the resident's family member assisted with the assessment. A nurse's note, dated 03/22/11 at midnight, documented, "...Pt is ambulatory. Keeps trying to get up out of bed and ambulate in room. Redirected et assisted back to bed..." A nurse's note, dated 03/23/11 on the 10 - 6 shift, documented, "...Res had trouble falling asleep. Non-compliance. Refused to use call light and also refused to stay in bed (sic) call for help. Resident confused..." A nurse's note, dated 03/23/11 at 8:45 a.m., documented, "...resident stated she did not want to lay down. She was placed in w/c in room c c/l in reach...when nursing aide left room resident attempted to transfer self to bed. Alarm went off...Nurse aide arrived in room pt was on the floor between w/c and bed..." An incident report, dated 03/23/11, documented,"...actions taken...frequent checks...PT/OT/ST eval...Pt is confused (and) trys (sic) to transfer self...Are any new interventions needed to prevent future falls...w/c and bed pressure alarm..." A nurse's note, dated 03/23/11 at 1:45 p.m., documented, "...Resident fell @0845...has been in front of nursing desk. Awake, confused... has been up and down out of chair redirected to stay in w/c..." A nurse's note, dated 03/23/11 on the 2 - 10 shift, documented, "...Pt continues to try and walk on her own..." A nurse's note, dated 03/27/11 at midnight, documented, "...Pt ambulated out in hallway... Pt redirected several times to bed...Alarm on et intact...Call light within reach..." A nurse's note, dated 03/28/11 on the 10 - 6 shift, documented, "...Pt very restless, confused @ present. Pt has bed alarm on. Redirected numerous times et assisted back to bed. Call light within reach..." An admission assessment, dated 04/01/11, documented the resident scored a 5 on the MDS Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. It was documented the resident exhibited inattention and disorganized thinking behavior. It was documented resident required limited assistance of one person with bed mobility, transfers, ambulation, dressing, toilet use and personal hygiene. A CAA narrative, dated 04/01/11, documented, "...has long and short term memory loss R/T she has dementia...she also has more confusion and agitation in the evening until she is able to go to sleep at night...needs limited assist with her ADLS. She is capable of completing her ADLS but needs reminding and supervision at all times. She tries to get up on her own and do things for herself but she is unsteady and falls. She primarily uses her w/c for locomotion but is able to ambulate with assist with a walker...PT evaled her but she stated she did not want to work on walking and did not participate further with them...had several falls at home prior to admission. She has had a fall since admission...she is unsteady and tries to get up on her own..She has a pressure alarm form (sic) her w/c and bed to alert staff when she gets up unassisted. She becomes more agitated and confused at night..." A care plan, dated 04/04/11, documented a problem, "...I had falls at home and have fallen here. I am able to walk with assistance d/t unsteady gait but I forget and get up on my own and fall..." The goal was, "...I will have a decrease in falls thru NRD and no adverse reactions..." Approaches included, "...Pressure alarm for my bed and w/c...Assist me with all transfers and ambulation. Remind me not to get up on my own... keep my call light with in reach while I am in my room. I use it at times but normally will yell out when I need something..." Another problem was, "...I am easily distracted, have long and short memory loss, and trouble finding appropriate words to express myself at times R/T I have dementia. My confusion is worse in the evening and at night..." The goal was, "...I will be able to communicate with others and be less anxious..." Approaches included, "...Reorient me to time as needed because I wake up at night and believe it is morning..." Another problem was, "...I need limited assist and cues with my adls. D/t my dementia I forget some of the task I need to do..." The goal was, "...I will complete my adls with staff assistance and remain clean and groomed q day..." Approaches included, "...Assist me with all transfers and ambulation...remind me to not get up alone..." A nurse's note, dated 04/12/11 on the 10 - 6 shift, documented, "...CNA interviewed and they reported that resident was observe (sic) on the floor in a sitting position with all the bedclothes under her. Res was assist back to bed and bed alarm was fix to function...alert with some confusion...Pt always like (sic) to walk to her roommates bed and say 'can you help me I don't want (sic) to do' the roommate said, she always (sic) afraid she might fall...call light within reach..." A care plan update, dated 04/12/11, documented, "...resident found on floor in sitting position (no) injury..." A review of the resident's care plan revealed no new interventions to aid in the prevention of falls. A nurse's note, dated 04/15/11 on the 2 - 10 shift, documented, "...Pt confused and restless. Yells out for people who are not there...pacing halls in w/c continues to attempt to stand..." A nurse's note, dated 04/18/11 on the 10 - 6 shift, documented, "...Awake @ intervals. Pt confused. Redirected et assisted back to bed..." A restorative care progress note, dated 04/22/11, documented, "Resident walked the first time today 1018 ft, using gait belt and roller-walker, with one person assist. The second time the same day she walked 818 ft with 1 person assist, using g-belt and RW." A restorative care progress note, dated 05/06/11, documented, "Resident went for a short walk before walk to dine seems to be a little weak 14 min. 83 feet with one person assist using RW and gait belt." A nurse's note, dated 05/07/11 on the 10-6 shift, documented, "...Res was in bed but awoke and was brought out to nurse desk area to be observed r/t (decreased) compliance c personal safety and falls (sic) risks..." A nurse's note, dated 05/11/11 on the 10-6 shift, documented, "...Res got up and bed alarm went off staff responded res attempted to ambulate to bathroom legs got weak and res was eased to a sitting position..." An incident report, dated 05/11/11, documented, "...actions taken: res was reminded to use wheelchair to ambulate (after) waking...new interventions needed to prevent future falls...in service staff on Q 2 (hour) bathroom assistance and prn..." A care plan update, dated 05/11/11, documented, "...alarm sounded, res got out of bed and was ambulating to B/R got weak was assisted to sitting position..." No new interventions were noted. A restorative care progress note, dated 05/14/11, documented, "Resident has not been walking well due to decline, has been to every meal." A restorative care progress note, dated 05/16/11, documented, "Res has not been able to amb due to a decline in resident's legs..." A nurse's note, dated 05/19/11 at 11:30 a.m., documented, "...Res witnessed to stand up from w/c and held on to handrail and lowered herself to the floor..." A restorative care progress note, dated 05/20/11, documented, "Res has attempted to amb c mod assist using R/W. Resident's gait is not steady..." A nurse's note, dated 05/21/11 on the 10 - 6 shift, documented, "...Awake @ intervals. Redirected back to bed et bed alarms reset. several x's..." A nurse's note, dated 05/21/11 at 9:30 a.m., documented, "...Up in w/c @ nursing station-chair alarm and personal alarm on- Resident is constantly trying to get up - Requires verbal redirection continuously..." A restorative care progress note, dated 05/21/11, documented, "Resident walk to dine is doing better this week using gait-belt and RW..." A nurse's note, dated 05/23/11 on the 6 - 2 shift, documented, "...(up) in wheelchair constantly attempts to stand 1:1 c staff for safety...confused (and) disoriented..." On 05/23/11 at 8:40 p.m., the resident was observed standing by the door to her room. The alarm was sounding. LPN #1 was standing in the hallway between the resident's room and the next room to the south. LPN #1 observed the resident standing by the door. LPN #1 did not call for assistance. CNA #1 came from the nurses' station to the resident's room and placed the resident back in bed. A nurse's note, dated 05/23/11 as a late entry, documented, "...Res in bed most of the night. Arose @ 0300 and set bed alarm off. Nurse and aide assisted resident to BR. Res didn't return to bed, ate a snack and set (sic) up c staff until 0530 then requested to be returned to bed...res assisted back to bed..." A nurse's note, dated 05/24/11 at 7:00 a.m., documented, "...Resident continues to sit to stand (up). Redirect resident as needed to 'please sit down.' Resident complys (sic)..." On 05/24/11 at 11:39 a.m., the resident was observed seated in her wheelchair on the right side of the dining room door on the east hall.

Based on observation, interview, and record review, it was determined the facility failed to update the resident's care plan to accurately address the resident's current condition for 1 (#38) of 2 sampled residents with wounds. The care plan did not address the need to assess for and provide interventions for pain related to wounds. The facility identified 5 residents with wounds. Findings: Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." A physician's orders [REDACTED]. [MEDICATION NAME]/acetamin 5mg/325mg tab - [MEDICATION NAME] 1 tab by mouth every 4 hrs. as needed for pain." An annual assessment, dated 07/15/11, documented the resident had a BIMS score of 10, did not have any behaviors, was at risk for pressure ulcer, and did not have any skin conditions. The care plan, dated 07/25/11, documented a problem, "I am at risk of developing pressure ulcers and stasis ulcers, I have had stasis ulcers in the past that have resolved...Approaches:...Monitor my legs daily, reporting abnormal findings to my physician..." The care plan failed to address the resident's routine and prn pain medication, premedicating the resident before a treatment, assessing the resident's pain level before a treatment, and assessing the resident's pain level after a treatment. On 08/29/11 at 10:00 a.m., RN #1 and LPN #1 were observed as they did a dressing change for resident #38. LPN #1 removed the ace bandage on the resident's left leg. The LPN sprayed [MEDICATION NAME] on the bandages stuck on the resident's left leg and pulled them off. The resident reached down with her hands and attempted to stop her from cleaning the wound. LPN #1 asked the resident if it hurt. The resident yelled out, "Yes." The wound was observed as a stage II stasis ulcer approximately 5 cm. in length. The LPN asked the resident how she was feeling. The resident shouted, "Terrible." At 10:13 a.m., the LPN put santyl on the wound and placed a 3x3 gauze pad on the ulcer and wrapped the leg with gauze. The resident yelled out, "Ouch that hurts." The LPN replied to the resident, "Sorry, I didn't want to hurt you." The resident yelled, "Don't do that, you are hurting me." The resident was grimacing and touching her forehead in pain. On 08/30/11 at 2:35 p.m., RN #1 was asked if she had assessed the resident for pain before the dressing change. The RN stated, "No." On 08/30/11 at 4:10 p.m., RN #2 was asked if resident #38's care plan should have addressed pain. RN #2 stated, "Yes, it should have been addressed. He was asked how he would know if a resident had pain. He stated, "I get most of my information from the staff but I also get information from physician orders [REDACTED]. No staff member reported to me the resident had experienced pain." The RN was asked if the resident was on pain medication. He stated, "Yes, but that doesn't trigger on the MDS assessment." He was asked if the resident had the potential to experience pain. He stated, "Yes."

Based on observation, interview, and record review, it was determined the facility failed to update resident's care plans to include falls, activities, wounds, amputations, and tube feedings for 8 (#1, #2, #3, #4, and #20) of 19 sampled residents whose care plans were reviewed. The facility's failure to care plan and identify care needs for resident #20's wounds and amputation contributed to actual harm for this resident. This had the potential to affect 85 of 85 residents who resided at the facility. All residents had resided at the facility for more than one month. Findings: The facility's policy on comprehensive care plans, dated August 2006, documented, "...Care plans are revised as changes in the resident's condition dictate..." The facility's policy on preliminary care plans, dated August 2006, documented, "...A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four...hours of admission...To assure that the resident's immediate care needs are met and maintained..." The facility's policy on care plans goals and objectives, dated August 2006, documented, "...Goals and objectives are reviewed and/or revised...when there has been a significant change in the resident's condition...When the desired outcome has not been achieved...When the resident has been readmitted to the facility from a hospital/rehabilitation stay..." 1. Resident #20 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, dated 03/05/11, documented a problem, "...I have [MEDICAL CONDITION], DM...I am at risk for skin breakdown..." The goal was, "...Skin will remain intact thru NRD..." Approaches included, "...Administer meds as ordered by my Dr...Monitor my skin while providing care. Notify nurse of any changes...Nurse to assess skin q week..." On 06/01/11 at 11:46 a.m., the resident's right foot was observed. A hardened black area, approximately 3 x 3 cm, was observed on the resident's right bunion area. A pin-head sized red area was observed on the tip of the great toe. A black area, approximately 1.5 x 1.5 cm was observed on the left side of the great toe's nail base. Three open areas with brown wound bases were noted on the top of the foot, below the great toe nail base. The largest of these areas was pea sized. An abrased area was noted near the center of the top of the foot. The DON was asked when the wounds on the resident's right great toe were first identified. She stated, "4/18 was when it was first reported to me." A review of the resident's care plan, dated 03/05/11, revealed no documentation to show the resident's care plan had been updated to include the left [MEDICAL CONDITION] or the wounds on his right foot. There were no goals or interventions identified. On 06/03/11 at 2:42 p.m., LPN #4 was asked how staff would know what interventions were in place for a resident if they were not identified on the care plan. She stated, "They wouldn't." 2. a. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 03/23/11 at 8:45 a.m., documented, "...resident stated she did not want to lay down. She was placed in w/c in room c c/l in reach...when nursing aide left room resident attempted to transfer self to bed. Alarm went off...Nurse aide arrived in room pt was on the floor between w/c and bed..." An incident report, dated 03/23/11, documented,"...actions taken...frequent checks...PT/OT/ST eval...Pt is confused (and) trys (sic) to transfer self...Are any new interventions needed to prevent future falls...w/c and bed pressure alarm..." A CAA narrative, dated 04/01/11, documented, "...has long and short term memory loss R/T she has dementia...she also has more confusion and agitation in the evening until she is able to go to sleep at night...needs limited assist with her ADLS. She is capable of completing her ADLS but needs reminding and supervision at all times. She tries to get up on her own and do things for herself but she is unsteady and falls. She primarily uses her w/c for locomotion but is able to ambulate with assist with a walker...PT evaled her but she stated she did not want to work on walking and did not participate further with them...had several falls at home prior to admission. She has had a fall since admission...she is unsteady and tries to get up on her own..She has a pressure alarm form (sic) her w/c and bed to alert staff when she gets up unassisted. She becomes more agitated and confused at night..." A care plan, dated 04/04/11, documented a problem, "...I had falls at home and have fallen here. I am able to walk with assistance d/t unsteady gait but I forget and get up on my own and fall..." The goal was, "...I will have a decrease in falls thru NRD and no adverse reactions..." Approaches included, "...Pressure alarm for my bed and w/c...Assist me with all transfers and ambulation. Remind me not to get up on my own... keep my call light with in reach while I am in my room. I use it at times but normally will yell out when I need something..." A nurse's note, dated 04/12/11 on the 10 - 6 shift, documented, "...CNA interviewed and they reported that resident was observe (sic) on the floor in a sitting position with all the bedclothes under her. Res was assist back to bed and bed alarm was fix to function...alert with some confusion...Pt always like (sic) to walk to her roommates bed and say 'can you help me I don't want (sic) to do' the roommate said, she always (sic) afraid she might fall...call light within reach..." A care plan update, dated 04/12/11, documented, "...resident found on floor in sitting position (no) injury..." A review of the resident's care plan revealed no new interventions to aid in the prevention of falls. A nurse's note, dated 05/11/11 on the 10-6 shift, documented, "...Res got up and bed alarm went off staff responded res attempted to ambulate to bathroom legs got weak and res was eased to a sitting position..." A care plan update, dated 05/11/11, documented, "...alarm sounded, res got out of bed and was ambulating to B/R got weak was assisted to sitting position..." No new interventions were noted. A nurse's note, dated 05/19/11 at 11:30 a.m., documented, "...Res witnessed to stand up from w/c and held on to handrail and lowered herself to the floor..." A review of the resident's care plan revealed no new interventions to aid in the prevention of falls. On 05/24/11 at 11:39 a.m., the resident was observed seated in her wheelchair on the right side of the dining room door on the east hall. CNA #12 was standing beside the resident. The resident was stooped over in her chair. She leaned over, placed her hand on the floor, brought her knees to the floor, and then rolled on to her left side. CNA #12 assisted the resident to the floor. The chair alarm did not sound. CNA #12 and the MDS coordinator transferred the resident back to her chair, pushed the resident to her room, and placed the resident in bed. A nurse's note, dated 05/24/11 at 11:45 a.m., documented, "...Resident in hallway by nurses desk c CNA present. She slid out of w/c onto floor. Alarm present in w/c..." A review of the resident's care plan revealed no new interventions to aid in the prevention of falls. On 06/03/11 at 2:42 p.m., LPN #4 was asked what new interventions had been put into place to aid in the prevention of falls. She stated, "Alarms, brought to the nurses station, music, papers, colors and [MEDICATION NAME]." LPN #4 stated she allowed the resident to watch movies on her phone. LPN #4 was asked if those interventions were identified on the resident's care plan. She stated, "No." When asked how the staff would know to use those interventions if they were not listed on the care plan, LPN #4 stated, "They wouldn't." On 06/03/11 at 6:02 p.m., the DON was asked what interventions had been put into place to help prevent the resident from falling. She stated, "Bed and chair alarm, concave mattress." When asked if the interventions had been effective, the DON stated, "The concave mattress has been effective. The chair alarm alerts us whenever she is getting up without assistance." The DON was asked if the care plan should be updated after each fall with new interventions identified. She stated, "Yes." b. An admission assessment, dated 04/01/11, documented the resident was severely impaired in cognitive skills with a BIMS score of 5. An activity assessment, dated 03/21/11, documented the facility was unsure of the frequency of activities for the resident. The activity assessment documented animals/pets, family/friend visits, religious services, and religious studies were important activity preferences for the resident, and music was somewhat important to the resident. The care plan, dated 04/04/11, did not address individualized activities for the resident. During all days of the survey (05/24/11 through 06/03/11), the resident was observed to attend only one activity. She was observed attending morning exercise on 05/24/11 at 10:00 a.m. On 06/02/11 at 3:11 p.m., the activity director was asked if she had activity care plans. She stated, "What is a care plan? Do I need one?" She also asked if the activity director was responsible for completing the care plan. 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 12/22/10, documented the resident had a BIMS score of 8, required extensive assistance with transfers, and had not experienced any falls. A fall care plan, dated 12/22/10, documented, "Problem: ...need assistance with transfers, unsteady with ambulation and balance, take an antidepressant q day and I am weak...I am at risk for falls...Goals: ...will not have any falls with injury thru NRD...Approaches: ...Personal alarm to be used to let staff know when I am getting up unassisted...Body alarm (marked through) error..." A physician's orders [REDACTED]. The fall care plan had not been updated to include the physician's orders [REDACTED]. A quarterly assessment, dated 03/18/11, documented the resident had a BIMS score of 6, required extensive assistance with transfers, and had not experienced any falls. The fall care plan, dated 03/21/11, documented, "Problem: ...need assistance with transfers, unsteady with ambulation and balance, take an antidepressant q day and I am weak...I am at risk for falls...Goals: ...will not have any falls with injury thru NRD...Approaches: ...Personal alarm to be used to let staff know when I am getting up unassisted..." An incident report, dated 03/29/11, documented, "...Res takes alarm off & attempts to get out of bed on his own...What interventions...Pressure alarms put in place..." The fall care plan had not been updated to include the fall from the bed on 03/29/11. The care plan did not address the resident's ability to remove the alarm and attempt to get out of bed unassisted. The care plan did not address any new interventions for the prevention of further falls. A nurse's note, dated 04/17/11, documented, "8 am...resident slipped out of the wheelchair and fell face down on the floor...Bruises noted on the forehead and on the R knee..." An incident report, dated 04/17/11, documented, "Resident slipped out of the wheelchair...Actions taken: Resident instructed to sit in the chair and not to stand up...Is there a previous history of falls? Yes...W/C alarm activated...Interventions...Close monitor and chair alarm...New interventions: No..." The fall care plan had not been updated to address the fall the resident had experienced on 04/17/11. The care plan did not address the resident's fall from the wheelchair, his injuries related to the fall, or new interventions in place to prevent further falls. A nurse's note, dated 04/24/11, documented, "Resident slipped out of the wheelchair and was observed by the nurse- Skin tear noted on the back of the R palm...Safety measures (not legible) will continue to monitor..." The fall care plan had not been updated to include the fall from the wheelchair, the injury, or new interventions for the prevention of further falls. A nurse's note, dated 05/28/11, documented, "1800...Resident slipped out of the wheelchair while was reaching for something on the floor...The incident was observed...Safety measures in place...Resident reminded to seek help when in need..." The fall care plan had not been updated to include the fall the resident had sustained when a staff person witnessed the fall. The care plan did not address how the resident was to seek help when he was seated in his wheelchair at the nurses' station. The resident had sustained 4 falls in three months (March, April, and May). Three of the four falls injury had occurred. There were no new interventions in place after the wheelchair alarm had been implemented in December 2010. On 05/25/11 at 11:10 a.m., the resident was observed seated in his wheelchair at the nurses' station. At 3:45 p.m., the resident was observed in his bed. No alarm was observed in use. On 05/31/11 at 11:00 a.m., and 2:55 p.m., the resident was observed in his bed. No alarm was observed in use. On 06/02/11 at 12:45 p.m., a confidential interview was conducted regarding the resident's falls from his bed. The interviewee stated a wedge was in the bed and the resident could not get out of the bed, so he doesn't fall. On 06/03/11 at 7:42 p.m., the DON was asked what new interventions had been implemented when the resident had fallen from his bed and his wheelchair. She stated, "We did a concave mattress. We did a pressure alarm. It wasn't effective. We added a chair alarm, it alerted us. He loves ice cream." The DON was asked why the falls and new interventions had not been addressed on the care plan. She stated, "It should have been updated everytime there is a fall. We address it." ACTIVITIES 4. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 12/22/10, documented the resident had a BIMS score of 8 and required extensive assistance transfers. An activity evaluation, dated 12/22/10, documented the resident's frequency of activities would be three times a month. The activity evaluation documented animals, arts/crafts, barber shop, bingo, cards, computer, current events, dominoes, educational programs, exercise, group discussion, movies, music, radio, reading, religious, resident council, television, volunteering, and walking were very important activity preferences for the resident. A care plan, dated 12/22/10, did not address individualized activities for the resident. A quarterly assessment, dated 03/18/11, documented the resident had a BIMS score of 6 and required extensive assistance with transfers. A care plan, dated 03/21/11, did not address individualized activities for the resident. During all days of the survey (05/24/11 through 06/03/11) the resident did not attend nor was provided any type of activity. The resident was observed in his room in bed or in his wheelchair in front of the nurses' station. On 06/02/11 at 3:11 p.m., the activity director was asked if she had activity care plans. She stated, "What is a care plan? Do I need one? She also asked if the activity director was responsible to do a care plan. 5. Resident #1 was admitted to facility on 04/16/06 with [DIAGNOSES REDACTED]. An unsigned, monthly weight history report, dated 04/06/11, documented, "...shut off tube feeding from 10:00 - 11:00..." A physcian's order, dated 04/08/11, documented, "[MEDICATION NAME] 1.2 run continuosly (sic) at 52 ml/h for 23 hours/day. May stop for one hour/day for therapy." A care plan, updated on 04/08/11, documented, "...Problem...N/O [MEDICATION NAME] 1.2 @ 52ml/hr x 23 hours..." The care plan did not include a plan for regulating when the tube feeding should be turned off and on each day, and who would turn the tube feeding off and on for 1 hour every day. On 06/01/11 resident #1 was observed from 9:10 a.m. through 7:20 p.m., with [MEDICATION NAME] 1.2 that was infused at 52 ml/hour. On 06/03/11 at 3:35 p.m., LPN # 4 was asked when the resident's tube feeding was turned off. She stated, "When she goes to therapy, that's how we know when to turn it off." She was asked if the resident had still been getting therapy. She stated, "No, but it covers for other things like when she gets her hair done." LPN #4 was asked where she had documented when the tube feeding had been turned off and when it had been turned back on. She stated, "I don't document it, it doesn't stop. The only time I have turned it off is when she got her hair done." She was asked if the tube feeding was now 24 hours a day. She stated, "Yes, I know other nurses have turned the tube feeding off and then back on and did not document it." LPN #4 was asked if she had called the physician and asked for new tube feeding orders when the resident was discharged from therapy. She stated, "No, I guess I should have done that." At 6:46 p.m., the DON was shown the physcian's order for [MEDICATION NAME] 1.2 to run continuously at 52ml/hr for 23 hours a day and off for 1 hour for therapy. She was asked if the tube feeding was now stopped for 1 hour for therapy. She stated, "I have to check. I don't believe she is on therapy." The DON was asked where was the documentation the nurses had turned off the tube feeding for 1 hour each day. She stated, "I don't know of any documentation." The DON was shown the the monthly weight history report, dated 04/06/11, that documented, "...turn off tube feeding from 10:00 - 11:00..." The DON was asked who had written this order. She stated, "That 10 - 11 was never an order." The DON was asked if the times the tube feeding was to be turned off and turned on was addressed on the care plan. She stated, "No." She was asked how the nurses would know when to turn off the tube feeding. She stated, "Well, it was turned off during therapy." She was asked if it was turned off since she stopped therapy. She stated, "We should have gotten another order." She was asked if there should be a better plan. She stated, "Yes, it should be on the TAR." 5. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 06/12/10, documented, "...Problem: I am cognitively impaired, have short attention span. I like to nap throughout the day and show little interest in activities. Goals: I will attend an activity at least 3 times a week or have in room visits thru next review. Approaches: Escort me to an activity that does not require active participation 3 times a week. I prefer music activities...Provide me with one on one activities that might interest me...Try to interest me in the selection of and participation with visit activities...Invite me to activities each day...Use an even calm voice when inviting me to an activity...Observe me for positive interaction to repeat success..." The care plan was not updated to include planned, individualized activities for the resident. On 06/03/11 at 3:15 p.m., the activity director was asked if the resident had an activity care plan. She stated, "What is that." She stated she did not know what that consisted of and she had not completed one on any resident.

Based on observation, record review, and interviews, it was determined the facility failed to be administered in a manner to enable residents to attain or maintain their highest practicable well-being. ~ The facility's administration failed to identify systems failures in the area of accidents/supervision which resulted in an Immediate Jeopardy situation and an actual harm situation. ~ The facility's administration failed to identify systems failures regarding physician notification of changes in condition which resulted in an Immediate Jeopardy situation. ~ The facility's administration failed to identify systems failures related to assessment and monitoring of wounds and provision of care and services to maintain the resident's highest practicable well-being which resulted in an Immediate Jeopardy situation. ~ The facility's administration failed to ensure there was an effective Quality Assessment and Assurance program in place to identify problems and concerns and correct quality deficiencies. This had the potential to affect 85 of 85 residents who resided in the facility. Findings: 1. The facility failed to notify the physician of: A. Right toe and foot wounds, significant changes to a left great toe wound, and changes to an incision on a left [MEDICAL CONDITION] stump for 1 (#20) of 9 sampled residents who were at high risk for health status changes. The facility identified 30 residents were at high risk for health status changes. The facility's failure to notify the physician of wounds to the resident's right toe and foot, significant changes to a left great toe wound, and changes to the incision on a left [MEDICAL CONDITION] constituted an Immediate Jeopardy situation for resident #20; Refer to F-157. 2. The facility failed to: A. Assess and monitor a resident with wounds to his right and left great toes; complete treatments to the wounds; administer antibiotics, vitamins and minerals to aid in wound healing; make wound clinic appointments in a timely manner; assess and monitor a left [MEDICAL CONDITION] stump, and provide pain medication prior to treatments for 1 (#20) of 9 sampled residents who were at high risk for health status changes. The facility identified 30 residents were at high risk for health status changes. The facility's failure to assess and monitor the resident's wounds and amputation stump, provide treatments for the wounds, administer medications to aid in the healing of the wounds, and make wound clinic appointments in a timely manner constituted an Immediate Jeopardy situation for resident #20. Refer to F-309. 3. The facility failed to: A. Ensure interventions were put in place after a hot coffee burn had occurred, to prevent hot [MEDICAL CONDITION] occurring in the future. This resulted in an immediate jeopardy situation for 1 (#16) of 1 sampled residents who had experienced a second degree burn that resulted in actual harm. This had the potential to affect 53 residents who the facility assessed and identified as needing supervision while drinking hot beverages; B. Provide supervision to prevent accidents while bathing for 1 (#20) of 19 sampled residents who required assistance while bathing. The facility's Census and Conditions report identified 62 residents as needing the assistance of at least one staff member while bathing; The facility's failure to provide supervision while bathing resulted in actual harm for resident #20 when he fell while alone in the shower and suffered a fractured left fibula. Refer to F323. 4. The facility failed to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies. The facility failed to identify and implement a plan of action to correct systems failures related to: a. physican notification of changes in condition; b. updating care plans to reflect the current needs of the residents; c. providing care and services to ensure residents reached their highest practicable well-being; d. identifying accident hazards and ensuring interventions were initiated to prevent hot coffee burns; e. providing supervision to prevent falls and/or identifying and implementing interventions to prevent falls. See F520. On 06/03/11 at 7:55 p.m., the administrator and the DON were asked what systems were in place to identify residents who were at risk for accident hazards. The DON stated, "I don't know that we have anything in place." They were asked what systems were in place to ensure the nursing staff was assessing and monitoring the residents in order to notify the physician. The DON stated, "We didn't really have a system." They were asked what systems were in place to determine residents who were at high risk for falls. The administrator stated they had a falling star program and a weekly resident at risk meeting. They were asked if the nursing department had been supervised effectively after receiving an IJ in supervision to prevent accidents, an IJ in failure to assess and monitor, and an IJ in failure to notify the physician. She stated, "No."

Based on observation, record review, and interviews, it was determined the facility failed to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies. The facility failed to identify and implement a plan of action to correct systems failures related to: a. physican notification of changes in condition; b. updating care plans to reflect the current needs of the residents; c. providing care and services to ensure residents reached their highest practicable well-being; d. identifying accident hazards and ensuring interventions were initiated to prevent hot coffee burns; e. providing supervision to prevent falls and/or identifying and implementing interventions to prevent falls. This had the potential to affect 85 of 85 residents who resided in the facility. Findings: 1. The facility failed to notify the physician of: A. Right toe and foot wounds, significant changes to a left great toe wound, and changes to an incision on a left [MEDICAL CONDITION] stump for 1 (#20) of 9 sampled residents who were at high risk for health status changes. The facility identified 30 residents were at high risk for health status changes. The facility's failure to notify the physician of wounds to the resident's right toe and foot, significant changes to a left great toe wound, and changes to the incision on a left [MEDICAL CONDITION] constituted an Immediate Jeopardy situation for resident #20; B. Second [MEDICAL CONDITION] the upper left arm received from a hot coffee spill for 1 (#16) of 1 sampled resident who had been burned by hot coffee in the facility. The facility identified 53 residents who required supervision when drinking hot liquids; and C. A newly acquired alteration in skin integrity for 1 (#21) of 13 sampled residents at high risk for skin breakdown. The facility's Census and Conditions report identified 83 residents who received preventative skin measures. See F157 2. The facility failed to: A. Assess and monitor a resident with wounds to his right and left great toes; complete treatments to the wounds; administer antibiotics, vitamins and minerals to aid in wound healing; make wound clinic appointments in a timely manner; assess and monitor a left [MEDICAL CONDITION] stump, and provide pain medication prior to treatments for 1 (#20) of 9 sampled residents who were at high risk for health status changes. The facility identified 30 residents were at high risk for health status changes. The facility's failure to assess and monitor the resident's wounds and amputation stump, provide treatments for the wounds, administer medications to aid in the healing of the wounds, and make wound clinic appointments in a timely manner constituted an Immediate Jeopardy situation for resident #20; See F309 3. The facility failed to: A. Ensure interventions were put in place after a hot coffee burn had occurred, to prevent hot [MEDICAL CONDITION] the future to occur, resulting in an immediate jeopardy situation for 1 (#16) of 1 sampled residents who had experienced a burn that resulted in actual harm. This had the potential to affect 53 residents who the facility assessed and identified as needing supervision while drinking hot beverages; B. Provide supervision to prevent accidents while bathing for 1 (#20) of 19 sampled residents who required assistance while bathing. The facility's Census and Conditions report identified 62 residents as needing the assistance of at least one staff member while bathing; The facility's failure to provide supervision while bathing resulted in actual harm for resident #20 when he fell while alone in the shower and suffered a fractured left fibula; See F323. 4. The facility failed to update resident's care plans to include falls, activities, wounds, amputations, and tube feedings for 8 (#1, #2, #3, #4, and #20). This had potential to affect 85 of 85 residents who resided at the facility. All residents had resided at the facility for more than one month. The facility failed to update resident's care plans to include falls, activities, wounds, amputations, and tube feedings for 8 (#1, #2, #3, #4, and #20) of 19 sampled residents whose care plans were reviewed. The facility's failure to care plan and identify care needs for resident #20's wounds and amputation contributed to actual harm for this resident. This had the potential to affect 85 of 85 residents who resided at the facility. See F280. On 06/03/11 at 7:55 p.m., the administrator and the DON were asked what systems were in place to identify residents who were at risk for accident hazards. The DON stated, "I don't know that we have anything in place." They were asked what systems were in place to ensure the nursing staff was assessing and monitoring the residents in order to notify the physician. The DON stated, "We didn't really have a system." They were asked what systems were in place to determine residents who were at high risk for falls. The administrator stated they had a falling star program and a weekly resident at risk meeting. She was asked if the QA committee had addressed these issues in the last 6 months. She stated, "No. We did address falls." The DON was asked if the QA committee was effective. She stated, "I do not."

Based on observation, record review, and interviews, it was determined the facility failed to have an effective quality assessment and assurance program in place to correct quality deficiencies. The facility failed to implement a plan of action to correct systems failures identified on the recertification survey, conducted from 05/23/11 through 06/03/11, related to: a. updating care plans to reflect the current needs of residents with wounds; and b. providing care and services to ensure resident with wounds reached their highest practicable well-being. This had the potential to affect five residents who the facility identified with wounds. Findings: 1. The facility failed to update the resident's care plan to accurately address the resident's current condition for 1 (#38) of 2 sampled residents with wounds. The care plan did not address the need to assess for and provide interventions for pain related to wounds. The facility identified 5 residents with wounds. Refer to F280. 2. The facility failed to provide pain medication prior to a wound treatment for 1 (#38) of 2 sampled residents with wounds. This resulted in actual harm for resident #38, who experienced pain during wound care. The resident was not assessed for pain prior to the treatment. The facility identified 5 residents with wounds. The facility identified only 2 of 5 residents with wounds were to receive pain medication. Refer to F309.