Every finding on record at Spiro Nursing Home, Inc.

Based on record review and interview, the facility failed to ensure residents were provided with a written notice of transfer and a copy of the bed hold policy when they transferred to a hospital for 1 (#42) of 2 sampled residents reviewed for hospitalization s. The ADON stated 22 separate residents have been transferred to a hospital between 11/01/24 and 06/01/25. This resulted in 38 hospital transfers having occurred during that time frame. Findings: On 06/03/25 a review of Res #42's EMR showed the resident had been transferred to a hospital on five separate occasions: 10/24/24, 12/04/24, 03/24/25, 04/18/25, and 04/30/25. A further review of the EMR did not find documentation bed hold polices or written letters of transfer were given to the resident or their representative. On 06/03/25 at 10:50 a.m., RN #1 was asked what documentation was given to a resident when they were transferred to a hospital. They stated forms such as assessments, vital signs, code status, face sheets, and allergies. They were asked if the residents were given a written notice of transfer and copy of the bed hold policy. They stated they had never given a resident either document when they were sent to a hospital. On 06/03/25 at 10:55 a.m., LPN #1 stated they had never given a written notice of transfer or copies of the bed hold policy when they had transferred residents to a hospital. They stated they had now been aware of the requirement for a written notice of transfer. On 06/03/25 at 11:05 a.m., the ADON was asked if they had a policy about giving residents a written notice of transfer and copy of the bed hold policy when they transferred to a hospital. They stated they had not been giving either to residents when they go to a hospital. They stated they were unaware it was a regulation. On 06/03/25 at 11:17 a.m., the administrator stated they were not aware of the requirement to provide written notices of transfers to residents or provide a copy of the bed hold policy. They stated it had never been done at the facility. The administator stated the bed hold policy was given to the residents when they were admitted to the facility and was in the residents' records. They stated the facility did not have a policy and procedure that included providing those two documents to residents when they transferred to a hospital.

Based on record review and interview, the facility failed to ensure a resident receiving an antipsychotic medication had an appropriate diagnosis for 1 (#6) of 5 sampled residents reviewed for unnecessary medications. The ADON reported 4 residents received antipsychotic medications. Findings: A facility policy titled Psychotropic Medication Policy and Procedure, dated 10/24/22, read in part, Psychotropic drugs will not be administered unless necessary to treat a specific condition diagnosed and documented in the clinical record. An admission record, dated 09/21/23, showed Res #6 had diagnoses which included dementia and depression. A quarterly assessment, dated 03/21/25, showed Res #6 had a BIMS score (a test for cognitive function) of 00, which was indicative of severe impairment for daily decision making. The assessment also showed Res #6 was receiving an antipsychotic medication. A physician's order, dated 04/01/25, showed Res #6 was receiving Seroquel (an antipsychotic medication) 25 mg by mouth at bedtime for dementia with other behavioral disturbance. On 06/03/25 at 1:35 p.m., the infection preventionist stated that dementia was not an appropriate diagnosis for an antipsychotic medication On 06/03/25 at 1:37 p.m., the ADON stated that dementia was not an appropriate diagnosis for an antipsychotic medication.

Based on record review and interview, the facility failed to ensure a Notice of Medicare Non-coverage form was provided to a resident in the required timeframe for 1 (#44) of 3 sampled resident reviewed for beneficiary notices. The BOM stated seven residents had discharged from Medicare part A services between 11/01/24 and 06/01/25. Findings: A CMS-10123 form [Notice of Medicare Non-Coverage], signed by Res. #44 on 03/03/25, showed the resident's Medicare Part A services would have ended on 03/04/25. On 06/02/25 at 3:16 p.m., the BOM was asked to explain the purpose of the CMS-10123 form. They stated it was a notice to inform a resident that skilled services funded by Medicare Part A would be ending on a particular date. The BOM was asked when the notice was required to be given to a resident. They stated it was to be given no later than 48 hours prior to the end date of the services. The BOM was asked to review Res #44's CMS-10123 signed on 03/03/25 for any deficiencies. They stated it appeared the resident received the form 24 hours prior to the end of skilled services which was 24 hours too late. They stated they had made a mistake with that resident's form. On 06/02/25 at 3:41 p.m., the administrator stated they did not have a policy and procedure to address the use of form CMS-10123. They stated it had been standard practice at the facility to present the form 48 hours prior to the end of skilled services. The administrator stated they had spoken with the BOM and decided not to pre-print the signature date onto the form in the future. They stated they believe the BOM had pre-printed the wrong date on that particular form.

Based on observation, record review, and interview, the facility failed to ensure medications were secured for one of one insulin cart observed. The Administrator identified one insulin cart. Findings: A Medication Cart Storage, policy, undated, read in part, .No insulin or injectables shall remain in the treatment cart unless they are being administered and they will remain with the nurse who is administering the drugs . On 02/01/24 at 10:30 a.m., LPN #1 was observed to walk into a resident's room. They left the insulin cart outside of the room with the drawers facing the hall. The LPN's back was to the door and the cart was not visible to the LPN. When the LPN exited the room, they stated they were supposed to lock the cart. They said a resident could have opened it while they were in the room and could have been injured.

Based on record review and interview, the facility failed to ensure OHCA was contacted when a resident had a serious mental illness for one (#2) of one resident reviewed for PASRR assessments. The DON identified 49 residents resided in the facility. Findings: A PASRR policy, undated, read in part, .To ensure compliance with federal regulations and the accurate determination of eligibility for admission to Spiro Nursing Home, all applicants, regardless of pay source, must undergo the Pre-Admission Screening and Resident Review (PASRR) process . Resident #2 was admitted to the facility on [DATE]. Resident #2 was diagnosed with bipolar on 03/09/22, TBI on 06/21/22, and dementia on 10/10/22. ON 02/01/24 at 11:04 a.m., the DON stated there was no documentation to show the state agency had be notified of the new diagnosis of bipolar. On 02/01/24 at 1:04 p.m., the DON stated the policy for determination of a level II PASRR being done was any patient who had a prior history of mental diagnosis, a level II PASRR was required before admission to the facilty. She stated if the resident is diagnosed after admission, call the state agency and fill out a form for a level II evaluation.

On 12/06/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Res #5 was free from burns while drinking coffee. On 12/06/22 at 3:15 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 12/06/22 at 3:25 p.m., the Administrator was notified of the IJ situation. On 12/06/22 at 4:25 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal, dated 12/06/22 at 4:25 p.m., read in parts: .We identified 10 resident who require assistance with feeding that would have the possibility of burning themselves with coffee. Any new admission who are assessed to require assistance with feeding will be added to this list. To prevent these issues in the future staff will put approximately 2 tablespoons of ice in the coffee of all residents who require assistance with feeding. The staff will check the coffee temperatures before and after the ice to ensure that the temperature is below 120 degrees. The dietary manager has in-serviced all dietary staff to the updated policy. All staff will be in-serviced before they are allowed to return to work. A sign will be placed on those resident's door and the doors of the kitchen as an additional safety measure to ensure that coffee is cooled prior to delivery to these residents. Administrator will research the possibility of acquiring a coffee pot that will allow us to regulate the temperature of our coffee. The DON will monitor these interventions weekly for the next six months to ensure that they are working and will report findings to the QA committee quarterly. The IJ was lifted, effective 12/07/22 at 10:00 a m., when all components of the plan of removal had been completed. The deficiency remains at an isolated level with a potential for harm. Based on record review, observation and interview the facility failed to ensure Res #5 was free from burns when drinking coffee. The DON identified 25 residents who drink hot liquids. Findings: Res #5 was admitted with diagnoses which included dementia and epilepsy. A nursing note, dated 07/17/21 at 4:39 p.m., read in part Incident Note: aprox [sic] 1300 (1:00 p.m.) called to residents room, resident keeps her own personal mug and had asked for coffee, resident is alert and oriented x's 4, attempted to drink the coffee half laying down and the lid came off and coffee spilled on her chest and ran down into both armpits, immediately we placed cool wet towels to all the areas to cool the burn, POA is in the room with her and call was placed to Dr (name withheld), areas are bright punk [sic] but will likely have some blistering. New order given for Silvadene (a topical antibiotic for burns) and this was applied topically to all areas and tx has been opened for a twice a day application for a week and then to reassess. A nursing note, dated 07/22/21 at 1:37 p.m., read in part, Physician's Order Note: Provider here on rounds and assessed burns s/t [sic] coffee spills. Provider concerned with infection and gave new orders to culture left arm burns and to start Flagyl 250mg TID 1 tab PO x 10 days . A nutrition care plan, updated on 07/17/21, read in parts, .I need supervision and/or assist during meals to ensure I eat .without incident .I will need ice placed in my coffee. Res #5's quarterly resident assessment, dated 07/12/22, documented a BIM (Brief Interview for Mental Status) score of 5 (severly cognitively impaired). A nursing note, dated 08/09/22, at 7:30 a.m., read in part, Resident spilt hot coffee on (R) side of abdomen and (R) breast and skin is reddened at this time. A skin/wound note, dated 08/15/22, at 2:29 p.m., read in part, CNA notified this LPN of a red area to right hip. Upon inspection it appeared to be a burn. Res #5 states she spilled her coffee two days ago her roommate states she spilled coffee yesterday. DON aware SSD order in place. Dr. aware. A physician's order, dated 08/15/22, read in part, SSD Cream 1% (a topical antibiotic cream for burns) - apply to right hip/side topically every shift for altered skin integrity. On 12/06/22 at 11:00 p.m., CNA #1 obtained coffee for Res #5, the coffee temperature was 159 degrees F. CNA #1 did not place ice in the coffee and reported they did not put ice in the coffee as part of the routine for Res #5. On 12/06/22 from 11:30 a.m. until 11:56 a.m., observed Res #5 with coffee at bedside without supervision. On 12/06/22 at 11:35 a.m., the Administrator reported the facility did not have a policy regarding accidents related to hot liquids. On 12/06/22 at 12:15 p.m., Res #5's roommate who is cognitively intact reported Res #5 always has coffee in their room even at night. On 12/06/22 at 12:20 p.m., CNA #2 and CMA #1 reported they did not put ice in the coffee for Res #5. On 12/06/22 at 3:45 p.m., the Administrator reported the staff should have been putting ice in Res #5's coffee.

Based on record review and interview, the facility failed to develop a comprehensive person centered care plan for two (#2 and #42) of five residents sampled for care plans. The Resident Census and Conditions of Residents, dated 12/05/22, documented a census of 55 residents. Findings: A Policy and Procedure for Care Planning, dated 10/14/15, read in part .develop a comprehensive narrative care plan for each resident which will describe the individualized care to be provided to attain or maintain the resident's highest possible physical, mental, and psychosocial well-being. Res #2 was admitted to the facility with diagnoses which included dementia and diabetes. A care plan, dated 12/01/22, did not contain documentation for dementia or diabetes. On 12/06/22 at 4:20 p.m., the DON reported neither dementia nor diabetes were documented on the care plan. On 12/06/22 at 4:24 p.m., the administrator reported the care plan should have included dementia and diabetes. Res #42 was admitted with diagnoses which included hypertensive heart disease. A physician's order dated, 06/16/20, read in part, Lasix (a diuretic) 20mg, give 1 tablet by mouth twice a day related to hypertensive heart disease with heart failure. A physician's progress note, dated 11/20/22 at 12:26 p.m., read in parts, CHF: .on Lasix 20mg: 1 po bid . There was no care plan for diuretic therapy due to hypertensive heart failure. On 12/07/22 at 2:00 p.m., the MDS Coordinator reported that Res #42 should have had a care plan for diuretic use. 45913

Based on record review and interview, the facility failed to notify a resident's family of a change in condition for one (#5) of one resident reviewed for notification of changes. The Resident Census and Conditions of Residents, dated 12/05/22, documented a census of 55 residents. Findings: A nursing note, dated 08/09/22, at 7:30 a.m., read in part, Resident spilt hot coffee on (R) side of abdomen and (R) breast and skin is reddened at this time. A skin/wound note, dated 08/15/22, at 2:29 p.m., read in part, CNA notified this LPN of a red area to right hip. Upon inspection it appeared to be a burn. Res #5 states she spilled her coffee two days ago her roommate states she spilled coffee yesterday. DON aware SSD order in place. Dr. aware. A physician's order, dated 08/15/22, read in part, SSD Cream 1% (a topical antibiotic cream for burns) - apply to right hip/side topically every shift for altered skin integrity. On 12/06/22 at 11:26 a.m., Family member #1 reported they were not notified Res #5 had burns due to hot coffee in August of 2022. On 12/08/22 at 9:28 a.m., the DON stated the family should have been notified at the time of the incident.

Based on record review and interview, the facility failed to revise a care plan related to burns from coffee for one (#5) of one resident reviewed for accidents. The Resident Census and Conditions of Residents dated, 12/05/22 documented a census of 55 residents. Findings: A nursing note, dated 08/09/22, at 7:30 a.m., read in part, Resident spilt hot coffee on (R) side of abdomen and (R) breast and skin is reddened at this time. A skin/wound note, dated 08/15/22, at 2:29 p.m., read in part, CNA notified this LPN of a red area to right hip. Upon inspection it appeared to be a burn. Res #5 states she spilled her coffee two days ago her roommate states she spilled coffee yesterday. DON aware SSD order in place. Dr. aware. A physician's order, dated 08/15/22, read in part, SSD Cream 1% (a topical antibiotic cream for burns) - apply to right hip/side topically every shift for altered skin integrity. A skin care plan last revised on 10/11/21 was not revised regarding burns received from coffee and Res #5's skin care treatment for burns. On 12/07/22 at 2:00 p.m., the MDS Coordinator reported Res #5's care plan should have been updated regarding their burns and skin care treatment.

Based on observation, interview, and record review, it was determined the facility failed to ensure oxygen tubing was changed per physician orders, the standard professional practice of care, and per the facilities policy for three (#1, #34, and #37) of five residents sampled for oxygen therapy. The facility identified 18 residents who received oxygen therapy. Findings: A facility policy related to oxygen tubing change, dated 07/16/19 documented the facility would replace tubing on all oxygen concentrators twice each month to maintain cleanliness. The policy documented the nursing staff would replace cannulas as needed. 1. Resident #1 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 07/18/19 documented to change oxygen tubing twice monthly. Every day shift starting on the 12th and ending on the 12th every month for protocol and every day shift starting on the 27th and ending on the 27th every month for protocol. An annual assessment, dated 06/23/21 documented the resident was cognitively intact. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident had shortness of breath while lying flat and required oxygen. On 07/06/21 at 10:10 AM, the oxygen tubing was observed and was labeled with a last change date of 06/12/21. The resident was observed wearing oxygen with the nasal cannula in her nose. On 07/07/21 at 8:26 AM, the oxygen tubing was observed and was labeled with a last change date of 06/12/21. The resident reported she was unsure when the oxygen tubing was last changed. On 07/07/21 at 9:00 AM, the treatment administration record was reviewed and documented the tubing had not been changed since 06/12/21. 2. Resident #37 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 07/28/2019, documented oxygen tubing was to be changed twice monthly. The order documented the oxygen tubing was to be changed every day shift starting on the 13th and ending on the 13th every month for protocol and every day shift starting on the 28th and ending on the 28th every month for protocol A quarterly assessment, dated 06/09/21 documented the resident was cognitively intact. The assessment documented the resident was dependent on staff for activities of daily living. The assessment documented the resident had shortness of breath while lying flat and required oxygen. On 07/06/21 at 10:00 AM, the oxygen tubing was observed and had a date last changed on 6/13/21. The resident was observed lying in bed with the oxygen cannula in his nose. On 07/07/21 at 8:24 AM, the oxygen tubing was observed and had a date last changed on 6/13/21. The resident was observed lying bed with the oxygen cannula in his nose. On 07/07/21 at 8:45 AM, the resident's treatment administration record was reviewed an documented the tubing had not been changed since 06/13/21. 3. Resident #34 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 7/10/20, documented to change the oxygen tubing every 14 days, on every day shift every 14 day(s) for protocol. An annual assessment, dated 05/20/21, documented the resident was cognitively intact for daily decision making and was independent for activities of daily living. On 07/06/21 at 11:07 AM, the oxygen tubing was observed to have been labeled as last changed on 05/28/21. On 07/07/21 at 8:18 AM, the oxygen tubing was observed to have been labeled last as changed on 05/28/21. On 07/07/21 at 1:54 PM, licensed practical nurse (LPN) #1 reported the oxygen tubing was supposed to be changed every two weeks and as needed. LPN #1 reported if the date is 6/12/21 on the oxygen tubing it is past due to have been changed. LPN #1 reported what is on the label is the last day the oxygen tubing and cannulas had been changed. On 07/08/21 at 1:37 PM, the director of nursing (DON) reported the policy documented the oxygen tubing and cannulas were to be changed every two weeks. The DON reported the oxygen tubing and cannulas should have been changed every two weeks and had not been done per policy and physician orders.

Based on observation, interview, and record review, it was determined the facility failed to ensure a baseline care plan was initiated within 48 hours of admission for one (#101) of one resident reviewed for new admission. The facility identified 16 new admissions in the past three months. Findings: Resident #101 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 06/29/21, documented hospice to evaluate and treat as indicated. On 07/06/21 at 10:03 AM, the resident was observed lying awake in bed. A fall matt was observed in the floor by her bed. The resident's wheelchair was located at the end of her bed. The resident reported she was admitted to the facility for respite care. On 07/06/21 at 10:32 AM, staff reported the resident was on hospice care. On 07/07/21, the admission assessment was in progress. The medical record did not document a baseline care plan within 48 hours of admission. A comprehensive care plan was initiated with a target completion date of 07/16/21. The comprehensive care plan in process did not document the resident's minimum healthcare information necessary to properly care for the resident or the resident or family received a summary of the baseline care plan. On 07/08/21 at 9:04 AM, the minimum data set (MDS) coordinator and the director of nursing (DON) reported they had began to initiate the comprehensive care plan upon admission instead of a 48 hour care plan. They reported the care plan did not document the minimum healthcare information necessary to properly care for the resident or documentation of the resident or the resident's family had reviewed a summary of the baseline care plan.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were supervised to prevent resident to resident altercations for one (#5) of five sampled residents whose incidents were reviewed. The facility identified a census of 63 residents. Findings: Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An incident report form, dated 11/04/18, documented a resident to resident altercation had occurred in the dining room. The report documented the resident was often unable to control his movements and had not meant to hit anyone. The report documented measures to decrease episodes of agitation. A request to add or change the care plan form, dated 11/06/18, documented the resident needed to be assisted to and from meals and to other activities. An incident report form, dated 11/22/18, documented a resident to resident altercation had occurred in the dining room. The report documented another resident had informed the kitchen staff of the incident. The report documented the resident was to receive meals in his room or one on one in the dining room. A quarterly assessment, dated 01/24/19, documented the resident's cognition was moderately impaired and the resident required extensive assistance with activities of daily living. The assessment documented the resident received an antipsychotic and an antidepressant seven days of the look back period. A care plan, updated 02/07/19, documented the resident was easily agitated, was angry at times, and became physical with others. The care plan documented the resident had uncontrolled muscle movements. The care plan documented the resident smoked cigarettes and was accompanied outside by staff. An incident report form, dated 03/01/19, documented a resident to resident altercation had occurred in the smoking room. The report documented another resident reported the incident to the nurses' station. The report documented an increase in antipsychotic medication and to continue to monitor behaviors. On 04/04/19 at 11:33 a.m., the resident was observed sitting the smoking room unsupervised. On 04/04/19 at 11:35 a.m., the administrator reported the resident was observed in the smoking room and throughout the facility via a video camera. On 04/04/19 at 2:30 p.m., the director of nursing (DON) reported the resident had behaviors and agitated easily. The DON reported the facility had not supervised the resident during the altercations.

Based on observation, interview, and record review, it was determined the facility failed to ensure an infection control program was maintained to prevent the possible development of infection for one (#31) of three residents reviewed for infection control. The facility identified three residents who had an indwelling catheter. The facility identified 58 residents in the facility. Findings: The facility policy and procedure for catheter care documented the staff was to ensure the catheter bag was off the floor at all times. Resident #31 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 04/16/18, documented the resident's cognition was severely impaired. The assessment documented the resident was independent with activities of daily living. The assessment documented the resident was incontinent of bowel and bladder. The care plan, dated 04/30/18, documented the resident was frequently incontinent of bladder. A nurse progress note, dated 05/15/18, documented the resident returned to the facility with an indwelling catheter. A physician order, dated 05/16/18, documented if the resident was unable to void in eight hours after the removal of the catheter to replace the catheter. A nurse progress note, dated 05/16/2018, documented the resident was unable to void in 8 hours after indwelling catheter was removed. The nurse note documented the indwelling catheter was re-inserted. A physician order, dated 05/17/18, documented catheter care every shift and to change the indwelling catheter every 30 days and as needed. On 06/05/18 at 1:04 p.m., the resident was sitting in a recliner in her room. The resident's catheter bag was lying on the floor. On 06/06/18 at 9:15 a.m., the resident was observed lying in bed with her eyes closed. The resident's catheter tubing was hanging taught down the side of the bed and the catheter bag was lying on the floor. On 06/07/18 at 8:15 a.m., the resident was observed lying in bed with her eyes closed. The resident's catheter bag was touching the floor. On 06/07/18 at 8:25 a.m., certified nurse aide (CNA) #1 was interviewed regarding care for residents with indwelling urinary catheters. The CNA stated the catheter bag should never touch the floor. The CNA stated the resident's catheter bag was touching the floor. On 06/07/18 at 11:30 a.m., licensed practical nurse (LPN) #1 was interviewed and reported the catheter bag should never be on the floor.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who received [MEDICAL TREATMENT] therapy was provide care and services to maintain the highest level of well-being for one (#54) of one sampled resident reviewed for [MEDICAL TREATMENT] services. The facility failed to ensure a system was in place to provide consistent coordination and collaboration of care between the nursing home and the [MEDICAL TREATMENT] facility related to monitoring and assessing the resident upon return from [MEDICAL TREATMENT]. The director of nursing (DON) identified one resident who received [MEDICAL TREATMENT] services. Findings: Resident #54 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The annual assessment, dated 02/09/18, documented the resident was independent for daily decision making and required extensive assistance with activities of daily living (ADLs). The assessment did not document [MEDICAL TREATMENT] services for the resident. The quarterly assessment, dated 05/12/18, documented the resident was independent for daily decision making and required extensive assistance with ADLs. The assessment did not document [MEDICAL TREATMENT] services for the resident. The care plan, dated 05/12/18, documented the resident received [MEDICAL TREATMENT] three times a week. The care plan did not document assessments, communication, or the collaboration of care with the [MEDICAL TREATMENT] facility. On 06/05/18 at 10:10 a.m., the resident was observed lying on his bed with his eyes closed. On 06/06/18 at 8:43 a.m., the DON was interviewed regarding a [MEDICAL TREATMENT] policy regarding care for residents who receive [MEDICAL TREATMENT] treatments. The DON reported the facility had no [MEDICAL TREATMENT] policy. The DON stated a licensed nurse should know what care needs to be provided. On 06/06/18 at 1:40 p.m., licensed practical nurse (LPN) #1 was interviewed regarding assessments and ongoing coordination and communication between the facility and the [MEDICAL TREATMENT] facility. The LPN reported the facility did not assess the residents after [MEDICAL TREATMENT] treatments. The LPN stated there had been no ongoing communication with the [MEDICAL TREATMENT] facility regarding the resident's plan of care. On 06/06/18 at 2:40 p.m., the DON was interviewed regarding assessments and coordination of services with the [MEDICAL TREATMENT] facility. The DON reported there had been no ongoing communication provided or documented in the resident's clinical record with the [MEDICAL TREATMENT] facility.

Based on observation, interview, and record review, it was determined the facility failed to ensure assessments accurately reflected the residents' status for two (#11 and #54) of 16 residents whose assessments were reviewed. The facility failed to ensure a quarterly assessment included the resident's antianxiety medication for resident #11. The facility failed to ensure a comprehensive and a quarterly assessment included [MEDICAL TREATMENT] services for resident #54. The director of nursing (DON) identified 58 residents who resided in the facility. Findings: 1. Resident #11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A physician order, dated 11/27/17, documented the resident was to receive [MEDICATION NAME] 0.25 milligrams (mg) every morning. A care plan, dated 11/27/17, documented the resident received medications for anxiety. A quarterly assessment, dated 03/08/18, documented the resident was moderately impaired with cognition. The assessment documented the resident required limited assistance with activities of daily living. The assessment documented the resident had not received antianxiety medications in the seven day look back period. The medication administration records (MARS) was reviewed. The MARS documented the resident received [MEDICATION NAME] 0.25 mg every morning 03/01/18 through 05/31/18 On 06/06/18 at 8:34 a.m., the resident was observed sitting in a recliner in the front lobby. On 06/06/18 at 11:02 a.m., the DON was interviewed and reported the quarterly assessment was inaccurate. The DON reported the resident received [MEDICATION NAME] 0.25 mg every morning without interruptions. 2. Resident #54 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The annual assessment, dated 02/09/18, documented the resident was independent for daily decision making and required extensive assistance with activities of daily living. The assessment did not document [MEDICAL TREATMENT] services for the resident. The quarterly assessment, dated 05/12/18, documented the resident was independent for daily decision making and required extensive assistance with activities of daily living. The assessment did not document [MEDICAL TREATMENT] services for the resident. The care plan, dated 05/12/18, documented the resident received [MEDICAL TREATMENT] three times a week. On 06/05/18 at 10:10 a.m., the resident was observed lying on his bed with his eyes closed. On 06/07/18 at 9:50 a.m., the minimum data set (MDS) coordinator was interviewed regarding [MEDICAL TREATMENT] assessments for the resident. The coordinator reviewed the annual assessment dated [DATE] and the quarterly assessment dated [DATE]. The MDS coordinator reported [MEDICAL TREATMENT] services were not identified on the assessments but should have been.

Based on observation, interview, and record review, it was determined the facility failed to ensure care plans were reviewed and revised after each assessment by the interdisciplinary team for one (#7) of sixteen sampled residents whose assessments were reviewed. The facility failed to ensure: a) care plans related to [MEDICAL CONDITION] medications was updated for resident # 7, b) care plans related to anticoagulant medications was updated for resident # 7, and c) care plans related to the presence of pressure ulcers was updated for resident # 7. The facility identified 48 residents who resided in the facility. Findings: Resident #7 was re-admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A physician order, dated 12/15/17, documented the resident was to receive Eliquis (an anticoagulant medication) 2.5 milligrams (mg) twice a day for the [DIAGNOSES REDACTED]. A physician order, dated 01/04/18, documented the resident was to receive [MEDICATION NAME] (an antidepressant medication) 75 mg two times a day for the [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/22/18, documented the resident was severely impaired with cognition. The assessment documented the resident required extensive assistance to total dependence with activities of daily living. The assessment documented the resident had no pressure ulcers. The assessment documented the resident had received an antidepressant medication and an anticoagulant seven of seven days. A care plan, last updated 02/22/18, had not documented the use of [MEDICAL CONDITION] medications or anticoagulant medications. A physician order, dated 05/03/18, documented the resident was to receive [MEDICATION NAME] to the left heel and the right heel for decubitus every shift until resolved. The order documented the resident was to wear bunny boots while in bed. A weekly pressure ulcer healing record and plan of care update, dated 05/04/18, documented a pressure ulcer Stage II located on the right heel and left heel. The pressure ulcer record documented an onset date of 05/03/18. On 06/04/18 at 11:34 a.m., the resident was observed lying on her left side in bed with her eyes closed. The resident was observed to have been wearing bunny boots on both feet. On 06/06/18 at 10:46 a.m., the resident was observed lying on her back in bed with her eyes closed. The resident was observed to have been wearing bunny boots on both feet. The care plan was reviewed and had not documented the presence of a pressure ulcer and the approaches to prevent and treat the pressure ulcers. On 06/07/18 at 9:15 a.m., the minimum data set (MDS)/care plan coordinator was interviewed related to care plans. The MDS/care plan coordinator reviewed the care plan and reported the care plan had not been revised to include [MEDICAL CONDITION] medications, anticoagulant medications, or pressure ulcers.

Based on interview and record review it was determined the facility failed to notify the resident's responsible party of a significant change for one (#1) of three residents sampled for significant changes. The facility failed to notify the resident's family when the resident removed his [MEDICAL CONDITION]. The facility identified a census of 64 residents. Findings: Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident was severely impaired with cognition. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident received antipsychotics, antidepressants, and antianxiety medications seven of seven days. A care plan, dated [DATE], documented the resident had a [MEDICAL CONDITION] with a button cap in place. The care plan documented the resident was on a regular pureed diet with nectar consistency liquids. A nurse note, dated [DATE] at 12:48 a.m., documented the resident was observed in bed. The note documented the resident's respirations were even and unlabored. The note documented the resident was on oxygen (O2) at three liters (L) per nasal canula (NC). A nurse note, dated [DATE] at 2:31 a.m., documented the resident was found with his [MEDICAL CONDITION] out. The note documented an attempt to reinsert the tube without success. The note documented the physician was notified. The note documented the nurse was informed to keep an eye on the resident and the resident should be okay without it. The note did not document family was notified of the incident. A nurse note, dated [DATE] at 6:00 a.m., documented the resident was resting well. The note documented the resident's respirations were even and unlabored on O2 at 3L per NC. The note documented the resident's oxygen saturation was 96%. The note documented the dressing to the stoma site was clean, dry, and intact. A nurse note, dated [DATE] at 10:42 a.m., documented the resident's O2 saturation was 97% on 2L per NC. The note documented, tolerating self removal of trach. A nurse note, dated [DATE] at 11:54 a.m., documented the resident was alert but confused. The note documented the resident's O2 saturation was 96% on 2.5L per NC with no signs or symptoms of distress. A nurse note, dated [DATE] at 12:29 p.m., documented the resident had increased anxiety. A nurse note, dated [DATE] at 1:29 p.m., documented the resident had returned from lunch. The note documented the resident had an appearance of a panic attack. The note documented the resident's respirations were 40 breaths per minute with O2 in place. The note documented the resident was assessed and vital signs obtained. The note documented the physician was notified and an order was received to send the resident to the emergency room . The note documented the resident's family was notified of the resident's change in condition. A hospital discharge summary, dated [DATE], documented the resident was deceased . The discharge summary documented the cause of death was [MEDICAL CONDITIONS], and dementia. On [DATE] at 3:50 p.m., the resident's physician was interviewed. The physician reported he was notified when resident #1 removed his [MEDICAL CONDITION] during the night. The physician reported the facility staff had attempted more than once to replace the [MEDICAL CONDITION]. The physician reported he gave the order to discontinue the tube when staff were unable to replace it. The physician reported the resident was not in distress and staff were instructed to monitor the resident for any signs or symptoms of respiratory distress. On [DATE] at 3:59 p.m., licensed practical nurse (LPN) #1 reported she had received a report from the night nurse the following morning after resident #1 had pulled his [MEDICAL CONDITION] out. The LPN reported the doctor had given an order to leave the tube out and monitor the resident. The LPN reported she spoke with the resident's family and apologized for them not being contacted. The LPN reported she did not realize the family had not been notified. The LPN reported she would not have called the family during the night since the resident was not in distress but she would have contacted them the next morning if she had realized they had not been notified. On [DATE] at 9:42 a.m., the director of nursing (DON) reported the facility charge nurses used their own judgement in determining when to contact family regarding changes in the resident's condition. The DON reported they do not always call families during the middle of the night if the resident is not in distress or has not suffered an injury. The DON reported resident #1 had been intubated in [DATE] related to [MEDICAL CONDITION]. The DON reported the resident's [MEDICAL CONDITION] was non-functioning and was plugged with a button cap. The DON reported the resident was somewhat confused but had expressed his desire many times to have the [MEDICAL CONDITION] removed. The DON reported he would not have called the resident's family during the night and he had assessed the resident himself the following morning. The DON reported the resident was doing well and was in no distress the morning after he had pulled the [MEDICAL CONDITION] out.

Based on observation, interview, and record review, it was determined the facility failed to prepare and serve food under sanitary conditions for 17 of 17 sampled residents who received meals from the facility kitchen. Kitchen staff obtained food temperatures and did not disinfect the thermometer between obtaining the temperature of each food. The facility identified a census of 54 residents who received meal trays from the kitchen. Findings: The facility food thermometer cleaning policy documented food thermometers would be cleaned with alcohol wipes between each food that the temperatures were being taken and before and after the thermometer was used. On 04/20/16 at 11:05 a.m., meal preparation was observed. Dietary staff #1 was observed to measure the temperature of chicken Alfredo, lasagna, salad, baked potatoes, and broccoli. The dietary staff rinsed the thermometer under running water and wiped it with a paper towel between taking the temperature of each food. On 04/20/16 at 12:00 p.m., the dietary manager (DM) was interviewed regarding the facility policy for cleaning the thermometer used to obtain the temperatures of the foods being served to the residents. The DM reported the facility policy was to clean the thermometer with an alcohol wipe between taking food temperatures.

Based on observation, interview, and record review, it was determined the facility failed to provide an environment free of accident hazards. The facility failed to maintain water temperatures below 120 degrees Fahrenheit (F) in the lobby bathroom on the new hall and in the resident rooms on the new hall for eight (#3, #7, #10, #11, #12, #13, #15, and #16) of eight sampled residents whose rooms were sampled for water temperatures. This had the potential to affect any staff, family, or residents who might use the lobby bathroom on the new hall. The facility identified six ambulatory residents who resided on the new hall. Findings: The facility maintenance policy documented the water temperatures were to be checked weekly. 1. On 05/19/15 at 9:10 a.m., an environmental tour was conducted. The water temperature in the back lobby bathroom sink on the new hall registered 133.8 degrees Fahrenheit (F). On 05/19/15 at 1:35 p.m., the administrator was interviewed regarding the lobby bathroom. The administrator reported the lobby bathroom was mainly used by facility employees. The admininstrator reported the lobby bathroom was a public bathroom and was available for resident use. 2. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual assessment, dated 03/19/15, documented the resident was severely impaired with cognitive skills. The assessment documented the resident required extensive to total assistance with all activities of daily living. The care plan, updated 03/27/15, documented the staff was to provide personal care, dressing, oral care, and bathing for the resident. The care plan documented staff was to provide assistance with mobility. The care plan documented the resident could sometimes propel herself around in her wheelchair. On 05/19/15 at 9:30 a.m., the temperature of the water in the sink in the resident's room was measured at 132 degrees Fahrenheit. On 05/19/15 at 12:15 p.m., certified nurse aide (CNA) #2 was interviewed regarding whether the resident used the sink in her room. The CNA reported the resident did not wash her hands at the sink unless assisted by facility staff. On 05/19/15 at 12:20 p.m., the resident was observed in her wheelchair in the facility lobby. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 11/26/14, documented the resident had dementia and memory problems. The care plan documented the resident required assistance with bed mobility, ambulation, and activities of daily living. A quarterly assessment, dated 05/08/15, documented the resident was severely impaired with cognitive skills. The assessment documented the resident required extensive assistance with bed mobility and activities of daily living. On 05/19/15 at 8:45 a.m., the resident was observed during personal care. On 05/19/15 at 9:20 a.m., the water from the resident's sink was checked and registered 132.7 degrees F. The resident was not interviewable. On 05/19/15 at 9:30 a.m., certified nurse aide (CNA) #1 was interviewed regarding the resident's cognition and activity of daily living skills. The CNA reported the resident was confused and totally dependent on staff for activity of daily living needs. The CNA reported the resident required assistance from staff for ambulation. 4. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 04/21/15, documented the resident was severely impaired with cognitive skills. The assessment documented the resident required extensive assistance with bed mobility, ambulation, and activities of daily living. A care plan, dated 04/29/15, documented the resident had dementia with periods of confusion. The care plan documented the resident needed help with transfers and ambulation. The care plan documented the resident could make his needs known. On 05/19/15 at 9:20 a.m., the water from the resident's sink was checked and registered 132.7 degrees F. On 05/19/15 at 12:15 p.m., the resident was interviewed. The resident was asked if he could get to his sink. The resident stated, "No, the girls help me." The resident reported he could not get to the sink by himself. The resident was asked if the water had ever been too hot for his use. The resident reported the water had never been too hot. The resident reported the girls always checked the water for him. 5. Resident #3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A quarterly assessment, dated 04/06/15, documented the resident's cognition was intact. The assessment documented the resident required limited assistance with activities of daily living needs. The assessment documented the resident ambulated independently with the use of a walker or wheelchair. A care plan, dated 04/08/15, documented the resident required one person assist with part of bathing. On 05/19/15 at 10:00 a.m., the water temperature in the resident's room was found to be 138.4 degrees Fahrenheit. On 05/19/15 at 12:30 p.m., the resident reported he had not noticed the water temperature in his room being too hot. The resident reported he used the sink in his room independently. 6. Resident #12 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/05/15, documented the resident's cognition was intact. The assessment documented the resident required extensive assistance with activities of daily living. A care plan, dated 03/05/15, documented the resident required a mechanical lift for transfers. The care plan documented the resident was totally dependent with bathing and required two person assistance. On 05/19/15 at 12:30 p.m., the resident's husband, who was the resident's roommate, reported he had not noticed the water temperature in the room being too hot. The resident also stated she had no complaints related to water temperature. On 05/19/15 at 3:55 p.m., the resident was observed to receive incontinent care. The resident reported the water temperature was satisfactory. 7. Resident #16 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/13/15, documented the resident's cognition was intact. The assessment documented the resident was independent with activities of daily living needs. A care plan, dated 03/13/15, documented the resident ambulated independently with a walker. The care plan documented the resident occasionally required assistance with part of bathing. On 05/19/15 at 9:56 a.m., the hot water temperature was checked in the resident's room and found to be 138.8 degrees Fahrenheit. On 05/19/15 at 1:08 p.m., the resident was observed to ambulate to the restroom in his room. The resident reported he had no complaints regarding water temperature. The resident reported he had never had problems with the water temperature being too hot. 8. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/06/15, documented the resident was cognitively intact. The quarterly assessment documented the resident required extensive assistance with transfers and hygiene. The quarterly assessment documented the resident did not ambulate and required extensive assistance with locomotion. A care plan, reviewed on 04/06/15, documented the resident was to be given a washcloth to clean her hands and face. On 5/19/15 at 10:03 a.m., the hot water temperature in the resident's room was checked. The temperature registered 135.5 degrees Fahrenheit (F). On 05/19/15 at 12:15 p.m., certified nursing assistant (CNA) #2 was interviewed. The CNA was asked if the resident was able to perform her own care including turning on the water in her room for personal hygiene needs. The CNA stated the resident was unable perform any personal care without assistance. The CNA stated the resident was unable to turn on the faucet independently. The CNA stated the resident was to be given a warm washcloth to clean her hands after using the restroom. On 05/19/15 at 12:20 p.m., the resident was interviewed. The resident was asked if she could turn on the water in her room. The resident stated she could not turn on the water in her room and that the staff would hand her a washcloth to clean up. The resident stated it took a while for the water to get warm. 9. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/14/15, documented the resident was severely impaired with cognitive skills. The assessment documented the resident was totally dependent with activities of daily living. A care plan, reviewed on 02/14/15, documented the resident was totally dependant for bowel and bladder needs, dressing, oral care, am/pm care, and personal hygiene. The care plan documented the resident did not ambulate and was totally dependent for locomotion. On 05/19/15 at 10:03 a.m., the hot water temperature in the resident's room was checked. The temperature registered 135.5 degrees Fahrenheit (F). The resident was observed in bed sleeping. On 05/19/15 at 12:14 p.m., CNA #2 was interviewed. The CNA was asked if the resident was able to get out of bed. The CNA reported the staff would get the resident out of bed at 1:00 p.m. as the resident preferred. The CNA stated the resident was totally dependent for all activities of daily living. On 05/19/15 at 1:05 p.m., the resident was observed sitting in a wheelchair. The resident's lower arms and hands were positioned on the resident's lap and supported with pillows. On 05/19/15 at 1:09 p.m., the maintenance man was interviewed regarding the procedure for checking the water temperatures. The maintenance man reported he checked the water temperatures once a week. The maintenance man reported he documented the water temperatures. The maintenance man reported he had checked the water temperatures, on each hall at each end and in whirlpool rooms, four days ago. The maintenance man reported the temperatures had been running around 116 degrees Fahrenheit. The maintenance man was asked if he was aware the water temperatures were high on the new hall. The maintenance man stated, "No." On 05/19/15 at 1:35 p.m., the administrator was interviewed. The administrator was asked if he was aware of the high water temperatures. The administrator reported he was not aware the water was too hot. The administrator was asked if the facility had a system in place to monitor the water temperatures. The administrator reported the maintenance man checked the water temperatures on a weekly basis. The administrator reported the water temperatures were checked last Friday. The administrator reported the water temperatures had been checked four times this month. The administrator was asked what the water temperatures should have been. The administrator reported the water should not have been above 120 degrees F.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from unnecessary medications for five (#2, #8, #10, #15 and #16) of eight residents who were sampled for unnecessary medications. The facility failed to attempt a gradual dose reduction for the use of psychoactive medications. The facility identified 46 residents who received psychoactive medication. Findings: On 05/21/15 at 11:00 a.m., the administrator reported he was not able to find a policy for the reduction of medications. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order, dated 09/16/13, documented an order for [MEDICATION NAME] 15 milligrams (mg). The order documented to give 1 capsule by mouth at bedtime as needed for [MEDICAL CONDITION]. The quarterly assessment, dated 04/09/15, documented the resident was cognitively intact. The care plan, updated on 04/10/15, documented the resident had a medication to take for [MEDICAL CONDITION]. Pharmacy medication records were reviewed for the past year. The records did not document a recommendation from the pharmacist requesting the physician consider a gradual dose reduction (GDR) for [MEDICATION NAME]. On 05/19/15 at 4:45 p.m., the resident was observed in the dining room in her wheelchair. On 05/21/15 at 9:50 a.m., the director of nursing (DON) was interviewed. The DON was asked if a gradual dosage reduction had been attempted for the [MEDICATION NAME]. The DON stated a gradual dose reduction had not been attempted since 01/30/14. The DON reported the [MEDICATION NAME] had been administered to the resident every day during the month of May. 2. Resident #15 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A physician order, dated 04/09/14, documented an order for [REDACTED]. The annual assessment, dated 03/19/15, documented the resident was severely impaired in cognition. The assessment documented the resident took an antidepressant seven out of seven days. The care plan, dated 03/27/15, documented the resident had a [DIAGNOSES REDACTED]. Pharmacy medication records were reviewed for the past year. The records did not document a recommendation from the pharmacist requesting the physician consider a gradual dose reduction (GDR) for [MEDICATION NAME] . On 05/19/15 at 12:20 p.m., the resident was observed in her wheelchair in the facility lobby. 3. Resident #16 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A physician order, dated 10/18/13, documented an order for [REDACTED]. A physician order, dated 06/03/14, documented an order for [REDACTED]. A quarterly assessment, dated 03/13/15, documented the resident's cognition was intact. The assessment documented the resident was independent with activities of daily living needs. The assessment documented the resident had received antipsychotics seven out of seven days, antianxiety medications four out of seven days, and antidepressants seven out of the last seven days. The assessment documented no behaviors. A care plan, dated 03/13/15, documented the resident took [MEDICATION NAME] and [MEDICATION NAME] for depression. Pharmacy medication records were reviewed for the past year. The records did not document a recommendation from the pharmacist requesting the physician consider a gradual dose reduction (GDR) for [MEDICATION NAME] and [MEDICATION NAME]. On 05/19/15 at 12:40 p.m., the resident was observed resting in bed. 4. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician order, dated 01/09/14, documented the resident was to be given [MEDICATION NAME], 5 milligrams, two times a day for anxiety. A physician order, dated 01/24/14, documented the resident was to be given [MEDICATION NAME], 15 milligrams, once a day at bedtime for treatment of [REDACTED]. A care plan, dated 02/16/15, documented the resident had experienced anxiety for years. The care plan documented the resident was currently on [MEDICATION NAME]. The care plan documented [MEDICATION NAME] helped for a while but the resident was still anxious and agitated at times. The care plan documented the resident was taking [MEDICATION NAME] for depression and the staff was to notify the nurse if signs of increased depression were observed. A quarterly assessment, dated 05/11/15, documented the resident was severely impaired with cognitive skills. The assessment documented the resident did not exhibit behaviors. The assessment documented the staff was unable to complete the mood assessment due to no response from the resident. On 05/19/15 at 8:54 a.m., the resident was observed in bed sleeping. Behavior sheets were reviewed for the last 6 months. No behaviors were documented. Pharmacy medication records were reviewed for the past year. The records did not document a recommendation from the pharmacist requesting the physician consider a gradual dose reduction (GDR) for [MEDICATION NAME] or [MEDICATION NAME]. 5. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order, dated 02/13/14, documented an order for [REDACTED]. A care plan, dated 04/06/15, documented the resident had experienced depression in the past but was now on a medication that was working well. The care plan documented the staff would notify the nurses if the resident was more depressed than usual. A quarterly assessment, dated 05/06/15, documented the resident was cognitively intact. The assessment documented the resident did not have problems with mood, behavior or psychosocial issues. Pharmacy medication review records were reviewed for the past year. The records did not document a recommendation from the pharmacist requesting the physician consider a gradual dose reduction (GDR) for [MEDICATION NAME]. On 05/19/15 at 12:20 p.m., the resident was observed sitting in a wheelchair in her room. On 05/20/15 at 3:00 p.m., the director of nursing (DON) was interviewed. The DON was asked if there was a GDR request for antidepressants and anxiety medications. The DON stated he would look. On 05/20/15 at 3:35 p.m., the DON reported he spoke with the consulting pharmacist. The DON stated the consulting pharmacist told him that a GDR was not required for anything except an antipsychotic. On 05/20/15 at 3:40 p.m, the DON stated they had never included antidepressants or antianxiety medications in the GDR recommendations. On 05/20/15 at 5:10 p.m., the DON stated he spoke with the consultant pharmacist and the consulting psychiatric service. The DON stated the psychiatric service saw the resident monthly and reviewed the medications. The DON stated the pharmacist and psychiatric service would review all psychopharmacological medications for GDR recommendations from now on.

On 04/12/13 an immediate jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide adequate supervision to prevent falls and implement interventions to prevent the recurrence of falls. Falls continued on a recurring basis for residents #4, #6, #13, #14, and #15. On 04/12/13 the Oklahoma State Department of Health (OSDH) was notified and verified the immediate jeopardy situation related to the facility's failure to provide adequate supervision to prevent falls and implement interventions to prevent the recurrence of falls for residents #4, #6, #13, #14, and #15. On 04/12/13 at 2:05 p.m., the administrator and director of nursing (DON) were informed of the IJ situation which also constituted substandard quality of care related to the facility's failure to provide adequate supervision to prevent falls and implement interventions to prevent the recurrence of falls resulting in a fracture for resident #13. On 04/12/13 at 6:55 p.m., the administrator and DON provided the survey team an acceptable plan of removal which stated: "Plan of Removal Immediately In-service: All employees who are not immediately available, and/or future employees will be in-serviced before being allowed to return to work. 1. LPNs on documentation, must update care plan on all falls & notify CNAs of all changes, Fall program, and provide them with updated list of interventions. 2. CNAs on Fall program and to observe and make sure all care planned interventions are being used or are in place. 3. Activities & Social Services on Fall program and to reassess all residents on fall program for activities that we can use as interventions. 4. Dietary Managers on Fall program and to reassess all residents on fall program for dietary interventions such as snacks. 5. Dietary Aides and Housekeeping staff on fall program and what is expected of them. Other Corrections: 1. Redo all fall risk assessments on all residents. 2. Change from quarterly to monthly fall assessment period. 3. Updated list of interventions. 4. Administrator, DON, and Fall Management Nurse will review all fall reports on all scheduled workdays. Looking for interventions and possible trends. A lack of intervention will result in disciplinary action. 5. A weekly Fall Meeting will be held with all department heads to review fall management program and results. This meeting will be documented. 6. A list of all residents for each wing that are on the fall management program will be placed in the front of the CNAs book on each wing. 7. We will begin reviewing care plan changes at all in-services. 8. Activities and Dietary Managers will reassess all residents on the fall program, and look for possible interventions in their areas. 9. Update Policy and Procedure on fall program. 10. The Quality Assurance team will review and monitor for compliance." On 04/15/13 at 11:20 a.m., the immediate jeopardy was removed when all components of the plan of removal had been completed. The deficient practice remained at a level of harm at a pattern. Based on observation, interview, and record review, 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 five (#4, #6, #13, #14, and #15) of nine residents sampled for falls. The deficient practice resulted in a fracture for resident #13. The facility identified 28 residents who had experienced a fall in the last 6 months. Findings: The facility's fall prevention program documented when a resident was admitted or readmitted to the nursing home, a fall risk assessment would be performed. The policy documented if a resident scored a six or above, the resident would be considered a moderate risk for falls. The policy documented if the resident scored a 16 or above the resident would be considered a high risk for falls. The policy documented any resident scoring a six or above, the health care team would determine if a resident should be on the fall prevention program. The policy documented residents would be reassessed on a quarterly basis and after any significant change. 1. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall assessment, dated 01/29/13, documented the resident had a fall assessment score of 22. The facility fall program documented the resident was on a low bed. An incident report, dated 02/07/13, documented the resident was found on the floor beside her bed. The incident report documented the resident reported she had hit her head. The incident report documented neurological checks were started and were within normal limits. The incident report documented there were no visible marks or open areas of the head. The incident report documented the resident was encouraged to use the call light when needing to get out of bed and await assistance for all transfers. An incident report, dated 02/09/13, documented the resident was found laying on the floor in front of her closet. The incident report documented the resident claimed she had bumped her right shoulder and right elbow. The incident report documented the resident was able to bend her right elbow without pain or discomfort. The incident report documented the resident was able to rotate her left shoulder. The incident report documented the resident sustained [REDACTED]. The incident report documented the resident was reminded to use the call light and not get up unassisted. An incident report, dated 02/11/13, documented the resident was on the floor. The incident report documented the resident had pulled the feeding pump and tubing stretching them across the room. The incident report documented the resident was sitting on her buttocks against closet. The incident report documented the resident had a water pitcher spilled on the floor. The incident report documented the resident thought she could walk across the room. No injuries were documented on the incident report. The incident report documented the resident had a body alarm in place. The incident report documented the resident was reminded to use the call light when she wanted to get up. An incident report, dated 02/13/13 at 10:42 a.m., documented the resident was sitting on the floor with her back against the bed. The incident report documented the resident was able to move all extremities with ease. The incident report documented the resident had a skin tear approximately 2 centimeters in size under her forearm. The incident report documented the staff was informed to check on the resident frequently. An incident report, dated 02/13/13 at 2:18 p.m., documented the resident was on the floor. The incident report documented the resident was able to move all extremities with ease and assistance. The incident report documented the resident was noted to have a small abrasion to the top of her head. The incident report documented the resident admitted she hit her head. The incident report documented the resident was reminded to use the call light when wanting to transfer. The incident report documented the staff was informed to check on the resident more frequently. A hospice travel log, dated 02/13/13, documented a hospice volunteer visited the resident for one hour. A nurse's note, dated 02/13/13 at 5:32 p.m., documented the resident had a bed alarm that she has been turning off. A significant change in status assessment, dated 02/15/13, documented the resident was moderately impaired with cognition. The assessment documented the resident required extensive assistance with bed mobility, transfers, and activities of daily living. The assessment documented the resident was not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, moving on and off the toilet, and surface to surface transfer. The assessment documented the resident had two falls with no major injury. In incident report, dated 02/15/13 at 8:45 p.m., documented the resident was on the floor with the trunk of her body between the chest of drawers and closet. The incident report documented the resident was holding her hand with her right hand. No bruising or raised areas were noted to her head. The incident report documented a head to toe assessment was performed. The incident report documented neurological checks were within normal limits. The incident report documented no noted rotation to the resident's feet or difference in the length of her legs. The incident report documented the resident's vital signs were within normal limits. The incident report documented the resident was assisted back to bed by staff. The incident report documented while performing incontinent care to the resident, she started yelling out with pain to her right hip. The incident report documented the resident's physician and husband were notified. The incident report documented the facility called (name deleted) to obtain an x-ray to the hip and femur. A nurse's note, dated 02/15/13 at 10:40 p.m., documented the resident requested to go to the emergency room . The nurse's note documented (name deleted) was called and the x-rays were canceled. The nurse's note documented the resident's husband and physician were notified. A nurse's note, dated 02/15/13 at 11:15 p.m., documented, "Out of facility via ambulance to (name deleted) for evaluation." A nurse's note, dated 02/16/13 at 9:50 a.m., documented, "Resident sent to (name deleted) via EMS at 11:15 a.m., was admitted ." A hospital orthopedic admission history and physical, dated 02/16/13, documented x-rays revealed a right hip fracture. A care plan, dated 04/02/13, documented the resident had several falls after coming back from the hospital. The care plan documented the last time the resident fell she broke her hip. On 04/12/13 at 9:10 a.m., the resident was observed in her bed. The resident was not observed to be on a low bed. On 04/12/13 at 10:15 a.m., registered nurse (RN) #1 was interviewed regarding the fall program. RN #1 reported any resident with an incident would be placed on 72 hour charting. The RN reported the facility decided what interventions to try on a resident according to their cognition. On 04/12/13 at 2:00 p.m., an interview was conducted with the director of nursing (DON) regarding the interventions put in place to prevent recurrence of falls. The DON reported when the resident came back from the hospital, she was on too many medications. The DON reported the facility notified the physician and the resident's medication orders were changed. The DON reported the resident was on too much Ativan, Fentanyl, and Hydrocodone. The DON reported the facility had called the resident's physician and got a medication reduction. The DON reported the facility notified the physician and got the Morphine changed from being administered as needed to being administered routinely. The DON reported the facility used a bed alarm for the resident. The DON reported the facility reported they had a certified nurses aide (CNA) to sit and color with her. The DON reported they did not use a fall mat for the resident. The DON reported the facility thought it might pose a fall risk. The facility was unable to provide documentation related to the interventions put in place to prevent the recurrence for falls for the resident were effective. On 04/12/13 at 4:00 p.m., the restorative nursing assistant (RNA) was interviewed regarding the residents on the fall program. The RNA reported the residents on the fall program had alarms. The RNA reported fall reports were passed from shift to shift. The RNA reported the resident was not on the restorative program. On 04/12/13 at 4:20 p.m., an interview was conducted with the activity director regarding resident's on the fall program. The activity director reported she had not been instructed to do anything extra with residents that were a high fall risk. On 04/12/13 at 4:30 p.m., an interview was conducted with certified nurses assistant (CNA #4) regarding residents on the fall program. The CNA stated, "We are to respond to alarms." The CNA reported she was never instructed on interventions for residents on the fall program. On 04/12/13 at 4:45 p.m., certified nurses aide #10 was interviewed regarding the facility's fall program. The CNA reported she was not aware of a fall prevention program. The CNA reported she was to report to the charge nurse if a resident had a fall. The CNA reported she was to keep a close eye on residents if they had a fall. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual assessment, dated 10/05/12, documented the resident was severely impaired with cognition and required extensive assistance with transfers and all activity of daily living needs. The assessment documented the resident had experienced one fall since the prior assessment. The care plan, dated 10/19/12, documented the resident needed help with transfers, but could not always remember and sometimes tried to transfer himself. The care plan documented staff were to check on the resident frequently to see if he needed to get out of or get into bed, be sure to have on shoes with soles that don't slip, make sure the brakes were locked on the resident's wheelchair when he was not using the chair. The care plan documented some of the resident's medications made him dizzy and he would need two staff to help him transfer. The care plan documented the resident had falls in the past. An incident report, dated 11/20/12 at 10:47 p.m., documented the resident was found on the floor on his right side next to a bed and his wheelchair was next to him. The report documented the resident was assessed, no injuries were noted, and the resident stated he was tired and going to get in that bed. The report documented the resident was assisted back into the wheelchair by staff. No fall interventions were documented. An incident report, dated 03/19/13 at 10:00 p.m., documented the resident was found on the floor in the hallway, laying on his right side with the wheelchair close by. The report documented the resident stated, "My bottom came out and the rest just followed." The report documented the resident was assessed and no injuries were noted. The report documented the resident was assisted back into his wheelchair by staff. A note on the incident report documented the resident had dementia and required frequent redirection, but there were no new changes or increased confusion at the time. An incident report, dated 03/30/13 at 10:40 a.m., documented the resident was found on the floor next to his wheelchair in another resident's room. The report documented the resident stated, "I need to lay down." The report documented the resident was assessed and a small purple bruise was noted to the resident's left elbow. The report documented the resident was assisted back into his wheelchair, taken to his room, and assisted to bed. The report documented the resident was advised to use the call light when assistance was needed. An incident report, dated 04/06/13 at 2:01 p.m., documented the resident was found on the floor in his room, lying on the buttocks, and the back, upper trunk and head were under his wheelchair. The report documented the resident stated he was getting himself to bed for a nap and fell . The report documented the brakes on the wheelchair were unlocked. The report documented the resident stated he hit his head on the front of the wheelchair while trying to get up off the floor. The report documented the resident was assessed and had a cut to the left side of the forehead approximately 1 centimeter (cm) long and 0.2 cm in width, the area was treated, neuro checks were started, and staff was instructed to not take the resident to his room until they were ready to change him and lay him down for a nap. An Oklahoma State Department of Health incident report form, dated 04/06/13, documented the fall on 04/06/13 at 2:01 p.m. The incident reported documented the resident was a moderate fall risk and was care planned accordingly. An undated fall program documentation, hanging at the nurses' station, documented the resident was on the fall program list. The document listed the resident had a low bed. No other interventions were listed on the document. On 04/10/13 at 9:50 a.m., the resident was observed in his room being provided incontinent care by staff. On 04/12/13 at 12:00 p.m., registered nurse (RN) #1 was interviewed regarding fall prevention for the resident. RN #1 reported the resident's problem was transferring. The RN reported a body alarm upsets the resident and staff watched him closely. On 04/12/13 at 4:20 p.m., the activity director (AD) was interviewed regarding the residents on the fall program. The AD reported she didn't do anything extra for residents who fall. The AD reported she was not involved with the fall prevention program. 3. The medical record for resident #6 documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. An incident report, dated 11/07/12 at 10:20 (a.m. or p.m. not known), documented the resident was found on the floor, hit her head, and had a knot on the left side of her head. There were no preventive measures documented on the incident report. A nurse's note, dated 11/25/12 at 6:00 p.m., documented the incident and documented the resident was encouraged to allow staff to assist with picking up clothing from floor. An incident report, dated 11/25/12 at 6:03 p.m., documented the resident was found sitting on the floor, the call light was on, and the resident was not near the call light. The report documented the resident reported she bent over to pick up laundry and slipped and fell . There were no preventive measures documented on the incident report. An incident report, dated 12/12/12 at 8:35 p.m., documented the resident was found sitting on the floor next to her bed. The report documented the resident reported she was going to the bathroom, the resident was reminded not to get too close to the edge of the bed before she was ready, and try to wear non-skid socks or shoes. An incident report, dated 12/27/12 at 8:10 p.m., documented the resident was found sitting on the floor next to her walker. The report documented the resident reported she got up to go to the nurses' station and lost her balance. The report documented the resident was reminded to slow down, make sure she used her wheeled walker correctly, and to wear non-slip socks or shoes. An incident report, dated 12/27/12 at 8:45 p.m., documented the resident was found sitting on the floor next to her recliner. The report documented the resident reported she was leaning over to pick something out of the recliner and lost her balance. The report documented the resident was reminded to be careful leaning over, to make sure she had her balance, her wheeled walker close by, and to wear non-slip socks or shoes. An incident report, dated 12/30/12 at 11:50 p.m., documented the resident was found laying on the floor. The report documented the resident had a one and half by one and half inch raised area to the back of her head and a 1 cm abrasion to her inner right wrist. The report documented the resident reported another resident grabbed her arm/shoulder and she lost her balance. The report documented the staff requested resident use call light when needing to get up out of bed. An incident report, dated 01/12/13 at 6:19 p.m., documented the resident was found sitting on the floor by the bed. The report documented the resident reported she was bending over to pick up a napkin from the floor. The report documented the resident was encouraged to use the call light and to request an aide to pick items off the floor. An incident report, dated 01/29/13 at 1:13 p.m., documented the resident was sitting on the floor, reported she lost her balance, and fell hitting her right shoulder and right hip. The report documented the resident was oriented to the call light, instructed to rise slowly, and not to attempt to transfer if dizziness occurred. An incident report, dated 02/04/13 at 2:38 p.m., documented the resident was found on the floor, the resident reported she got up out of bed, got her walker, and they both fell over. The report documented the resident was wearing slip proof socks and the staff advised the resident to transfer slowly and not to transfer when dizzy. The report documented the resident was re-oriented to the call light. An incident report, dated 02/10/13 at 6:50 p.m., documented the resident was found sitting in the floor. The resident reported she turned her right ankle and lost her balance and fell . Staff reminded the resident to come to a stop after turning and before continuing forward with ambulation. An incident report, dated 02/13/13 at 3:57 p.m., documented the resident was found sitting on the floor near the doorway and the resident complained of leg pain. The report documented the resident stated she slipped and fell because of her house shoes. The report documented staff requested a pharmaceutical review due to several falls. An incident report, dated 02/19/13 at 11:20 a.m., documented the resident was found on the floor. The resident reported she had lost her balance and sat in the floor. The report documented the resident's medications were under review due to frequent falls. A quarterly assessment, dated 03/09/13, documented the resident was cognitively intact without memory problems; had little interest or pleasure in doing things, feeling or appearing down or depressed; and had difficulty with sleep. The assessment did not document any behaviors for the resident. The assessment documented the resident required extensive assist with transfers, ambulation, dressing, hygiene, and was occasionally incontinent of urine. The resident's care plan, dated 03/09/13, documented the resident had medications which made her dizzy and she had frequent falls. The care plan documented, "peek in on me every two hours..." The care plan documented the physician had decreased her medications because of the falls. The care plan documented the resident reported she was falling due to tripping over her feet or sliding from the bed or chair and the falls had nothing to do with her medications. An incident report, dated 03/21/13 at 2:52 p.m., documented the resident was found on her buttocks on the floor. The report documented the resident stated she was bending over in wheelchair (W/C) to pick up a video off the floor and slid out of the W/C. The report documented the resident was instructed to alert staff when something was on the floor. The report documented the resident had taken Zanaflex an hour before the fall. On 04/10/13 at 5:00 p.m., the resident was observed in her room. The resident was alert, oriented and answered questions. The resident had a neck collar on to support her head/neck. She reported she had fallen at home prior to admission and had broken her neck. She reported she had been ambulatory in the past without assistance, but now she needed assistance from the staff. There was no alarm observed in the resident's room. The resident had sustained 12 falls since November 2012. There were 10 falls before the facility had a pharmacy review. The resident's care plan did not address interventions by the staff other than "peeking in on her every two hours" and some medication being taken away. On 04/12/13 at 12:00 p.m., RN #1 was interviewed regarding the multiple falls. She was asked if they had tried activities, scheduled toileting or more frequently room checks. She reported she was not sure about the activities, but the resident could tell you when she needed to go to the bathroom. The RN was asked if the multidisciplinary team had discussed ways to prevent the resident's falls. She reported she was not aware of the team discussing it, but they had the pharmacist review the medications. She reported the pharmacist had not found any medications that interacted and no changes were made. She reported doing education with the resident and she thought they may have tried an alarm. 4. The medical record for resident #14 documented the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. An incident report, dated 11/03/12 at 1:36 p.m., documented the resident was on the floor on her knees with the wheelchair (W/C) behind her. The incident report documented the resident had severe dementia. There were no preventive measures documented on the incident report. An incident report, dated 11/17/12 at 2:51 p.m., documented the resident was on the floor in the front lobby near her W/C. The report documented the resident had two skin tears to the top of her left wrist and the resident reported she was leaning over to pick something off the floor. There were no preventive measures documented on the incident report. An incident report, dated 01/02/13 at 9:24 p.m., documented the resident was sitting in the hallway in front of her W/C. The report documented the resident was assisted to her room where a body alarm was placed, the call light was put in reach, and resident and staff were reminded to ensure the resident had shoes or non-skid socks when up. An incident report, dated 01/18/13 at 11:50 p.m., documented the resident was sitting on the floor beside her W/C on the new wing and the resident reported she fell . There were no preventive measures documented on the incident report. An incident report, dated 01/28/13 at 8:43 p.m., documented the resident was on her knees in front of her W/C on the new wing and the resident stated she fell out on her knees. There were no preventive measures documented on the incident report. The quarterly assessment, dated 02/06/13, documented the resident had severely impaired cognition and required supervision with transfers and ambulation. The assessment documented the resident had experienced falls. The resident's care plan, dated 02/07/13, documented the following: "Mental wellness:..My memory is getting so bad... Behaviors: Sometimes I wander around the nursing home... Safety: I get very dizzy at times. I take medication to help with my dizzy spells. I take some medications that can make me dizzy as well. Please stand by me anytime I am up or when I transfer so don't fall. Also if you notice that I am dizzy, please tell my nurse so I can get my medication for my dizzy spells. I have had falls and the nurse put an alarm on my bed and my chair. Please make sure it is working at the beginning of your shift." A nurse's note, dated 03/06/13 at 9:44 p.m., documented the resident had been found that evening sitting in the hallway. The note documented the resident reported she went to get up to the hand rail and sat down. The note documented the resident's removable W/C cushion was also on the floor next to her. There were no preventive measures documented. An incident report, dated 03/07/13 at 12:52 a.m., documented the resident was found on the floor in the front hallway. The report documented the resident was unable to say what happened and a gripright was placed in the W/C. An incident report, dated 03/25/13 at 9:17 a.m., documented the resident was sitting on the floor in the activity room near her W/C. The report documented the resident was trying to re-situate the rug and fell out of the W/C. There were no preventive measures documented on the incident report. An incident report, dated 04/04/13 at 1:15 a.m., documented the resident was found on the floor in her room in front of her W/C and the resident reported she stood up and fell . There were no preventive measures documented on the incident report. A fall program update, dated 04/09/13, documented the body alarm was ineffective due to the resident taking it apart and a floor mat was not used due to it would increase her risk for falls. An incident report, dated 04/10/13 at 8:52 a.m., documented the resident was found on the floor in her room next to her bed and staff was instructed to check on the resident more frequently as she had dementia and could not remember to ask for assistance. On 04/12/13 at 12:30 p.m., RN #1 was interviewed regarding the falls and the lack of preventive measures on the incident reports and the care plan not containing new interventions other than to stand by the resident when dizzy and when she was ambulating or transferring and the alarm which was not successful. The RN reported they had tried an alarm, but she took it apart. She reported the resident was able to ambulate with her son daily and he came daily. She reported the resident had a low bed. The RN reported she was not sure what else they could do. On 04/12/13 at 5:00 p.m., the resident was observed in her W/C wheeling her self in the hallway near the nurses' station. The resident was pleasant and talkative. The resident was asked if she had fallen. The resident reported she did have falls. She reported she fell at night when going to the bathroom. There was no alarm on the resident. The resident was observed to wheel herself up the hallway. On 04/12/13 at 5:30 p.m., the resident's son was observed walking next to the resident who was ambulating behind her W/C. He reported the resident had frequent falls and he was not sure what the staff could do to stop her from falling. He reported she had taken the alarm apart. On 04/12/13 at 4:55 p.m., the ADM was interviewed regarding the problem with the resident's falls and no preventive measures. He reported he was aware they had a problem with the incident reports. 5. Resident #15 was admitted on [DATE] with [DIAGNOSES REDACTED]. An incident report, dated 10/30/12 at 4:03 p.m., documented the resident's chair alarm sounded, staff entered the room, and the resident was sitting in the floor in front of her wheelchair. The report documented the resident was assessed, no injury was noted, and the resident stated she fell asleep and fell out of her wheelchair. The report documented the resident was instructed to let staff know if she began feeling sleepy and she would be assisted to bed. The report documented the resident stated no and she would nap in her wheelchair. A nurse's note, dated 10/30/13 at 4:03 p.m., documented the fall, assessment, and intervention. The nurse's note documented the resident was already in therapy part B to assist with balance. No documentation was provided regarding therapy part B. An incident report, dated 11/03/12 at 10:21 a.m., documented the resident was on the floor in her bathroom, the chair alarm did sound, and the resident was leaning on right side. The report documented the

Based on record review, observation, and staff interview, it was determined the facility failed to: a) ensure accurate assessments for pain were completed to reflect the daily pain status for two (#2 and #3) of three sampled residents with documented pain. This had the potential to affect 34 residents identified by the facility as requiring medication for pain. b) ensure a pain medication was administered prior to provided treatments to stage III pressure sores for one (#3) of two sampled residents identified with pressure sores. This had the potential to affect three residents identified by the facility as receiving pressure sore treatments. c) ensure a resident was re-assessed for pain after the resident experienced pain and requested pain medication for one (#2) of three sampled residents with documented pain. This had the potential to affect 34 residents identified by the facility as requiring medication for pain. Findings: 1. The medical record for resident #3 documented the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/10/10, documented the resident had short term memory problems and moderately impaired decision making skills. The assessment documented the resident required total assist with transfers, bathing, and hygiene. The assessment documented the resident experienced moderate pain daily. The assessment documented the resident had three stage II pressure sores. The resident's care plan, dated 09/25/07, and updated on 05/13/10, documented the resident had a potential for pain R/T immobility, DMII, Bil [MEDICAL CONDITION], and mononeuritis. The care plan documented to medicate the resident as ordered. The care plan documented the resident should be assessed for the cause of pain and to document the location and intensity of pain. On 5/13/10, [MEDICATION NAME] Q 4h PRN was added to the care plan. On 09/30/08, the care plan documented the resident was at risk for skin breakdown D/T incont, DMII, gen debility and dementia. The care plan documented the resident had severe excoriation to buttocks. On 9/24/09, an order for [REDACTED]. A comprehensive pain assessment, dated 06/10/10, documented, "Does the resident have any diagnosis(es) which would give reason to believe he/she would be in pain? Yes If yes, describe cause and origin of pain: Bil amp, mononeuritis. Does the resident verbalize pain? No...Primarily non verbal. Nonverbal/noncognitive signs of pain No...Conclusion Requests pain meds freq. motions c hands toward mouth to request meds. Yells out freq at times..." A weekly pressure ulcer assessment, dated 08/20/10, documented, "1cm open area noted @ L hip c sloughing tissue noted @ wound bed...2 X 2.5 cm open area noted @ R buttocks c red color wound bed c excoriation noted surrounding area...2.0 X 1.5 cm open area noted @ R stump c sloughy tissue noted @ wound bed...2.5 X 1.5 black color eschar noted @ R stump c possible deep tissue damage. On 08/31/10 at 11:30 a.m., the ADM was informed of the need to observe the treatment to the resident's pressure sores. The ADM reported the resident was to receive a W/P after lunch and the treatment would be done after the W/P. On 08/31/10 at 1:15 p.m., the resident was observed in his bed. The resident had a left above the knee amputation and a right [MEDICAL CONDITION]. LPN #1 was observed to clean a stage III pressure sore to the right lateral aspect of the resident's leg. LPN #1 was observed to wet 4X4 gauze pads with NS and then placed the guaze pads into the open pressure sore and wiped around the entire circumference of the pressure sore with the wet 4X4s. The resident groaned out loudly. LPN #1 then took dry 4X4 gauze pads and placed them into the open area and wiped around the entire circumference of the pressure sore. The resident again groaned out loudly. LPN #1 told the resident he was sorry. LPN # 1 then cleaned an un-stageable pressure sore to the resident's left hip, which was covered with a yellow slough. LPN #1 was observed to wet 4X4 gauze pads with NS and then placed the guaze pads into the open area and wiped over the slough tissue, wiping around the entire circumference of the pressure sore. The resident groaned out loudly. LPN #1 then took dry 4X4 gauze pads and placed them into the pressure sore and wiped across the slough tissue around the entire circumference of the pressure sore. The resident again groaned out loudly. The resident was then turned onto his right side. The resident's buttocks were bright red with peeling skin. An open area was observed in the center of the coccyx area, which bled bright, red blood when touched. LPN #1 was observed to clean the excoriated buttocks with 4x4 pads and NS and then dry the entire area with dry 4X4 pads. The resident groaned out in pain during this procedure. On 08/31/10 at 1:30 p.m., LPN #1 was interviewed regarding the pressure sore treatment and the resident groaning out as if in pain. LPN#1 was asked if the resident had been medicated prior to the treatment. LPN #1 reported he was not sure if the resident had been medicated before he had provided the pressure sore treatment. LPN #1 reported he had not medicated the resident for pain. The resident's PRN MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The resident's care plan was reviewed again for any documentation regarding medicating the resident prior to providing pressure sore treatments. The care plan did not address providing pain medication before doing pressure sore treatments. On 08/31/10 at 3:20 p.m., the DON was interviewed regarding the wound treatment for [REDACTED]. The DON was asked if the nursing staff provided pain relief measures before providing pressure sore treatments. The DON reported some residents were medicated for pain before providing wound care. The DON was asked why the resident had not been medicated. The DON reported she did not know, but would get the nurse who was passing medications. On 08/31/10 at 3:25 p.m., LPN #2 was interviewed regarding the lack of medicating the resident prior to the pressure sore treatments. LPN #2 reported the resident had received pain medication at 9:30 a.m., and it was too soon to give another dose of the pain medication. On 08/31/10 at 3:55 p.m., the DON was interviewed regarding pain assessments. The DON reported a new assessment should be done when there was a change. A new comprehensive pain assessment was not developed to include the pain related to the resident's pressure sore treatment. There was no coordination of pressure sore treatment and pain medication administration documented to ensure the resident's comfort during pressure sore treatments. The observed pressure sore treatment was started at 1:15 p.m. The resident could have had the PRN [MEDICATION NAME], which was ordered every 4 hours at 1:30 p.m. 2. The medical record for resident #2 documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's care plan, dated 03/11/09, and last reviewed on 05/27/10, documented the resident had a potential for pain related to an amputation/debridement of the R heel due to osteo[DIAGNOSES REDACTED]. On 4/13/09, the care plan documented the resident had been readmitted with a RBKA. On 09/14/09, an order for [REDACTED]. A quarterly assessment, dated 04/09/10, documented the resident had long and short term memory problems with severely impaired decision making skills. The assessment documented the resident required total assist with transfers, hygiene and bathing. The assessment documented the resident had no pain and had two stage IV pressure sores. A comprehensive pain assessment, dated 04/09/10, documented, "Does the resident have any diagnosis(es) which would give reason to believe he/she would be in pain? Yes If yes, describe cause and origin of pain: [MEDICAL CONDITION], Amp (amputation). Does the resident verbalize pain? No...Conclusion No pain, intervention is not necessary. Re-assess quarterly or with onset of pain." The April 2010, physician's orders [REDACTED]. The PRN MAR for April 2010 documented the resident had received the [MEDICATION NAME] 7.5/500 mg twice on the 2nd, 3rd, and 9th. The [MEDICATION NAME] was also given once on the 21st, 22nd, and 29th. The quarterly assessment and the pain assessment, completed on 04/09/10, documented the resident did not have pain. However the PRN MAR indicated severe coccyx pain" The medical record contained pain screen assessments which documented: On 4/30/10, "No c/o pain stated @ this time." On 05/31/10, "Denies any c/o pain @ this time." On 06/29/10, "No c/o pain stated @ this time." On 07/28/10, "No c/o pain stated." A quarterly assessment, dated 07/08/10, documented the resident experienced moderate pain less than daily and had one stage III pressure sore. The August 2010 medication record documented the resident had received the [MEDICATION NAME] nine times. On 08/31/10 at 1:40 p.m., the resident was observed in her bed during a pressure sore treatment. The resident's buttocks were red and a stage III open area was observed at the sacral area. LPN #1 was observed to clean the pressure sore by flushing the area with NS. LPN #1 then injected Iodosorb into the open area and covered the area with a dressing. On 08/31/10 at 3:45 p.m., LPN #2, who had completed the pain screen for the resident, was interviewed regarding the resident's pain assessments documenting the resident had no complaints of pain when the PRN MAR indicated [REDACTED]. LPN #2 reported the resident did not complain of pain when she asked her. LPN #2 reported the assessment was just for the pain level on "that day." LPN #2 was then asked if the pain assessments were a true indication of the resident's pain since the assessments documented the resident was not experiencing pain and the PRN MAR indicated [REDACTED]. LPN #2 reported she only answered the questions on the form. She reported there was no place to document on the form if the resident was experiencing pain at other times. There was no comprehensive pain assessment in the medical record documenting the resident was experiencing pain or to address the location, severity, or pain relief measures, including non pharmacological measures to be attempted for the resident's pain. On 08/31/10 at 3:55 p.m., the DON was interviewed regarding the resident experiencing pain and the comprehensive pain assessment documenting the resident did not have pain. The DON reported a new comprehensive pain assessment should have been completed when the resident complained of pain or when the resident received a new order for pain medication. On 08/31/10 at 4:30 p.m., the MDS coordinator was interviewed regarding the resident's quarterly assessment, dated 04/09/10, documenting no pain when the PRN MAR indicated [REDACTED]. The MDS coordinator reported she did not know why she had marked it no pain. The MDS coordinator stated, "It is not right."