Every finding on record at The Cottage Extended Care

Based on observation and interview, the facility failed to: a. ensure medications were secure for 1 of 1 wound care cart, and b. ensure medications were secure for 1 of 2 nurse treatment carts observed. The administrator identified 86 residents resided in the facility. Findings: On 06/18/26 at 8:10 a.m., the wound care cart on the north wing of the facility was observed to be unlocked and unattended. The cart was observed to contain medicated wound care cream and wound wash. On 06/18/26 at 8:12 a.m., LPN #1 stated the wound care cart should have been locked. LPN #1 stated the wound care nurse did not come in until 9:00 a.m. and the night shift did not have a key to the cart and may have needed to change a dressing during the night. On 06/18/26 at 8:25 a.m., the DON stated the wound care cart should be locked when unattended. The DON stated the night shift had a key to the wound care cart. On 06/18/26 at 8:40 a.m., the nurse treatment cart on the south wing of the facility was observed to be unlocked and unattended. The cart was observed to contain insulin. On 06/18/26 at 8:42 a.m., the administrator stated for the security of the residents, the nurse treatment cart should be locked. On 06/18/26 at 8:45 a.m., LPN #2 stated they should have locked the nurse's treatment cart, but the phone rang and they went to answer it. LPN #2 stated the nurse's treatment cart should be locked at all times when not in use.

On 05/29/25 at 4:40 p.m., the OSDH was notified and verified the existence of a past non-compliance immediate jeopardy (IJ) situation related to the facility's failure to ensure wound care was completed as ordered. On 05/29/25 at 4:47 p.m., the administrator was notified of the immediate jeopardy (IJ) situation. The administrator was provided the IJ template Based on record review and interview, the facility failed to ensure a resident had wound care completed as ordered for 1 (#1) of 3 sampled residents reviewed for wound care. The DON identified 10 residents received wound care. Findings: A quarterly assessment, dated 02/07/25, showed Resident #1 had a brief interview for mental status score of 11, which indicated moderate impairment in cognitive ability, and had diagnoses which included chronic obstructive pulmonary disease and cognitive communication deficit. A physician order for Resident #1, dated 05/08/25, showed daily dressing changes for left medial ankle venous wound. A progress note, dated 05/27/25 at 1:18 a.m., showed LPN #1 changed the ankle dressing for Resident #1 because it was saturated. LPN #1 removed the soiled dressing and found live maggots in the wound. LPN #1 sought assistance from RN #1 who called the on-call physician, the DON, family, and hospice. Orders were received to send the resident to the hospital. A facility incident report, dated 05/27/25, showed LPN #1 found maggots in Resident #1's leg wound. Documentation showed the facility completed staff in-service regarding abuse on 05/27/25. A quality assurance meeting was held on 05/29/25 regarding abuse and wound care. All staff were educated on neglect on 05/27/25. All nursing staff were educated on wound care on 05/27/25. A head to toe assessment and an abuse neglect survey was conducted for all residents on 05/27/25. The DON began daily monitoring of all wound care to ensure it was being completed as ordered beginning on 05/27/25. On 05/29/25 at 1:42 p.m., the administrator stated there was no documentation for wound care for Resident #1 for several days and they had suspended all three nurses who were responsible for wound care. The administrator stated they had visited Resident #1 in the hospital, but Resident #1 did not have a reliable memory as the resident had insisted they had received wound care on 05/26/25. On 05/29/25 at 2:57 p.m., the DON stated a review of wound documentation for Resident #1 showed wound care had not been completed for five days. The facility had terminated the three staff members who had failed to complete wound care during this time period. On 05/30/25 at 3:14 p.m., LPN #1 stated on 05/27/25 just after midnight, they went to assist Resident #1 and noticed their ankle dressing was soiled and saturated through the sock that was covering the dressing. LPN #1 stated when they removed the sock, they could see the date on the dressing was 05/22/25. They removed the soiled dressing and found maggots in the wound bed. LPN #1 stated they asked RN #1 for assistance, RN #1 called the on-call physician, the family, the DON and hospice. LPN #1 stated the physician gave orders to send the resident to the hospital which they did immediately.

Based on record review and interview, the facility failed to complete a discharge summary for one (#98) of three sampled residents reviewed for discharge. The administrator identified 100 residents resided in the facility. Findings: A Discharging the Resident policy, revised December 2016, read in part, the following information should be recorded in the resident's medical record: the date and time the discharge was made, all assessment data obtained during the, and the signature and title of the person recording the data. Resident #98 had diagnoses which included chronic kidney disease stage 4, anxiety, and chronic obstructive pulmonary disease. Upon review of the resident's chart there was no discharge summary noted. On 01/08/25 at 8:07 a.m., the DON was asked what was the facility policy on discharge of a resident. The DON stated if the resident had a physician order to discharge, then the proper paper work was filled out, and the resident and/or family was educated. They stated if the resident was unsafe to go AMA the doctor would not write an order and the staff would do education with the resident and/or family. The DON was asked if when a resident was discharged if a discharge summary should be completed. They stated, Yes. The DON was then asked to review Resident #98's chart and was asked if a discharge summary was done upon discharge. They stated one was not done.

Based on observation, record review, and interview, the facility failed to ensure oxygen and breathing nebulizer tubing was dated for two (#24 and #59) of three sampled residents reviewed for oxygen and breathing nebulizer tubing. The administrator identified 100 residents resided in the facility. The DON identified 19 residents used oxygen in facility Findings: 1. Resident #24 had diagnoses which included chronic respiratory failure, hemiplegia left side effected, asthma, and history of transient ischemic attack. A Physician order, dated 11/26/24 documented an order for oxygen at 3L via NC to keep sats greater than 90%. On 01/06/25 at 1:57 p.m., Resident #24's oxygen tubing was observed with no date. On 01/08/25 at 8:56 a.m., Resident #24's oxygen tubing was observed with no date. A Treatment Administration record, dated December 2024 and January 2025, documented no order for nursing staff to change and date the oxygen tubing. On 01/08/25 at 10:20 a.m., the DON was asked what expectations the facility had for oxygen tubing to be changed and dated. The DON stated if oxygen was used routinely then the tubing should be changed and dated weekly. 41873 2. Resident #59 had diagnoses which included chronic obstructive pulmonary disease. A physician's order, dated 10/27/21, read in part, Budesonide Suspension [corticosteriod] 0.5 MG/2 ML 1 vial inhale orally two times a day for shortness of breath. A resident assessment, dated 11/10/24, documented Resident #59's cognition was severly impaired. A Treatment Administration record, dated December 2024 and January 2025, documented no order for nursing staff to change and date the nebulizer tubing. On 01/07/25 at 9:55 a.m., Resident #59's nebulizer tubing was dated 12/03/24. On 01/08/25 at 11:41 a.m., LPN #1 reported Resident #59 had nebulizer treatments twice a day. On 01/08/25 at 10:20 a.m., the DON was asked what expectations the facility had for oxygen tubing to be changed and dated. The DON stated if oxygen was used routinely then tubing should be changed and dated weekly.

Based on observation and interview, the facility failed to ensure call light cords were available in resident rooms for three (#1, 43, and #62) of twenty sampled residents whose call light cord system was observed. The administrator identified 100 residents resided in the facility. Findings: An Answering the Call Light policy, revised September 2022, read in part, Ensure that the call system is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. 1. Resident #1 had diagnoses which included functional quadriplegia, neuromuscular dysfunction, and expressive language disorder A communication care plan, dated 01/08/25, documented the resident had been offered a call light they could blow into, but refused respiratory exercises to make them able to use it. On 01/08/25 at 4:15 p.m., an observation was made of Resident #1's call light on the floor behind the head board of the bed. On 01/09/25 at 7:39 a.m., an observation was made of Resident #1's call light on the floor behind the head board of the bed. On 01/09/25 at 7:40 a.m., CNA #1 was asked the procedure for ensuring call lights were within reach of a resident at all times. CNA #1 stated they had to check and make sure the call light was where a resident could reach it. CNA #1 was asked to observe Resident #1's room and then asked if the call light that was on the floor was in reach of Resident #1. CNA #1 stated, No. 2. Resident #43 had diagnoses which included dementia and cognitive communication deficit. A fall care plan, dated 10/24/24, documented to routinely check that the resident's call light was within reach and encourage them to use it for assistance as needed. On 01/08/25 at 4:17 p.m., Resident #43's call light was observed clipped to the privacy curtain at the foot of their bed which was out of reach from the resident. On 01/09/25 at 7:50 a.m., Resident #43's call light was observed clipped to the privacy curtain at the foot of their bed. On 01/09/25 7:51 a.m., CNA #2 was asked what was the procedure for ensuring a call light was within reach of a resident at all times. CNA #2 stated they clipped it close to a residents hand so they could push the button when needed. CNA #2 was asked to observe Resident #43's room and shown call light clipped to the privacy curtain at the foot of bed and then asked if the placement of the call light was within reach of Resident #43 while in bed. They stated, No. 3. Resident #62 had diagnoses which included Alzheimer's and dementia. A care plan for impaired mobility, dated 11/12/24, documented to routinely check that the resident's call light was within reach and encourage them to use it for assistance as needed. On 01/06/25 at 4:33 p.m., an observation was made of the call light hooked to the cord on the wall behind the resident and not within reach of resident. On 01/07/25 at 8:30 a.m., an observation was made of the call light. It remained hooked to the back wall and not within reach of the resident. On 01/07/25 at 10:49 a.m., an observation was made of the call light. It remained hooked to the back wall and not with in reach of the resident. On 01/08/25 at 9:08 a.m., an observation was made of the call light hooked to the bed sheets not within reach of the resident. The resident was in their geri chair. On 01/08/25 at 10:38 a.m. the DON was asked the policy for placement of call lights for the residents while in their bed and/or chair. The DON stated call lights should be within reach at all times. On 01/09/25 at 7:51 a.m., CNA #3 was asked what the procedure was for ensuring a resident's call light was within reach at all times. CNA #3 stated they clipped it as close to resident as they could. CNA #3 was asked to observe Resident #62's room and asked if the call light hooked to their bed sheets was within reach of Resident #62 while up in geri chair. They stated, No.

Based on record review and interview, the facility failed to ensure physician's orders were obtained for catheter care for one (#1) of four residents reviewed for catheters. The DON identified 16 residents with catheters. Findings: Resident #1 had diagnoses which included urinary retention and chronic kidney disease. Resident #1's Significant Change in Status Assessment, dated 05/25/23, documented the resident was moderately impaired for daily decision making. A physician order, dated 09/22/23, documented Install Foley Catheter for Urinary Retention. On 11/28/23 at 1:05 p.m., LPN #1 stated that all residents with catheters should have an order for catheter care every shift and it should be documented in the TAR. At 1:40 p.m., RN #1 stated nurses typically perform catheter care and documented it on the TAR. They also stated all residents with a catheter should have an order for catheter care every shift. The TAR, dated 09/23, did not document any catheter care. The TAR, dated 10/23, did not document any catheter care. The TAR, dated 11/23, did not document any catheter care. The physician orders for Resident #1 did not document an order for catheter care. On 11/29/23 at 1:00 p.m., the DON was asked to provide documentation of catheter care and a physician order for catheter care. No additional documentation was provided.

Based on record review and interview, the facility failed to prevent facility staff from uploading a video recording of a resident being abused onto a social media platform for one (#73) of three sampled residents reviewed for abuse and neglect. The Resident Census and Conditions of Residents form, dated 09/06/23, documented 86 resident resided in the facility. Findings: Resident #73 had diagnoses which included Alzheimer's Disease and anxiety disorder. An Abuse and Neglect Prohibition policy, undated, read in part .Mental Abuse Includes, but is not limited to, humiliation, threats of punishment, deprivation or taking pictures/video that depicts the resident in a demeaning or humiliating way .No nursing home staff member is to publish or distribute pictures/video on personal social media . A cell phone policy, undated, read in part .Do not use cell phones or any other recording devices to take pictures or videos of residents . A hand written and signed statement, reported to be from CNA #5, dated 08/08/23, documented the CNA had viewed a video of CNA #4, FE #1, and Resident #73 on a social media platform in which the resident had been abused. An incident report, dated 08/08/23, documented CNA #5 had reported to the DON that two staff members, CNA #4 and FE #1, had abuse Resident #73 while CNA #4 recorded and then posted the recording onto a social media platform. A copy of a screen shot from the DON's email account, dated 08/09/23 at 3:27 p.m., documented a written statement reported to be from CNA #4 that stated they had recorded Resident #73 and FE #1 interacting and posted it. The document stated FE #1 had been joking with Resident #73 as they attempted to remove a towel from the resident. It further documented FE #1 had jokingly instructed the resident to stop fighting. A copy of a screen shot from the DON's email account, dated 08/09/23 at 3:30 p.m., documented the first name of FE #1 and a statement reportedly made by FE #1 which stated they had jokingly spoke to Resident #73, that the resident had resisted care in some manner not described, and that they were aware the interaction was being recorded at that time. A quarterly assessment, dated 08/10/23, documented the resident's cognition as severely impaired and they were totally dependent on staff for activities of daily living. On 09/15/23 at 9:19 a.m., the DON was asked to describe their investigation into the incident regarding Resident #73 reported by CNA #5 on 08/08/23. They stated CNA #5 had reported to the ADON that on 08/04/23 they had watched a video recording of Resident #73, CNA #4 and FE #1 posted on a social media platform. They stated, as reported by CNA #5, the video had shown FE #1 being recorded as they harassed, mocked, and put down the arms of the resident. The DON was asked who had written the incident report, dated 08/08/23, that was sent to the OSDH. They stated they did.

Based on observation, record review, and interview, the facility failed to protect a resident from physical and verbal abuse for one (#73) of three sampled residents reviewed for abuse and neglect. The Resident Census and Conditions of Residents form, dated 09/06/23, documented 86 resident resided at the facility. Findings: Resident #73 had diagnoses which included Alzheimer's Disease and anxiety disorder. An Abuse and Neglect Prohibition policy, undated, read in part .Residents will not be subjected to abuse by anyone (including, but not limited to: facility staff, other residents, consultants, or volunteers, staff of other agencies servicing the individual, family members or legal guardians, friends, and other individuals). A report will be made immediately to a supervisor or charge person in the event that an abusive action or an injury is suspected or observed . A cell phone policy, undated, read in part .Do not use cell phones or any other recording devices to take pictures or videos of residents . An incident report, incident date 08/08/23, read in part .[CNA #5] reported that [CNA #4] and [FE #1] were working on the 3-11 shift on 08/04/23. She reported that [FE #1] was harassing and mocking [resident #73], telling her to shut up, and putting her hands down while [CNA #4] was behind the camera laughing, and it was posted on social media . A copy of a screen shot from the DON's email account, dated 08/09/23 at 3:27 p.m., documented the full name of CNA #4 and that they had recorded Resident #73, that the resident was resisting care from FE #1, and that the video recording was posted. A copy of a screen shot from the DON's email account, dated 08/09/23 at 3:30 p.m., documented the first name of FE #1 and that they had jokingly spoke to Resident #73, that the resident had resisted in some manner not described, and that they were aware the interaction was being recorded at that time. A quarterly assessment, dated 08/10/23, documented the resident's cognition as severely impaired and they were totally dependent on staff for activities of daily living. On 09/08/23 at 11:25 a.m., Resident #73 was observed in bed with their eyes closed. No outward signs of abuse was observed. On 09/15/23 at 9:19 a.m., the DON was asked to describe their investigation into the incident regarding Resident #73 reported by CNA #5 on 08/08/23. They stated CNA #5 had reported to the ADON that on 08/04/23 they had watched a video recording of resident #73, CNA #4 and FE #1 posted on a social media platform. They stated, as reported by CNA #5, the video had shown FE #1 being recorded as they harassed, mocked, and held down the arms of the resident. The DON was asked who had written the incident report, dated 08/08/23, that was sent to the OSDH. They stated they did. They stated that was their documentation of their investigation

Based on record review, observation, and interview, the facility failed to ensure a suspected incident of abuse was reported to the administrator within two hours of discovery for one (#73) of three sampled residents reviewed for abuse and neglect. The Resident Census and Conditions of Residents form, dated 09/06/23, identified 86 residents resided in the facility. Findings: Resident #73 had diagnoses which included Alzheimer's Disease and anxiety disorder. An Abuse and Neglect Prohibition policy, undated, read in part .A report will be made immediately to a supervisor or charge person in the event that an abusive act or an injury is suspected or observed . An incident report, incident date 08/08/23, documented CNA #5 had reported viewing a video on social media of CNA #4 and FE #1 verbally abusing Resident #73 on 08/04/23. The report further documented CNA #5 had reported the incident to the ADON and DON on 08/08/23. A quarterly assessment, dated 08/10/23, documented the resident's cognition as severely impaired and they were totally dependent on staff for activities of daily living. On 09/08/23 at 11:25 a.m., Resident #73 was observed in bed with thier eyes closed. No outward signs of abuse was observed. On 09/15/23 at 9:19 a.m., the DON was asked about the incident of alleged abuse regarding Resident #73 that had been reported by CNA #5. They stated that on 08/08/23, CNA #5 had reported they had viewed a video recording that involved Resident #73 on a social media platform after getting off from work on 08/04/23. They stated CNA #5 reported the recording on their next work day which was 08/08/23. They stated CNA #5 originally informed the ADON then both reported to the DON. The DON then stated they had immediately informed the Administrator. They were asked if they knew the time frame in which an employee was required to report suspected abuse. They stated two hours but that CNA #5 believed it was ok to do so on their next work day. On 09/15/23 at 9:53, the ADON was asked what they knew about the incident regarding Resident #73 that had been reported by CNA #5. The ADON stated CNA #5 had reported viewing a video of Resident #73, CNA #4, and FE #1 on a social media platform that included the staff members speaking badly to the resident. They were asked when they had be alerted to the presence of the video recording. They stated it was 08/08/23. They were asked when did CNA #5 report watching the recording. They stated it was on 08/04/23. On 09/15/23 at 10:00 a.m., the administrator was asked when they had been informed of the recording of Resident #73. They stated the DON had contacted them on 08/08/23.

Based on interview and record review, the facility failed to ensure baths were provided for dependent residents for two (#63 and #244) of two sampled residents reviewed for ADL care. The Resident Census and Conditions of Residents form documented 82 residents required assistance or were dependent on staff for ADL care. Findings: The undated Bath Shower/Tub policy, read in part, .The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . 1. Resident #63 had diagnoses which included functional quadriplegia. The care plan, dated 07/11/23, documented the the resident had an ADL self care performance deficit with the goal of having all needs met on a daily basis. The five day MDS, dated [DATE], documented the resident was totally dependent on staff for personal hygiene and bathing. On 09/06/23 at 10:54 a.m., the resident's spouse stated the resident does not get scheduled baths. A review of bath sheets for Resident #63 documented bath/showers were provided on 07/26/23, 08/05/23, 08/09/23, 08/17/23. 08/23/23. 08/31/23, and 09/02/23. The resident received seven baths out of 16 opportunities. There was no documentation provided that indicated the resident had refused any opportunity for bathing. On 09/12/23 at 12:02 p.m., the DON stated all residents are to be offered two shower or bath opportunities each week. The DON reviewed the shower sheets for Resident #63 and stated it did not look like the resident received two showers per week. 2. Resident #244 had diagnoses which included legal blindness. The MDS assessment, dated 07/29/23, documented the resident was total assistance for personal hygiene. The Care Plan, dated 8/13/23, documented the resident had a self care deficit for bathing, dressing and feeding. On 09/06/23 at 11:16 a.m., the resident stated they do not get a bath very often. The resident stated they would like a bath more frequently. On 09/12/23 at 08:12 a.m., Resident #244 asked LPN#4 if they could get a bath today, that it had been 10 days since they had a bath. LPN#4 assured the resident that they would get a bath today The facility bath sheets documented the resident received a bath on 08/10/23, 08/16/23, 08/18/23, 08/24/23, 08/29/23, and 09/02/23. The resident received six baths out of 13 opportunities. On 09/12/23 at 12:02 p.m., the DON stated all residents are to be offered two shower or bath opportunities each week. The DON reviewed the shower sheets for resident #244 and stated it did not look like the resident received 2 showers per week.

Based on observation, record review, and interview, the facility failed to place functioning call light activation buttons where residents could access them for two (#38 and #76) of two sampled residents reviewed for call systems. The Resident Census and Conditions of Residents form, dated 09/06/23, documented 86 residents resided in the facility. Findings: A facility policy titled Call System, Resident , undated, read in part, .Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor . 1. Resident #38 had diagnoses which included frontotemperal neurocognitive disorder and age related physical debility. A quarterly assessment, dated 06/23/23, documented the resident required extensive staff assistance with activities of daily living. On 09/06/23 at 1:11 p.m., Resident #38 stated they had a problem with the call light activation button. They stated they could never find it. The button was observed on the floor to the left of the resident's bed. They were asked how often they could not reach the button. They stated it was daily. They stated the button also did not work. On observation the red button was depressed into the mechanism instead of protruding from the top. The resident was asked to activate the button. The resident was unable to place their finger into the hole to push the button. They were asked if anyone had been informed of the broken mechanism. They stated they could not give a name, but they told the aides many times. They were asked if the situation had caused them any problems. They stated no, because the aides come in periodically to check on them. On 09/07/23 at 10:29 a.m., the resident's call light was observed on the resident's floor. The mechanism was in the same condition. The resident was in bed with their eyes closed. On 09/08/23 at 8:51 a.m., the resident's call light was between the bed and frame to the left of the resident. When asked to retrieve the button, the resident could not reach the device. Once given the device the resident was asked to activate the call light. They were unable to place their finger into the hole where the button was located. 2. Resident #76 had diagnoses which included hemiplegia, hemiparesis, and absence of the left leg below the knee. A quarterly assessment, dated 08/25/23, documented the resident required extensive staff assistance with activities of daily living. On 09/06/23 at 12:09 p.m., Resident #76 stated their call light button did not work. They were asked where the button was. They motioned with their head to their left and stated it was somewhere in that direction. The call light mechanism cord was wrapped around the bed frame close to the resident's head with the actual button hanging within inches of the floor. Once given the call light button the resident was asked to activate the call light. They pushed the button but the light in the hall did not activate. The resident was asked how often the call light was out of their reach. They stated it was always out of reach. They were asked if it had caused them any problems. They stated no and they would wait for staff to come in the next time and tell them what they needed. On 09/07/23 10:29 a.m., the resident's call light button was observed hanging behind the resident's bed. The resident was in bed with their eyes closed. On 09/08/23 at 8:54 a.m., the resident's call light was observed hanging down from the bed frame to the right of the resident's head. The resident was asked if they could reach the button. They stated they could not. On 09/12/23 at 10:59 a.m., the DON was asked to make an observation in the room of Residents #38 and #76. Resident #76 was asked where their call light was. They stated they did not know. The call light button was found hanging from the resident's bed frame toward the floor. Moving to resident #38's bed their call light button was observed laying of the floor to the left of the resident. Resident #38 was asked where their call light button was. They stated they did not know. Observation of the call light button mechanism found it in the same state as before with the button situation pushed into the mechanism. The DON was asked what their expectation was regarding call light button placement. They stated the button should always be within reach and that staff would check for proper placement each time they entered the room. The DON pointed out that each button had a clip on it to secure the mechanism to the residents bedding. The DON used the clips to secure the mechanisms to the bedding of each resident. They stated they believe the cords may have been too short and would have them replaced.

Based on observation, interview, and record review, the facility failed to ensure dignity was maintained by covering urinary drainage bags with dignity bags for two (#32 and #61) of two residents reviewed for dignity. The DON identified 14 residents who required urinary drainage bags. Findings: 1. Resident (Res) #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan updated 04/20/21, read in parts, .Be sure cath bag is covered with dignity bag . A quarterly assessment, dated 10/13/21, documented the resident was severely impaired with cognition, was dependent on staff for activities of daily living, required an indwelling urinary catheter and was incontinent of bowel. On 11/29/21 at 11:13 a.m., Res #32's urinary drainage bag was observed from the hall and was not covered with a dignity bag. On 11/29/21 at 3:14 p.m., Res #32's urinary drainage bag was observed from the hall and was not covered with a dignity bag. Visitors were observed in the hall. On 11/30/21 at 9:35 a.m., Res #32's urinary drainage bag was observed from the hall and was not covered with a dignity bag. On 11/30/21 at 1:41 p.m., Res #32's urinary drainage bag was observed from the hall and was not covered with a dignity bag. On 11/30/21 at 2:23 p.m., CNA #1 stated the urinary drainage bag should have been covered with a dignity bag. On 11/30/21 at 3:30 p.m., the DON stated the urinary drainage bag should have been covered with a dignity bag. 2. Res #61 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan updated 10/08/21, read in part, . the resident had cognitive communication deficits . A quarterly assessment, dated 11/09/21, documented the resident was severely impaired with cognition, required extensive to total dependence on staff for activities of daily living, and required an indwelling urinary catheter. On 11/29/21 at 11:15 a.m., Res #61's urinary drainage bag was observed from the hall and was not covered with a dignity bag. On 11/29/21 at 3:10 p.m., Res#61's urinary drainage bag was observed from the hall and was not covered with a dignity bag. On 11/30/21 at 2:27 p.m., CNA #1 stated Res #61 was dependent on staff to maintain dignity and the urinary drainage bag should have been covered. On 11/30/21 at 2:30 p.m., LPN #1 stated the urinary drainage bag should have been in a dignity bag. On 11/30/21 at 3:30 p.m., the DON stated all residents who required a urinary drainage bag should have had dignity bags in place.

Based on observation and interview, the facility failed to ensure infection control was maintained in the kitchen. The facility failed to: a. cover raw chicken in the kitchen area. b. date and label ham and cheese in the walk in refrigerator. The DM reported 82 of 83 residents received meals from the kitchen. Findings: On 11/29/21 at 9:49 a.m., during the initial tour, raw chicken was observed thawing at room temperature, was unattended, and was not covered. A large package of cheese was observed in the refrigerator, was opened to air, slices were not individually wrapped, and had no open or expiration date. A package of sandwich ham was observed in the refrigerator and did not have a open or expiration date. On 11/30/21 at 11:30 a.m., a package of sandwich ham was observed in the refrigerator and did not have a open or expiration date. On 11/30/21 at 11:35 a.m., the DM stated the raw chicken should not have been thawing at room temperature, left unattended, and uncovered. The cheese and ham should have been dated and labeled.

Based on observation, interview, and record review, the facility failed to ensure nutritional status was maintained via tube feedings for one resident (#31) of one reviewed for weight loss with tube feedings. The census and condition form documented six residents who required tube feedings. Findings: Resident (Res) #31 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A re-admission MDS assessment, dated 10/13/21, documented the resident was severely impaired with cognition, required extensive assistance with activities of daily living, and required tube feeding. The assessment documented the resident had weight loss. A physician order, dated 10/06/21, documented the resident was to receive enteral feeding of [MEDICATION(S)] ( a nutritional replacement) at a rate of 55 ml/hr continuously. The order documented the resident was NPO (nothing by mouth). A care plan, dated 09/16/21, documented the resident required tube feeding related to dysphagia. The care plan documented intervention included [MEDICATION(S)] 1.5 at 55 ml an hour via peg tube, obtain weights twice a month, and was dependent with tube feedings. The EHR weights documented a weight change from 141 lbs. on 09/16/21 to 132.8 lbs. on 11/17/21. The weight loss percentage for the two months was 6.38%. The EHR did not document weight loss dietary notes, weight change notes, or physician notification of the weight loss. On 11/29/21 at 10:00 a.m., the resident was observed lying in bed with the head of the bed elevated 45 degrees. The resident's feeding pump was observed to have been set at 52 ml/hr. On 11/29/21 at 12:33 p.m., the resident's feeding pump was set at 52 ml/hr. On 11/30/21 at 8:30 a.m., the resident's feeding pump was set at 52 ml/hr. On 11/30/21 at 4:08 p.m., LPN #3 reported the feeding rate was ordered at 55 ml/hr. LPN #3 observed the feeding pump and stated the setting was set at a rate of 52 ml/hr and should have been 55 ml/hr. On 12/01/21 at 8:02 a.m., the DON reported they were unaware of the resident's weight loss. The DON stated the resident was weighed this morning and their weight was 140.2 lbs. The DON stated the nurses were aware of the correct rate of the feeding pump and failed to ensure the correct feeding pump rate was programmed.

Based on observation, interview, and record review, the facility failed to prevent accidents for three residents (#51, 73, and #191) of three reviewed for accidents. The DON identified 19 residents who had accidents in the past six months. Findings: 1. Resident (Res) #51 was admitted on [DATE] with diagnoses which included [CONDITION(S)], pathological fracture of the right femur, fracture of left pubis and left femur, and repeated falls. The resident's Care Plan dated 03/08/21, read in part .The resident was known to crawl out of bed. Minimize falls by anticipating contributing factors . A quarterly assessment, dated 11/02/21, documented the resident was severely impaired with cognition, required extensive to total dependence on staff for activities of daily living, and was always incontinent of bowel and bladder. The assessment documented there were no falls since the prior assessment. An incident note, dated 07/18/21, documented Res #51 was found on the floor and had an abrasion to the knee. An incident note, dated 08/25/21, documented Res #51 was found in the floor on a fall matt with no documented injuries. An incident note, dated 08/30/21, documented Res #51 was found lying on their right side on top of the floor matt with no physical injuries. On 11/29/21 at 10:45 a.m., Res #51 was observed lying in bed with their feet off the bed and facing the wall. On 11/29/21 at 3:11 p.m., Res #51 was observed lying in bed with their feet off the bed and facing the wall. The bed was observed raised in mid position. On 11/30/21 at 1:38 p.m., Res #51 was observed repositioning self in the bed. On 11/30/21 at 2:17 p.m., CNA #1 stated the resident's bed should have been at the lowest position to prevent accidents. On 11/30/21 at 2:33 p.m., LPN#1 stated the resident's bed was to be in the lowest position to prevent accidents. On 11/30/21 at 3:35 p.m., the DON stated the resident's bed should always be in the lowest position to prevent accidents. 2. Resident #73 was admitted on [DATE] with diagnoses which included [CONDITION(S)], anxiety, and major depressive disorder. An incident report form, dated 05/06/20, documented in parts, .came to nurse and stated they fell last night or early am .reported their right hip was hurting. Nursing staff documented they were unaware of the fall and was unable to locate documentation regarding the fall. The resident reported they fell in the hallway, there was water in the hallway and there were blankets down to soak up the water and the resident thought they had got around the water, but once they stepped in the water they went sliding down hard and the right hip now hurts. The resident stated they actually fell on their knees. a skin assessment was done and the resident's family and physician were notified. The resident was assessed, new bruises were found, and the bilateral hips are hurting. resident denies to have x-rays done at this time. pain 7 . The incident report form documented a wet floor as a predisposing environmental factor. A Fall Risk Evaluation, dated 05/06/20 at 3:08 a.m., documented the reason for the assessment was recent falls and history of one to two falls within the last six months. A quarterly assessment, dated 11/16/21, documented Res #73 was cognitively intact, was independent with all ADLs and required supervision for transfers and bathing. A care plan, last reviewed on 11/21/21, documented Res #73 was at risk for falls due to unsteady gait at times and obesity. The care plan documented, on 05/06/20, the resident reported a fall in the resident's room. The care plan documented interventions which included to assure the floor was dry, eliminate potential hazards, and monitor the resident's floor. On 11/29/21 upon arrival to the facility, and throughout the survey, a large blue tarp was observed on the roof of the facility. On 12/01/21 at 7:15 a.m., Res #73 was observed sitting in a chair by the nurse's station between hallways 1 and 2. Res #73 reported they had fallen in the past due to water in hallway 2. Res #73 reported there was a yellow portable sign further down hallway 2 warning of water. Res #73 reported the water had pooled beyond the sign and they didn't see the water until after they fell . Res #73 reported they saw water coming down the wall onto the floor after the fall. On 12/01/21 at 7:30 a.m., an unidentified resident reported they had seen water coming down the walls onto the floor in hallway 2 on more than one occasion. 3. Resident (Res) #191 was admitted on [DATE] with diagnoses which included presence of left and right artificial knee joints and morbid obesity. An annual assessment, dated 05/08/20, documented Res #191 was cognitively intact. The assessment documented the resident was independent with ADLs, except dressing and bathing, which required supervision. The assessment documented the resident was ambulatory with no use of devices and was steady at all times with ambulation and transfers. The assessment documented falls were triggered in the care area assessment. A progress note, dated 06/26/20 at 10:11 a.m., documented in parts, .the resident found themselves on the floor after they stepped and slipped on a wet place on the floor outside their room. non injury fall at this time. resident educated to be aware of wet areas and to avoid them especially when signs are up and near wet areas. Fixed water leak and educated resident to pay attention to watch out for surroundings . On 12/01/21 at 10:30 a.m., the MS reported there were currently two ceiling leaks in the facility. The MS reported the leaks were located over the gym and office areas. The MS reported the tarps located on the facility's roof were due to a dispute between the owners and an insurance company. On 12/01/21 at 10:40 a.m., the Administrator reported the maintenance department had had a turnover of personnel and they were unable to locate maintenance logs dated 2020 concerning water leaks from the ceiling. The Administrator reported there was no leak in the ceiling during the time of Res #73's fall. The Administrator further reported there were no repairs of the roof or ceiling during the time of Res #73's fall. On 12/01/21 at 2:07 p.m., the DON reported she did not remember where the water leak documented on the 06/26/20 progress note was located or when it was repaired.

Based on observation, interview, and record review, the facility failed to ensure eye glasses were repaired for one resident (#42) of one sampled for vision. The DON identified 30 residents who required eye glasses. Findings: Resident (Res) #42 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 10/22/21, documented Res #42 was severely impaired in cognition and required moderate assistance with activities of daily living. A care plan, dated 10/30/21, documented in part I have impaired visual function. I will use appropriate visual devices glasses to promote participation in activities of daily living and other activities. Ensure appropriate visual aids, are available to support by participation in activities . On 11/29/21 at 10:09 a.m., Res #42 was observed with a piece of tape on the bridge of their eye glasses. Res #42 reported their eye glasses had been broken for approximately one month and had informed social services. On 11/30/21 at 2:10 p.m., SS #1 reported they were responsible for making eye appointments. SS #1 reported they were aware the eye glasses had been broken for about a month. SS #1 stated there no was documentation of appointment attempts for Res #42. On 11/30/21 at 2:21 p.m., LPN #1 reported, about a month ago, Res #42 had requested replacing the tape on the eye glasses. LPN #1 reported removing and replacing the tape on the eye glasses. LPN #1 reported notifying SS #1 about the broken eye glasses about a month ago.

Based on interview and record review, the facility failed to ensure the facility surety bond was in an amount to secure all personal funds of residents who deposited with the facility. The Administrator identified ten residents who had personal funds with the facility. Findings: On 12/01/21 at 11:00 a.m.,, the business office manager provided a trust fund statement for November 2021 in the amount of $73, 319.39. On 12/01/21 at 1:00 p.m., the Administrator provided a Certificate of Liability Insurance form, dated 09/20/21- 09/20/22, which documented the resident fund bond was $25,000. The Administrator reported they were unaware the surety bond did not cover liability of the resident trust fund.

Based on observation, interview, and record review, the facility failed to ensure a gradual dose reduction for a [CONDITION(S)] medication was conducted and a rationale was documented for one resident (#73) of five whose medications were reviewed. The census and condition form documented 22 residents who received [CONDITION(S)] medications. Findings: Resident (Res) #73 was admitted on [DATE] with diagnoses which included [CONDITION(S)], anxiety, and major depressive disorder. A physician order, dated 09/21/20, documented lurasidone HCl (an antipsychotic medication) 60 mg a day for [CONDITION(S)]. A physician order, dated 02/02/21, documented [MEDICATION(S)] (a sedative medication) one mg two times a day for anxiety. A progress note, dated 10/26/21, documented a pharmacy recommendation to reduce Res #73's [MEDICATION(S)] dosage. The physician documented to continue the medication the same with no documented rationale. A quarterly assessment, dated 11/16/21, documented Res #73 was cognitively intact. The assessment documented the resident had received antipsychotic medications on a regular basis and a GDR had not been attempted. The assessment documented the physician had documented a GDR was clinically contraindicated on 08/17/20. A care plan, last reviewed on 11/21/21, read in part, .consult with pharmacy, MD to consider dosage reduction when clinically appropriate . On 12/01/21 at 7:20 a.m., CMA #1 was observed administering [MEDICATION(S)] one mg to Res #73. On 12/01/21 at 7:30 a.m., Res #73 reported they didn't recall having medication changes in the past year. Res #73 reported they had a physician, per their request, who doesn't mess up my medicines. On 12/01/21 at 9:27 a.m., the DON reported the physician for Res #73 was utilized by a few residents who requested a different physician. The DON reported that another physician, who cared for the majority of the residents, was better with providing rationales on gradual dose reductions.

Based on interview and record review, the facility failed to ensure a baseline care plan was provided within 48 hours of admission for one (#81) of three newly admitted residents reviewed. The DON identified 83 new admissions in the past three months. Findings: Resident (Res) #81 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 08/25/21, documented to admit to hospice for [CONDITION(S)]. The EHR was reviewed and a baseline care plan was not documented. On 12/01/21 at 1:42 p.m., the DON stated the facility failed to perform an an baseline care plan within 48 hours of admission.

Based on interview and record review, it was determined the facility failed to ensure unauthorized images of a resident were not posted on social media for one (#3) of three sampled residents. This had the potential to affect all 79 residents who resided in the facility. Findings: A facility policy for cell phone use documented: .do not use cell phones or any other recording devices to take pictures or videos of residents . This policy was not in the new hire packet. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 06/23/2021, documented the resident was cognitively impaired and required the assistance of one person with transfers. A review of facility incident reports for August 2021 did not include an incident report pertaining to this video snapchat. On 09/08/21 at 11:05 a.m., the resident was asked if she remembered being videotaped while in the transport bus. She stated she did not. At 2:45 p.m., seven CNA's were asked if they had ever observed or knew of any incidents of a staff member videotaping a resident and sharing it on social media. All staff members except one stated no. CNA #1 stated on 08/25/21, she had seen a brief snapchat video on her cell phone of a transportation staff #1 and the resident. She stated it showed the transportation staff #1 and the resident smiling and waving at the cell phone camera while in the transportation van. She stated she reported the video to the social services person. At 3:14 p.m., social services (ss) was asked what they did with the information. SS stated they notified the administrator immediately. On 09/09/21 at 9:35 a.m., the administrator was asked what he did with the video information. He stated he viewed the video and immediately asked the transportation staff #1 to take the video off the social media. The administrator stated the video was removed from social media. The administrator stated he was not sure if the employee was provided with the cell phone policy on hire. He stated the cell phone policy was not in the new hire packet. The administrator stated an investigation of the incident was not conducted nor an incident report completed. A record review of the employee file documented a termination form dated 09/01/2021. The file documented he was terminated due to employee failed to follow policy on resident rights/exposing anything of a personal nature for a resident at any time.

Based on observation, interview, and record review it was determined the facility failed to ensure: ~ A resident, who required the assistance of two staff members with a lift transfer, received the necessary assistance for a safe transfer for one (#8) of three sampled residents who were reviewed for accident hazards. Resident #8 was transferred with a hoyer lift by one staff member and sustained a fractured tibia and a laceration to her leg that required sutures. ~ A resident who had been burned by coffee was assessed, supervision was provided, and interventions were put into place to prevent additional [MEDICAL CONDITION] one (#5) of three sampled residents who were reviewed for accident hazards. Resident #5 [MEDICAL CONDITION] her legs on three different occasions from the resident spilling hot coffee on herself. The administrator identified 72 residents who resided at the facility. Findings: An abuse policy documented that any incident that caused any injury to a resident must be reported to the abuse coordinator/administrator immediately during the day or night, the abuse coordinator would conduct an investigation or assign it to the SSD, DON, or ADON, the investigator should obtain statements from staff that may know something about the incident including signatures and dates, and a written report would be maintained with all recorded statements. A policy addendum, dated 06/01/12, documented the facility staff would report any incidents that resulted in fractures or treatment in a hospital to the Oklahoma State Department of Health. 1. Resident #8 had [DIAGNOSES REDACTED]. A care plan focus, dated 11/07/18, documented the resident had an ADL deficit related to acute and chronic illnesses and had a corresponding intervention which stated the resident required a total assist of two staff members for transfers, dated 04/03/19. An annual assessment, dated 11/14/18, documented the resident's cognition was moderately impaired, the resident was totally dependent on staff for transfers and required a two person physical assist. A quarterly assessment, dated 05/17/19, documented the resident's cognition was intact and she required extensive assistance with a two person physical assist for transfers. A progress note, dated 07/05/19 at 3:48 p.m., documented, CNA called this nurse to resident room resident in w/c with large pool of blood on floor under residents left calf area, pulled sock down and pant leg up large gash on inside of calf. grabbed stack of 4x4 (gauze) to stop bleeding trying to apply pressure to area using another stack of 4x4. another nurse came to room trying to help with pressure drsg finally able to get enough 4x4 then using [MEDICATION NAME] to help with pressure we were able to slow area down. resident and cnas state her leg hit the handle on the outside of her leg rest during the transfer using the hoyer .after slowing blood flow nurse called (ambulance) they arrived at 1510 (3:10 p.m.) and transported her out to (hospital name deleted) to eval and treat. An after visit summary, dated 07/05/19, documented the resident had been seen in the emergency department of an acute care facility on that date. It documented the resident was treated for [REDACTED]. A physician's assessment note, dated 07/11/19, documented the resident was examined at an orthopedic clinic on the above date. The note documented the resident had been injured on or about 07/05/19 and an evaluation of the resident found her to have a [MEDICAL CONDITION] distal tibia shaft and a laceration of her lower leg. It further documented the resident had reported her leg had gotten caught between a lift and a wheelchair as a nurse was trying to help her. On 08/21/19 at 9:05 a.m., the resident was observed resting in bed watching television. The resident was asked how in general her care had been at the facility. She stated that in (MONTH) a CNA working alone had transferred her from her bed to a wheel chair during which her left leg had come into contact with the lift which caused a cut and a lot of blood. The resident then referred to the injury as a broken leg. The resident was observed to have an orthopedic boot on her left leg. At 10:50 a.m., CNA #1 was asked how long she had worked as a CNA at the facility. She stated it had been six months. She was asked if she had worked with the resident. She stated she had done so frequently. She was asked if she had any information regarding an incident which occurred involving the resident in (MONTH) 2019. She stated she had transferred the resident out of bed and was lowering the resident into a wheelchair with a lift when the resident's leg hit a metal piece of the resident's wheelchair. She stated the resident's left leg had been cut and she had to be sent to the hospital. She was asked who had assisted her with the transfer. She stated she performed the transfer alone and that no other staff was in the room. She was asked if that lift required a one or two person assist. She stated there should have been a second staff present but there was only one CNA assigned to each hall that day. She was asked if she had requested assistance. She stated she had not as they were always short staffed. She was asked if she had filled out an incident report. She stated she had not and did not know if someone else had. She was asked if she was aware the resident had a broken leg. She stated she was told later after the resident's return from the hospital. She was asked if the resident had a broken leg prior to the incident. She stated she had no knowledge of a previous broken leg. At 11:15 a.m., the facility owner was asked to provide copies of any incident reports and investigative documentation for the resident in the month of (MONTH) 2019. At 1:56 p.m. the administrator was reminded of the request for incident reports and investigation documentation related to the resident which occurred in (MONTH) 2019. The administrator handed this surveyor a post fall evaluation form with an attached document titled, 5 whys worksheet, and a copy of a facility incident report dated 07/05/19 at 2:40 p.m. The incident report restated the facts of the incident as written in the nurse progress note, dated 07/05/19 at 3:48 p.m.; identified the injury as a laceration of the left lower leg; documented the resident's mental status as oriented to person, place, situation, and time; documented environmental factors as clutter and crowding; documented the incident had occurred during a transfer; listed witnesses as staff; the date as 07/05/19; and listed the physician as the person notified with the date 07/05/19 at 3:47 p.m. The post fall evaluation form, dated 07/05/19, documented LPN #2 had completed a nurse assessment, the fall [DIAGNOSES REDACTED]. An undated five why worksheet, documented the defined problem as the resident's left leg had been gouged by a wheelchair leg. It documented the reason why the incident occurred was that the wheelchair leg had been damaged, it had been dropped at some point in time, the aid may have missed the wheelchair, that many factors were possible, that the wheelchair had never been reported to have had any defects until post fall, and interventions were listed as hospital and new rounded left wheelchair leg. The document was signed by the administrator. On 09/22/19 at 12:28 p.m., the administrator was asked what information from staff, a resident, or family member would cause him to initiate an investigation. He stated any allegation of abuse, neglect, or misappropriation. He was asked how he would investigate the report of a newly discovered fracture or other injury. He stated he used a tool called a five why form that once completed would indicate the root cause and then he would put an intervention in place. He then stated any further investigation would be based on the conclusions found using the five why tool. He was asked what type of injury had the resident experienced on 07/05/19. He stated she had received a gash in her leg during a transfer. He was asked the cause of the injury. He stated that after he performed a root cause analysis he determined the cause was a defective piece of the resident's wheelchair. He was asked if any interventions were implemented. He stated the offending part of the wheelchair was replaced and other wheelchairs in the facility were inspected for the same defect. He was asked if any other interventions were put in place related to the incident. He stated the resident was sent out to the hospital. He was asked who he had interviewed post incident to determine what had caused the incident. He stated he had pulled his information from the incident report and had spoken to (CNA #1). He stated when he had found out the limit of the injury he had left it to the DON to handle the situation. He was asked if he had conducted a thorough investigation of the incident. He stated he had not but believed the former DON had. He was asked if he had followed up with the DON about the incident. He stated he had not as he had found the root cause of the incident and had put an intervention in place. He was asked if he had any documentation of any investigation the DON may have performed. He stated he would look. He was asked if he had reported the incident to the state. He stated he had not believed it was necessary and would attempt to contact the former DON to see if she had made a report. He was asked what the purpose of conducting a thorough investigation was. He stated to find the root cause and put interventions in place. He was asked how he found out the resident had a broken leg. He stated the resident had told him. He was asked when he had been told. He stated, yesterday. He was asked if he knew which leg had been broken. He stated the left leg. He was asked if a more thorough investigation should have been performed. He stated, yes and he should have followed-up. He was asked if he knew a single CNA had performed the transfer that day. He stated CNA #1 had told him she had help and he did not investigate further. At 12:42 p.m., the resident was asked when she acquired the fracture to her left leg. She stated in (MONTH) when the CNA transferred her and she had to go to the hospital. She was asked if she had previously fractured her leg. She stated she had never had a broken left leg. On 08/26/19 at 8:27 a.m., the current DON was asked if she had knowledge or if the facility had any documentation that the resident had a broken left tibia prior to 07/05/19. She stated she did not have knowledge of a previous fracture nor did she believe the facility had any such documentation. She was informed of the administrator's previous comment to search for an investigation that may have been conducted by the former DON and was asked if any such documentation had been found. She stated she had not found any such documentation. She was asked what should occur in the facility when a resident was injured. She stated an investigation which would include interviews with staff and residents who may have had knowledge of the incident, reporting of the incident to the physician, family, and administration, and if required, the state. She further stated corrective training of staff should also have occurred. 2. Resident #5 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/14/19, documented the resident was moderately impaired cognitively and required extensive to total assistance with ADLs. A wound evaluation and management summary report, dated 08/07/19, documented an initial evaluation of a shear wound of the right thigh. The wound measured 4 x 3.5 x not measurable cm. The wound had light serous exudate. The dressing treatment plan documented to apply hydrogel, apply a Gauze Island dressing with border, and apply skin prep to the peri wound area once daily. A wound evaluation and management summary report, dated 08/14/19, documented, .a thorough wound care assessment and evaluation was performed today. She has a shear wound of the right, posterior thigh for at least 1 days duration. There is light serous exudate. The patient appears to have associated pain evidenced by grimacing . The focused wound exam of Site 3 documented it was a shear wound of the right thigh. The wound size was 2.9 x 2.9 x Not Measureable cm. The wound had 100% thick adherent devitalized necrotic tissue. The wound was debrided. The dressing treatment plan was to apply collagen powder, apply a Gauze Island dressing with border, and apply skin prep to the peri wound area once daily. An initial evaluation of Site 4 documented it was a shear wound of the right, posterior thigh. It measured 6 x 9 x 0.025cm. The wound had light serous drainage. The dressing treatment plan was to apply Xeroform sterile gauze, with a Gauze island dressing with border once daily. The Physician's Order Summary Report, dated 08/21/19, documented: Skin assessments done weekly by a licensed professional. Document any abnormal findings in the nurse's notes. A care plan, initiated on 08/21/19 and revised on 08/23/19, documented: Focus The resident has actual impairment to her skin integrity related to blisters on both upper thighs. Right upper thigh anterior. Right upper thigh posterior and left upper thigh anterior (healed) The resident reported on 08/26/19 all of the wounds were from coffee burns. Goal The resident will remain free from complications related to skin impairment through the next review date. Interventions 08/26/19 cleanse the right thigh with normal saline, pat dry with clean gauze, apply thin layer of [MEDICATION NAME], cover with non-adherent dressing, and wrap with [MEDICATION NAME] Cleanse right thigh posterior with normal saline, pat dry with clean gauze, apply thin layer of [MEDICATION NAME], cover with non-adherent dressing, and wrap with [MEDICATION NAME]. Administer medications and/or treatments per the physician's orders. Monitor for adverse side effects and notify the physician as needed. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Coffee cup with a lid to be used to prevent spilling. Supervise/monitor resident while drinking hot liquids. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Monitor/document current location, size and treatment of [REDACTED].and notify the physician of changes. A hospital (name deleted) after visit summary, dated 08/23/19 through 08/24/19, documented, .Burn 08/23/19 Thigh Right; Inner;Anterior;Posterior Superficial partial, deep partial thickness (2nd) coffee [MEDICAL CONDITION] right thigh that wraps around to posterior . On 08/26/19 at 8:26 a.m., the DON was asked what should have been done when it was discovered the resident had a burn related to spilling coffee. She stated there should have been an investigation to ensure it did not happen again. The DON was asked how often skin assessments were completed for each resident. She stated skin assessments should be done one time a week. She was asked to provide weekly skin assessments for the resident. She stated the resident had only one weekly skin assessment. At 8:35 a.m., the resident showed the surveyor a new burn on her left inner thigh. She stated this was the third time she had been burned by coffee. She stated her son had brought her a coffee cup with a lid but it did have an opening to drink out of. She stated she did not know it was spilling because she had no feelings in her legs until she noticed the blanket she had across her lap was wet. She stated the first time she had burned her leg a male nurse had sprayed it with something and the blisters had collapsed. She stated she had peeled off the outer skin. She stated it was very red and had yellow in it. She stated she was holding a cup of coffee between her legs and it had spilled on her causing the burn. She stated the second time she had been burned by coffee she had decided to put the coffee cup between her leg and the side of the wheelchair. She stated it had spilled forward and had burned under the side of her knee and leg. At 8:36 a.m., CNA #2 was asked if she knew about the resident's first coffee burn. She stated yes. She stated she had notified her nurse about it. At 12:40 p.m., the wound physician was asked about the resident's [MEDICAL CONDITION] her right thigh. She stated she had noticed the first wound on her inner right thigh and then on her next visit she had noticed the second wound. She was asked why she had called it a shear. She stated she had no idea what the wounds were from so that was why she had called the wounds shear wounds. She stated she had asked the staff if they knew where the wounds had originated. She stated the staff did not mention anything about a coffee burn. At 1:00 p.m., LPN #1 was asked about the resident's burns. She stated she was aware of the resident's first burn but had been unaware of the second burn. She stated she thought she was notified of the first burn in (MONTH) 2019. The LPN stated there had been an area with blisters from the resident's coffee and she had called the physician and had received orders. She was asked when she had noticed the resident's first burn area. She stated she could not remember. At 1:15 p.m., the ADON and an LPN provided burn care to the resident. The ADON stated these wounds were coffee burn wounds. The oldest looking burn was on the resident's upper inner thigh. The wound measured 2.5cm by 4cm. The wound was red. The wound was cleaned with normal saline and Collagen Alginate was applied. The wound was wrapped with gauze. The second oldest looking burn was under the resident's knee and back of the lower thigh. The wound was cleaned with normal saline and Xeroform was applied. The wound was wrapped with gauze. The burn measured 9.2cm by 3cm and 5.2cm by 3.4cm. The new burn was on the resident's right inner lower thigh and the other burn area was on the front of the right thigh. The area had blisters which measured 4.5cm by 9cm and the other area measured 4.5cm by 3cm. The resident had a burned area on her left inner thigh. The blisters had opened and there were two areas which measured 4cm by 1.2cm and 1.5cm by 2.5cm. The new wounds were not dressed at the time of the wound care because they were waiting for orders. At 2:40 p.m., LPN#1 was asked about whether she had called the physician or reported the burn to the DON. She was asked what orders she had received because there were no orders in the physician's orders and there was no orders on the TAR to document the burn wound care had been completed. She stated it had been a very busy time and she was not sure she had reported it to the DON or the physician. She stated she may have notified hospice. She stated there were no orders for treatment of [REDACTED]. At 3:15 p.m., the ADON was asked about orders for the resident's burn wound care. She stated there were no physician orders and there were no orders on the treatment sheet. She was asked how staff knew about the wounds and what type of treatment should have been done. She stated no one would know. She was asked what should have been done when the first wound was discovered. She stated an assessment should have been done, an incident report/state reportable should have been completed, and orders should have been received and put on the TAR.

On [DATE], a past non compliance Immediate Jeopardy (IJ) situation was determined to exist on [DATE], related to the failure of the facility to provide suctioning and notification of emergency medical services for a choking resident. The Oklahoma State Department of Health was notified and verified the IJ situation. At 2:55 p.m., the administrator and the director of nursing (DON) were notified of the past non-compliance IJ. The Immediate Jeopardy situation was determined to be past non-compliance. The facility had identified the deficient practice and put measures in place to prevent reoccurrence. ~ On [DATE], the DON initiated an investigation related to the incident on [DATE], which involved the failure to provide suctioning for a choking resident and the notification of emergency medical services. ~ The DON obtained interviews and written statements from the staff involved with the resident's care. ~ At 7:30 p.m., an inservice was initiated to the nursing staff which addressed the following: care for a choking resident, including [MEDICATION NAME] maneuver, suctioning if the [MEDICATION NAME] is unsuccessful with removal of the obstruction, and notification of emergency medical services. The inservices for all nursing staff concluded at 3:00 p.m. on [DATE]. Based on staff interviews and clinical record review, it was determined the facility failed to provide suctioning and call emergency medical services for a resident with a history of dysphagia, who had choked while being fed a mechanically altered meal, for one (#1) of one sampled resident who had choked during a meal. The facility identified 11 residents who had a [DIAGNOSES REDACTED]. Findings: The facility policy for Choking (Obstructed Airway Clearance), documented, Basic Responsibility: Licensed Nurse . Purpose: To clear airway of blockage of foreign object or food. Definition: The [MEDICATION NAME] Maneuver is a technique which involves sudden compression of the lungs to provide air pressure within the trachea to eject an object from the throat. The [MEDICATION NAME] Maneuver may restore airway patency and prevent anoxia by removing the airway obstruction. Assessment Guidelines: (MONTH) include, but are not limited to: ~ Inability to speak. ~ Presence/absence of respirations. ~ Cyanosis. ~ Level of consciousness. ~ Respiratory distress. ~ Universal sign of inability to breathe by holding the neck . General Documentation Guidelines: Documentation may include: ~ Date and exact time symptoms of obstruction noted. ~ Procedure performed. ~ Notification of paramedics (exact time). ~ Notification of attending physician (exact time). ~ Notification of resident's representative. ~ Resident's response to procedure to relieve obstruction. ~ Exact time airway obstruction was relieved. ~ Condition of the resident after obstruction was removed, including vital signs and neurological signs. ~ Exact time paramedics responded to call. ~ physician's orders [REDACTED]. ~ Frequent follow-up monitoring and assessment of resident's condition. ~ Signature and title . The facility policy for Suctioning, Oropharyngeal/Nasopharyngeal, documented, Basic responsibility: Licensed Nurse . Purpose: ~ To remove secretions from the mouth, oropharynx and nasopharynx. ~ To prevent airway obstruction . Documentation Guidelines: Documentation may include: ~ Date, time, procedure. ~ Amount, color and consistency of material suctioned. ~ Condition of mouth, oropharynx, nasopharynx. ~ Frequency of suctioning. ~ Notification of physician if condition changes. ~ Signature and title . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A DNR consent form, dated [DATE], documented, .I understand that this decision will not prevent me from receiving other health care such as the [MEDICATION NAME] maneuver or oxygen and other comfort measures . An admission assessment, dated [DATE], documented the resident had a BIMS score of four. This score indicated the resident was severely impaired with daily decision making. The assessment documented the resident required extensive assistance with eating by one person, received a mechanically altered diet, had no difficulty with coughing or choking, and was received speech therapy. A care plan, dated [DATE], documented, Focus: I have a potential nutritional problem r/t Diet restrictions, dementia, dysphagia, hand contractures . Goal: I will have optimal nutrition . Interventions: I currently receive a regular diet with ground meat and nectar liquids .Monitor/record/report to MD PRN for s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals . A physician's orders [REDACTED]. A significant change assessment, dated [DATE], documented the resident had a BIMS score of four. This score indicated the resident was severely impaired with daily decision making. The assessment documented the resident required extensive assistance with eating by one person, received a mechanically altered diet, had no difficulty with coughing or choking, had a prognosis of life at six months or less, and received hospice services. An electronic progress note written by LPN #1, dated [DATE] at 6:40 p.m., documented, This nurse was in the dining room during dinner getting a resident something to drink when CMA (name deleted) called out for a nurse to help. This nurse went over to assisted dining room table and resident's face was red and she was unable to speak. Res had been eating her normal diet of ground meat with regular foods Nectar liquids. Two CNA's sitting at table. Resident's face went from red to blue and this nurse then initiated the [MEDICATION NAME] maneuver. This nurse called East Hall nurse back into the dining room from taking another resident back to their room. (Name deleted), LPN came into the dining room and took over the [MEDICATION NAME]. Then this nurse notified (name deleted) Hospice and they stated they would notify the nurse . An electronic progress note written by LPN #2, dated [DATE] at 6:50 p.m., documented, This nurse was called to to the dining room per CNA stating Resident is choking. Entered dining room, CMA was at resident's side, LPN (name deleted) was at resident's side performing [MEDICATION NAME] maneuver. Residents lips were cyanotic and particles of food noted in mouth and around lips. Sweep of the mouth brought a tablespoon amount of heavy secretions and ground hamburger. After multiple attempts to remove blockage, resident became unresponsive. (Name deleted), LPN, called (name deleted) hospice. Resident removed from dinging (sic) room to bedroom. Resident is DNR. Assessed per 2 LPNs, no s/s of life noted after two minutes. Time of last S/s of life was 1815. Don (sic), Adon (sic), Dr made aware of resident's passing. After life care performed. (Name deleted) hospice arrived. Family notified, funeral home notified. ME notified. On [DATE] at 12:45 p.m., the DON was asked to give an account of what had occurred with the resident on [DATE]. She stated she had been called and received report the resident had expired after choking in the dining room. She stated the nurse stated the [MEDICATION NAME] maneuver had been utilized by two LPNs and was unsuccessful. The DON stated the LPNs told her the resident had no signs of life and CPR was not initiated because the resident was a DNR. The DON stated the CMAs, CNAs, and the LPNs did not suction the resident nor did they notify emergency medical services. The DON stated she came to the facility to begin inservice at approximately 7:30 p.m. with nursing staff on duty, those that came in for the inservice, and those as they arrived for work. She stated she continued to inservice the nursing staff throughout the weekend on [DATE] and [DATE]. She stated she contacted the nursing staff by phone if they were unable to come to the facility until [DATE] at 3:00 p.m. The DON stated she verbally counseled the LPNs involved in the resident's choking on [DATE]. On [DATE] at 1:15 p.m., CMA #1 was asked to recall the incident of the resident choking on [DATE]. The CMA stated she had gone to assist with meal assistance in the dining room for the dinner meal. The CMA stated LPN #2 had advised to feed the resident small bites because the resident had trouble swallowing. She stated the resident had eaten one half to three fourths of her meal and had no coughing episodes. She stated she turned to assist another resident with her meal, turned back to see the resident was red in the face and was not able to talk. The CMA stated she yelled for LPN #1 who was in the dining room for help. She stated the LPN came over, observed the resident and started performing the [MEDICATION NAME] maneuver. She stated the LPN tried several times and asked someone to get the other nurse. The CMA stated LPN #2 took over the [MEDICATION NAME] maneuver and got something out of the resident's mouth. She stated the nurses removed the resident from the dining room. The CMA was asked if the LPNs attempted to suction the resident. She stated, No. The CMA was asked if anyone got the emergency cart. She stated, No. The CMA was asked if anyone called 911. She stated, No, not that I am aware of. I was so frightened. At 3:03 p.m., LPN#2 was asked to recall the incident when the resident choked on [DATE]. The LPN stated he had been in the dining room during the meal but had left to do an admission of a new resident. He stated a CNA came and told him he was needed in the dining room because the resident was choking and LPN #1 needed help. The LPN stated he took over the [MEDICATION NAME] maneuver and the resident was cyanotic around her mouth. He stated he got a tablespoon amount of thick secretions and hamburger meat swept from the resident's mouth. He stated the resident had no respirations and no pulse. The LPN stated he and LPN #1 took the resident out of the dining room back to her room because she had no signs of life. He stated CPR was not initiated because the resident was a DNR. The LPN was asked if he had suctioned the resident and had emergency medical services been called. The LPN stated he did not suction because he was afraid he would push the obstruction farther down and had hoped the [MEDICATION NAME] maneuver would dislodge the obstruction. He stated 911 was not contacted because the resident was on hospice and was a DNR. At 3:32 p.m., LPN #1 was asked to recall the incident when the resident choked on [DATE]. LPN #1 stated she was in the dining room during the evening meal and had gone to get another resident a drink when CMA #1 called for help. The LPN stated she looked at the resident, attempted to get the resident to speak, and proceeded to perform the [MEDICATION NAME] maneuver on the resident. She stated she was not successful with dislodging the obstruction. The LPN stated she asked someone to go get LPN #2 for assistance. She stated LPN #2 took over the [MEDICATION NAME] maneuver and she had gone to contact the resident's hospice. The LPN stated, she and LPN #2 took the resident back to the resident's room because the resident did not have a pulse or respirations. The LPN was asked if she had attempted to suction the resident. She stated she did not get the crash cart or attempt to suction the resident because she could not get the resident's mouth open to even sweep it out. The LPN was asked if 911 had been called. She stated no the resident was a DNR. On [DATE] at 12:05 p.m. through 3:48 p.m., nursing staff were interviewed regarding the inservice given after the choking incident on [DATE]. The staff stated they were taught about choking, the [MEDICATION NAME] maneuver, to suction if the [MEDICATION NAME] maneuver does not dislodge the obstruction, and to notify 911 even if the resident is a DNR.

Based on record review and interview, it was determined the facility failed to provide supervision to prevent accidents for one (#1) of four residents sampled for prevention of accidents. The facility failed to use two people for transferring the resident from the bed to the wheelchair according to the care plan. According to facility documentation, the resident experienced a fractured femur. The facility identified eight current residents who required assistance of two staff persons for transfers. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 10/19/13, documented the resident was at risk for falls related to weakness and poor vision, pain related to [DIAGNOSES REDACTED]. The care plan did not document the amount of staff assistance required for transfers or changing position in bed. The annual comprehensive assessment, dated 11/13/14, documented the resident's cognition was severely impaired with memory problems. The assessment documented the resident required extensive assistance of one staff person with bed mobility and transfers. The assessment documented the resident had occasional pain identified as a 6/10. The assessment documented the resident had a history of [REDACTED]. The physician's orders [REDACTED]. A nursing progress note, dated 08/05/14 at 7:26 p.m., documented a 2 inch by 3 inch purple bruise of unknown origin was noted to the top of the resident's right breast. The note documented a message was left for the resident's family to return the call to the facility. The notes did not document follow-up monitoring of the bruise. An incident report with investigation was not provided by the facility. A nursing progress note, dated 08/11/14 at 1:57 p.m., documented a large raised bruise had been noted to the left lower leg during the morning. The note documented the area was tender to touch. The note documented an x-ray was obtained which revealed no fractures. The note documented the family was notified. The notes did not document follow-up monitoring of the bruise. An incident report was provided to the surveyor. The report did not include documentation of a thorough investigation to determine the cause of the bruising. A nursing progress note, dated 08/13/14 at 4:43 p.m., documented a certified nurse aide (CNA) notified the nurse the resident had a bruise to the chest. The note documented the nurse assessed the resident and observed a large yellow and purple bruised area to the chest and breast with severe swelling to the right chest wall. The note documented the physician was notified and ordered a chest x-ray to be obtained. The notes did not document follow-up monitoring of the bruise. An incident report was provided to the surveyor. The report did not include documentation of a thorough investigation to determine the cause of the bruising. The care plan, updated 08/14/14, documented the resident was to be transferred by two staff members and the use of a gait belt. A physician progress notes [REDACTED]. A nursing progress note, dated 08/18/14 at 5:22 p.m., documented a CNA had notified the nurse of a bruise on the resident's right arm. The note documented the bruise extended from the neck down the arm. The note documented the physician was notified and ordered the resident to be evaluated at the emergency room . The note documented the resident's family was notified and informed the staff of the hospital of choice for the evaluation. The note documented the resident was transported to the hospital via the ambulance. An incident report was provided to the surveyor. The report did not include documentation of a thorough investigation to determine the cause of the bruising. A nursing progress note, dated 08/18/14 at 10:40 p.m., documented the resident returned to the facility with a [DIAGNOSES REDACTED]. The notes did not document follow-up monitoring of the bruise. An incident report was provided to the surveyor. The report did not include documentation of a thorough investigation to determine the cause of the bruising. A hospital emergency room report, dated 08/18/14, documented the resident had bruising in the right axilla which appeared to be secondary to minor trauma during lifting or moving the resident. The report documented a secondary cause of the bleeding could not be identified and suspected the large bruised area was secondary to antiplatelet therapy and minor trauma. The care plan, updated 09/01/14, documented the resident was at risk for spontaneous fractures related to osteoporosis and received medication which could increase bleeding into the tissues. The care plan documented the resident and staff were to be careful during transfers and movement to prevent bruises, cuts, or skin tears. A nursing progress note, dated 10/04/14 at 9:47 p.m., documented at 5:30 p.m. a CNA notified the nurse the resident was bleeding from her left big toe. The note documented the CNA stated she had assisted the resident from the bed to the wheelchair by herself for the dinner meal. The note documented the nurse had gone to check the resident when the report had been made of the resident's toe bleeding. The note documented when the nurse arrived at the resident's room the resident was observed sitting in the doorway to the room crying in pain and bleeding from the left big toe. The note documented the nurse observed the resident's left knee was swollen and the resident could not lift the left foot. The note documented the resident could not tell the nurse what had happened but continued to hold her left foot and cried. The note documented the resident was given pain medication. The note documented the physician was notified and an x-ray was ordered. The note documented a message was left for the resident's family to call the facility regarding the change of condition. The note documented the x-ray revealed a fracture of the left femur and the resident was transported to the hospital. The note did not document an assessment related to the bleeding toe. An incident report was completed but did not include a thorough investigation or measures to prevent recurrence. On 10/20/14 at 3:10 p.m., registered nurse (RN) #1 was interviewed regarding the resident's bruising. The RN stated the resident took Plavix daily. The RN stated the resident had a bruise on her upper chest which she thought had occurred on the weekend. The RN stated when she had seen it the bruise was yellow and red. The RN stated the resident frequently leaned forward. The RN stated she thought the resident might have leaned hard against the table causing the bruising but she did not really know how the bruise had occurred. The RN was asked if the resident had fallen to which she replied it was never documented the resident had fallen and the resident could not have gotten up from a fall without assistance. The RN stated she found the bruising on the resident's leg and reported it in the morning meeting. The RN stated she did not know how the bruise had occurred. The RN stated the resident would not ask for help and could not tell the staff if something was wrong. On 10/21/14 at 3:00 p.m., licensed practical nurse (LPN) #3 was interviewed regarding the resident's bleeding toe and fractured femur. The LPN stated she was asked by a certified nurse aide (CNA) to check on the resident because the CNA discovered the resident's toe was bleeding. The LPN stated when she arrived at the resident's room, the resident was sitting in the doorway to her room crying. The LPN stated she assessed the resident's foot and leg at that time. The LPN stated the toenail of the resident's left great toe was peeled away like it had been caught and was bleeding bright red blood. The LPN stated the resident's left knee was swollen and the resident continued to cry. The LPN stated the resident could not tell the staff if she was hurting but they knew when she cried she was in pain. The LPN stated she asked the certified medication aide (CMA) to give the resident pain medication and she (the LPN) contacted the physician. The LPN stated the physician ordered a portable x-ray be obtained. The LPN stated the x-ray indicated the resident had a fractured femur and the physician ordered for the resident be sent to the hospital for further evaluation. The LPN stated she asked the CNA what happened to the resident to which the CNA replied she did not know. The LPN stated the CNA told her she had transferred the resident by herself from the bed to the wheelchair without assistance from another staff person because the person assigned to the resident's care was running behind and she was trying to help her. The LPN was asked if the resident had fallen to which she replied no. On 10/21/14 at 3:30 p.m., CNA #10 was asked how much assistance the resident required for transfers. The CNA stated the resident was supposed to have two people assisting with transfers. The CNA was asked how long the resident had required two people for transfers to which she replied the entire time she had been employed which was approximately 6 months. The CNA was asked if two people had transferred the resident from the bed to the wheelchair at the time the incident occurred. The CNA stated a CMA had gone in to the room with her but she had transferred the resident from the bed to the wheelchair by herself. The CNA was asked how the incident occurred to which she replied she did not know. The CNA stated she had been in the dining room and did not see the resident so she went to the resident's room. The CNA stated the resident was fully dressed lying on the bed. The CNA stated the CNA assigned to the resident was running late so she got the resident out of bed to take to the dining room. The CNA stated that was when she noticed the resident's sock was full of blood and she went to tell the nurse. On 10/21/14 at 3:45 p.m., the physician was interviewed regarding the resident's bruising, the bleeding toe, and the fractured femur. The physician stated he had only assumed the care of the resident in mid August so did not have personal knowledge of the resident's past history. The physician stated the resident had a [DIAGNOSES REDACTED]. The physician stated the resident took Plavix which would put the resident at increased risk for bruising. The physician stated it was his policy the nursing staff contact him with any change of condition and stated the staff frequently called him. The physician stated when he received the call about the bruised arm he ordered an x-ray and the resident was evaluated at the hospital. The physician stated when the x-ray in October revealed the fractured femur he ordered for the resident be sent to the hospital for evaluation. The physician stated the resident did not get out of bed on her own so he wasn't sure how the fracture would have occurred.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care to attain and/or maintain residents' highest levels of well-being for three (#5, #7, and #8) of 15 sampled residents reviewed for care and/or services. The facility failed to: a) recognize and treat a change in pain status for resident #7. The resident fell and the facility did not notify the physician of the resident's fall or increased pain. b) assess risk factors for pain and implement measures to relieve pain for resident #5. The resident cried out, flinched, and resisted care during wound treatment. c) seek treatment for [REDACTED]. The census and condition identified zero residents on a pain management program. The census and condition documented 62 residents lived at the facility. Findings: The facility policy for pain management documented that all residents would be free from pain and would be screened for pain on admission or re-admission, quarterly and whenever a pain medication had been changed. 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The annual assessment, dated 02/06/13, documented the resident was severely impaired for daily decision making and required total assistance with the activities of daily living (ADLs). The assessment documented the resident did not have behaviors, did not refuse care, was incontinent of bowel and bladder, had impairment to both lower extremities, required two persons for transfers, and received nutrition via a feeding tube. The assessment documented the resident received routine and as needed pain medication, had verbal and non verbal expressions of pain, but did not have pain. The assessment documented the resident had a non-stageable necrotic pressure ulcer. The pain assessment, dated 02/06/13, documented the resident was unable to describe pain and did not have pain. The pain assessment documented the resident received routine and as needed pain medications as the physician ordered. The pain assessment documented the resident's pain was monitored and managed together with hospice. The care plan, dated 02/08/13, documented the resident had pain and was placed on hospice. The goal was to keep the resident comfortable and as free of pain as possible. The care plan documented a pain assessment was to be completed on admission, was to be updated per the facility policy, and pain screens were to be done as needed. The care plan documented the staff was to give the resident pain medication as the physician ordered and to position for comfort. The staff were to observe the resident for verbal and nonverbal expressions of pain and if the resident's pain was not relieved in 30 to 60 minutes hospice would be notified. The care plan documented the staff and hospice were to work closely together to manage the resident's pain. The physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 02/13/13 at 10:00 a.m., the resident was observed during peri-care. The resident flinched, cried out, and resisted care when care was given. On 02/13/13 at 10:20 a.m., the resident was observed while receiving wound care to the right heel. Licensed practical nurse (LPN) #3 washed the wound with normal saline and gauze. The resident groaned and began to resist care. The certified nurse aide (CMA) #1 asked the resident if the wound care hurt and asked the resident if she wanted medication for pain. The resident did not verbalize an answer but continued to groan and resist care. The nurse's notes, dated 02/13/13 on the 6:00 a.m. to 2:00 p.m. shift, documented the resident cried out with activity. The note documented the dressing change to the resident's right heel. The note did not document the pain the resident experienced during the wound care. There was no documentation to show the resident received pain medication before or after wound care. The MAR, dated 02/13/13, documented no [MEDICATION NAME] DM had been given to the resident during the day. On 02/15/13 at 10:55 a.m., the director of nurses (DON) was interviewed regarding the identification and treatment of [REDACTED]. The residents received pain medication for both verbal and nonverbal complaints of pain. The DON was asked about the pain resident #5 experienced. The DON stated the resident was not able to verbalize her pain. The DON stated when the resident had pain in her abdomen, the resident would frown and rub her stomach. The staff would give the resident pain medication and her pain would resolve in 30 to 45 minutes. The DON was asked if the facility had a policy regarding pre-medication for pain prior to a dressing change. The DON stated the facility did not have a policy for pre-medicating residents but the residents did receive pain medication if the resident did not tolerate the procedure. The DON stated if a resident experienced pain during a dressing change then the resident would certainly be pre-medicated for pain prior to the procedure. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission vital sign assessment, dated 11/15/12, documented the resident was in pain. There was not an admission pain assessment and it was not documented in the admission nurse's note that a follow-up was performed related to the report of pain on the 11/15/12 vital sign sheet. The admission assessment, dated 11/21/12, documented the resident was severely impaired for daily decision making and required assistance with activities of daily living (ADLs). The assessment documented that an admission pain assessment was needed. The care plan, dated 11/28/12, did not document interventions for pain. Physician monthly orders for February 2013 documented the resident did not have orders for medications for pain or fever. An incident report, dated 02/14/13 at 8:10 a.m., documented the resident fell in her room. On 02/14/13 at 12:15 p.m., the resident was observed in her room in the wheelchair crying. The resident stated, " I hurt so bad." The resident stated she did not want to sit in the wheelchair because her back hurt too badly. Certified nurse aide (CNA) #1 stated she would put a pillow behind the resident's back to help with the pain. On 02/14/13 at 12:30 p.m., the resident was observed in the wheelchair in the dinning room crying. The resident stated that her back hurt too much to eat. CNA #1 told the resident she would put the resident back in bed to eat and tell the nurse the resident was in pain. On 02/14/13 at 12:45 p.m., the resident was observed in her room in bed eating her lunch. The resident was crying and stated she hurt too much to eat. Certified medication aide (CMA) #1 stated the charge nurse had called the physician and gotten an order for [REDACTED]. On 02/14/13 at 1:30 p.m., the resident was observed in her room resting in bed. The resident stated she could not tell if the Tylenol helped the pain. On 02/14/13 at 1:45 p.m., licensed practicable nurse (LPN) #3 was interviewed regarding the resident's pain. The LPN stated there had not been an admission pain assessment performed nor had there been a change in pain condition assessment performed for the resident. On 02/14/13 at 2:15 p.m., the resident was observed lying in bed. Her brow was furrowed, and she was grimacing. The resident was asked if she was in pain. The resident stated she was in pain. CNA #2 was in the room and reported the resident's pain to the charge nurse. On 02/14/13 at 3:30 p.m., the resident was observed in the hallway in the presence of the assessment nurse. The resident stated her back hurt so badly because of the fall that occurred that morning. The resident asked the surveyor to please help her because her pain was horrible. On 02/14/13 at 3:40 p.m., the assessment nurse was interviewed regarding the resident's pain. The assessment nurse stated she would call the physician to get different pain medication. On 02/14/13 at 4:30 p.m., the registered nurse (RN) was interviewed regarding the resident's pain. The RN stated the physician had been notified and they had just received orders to get an X-ray and to give the resident [MEDICATION NAME] 50 mg one every six hours as needed for pain. On 02/14/13 at 5:30 p.m., the assessment nurse was interviewed regarding the change in the resident's pain. The assessment nurse stated the resident had not been reassessed for pain. On 02/15/13 at 4:56 p.m., CNA #3 was asked how she could tell if a resident was in pain. The CNA stated by the signs the residents were expressing. The CNA was asked what she would do if she thought a resident was in pain. The CNA stated she would let the nurse know. The CNA was asked if resident #7 had complained of pain. The CNA stated the resident had been complaining her back was hurting. On 02/15/13 at 5:00 p.m., the licensed practical nurse (LPN #2) was asked how residents were monitored for pain. The LPN stated by observation of by facial expressions and nonverbal signs and asking the residents. LPN #2 was asked how often residents were assessed for pain. The LPN stated the resident were assessed for pain when needed. When asked where the information was documented the LPN stated that she was not sure. On 02/15/13 at 6:30 p.m., the physician was interviewed regarding pain management for the resident. The physician stated he was not notified when the resident first exhibited signs of pain. 3. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 11/08/12, documented the resident was totally dependent for activities of daily living, was at risk for pressure sores, and did not have pressure sores. A care plan, dated 11/13/12, documented the resident was dependent on staff for activities of daily living. The care plan documented the charge nurse would be notified of open areas in the skin and the physician would be notified as needed. The care plan did not document the resident had a bruised and/or open area on the right elbow. A physician's orders [REDACTED]. A weekly head to toe skin review record, dated 02/03/13, documented the resident had a healing bruise on the right elbow. A quarterly assessment, dated 02/08/13, documented the resident was totally dependent for activities of daily living, was at risk for pressure sores, and did not have pressure sores. A weekly head to toe skin review record, dated 02/10/13, documented the resident's skin had no open areas. On 02/15/13 at 10:45 a.m., the resident's skin was observed with the assistance of certified nurse aide (CNA) #7. A white wound dressing was observed on the resident's right elbow. Licensed practical nurse (LPN) #4 was asked if the resident had open areas of the skin. The LPN stated she was not aware the resident had a wound dressing on the right elbow. The LPN attempted to remove the soiled dressing from the resident's right elbow. The dressing was adhered to the open area on the elbow. The LPN left the room and returned with normal saline and gauze and soaked the dressing off the right elbow. The LPN was asked to describe the skin on the resident's right elbow. The LPN stated the area was red and pink and partially covered with a dried dark red area. The LPN was asked how long the wound on the resident's right elbow had been open and what treatment had been ordered. The LPN stated she did not know the wound was open. The LPN walked to the nurses' desk and reviewed the nurses' notes and physician's orders [REDACTED]. [REDACTED]. The LPN stated she received a verbal report from the previous shift, but did not receive information regarding the wound on the resident's right elbow.