Every finding on record at The Golden Rule Home

Based on interview and facility document review, the facility failed to ensure that the designated director of food service met the minimum required qualifications. Specifically, the facility did not employ a full-time Registered Dietitian (RD), and the facility Dietary Manager (DM) was not a certified dietary manager or certified food service manager, nor did she have an associate's degree or higher in food service management. This failed practice had the potential to affect 52 residents who received meals from the kitchen (total census: 56).Findings included: A facility Job Description & [and] Orientation Checklist, dated 07/1998, indicated the Dietary Manager (DM) position required, Bachelor's degree (B.A.) from four-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience. The job description further indicated the DM, Must hold or be capable of acquiring certificates required by the state. In an interview on 06/08/2026 at 10:14 AM, the DM stated she was not a Certified Dietary Manager (CDM) but was currently enrolled in the course. The DM stated the facility Registered Dietitian was at the facility one day per month. In an interview on 06/11/2026 at 1:13 PM, the DM stated she had been in the Dietary Manager position for about a year. The DM stated she had completed the Food Service Manager Exam and had a certificate. In an interview on 06/11/2026 at 2:04 PM, the Executive Director (ED) stated she thought the DM had a Food Service Manager certificate. In an interview on 06/11/2026 at 2:07 PM, the DM stated she did not have a Food Service Manager certificate. The DM stated she previously had the certification, but it had expired and she did not have a copy of the expired certificate. The DM stated she was working with the Registered Dietitian to do the Food Service Manager program and Certified Dietary Manager program. A review of the DM's employee file revealed the DM did not have an associate degree or bachelor's degree. The DM's employee file did not include any documentation that the DM was a Certified Dietary Manager or Certified Food Service Manager. In a telephone interview on 06/11/2026 at 3:42 PM, the Registered Dietitian stated the DM had a food handler certificate that all the kitchen staff completed once per year. The RD stated she thought the DM had a Food Service Manager certification, but because the RD was a contracted employee, she did not keep any employee records. The RD stated she would expect the DM to have the Food Service Manager certification after being in the position for a year. In an interview on 06/12/2026 at 8:40 AM, the ED stated she usually managed the hiring process. The ED stated the facility did not have a completed job description and orientation checklist for the DM. In an interview on 06/12/2026 at 12:50 PM, the ADM stated he was not aware that the DM did not have food service manager certificate. In a follow-up interview on 06/12/2026 at 3:26 PM, the DM confirmed that she did not have her Certified Dietary Manager or Certified Food Service Manager certifications. The DM further confirmed that she did not have an associate's or higher degree in food service management or hospitality. The DM stated she had been in the management position for about a year, with no previous experience as a food service director at any other nursing facility.

Based on observation, interview, and facility document and policy review, the facility failed to follow the planned, written menu for 1 of 2 meals observed. Specifically, the facility served incorrect portion sizes for the lunch meal on 06/09/2026. This failure had the potential to affect 52 residents who received meals from the kitchen (total census: 56).Findings included: A facility policy titled Menus, revised 10/2008, indicated Menus shall a) meet the nutritional needs of residents; b) be prepared in advance; and c) be followed. A facility Menu Guide Report for the lunch meal on Tuesday 06/09/2026 indicated the planned menu included 1/3 cup (c.) garlic mashed potatoes and 1/3 c. green peas for regular diets, pureed diets, and mechanical soft diets. The menu also included a #12 (1/3 c.) dipper of pureed meatloaf and a #16 (1/4 c.) dipper of pureed bread for residents on pureed diets. During observations of the lunch meal on 06/09/2026 beginning at 12:05 PM, the Dietary Manager (DM) served the mashed potatoes for all diets and the pureed meat and pureed green peas for pureed diets with a blue #16 (1/4 c.) dipper. The DM served the pureed bread with a black #30 (1/8 c.) dipper. In an interview on 06/09/2026 at 12:22 PM, the DM confirmed she had used a #16 dipper to serve mashed potatoes, pureed meat, and pureed green peas. The DM confirmed that she had used the #30 dipper to serve the pureed bread. The DM stated dietary staff should look in the menu book to know what size portion to serve. The DM looked at the menu and confirmed that she should have used the #12 (1/3 c.) dipper. The DM stated they had always used the blue #16 dippers and did not have enough of the #12 dippers to serve that size portion. The DM stated if they served the wrong portion sizes, residents could receive too much or too little food. In a telephone interview on 06/11/2026 at 3:42 PM, the Registered Dietitian (RD) stated she reviewed and approved the menus. The RD stated she expected the kitchen staff to follow the menus or make appropriate substitutions. The RD stated she expected staff to serve the correct portion sizes to ensure that residents received the right amount of nutrients. In an interview on 06/12/2026 at 11:58 AM, the Director of Nursing (DON) stated she expected the kitchen staff to follow the menus to meet the regulations. In an interview on 06/12/2026 at 12:50 PM, the Administrator (ADM) stated he expected the kitchen to follow the policy and procedures for following the menus. The ADM stated he was not aware that the kitchen did not have enough of the proper-sized dippers.

Based on interview and facility document and policy review, the facility failed to ensure the Medical Director participated in the facility's Quality Assurance and Performance Improvement (QAPI) Committee meetings as required for 13 of 13 reviewed QAPI meetings held during the timeframe from 05/30/2025 through 05/29/2026.Findings included: A facility policy titled. Quality Assurance and Performance Improvement (QAPI) Committee, dated 04/2014, revealed, This facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program. The policy specified, 3. The following individuals will serve on the committee: d. Medical Director. Review of QAPI meeting sign-in sheet dated 05/30/2025, 06/30/2025, 07/31/2025, 08/29/2025, 09/30/2025, 10/31/2025, 11/28/2025, 12/29/2025, 01/30/2026, 02/27/2026, 03/31/2026, 04/29/2026, and 05/29/2026 revealed no documented evidence the Medical Director participated in the meetings.During an interview on 06/12/2026 at 1:27 PM, the Administrator reviewed the QAPI meeting sign-in sheets and confirmed the signatures of those who signed as having attended and stated the Medical Director had not attended. During an interview on 06/12/2026 at 1:40 PM, the Administrator stated the Medical Director was in the facility on Wednesdays, but QAPI meetings did not always fall on Wednesdays. He stated the Medical Director's availability was limited. The Administrator stated they could reach out to the Medical Director if there were concerns but stated the Medical Director did not participate in the QAPI meetings by phone either. The Administrator suggested the facility may need to start conducting QAPI meetings at times the Medical Director was in the facility.

Based on observation, interview, record review, and facility policy review, the facility failed to assess smoking safety prior to allowing residents to smoke unsupervised, failed to supervise residents who required supervision with smoking, and failed to ensure residents who smoked did so in accordance with the facility's smoking policy. Failed practices were identified for 3 (Residents #68, #50, and #55) of 3 residents reviewed for smoking. The failed practices had the potential to affect 14 residents who smoked, according to a list provided by the facility. Specifically, the facility failed to:- reassess smoking safety and need for supervision for Resident #68 after the resident was observed in the smoking area with oxygen in use on two occasions;- assess Resident #50 for safety while smoking; and,- provide supervision with smoking to Resident #55, whose assessment indicated they were an unsafe smoker.Findings included: An undated facility policy titled, The Golden Rule Smoking/Vaping Policy indicated, All residents who smoke/vape will have a Safe Smoking Assessment completed upon or prior to admission and then will be re-evaluated periodically and/or upon a change in condition. The policy indicated, For the safety of our residents and staff, ALL residents that smoke, are not permitted to smoke with oxygen on or with oxygen cylinders in the smoking area. The policy further indicated, Residents that have been determined to be 'unsafe smokers,' may smoke in the designated area, but ONLY with supervision and only at designated smoke times. Unsafe smokers cannot keep any smoking material in their rooms or on their person. 1. An admission Summary (Standard) indicated the facility admitted Resident #68 on 01/09/2026. According to the admission Summary, the resident had a medical history that included diagnoses of polyneuropathy, dependence on supplemental oxygen, obstructive pulmonary disease, and type 2 diabetes mellitus. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2026, revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident had no limitations in functional range of motion of the upper extremities. According to the MDS, the resident had shortness of breath, currently used tobacco, and received oxygen therapy. Resident #68's Care Plan, with an onset date of 01/23/2026, included a Category/Problem statement that revealed the resident was homeless as a result of a fire, having lost all of their belongings. The Category/Problem statement indicted Resident #68 had not planned to move to a nursing home and was acclimating to the environment. The Category/Approaches section of the care plan revealed Resident #68 liked to go outside to the patio to smoke. Another Category/Problem statement indicated Resident #68 became teary when they had an altercation with a previous roommate and required redirection and distraction. The Category/Approaches section directed staff to remind the resident of the dangers of not following the physician's advice such as smoking, safe smoking practices, and following the physician's orders. The Care Plan also indicated the resident had been educated on the dangers of smoking and offered tools to help them quit smoking, but Resident #68 chose to continue to smoke. The Care Plan directed staff to redirect the resident when their behaviors were inappropriate and to remind the resident that oxygen must be removed prior to smoking for fire safety. Resident #68's Safe Smoking Assessment dated 01/09/2026 included Yes responses to all questions, meaning the resident had no cognitive, visual, communication, or physical concerns that would prevent them from smoking safely. The Registered Nurse (RN) who signed as having completed the Yes/No questions section of the form did not check a response at the bottom of the form to indicate whether Resident #68 was deemed to be a Safe smoker or an Unsafe smoker. The bottom section of the form contained a space for an interdisciplinary team (IDT) member to sign and date the form. The signature and date line were left blank. Resident #68's Nurses Notes, dated 04/20/2026 at 10:00 AM and authored by Licensed Practical Nurse (LPN) #3, indicated the resident had increased lethargy and was unable to hold a medication cup, spilling the contents on the floor. The note indicated that the resident was slurring words and unable to keep their eyes open. A Nurse's Note, dated 04/20/2026 at 12:00 PM and authored by LPN #3, indicated that Resident #68 was outside in the smoking area with their oxygen on. The note indicated that the resident was removed from the smoking area and education provided. The note indicated that the resident denied smoking, and the nurse revealed that it was explained to the resident that the resident had been witnessed smoking. The resident then denied that the oxygen was turned on, and the note indicated that the resident was shown that the oxygen was on. The note indicated that Resident #68 was educated on not taking their oxygen outside to the smoking area. A Nurse's Note, dated 04/21/2026 at 11:00 AM and authored by LPN #3, revealed that Resident #68 was outside in the smoking area with their oxygen on. The note indicated that the Social Services Director (SSD) was notified the resident was noncompliant with removing their oxygen when outside smoking. A Notes Report for the timeframe from 01/01/2000 through 06/30/2026 revealed that on 04/21/2026 at 11:37 AM, the SSD documented in the notes that she was informed that Resident #68 had been outside around smokers with their oxygen on. The note indicated that the SSD went outside and had a conversation with the resident and informed the resident that no resident was to be in the smoking area while using oxygen. Further review of smoking information for Resident #68 revealed a copy of the facility's Smoking/Vaping Policy was signed by Resident #68 on 05/13/2026. Resident #68 was interviewed on 06/10/2026 at 8:50 AM and stated that when staff observed them in the smoking area with oxygen, the oxygen was not turned on, and the tubing was not connected to the oxygen machine. Resident #68 stated they went to the smoking area every two to three hours, adding that sometimes they just sat outside and sometimes they smoked. Resident #68 stated they kept their own smoking materials and had no supervision when smoking. The resident remembered being approached by the Executive Director (ED) and the SSD about smoking but was unable to recall Licensed Practical Nurse (LPN) #3 addressing the smoking and oxygen issue with them. Resident #68 confirmed again that the oxygen tank was not turned on and they had not been smoking at the time they were approached by staff. Certified Nursing Assistant (CNA) #9 was interviewed on 06/10/2026 at 9:05 AM and stated she had not observed any residents using oxygen in the smoking area. The CNA stated most residents were independent smokers and were allowed to keep their smoking materials. CNA #6 was interviewed on 06/10/2026 at 9:10 AM and stated she had not seen any residents smoking while using oxygen, and if she did, she would report it to the nurse and remind the resident they should not be wearing oxygen while smoking. During an interview on 06/10/2026 at 9:15 AM, LPN #3, who authored the 04/20/2026 and 04/21/2026 nurse's notes regarding Resident #68's smoking, stated Resident #68 used a portable oxygen tank and had been sitting in the smoking area with the oxygen tank. LPN #3 stated he had reminded the resident to leave the oxygen in the facility, and the resident agreed. LPN #3 stated that after he saw Resident #68 on 04/20/2026 in the smoking area with the oxygen, he saw the resident again in the smoking area with the oxygen tank and got the ED to go with him and witness the resident with the oxygen tank in the smoking area. LPN #3 stated there were no problems after that day. LPN #3 then reviewed the 04/20/2026 note that indicated he had seen Resident #68 smoking and stated he had not actually seen the resident smoking but had seen the resident sitting with a cigarette in one hand and the lighter in the other hand, adding he knew if he had not gone outside and stopped the resident, Resident #68 would have lit the cigarette. LPN #3 stated that at the time he stopped the resident, the resident's oxygen was functioning, and the resident was receiving oxygen through the nasal cannula. LPN #3 stated he turned the oxygen off and took the oxygen tank into the facility and acknowledged he had not documented any of his actions. LPN #3 stated he and the ED educated Resident #68 but had not documented what the education was about. The LPN stated Resident #68's smoking materials were not removed from the resident; he could give no reason why the smoking materials were not taken from the resident and stated he had not reassessed the resident for safe smoking. LPN #3 reviewed the nurse's notes he had written on 04/21/2026 and stated he had gotten the SSD to go with him to the smoking area to speak with Resident #68 about the resident's non-compliance with the smoking policy. The LPN stated the SSD told Resident #68 that if they wanted to go outside to just sit, to choose another location rather than going to the smoking area. LPN #3 stated he had not documented that education. LPN #3 stated he was unable to remember if there were any other residents in the smoking area when Resident #68 was there with their oxygen on 04/20/2026 or on 04/21/2026. LPN #3 stated smoking assessments were completed on admission by the admitting nurse. LPN #3 stated if Resident #68 had continued to smoke while using oxygen, the resident could have caught on fire or an explosion could have occurred that affected the entire facility. The Director of Nursing (DON) was interviewed on 06/10/2026 at 9:42 AM. The DON stated that smoking assessments were completed on admission and upon a change in condition and were completed by the assistant DON (ADON) or the charge nurse. The DON described unsafe smoking practices, such as a resident being unable to hold the cigarette, falling asleep while smoking, cognitive impairment, or smoking with oxygen on, but stated that each resident and situation was different. The DON stated if a resident with oxygen was alert and oriented, additional education and monitoring may be sufficient and defined monitoring as having the resident come by the nurse's station before going out to make sure the oxygen was not with the resident. The DON stated she had worked at the facility for three weeks, and she had no knowledge of any resident smoking with oxygen in use, but she had been made aware of a resident that had been in the smoking area with oxygen. The DON stated she had been informed that the resident had been educated and now left the oxygen inside the facility. The DON stated that upon admission, residents were asked if they smoked, and if they did smoke, a smoking assessment was completed. The DON stated she expected the resident's smoking status to be care planned, with smoking as the focus area and appropriate goals and interventions. The DON stated if a resident was smoking or in the smoking area with oxygen, the care plan should be revised to identify the hazard. The DON stated if a resident was observed smoking with oxygen, she expected a safe smoking reassessment to be completed. An observation was made on 06/10/2026 at 11:02 AM of Resident #68 returning to the facility from the smoking area. There was no oxygen tank on the resident's wheelchair. On 06/10/2026 at 11:09 AM, the ED was interviewed and stated she had educated Resident #68 that the resident was unable to go to the smoking area with oxygen in use. After that, the resident left the oxygen canister inside the facility. The ED stated Resident #68 also went outside to sit, since the resident frequently had no cigarettes. The ED stated she had not documented the education given to Resident #68. The ED stated the resident was frequently non-compliant with all things, but she had observed the oxygen being left by the door. However, since she was not there all the time, she could not say that the resident had not gone out with the oxygen again. The ED stated she was not sure what the smoking assessment said, and even if they did another smoking assessment, the resident was still going to be non-compliant with the smoking policy. The ED stated the way to make sure that all residents were safe was to keep an eye on Resident #68. The ED stated they had never given Resident #68 smoking materials and stated if she asked Resident #68 if they had smoking materials, the resident would say no. The ED stated she was not able to strip search the resident looking for smoking materials. The ED stated she expected Resident #68's care plan to reflect the resident's non-compliance with the smoking policy. Resident #64, who was identified as one of the 14 residents in the facility who smoked, was interviewed on 06/10/2026 at 11:23 AM. Resident #64 stated they admitted to the facility on [DATE] and had not seen any residents in the smoking area with an oxygen tank. Resident #64 stated the resident who used oxygen took the oxygen tank off their wheelchair and left it inside the facility when they went out to smoke. Resident #64's admission MDS, with an ARD of 05/27/2026, indicated the resident scored 15 on a BIMS, which indicated the resident had intact cognition. Resident #68 was interviewed again on 06/10/2026 at 1:50 PM and stated they used a small oxygen machine that fit on the side of the wheelchair. Resident #68 stated the machine was not heavy and was very manageable and that they were able to easily take the machine off the wheelchair and leave it in facility before going out to smoke. Resident #68 stated they had not used the portable oxygen machine in the past week since they were doing well. During the conversation, the resident was able to carry on a conversation without being short of breath. Resident #68 stated not taking methadone and keeping their fluid level down had helped them to breathe better. Resident #68 stated that upon admission, they were sure the facility had asked if they smoked but did not recall this for certain. Resident #68 stated that until the ED and SSD had spoken to them about smoking while using oxygen, they had not been educated about the risks of smoking with oxygen. Resident #68 stated again that at the time the SSD and ED approached them in the smoking area, they had not been smoking and the oxygen was not in the on position, the hose was unhooked from the machine, and the oxygen tubing was not on their face. Resident #68 stated at that time, that they understood the risks of having oxygen in the smoking area. Resident #68 stated that when the ED and SSD approached, there were no other residents in the smoking area. Resident #68 stated the only time they received cigarettes was when their family visited, and the last time they visited was in April. Resident #68 stated since April when they were in the hospital, the family would not buy any cigarettes, and residents did not share their cigarettes with other residents. During an interview on 06/10/2026 at 2:50 PM, the ED stated that even though Resident #68 had been non-compliant with the smoking policy, a 30-day discharge was not issued. The ED stated that Resident #68 had nowhere to go and discharging the resident would have been unsafe. The ADON was interviewed on 06/10/2026 at 2:25 PM and stated smoking assessments were completed on admission by the admitting nurse. She stated the interdisciplinary team (IDT) did not meet to determine if the resident was a safe smoker, but the admitting nurse completed the form and decided based on the answers to the assessment if the resident was safe to smoke independently. The ADON stated all smoking materials were to be kept in the medication room and added residents should not be in possession of their smoking materials. The ADON stated there was no set time for independent smokers to smoke. The ADON stated she was unaware that any residents were keeping their own smoking supplies. The ADON stated it was her responsibility to make sure the smoking book that kept the smoking assessments was accurate and up to date. The ADON stated she had no set time to review the book for accuracy. She stated the smoking book was updated not long ago; she was not sure when the update was done but knew she had reviewed the book after the former DON left. The ADON stated she sometimes missed things, such as removing discharged residents. The ADON stated she was in the facility when Resident #68 was outside in the smoking area with the oxygen machine. The ADON stated LPN #3 and the SSD were the ones who addressed the issue with Resident #68. The ADON stated that since April 2026, the resident had been leaving the oxygen equipment inside the building. The ADON stated that after Resident #68 was found with the oxygen machine in the smoking area, the resident was educated about the dangers of combining smoking and oxygen. The DON was interviewed on 06/12/2026 at 1:10 PM and stated she was not working in the facility when Resident #68 had been observed outside in the smoking area with oxygen. The DON stated that since she had been employed with the facility, she had not observed any issues related to Resident #68 and had observed the resident leaving the oxygen machine inside the facility when going out to the smoking area. The Administrator was interviewed on 06/12/2026 at 3:19 PM and stated he would have expected staff to document the education provided to Resident #68. The Administrator stated the reason Resident #68 had not been issued a 30-day discharge was because the resident was under Adult Protective Services (APS) supervision. The Administrator stated that as far as he knew, APS was not made aware of the resident not adhering to the smoking policy. The Administrator acknowledged that having the resident in the smoking area with oxygen could have a negative outcome. The Administrator stated that since April 2026, he had not seen the resident in the smoking area with their oxygen on the wheelchair. 2. An admission Summary indicated the facility admitted Resident #50 on 03/10/2026. According to the admission Summary, the resident had a medical history that included diagnoses of gout, rheumatoid arthritis, and heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/24/2026, indicated Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. An undated Safe Smoking Assessment with Resident #50's name at the top had a notation handwritten on the form to indicate the resident was a non-smoker. None of the questions on the form had a Yes or No response checked, and the form was not signed in the area designated for IDT [interdisciplinary team] Member Signature. Resident #50's Care Plan dated 04/29/2026 did not address Resident #50 smoking. In an interview on 06/08/2026 at 1:09 PM, Resident #50 stated they smoked independently and kept their smoking supplies in their room. In a follow-up interview on 06/10/2026 at 9:10 AM, Resident #50 confirmed that they smoked and showed the surveyor their cigarettes on the nightstand. Resident #50 stated they thought staff had assessed them for safe smoking. In an interview on 06/10/2026 at 9:26 AM, the Director of Nursing (DON) stated nursing completed the smoking assessments and the Assistant Director of Nursing (ADON) managed the smoking program. In an interview on 06/10/2026 at 10:40 AM, the DON stated nursing asked newly admitted residents if they smoked. The DON stated if a resident reported smoking, the nurse would complete a smoking assessment and add smoking to the resident's care plan. An observation on 06/10/2026 at 10:58 AM revealed Resident #50 outside smoking in the smoking area with other residents. No staff were present. In an interview on 06/10/2026 at 11:15 AM, Licensed Practical Nurse (LPN) #3 stated nurses completed smoking assessments upon a resident's admission. LPN #3 stated if they saw a resident smoking or found out later that a resident smoked, they would complete a smoking assessment at that time. LPN #3 stated he was not sure who was responsible for updating the list of residents who smoked. In an interview on 06/10/2026 at 2:33 PM, Advanced Certified Medication Aide (ACMA) #13 stated she knew who needed supervision while smoking by getting to know the residents. ACMA #13 stated she assisted Resident #50 up and down the ramp so that Resident #50 could go outside to smoke. 3. An admission Summary indicated the facility admitted Resident #55 on 04/01/2023. According to the admission Summary, the resident had a medical history that included diagnoses of diabetes mellitus, peripheral vascular disease, and atherosclerotic heart disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/10/2026, indicated Resident #55 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A Safe Smoking Assessment, dated 05/05/2025, indicated Resident #55 was determined to be an Unsafe smoker. The assessment indicated Resident #55 could not light and smoke a cigarette while demonstrating a safe technique for putting out the matches or lighter and disposing of ash. A Care Plan dated 06/16/2025 included a Category Problem statement that indicated Resident #55 was at risk for social isolation from decreased mobility and pain. Planned approaches indicated the resident liked to smoke and go outside to the smoking area and directed staff to encourage and remind the resident of the dangers of not following the doctor's advice such as smoking and safe smoking practices. In an interview on 06/10/2026 at 10:49 AM, Certified Nurse Aide (CNA) #16 stated she knew who smoked because she saw the smokers go outside or someone would tell her. CNA #16 stated she was not sure who supervised the smokers, but it was not her. CNA #16 stated she was not aware of any residents who required supervision with smoking. In an interview on 06/10/2026 at 11:08 AM, CNA #1 stated she was not aware of any residents who required supervision while smoking. An observation on 06/10/2026 at 1:55 PM revealed Resident #55 outside in the smoking area. Resident #55 stated they were a current smoker. In an interview on 06/10/2026 at 3:00 PM, the Assistant Director of Nursing (ADON) stated the charge nurse should let staff know if a resident required supervision with smoking. The ADON stated the nurse was responsible for knowing if anyone required supervision. The ADON stated she reviewed the smoking assessment binder but not daily and had only been responsible for the smoking program since March 2026. In an interview on 06/10/2026 at 4:15 PM, Licensed Practical Nurse (LPN) #2 stated she did not think any of the residents required supervision with smoking. LPN #2 stated if someone required supervision, they would have to set up smoking times for staff to go out to the smoking area to supervise the residents. LPN #2 stated she was not aware of any system to communicate if a resident required supervision with smoking. LPN #2 stated that nursing kept Resident #55's cigarettes in the medication room but gave Resident #55 a pack at a time to keep on their person. In an interview on 06/12/2026 at 12:42 PM, the Director of Nursing (DON) stated residents who smoked should have complete and accurate assessments. The DON stated if the assessment indicated a resident should be supervised, then she would expect them to be supervised. In an interview on 06/12/2026 at 12:50 PM, the Administrator (ADM) stated he expected residents who smoked to have a smoking assessment. The ADM stated the facility needed to find a way to keep the assessments updated. The ADM stated if the assessment indicated a resident was unsafe, staff should determine what was needed and implement appropriate interventions to assist them.

Based on record review, interview, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed on a quarterly basis and submitted within the required timeframe for 17 (Residents #33, #12, #16, #17, #18, #22, #23, #3, #35, #38, #40, #43, #44, #45, #5, #54, and #8) of 18 residents reviewed for resident assessments. Findings included: A facility policy titled, Resident Assessment Instrument, revised 09/2010, specified, 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: c. at least quarterly. The State Operations Manual Appendix PP guidance at F638 indicated, A Quarterly assessment is considered timely if:- The Assessment Reference Date (ARD) of the Quarterly MDS is within 92 days (ARD of most recent OBRA [Omnibus Budget Reconciliation Act] assessment + [plus] 92 days) after the ARD of the previous OBRA assessment (Quarterly, Admission, Annual, Significant Change in Status, Significant Correction to Prior Comprehensive or Quarterly assessment) AND- The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD +14 days).If the resident has experienced a significant change in status, the next quarterly review is due no later than 3 months after the ARD of the Significant Change in Status Assessment. During an interview on 06/10/2026 at 8:40 AM, the Director of Nursing (DON) explained the symbols displayed within the MDS screen of the facility's electronic medical records (EMR) system. The DON stated a thumbs up symbol in the EMR system meant the assessment was accepted by CMS. A triangle symbol (with an exclamation mark) meant the assessments were submitted late. She stated she kept a calendar to keep up with the dates when the MDS assessments were due. 1. An admission Summary revealed the facility admitted Resident #33 on 11/14/2025. According to the admission Summary, the resident had a medical history that included diagnoses of essential hypertension and polyneuropathy. A quarterly MDS with an ARD of 02/17/2026 revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. As of 06/10/2026, the quarterly MDS with an ARD of 02/17/2026 was the most recently completed MDS assessment available for review for Resident #33. 2. An admission Summary revealed the facility admitted Resident #12 on 05/30/2025. According to the admission Summary, the resident had a medical history that included diagnoses of essential hypertension and type 2 diabetes mellitus. Resident #12's MDS records revealed that the most recent quarterly MDS had an ARD of 12/14/2025. A significant change MDS with an ARD of 12/25/2025 revealed Resident #12 had a BIMS score of 13, which indicated the resident had intact cognition. As of 06/10/2026, the 12/25/2025 significant change MDS was the most recent MDS assessment available for review for Resident #12. 3. An admission Summary revealed the facility admitted Resident #16 on 01/02/2026. According to the admission Summary, the resident had a medical history that included diagnoses of depression and anxiety disorder. Resident #16's electronic medical record (EMR) revealed a quarterly MDS with a created date of 05/15/2026. As of 06/10/2026, the EMR screen had a triangle symbol with an exclamation mark next to the 05/15/2026 MDS entry, indicating the assessment was submitted late. There was no thumbs up symbol to indicate the assessment had been accepted by CMS. The EMR also revealed a discharge MDS with a created date of 05/15/2026. The discharge assessment had no thumbs-up symbol to indicate the assessment had been accepted by CMS, and there was a triangle/exclamation mark symbol to indicate late submission. The most recent MDS documented as having been completed and accepted was an admission MDS with an ARD of 01/06/2026. 4. An admission Summary revealed the facility admitted Resident #17 on 01/19/2026. According to the admission Summary, the resident had a medical history that included diagnoses of hyperlipidemia and depressive disorder. Resident #17's EMR revealed a quarterly MDS with a created date of 05/15/2026 that had not been completed and submitted as of 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. The most recent MDS assessment that was documented as having been completed and accepted was an admission MDS with an ARD of 01/26/2026. 5. An admission Summary revealed the facility admitted Resident #18 on 11/06/2023. According to the admission Summary, the resident had a medical history that included diagnoses of depression and anxiety disorder. A quarterly MDS with an ARD of 05/03/2026 revealed Resident #18 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #18's EMR revealed the quarterly MDS with an ARD of 05/03/2026 (which had a created date of 05/28/2026) had not been completed and submitted as of 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. The most recent MDS that was documented as having been completed and accepted was a quarterly MDS with an ARD of 01/31/2026. 6. An admission Summary revealed the facility admitted Resident #22 on 06/05/2025. According to the admission Summary, the resident had a medical history that included diagnoses of hypertension and muscle spasms. Resident #22's EMR revealed a quarterly MDS with a created date of 05/15/2026 that had not been completed and submitted as of 06/10/2026. The EMR also revealed a discharge MDS with a created date of 06/03/2026 that had not been completed and submitted. There were triangle/exclamation mark symbols and no thumbs up symbols next to the two assessments. The most recent MDS that was documented as having been completed and accepted was a quarterly MDS with an ARD of 01/03/2026. 7. An admission Summary revealed the facility admitted Resident #23 on 01/31/2026. According to the admission Summary, the resident had a medical history that included diagnoses of pain and osteoporosis. Resident #23's EMR revealed a quarterly MDS with a created date of 05/15/2026 and an ARD date of 05/05/2026 that had not been completed and submitted as of 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. The most recent MDS documented as having been completed was a quarterly MDS with an ARD of 01/03/2026, which indicated the next quarterly MDS would have been due by 04/03/2026. 8. An admission Summary revealed the facility admitted Resident #3 on 03/14/2019. According to the admission Summary, the resident had a medical history that included diagnoses of type 2 diabetes mellitus and gastro esophageal reflux. Resident #3's EMR revealed a quarterly MDS with a created date of 05/15/2026 that had not been completed and submitted as of 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. The previous quarterly MDS had an ARD of 01/16/2026, which indicated the next MDS would have been due by 04/16/2026. 9. An admission Summary revealed the facility admitted Resident #35 on 07/20/2021. According to the admission Summary, the resident had a medical history that included diagnoses of severe intellectual disability and cerebral palsy. Resident #35's EMR revealed a quarterly MDS with a created date of 05/15/2026 that had not been completed and submitted as of 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. The previous quarterly MDS had an ARD of 12/26/2025, which indicated the next MDS would have been due by 03/26/2026. 10. An admission Summary revealed the facility admitted Resident #38 on 10/03/2024. According to the admission Summary, the resident had a medical history that included diagnoses of type 2 diabetes and hypertension. Resident #38's EMR revealed a quarterly MDS with a created date of 05/15/2026 that had not been completed and submitted as of 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. The previous quarterly MDS had an ARD of 01/03/2026, which indicated the next MDS would have been due by 04/03/2026. 11. An admission Summary revealed the facility admitted Resident #40 on 12/03/2022. According to the admission Summary, the resident had a medical history that included diagnoses of gastro esophageal reflux and hypothyroidism. Resident #40's EMR revealed a quarterly MDS with a created date of 05/15/2026 that had not been completed and submitted as of 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. The previous quarterly MDS had an ARD of 01/29/2026, which indicated the next MDS would have been due by 04/29/2026. 12. An admission Summary revealed the facility admitted Resident #43 on 12/03/2022. According to the admission Summary, the resident had a medical history that included diagnoses of gastro esophageal reflux and hypothyroidism. Resident #43's EMR revealed a quarterly MDS with a created date of 05/15/2026 that had not been completed and submitted by 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. The most recent MDS documented as having been completed and accepted was an admission assessment with an ARD of 01/28/2026. 13. An admission Summary revealed the facility admitted Resident #44 on 01/09/2026. According to the admission Summary, the resident had a medical history that included diagnoses of pain and major depressive disorder. Resident #44's EMR revealed a quarterly MDS with a created date of 05/15/2026 that had not been completed and submitted as of 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. The most recent MDS documented as having been completed and accepted was an admission assessment with an ARD of 01/19/2026. 14. An admission Summary revealed the facility admitted Resident #45 on 01/09/2026. According to the admission Summary, the resident had a medical history that included diagnoses of gastro esophageal reflux and insomnia. Resident #45's EMR revealed a quarterly MDS with a created date of 05/15/2026 that had not been completed and submitted as of 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. The previous quarterly MDS had an ARD of 01/29/2026, which indicated the next MDS would have been due by 04/29/2026. 15. An admission Summary revealed the facility admitted Resident #5 on 01/09/2026. According to the admission Summary, the resident had a medical history that included diagnoses of hypertension and kidney failure. Resident #5's EMR revealed a quarterly MDS with a created date of 05/15/2026 that had not been completed and submitted as of 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. The most recent MDS documented as having been completed as an admission assessment with an ARD of 01/17/2026. 16. An admission Summary revealed the facility admitted Resident #54 on 09/25/2025. According to the admission Summary, the resident had a medical history that included diagnoses of end stage renal disease and hypertension. Resident #54's EMR revealed a quarterly MDS with a created date of 05/15/2026 and an ARD of 03/25/2026 that had not been completed and submitted as of 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. 17. An admission Summary revealed the facility admitted Resident #8 on 11/20/2024. According to the admission Summary, the resident had a medical history that included diagnoses of osteoporosis and heart failure. Resident #8's EMR revealed a quarterly MDS with a created date of 05/15/2026 and an ARD of 05/01/2026 that had not been completed and submitted as of 06/10/2026. There was a triangle/exclamation mark symbol and no thumbs up symbol next to the assessment. The previous quarterly MDS had an ARD of 01/31/2026, which indicated the next MDS would have been due by 05/01/2026. During an interview on 06/12/2026 at 10:13 AM, the DON stated she was in charge of completing the MDS assessments. She stated there were late MDS assessments pending when she started her employment with the facility three weeks ago. She stated no one was completing the MDS assessments after the former DON was no longer working at the facility. The DON stated she went through each resident's record individually to catch up the MDS assessments, starting with the month of February 2026. She stated the MDS assessment should be submitted quarterly and with any significant change. After that, she had 14 days to submit the MDS assessments to CMS. The DON provided the following information about the individual residents' assessments: - The DON stated Resident #12 was not in the facility's EMR system to enable her to complete the MDS because the resident had been discharged and their record was archived. She stated no discharge MDS was completed for Resident #12. - The DON confirmed the quarterly MDS assessments for Residents #33, #12, #16, #17, #18, #22, #23, #3, #35, #38, #40, #43, #44, #45, #5, #54, and #8 were not completed and submitted timely. During an interview on 06/12/2026 at 1:40 PM, the Administrator stated the facility had a lapse in completing the MDS assessments because the person completing the MDS assessments left. His expectation was for staff to follow the policy and procedure.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure the proper storage of respiratory equipment for 1 (Resident #33) of 2 sampled residents reviewed for respiratory care, and failed to ensure staff used personal protective equipment (PPE) during the care of a resident on Enhanced Barrier Precautions (EBPs) for 1 (Resident #7) of 1 sampled resident reviewed for EBP. Specifically, Resident #33's nebulizer mouthpiece was not stored in a bag or closed container when not in use to prevent potential contamination, and staff performed wound and incontinence care for Resident #7 without donning the appropriate PPE.Findings included: 1. A facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised 10/2010, specified, The purpose of this procedure is to safely and aseptically administer aerosolized particles of medications into the resident's airway. The Steps in the Procedure indicated that after administering the treatment, staff should, 27. Rinse and disinfect the nebulizer equipment according to facility protocol, or: a. Wash pieces with warm, soapy water; b. Rinse with hot water; c. Place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes; d. Rinse all pieces with sterile water (NOT tap, bottled, or distilled); and e. Allow to air dry on a paper towel. 28. Wash and dry hands. 29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. An undated facility document, titled, For Our Oxygen and Respiratory Customers, specified, Nebulizers. Keep circuit stored in a plastic bag labeled with pts [patient's] name and date. The document also indicated, Miscellaneous Disposable equipment should be covered when not in use. An admission Summary revealed the facility admitted Resident #33 on 11/14/2025. According to the admission Summary, the resident had a medical history that included diagnoses of essential hypertension and polyneuropathy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 02/17/2026, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had shortness of breath or trouble breathing with exertion. Resident #33's June 2026 Physician Orders contained an order, dated 11/14/2025, for ipratropium bromide 0.02 percent (%) inhale by mouth via nebulizer three times a day as needed. During a concurrent observation and interview on 06/08/2026 at 11:27 AM, Resident #33 was sitting in wheelchair in their room with a nebulizer machine on their bedside table. The medication chamber and mouthpiece were attached and lying directly on the bedside table with no cover/bag over the mouthpiece. Resident #3 stated they normally self-administered their nebulizer treatments. They stated the nebulizer mouthpiece was never stored in a bag but should be in a bag when not in use. During an observation on 06/08/2026 at 11:44 AM, Resident #33 was seated in a wheelchair in their room self-administering a nebulizer treatment. At 11:52 AM, Resident #33 remained seated in the wheelchair in their room. The nebulizer machine was on the bedside table with the mouthpiece lying directly on the bedside table, not covered or bagged. During an observation on 06/09/2026 at 1:23 PM, Resident #33 was seated in a wheelchair in their room. The nebulizer machine was on the bedside table with the mouthpiece resting directly on the bedside table, not covered or bagged. During an interview on 06/09/2026 at 1:28 PM, Licensed Practical Nurse (LPN) #2 confirmed that Resident #33 had a PRN [as needed] physician's order for ipratropium updraft treatments. She stated the nebulizer mouthpiece should be cleaned and dried after use and then stored in a bag until the next use. She stated the nebulizer mouthpiece should not be lying on the bedside table uncovered. During an interview on 06/09/2026 at 1:33 PM, LPN #3 stated he was responsible for Resident #33's care on 06/08/2026 and 06/09/2026. He confirmed that Resident #33 had a physician's order for ipratropium PRN. He stated that the process after administering a nebulizing treatment was to store the nebulizer's mouthpiece in a plastic bag. During a concurrent observation and interview on 06/09/2026 at 1:37 PM, LPN #3 confirmed that Resident #33's nebulizer mouthpiece was sitting on the bedside table with the mouthpiece touching the table and not bagged/contained. He then stated that all nurses were responsible for ensuring the nebulizer's mouthpiece was bagged when not in use. He stated he made rounds hourly looking for proper respiratory equipment storage. He stated he expected the nebulizer's mouthpiece to be in a bag, even if it was a PRN physician's order, when not in use. During a concurrent observation and interview on 06/09/2026 at 1:45 PM, LPN #2 confirmed that Resident #33's nebulizer with mouthpiece was sitting on the bedside table with the mouthpiece touching the table. She stated that the nebulizer mouthpiece should be stored in a bag when not in use. During an interview on 06/09/2026 at 1:49 PM, LPN #2 stated she and LPN #3 were responsible for ensuring the nebulizer mouthpiece was stored properly in a bag when not in use. During an interview on 06/09/2026 at 2:26 PM, LPN #3 stated he put the nebulizer's mouthpiece in a bag and dated it. He stated he expected the nebulizer mouthpiece to be stored in a bag when not in use. During an interview on 06/10/2026 at 10:07 AM, the Nurse Practitioner (NP) stated it would be a smart idea to store the nebulizer mouthpiece in a bag when not in use. During an interview on 06/11/2026 at 9:05 AM, LPN #4 stated the nebulizer mouthpiece should always be stored in a bag when not in use and should not be sitting on a bedside table uncontained, as it was an infection control issue. During an interview on 06/11/2026 at 1:49 PM, the Pharmacist stated that a nebulizer's mouthpiece should be stored in a bag or container when not in use. During an interview on 06/11/2026 at 2:46 PM, the Director of Nursing (DON) stated that when a nebulizing mouthpiece was not being used, it should be stored in a bag to ensure proper infection control was maintained. During an interview on 06/11/2026 at 3:23 PM, the Administrator stated he would defer to nursing on how a nebulizing mouthpiece should be stored when not in use.2. The State Operations Manual (SOM) Appendix PP guidance at F880 indicated, Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [multi-drug-resistant organisms] to staff hands and clothing. EBP are indicated for residents with any of the following:- Infection or colonization with a CDC [Centers for Disease Control and Prevention]-targeted MDRO when Contact Precautions do not otherwise apply; or- Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. The guidance also specified, For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities:- Dressing- Bathing/showering- Transferring- Providing hygiene- Changing linens- Changing briefs or assisting with toileting- Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator- Wound care: any skin opening requiring a dressing. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/2026, revealed the facility re-admitted Resident #7 on 06/13/2025. The MDS indicated that Resident #7 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. The MDS also revealed that Resident #7 had one Stage 4 pressure ulcer that was present upon admission. Resident #7's Care Plan dated 06/16/2025 indicated the resident was being treated for two pressure wounds to the buttocks. On 06/11/2026 at 11:50 AM, an observation was made of the wound physician (WMD) and the wound Nurse Practitioner (WNP) measuring Resident #7's wound and providing a specialized treatment. Prior to the treatment beginning, it was noted that there was no Enhanced Barrier Precaution (EBP) sign on the resident's door. There was no personal protective equipment (PPE) beside the resident's door or inside the resident's room. Licensed Practical Nurse (LPN) #4 and Certified Nursing Assistant (CNA) #6 were observed transferring Resident #7 from the wheelchair to the bed, removing the resident's pants and brief, and preparing the resident for the measurements and treatment. LPN #4 and CNA #6 did not don gowns prior to the transfer. The WMD and the WNP wore gowns and gloves while measuring the resident's wound and providing the treatment. After the WMD and WNP completed the treatment, LPN #4 donned a disposable gown and completed wound care for Resident #7. After completion of the wound care, CNA #5 and CNA #6 provided incontinence care to Resident #7. CNA #6 and CNA #5 then applied a clean brief and transferred Resident #7 back to the wheelchair without donning gowns for protection. CNA #5 and CNA #6 were interviewed on 06/12/2026 at 10:32 AM. CNA #6 stated she had not been educated on EBP and was unaware of what the term meant. She stated she did not know she should have worn a gown when providing care to Resident #7. CNA #5 stated she did not know she should wear a gown when providing care to Resident #7. LPN #4 was unavailable for interview after the above observations. LPN #3 was interviewed on 06/12/2026 at 12:30 PM and stated he was not sure what EBP stood for and had not heard the term enhanced barrier precautions. Advanced Certified Medication Aide (ACMA) #7 was interviewed on 06/12/2026 at 12:54 PM. ACMA #7 stated he had heard the term enhanced barrier precautions and knew they were used when wound care was provided. The ACMA stated the type of PPE worn depended upon the type of wound a resident had. The Director of Nursing (DON) was interviewed on 06/12/2026 at 1:10 PM and stated she was familiar with the term EBP and that EBP should be in place for residents who had wounds, feeding tubes, indwelling urinary catheters, tracheostomies, and certain microorganisms. The DON stated signage should be on the door that notified all staff that the resident needed EBP. The DON admitted the facility had not been practicing EBP and stated she first realized this when she started her employment with the facility three weeks prior. The Administrator stated that he expected staff to follow infection control guidelines and the facility infection control policy.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was assessed for the ability to safely self-administer medication and failed to obtain a physician's order prior to allowing the resident to self-administer medication for 1 (Resident #33) of 8 sampled residents reviewed for self-administration of medications.Findings included: A facility policy titled, Administering Medications, revised 04/2010, specified, 18. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do safely. A facility policy titled, Self-Administration of Medications, revised 12/2012, specified, Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. An admission Summary revealed the facility admitted Resident #33 on 11/14/2025. According to the admission Summary, the resident had a medical history that included diagnoses of essential hypertension and polyneuropathy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 02/17/2026, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had shortness of breath or trouble breathing with exertion. Resident #33's June 2026 Physician's Orders contained an order, dated 11/14/2025, for ipratropium bromide 0.02 percent (%), one vial inhale by mouth via nebulizer three times a day as needed. There was no order to self-administer any medications, specifically nebulizer treatments or to keep medications at bedside. Resident #33's Care Plan, dated 11/21/2025, included a category problem that indicated the resident was at risk for shortness of breath. Interventions directed staff to administer medications as ordered and administer ipratropium as ordered by the physician. There was no evidence of a category or approach that indicated the resident could self-administer their medications. During a concurrent observation and interview on 06/08/2026 at 11:27 AM, Resident #33 was seated in a wheelchair in their room with a nebulizer machine in the room. Resident #33 stated they normally self-administered their nebulizer treatment as needed. During a concurrent observation and interview on 06/08/2026 at 11:44 AM, Resident #33 was observed seated in a wheelchair in their room and self-administering a nebulizer treatment. Resident #33 had the nebulizer mouthpiece up to their mouth with the nebulizer machine on and solution in the medication cup of the nebulizer machine. Resident #33 stated they were administering a nebulizer treatment. They stated they kept the nebulizing medication in their room. Resident #33 stated they wanted to self-administer the nebulizing treatment but did not know if they had been assessed to self-administer. During a concurrent observation and interview on 06/08/2026 at 11:46 AM, as Resident #33 had the nebulizer on and mouthpiece in their mouth, they opened a bedside drawer and showed four vials of ipratropium bromide inhalation solution. Resident #33 stated Licensed Practical Nurse (LPN) #3 gave them the nebulizing solution to self-administer as needed. During an interview on 06/09/2026 at 1:28 PM, LPN #2 confirmed Resident #33 had a PRN order for ipratropium. She stated that Resident #33 did not have a physician's order and had not been assessed to self-administer medications. She stated before a resident could self-administer medications, they should have an assessment to self-administer and a physician's order. She stated she expected only residents who had been assessed with a physician's order to self-administer medications. She stated that otherwise a resident should not be self-administering medications without a physician's order and should not keep medications in their room. During an interview on 06/09/2026 at 1:33 PM, LPN #3 confirmed Resident #33 had a PRN order for ipratropium and stated he was responsible for Resident #33's care on 06/08/2026 and 06/09/2026. He stated he thought Resident #33 had been assessed to self-administer ipratropium nebulizing treatments. He stated that when Resident #33 asked for a nebulizing treatment, he gave them one vial of the ipratropium, but it had been weeks ago because they had not asked for it since then. During an interview on 06/09/2026 at 1:37 PM, LPN #3 stated that when a resident had not been assessed to self-administer medications they should not be doing so. He stated he gave the medication to Resident #33 to self-administer because he thought they had been assessed and had a physician's order to self-administer. He stated Resident #33 should not have had the vials of ipratropium in their room. During an interview on 06/09/2026 at 2:26 PM, LPN #3 stated the process for self-administration would be to look at the resident's physician's orders, care plan, and assessment before allowing a resident to self-administer, but he did not do that before giving the resident the ipratropium and allowing the resident to self-administer. He stated that the Previous Director of Nursing (DON) told him the resident could self-administer medications. During an interview on 06/10/2026 at 10:07 AM, the Nurse Practitioner (NP) stated that when a resident had not been assessed as competent to self-administer medications, they should not be self-administering medication. He further stated that when there was no physician's order or assessment to self-administer medications, then medications should not be left at a resident's bedside. During an interview on 06/11/2026 at 1:49 PM, the Pharmacist stated residents should not self-administer medications or have medications at their bedside if they did not have an assessment or physician's order to self-administer. During an interview 06/11/2026 at 2:02 PM, the Previous DON stated she did not remember if Resident #33 had a self-administration assessment or physician's order to self-administer, but if they did, it would be in their medical record. She stated that before a resident self-administered, they must have a physician's order and assessment. She stated she did not tell any staff that Resident #33 could self-administer ipratropium nebulizing solution. During an interview on 06/11/2026 at 2:46 PM, the DON stated that before a resident self-administered medication they must be assessed first, the doctor must approve that a resident could safely self-administer, and then a physician's order must be obtained to self-administer. She stated that some medications could be stored safely in a resident's room in a locked box if they had been assessed to self-administer medications, but respiratory medications were not generally stored in a resident's room because they must be assessed prior to and after the respiratory treatment. She stated a nurse should not have given Resident #33 any nebulizing treatment to self-administer because they did not have a physician's order or an assessment to self-administer. She stated that when LPN #3 knew Resident #33 wanted to self-administer the nebulizing treatment he should have gotten the resident assessed and consulted with the physician before giving the resident medication to self-administer. She stated she expected residents to self-administer medication only if they had been deemed clinically appropriate and had a physician's order to do so. During an interview on 06/11/2026 at 3:23 PM, the Administrator stated he would defer to nursing on the self-administration process and procedure.

Based on interview, record review, and facility document and policy review, the facility failed to ensure a certified nursing assistant (CNA) immediately reported an allegation of suspected abuse in a manner consistent with the process outlined in the facility's abuse policy for an incident involving 1 (Resident #20) of 4 sampled residents reviewed for abuse. Specifically, CNA #11 notified the off-duty Assistant Director of Nursing (ADON) of suspected abuse by way of text message instead of notifying a supervisor on-duty or the facility's Abuse Coordinator directly as specified in the facility's abuse policy, which resulted in a delayed initial report submission to the state survey agency (SSA).Findings included: An undated facility policy titled, Abuse and Neglect Prohibition Program, Section 3, revealed, When abuse, neglect, mistreatment, or misappropriation of personal property of a resident is observed, or suspected, staff must immediately notify their supervisor on duty, who, in turn, should notify the abuse coordinator/administrator and director of nursing services. The policy further revealed, Reporting & [and] Investigating: We follow a specific procedure to report and investigate allegations. This ensures that the resident receives appropriate care, that an investigation is begun, and that the resident's care plan is adjusted, as needed. An admission Summary (Standard) revealed the facility admitted Resident #20 on 07/01/2025. According to the admission Summary, Resident #20 had a medical history that included diagnoses of Alzheimer's disease, anxiety disorder, and major depressive disorder. Resident #20's Nurse's Notes revealed an untimed entry dated 05/18/2026 that indicated after dinner a nurse was seated at the nurse's station. According to the note, the nurse turned and observed a CNA sitting at eye-level and talking with Resident #20. The note indicated that Resident #20 slapped the CNA on the left side of the face, and the CNA quickly got up from the chair c [with] his hands raised like trying to block another slap. According to the note, the nurse requested the CNA step away while the nurse took over sitting with and monitoring the resident. The note indicated that while the nurse tried to assess the resident, the resident took items off the desk and the medication cart and upon assessment, the nurse identified two small skin tears on the back of Resident #20's left hand that were actively bleeding. A copy of text message correspondence from CNA #11 to the ADON, dated Yesterday [05/18/2026] 5:54 PM, revealed CNA #11 initially contacted the ADON to report that something happened that bothered her and she did not know who else to talk to about it. Per the text message correspondence, the ADON responded at an unknown time and asked what happened. CNA #11 responded at an unknown time and described that CNA #10 got close to a resident's face and when the resident attempted to hit CNA #10, CNA #10 grabbed [the resident's] arms really tight and yelled at [the resident] not to hit. Per the text message, after CNA #10 let go of the resident's arms, the resident slapped CNA #10.A facsimile Confirmation Report revealed the facility submitted an initial report involving Resident #20 to the SSA on 05/19/2026 at 1:29 PM. An undated initial Incident Report Form revealed the facility submitted an allegation of abuse/mistreatment involving Resident #20 and CNA #10. The initial Report Form indicated that it was reported that on 05/18/2026 at the nurse's station, CNA #10 allegedly maintained proximity to Resident #20's face and guided the resident's left hand and placed it on the resident's lap while redirecting the resident from sliding out of their wheelchair. A telephone interview was held with CNA #11 on 06/12/2026 at 11:50 AM. CNA #11 stated she did not recall what happened during the alleged incident but she notified the ADON of the events; however, CNA #11 stated she deleted the messages after she sent them and then just left it alone. The ADON was interviewed on 06/11/2026 at 2:51 PM and stated she was not in the building when the alleged incident occurred. The ADON stated CNA #11 sent her a text message about an incident at the facility that made the CNA feel uncomfortable, but the message did not say who or what was involved. The ADON initially stated she did not reply to the message; however, after reviewing a copy of the text message correspondence, she stated she had responded and asked what happened but did not see the CNA's subsequent reply. The ADON stated she found out about the alleged incident the next day but did not recall when she was told or how she found out. The ADON stated CNA #11 could have reported to the charge nurse that was working on the night of the alleged incident. The Director of Nursing (DON) was interviewed on 06/11/2026 at 3:20 PM and stated allegations of abuse had to be reported within two hours, and that had not been adequately completed, since the incident allegedly occurred on 05/18/2026 and was not reported to the SSA until 05/19/2026. A telephone interview was held with the SSD on 06/11/2026 at 4:11 PM. The SSD stated she was the facility's Abuse Coordinator and expected to be notified immediately for any allegations of abuse since there was a two-hour window to report allegations to the SSA. The SSD stated the two hours began as soon as someone in the facility was aware of the allegation. The SSD stated she was not notified of the alleged incident between CNA #10 and Resident #20 until sometime mid-morning on 05/19/2026. The DON was interviewed on 06/12/2026 at 1:10 PM. The DON stated she expected staff to report alleged or suspected abuse to the Abuse Coordinator, whose number was posted in the facility, or report to their supervisor. The Administrator was interviewed on 06/12/2026 at 3:07 PM and acknowledged the Abuse Coordinator was not made aware of the allegation involving Resident #20 and CNA #10 within the two-hour timeframe.

Based on interview, medical record review, and facility policy review, the facility failed to ensure medication administration was accurately documented in the medical record for 1 (Resident #73) of 22 residents whose medical records were reviewed.Findings included: A facility policy titled, Charting Errors and/or Omissions, revised 12/2006, indicated, Accurate medical records shall be maintained by this facility. An admission Summary for Resident #73 revealed the facility admitted Resident #73 on 06/12/2023. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2025, revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #73 had diagnoses that included dementia, anxiety, and respiratory failure. The MDS indicated Resident #73 had shortness of breath with exertion and when lying flat. Resident #73's Monthly Orders Sheets for February 2025 indicated Resident #73 had a physician's order dated 06/28/2023 for Ventolin hydrofluoroalkane (HFA) (an inhaled medication containing albuterol sulfate) two puffs by mouth every four hours as needed (PRN) for shortness of breath and wheezing. A Nurse's Notes entry dated 01/30/2025 at 4:30 PM indicated Resident #73 requested their PRN inhaler. The note indicated Resident #73 was given the inhaler then refused to give the inhaler back to the nurse. Resident #73's January 2025 medication administration record indicated Resident #73 received an as-needed (PRN) dose of the Ventolin HFA inhaler on 01/13/2025. There was no documentation the PRN inhaler was administered on any other date in January 2025. A Nurse's Notes entry dated 02/13/2025 for Resident #71 (Resident #73's roommate) indicated that Resident #73 requested an as-needed (PRN) breathing treatment, and Resident #71 became irritated and verbally aggressive when staff would not allow Resident #73 to have extra doses of med [medication]. Resident #73's February 2025 medication administration record did not indicate that Resident #73 had received the Ventolin HFA inhaler or any other inhaled medication during the month of February 2025. In an interview on 06/11/2026 at 10:15 AM, Advanced Certified Medication Aide (ACMA) #8 stated that when she administered a PRN inhaler, she would initial the MAR and document on the PRN medication sheet at the back of the MAR. ACMA #8 stated she would document before she administered the medication to ensure that she did not forget to document it. In an interview on 06/11/2026 at 10:18 AM, ACMA #7 stated he documented the administration of any PRN medication as soon as he was done giving it. ACMA #7 stated he had forgotten to document PRN medication administrations at times. ACMA #7 stated he remembered Resident #73 requesting their PRN inhaler frequently. In an interview on 06/11/2026 at 2:37 PM, Licensed Practical Nurse (LPN) #3 stated if a PRN medication or inhaler was administered, it should be documented in the MAR so staff could keep track of how often the resident was receiving the medication. In an interview on 06/12/2026 at 11:58 AM, the Director of Nursing (DON) stated Resident #73 would frequently talk about their inhaler. The DON stated Resident #73 would request the inhaler more frequently than it was ordered and would become upset if they could not get it. The DON stated that Resident #73 received the PRN inhaler frequently, and it should have been documented on the MAR. The DON stated she expected nursing to document medication administration appropriately. In an interview on 06/12/2026 at 12:50 PM, the Administrator (ADM) stated he expected staff to document any administration of PRN inhalers or medication.

Based on record review and interview, the facility failed to ensure careplans were updated quarterly for three (#14, 26, and #27) of 14 sampled residents reviewed for careplans. The DON identified 34 residents resided in the facility. Findings: A Care Plans policy, dated October 2010, read in part, .care plan that includes measurable objectives and timetables to meet the resident's .needs .The comprehensive care plan is based on a thorough assessment that includes .the MDS .The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .At least quarterly . 1. Resident #14 had diagnoses which included depression and anxiety. A care plan, dated 12/11/23, did not contain quarterly updates. Resident #14 had a comprehensive resident assessment, dated 12/12/23. 2. Resident #26 had diagnoses which included acute kidney failure, cerebral infarction, bipolar, COPD, and HTN. A care plan, dated 11/20/23, did not contain quarterly updates. Resident #26 had comprehensive resident assessments dated 05/25/24 and 08/25/24. 3. Resident #27 had diagnoses which included neuralgia, ALS, and major depressive disorder. A care plan, dated 03/06/24, did not contain quarterly updates. Resident #27 had comprehensive resident assessments on 06/30/24 and 09/25/24. On 10/02/24 at 1:50 p.m., the DON was asked when careplans were updated. They stated they were updated with each new order. The DON was asked if they conducted quarterly updates. They stated they did quarterly MDS assessments, but quarterly care plan updates. The DON stated they just did those annually. The DON was asked how the facility evaluated the effectiveness of interventions. They stated, I just know them. The DON was informed quarterly updates had not been conducted for Resident #14, Resident #26, and Resident #27.

Based on record review and interview, the facility failed to ensure residents were offered the right to formulate an advance directive for two (#24 and #25) of three sampled residents reviewed for advance directives. The Long-Term Care Facility Application for Medicare and Medicaid form, dated 10/01/24, documented 36 residents resided in the facility. Findings: An Advance Directive policy, dated April 2008, read in part, .upon admission to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care .and the right to formulate advance directives . 1. Resident #24 admitted to the facility on [DATE]. Resident #24's medical record did not contain an advanced directive or an advance directive acknowledgement form. 2. Resident #25 admitted to the facility on [DATE]. Resident #25's medical record did not contain an advanced directive or an advance directive acknowledgement form. On 10/01/24 at 1:47 p.m., the DON was asked to provide advance directives or advance directive acknowledgement forms for Resident #24 and Resident #25. They stated they were in the front of residents' charts. The DON was informed they were not located in the medical records. On 10/01/24 at 1:53 p.m., the SSD stated Resident #24 and Resident #25 did not have advance directives or acknowledgement forms.

Based on observation, record review, and interview, the facility failed to conduct thorough skin assessments weekly for one (#138) of one sampled resident reviewed for non-pressure related skin conditions. The DON identified 34 residents resided in the facility. Findings: A Pressure Ulcer Risk Assessment form, dated September 2013, read in part, .Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis .Documentation .The conditions of the resident's skin . Res #138 admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, neuropathy, and gout. A physician order, dated 09/16/24, documented to complete a skin assessment weekly on the 7-3 shift on Mondays. A Weekly Wound Assessment form, documented Res #138 refused a skin assessment on 09/16/24. On 09/17/24 at 2:00 p.m., LPN #1 documented a head to toe skin assessment was completed. The note did not document the presence of dressings to the heels. On 09/30/24 at 10:29 a.m., Res #138 was observed in their room in the bed. They stated they had a dressing on each ankle that had been placed by the hospital prior to their arrival. They stated the facility had not done anything with the dressings. On 09/30/24 at 10:32 a.m., LPN #1 was observed removing Res #138 socks. Adhesive foam dressings were observed on their bilateral heels dated 09/10/24. The skin beneath the dressings was intact. A Weekly Wound Assessment form documented Res #138 refused a skin assessment on 09/23/24. On 09/30/24 at 10:36 a.m., LPN #1 stated the resident initially refused a skin assessment on the day of admission, but the DON had performed one the day after. They stated the DON had told the LPN the resident's skin was all clear. They stated the skin assessments were scheduled on the TAR. On 10/01/24 at 1:20 p.m., the ADON stated skin assessments should be performed in a limited capacity whenever the resident was changed, a shower was completed, or wound care was completed. They stated a weekly head to toe skin assessment should be performed which included the heels. They stated any dressings in place during a skin assessment should be removed to assess the skin under the dressing. They stated this should have been completed for Res #138.

Based on observation and interview, the facility failed to ensure dietary staff properly utilized hair nets for one (Cook #1) of three sampled employees observed for kitchen sanitation. The DON identified 34 residents resided in the facility. Findings: On 09/30/24 at 9:14 a.m., [NAME] #1 was observed preparing the noon meal. They were observed to have hair outside of their hairnet around their ears and a ponytail in the back. On 09/30/24 at 9:17 a.m., the DM was asked what was the policy for hair nets. They stated everyone should have one on and we all have them on. The DM was asked to observe [NAME] #1 and asked if all of their hair was secured in their hair net. The DM stated, No, not around [Cook #1's] hair. The DM was informed [NAME] #1's ponytail was not secured in the hair net.

Based on observation, record review, and interview, the facility failed to: a) turn and reposition a resident with pressure ulcers for one (Res #2) of three sampled residents reviewed for pressure ulcers, b) obtain orders for treatment of pressure ulcers upon admission for one (Res #2) of three sampled residents reviewed for pressure ulcers, and c) complete weekly wound assessments for one (Res #3) of three sampled residents reviewed for pressure ulcers. The ED identified 36 residents resided in the facility. Findings: 1. A facility repositioning policy, revised April 2013, documented a resident in bed should be repositioned at least every two hours, and a resident with a stage one or higher pressure ulcer may require more frequent repositioning. The policy documented the information recorded in the resident's record should include the position in which the resident was placed, the name and title of the individual who gave the care, and if the resident refused, why. Res #2 admitted to the facility on [DATE] with diagnoses which included edema, pain, and muscle weakness. An admission assessment, dated 05/09/24 at 10:10 a.m., documented Res #2 had wounds to the left heel, right hip, back, left hip, and right ischium. The assessment documented the resident was totally dependent on staff for bed mobility and transfers. A turning schedule and/or documentation of repositioning was not provided for 05/09/24 to 05/30/24. A Turning Schedule dated 05/30/24 through 06/04/24, documented the resident was not repositioned on 05/30/24 from 9:00 p.m. until 1:00 a.m., and 05/31/24 from 1:00 p.m. to 5:00 p.m A Turning Schedule dated 06/05/24 through 06/10/24, documented the resident was not repositioned on 06/06/24 from 9:00 a.m. to 1:00 p.m. A Turning Schedule was not provided for 06/23/24 through 06/27/24. A Turning Schedule dated 06/28/24 through 06/30/24, document the resident was not repositioned on 06/29/24 from 5:00 a.m. to 9:00 a.m., and from 9:00 a.m. to 1:00 p.m. A Turning Schedule, dated 07/01/24 through 07/06/24, documented the resident was not repositioned: a) on 07/01/24 from 9:00 p.m. to 07/02/24 at 9:00 a.m., b) on 07/02/24 from 1:00 p.m. to 5:00 p.m., c) on 07/02/23 from 11:00 p.m. to 07/03/24 at 9:00 a.m., d) on 07/03/24 from 1:00 p.m. to 5:00 p.m., e) on 07/05/24 from 11:00 p.m. to 07/06/24 at 7:00 a.m., and f) on 07/06/24 after 9:00 p.m. A turning schedule and/or documentation of repositioning was not provided from 07/07/24 to 07/17/24 when the resident discharged from the facility. ADL records were reviewed and did not include repositioning. On 08/13/24 at 2:18 p.m., the ADON stated residents who require assistance with positioning should be repositioned every two hours. Stated there was no additional documentation for repositioning. 2. Res #2 admitted to the facility on [DATE] with diagnoses which included edema, pain, and muscle weakness. An admission assessment, dated 05/09/24 at 10:10 a.m., documented Res #2 had wounds to the left heel, right hip, back, left hip, and right ischium. The assessment documented the resident was totally dependent on staff for bed mobility and transfers. A TAR for May 2024, documented orders were not placed for wound care until 05/10/24. An order to consult with wound care specialists was documented on 05/14/24. On 08/13/24 at 3:19 p.m., the ADON stated orders for new admissions including referrals as needed should be placed by end of day of admission. They stated they did not know why Res #2's wound care orders were delayed. They stated they did not know why the order for the specialist was placed 5 days after admission. 3. A facility Pressure Ulcer Risk Assessment policy, revised September 2013, documented nurses should conduct skin assessments at least weekly to identify changes. Res #3 readmitted to the facility on [DATE] with diagnoses which included diabetes, renal insufficiency, and bradycardia. A wound care specialist note, dated 05/22/24, documented Res #3 had a stage four pressure wound to the right heel with an onset of over 99 days, measuring 1.0 X 1.2 X 0.1 cm. A weekly wound assessment log for June 2024, documented on 06/12/24, the resident had a DTI to the right heel, was being seen by the wound care specialist and a treatment was in place. No measurements were recorded for the wound. There was no documentation Res #3 was seen by the wound care specialists the week of 06/12/24. A wound care specialist note, dated 07/17/24, documented Res #3's heel wound measured 1.0 X 0.8 X 0.1 cm. A weekly wound log for July 2024, documented on 07/24/24 did not document measurements or observations of the pressure ulcer to the heel. On 08/14/24 at 1:45 p.m., the DON stated the missing skin assessments in June and July were not completed.

Based on record review and interview, the facility failed to provide hydration to a resident each shift for one (Res #2) of three residents reviewed for hydration and nutrition. The ED identified 36 residents resided in the facility. Findings: Res #2 admitted to the facility on [DATE] with diagnoses which included hypotension and acute kidney failure. A review of meal percentage records and intake and output records for May 2024 documented Res #2 did not receive hydration 13 of 69 opportunities. A review of meal percentage records and intake and output records for June 2024 documented Res #2 did not receive hydration two out of 90 opportunities. A review of intake and output records for July 2024 documented Res #2 did not receive hydration seven out of 51 opportunities. On 08/13/24 at 3:19 p.m., the ADON stated hydration and ice are passed to the residents three times per day, once on each shift. They stated they did not know why there were blanks on Res #2's hydration records.

Based on record review and interview, the facility failed to provide adequate supervision to prevent elopement which resulted in a past noncompliance immediate jeopardy (IJ) situation effective from 05/28/23 to 05/30/23 for one (#15). Res #15 eloped from the facility on 05/24/23 and was found 300 yards away on a county road. The facility put interventions in place up through 05/28/23. The resident eloped again on 05/30/30 and was found in a nearby field. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: Res #15 was admitted to the facility on [DATE] and had diagnoses which included dementia and Parkinson's disease. An Elopement Risk Scale, dated 08/24/22, documented the resident was a high risk to wander. The elopement risk assessment documented the resident Wanders aimlessly within facility or off facility grouns or has a reported history of elopement. There was no care plan initiated at that time. An Elopement Risk Scale, dated 09/12/22, documented the resident was a high risk to wander. The elopement risk assessment documented the resident could follow instructions, was ambulatory, could communicate, and was medically diagnosed with dementia, and Wanders aimlessly within facility or off facility grouns or has a reported history of elopement. There was no care plan initiated at that time. An incident report, dated 05/24/23, documented the resident had gotten out of the facility and was found about 300 yards from the facility on a county road. The report documented every 15 minute checks were initiated. A nurse note, dated 05/24/23 at 8:00 p.m., documented the resident was picked up by the nurse and physical therapist in the therapist personal vehicle. The note documented Res #15 was approximately 300 yards from the facility headed eastbound. A care plan, initiated on 05/24/23, documented the resident had eloped and every 15 minute checks were put in place for 72 hours. No other interventions were added at that time. Nurse notes, dated 05/25/23, documented safety checks were performed every 15 minutes for the resident. Safety check sheets, dated 05/26/23, 05/27/23, and 05/28/23, documented the resident had been checked every 15 minutes for those days. The resident's record contained no documentation on the resident from 05/28/23 at 11:00 p.m. until 05/30/23 at 9:35 p.m. A state reportable document, dated 05/30/23, documented the resident eloped at 9:35 p.m. and was found outside the facility in a field behind the apartments on the west side of the facility at 10:36 p.m. The report documented every 15 minute checks were initiated. The resident's record documented they were discharged to a mental health facility on 06/01/23 for evaluation and treatment and reentered the facility on 06/27/23. On 06/09/23 an in-service was held on elopement. Interviews were conducted with staff related to their knowledge of interventions to prevent elopement. Incident reports and resident records were reviewed to ensure no other elopements had occurred. The care plan was updated to include interventions to prevent further elopements. On 09/06/23 at 3:00 p.m., the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to have adequate supervision and continued interventions to prevent elopement. On 09/06/23 at 4:08 p.m., the interim administrator/owner was notified of the past noncompliance IJ. On 09/06/23 at 4:15 p.m., the interim administrator/owner reported the facility should have had continued interventions to prevent the resident's elopement. 46582

Based on record review and interview, the facility failed to ensure the physician responded to the pharmacy medication regimen review recommendations in a timely manner and failed to have a policy which included time frames for the different steps in the process for two (#25 and #15) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: A Consultant Pharmacist policy, dated June 2017, read in parts, .Recommendations, plans for implementation, assessments, and any irregularities noted during the consultant's review are compiled into a Drug Regimen Review report .The facility is responsible to assure that the appropriate personnel address these recommendations. The DON is responsible for ensuring the Drug Regimen Reviews are reviewed by the attending physician and medical director . 1. Res #25 had diagnoses which included hypothyroidism, dementia without behavioral disturbance, and major depressive disorder. A physician order, dated 02/18/22, documented to administer Prozac 40 mg daily related to major depressive disorder. An annual assessment, dated 02/22/23, documented the resident was moderately cognitively impaired, required extensive assistance with most ADLs, and received antidepressant medication. A care plan, dated 05/01/23, documented the resident received medications for management of depression and was at risk for adverse side effects with an intervention of gradual dose reduction of psychoactive drugs to the lowest possible maintenance level. A MRR, dated 05/15/23, documented a GDR request for Prozac. The MRR documented the physician had agreed to decrease the Prozac dosage from 40 mg daily down to 20 mg daily. The physician response was not dated. A physician order, dated 08/13/23, documented to administer Prozac 20 mg daily related to major depressive disorder. The facility's policy was reviewed and did not include the timeframes for the different steps in the process of the pharmacy MRRs. On 09/06/23 at 2:00 p.m., the ADON stated the drug regimen reviews for May 2023 were misplaced for a couple of months and the GDR request for Res #25 was not provided to the physician for response until 08/13/23. They stated the GDR request should have been addressed in a more timely manner. 43023 2. Res #15 was admitted with diagnoses of DM, dementia, HTN, anemia, heart failure, major depressive disorder, Parkinson's disease, angina, chronic pain, and anxiety. A physician order, dated 06/27/23, documented Riluzole (a benzothiazole medication) 50 mg three times daily for ALS. A MRR, dated 07/10/23, documented the resident was receiving Riluzole 50 mg three times a day for ALS. The MRR documented there was no documentation in the resident's medical record that he had a diagnosis of ALS. On 09/07/23 at 11:25 a.m., the ADON was shown the current summary of the physician orders for September 2023 and asked about the diagnosis for Rizzoli. The ADON was asked if the resident had a diagnosis of ALS. They reported, No. The ADON was then shown the MRR from July 2023 and asked if the physician ever addressed it and they reported, No.

Based on record review and interview, the facility failed to ensure a resident who received psychotropic medications received a gradual dose reduction for an antidepressant medication in a timely manner for one (#25) and an acceptable diagnoses/indication for the use of an antipsychotic medication for one (#15) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, documented 22 residents received psychoactive medications. Findings: A Consultant Pharmacist policy, dated June 2017, read in parts, .Recommendations, plans for implementation, assessments, and any irregularities noted during the consultant's review are compiled into a Drug Regimen Review report .The facility is responsible to assure that the appropriate personnel address these recommendations. The DON is responsible for ensuring the Drug Regimen Reviews are reviewed by the attending physician and medical director . 1. Res #25 had diagnoses which included hypothyroidism, dementia without behavioral disturbance, and major depressive disorder. A physician order, dated 02/18/22, documented to administer Prozac 40 mg daily related to major depressive disorder. An annual assessment, dated 02/22/23, documented the resident was moderately cognitively impaired and received antidepressant medication. A care plan, dated 05/01/23, documented the resident received medications for management of depression and was at risk for adverse side effects with an intervention of gradual dose reduction of psychoactive drugs to the lowest possible maintenance level. A MRR, dated 05/15/23, documented a GDR request for Prozac. The MRR documented the physician had agreed to decrease the Prozac dosage from 40 mg daily down to 20 mg daily. The physician response was not dated. A physician order, dated 08/13/23, documented to administer Prozac 20 mg daily related to major depressive disorder. On 09/06/23 at 2:00 p.m., the ADON stated the drug regimen reviews for May 2023 were misplaced for a couple of months and the GDR request for Res #25 was not provided to the physician for response until 08/13/23. The ADON stated the resident would be considered to have received an unnecessary medication since the May 2023 dose reduction request of a psychoactive medication had not been addressed until August 2023. 43023 2. Res #15 was admitted with diagnoses of DM, dementia, HTN, anemia, heart failure, major depressive disorder, Parkinson's disease, angina, chronic pain, and anxiety. A physician order, dated 06/27/23, documented Seroquel XR (an antipsychotic medication) tab 150 mg at bedtime for insomnia. A MRR, dated 07/10/23, documented the resident was readmitted to the facility on [DATE] and was now taking Seroquel XR 150 mg QHS. The MRR questioned the diagnosis of insomnia and documented the diagnosis given was major neurocognitive disorder of the Alzheimers type, with behavioral changes of agitation and aggression. On 09/07/23 at 11:25 a.m., the ADON was shown the current summary of the resident's physician orders for September 2023 and asked about the diagnosis for Seroquel. The ADON was asked if they are proper diagnosis for the medication. They reported, No. The ADON was then shown the MRR from July 2023 and asked if the physician ever addressed it and they reported, No.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5% for three (#2, 6, and #14) of eight residents observed during medication pass. A total of 36 opportunities were observed with 21 errors. Total error rate was 58.33%. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: A Medication Administration Procedures policy, undated, documented medication can be administered within a two-hour time frame (one hour before to one hour after the time prescribed by the physician or as established by medications administration time policy). Administering medications too early or too late is considered a medication error. Medications specifically ordered before or after meals must be administered as such or will be considered a medication error. A Medication Administration Times form, updated 05/30/21, documented as follows: a. All orders that have a specific time will be administered as requested. b. Anti-ulcer medications to be administered before meals or at bedtime. c. Lasix will be administered at 8:00 a.m. and 2:00 p.m. d. Daily medications to be administered 7:00 a.m. to 10:00 a.m. e. Twice daily medications to be administered 7:00 a.m. to 10:00 a.m. and 7:00 p.m. to 10:00 p.m. f. Three times daily medications to be administered 8:00 a.m., 2:00 p.m., and 8:00 p.m. g. Four times daily medications to be administered 8:00 a.m., 12:00 p.m., 2:00 p.m., and 8:00 p.m. 1. Res #14 had diagnoses which included atrial fibrillation and GERD. A physician order, dated 04/18/21, documented to administer sucralfate 1 gram four times daily before meals and nightly at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. for GERD. On 08/31/23 at 1:35 p.m., ACMA #1 was observed during medication pass. The ACMA was observed administering sucralfate to Res #14. The medication was observed to have been given after the lunch meal and outside of the one hour before or after time frame. On 08/31/23 at 1:38 p.m., ACMA #1 stated the policy for medications with specific administration times was to have administered the medications within one hour before or one hour after their scheduled administration time or the medications were considered late. 2. Res # 6 had diagnoses which included heart failure and GERD. A physician order, dated 11/20/20, documented to administer sucralfate 1 gram three times daily before meals at 7:30 a.m., 11:30 a.m., and 4:30 p.m. for GERD. On 08/31/23 at 2:10 p.m., ACMA #1 was observed during medication pass. The ACMA was observed administering sucralfate to Res #6. The medication was observed to have been given after the lunch meal and outside of the one hour before or after time frame. 3. Res #2 was admitted with diagnoses which included DM, Alzheimer's disease, and unspecified convulsions. A physician order, dated 08/25/08, documented to administer docusate sodium 100 mg twice daily at 7:00 a.m. to 10:00 a.m. and 5:00 p.m. to 8:00 p.m. for constipation. A physician order, dated 02/19/14, documented to administer hydrochlorothiazide 12.5 mg daily at 7:00 a.m. to 10:00 a.m. for edema. A physician order, dated 02/09/14, documented to administer glipizide 5 mg daily at 7:00 a.m. to 10:00 a.m. for DM. A physician order, dated 02/19/14, documented to administer levetiracetam 750 mg twice daily at 7:00 a.m. to 10:00 a.m. and 5:00 p.m. to 8:00 p.m. for convulsions. A physician order, dated 05/27/15, documented to administer divalproex 500 mg twice daily at 7:00 a.m. to 10:00 a.m. and 5:00 p.m. to 8:00 p.m. for convulsions. A physician order, dated 08/17/15, documented to administer oxcarbazepine 150 mg twice daily at 7:00 a.m. to 10:00 a.m. and 5:00 p.m. to 8:00 p.m. for convulsions. A physician order, dated 10/13/15, documented to administer metformin 1000 mg twice daily at 7:00 a.m. to 10:00 a.m. and 5:00 p.m. to 8:00 p.m. for DM. A physician order, dated 03/22/17, documented to administer venlafaxine 25 mg daily at 7:00 a.m. to 10:00 a.m. for major depressive disorder. A physician order, dated 12/22/17, documented to administer omega-3 fish oil 1000 mg twice daily at 7:00 a.m. to 10:00 a.m. and 5:00 p.m. to 8:00 p.m. for vitamin deficiency. A physician order, dated 12/22/17, documented to administer gabapentin 300 mg twice daily at 7:00 a.m. to 10:00 a.m. and 5:00 p.m. to 8:00 p.m. for mononeuropathy. A physician order, dated 12/29/17, documented to administer memantine 10 mg twice daily at 7:00 a.m. to 10:00 a.m. and 5:00 p.m. to 8:00 p.m. for Alzheimer's disease. A physician order, dated 11/08/19, documented to administer escitalopram 10 mg daily at 7:00 a.m. to 10:00 a.m. for major depressive disorder. A physician order, dated 09/21/20, documented to administer cetirizine 10 mg daily at 7:00 a.m. to 10:00 a.m. for allergy. A physician order, dated 09/21/20, documented to administer pantoprazole 40 mg daily at 7:00 a.m. to 10:00 a.m. for GERD. A physician order, dated 09/02/21, documented to administer Lasix 40 mg twice daily at 8:00 a.m. and 2:00 p.m. for edema. A physician order, dated 12/01/21, documented to administer risperidone 0.5 mg twice daily at 7:00 a.m. to 10:00 a.m. and 5:00 p.m. to 8:00 p.m. for bipolar disorder. A physician order, dated 05/26/22, documented to administer cilostazol 100 mg twice daily at 7:00 a.m. to 10:00 a.m. and 5:00 p.m. to 8:00 p.m. for convulsions. A physician order, dated 07/14/23, documented to administer ferosul 325 mg daily at 7:00 a.m. to 10:00 a.m. for supplement. A physician order, dated 08/16/23, documented to administer potassium chloride 40 meq twice daily at 7:00 a.m. to 10:00 a.m. and 5:00 p.m. to 8:00 p.m. for vitamin deficiency. On 09/05/23 at 10:47 a.m., ACMA #1 was observed during medication pass. The ACMA was observed administering docusate sodium, hydrochlorothiazide, glipizide, levetiracetam, divalproex, oxcarbazepine, metformin, venlafaxine, omega-3 fish oil, gabapentin, memantine, escitalopram, cetirizine, pantoprazole, Lasix, risperidone, cilostazol, ferosul, and potassium chloride to Res #2. The medications were observed to have been given past the 7:00 a.m. to 10:00 a.m. time frame. On 09/05/23 at 11:50 a.m., the ADON was made aware the medication error rate was 58.33%. The ADON stated Res #6 and Res #14's medications were not given prior to meals per orders but should have been. The ADON stated all medications administered at any time outside of the 7:00 a.m. to 10:00 a.m. time frame for Res #2 were considered late and a medication error.

Based on record review and interview, the facility failed to ensure accurate coding of MDS assessments for indwelling catheters and anticoagulant use for two (#3 and #10) of 16 residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: 1. Res #3 had diagnoses which included anoxic brain damage, gastroparesis, and diabetes insipidus. An annual assessment, dated 01/17/23, documented the resident was severely cognitively impaired, required total assistance with toileting, and had an indwelling catheter. An quarterly assessment, dated 04/17/23, documented the resident was severely cognitively impaired, required total assistance with toileting, and had an indwelling catheter. An quarterly assessment, dated 07/17/23, documented the resident was severely cognitively impaired, required total assistance with toileting, and had an indwelling catheter. Res #3's records were reviewed and did not document an order for an indwelling catheter during the review periods. On 09/05/23 at 8:19 a.m., the MDS coordinator stated the resident has not had an indwelling catheter and the MDS assessments were documented in error. 2. Res #10 had diagnoses which included pneumonia, thrombocytopenia, and peripheral vascular disease. A quarterly assessment, dated 07/29/23, documented the resident was cognitively intact, required limited assistance with most ADLs, and received an anticoagulant seven out of seven days during the review period. Res #10's records were reviewed and did not document an order for an anticoagulant during the review period. On 09/05/23 at 10:34 a.m., the MDS coordinator stated the MDS assessment was coded for an anticoagulant in error. They stated the resident received clopidogrel and they thought this medication was considered an anticoagulant.

On 02/17/23 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents #2 and #4 were protected from further sexual abuse and investigations were timely and thorough. a. CNA #1 reported an allegation of sexual abuse to the charge nurse on 02/11/23 at approximately 8:45 a.m. CNA #1 reported she observed Res #6 with his arm and hand under the blanket of Res #2. The CNA reported Res #6's arm and hand were moving fast in an up and down motion causing the blanket to move and the bed to shake. The alleged perpetrator was not removed from Res #2's room and was allowed to re-enter the room multiple times and was not separated from the resident in the common areas for the entire length of the investigation. The investigation was not started until two days after the allegation and ended on 02/16/23. The investigation did not include CNA #1, other CNAs who worked the shift, RN #1, and resident interviews, except for the alleged perpetrator. b. CNA #2 reported she witnessed, on 12/31/22, Res #5 lift the shirt of Res #4 and touch her breast and was trying to put his hand in her pants. The resident was protected for a couple of days but no long term interventions were communicated and put in place. CNA #3 reported she witnessed, around the first of February 2023, Res #5 with one hand on the inner thigh of Res #4 and the other kneading the breast of Res #4. CNA #3 reported to the abuse coordinator and DON. The allegation was not investigated and there were no interventions or corrective measures to protect Res #4. On 02/17/23 at 6:04 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 02/17/23 at 6:35 p.m., the administrator was notified of the IJ situation. On 02/18/23 at 2:06 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: The Administrator in conjunction with the entire department heads team members will ensure that adverse events that are ongoing, urgent or emergent are reported timely. The Administrator has provided direction to all levels of leadership on how to appropriately report any adverse events that occur. In addition, the quality assurance team meets daily during morning meetings to review all reported events and ensure timeliness in reporting. Immediate action taken to ensure resident safety: 1. Facility will immediately meet the federal and state health, safety, and quality regulations regarding the alleged. 2. Resident #6 discharged to [name of location deleted] under [name of person deleted] watch. 3. Resident #5 placed on an hourly watch in a private room per Doctors Orders until a bed available at the behavioral health hospital. 4. Resident #2 roommate swapped for a more cognitive resident to prevent any future incidents. On hourly staff watch 5. Resident #4 will be protected by hourly staff watch. 6. DON, Admin, Abuse Coordinator and other designated staff will immediately assess all residents for any behavioral signs of abuse. Assessment will include continued observation and monitoring for resident behaviors indicative of abuse. 7. Admin and DON will in-service MDS Coordinator for updates to affected residents care plan to include resident specific interventions to remove immediate jeopardy and ensure continued compliance and safety. A handwritten care plan will be completed immediately for affected residents and placed in chart. EMR will be updated by MDS Coordinator immediately upon return to work. In-service and training to all staff will be completed on 2 levels: 1. Upper management to include Administrator, DON, and Abuse Coordinator will be in-serviced immediately via telephone by Owner/Operator. In-service training to include the following: a. Facility Policy & Procedures, State and Federal guidelines reviewed regarding abuse identification, reporting and investigation requirements. b. Reporting requirements for 2-hour reporting include allegation of abuse, neglect and misappropriation of funds; all other qualifying reportable incidents will be completed within 24 hours of notification per facility Policy. c. Notification of required agencies, physician and family will be made immediately in conjunction with reporting guidelines. d. Interventions put in place immediately to ensure resident safety. e. Investigation process initiated immediately and must include resident assessment and interviews, staff interviews and interviews from any and all witnesses and reporting and involved individuals. f. If allegation includes staff to resident abuse, staff member must be suspended immediately, pending investigation. If allegation includes resident to resident abuse, offending resident must be placed on watch and monitored (i.e. one to one, hourly, etc.) and resident victim must be kept safe and free from alleged offender. Remove the resident immediately! g. Long-term interventions must be identified, care-planned and implemented. MDS must update care plan! If necessary, a hand-written update may be completed and MDS should include in the EHR as soon as possible (i.e., on a weekend). 2. In turn, training of all care staff will be conducted by Administrator, DON, Abuse Coordinator and other appointed Department Heads through immediate in-person and telephone in-servicing. In-service education will include the following: a. Report immediately!! b. Report to your direct supervisor and up the chain of command (i.e. CNA report to Charge Nurse; Charge Nurse report to DON; DON report to Administrator) (housekeeper report to Housekeeping Supervisor; Housekeeping Supervisor report to Administrator). Again, report immediately! Over report .you can not report enough to appropriate personnel. Ultimately, all reporting should be made to Administrator. A rule of thumb to implement is that all staff members should immediately report to their direct supervisor and/or at least two people in the Chain of Command! c. Write down details while they are fresh! This will assist in our internal investigation. Include date, time, and details. d. Immediately separate or remove a resident that may be harming another resident and report to your supervisor to ensure resident safety. e. Watch for signs of abnormal behavior or atypical behavior of a resident as this may be a sign of abuse. Report any unusual resident behavior to your supervisor immediately. All in-service training will be completed by February 18, 2023, approximately noon. In-service training will be conducted by phone for employees not currently in the building. The IJ was lifted, effective 02/18/23 at 12:00 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern with potential for harm to the residents. Based on record review, observation, and record review, the facility failed to ensure residents were protected from further sexual abuse and investigations were timely and thorough for two (#2 and #4) of five residents sampled for abuse. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: A facility abuse policy, revised April 2022, read in parts .The center ensures that all alleged violations involving mistreatment, neglect, or abuse .is reported immediately to the Administrator of the center and to other officials in accordance with State law through established procedures (including to the state survey and certification agency) .Any and all allegations are reported to the DON and/or Administrator .Immediate response is taken to ensure the safety of the resident .Timelines and investigation begin immediately .An initial report will be completed and submitted to the Department of Health Immediately upon notification of the allegation .Within five (5) days (or per state regulations) of the incident-final report is submitted in writing to appropriate state agencies .Events are reviewed by the Quality Management Committee to determine what actions are necessary to prevent recurrence .The regulations do not give us any leeway to decide if an allegation is valid before we report it .You can never assume an event didn't happen .A system to follow up on altercations will place an emphasis on preventing further altercation . 1. Res #2 was admitted to the facility on [DATE] and had diagnoses which included aphasia, TBI, anxiety, contractures, and tracheostomy status. Res #6 was admitted to the facility on [DATE] and had diagnoses which included aftercare following joint replacement and post-polio syndrome. Res #6's quarterly MDS assessment, dated 11/23/22, documented Res #6's cognition was intact, had no behaviors, was independent with most ADLs, and used a w/c and a walker for mobility. Res #2's annual MDS assessment, dated 01/17/23, documented the resident's cognition was severely impaired, required total assistance with ADLs, had impairment in both upper and lower extremities, had an indwelling urinary catheter, and received nutrition by a feeding tube. A facility Incident/Accident Report, signed by RN #1 and the DON on 02/13/23, documented an incident date of 02/11/23 at 10:20 a.m. The report documented the following: CNA #1 reported to RN on duty that she saw Res #6 with his hand under the covers of Res #2. CNA #1 did not see anything inappropriate. CNA #1 said she had a feeling. The RN reported to the DON who immediately reported to the abuse coordinator (SSD). The door was open and CMA #1 stated she asked Res #6 why his hand was under the covers. Res #6 said he was patting Res #2's hand. The steps taken to prevent recurrence was staff were informed to make frequent observations if residents were together and keep the door open. A facility Resident Abuse Investigation Report Form, dated 02/15/23, documented an incident date of 02/11/23 and time unknown. The form documented CMA #1 reported an allegation of sexual abuse involving Res #6, the accused, and Res #2, the alleged victim. The form read in part, .Summary of witnesses .see attached (No other witnesses came forward) . CMA #1's statement dated 02/12/23 was attached. (The first staff to report was CNA #1 who reported to RN #1.) CNA #1's interview and/or statement was not provided. The form read in part, .Corrective action taken ., the line was blank. The form read in part, .Did the resident and/or the representative participate in determining the appropriate corrective action that was taken? . The form documented, No, Resident is non verbal. The form documented the administrator was notified on 02/11/23 at 2:23 p.m., the resident representative was notified on 02/15/23 at 12:40 p.m. and the law enforcement agency was notified on 02/15/23 at 11:00 a.m. The report form had a hand written signature by the SSD/abuse coordinator on the signature line for the Investigating Representative. The abuse coordinator/SSD provided a document containing an interview with Res #6, dated 02/13/23. The interview documented Res #6 denied sexually touching Res #2. The interview documented Res #6 admitted he had put hand under Res #2's covers. The interview documented Res #6 admitted he had touched Res #2's hand, shoulders, and face. The abuse coordinator/SSD provided statements from LPN #1; CMA #1 and #3; CNA #3, 4, and #5; and a cook. Interviews and/or statements were not provided to include RN #1 and CNA #1, 2, and #6 who had worked the shift the allegations were reported. LPN #1's statement, dated 02/16/23 no time, documented CMA #1 reported to her about her concerns related to Res #6 and Res #2 on 02/11/23. LPN #1 documented she had, not witnessed any inappropriate touching or unwanted behaviors. This was the last statement/interview obtained, therefore ending the facility's investigation. An initial 283 Incident Report Form, to OSDH, had a facsimile date of 02/16/23 at 10:47 a.m. The report documented an incident date of 02/11/23. The report documented an allegation of abuse and the resident involved was Res #2, no other resident was named. The report read in parts, .Part B Description of Incident: Please include injuries sustained as well as measures taken to protect the resident(s) during investigation .Med aide verbalized that another resident's hand was under his blanket but did not see anything suspicious . The report did not included the measures taken to protect the resident. The report documented the physician, family, and APS were notified. The report documented the local sheriff's office was notified at 02/15/23 at 11:30 a.m. and the case number was documented. The report had the DON's electronic signature. An initial and final 283 Incident Report Form, to OSDH, had a facsimile date of 02/16/23 at 10:50 a.m. The report documented an incident date of 02/11/23. The report documented a CMA's allegation of another resident's hand under Res #2's blanket but did not see anything suspicious. The other resident, the alleged perpetrator, was not named on the report. Part C of the report documented after an investigation no form of abuse or mistreatment noted. The report had the DON's electronic signature. On 02/16/23 at 11:28 a.m., Res #6 was observed in a wheelchair in the common area next to Res #2's wheelchair. Res #6 was observed facing Res #2's chair from the side with his back to the room. On 02/16/23 at 1:03 p.m., CNA #3 was interviewed. CNA #3 stated she had seen Res #6 in Res #2's room multiple times but had not seen any inappropriate touching. She stated she had heard people say that they thought Res #6 was being inappropriate but no one had ever told me that they had seen any thing inappropriate. She stated she had heard Res #6 being called a chomo because he goes in the one room with the two young guys. She stated she didn't think any thing inappropriate because he was always getting Res #2 to laugh. She stated Res #6 treated Res #2 like a kid, like when you tried to make a baby laugh was how he treated him. On 02/16/23 at 2:28 p.m., RN #3 was interviewed. She stated no one had reported to her any allegations of abuse related to Res #6 and Res #2. She stated she had never seen him do anything inappropriate, but it has always kinda bothered me how attentive he is to the boys. She stated the facility had not interviewed her related to the allegation. On 02/16/23 at 2:58 p.m., CMA #3 was interviewed. CMA #3 stated he had not seen anything inappropriate, but RES #6 did spend a lot of time in Res #2's room. The CMA stated he had seen Res #6 put his hand under Res #2's blanket over the weekend, and maybe he was rubbing his arm as far as he could tell. The CMA said the administration already knew about it so there was nothing to report. The CMA stated over the weekend when it was an issue the nurses just said if he goes in there, we can't keep him out, but just keep an eye on him. The CMA stated some think Res #6 was doing something he shouldn't be doing, but if it was under the covers you couldn't tell. The CMA stated the way the bed sits and all you could see was that his arm is out but you couldn't see what was going on. On 02/16/23 at 3:32 p.m., LPN #1 was interviewed. She stated she usually works weekends and last weekend CMA #1 had reported she saw Res #6 with his hand under the blanket of Res #2 making up and downward movements. She stated CMA #1 had reported it to the DON and the abuse coordinator. LPN #1 stated she kept a pretty good eye on Res #2 just in case because he is nonverbal. She stated Res #6 was in Res #2's room quite a bit. She stated around meal times or towards the ends of meals Res #6 would head in there and visit with Res #2. She stated it varied how long he stayed, some weekends a long time, like 30 minutes to an hour. LPN #1 stated Res #6 was pretty independent so it was hard to keep up with him sometimes but you start to pick up on his routine. She stated she had not witnessed any inappropriate behavior. On 02/16/23 at 5:30 p.m., CNA #6 was interviewed. CNA #6 stated it was brought to her attention that CNA #1 caught Res #6 with his hand under Res #2's blanket in his private area. She stated the CNA had reported it to the nurse and the med aide. CNA #6 stated that on 02/11/23 she had also witnessed Res #6's hand under the covers of Res #2 as she walked by the room and had told her nurse. CNA #6 stated we have started to put the tab on Res #2's brief a certain way when we change him so to tell us if it had been moved. CNA #6 stated she had asked the nurse why we couldn't tell Res #6 that he can't go in there, but they have said we can't do that. The CNA was asked if the facility had interviewed her about the abuse allegation and stated she had not been interviewed until now. On 02/16/23 at 7:15 p.m., CMA #1 was interviewed over the phone. She stated around 9:00 a.m., CNA #1 came to her while she was passing meds and asked her if she could go check on Res #2. CMA #1 stated CNA #1 said Res #6 was in Res #2's room with his arm under Res #2's blanket touching his private area. CMA #1 stated she moved her med cart outside of Res #2's door. She said she saw Res #6 with his arm under the blanket and appeared to be in his private area. She stated she then went in the room and stood by the bed, and at that time Res #6's slowly moved his arm back and began patting Res #2's hand at the edge of the bed. She stated Res #6's demeanor went from serious to laughing and loudly talking to Res #2. She stated she talked to Res #2, who was unable to speak, for a minute then went back to her cart. The CMA stated Res #6 continued playing and patting Res #2, rubbing his hands on Res #2's face, touching his lips, and using a stuffed animal to attack him playfully. She stated Res #6 kept looking to see if I was there and after about 10 minutes Res #6 left. She stated she then reported to her charge nurse, RN #1, immediately. The CMA stated she heard the RN contact the DON at approximately 9:30 a.m. After the phone call I was told to keep an eye on Res #6 but we can not say anything to Res #6. The CMA stated the RN told her the DON was going to notify the abuse coordinator (SSD). The CMA stated Res #6 went back to Res #2's room a couple of times before lunch that she knew. She stated she tried to watch him the best she could, but she had meds to give, and the CNAs were trying to watch also. She stated after lunch Res #6 returned to Res #2's room and his back was to the door and he wasn't aware she was there. She stated Res #6's arm and hand was again under the blanket and as she began to tell Res #6 that their hand was under the blanket, they moved their arm back and began patting Res #2's hand again and Res #6 stated, He likes that. She stated Res #6 then pulled his hand out from under the blanket and I went back to the hallway to observe. She stated Res #6 looked over their shoulder a few times and saw that she was there and then left the room. CMA #1 stated after that, at 2:12 p.m., she sent a text to the DON, because she felt something should be done. She said she then texted the abuse coordinator. She stated the abuse coordinator said there was nothing that could be done and that it was hearsay. The CMA stated the abuse coordinator told her without proof she couldn't say anything to Res #6. The CMA stated she shared her concern that they should protect the resident until it was investigated. The CMA stated she told the abuse coordinator other staff had made comments about how strange it was that Res #6 was in Res #2's room multiple times a day. The CMA stated the abuse coordinator became defensive towards her and told her it was hearsay. The CMA stated she asked the abuse coordinator if this was a state reportable and she stated it was. She stated the abuse coordinator stated it was just like another instance that often happens when Res #5 touches Res #4's breast and she can't consent, but nothing can be done because it's hearsay. The CMA stated she was not aware of occurrences involving Res #4 and #5. CMA #1 stated she asked the abuse coordinator if that also should be a state reportable that needed to be investigated and the abuse coordinator told her it had been and did not need CMA #1 telling her how to do her job. On 02/17/23 at 9:45 a.m., Res #2's representative stated she was not notified of an allegation of abuse involving her loved one. The representative stated Res #2 was not able to consent and it was inappropriate for another resident to have their hands under his covers. On 02/17/23 at 10:29 a.m., Res #6 was observed in the day area in a wheelchair next to Res #2's wheelchair. Res #6 noticed surveyor at the nurses station and began laughing and rocking Res #2's wheelchair from side to side by the handles on the back of the wheelchair briefly before leaving the day area. On 02/17/23 at 11:38 a.m., the DON was interviewed. She stated on Saturday, the 11th, RN#1 called her around 10:00 a.m. and said there was an allegation of abuse against Res #6 involving Res #2. She said CNA #1 and CMA #1 had said Res #6 had his hand under Res #2's blanket. The DON stated she then called the abuse coordinator and told her. The DON stated CMA #1 called her later in the day because she was worried it wasn't being taken care of. The DON stated she was instructed to contact the abuse coordinator. The DON stated she suggested to not allow the resident to go back into Res #2's room, but was told by the abuse coordinator that he could go in there, he just had to be watched. The DON was asked if she had done an investigation. She stated the abuse coordinator was the one who did the investigations and had not directed her to do any interviews. The DON was asked if Res #2 was protected after the allegation was made? She stated they protected him by telling the staff to make frequent observations when Res #6 was in Res #2's room. She stated Res #2 should be protected while the investigation was on going. The DON stated she was directed by the abuse coordinator to allow Res #6 to go in the room but to ensure he is observed. She was asked if other residents should have been interviewed and she stated, Yes. The DON was asked if there should have been a more timely investigation started and she stated, Yes. On 02/17/23 at 11:47 a.m., CNA #1 was interviewed over the phone. She stated on 02/11/23 around 8:30 to 8:45 a.m., she was passing ice to a room across the hall from Res #2's room. She said she heard a noise from Res #2's room and when she looked in the room, she witnessed Res #6 at Res #2's bedside with his arm under the covers. She said she could tell his hand was moving in the middle of the bed and the whole bed was shaking. She stated the blanket was moving. She stated Res #2 was unable to rotate, move, or even speak, and he had a weird look on his face. She stated Res #6's arm and hand were moving super fast under the blanket. She said you could tell what he was doing. There was nothing else he could have been doing. When Res #6 heard my cart he took his hand out from the blanket. She stated she was distraught and had a sick feeling. She stated she then went to tell RN #1 and she told me she didn't know how to go about asking him or doing anything about it. I had been assigned showers all day and then went to help one of my co-workers in the showers. She stated when she came back to check on Res #2, Res #6 was still in the room. She stated she felt like nothing was being done because Res #6 was still in there so she asked CMA #1 to check on Res #2 because she could not continue to watch him and CMA #1 did go. CNA #1 stated that later CMA #1 told her that Res #6 had finally left so finally left so she went in to check on Res #2 and checked his brief to see if he was soiled. She stated anyone who had changed Res #2 knew it was hard to loosen his diaper because of his contractures. She stated when she checked him the brief was super loose in the front main area where the peri-area was. She stated the resident was so contracted he was not able to put his hands down there and normally his brief was not moved like that. CNA #1 was asked if she had been interview by the administration. She said the DON had called her yesterday. (No documentation was provided related to an interview with CNA #1.) The CNA #1 stated the DON had explained to her that Res #6 had been there for a whole year and that was the first time that anything had been reported to her. The CNA stated she told her that just because that's the first time she had reported it doesn't mean it's the first time. The CNA stated there was an agency lady that had been there much longer and had told her and CMA #1 that she had reported it repeatedly. CNA #1 stated Res #2 was not the first one that it had happened to, it had also happened to Res #3, Res #2's roommate. (Res #3 unable to be interviewed related to severly impaired cognition.) On 02/17/23 at 1:16 p.m., CNA #2 was interviewed over the phone. CNA #2 stated Res #6 was in Res #2's room multiple times a day and thought it was odd. She stated there were times she had walked by Res #2's room and it looked like Res #6's hand was under the cover but was hard to tell if you're just walking by. She stated sometimes when they would walk in Res #6 would get startled and then leave. CNA #2 stated she did see his hand under the covers for sure once last weekend but couldn't tell what he was doing. She stated Res #6 messes with Res #2's face and was actually kinda rough with him, touching him too hard on his face and on his chest. The CNA stated Res #6 pats Res #2 and sometimes he rubs his chest really hard, I guess he was trying to get him to laugh. She stated no one said to not let Res #6 go in there, they just told us to watch him, and see what Res #6 was doing. The CNA stated if we're busy we can't just stand there and watch him all the time and no one was assigned to watch him that she knew of. She stated anytime he would have been in there he would have been in there alone. On 02/17/23 at 2:03 p.m., the SSD/abuse coordinator was interviewed. The abuse coordinator stated she was aware of the allegation of abuse involving Res #6 and Res #2. She stated the DON notified her Saturday the 11th. She stated she was told that ''some staff'' had seen Res #6 in Res #2's room with his hand under the cover. The abuse coordinator stated she told the DON to tell the staff that the door remains open and when Res #6 visits Res #2 the staff were to go in there. The abuse coordinator was asked if she had the staff remove Res #6 from Res #2's room. She stated, No mam, because because it was an allegation, did they ask [Res name deleted] where was his hand was, did they witness him in the groin area, they said no, I said ok. The abuse coordinator was asked if she interviewed all the staff working the shift when the allegation was reported. She said she asked for statements, but nobody came forward, just CMA #1. She stated she called CNA #1 but she did not return the call. She stated she received statements from CMA #1, Res #6, CNA #4, CMA #3, and LPN #1. She was asked if she documented her attempt and she said she did not. She was asked if she came to the facility on Saturday the 11th or Sunday the 12th to start the investigation. She stated she came in on Monday to begin the investigation. She stated the DON came into the facility at 6:00 on Sunday. The abuse coordinator was informed that the DON stated that she was not directed to do any of the investigations. The abuse coordinator was asked if two days after the allegation was a timely start of the investigation of sexual abuse. The Abuse coordinator stated, My opinion I was protecting [Res #2 name deleted] by telling them to stay in the room and I notified my proper people, the administrator. The abuse coordinator was asked if she interviewed any residents and she responded, Res #6. She was asked if she considered it a thorough investigation if you interview the alleged only? She stated she interviewed Res #6 because he was the one the allegation was against. She stated she didn't interview other residents. She stated Res #2 and Res #3 are nonverbal. The abuse coordinator was asked how the staff were to know to watch Res #6. She stated she trusted her DON to relay that information. The abuse coordinator was then informed that multiple staff did not know to watch Res #6 if he went into Res #2's room. On 02/17/23 at 3:55 p.m., the administrator was interviewed. The administrator stated she was aware of the allegation of abuse involving Res #6 and Res #2. She stated the DON reported it to her Saturday, the 11th, in the afternoon. She stated the DON was the one who completed the reportables most of the time. She stated the DON at least does the initial report and she would do the final when the investigation was complete. The administrator was asked why the allegation of abuse was not reported within the two hour time frame. She stated she thought the DON had taken care of it on Sunday, the 12th. She sated it should have been done on Saturday. The administrator was asked if the resident was protected while the investigation was pending. The administrator stated CMA #1 was not for certain what she actually witnessed, that's why we told her to stay in there and not allow Res #6 into the room by himself. The administrator stated when they called her on the weekend she tried to make sure they protected the resident and it was not happening again. The administrator was asked whose responsibility was it to watch the resident? She stated the abuse coordinator told them to make sure there was a staff in the room at all times. She stated usually we have only certain number who are supposed to work and we had too many so she told CMA #1 to make sure that someone watched him. The administrator was asked if the investigation was timely and thorough. She stated the abuse coordinator started the investigation and told them what to do and then the DON came in on Sunday the 12th which made me feel better. She stated when she came in on Monday she called CMA #1 and put her on speaker with the abuse coordinator. The administrator stated that what got her alarmed was that Res #6 kept coming back. She stated she didn't get to talk to CNA #1 because she was agency. The administrator was asked what the tasks were for the abuse coordinator. She stated For years, this is now going to change, she does the investigation and we do the reportable. She has never done the reportable. The people report to [abuse coordinator name deleted] and she does the investigation and I help. The administrator was asked if she thought the investigation should have started on Saturday the 11th? She stated the statements were dated the 13th. She stated she told the DON to get a hold of CNA #1 and we didn't get anything from her timely. She stated the investigation should have started on Saturday. She stated when the DON came in on Sunday she intentionally came in to make sure that nothing would repeat from Saturday and eventually she told me she talked to RN #1. The administrator was asked about resident interviews. The administrator stated the DON told her she didn't do any because the residents in the room were non-verbal. She stated she told the DON to conduct interviews with at least three random residents in the hallway. 46387 2. Res #4 had diagnoses which included cerebral infarction, major depressive disorder, dementia, and bipolar disorder. A quarterly MDS, dated [DATE], documented Res #4 was severely cognitively impaired, required limited to extensive assistance of one staff with ADLs, and utilized a walker and wheelchair for mobility. A nurse progress note, dated 12/28/22 at 1:00 p.m., documented Res #5 was incontinent of bowel and bladder by choice. The note documented Res #5 was able to toilet self but refused and enjoyed being changed by staff. The note documented Res #5 made inappropriate comments to staff during care. A nurse progress note, dated 12/29/22 at 1:00 p.m., d [TRUNCATED]

On 02/17/23 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents #2 and #4 were free from abuse. a. CNA #1 reported she witnessed, on 02/11/23, Res #6 with his arm and hand under the blanket of Res #2. The CNA reported Res #6's arm and hand were moving fast in an up and down motion causing the blanket to move and the bed to shake. CMA #1, CMA #3, CNA #2 and CNA #6 also reported they witnessed, on 02/11/23, Res #6 with his hand under the covers of Res #2. Multiple staff reported Res #6 had been going in Res #2's room numerous times everyday and reported they thought it was odd and some reported they were suspicious. Res #2 had diagnoses of aphasia and traumatic brain injury and was unable to be interviewed. b. CNA #2 reported she witnessed, on 12/31/22, Res #5 lifted the shirt of Res #4 and touched her breast and was trying to put his hand in her pants. CNA #3 reported she witnessed, around the first of February 2023, Res #5 with one hand on the inner thigh of Res #4 and the other kneading the breast of Res #4. Res #4 had severely impaired cognition and was unable to be interviewed. In the days following the 12/31/23 incident, nurses notes documented Res #4 had been short tempered, difficult to redirect, had bit, hit, kicked, and pinched staff during care, had been argumentative with other residents, had attempted to access restricted areas of the facility, had attempted to get in bed with female residents, tearful at times, easily angered, easily agitated, was refusing to allow staff to put her to bed, and was sleeping in the lobby. On 01/04/23 the resident was started on a new order for Ativan 0.25 mg as needed for anxiety and agitation. On 02/17/23 at 6:04 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 02/17/23 at 6:35 p.m., the administrator was notified of the IJ situation. On 02/18/23 at 2:06 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: The Administrator in conjunction with the entire department heads team members will ensure that adverse events that are ongoing, urgent or emergent are reported timely. The Administrator has provided direction to all levels of leadership on how to appropriately report any adverse events that occur. In addition, the quality assurance team meets daily during morning meetings to review all reported events and ensure timeliness in reporting. Immediate action taken to ensure resident safety: 1. Facility will immediately meet the federal and state health, safety, and quality regulations regarding the alleged. 2. Resident #6 discharged to [name of location deleted] under [name of person deleted] watch. 3. Resident #5 placed on an hourly watch in a private room per Doctors Orders until a bed available at the behavioral health hospital. 4. Resident #2 roommate swapped for a more cognitive resident to prevent any future incidents. On hourly staff watch 5. Resident #4 will be protected by hourly staff watch. 6. DON, Admin, Abuse Coordinator and other designated staff will immediately assess all residents for any behavioral signs of abuse. Assessment will include continued observation and monitoring for resident behaviors indicative of abuse. 7. Admin and DON will in-service MDS Coordinator for updates to affected residents care plan to include resident specific interventions to remove immediate jeopardy and ensure continued compliance and safety. A handwritten care plan will be completed immediately for affected residents and placed in chart. EMR will be updated by MDS Coordinator immediately upon return to work. In-service and training to all staff will be completed on 2 levels: 1. Upper management to include Administrator, DON, and Abuse Coordinator will be in-serviced immediately via telephone by Owner/Operator. In-service training to include the following: a. Facility Policy & Procedures, State and Federal guidelines reviewed regarding abuse identification, reporting and investigation requirements. b. Reporting requirements for 2-hour reporting include allegation of abuse, neglect and misappropriation of funds; all other qualifying reportable incidents will be completed within 24 hours of notification per facility Policy. c. Notification of required agencies, physician and family will be made immediately in conjunction with reporting guidelines. d. Interventions put in place immediately to ensure resident safety. e. Investigation process initiated immediately and must include resident assessment and interviews, staff interviews and interviews from any and all witnesses and reporting and involved individuals. f. If allegation includes staff to resident abuse, staff member must be suspended immediately, pending investigation. If allegation includes resident to resident abuse, offending resident must be placed on watch and monitored (i.e. one to one, hourly, etc.) and resident victim must be kept safe and free from alleged offender. Remove the resident immediately! g. Long-term interventions must be identified, care-planned and implemented. MDS must update care plan! If necessary, a hand-written update may be completed and MDS should include in the EHR as soon as possible (i.e., on a weekend). 2. In turn, training of all care staff will be conducted by Administrator, DON, Abuse Coordinator and other appointed Department Heads through immediate in-person and telephone in-servicing. In-service education will include the following: a. Report immediately!! b. Report to your direct supervisor and up the chain of command (i.e. CNA report to Charge Nurse; Charge Nurse report to DON; DON report to Administrator) (housekeeper report to Housekeeping Supervisor; Housekeeping Supervisor report to Administrator). Again, report immediately! Over report .you can not report enough to appropriate personnel. Ultimately, all reporting should be made to Administrator. A rule of thumb to implement is that all staff members should immediately report to their direct supervisor and/or at least two people in the Chain of Command! c. Write down details while they are fresh! This will assist in our internal investigation. Include date, time, and details. d. Immediately separate or remove a resident that may be harming another resident and report to your supervisor to ensure resident safety. e. Watch for signs of abnormal behavior or atypical behavior of a resident as this may be a sign of abuse. Report any unusual resident behavior to your supervisor immediately. All in-service training will be completed by February 18, 2023, approximately noon. In-service training will be conducted by phone for employees not currently in the building. The IJ was lifted, effective 02/18/23 at 12:00 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern with potential for harm to the residents. Based on record review, observation, and record review, the facility failed to ensure residents were free from abuse for two (#2 and #4) of five residents sampled for abuse. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility. Findings: A facility abuse policy, revised April 2022, documented in parts .The resident has the right to be free from verbal, sexual, physical, and mental abuse .The center ensures that all alleged violations involving mistreatment, neglect, or abuse .reported immediately to the Administrator of the center and to other officials in accordance with State law through established procedures (including to the state survey and certification agency) .Any and all allegations are reported to the DON and/or Administrator .Immediate response is taken to ensure the safety of the resident .Timelines and investigation begin immediately .An initial report will be completed and submitted to the Department of Health Immediately upon notification of the allegation .Within five (5) days (or per state regulations) of the incident-final report is submitted in writing to appropriate state agencies .Events are reviewed by the Quality Management Committee to determine what actions are necessary to prevent recurrence .The regulations do not give us any leeway to decide if an allegation is valid before we report it .You can never assume an event didn't happen .A system to follow up on altercations will place an emphasis on preventing further altercation . 1. Res #2 was admitted to the facility on [DATE] and had diagnoses which included aphasia, TBI, anxiety, contractures, and tracheostomy status. Res #6 was admitted to the facility on [DATE] and had diagnoses which included aftercare following joint replacement and post-polio syndrome. Res #6's quarterly MDS assessment, dated 11/23/22, documented Res #6's cognition was intact, had no behaviors, was independent with most ADLs, and used a w/c and a walker for mobility. Res #2's annual MDS assessment, dated 01/17/23, documented the resident's cognition was severely impaired, required total assistance with ADLs, had impairment in both upper and lower extremities, had an indwelling urinary catheter, and received nutrition by a feeding tube. A facility Incident/Accident Report, signed by RN #1 and the DON on 02/13/23, documented an incident date of 02/11/23 at 10:20 a.m. The report documented the following: CNA #1 reported to RN on duty that she saw Res #6 with his hand under the covers of Res #2. CNA #1 did not see anything inappropriate. CNA #1 said she had a feeling. The RN reported to the DON who immediately reported to the abuse coordinator (SSD). The door was open and CMA #1 stated she asked Res #6 why his hand was under the covers. Res #6 said he was patting Res #2's hand. The steps taken to prevent recurrence was staff were informed to make frequent observations if residents were together and keep the door open. A facility Resident Abuse Investigation Report Form, dated 02/15/23, documented an incident date of 02/11/23 and time unknown. The form documented CMA #1 reported an allegation of sexual abuse involving Res #6, the accused, and Res #2, the alleged victim. The form read in part, .Summary of witnesses .see attached (No other witnesses came forward) . CMA #1's statement dated 02/12/23 was attached. (The first staff to report was CNA #1 who reported to RN #1.) CNA #1's interview and/or statement was not provided. The form read in part, .Corrective action taken ., the line was blank. The form read in part, .Did the resident and/or the representative participate in determining the appropriate corrective action that was taken? . The form documented, No, Resident is non verbal. The form documented the administrator was notified on 02/11/23 at 2:23 p.m., the resident representative was notified on 02/15/23 at 12:40 p.m. and the law enforcement agency was notified on 02/15/23 at 11:00 a.m. The report form had a hand written signature by the SSD/abuse coordinator on the signature line for the Investigating Representative. The abuse coordinator/SSD provided a document containing an interview with Res #6, dated 02/13/23. The interview documented Res #6 denied sexually touching Res #2. The interview documented Res #6 admitted he had put hand under Res #2's covers. The interview documented Res #6 admitted he had touched Res #2's hand, shoulders, and face. The abuse coordinator/SSD provided statements from LPN #1; CMA #1 and #3; CNA #3, 4, and #5; and a cook. Interviews and/or statements were not provided to include RN #1 and CNA #1, 2, and #6 who had worked the shift the allegations were reported. LPN #1's statement, dated 02/16/23 no time, documented CMA #1 reported to her about her concerns related to Res #6 and Res #2 on 02/11/23. LPN #1 documented she had, not witnessed any inappropriate touching or unwanted behaviors. This was the last statement/interview obtained, therefore ending the facility's investigation. An initial 283 Incident Report Form, to OSDH, had a facsimile date of 02/16/23 at 10:47 a.m. The report documented an incident date of 02/11/23. The report documented an allegation of abuse and the resident involved was Res #2, no other resident was named. The report read in parts, .Part B Description of Incident: Please include injuries sustained as well as measures taken to protect the resident(s) during investigation .Med aide verbalized that another resident's hand was under his blanket but did not see anything suspicious . The report did not included the measures taken to protect the resident. The report documented the physician, family, and APS were notified. The report documented the local sheriff's office was notified at 02/15/23 at 11:30 a.m. and the case number was documented. The report had the DON's electronic signature. An initial and final 283 Incident Report Form, to OSDH, had a facsimile date of 02/16/23 at 10:50 a.m. The report documented an incident date of 02/11/23. The report documented a CMA's allegation of another resident's hand under Res #2's blanket but did not see anything suspicious. The other resident, the alleged perpetrator, was not named on the report. Part C of the report documented after an investigation no form of abuse or mistreatment noted. The report had the DON's electronic signature. On 02/16/23 at 11:28 a.m., Res #6 was observed in a wheelchair in the common area next to Res #2's wheelchair. Res #6 was observed facing Res #2's chair from the side with his back to the room. On 02/16/23 at 1:03 p.m., CNA #3 was interviewed. CNA #3 stated she had seen Res #6 in Res #2's room multiple times but had not seen any inappropriate touching. She stated she had heard people say that they thought Res #6 was being inappropriate but no one had ever told me that they had seen any thing inappropriate. She stated she had heard Res #6 being called a chomo because he goes in the one room with the two young guys. She stated she didn't think any thing inappropriate because he was always getting Res #2 to laugh. She stated Res #6 treated Res #2 like a kid, like when you tried to make a baby laugh was how he treated him. On 02/16/23 at 2:28 p.m., RN #3 was interviewed. She stated no one had reported to her any allegations of abuse related to Res #6 and Res #2. She stated she had never seen him do anything inappropriate, but it has always kinda bothered me how attentive he is to the boys. She stated the facility had not interviewed her related to the allegation. On 02/16/23 at 2:58 p.m., CMA #3 was interviewed. CMA #3 stated he had not seen anything inappropriate, but RES #6 did spend a lot of time in Res #2's room. The CMA stated he had seen Res #6 put his hand under Res #2's blanket over the weekend, and maybe he was rubbing his arm as far as he could tell. The CMA said the administration already knew about it so there was nothing to report. The CMA stated over the weekend when it was an issue the nurses just said if he goes in there, we can't keep him out, but just keep an eye on him. The CMA stated some think Res #6 was doing something he shouldn't be doing, but if it was under the covers you couldn't tell. The CMA stated the way the bed sits and all you could see was that his arm is out but you couldn't see what was going on. On 02/16/23 at 3:32 p.m., LPN #1 was interviewed. She stated she usually works weekends and last weekend CMA #1 had reported she saw Res #6 with his hand under the blanket of Res #2 making up and downward movements. She stated CMA #1 had reported it to the DON and the abuse coordinator. LPN #1 stated she kept a pretty good eye on Res #2 just in case because he is nonverbal. She stated Res #6 was in Res #2's room quite a bit. She stated around meal times or towards the ends of meals Res #6 would head in there and visit with Res #2. She stated it varied how long he stayed, some weekends a long time, like 30 minutes to an hour. LPN #1 stated Res #6 was pretty independent so it was hard to keep up with him sometimes but you start to pick up on his routine. She stated she had not witnessed any inappropriate behavior. On 02/16/23 at 5:30 p.m., CNA #6 was interviewed. CNA #6 stated it was brought to her attention that CNA #1 caught Res #6 with his hand under Res #2's blanket in his private area. She stated the CNA had reported it to the nurse and the med aide. CNA #6 stated that on 02/11/23 she had also witnessed Res #6's hand under the covers of Res #2 as she walked by the room and had told her nurse. CNA #6 stated we have started to put the tab on Res #2's brief a certain way when we change him so to tell us if it had been moved. CNA #6 stated she had asked the nurse why we couldn't tell Res #6 that he can't go in there, but they have said we can't do that. The CNA was asked if the facility had interviewed her about the abuse allegation and stated she had not been interviewed until now. On 02/16/23 at 7:15 p.m., CMA #1 was interviewed over the phone. She stated around 9:00 a.m., CNA #1 came to her while she was passing meds and asked her if she could go check on Res #2. CMA #1 stated CNA #1 said Res #6 was in Res #2's room with his arm under Res #2's blanket touching his private area. CMA #1 stated she moved her med cart outside of Res #2's door. She said she saw Res #6 with his arm under the blanket and appeared to be in his private area. She stated she then went in the room and stood by the bed, and at that time Res #6's slowly moved his arm back and began patting Res #2's hand at the edge of the bed. She stated Res #6's demeanor went from serious to laughing and loudly talking to Res #2. She stated she talked to Res #2, who was unable to speak, for a minute then went back to her cart. The CMA stated Res #6 continued playing and patting Res #2, rubbing his hands on Res #2's face, touching his lips, and using a stuffed animal to attack him playfully. She stated Res #6 kept looking to see if I was there and after about 10 minutes Res #6 left. She stated she then reported to her charge nurse, RN #1, immediately. The CMA stated she heard the RN contact the DON at approximately 9:30 a.m. After the phone call I was told to keep an eye on Res #6 but we can not say anything to Res #6. The CMA stated the RN told her the DON was going to notify the abuse coordinator (SSD). The CMA stated Res #6 went back to Res #2's room a couple of times before lunch that she knew. She stated she tried to watch him the best she could, but she had meds to give, and the CNAs were trying to watch also. She stated after lunch Res #6 returned to Res #2's room and his back was to the door and he wasn't aware she was there. She stated Res #6's arm and hand was again under the blanket and as she began to tell Res #6 that their hand was under the blanket, they moved their arm back and began patting Res #2's hand again and Res #6 stated, He likes that. She stated Res #6 then pulled his hand out from under the blanket and I went back to the hallway to observe. She stated Res #6 looked over their shoulder a few times and saw that she was there and then left the room. CMA #1 stated after that, at 2:12 p.m., she sent a text to the DON, because she felt something should be done. She said she then texted the abuse coordinator. She stated the abuse coordinator said there was nothing that could be done and that it was hearsay. The CMA stated the abuse coordinator told her without proof she couldn't say anything to Res #6. The CMA stated she shared her concern that they should protect the resident until it was investigated. The CMA stated she told the abuse coordinator other staff had made comments about how strange it was that Res #6 was in Res #2's room multiple times a day. The CMA stated the abuse coordinator became defensive towards her and told her it was hearsay. The CMA stated she asked the abuse coordinator if this was a state reportable and she stated it was. She stated the abuse coordinator stated it was just like another instance that often happens when Res #5 touches Res #4's breast and she can't consent, but nothing can be done because it's hearsay. The CMA stated she was not aware of occurrences involving Res #4 and #5. CMA #1 stated she asked the abuse coordinator if that also should be a state reportable that needed to be investigated and the abuse coordinator told her it had been and did not need CMA #1 telling her how to do her job. On 02/17/23 at 9:45 a.m., Res #2's representative stated she was not notified of an allegation of abuse involving her loved one. The representative stated Res #2 was not able to consent and it was inappropriate for another resident to have their hands under his covers. On 02/17/23 at 10:29 a.m., Res #6 was observed in the day area in a wheelchair next to Res #2's wheelchair. Res #6 noticed surveyor at the nurses station and began laughing and rocking Res #2's wheelchair from side to side by the handles on the back of the wheelchair briefly before leaving the day area. On 02/17/23 at 11:38 a.m., the DON was interviewed. She stated on Saturday, the 11th, RN#1 called her around 10:00 a.m. and said there was an allegation of abuse against Res #6 involving Res #2. She said CNA #1 and CMA #1 had said Res #6 had his hand under Res #2's blanket. The DON stated she then called the abuse coordinator and told her. The DON stated CMA #1 called her later in the day because she was worried it wasn't being taken care of. The DON stated she was instructed to contact the abuse coordinator. The DON stated she suggested to not allow the resident to go back into Res #2's room, but was told by the abuse coordinator that he could go in there, he just had to be watched. The DON was asked if she had done an investigation. She stated the abuse coordinator was the one who did the investigations and had not directed her to do any interviews. The DON was asked if Res #2 was protected after the allegation was made? She stated they protected him by telling the staff to make frequent observations when Res #6 was in Res #2's room. She stated Res #2 should be protected while the investigation was on going. The DON stated she was directed by the abuse coordinator to allow Res #6 to go in the room but to ensure he is observed. She was asked if other residents should have been interviewed and she stated, Yes. The DON was asked if there should have been a more timely investigation started and she stated, Yes. On 02/17/23 at 11:47 a.m., CNA #1 was interviewed over the phone. She stated on 02/11/23 around 8:30 to 8:45 a.m., she was passing ice to a room across the hall from Res #2's room. She said she heard a noise from Res #2's room and when she looked in the room, she witnessed Res #6 at Res #2's bedside with his arm under the covers. She said she could tell his hand was moving in the middle of the bed and the whole bed was shaking. She stated the blanket was moving. She stated Res #2 was unable to rotate, move, or even speak, and he had a weird look on his face. She stated Res #6's arm and hand were moving super fast under the blanket. She said you could tell what he was doing. There was nothing else he could have been doing. When Res #6 heard my cart he took his hand out from the blanket. She stated she was distraught and had a sick feeling. She stated she then went to tell RN #1 and she told me she didn't know how to go about asking him or doing anything about it. I had been assigned showers all day and then went to help one of my co-workers in the showers. She stated when she came back to check on Res #2, Res #6 was still in the room. She stated she felt like nothing was being done because Res #6 was still in there so she asked CMA #1 to check on Res #2 because she could not continue to watch him and CMA #1 did go. CNA #1 stated that later CMA #1 told her that Res #6 had finally left so finally left so she went in to check on Res #2 and checked his brief to see if he was soiled. She stated anyone who had changed Res #2 knew it was hard to loosen his diaper because of his contractures. She stated when she checked him the brief was super loose in the front main area where the peri-area was. She stated the resident was so contracted he was not able to put his hands down there and normally his brief was not moved like that. CNA #1 was asked if she had been interview by the administration. She said the DON had called her yesterday. (No documentation was provided related to an interview with CNA #1.) The CNA #1 stated the DON had explained to her that Res #6 had been there for a whole year and that was the first time that anything had been reported to her. The CNA stated she told her that just because that's the first time she had reported it doesn't mean it's the first time. The CNA stated there was an agency lady that had been there much longer and had told her and CMA #1 that she had reported it repeatedly. CNA #1 stated Res #2 was not the first one that it had happened to, it had also happened to Res #3, Res #2's roommate. (Res #3 unable to be interviewed related to severely impaired cognition.) On 02/17/23 at 1:16 p.m., CNA #2 was interviewed over the phone. CNA #2 stated Res #6 was in Res #2's room multiple times a day and thought it was odd. She stated there were times she had walked by Res #2's room and it looked like Res #6's hand was under the cover but was hard to tell if you're just walking by. She stated sometimes when they would walk in Res #6 would get startled and then leave. CNA #2 stated she did see his hand under the covers for sure once last weekend but couldn't tell what he was doing. She stated Res #6 messes with Res #2's face and was actually kinda rough with him, touching him too hard on his face and on his chest. The CNA stated Res #6 pats Res #2 and sometimes he rubs his chest really hard, I guess he was trying to get him to laugh. She stated no one said to not let Res #6 go in there, they just told us to watch him, and see what Res #6 was doing. The CNA stated if we're busy we can't just stand there and watch him all the time and no one was assigned to watch him that she knew of. She stated anytime he would have been in there he would have been in there alone. On 02/17/23 at 2:03 p.m., the SSD/abuse coordinator was interviewed. The abuse coordinator stated she was aware of the allegation of abuse involving Res #6 and Res #2. She stated the DON notified her Saturday the 11th. She stated she was told that ''some staff'' had seen Res #6 in Res #2's room with his hand under the cover. The abuse coordinator stated she told the DON to tell the staff that the door remains open and when Res #6 visits Res #2 the staff were to go in there. The abuse coordinator was asked if she had the staff remove Res #6 from Res #2's room. She stated, No mam, because because it was an allegation, did they ask [Res name deleted] where was his hand was, did they witness him in the groin area, they said no, I said ok. The abuse coordinator was asked if she interviewed all the staff working the shift when the allegation was reported. She said she asked for statements, but nobody came forward, just CMA #1. She stated she called CNA #1 but she did not return the call. She stated she received statements from CMA #1, Res #6, CNA #4, CMA #3, and LPN #1. She was asked if she documented her attempt and she said she did not. She was asked if she came to the facility on Saturday the 11th or Sunday the 12th to start the investigation. She stated she came in on Monday to begin the investigation. She stated the DON came into the facility at 6:00 on Sunday. The abuse coordinator was informed that the DON stated that she was not directed to do any of the investigations. The abuse coordinator was asked if two days after the allegation was a timely start of the investigation of sexual abuse. The Abuse coordinator stated, My opinion I was protecting [Res #2 name deleted] by telling them to stay in the room and I notified my proper people, the administrator. The abuse coordinator was asked if she interviewed any residents and she responded, Res #6. She was asked if she considered it a thorough investigation if you interview the alleged only? She stated she interviewed Res #6 because he was the one the allegation was against. She stated she didn't interview other residents. She stated Res #2 and Res #3 are nonverbal. The abuse coordinator was asked how the staff were to know to watch Res #6. She stated she trusted her DON to relay that information. The abuse coordinator was then informed that multiple staff did not know to watch Res #6 if he went into Res #2's room. On 02/17/23 at 3:55 p.m., the administrator was interviewed. The administrator stated she was aware of the allegation of abuse involving Res #6 and Res #2. She stated the DON reported it to her Saturday, the 11th, in the afternoon. She stated the DON was the one who completed the reportable's most of the time. She stated the DON at least does the initial report and she would do the final when the investigation was complete. The administrator was asked why the allegation of abuse was not reported within the two hour time frame. She stated she thought the DON had taken care of it on Sunday, the 12th. She sated it should have been done on Saturday. The administrator was asked if the resident was protected while the investigation was pending. The administrator stated CMA #1 was not for certain what she actually witnessed, that's why we told her to stay in there and not allow Res #6 into the room by himself. The administrator stated when they called her on the weekend she tried to make sure they protected the resident and it was not happening again. The administrator was asked whose responsibility was it to watch the resident? She stated the abuse coordinator told them to make sure there was a staff in the room at all times. She stated usually we have only certain number who are supposed to work and we had too many so she told CMA #1 to make sure that someone watched him. The administrator was asked if the investigation was timely and thorough. She stated the abuse coordinator started the investigation and told them what to do and then the DON came in on Sunday the 12th which made her feel better. The administrator stated when she came in on Monday she called CMA #1 and put her on speaker with the abuse coordinator. The administrator stated that what got her alarmed was that Res #6 kept coming back. She stated she didn't get to talk to CNA #1 because she was agency. The administrator was asked what the tasks were for the abuse coordinator. She stated For years, this is now going to change, she did the investigation and we did the reportable, the abuse coordinator had never completed the reportable. The people report to [abuse coordinator name deleted] and she does the investigation and I help. The administrator was asked if she thought the investigation should have started on Saturday the 11th? She stated she told the DON to get a hold of CNA #1 and we didn't get anything from her timely. She stated the investigation should have started on Saturday. She stated when the DON came in on Sunday she intentionally came in to make sure that nothing would repeat from Saturday and eventually she told me she talked to RN #1. The administrator was asked about resident interviews. The administrator stated the DON told her she didn't do any resident interviews because the residents in the room were non-verbal. She stated she told the DON to conduct interviews with at least three random residents in the hallway. 46387 2. Res #4 had diagnoses which included cerebral infarction, major depressive disorder, dementia, and bipolar disorder. A quarterly MDS, dated [DATE], documented Res #4 was severely cognitively impaired, required limited to extensive assistance of one staff with ADLs, had no behaviors, and utilized a walker and wheelchair for mobility. A nurse progress note, dated 12/28/22 at 1:00 p.m., documented Res #5 was incontinent of bowel and bladder by choice. The note documented Res #5 was [TRUNCATED]

Based on observation, interview and record review, it was determined the facility failed to ensure the care plan was implemented for six (#9, 40, 45, 56, 62 and #84) of 18 residents whose care plans were reviewed. The facility failed to implement the intervention of repositioning for residents #56, 62 and #84. These residents developed avoidable pressure ulcers, resulting in harm. The failure to implement care plans had the potential to affect all 70 residents who resided in the facility. Findings: 1. Resident #62 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, with an ARD of 12/20/16, documented the resident was totally dependant on staff for all aspects of ADLs, including repositioning, bed mobility and incontinent care. The assessment documented the resident was at risk for developing pressure ulcers, had one stage II pressure ulcer. A wound care physician's note dated 12/28/16 documented the wound had been resolved. On 01/09/17, from 12:15 p.m. to 3:52 p.m. (three hours and 37 minutes), the resident was observed sitting in her reclining positioning chair. She was not assisted with repositioning. On 01/10/16 at 08:50 a.m. to 1:23 p.m. (four hours and 33 minutes), the resident was observed in her bed on her back. At 1:23 p.m., the resident was asked how she was feeling today and she stated, My butt hurts! CNA #3 entered the room and was asked to assist the resident onto her side for her skin to be observed. On her left buttock a nickel sized, round shaped, dried area with a small opening was observed. The area did not have any exudate, bleeding or other drainage. The CNA positioned the resident on her back and exited the room. On 01/11/17 from 8:36 a.m. to 2:40 p.m. the resident was observed lying on her back in bed. She had not been out of bed or repositioned during that time (six hours and four minutes). A nurse's note dated 01/16/17 at 7:15 a.m., documented a small pressure area to the left upper buttock, documented as a stage 2 and had increased in size. On 01/18/17 at 12:54 p.m., the DON was asked about the resident's plan of care r/t repositioning. She stated staff was expected to reposition residents every two hours, and as needed, and the resident's plan of care had not been implemented. As a result of the facility's failure to implement the plan of care, the resident developed an avoidable pressure ulcer to the buttocks/sacrum area, which had increased in size from 01/10/17 to 01/16/17, resulting in harm. 2. Resident #84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 'Skilled Daily Nurses Note', dated 12/14/17, documented the resident required total assistance with bed mobility and . dark unstageable wounds to both heels .Coccyx and peri-area red . An 'Initial Plan of Care' documented a nursing problem included skin integrity. Interventions included: ~turning program to meet needs q 1-2 hrs and ~notify physician for treatments to any wounds identified. On 01/09/17 from 10:00 a.m. to 11:18 a.m., the resident was observed asleep lying on her right side. At 11:18 a.m., RN #1 provided wound care for the resident's coccyx and bilateral heels. After the treatment was completed, the resident was again turned to the right side, where she remained until 1:30 p.m. At 1:30 p.m., three hours and 30 minutes after first being observed lying on her right side at 10:00 a.m., staff assisted the resident from the bed to the wheelchair. The resident remained sitting in the wheelchair from 1:30 p.m. to 5:00 p.m., and had not been repositioned for three hours and 30 minutes. On 01/10/17, from 10:45 a.m. to 1:30 p.m., the resident was observed to be sitting in a wheelchair. The resident was not repositioned for two hours and 45 minutes. From 1:30 p.m. to 5:00 p.m., the resident was observed to by lying in bed on her right side. The resident was not repositioned for three hours and 30 minutes. On 01/11/17 at 2:00 p.m., the resident's heels were observed on a flattened pillow with both heels touching the bed. At 2:50 p.m., LPN #2 was asked about the care for the resident. She stated the resident should not be on her buttocks much at all due to the pressure ulcer, and should be turned from side to side at least every two hours. She stated heels were to be floated. She stated the CNAs were responsible for repositioning residents, but the nurse was responsible for ensuring the CNAs provided the care as needed for each individual resident. She stated if residents at risk for pressure ulcers did not get repositioned every two hours, they could develop pressure ulcers. When asked if the pressure ulcer for resident #84 could have developed from a lack of consistent repositioning every two hours, she stated, Yes. At 3:15 p.m., the DON was asked about the specific needs for the resident. She stated the resident's needs included a turning/repositioning program every two hours, weekly skin assessments and treatments to the skin as ordered. When advised of the surveyor's findings, she stated the facility had not provided the care needed as per the resident's plan of care. As a result of the facility's failure to implement the plan of care, the resident developed an avoidable pressure ulcer to the buttocks/sacrum area, resulting in harm. On 01/12/17 at 4:30 p.m., a family member was asked about the staff repositioning the resident. The family member stated he/she would often have to ask the staff to come turn the resident, and at times staff would not reposition the resident for up to four hours. 3. Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An assessment for predicting pressure ulcer risk dated 12/08/16, documented the resident was a moderate risk. An 'Initial Plan of Care' documented nursing problems included skin integrity. Interventions included: ~turning program to meet the resident's needs every one to two hours and ~notify wound nurse for evaluation. Nurses' Notes dated 12/27/16 at 3:45 a.m., documented, .Notice bottom had a small open area and excoriated. Applied barrier cream . On 01/09/17 from 9:00 a.m. to 12:00 p.m., the resident was observed lying in bed on his back with a blanket over his head. No staff had repositioned the resident. At 4:30 p.m., LPN #3, CMA #3 and the surveyor entered the resident's room to observe the resident's skin. The resident, who was unable to turn himself from his back to his side, required two staff to assist him. The resident was observed with stage 2 pressure ulcers to the left side and right side of the coccyx area. The LPN was asked about measures to prevent the development of pressure ulcers. She stated the resident should be turned at least every two hours to prevent pressure ulcers from developing as per the plan of care. As a result of the facility's failure to implement the plan of care, the resident developed an avoidable pressure ulcer to the buttocks/sacrum area, resulting in harm. 4. Resident #45 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan, last updated on 12/12/16, documented: .Focus .at risk for altered nutrition d/t he is receiving therapeutic diet .d/t diabetes .He is receiving insulin . Interventions .Administer insulin routinely and per sliding scale as ordered . A quarterly assessment, with an ARD of 12/27/16, documented the resident had received insulin on seven of the seven days prior to the assessment. The monthly physician's orders [REDACTED]. A lab result sheet, dated 12/14/16, documented an order to increase the resident's [MEDICATION NAME]from 14 U sq at hs to 20 U sq at hs. The order was written at the bottom of the lab results page and had been signed by the resident's physician. A diabetic and injection sheet, dated December 2016, documented the resident had received [MEDICATION NAME] 14 U sq at bedtime every night in December with the exception of 12/23/16 which was left blank. The resident did not receive insulin as per the physician's orders [REDACTED]. A diabetic and injection sheet, dated January 2017, documented the resident had received [MEDICATION NAME] 14 U sq at bedtime every night in January through the 17th. On 01/18/17 at 3:00 p.m., LPN #2 was interviewed with the DON present. The LPN was asked what the resident's orders were for his [MEDICATION NAME] insulin. After looking at the MAR, she stated he received [MEDICATION NAME] 14 U sq at hs. The LPN and DON were shown the lab result sheet and asked if the notation at the bottom of the sheet was an order to increase the [MEDICATION NAME] dosage. The LPN stated it was, however, it had not been signed or noted. They were shown the diabetic/injection sheets and asked if the resident had received his insulin as ordered. They both stated he had not. 01/19/17 at 10:23 a.m., LPN #2 was asked if the resident was receiving his insulin as ordered. She stated, No. She was asked if they were following the resident's care plan related to insulin administration. She stated, No. 5. Resident #40 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 10/03/16, documented the resident had moderate cognitive impairment, displayed wandering and required extensive assistance with most ADLs and required supervision with eating; The care plan, most recently reviewed/revised on 09/21/16, documented the resident required supervision/setup of meals and frequent reminders/cues to eat during meals. The care plan also addressed a problem related to the resident's refusal of some meals and poor intake. The care plan documented the resident takes meals in the dining room but will frequently leave with her clothing protector on and then come back later .She is at risk for altered nutrition d/t confusion r/t dementia and [MEDICAL CONDITION]. On 01/09/17 at 12:25 p.m., during observation of the noon meal in the south dining room, the surveyor observed the resident as she self-propelled her w/c into the dining room to her assigned place at the end of a table. The residents's meal had already been served and 100% of her health shake had been consumed. Upon arriving at her place, the resident looked at her tray card, took a drink of coffee and left the dining room to go back out into the hallway. At 12:38 p.m., the resident had been in and out of the dining room three times. She had not taken a bite of food from her plate. No staff members had directed/supervised or offered to assist the resident. At 12:50 p.m., the resident had been in and out of the dining room nine times in the past 25 minutes. Each time she propelled herself to her place at the dining table, she would look at her tray card, take a drink of coffee, and leave the dining room. She had still not attempted to take a bite of her meal. No staff member had directed her to eat and/or offered assistance to eat. At 12:53 p.m., the resident was in the hallway and a staff member pushed the resident to the TV area. Another staff member then pushed the resident to her room. The resident's meal had been left untouched in the dining room. At 12:55 p.m., the surveyor reviewed the above observations with the DON and asked if the resident had received the supervision/assistance she needed to eat. The DON stated, No. On 01/11/17 at 8:30 a.m., the surveyor reviewed the care plan documentation regarding the resident's requirement for supervision with meals with the DON and asked if the resident's care plan had been followed on 01/09/17 during the noon meal. She acknowledged the resident had not been supervised or cued to eat her meal. 6. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 12/28/16, documented the resident was severely impaired in cognition, totally dependent on two staff for all aspects of ADLs, and exhibited impairment on both sides of the upper and lower extremities. A care plan last updated 06/23/16, documented, Focus: (Resident) receives Restorative Nursing for splint placement and PROM d/t contractures . Interventions: .Turn and reposition q 2 hours and prn . On 01/09/17 at 10:22 a.m., 12:31 p.m., and 3:13 p.m., staff was not observed to reposition, perform any type of ROM, PROM or apply any type of splint throughout the observation (four hours and 51 minutes). On 01/09/17 at 3:57 p.m., LPN #1 was interviewed and asked if the resident had been up and out of bed today. She stated, No. She was asked if any range of motion exercises had been provided for the resident. The LPN stated, I'm sure there hasn't been any. We don't have a restorative person anymore. She was asked if the facility previously had a restorative program. She stated there had been no staff who provided restorative services since May or June 2016.

Based on observation, interview, and record review, it was determined the facility failed to ensure the residents' physician/family was notified of a change in condition for five (#56, 62, 74, 76, and #84) of five residents whose records were reviewed for a change of condition. The facility failed to notify the physician of: a) the development of pressure ulcers when they developed for residents #56, 62 and #84, b) the development of a severe weight loss of 29% for resident #84, c) the development of dehydration signs/symptoms and inadequate fluid intake for residents #56 and #84, d) a change in [MEDICATION NAME] (blood thinner medication) dosage and the failure to implement the change for resident #74 and e) a fall for resident #76. The facility's failure to notify the physician of the development of pressure ulcers for residents #56, 62 and #84 resulted in treatment not being provided and/or increased size, and lack of improvement of unstageable pressure ulcers, resulting in harm. The facility's failure to notify the physician of weight loss for resident #84 resulted in lack of interventions obtained to prevent further weight loss and address the resident's protein needs, resulting in harm. The facility's failure to notify the physician of inadequate fluid intake for resident #56 resulted in the resident requiring emergency room treatment for [REDACTED]. The facility's failure to notify the physician of inadequate fluid intake for resident #84 resulted in the resident exhibiting s/s of dehydration and abnormal lab results indicating dehydration, resulting in harm. This had the potential to affect all 70 residents residing in the facility. Findings: 1. Resident #84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. No comprehensive admission assessment and no comprehensive care plan had been developed to address the resident's status and individualized needs. An admission nursing assessment dated [DATE], documented the resident's weight was 124 lbs. The 'Skilled Daily Nurses Note', dated 12/14/17, documented the resident had . dark unstageable wounds to both heels. Tx ongoing .Coccyx and peri-area red . The initial physician's orders dated 12/14/16, documented the resident was to receive: ~ [MEDICATION NAME] (a specific type of honey promoting autolytic debridement to cleanse debris and necrotic tissue from the wound through to healing) to the left and right heels on Mondays and Thursdays, heels were to be floated while in bed and JW Butt paste (Zinc Oxide 20%) was to be applied to buttocks twice daily as needed and ~a puree with nectar thick liquids diet, and if intake was less than 50%, the resident was to receive one can [MEDICATION NAME] per PEG tube. The orders documented the PEG tube was to be flushed with 100 ml of liquid four times daily. On 12/18/16, a physician's telephone order documented to discontinue the initial order for [MEDICATION NAME] and begin Glucerna 1.5 one can per PEG tube at 9:00 a.m., 1:00 p.m., 6:00 p.m. and 10:00 p.m., if less than 50% of meal was consumed. Glucerna 1.5 provided 237 ml of fluid, 356 calories and 19.6 gm protein per can. The December 2016 Meal Intake records, December 2016 Treatment sheet and December 2016 Intake/Output records documented from 12/20/16 through 01/09/17, for 21 days, the resident did not receive the amount of calories, protein and fluids provided by tube feedings, as assessed by the dietician on 01/09/17. The resident should have received tube feeding amounts of 948 ml per day and flushes of 400 ml per day, due to refusing all meals. On 01/04/17, the resident's weight was documented to be 88 lbs. The resident was not reweighed at that time, nor was the physician/family notified of the severe weight loss. This resulted in a 29% weight loss in less than one month, resulting in harm. There was no documentation in the resident's record that staff had: ~performed weekly comprehensive skin assessments from admission through 01/09/17 and ~notified the physician/family of an open area to the buttocks/sacrum area prior to 01/09/17. The January 2017 Treatment Record documented, Apply [MEDICATION NAME] drsg (dressing) to open area on buttocks (change) q 3 days 1/6/17. The resident's record contained no assessment of an open area on 01/03/17, no documentation the physician/family had been notified on 01/03/17 and no physician's order for this treatment. A 'Nutritional Risk Assessment' conducted by the registered dietician on 01/09/17, 27 days following admission to the facility, documented the resident's total calorie needs were 1687 calories per day, total protein needs were 56 grams per day, and total fluid needs were 1680 ml per day. On 01/09/17 through 01/11/17, the resident's skin was observed to be dry and flaky, and lips were observed to be dry. On 01/09/17 at 11:18 a.m., RN #1 (the wound nurse), with the assistance of CNA #1, was observed to examine the resident's skin. She assessed and measured the pressure ulcer to the buttocks/scacrum area and heels and provided dressing changes. As the RN was assessing the resident's skin, the CNA stated the open area to the buttocks area had been present for several days and was getting bigger. She was asked if the area had been reported to a charge nurse and she stated she did not know. The RN was asked if the physician had been notified of the area to the buttock/sacrum. She stated she had only been working in the facility a couple of days and did not know. She stated the wound physician was to see all pressure ulcers/wounds weekly. She stated the resident would be seen by the wound physician this week. On 01/11/17, the wound physician documented an assessment of the resident's pressure ulcers to the buttocks/sacrum area and bilateral heels, and provision of treatment to bilateral heels. The wound physician's assessment documented the buttock/sacral area pressure ulcer had increased in size from the measurements obtained by the wound nurse on 01/09/17, resulting in harm. The wound physician debrided the left and right heel to enable healing to occur. On 01/11/17 at 2:50 p.m., LPN #2 was asked when physician's were notified of a resident's change in condition, such as a newly developed open area to the skin or significant weight loss. She stated when open areas were found or significant weight loss occurred, the physician and family were to be notified at the time of the occurrence. On 01/11/17 at 3:15 p.m., the DON was asked about the resident's weight on 01/04 17. She stated the resident should have been reweighed at that time, as per the facility's policy. She was asked if the wound physician should have seen the resident prior to 01/11/17 in order to assess the heels and effectiveness of the treatment program that had been provided. She stated, Yes. The delayed notification of the wound physician resulted in a delay of treatment/lack of healing to the heels, resulting in harm. On 01/13/17, lab results for a CMP documented the resident's BUN was 50. Normal results were 6-20. A high BUN could indicate dehydration. The physician was not notified of the resident's inadequate fluid intake, resulting in harm. 2. Resident #56 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An assessment for predicting pressure ulcer risk was completed on 12/08/16 and documented the resident was a moderate risk. On 12/09/16, a nutritional risk assessment completed by the registered dietician documented the resident's total fluid needs were 1700 ml per day. The assessment documented the resident consumed 1500-2000 ml fluids per day and was able to feed self. An admission assessment with an ARD of 12/13/16, documented the resident had no unhealed pressure ulcers. The assessment documented the resident required limited assistance with bed mobility, eating and drinking. An 'Initial Plan of Care' documented hydration was a problem for the resident. Interventions circled as appropriate included staff was to monitor for s/s dehydration, decreased urine output, poor skin turgor, low grade fever, thirst, etc. No comprehensive plan of care had been developed to address the resident's specific individualized needs. There was no evidence the resident's fluid intake had been monitored to ensure adequate intake. Nurse's Notes dated 12/27/16 at 3:45 a.m. documented, .Notice bottom had a small open area and excoriated. Applied barrier cream . The physician and family were not notified of the open area. On 12/28/16, nurses notes documented the resident was sent to the emergency room for evaluation and treatment of [REDACTED]. The resident returned to the facility the same day with a [DIAGNOSES REDACTED]. needs implemented, resulting in harm. On 01/09/17 at 4:30 p.m., LPN #3 assessed the resident's skin. The coccyx area was observed with a stage 2 pressure ulcer to the left side of the coccyx and a stage 2 to the right side of the coccyx area. The facility's failure to notify the physician of the open area identified on 12/27/17 resulted in appropriate treatments not being provided. Two stage 2 pressure ulcers developed to the coccyx, resulting in harm. On 01/09/17 at 4:30 p.m., LPN #3 was asked when physician's were to be notified of open areas/pressure ulcers to any residents' skin. She stated the physician and family should be notified at the time they were identified. On 01/18/17 at 8:15 a.m., the DON was asked about notification of the physician. She stated anytime an open area was found, weight loss that was significant or severe and any other changes in condition, the charge nurse was to notify the physician at that time. 3. Resident #62 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The initial plan of care, dated 03/16/16, documented the resident was at risk for alteration in skin integrity. Interventions included to assess skin weekly and report any changes. A quarterly assessment, with an ARD of 09/20/16, documented the resident was totally dependent on staff for all aspects of ADLs, including repositioning, incontinent care, eating and bed mobility. A wound care physician note dated 12/28/16 documented a shear wound had been resolved. There was no documentation showing any other pressure ulcers at this date. On 01/10/16 at 1:23 p.m., the resident's skin was observed. The left buttock had a nickel sized, round shaped, dried area with a small opening. A nurses note dated 01/16/17 at 7:15 a.m., documented a small pressure area to the left upper buttock. The area was documented as a stage 2 measuring 2.0 cm x 2.4 cm with a 0.2 cm x 0.3 cm area of dark redness noted at the proximal aspect. The pressure ulcer had increased in size. On 01/18/17 at 12:00 p.m., LPN #1 was asked if the resident was currently being treated for [REDACTED]. The physician and family had not been notified of the pressure ulcer. The facility's failure to notify the physician of the development of the open area on 01/10/17 resulted in appropriate treatments not being provided and the pressure ulcer increased in size, resulting in harm. 4. Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. A nurse's note, dated 12/31/16, documented the resident was sent to an emergency room . emergency room discharge orders, dated 12/31/16 at 11:25 a.m., documented a change in the dosage of [MEDICATION NAME] from 5 mg po daily to 5 mg po on Monday/Wednesday/Friday and 7.5 mg po on Tuesday/Thursday/Saturday/Sunday. The January 2017 monthly physician's orders documented the resident was to receive [MEDICATION NAME] 5 mg daily. The January 2017 MAR indicated [REDACTED]. On 01/11/17 at 10:00 a.m., the DON was asked if the resident's primary care physician was notified of the [MEDICATION NAME] dosage change and the failure to implement the change of orders and she stated, No. 5. Resident #76 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nurse's note, dated 01/05/17, documented the resident had fallen off the toilet. The nurse noted a small purple area on the resident's right outer elbow, and no [MEDICAL CONDITION] was observed. There was no documentation the physician was notified of the incident in the nurses' notes. On 01/18/17 at 2:26 p.m., the DON was asked about physician notification of the fall. The DON stated the nurse who was working when the incident occurred did not notify the physician of the fall. The DON was asked if the physician should have been notified and she stated, Yes.

Based on observation, interview and record review, it was determined the facility failed to prevent the development of avoidable pressure ulcers/and or provide care and interventions to existing pressure ulcers for three (#56, 62 and #84) of four residents whose records were reviewed for pressure ulcers. This resulted in actual harm for each of the residents. This had the potential to affect seven residents with pressure ulcers and 17 residents receiving preventative skin care identified by the facility. Findings: 1. Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 'Resident-Data Collection Admission Notes', dated 12/14/16 at 3:00 p.m., documented redness to the coccyx, [MEDICATION NAME] (a specific type of honey promoting autolytic debridement to cleanse debris and necrotic tissue from a wound through to healing) to both heels and heels were to be floated. The 'Skilled Daily Nurses Note', dated 12/14/17, documented the resident required total assistance with bed mobility and . dark unstageable wounds to both heels. Tx ongoing .Coccyx and peri-area red . There was no comprehensive assessment of the resident's skin. There were no descriptions of the appearance of the reddened area to the coccyx or the appearance of both heels which were described as unstageable wounds. The facility did not develop a comprehensive assessment to identify the resident's status. A comprehensive plan of care was not developed to address the resident's specific individualized needs. An 'Initial Plan of Care' documented a nursing problem included skin integrity. The plan of care documented the resident was at high risk for the development of pressure ulcers. Interventions for the problem of skin integrity included: ~turning program to meet needs q 1-2 hrs, ~notify physician for treatments to any wounds identified and ~notify wound nurse for evaluation. The initial physician's orders, dated 12/14/16, documented the resident was to receive: ~[MEDICATION NAME] to the left and right heels on Mondays and Thursdays, ~heels were to be floated while in bed and ~JW Butt paste (Zinc Oxide 20%) was to be applied to buttocks twice daily as needed. The December 2016 TAR did not contain documentation of the physician's order for Zinc Oxide 20%, nor was there any documentation staff had applied the Zinc Oxide. The December 2016 and January 2017 TAR documented staff were to: ~float heels while in bed and ~apply [MEDICATION NAME] to L and R heels M & Fr (Monday and Friday) . The January 2017 TAR documented: ~staff had applied Zinc Oxide 20% one time on 01/03/17, 01/08/17, 01/09/17 and 01/10/17, ~there had been no [MEDICATION NAME] treatments provided on 01/03/17 and 01/06/17, and ~heels had not been floated on 01/03/17 through 01/06/17 on the 11 p.m. to 7 a.m. shifts and/or the 7 a.m. to 3 p.m. shifts. The January 2017 TAR documented, .Apply [MEDICATION NAME] drsg to open area on buttocks (change) q 3 days 1/6/17. There was no documentation in the resident's record that staff had: ~identified or assessed an open area to the resident's buttocks on 01/06/17 and ~notified the physician of the open area. There was no physician's order for the [MEDICATION NAME] treatment found in the resident's record. Staff documented the treatment had been completed on 01/06/17 and 01/09/17. There were no comprehensive skin assessments or documentation the resident's skin was examined at any time from the date of admission on 12/14/16 until 01/09/17. On 01/09/17 at 10:00 a.m., the resident was observed asleep lying on her right side. At 11:18 a.m., RN #1 (the wound nurse), with the assistance of CNA #1, was observed to examine the resident's skin and provide drsg changes to the buttocks/sacrum area and bilateral heels. The RN assessed and measured the size of the open areas to the buttocks/sacrum and bilateral heels. The heels were observed to be covered with eschar (thick adherent black necrotic tissue). As she measured the heels, she stated the tissue surrounding the eschar was mushy feeling. As the RN was assessing the resident's skin, the CNA stated the open area to the buttocks had been small, but was getting bigger and had been present for several days. The RN documented on the 'Weekly Pressure Ulcer Report': ~a stage 2 pressure ulcer to buttocks measuring 5 cm length x 2.8 cm width, the space for depth was left blank, ~the left heel with eschar measuring 0.9 cm x 0.9 cm and ~the right heel with eschar measuring 2.7 cm x 3 cm. The CNA was asked what type of care residents who were at risk for pressure ulcer development needed to ensure pressure ulcers did not develop or to ensure pressure ulcers healed. She stated residents should be turned every two hours and not left sitting up for longer than one to two hours. The CNA was asked how open skin areas were reported when they were discovered. She stated they should be reported to the charge nurse. She stated she was unsure when the open area had been reported to the charge nurse. After the resident's skin was assessed and treatments were provided as per documentation on the TAR, the resident was again turned to the right side, where she remained until 1:30 p.m. At 1:30 p.m., three hours and 30 minutes after first being observed to be lying on her right side, staff assisted the resident from the bed to the wheelchair. The resident remained sitting in the wheelchair at 5:00 p.m., when the surveyor last observed the resident on that day. The resident was not repositioned for three hours and 30 minutes. On 01/10/17, from 10:45 a.m. to 1:30 p.m., the resident was observed to be sitting in a wheelchair. The resident was not repositioned for two hours and 45 minutes. From 1:30 p.m. to 5:00 p.m., the resident was observed to by lying in bed on her right side. The resident was not repositioned for three hours and 30 minutes. On 01/11/17, the wound physician documented he assessed and provided treatment to the resident's pressure ulcers. The wound physician examined the wound to the buttocks/sacrum area and documented a stage 2 pressure ulcer. Wound size was documented as 5.3 cm length x 3.4 cm width x 0.1 cm depth with light serosanguinous exudate. Recommendations included off-load wound and limit sitting to 60 minutes. The wound had increased in size from the measurements obtained on 01/09/17. The wound physician's examination of the right and left heels documented unstageable wounds due to necrosis with 100% eschar. The right heel area of eschar measured 4.7 cm length x 2.7 cm width x not measurable depth. The left heel area of eschar measured 1.6 cm length x 1.4 cm width x not measurable depth with light serous exudate. The wound physician discussed debridement with the primary physician and the necessity was mutually agreed upon. The wound physician documented both heels were then debrided to a depth of healthy bleeding tissue. Treatment with [MEDICATION NAME] was recommended three times per week with a dry protective dressing and heels were to be floated when in bed. At 2:00 p.m., LPN #2 was observed as she prepared to provide treatments to the resident's buttocks/sacral area and heels. When she removed the covers from the resident, the heels were observed propped on a flattened pillow with both heels touching the bed. At 2:50 p.m., the LPN was asked how the facility ensured residents at risk for pressure ulcers received the care needed to prevent the development of pressure ulcers. She stated those residents should be turned every two hours, skin should be assessed weekly and heels should be propped off the bed as needed. She stated when open areas were found, the physician was to be notified and treatment was then to be provided as ordered. The LPN was asked how the facility monitored the skin of resident #84. She stated skin assessments were to have been completed weekly, and had not been. She stated the resident should not be on her buttocks much at all due to the pressure ulcer on her buttocks, and should be turned from side to side at least every two hours. She stated heels were to be floated. She stated the CNAs were responsible for repositioning residents, but the nurse was responsible for ensuring the CNAs provided the care as needed for each individual resident. She stated if residents at risk for pressure ulcers did not get repositioned every two hours, they could develop pressure ulcers. When asked if the resident's pressure ulcer could have developed from a lack of consistent repositioning every two hrs, she stated, Yes. At 3:15 p.m., the DON was asked how residents were assessed for their skin needs. She stated a Braden scale assessment was to be completed on every resident admitted . She stated if the resident was assessed to be at risk for pressure ulcers, then interventions specific to the residents' needs were to be implemented on the plan of care. She stated these interventions would include weekly skin assessments, a turning/repositioning program specific to the residents' needs, and the provision of treatments as ordered by the physician. She stated residents with pressure ulcers/wounds were to be seen weekly by the wound physician. She was asked if the wound physician should have seen resident #84, admitted with eschar to both heels, in order to assess the heels and effectiveness of the treatment program being provided. She stated, Yes. She was asked if this should have been done prior to 01/11/17 (29 days after admission) and she stated,Yes. She stated the resident's specific needs included a turning/repositioning program every two hours, weekly skin assessments and treatments to the skin as ordered. When she reviewed the record and the surveyor's findings, she stated the facility had not provided the care the resident needed. On 01/12/17 at 4:30 p.m., an interview was conducted with a family member. The family member was asked about the staff repositioning the resident. The family member stated he/she would often have to ask the staff to come turn the resident, and at times staff would not reposition the resident for up to four hours. 2. Resident #56 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission assessment with an ARD of 12/13/16, documented the resident had no unhealed pressure ulcers. The assessment documented the resident required limited assistance with bed mobility. An assessment for predicting pressure ulcer risk was completed on 12/08/16 and documented the resident was a moderate risk. There was no comprehensive care plan developed to address the resident's specific individualized needs. An 'Initial Plan of Care' documented nursing problems included skin integrity. Interventions circled as appropriate for the resident included: ~turning program to meet the resident's needs every one to two hours, ~notify wound nurse for evaluation and ~float heels while in bed, added on 12/12/16. There was no documentation the resident's skin was examined at any time from the date of admission on 12/08/16 until 01/09/17. Nurse's Notes dated 12/27/16 at 3:45 a.m., documented, .Notice bottom had a small open area and excoriated. Applied barrier cream . There was no comprehensive assessment of the open area. The physician was not notified of the open area. Treatment orders were not obtained from the physician. There were no orders for the application of a barrier cream. On 01/09/17, for three hours, from 9:00 a.m. to 12:00 p.m., the resident was observed lying in bed on his back with a blanket over his head. No staff had repositioned the resident. At 4:30 p.m., LPN #3 was asked if the resident had a pressure ulcer. The LPN stated she was not sure. The LPN, CMA #3 and the surveyor entered the resident's room to observe the resident's skin. The resident, who was unable to turn himself from his back to his side, required two staff to assist him. The coccyx area, covered with a white cream, was observed with a stage 2 pressure ulcer to the left side of the coccyx estimated by the LPN to be approximately 2 cm width x 1 cm length x very slight depth, and a stage 2 to the right side of the coccyx area which was slightly smaller in size than the left side. The surveyor asked about the cream that was on the resident's coccyx area. The CMA stated a family member of the resident had brought the cream to the facility several days prior, and the areas had been open for several days. The LPN was asked about the open area on the coccyx. She stated the physician should be notified when a pressure ulcer was identified. She stated treatment orders were to be obtained and implemented when open areas were identified. The LPN was asked about measures to prevent the development of pressure ulcers. She stated the resident should be turned at least every two hours to prevent pressure ulcers from developing. She stated the physician should have been notified of the pressure ulcer and orders for treatment to aid in healing should have been obtained and implemented by the staff. 3. Resident #62 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A skilled daily nurses note dated 03/07/16 at 8:00 p.m., documented, Removed dressing to sacral area. No redness or open area noted @ this time, will continue to monitor. A Braden scale assessment, dated 03/08/16 documented the resident was at moderate risk for pressure ulcers with a score of 14. The initial plan of care, dated 03/16/16, documented the resident was at risk for alteration in skin integrity. Interventions included: ~assist the resident with repositioning every two hours and as needed, ~float heels while in bed, ~monitor skin for red or open areas, ~provide peri care after each episode and ~assess skin weekly and report any changes. Monthly physician's orders, dated 07/13/16 documented, Body Audit weekly on Wednesdays. There was no documentation on the monthly TARs for August 2016 and September 2016 that body audits had been performed weekly as ordered. Monthly nurse summary notes, dated 08/2016 and 09/2016, documented the resident was to be positioned every two hours in bed and in the chair, and skin was intact, clear, and free of any open areas. A quarterly assessment, with an ARD of 09/20/16, documented the resident was totally dependent on staff for all aspects of ADLs, including repositioning, incontinent care, eating and bed mobility. The assessment documented the resident was at risk for developing pressure ulcers and did not have any healed or unhealed pressure ulcers. There was no documentation on the monthly TARs for October 2016, November 2016 and December 2016 that body audits had been performed weekly as ordered. A nurse's note dated 11/18/16 at 2:30 p.m., documented three areas with redness on the left posterior thigh which were a stage II and the left buttock had redness to the area. The measurements of the wounds were documented as: ~L thigh 2.0 cm x 2.5 cm x 0.1 cm, ~L thigh 1.0 cm x 3.0 cm x 0.1 cm and ~L buttock 3.0 cm x 2.0 cm x 0 cm. A physician's order dated 11/18/16, documented [MEDICATION NAME] (topical wound paste) was to be applied, covered with Opsite (occlusive dressing) and changed every three days. Wound care physician's notes from 11/23/16 through 12/14/16, documented the resident had a shear wound to the left buttock and received treatment as ordered. A care plan last updated 11/23/16, documented, the resident was at increased risk for alteration in skin integrity r/t decreased mobility, incontinence and assistance required with ADLs. Interventions included: ~apply preventive ointment as ordered, ~assist with turning and repositioning q 2 hr and prn, ~float heels while in bed, ~monitor skin for red or open areas and ~provide peri care after each episode of incontinence. A quarterly assessment, with an ARD of 12/20/16, documented the resident was totally dependant on staff for all aspects of ADLs, including repositioning, bed mobility and incontinent care. The assessment documented the resident was at risk for developing pressure ulcers, had one stage II pressure ulcer. A wound care physician note dated 12/28/16 documented the shear wound had been resolved. On 01/09/17 at 12:15 p.m., the resident was observed sitting in her reclining positioning chair in the south dining room. At 12:32 p.m., the DON removed the resident and positioned her in the center foyer. The DON did not assist the resident with toileting prior to placing her in the foyer. At 12:52 p.m., the resident was asked how her lunch was. She stated it was ok. She then stated she had asked three people to take her to the bathroom and no one had come to take her yet. At 3:52 p.m., the resident remained in the foyer area in her reclining positioning chair. The resident was not assisted with repositioning or toileting from 12:15 p.m. to 3:52 p.m. (three hours and 37 minutes). On 01/10/16 at 08:50 a.m., and at 10:25 a.m., the resident was observed asleep in her bed on her back. At 1:23 p.m. (four hours and 33 minutes later), the resident remained in bed on her back. She was observed to be awake. She was asked how she was feeling today and she stated, My butt hurts! CNA #3 entered the room and was asked to assist the resident onto her side for her skin to be observed. On her left buttock a nickel sized, round shaped, dried area with a small opening was observed. The area did not have any exudate, bleeding or other drainage. The CNA positioned the resident on her back and exited the room. On 01/11/17 at 8:36 a.m., 10:26 a.m., 11:08 a.m., 12:46 p.m. and 2:40 p.m. the resident was observed lying on her back in bed. The resident had not been out of bed or repositioned during that time (six hours and four minutes). At 3:20 p.m., LPN #1 was interviewed and asked if staff had assisted the resident out of bed today and/or repositioned her. The LPN stated, Hospice got her up today and showered her. She was asked when hospice had seen the resident. She stated she didn't know the time, but was sure they had assisted her out of bed. On 01/12/17 at 1:40 p.m., and again at 4:40 p.m., the resident was observed lying on her back in bed. On 01/12/17 at 2:36 p.m., a hospice staff was observed to exit the resident's room. She was asked what care had been provided for the resident. She stated she had provided the resident with a bed bath as part of her care. The hospice staff was asked if she had provided the resident with a shower or bed bath the prior day (01/11/17). She stated, No. She was asked what type of care was provided for her on 01/11/17. She stated she provided the resident with incontinent care only. She was asked if she had assisted the resident out of bed. She stated, No. She had left her in bed after providing incontinent care. A nurse's note dated 01/16/17 at 7:15 a.m., documented a small pressure area to the left upper buttock. The area was documented as a stage 2 measuring 2.0 cm x 2.4 cm with a 0.2 cm x 0.3 cm area of dark redness noted at the proximal aspect. The pressure ulcer had increased in size. On 01/18/17 at 8:11 a.m., and at 10:00 a.m., the resident was observed lying on her back in bed asleep. At 12:00 p.m., the resident was assisted out of bed to a reclining positioning chair and was moved to the foyer area. The resident had not been repositioned or had incontinent care during the previous three hours and 50 minutes. LPN #1 and CMA #2 were asked who had assisted resident #62 out of bed at noon. CMA #2 stated she and CNA #3 had assisted the resident out of bed. The LPN was asked if the resident was currently being treated for [REDACTED]. The physician had not been notified of the pressure ulcer. At 12:45 p.m., CNA #3 was asked how much assistance the resident required from staff for ADLs. She stated, We do everything for her . The CNA was asked if the resident could reposition herself in bed and she stated, No. She was asked how often the resident was repositioned. She stated residents were repositioned and turned every two hours. She was asked when she had last repositioned the resident. She stated at noon. On 01/18/17 at 12:54 p.m., the DON was asked about the lack of repositioning and ADL assistance the surveyor had observed, and the pressure ulcer. She stated staff was expected to reposition residents every two hours, and as needed. She was asked how she monitored staff to ensure residents were repositioned in a timely manner. She stated, By their skin and if something pops up or not. She was advised of the observations over the three days and asked if the resident should have been repositioned and provided incontinent care more frequently. She stated, Yes.

Based on observation, interview and record review, it was determined the facility failed to ensure one (#84) of four residents whose records were reviewed for nutrition was provided with timely interventions to maintain or increase his/her nutritional status. As a result of these failures, the resident experienced a severe weight loss of 29% in less than one month, resulting in harm. This had the potential to affect 13 residents identified by the facility as being at risk for weight loss. Findings: Resident #84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission 'Resident-Data Collection' nursing assessment, dated 12/14/16, documented the resident's weight was 124 lbs. physician's orders [REDACTED]. The orders documented the PEG tube was to be flushed with 100 ml of water four times daily. A 'Malnutrition Risk Assessment' completed on 12/14/16 by LPN #4, documented the resident was at high risk for malnutrition. An 'Initial Plan of Care' did not address any nutritional problems. No comprehensive assessment, which identified the resident's specific nutritional status, had been developed. No comprehensive plan of care, which identified specific individualized interventions to meet the resident's nutritional needs, had been developed. On 12/18/16, a physician's telephone order documented to discontinue the [MEDICATION NAME] and begin Glucerna 1.5 one can per PEG tube at 9:00 a.m., 1:00 p.m., 6:00 p.m. and 10:00 p.m. if less than 50% of a meal was consumed. Glucerna 1.5 provided the following: ~237 ml fluids per can; 948 ml fluids per four cans, ~356 calories per can; 1424 cal per four cans and ~19.6 gm protein per can; 78.4 gm protein per four cans. A December 2016 'Meal Intake Monitoring Form' documented the resident consumed 10% of breakfast on 12/17/16 and 12/18/16, and 5% of lunch on 12/18/17. There was no documentation of any sort of intake on 12/14/16 through 12/16/16, 12/29/16 and 12/30/16. All other meals were documented as refused by the resident. The December 2016 Meal Intake records, December 2016 Treatment sheet and the December 2016 Intake-Output records documented the resident did not receive tube feedings as ordered. Tube feeding amounts should have been 948 ml per day, due to the resident refusing all meals. Amounts of tube feeding administered were documented as follows: ~480 ml on 12/20/16 through 12/23/16, ~720 ml on 12/24/16 and 12/25/16, ~480 ml on 12/26/16 and ~none on 12/27/16 through 12/31/16. The January 2017 Meal Intake records documented the resident refused all meals. Tube feeding amounts should have been 948 ml per day, due to the resident refusing all meals. The January 2017 Meal Intake records, January 2017 Treatment sheet and the January 2017 Intake Output records documented the resident did not receive tube feedings as ordered. Amounts of tube feeding with calorie and protein amounts received were documented on the following dates as follows: ~340 ml, on 01/01/17, ~no amounts on 01/02/17 and 01/03/17, ~500 ml on 01/04/17, ~360 ml on 01/05/17, ~600 ml on 01/06/17, ~960 ml on 01/07/17, ~720 ml on 01/08/17 and ~948 ml on 01/09/17. From 12/20/16 through 01/09/17, the resident did not receive the amount of calories and/or protein needed for 21 days as assessed by the dietician on 01/09/17. On 01/04/17, the resident's weight was documented to be 88 lbs, a severe weight loss of 29%. The resident was not reweighed to ensure accuracy, and the physician was not notified of the weight loss. A 'Nutritional Risk Assessment' conducted by the registered dietician on 01/09/17, 27 days following admission to the facility, documented the resident's total calorie needs were 1687 calories per day, total protein needs were 56 grams per day, and total fluid needs were 1680 ml per day. The assessment documented the resident was a moderate risk for weight loss. On 01/10/17 at 8:45 a.m., the resident was observed as a family member attempted to feed her. The resident would not open her mouth to eat. The family member stated the resident had not been opening her mouth or trying to eat or drink since being admitted to the facility. The family member stated he/she often offered her something to drink but the resident always refused to open her mouth. At 10:00 a.m., the resident was reweighed. Her weight was 100 lbs, a loss of 19.35%. The resident's weight loss resulted in actual harm. On 01/11/17 at 2:40 p.m., LPN #3 was interviewed. She was asked about the resident's nutritional intake. She stated the resident received enteral nutrition through a PEG tube. She was asked how she ensured the resident received adequate nutrition. She stated the treatment sheets documented the enteral nutrition was administered and the amount that was administered was documented on the intake-output form. She stated the ACMA administered the tube feedings and then told the nurse the amount of intake so the nurse could document the amount. At 3:15 p.m., the DON was interviewed. She was asked about the resident's nutritional status. The DON stated residents with tube feedings should be weighed weekly in order to ensure resident's were receiving proper amounts of enteral feedings to ensure maintenance of weight. She stated the registered dietician was to assess the resident's specific nutritional needs, and any resident who received enteral nutrition should be assessed with [REDACTED]. When advised 27 days had lapsed before the resident's nutritional needs had been assessed, she stated that was too long. She was asked who was responsible for reviewing weights to assess for weight loss. She stated this was her responsibility, although she had only been working in the facility since the previous week. She was asked who was responsible for notifying the physician of weight loss. She stated the charge nurses. On 01/13/17, lab results for a CMP documented the resident's total protein was 5.1 (normal values range from 6.4-8.3) and [MEDICATION NAME] was 2.8 (normal values range from 3.5-5.2). Total protein and [MEDICATION NAME] tests measure the amount of protein in the blood. Low levels can be a result of malnutrition.

Based on observation, interview and record review, it was determined the facility failed to: a) assess the fluid needs of resident #84 timely and b) monitor and provide adequate fluid intake for two (#84 and #56) of two residents whose records were reviewed for hydration. Resident #84 received inadequate amounts of fluids, resulting in dryness to the skin and lips, and an elevated lab indicating dehydration, resulting in harm. Resident #56 was transferred to an emergency room for evaluation of a low grade temperature and weakness, and was diagnosed with [REDACTED]. This had the potential to affect 13 residents identified by the facility who were at risk for altered hydration. Findings: 1. Resident #84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The orders documented the PEG tube was to be flushed with 100 ml of liquid four times daily. A 'Malnutrition Risk Assessment', completed on 12/14/16 by LPN #4, documented the resident received [PHONE NUMBER] ml of fluid intake daily. An 'Initial Plan of Care' documented hydration was a problem. Interventions were circled on the care plan and included: ~monitor resident for s/s dehydration, decrease urine output, poor skin turgor, low grade fever, thirst, etc, ~monitor intake and output q shift and ~monitor for decreased urine output. No comprehensive assessment, which identified the resident's specific fluid status, had been developed. No comprehensive plan of care, which identified specific individualized interventions to meet the resident's fluid/hydration needs, had been developed. On 12/18/16, a physician's telephone order documented to discontinue the initial order for [MEDICATION NAME] and begin Glucerna 1.5 one can per PEG tube at 9:00 a.m., 1:00 p.m., 6:00 p.m. and 10:00 p.m. if less than 50% of meal was consumed. Glucerna 1.5 provided 237 ml of fluid per can and 948 ml of fluid per four cans. The December 2016 Meal Intake records, December 2016 Treatment sheet and December 2016 Intake/Output records documented the resident did not receive tube feedings/flushes as ordered. The resident should have received tube feeding amounts of 948 ml per day and flushes of 400 ml per day, due to refusing all meals. Amounts of fluid intake received were documented as follows: ~1070 ml on 12/20/16 through 12/22/16, ~800 ml on 12/23/16 and 12/26/16, ~300 ml on 12/31/16 and ~none on 12/27/16 through 12/30/16. The January 2017 Meal Intake records documented the resident refused all meals. The resident should have received tube feeding amounts of 948 ml per day and flushes of 400 ml per day, due to refusing all meals. Amounts of fluid intake received were documented as follows: ~350 ml on 01/01/17, ~none on 01/02/17, 120 ml on 01/03/17, ~500 ml 01/04/17, ~360 ml on 01/05/17 and ~600 ml on 01/06/17. A 'Nutritional Risk Assessment' conducted by the registered dietician on 01/09/17, 27 days following admission to the facility, documented the resident's total fluid needs were 1680 ml per day. From 12/20/16 through 01/09/17, the resident did not receive the amount of fluids needed as assessed by the dietician for 16 of 21 days. On 01/09/17 through 01/11/17, the resident's skin and lips were observed to be dry. Skin was observed to be flaky. On 01/10/17 and 01/11/17 at 8:45 a.m., the resident was observed as a family member attempted to feed her. The resident would not open her mouth to eat or drink anything. The family member stated the resident had not been opening her mouth or trying to eat or drink since admitted to the facility. On 01/11/17 at 2:00 p.m., after completing a skin treatment, LPN #2 stated the resident's skin was so dry, and proceeded to apply lotion to the resident's legs and feet. As she was applying the lotion, the resident's skin was observed to be flaky and wrinkle easily as her hands rubbed the lotion onto the skin. At 2:40 p.m., LPN #2 was interviewed. She was asked about the resident's fluid intake. She stated the resident received enteral nutrition/fluids through a PEG tube. She was asked how she ensured the resident received adequate fluid intake. She stated the amounts of fluids administered were documented on the intake/output record. She stated the ACMA administered the tube feedings and flushes and then told the nurse the amount of intake so the nurse could document the amount. At 3:15 p.m., the DON was interviewed. She was asked about the resident's fluid status. She stated the amounts of daily fluid intake should be documented on the resident's intake/output record to ensure adequate fluid intake. She stated the registered dietician was to assess the resident's specific nutritional and fluid needs, and stated any resident who received enteral nutrition should be assessed with [REDACTED]. When advised 27 days had lapsed before the resident's fluid/nutritional needs had been assessed, she stated that was too long. On 01/13/17, lab results for a CMP documented the resident's BUN was 50. Normal results were 6-20. A high BUN can indicate dehydration. 2. Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/09/16, a nutritional risk assessment completed by the registered dietician documented the resident's total fluid needs were 1700 ml per day. The assessment documented the resident consumed 1500-2000 ml per day and was able to feed self. An admission assessment, with an ARD of 12/13/16, documented the resident required limited assistance with eating and drinking. An 'Initial Plan of Care' documented hydration was a problem for the resident. Interventions circled as appropriate included staff was to monitor for s/s dehydration, decreased urine output, poor skin turgor, low grade fever, thirst, etc. No comprehensive plan of care, which identified specific individualized interventions to meet the resident's fluid/hydration needs, had been developed. On 12/28/16, nurses' notes documented the resident was sent to the emergency room for evaluation and treatment of [REDACTED]. The resident returned to the facility the same day with a [DIAGNOSES REDACTED]. There was no evidence the resident's fluid intake had been monitored to ensure adequate intake, resulting in harm. The facility did not reassess the resident's fluid needs or implement additional interventions to ensure the resident received adequate fluid intake according to his fluid needs. On 01/09/17 from 9:00 a.m. to 4:00 p.m., the resident was observed throughout the day. Staff were observed as they provided care for the resident. They were not observed to offer the resident any fluids. On 01/18/17 at 8:08 a.m., the DON was asked how the facility ensured adequate hydration for residents at risk for dehydration or with a [DIAGNOSES REDACTED]. She stated most importantly to encourage fluids each time the resident received care or was checked on.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were free of significant medication errors for three (#33, 45 and #74) of 16 residents whose medication regimen was reviewed. Resident #45 was administered an incorrect dose of insulin from 12/14/16 through 01/17/17. Abnormal FSBS levels increased, resulting in harm. The facility's failure to ensure residents were free of significant medication error had the potential to affect all 70 residents residing in the facility. Findings: 1. Resident #45 was admitted to the facility, on 03/15/15, with [DIAGNOSES REDACTED]. A comprehensive care plan, updated 06/06/16, documented the resident had DM. Interventions included insulin was to be administered routinely and per sliding scale as ordered. A quarterly assessment, with an ARD of 12/27/16, documented the resident had received insulin on seven of the seven days prior to the assessment. The monthly physician's orders [REDACTED]. A lab result sheet, dated 12/14/16, documented the resident's HgbA1C level (a blood test which measures a three month average glucose concentration), was elevated at 8.3, with a normal range of 4.0 to 5.6. There was an order to increase the resident's [MEDICATION NAME]from 14 U sq at hs to 20 U sq at hs written at the bottom of the lab sheet. The page had been initialed by the resident's physician. A diabetic and injection sheet, dated December 2016, documented the resident had received [MEDICATION NAME] 14 U sq at bedtime every night in December with the exception of 12/23/16, which was left blank. Prior to the physician's orders [REDACTED]. Normal levels for non-fasting blood sugar levels are 70-140. The sheet documented from 12/15/16 through 12/31/16, the resident's FSBS had been in the 200s twenty two times, and in the 300s six times since the physician ordered the insulin to be increased and it wasn't. A diabetic and injection sheet, dated January 2016, documented the resident had received [MEDICATION NAME] 14 U sq at bedtime every night from 01/01/17 through 01/17/17. The sheet documented the resident had continued to have FSBS results in the 200's and 300's. The facility's failure to increase the insulin on 12/14/16 as ordered, and the resident's increased abnormal FSBS levels, resulted in harm. On 01/18/17 at 3:00 p.m., LPN #2 was interviewed with the DON present. The LPN was asked what the resident's orders were for his [MEDICATION NAME] insulin. After looking at the MAR, she stated he was to receive [MEDICATION NAME] 14 U sq at hs. The LPN and DON were shown the lab result sheet and asked if the notation at the bottom of the sheet was an order to increase the [MEDICATION NAME] dosage. The LPN stated it was, however, it had not been signed or noted. They were shown the diabetic/injection sheets and asked if the resident had received his insulin as ordered. They both stated he had not. 2. Resident #33 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's admission orders [REDACTED]. Imdur is a [MEDICATION NAME] given for the prevention of [MEDICAL CONDITION] pectoris (chest pain, which typically occurs with coronary [MEDICAL CONDITION]). The December 2016 MAR documented the resident [MEDICATION NAME] mg dly from 12/18/16 through 12/31/16. On 01/12/17 at 12:48 p.m., the DON was shown the MAR and asked about [MEDICATION NAME]. She stated she was aware of medication problems and would look for the pharmacy delivery records for the resident's Imdur. At 12:50 p.m., LPN #1 was asked if the resident had ever complained of chest pain. She stated the resident had never complained of chest pain since she was admitted . At 1:00 p.m., CMA #1 was asked how many tablets [MEDICATION NAME] mg she administered to the resident currently. After looking at the medication package and the MAR, she stated, Three. She was asked how many she gave in December. After looking at the December 2016 MAR, she stated according to the documentation she had administered one tablet daily. At 2:06 p.m., the DON provided the surveyor the December 2016 pharmacy delivery log for the resident and stated the resident did not receive three 30 mg tablets daily according to the number of pills delivered to the facility in December. 3. Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no comprehensive assessment available. The initial nursing assessment, dated 12/29/16, documented the resident was alert/oriented to person, had good comprehension and was dependent with ADLs. The admission orders [REDACTED]. The initial care plan, dated 12/29/16, did not include the use of [MEDICATION NAME]. The December 2016 MAR documented the resident received [MEDICATION NAME] 5 mg one tablet on 12/30/16 and 12/31/16. A nurse note, dated 12/31/16, documented the resident was sent to an emergency room at the family's request for evaluation of the surgical site of the resident's pacemaker removal. emergency room discharge orders, dated 12/31/16 at 11:25 a.m., documented a change in the dosage of [MEDICATION NAME] from 5 mg po daily to 5 mg po on Monday/Wednesday/Friday and 7.5 mg po on Tuesday/Thursday/Saturday/Sunday. The January 2017 monthly physician orders [REDACTED]. The January 2017 MAR documented the resident received [MEDICATION NAME] 5 mg daily. On 01/09/17 at 11:00 a.m. and 01/10/17 at 3:46 p.m., the resident was observed sitting in his wheelchair visiting with his family. The resident's forearms and top of both hands were observed to have purple colored bruising. During the resident interview, the resident was asked about the bruised areas. The resident reported he had taken several blood thinners and was very easily bruised. On 01/11/17 at 10:22 a.m., the DON was interviewed regarding the resident's current order for [MEDICATION NAME]. The DON reported the resident's order was for [MEDICATION NAME] 5 mg daily. The DON was asked if the resident's return orders from the ER visit on 12/29/16 had been reviewed. She stated she did not know if the orders had been checked. After reviewing the orders from the ER visit on 12/29/16, the DON stated the dosage of [MEDICATION NAME] had been changed to a rotating dose of 5 mg and 7.5 mg. The DON was asked if the resident had received the correct dosage of [MEDICATION NAME]. She stated he had not received the correct dosage since it was changed on 12/31/16.

Based on observation, record review and interview, it was determined the facility failed to ensure there was sufficient nursing staff available to provide care/services according to residents' individualized needs for five (#30, 40, 56, 62 and #84) of eighteen sampled residents whose care/services were reviewed. The failure of not having sufficient staff to provide care resulted in harm to residents #56, 62 and #84. This had the potential to affect all 70 residents. Findings: 1. It was determined the facility failed to ensure: a) supervision/cueing/assistance with eating was provided for one (#40), b) assistance was provided with grooming, oral hygiene and incontinent care for one (#62), c) assistance was provided with bathing and grooming for one (#30) of four sampled residents who required assistance with ADLs and d) assistance was provided with positioning for three (#56, 62 and #84). Please refer to F312. 2. It was determined the facility failed to ensure one (#84) of four residents whose records were reviewed for nutrition was provided with timely interventions to maintain or increase his/her nutritional status. As a result of these failures, the resident experienced a severe weight loss of 29% in less than one month, resulting in harm. Please refer to F325. 3. It was determined the facility failed to prevent the development of avoidable pressure ulcers/and or provide care and interventions to existing pressure ulcers for three (#56, 62 and #84) of four residents whose records were reviewed for pressure ulcers. This resulted in actual harm for each of the residents. Please refer to F314. 4. Based on observation, interview and record review, it was determined the facility failed to: a) assess the fluid needs of resident #84 timely and b) monitor and provide adequate fluid intake for two (#84 and #56) of two residents whose records were reviewed for hydration. Resident #84 received inadequate amounts of fluids, resulting in dryness to the skin and lips, and an elevated lab indicating dehydration, resulting in harm. Resident #56 was transferred to an emergency room for evaluation of a low grade temperature and weakness, and was diagnosed with [REDACTED]. Please refer to F327

Based on observation, interview and record review, it was determined the facility failed to provide pharmaceutical services to ensure residents were administered the correct physician ordered medication for three (#33, 45 and #74) of sixteen residents whose medication regimen was reviewed. Resident #45 received an incorrect dose of insulin from 12/14/16 through 01/17/17. Abnormal FSBS levels increased, resulting in harm. Medications were administered to all 70 residents residing in the facility. Findings: 1. Resident #45 was admitted to the facility, on 03/15/15, with [DIAGNOSES REDACTED]. A comprehensive care plan, updated 06/06/16, documented the resident had DM. Interventions included insulin was to be administered routinely and per sliding scale as ordered. A quarterly assessment, with an ARD of 12/27/16, documented the resident had received insulin on seven of the seven days prior to the assessment. The monthly physician's orders [REDACTED]. A lab result sheet, dated 12/14/16, documented the resident's HgbA1C level (a blood test which measures a three month average glucose concentration), was elevated at 8.3, with a normal range of 4.0 to 5.6. There was an order to increase the resident's Levemir insulin from 14 U sq at hs to 20 U sq at hs written at the bottom of the lab sheet. The page had been initialed by the resident's physician. A diabetic and injection sheet, dated December 2016, documented the resident had received Levemir 14 U sq at bedtime every night in December with the exception of 12/23/16 which was left blank. Prior to the physician's orders [REDACTED]. Normal levels for non-fasting blood sugar levels are 70-140. The sheet documented from 12/15/16 through 12/31/16, the resident's FSBS had been in the 200s twenty two times, and in the 300s six times. A diabetic and injection sheet, dated January 2016, documented the resident had received Levemir 14 U sq at bedtime every night from 01/01/17 through 01/17/17. The sheet documented the resident had continued to have FSBS results in the 200's and 300's and the results had actually increased some since the physician had ordered the increase in the insulin and it wasn't given. On 01/18/17 at 3:00 p.m., LPN #2 was interviewed with the DON present. The LPN was asked what the resident's orders were for his Levemir insulin. After looking at the MAR, she stated he was to receive Levemir 14 U sq at hs. The LPN and DON were shown the lab result sheet and asked if the notation at the bottom of the sheet was an order to increase the Levemir dosage. The LPN stated it was, however, it had not been signed or noted. They were shown the diabetic/injection sheets and asked if the resident had received his insulin as ordered. They both stated he had not. 2. Resident #33 was admitted to the facility, on 12/17/16, with [DIAGNOSES REDACTED]. The resident's admission orders [REDACTED] ~ Novolog insulin 100 unit/ml AC & HS per sliding scale. The physician's standing order was FSBS 0 -150 no insulin, 151 - 200 two units, 201 - 250 four units, 251 - 300 six units, 301 - 350 eight units, 351 - 400 ten units and if over 400 call the physician, ~ isosorbide Mono CR (Imdur) 30 mg three tablets (three 30 mg tablets equals 90 mg) dly and ~ Renvela 800 mg tid with meals. An admission assessment, with an ARD of 12/23/16, documented the resident was understood, understood others and was cognitively intact. The assessment documented the resident was receiving dialysis while a resident and received insulin and hypnotic meds on seven of the seven days prior to the assessment. The December 2016 MAR documented the resident received Imdur 30 mg dly from 12/18/16 through 12/31/16. The December 2016 Diabetic and Injections sheet documented the following: ~ Novolog insulin 100 unit/ml AC & HS if FSBS was 60 - 150 = 0 U was to be given, if 151 - 199 = 2 U was to be given, if 200 - 249 = 6 U was to be given, if 250 - 299 = 8 U was to be given, if 350 - 400 = 10 U was to be given, and if >401 the physician was to be notified; ~ on 12/17/17 at 8:30 p.m., FSBS was 200 and the resident received 6 U (should have received 4 U), ~ on 12/22/17 at 4:30 p.m., FSBS was 242 and the resident received 6 U (should have received 4 U), ~ on 12/24/17 at 4:30 p.m., FSBS was 261 and the resident received 8 U (should have received 6 U), ~ on 12/25/17 at 4:30 p.m., FSBS was 244 and the resident received 6 U (should have received 4 U), ~ on 12/26/17 at 4:30 p.m., FSBS was 240 and the resident received 6 U (should have received 4 U) and at 8:30 p.m., FSBS was 219 and the resident received 6 U (should have been 4 U), ~ on 12/27/17 at 4:30 p.m., FSBS was 236 and the resident received 6 U (should have received 4 U), ~ on 12/28/17 at 4:30 p.m., FSBS was 215 and the resident received 6 U (should have received 4 U), ~ on 12/29/17 at 8:30 p.m., FSBS was 238 and the resident received 6 U (should have received 4 U), and ~ on 12/30/17 at 4:30 p.m., FSBS was 239 and the resident received 6 U (should have received 4 U). The January 2017 MAR documented the following: ~ Renvela 800 mg was to be administered tid with meals. The times the medication was administered was documented as 8:00 a.m., 2:00 p.m. and 6:00 p.m. Meal times were at 8:00 a.m., 12:00 noon and 5:00 p.m. The January 2017 Diabetic and Injections sheet documented the following: ~ Novolog Flexpen 100 unit/ml AC & HS if FSBS was 60 - 150 = 0 U was to be given, if 151 - 199 = 2 U was to be given, if 200 - 249 = 4 U was to be given, if 250 - 299 = 6 U was to be given, if 300 - 349 = 8 U was to be given, if 350 - 400 = 10 U was to be given, and if >401 adm SS and recheck in 1 hr. If still >401 call physician; and ~ on 01/10/17 at 8:00 p.m., FSBS was 202 and the resident received 6 U (should have received 4 U). On 01/10/17 at 9:16 a.m., LPN #2 was asked about the resident's admission orders [REDACTED]. She stated the resident's physician had a standing sliding scale which he used for all of his residents unless he wrote otherwise. On 01/12/17 at 11:53 a.m., LPN #2 was asked what the resident's orders were for FSBS and insulin. She stated the resident received Novolog insulin per SS according to her FSBS results ac and hs. The LPN was asked what the physician's standing order for sliding scale insulin was. She stated, If the fingerstick blood sugar is 0 -150 no insulin, 151 - 200 two units, 201 - 250 four units, 251 - 300 six units, 301 - 350 eight (units), 351 - 400 ten (units) and if it's (FSBS) over 400 call the physician. The LPN was shown the December 2016 and January 2017 Diabetic and Injections sheets and asked if the resident had received the SS insulin as ordered. After reviewing the sheets, she stated, No. The LPN was shown the December 2016 and January 2017 MARs. The LPN was asked if the resident had received the Renvela as ordered in January. She stated lunch was at noon and dinner at 5:00 p.m., so she had not received it as ordered. On 01/12/17 at 12:48 p.m., the DON was shown the MAR and asked about the Imdur dosage. She stated she was aware of medication problems and would look for the pharmacy delivery records for the resident's Imdur. At 1:00 p.m., CMA #1 was asked how many tablets of Imdur 30 mg she administered to the resident currently. After looking at the medication package and the MAR, she stated, Three. She was asked how many she gave in December. After looking at the December 2016 MAR, she stated according to the documentation she had administered one tablet dly. At 2:06 p.m., the DON provided the surveyor the December 2016 pharmacy delivery log for the resident and stated the resident did not receive three 30 mg tablets daily according to the number of pills delivered to the facility in December. 3. Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no comprehensive assessment available. The initial nursing assessment, dated 12/29/16, documented the resident was alert/oriented to person, had good comprehension and was dependent with ADLs. The admission orders [REDACTED]. The initial care plan, dated 12/29/16, did not include the use of Coumadin. The December 2016 MAR documented the resident received Coumadin 5 mg one tablet on 12/30/16 and 12/31/16. A nurse note, dated 12/31/16, documented the resident was sent to an emergency room at the family's request for evaluation of the surgical site of the resident's pacemaker removal. emergency room discharge orders, dated 12/31/16 at 11:25 a.m., documented a change in the dosage of Coumadin from 5 mg po daily to 5 mg po on Monday/Wednesday/Friday and 7.5 mg po on Tuesday/Thursday/Saturday/Sunday. The January 2017 monthly physician orders [REDACTED]. The January 2017 MAR documented the resident received Coumadin 5 mg one tablet po everyday at 4:00 p.m., from 01/01/17 through 01/10/17. On 01/11/17 at 10:22 a.m., the DON was interviewed regarding the resident's current order for Coumadin. She stated the resident's order was for Coumadin 5 mg daily. The DON was asked if the resident's return orders from the ER visit on 12/29/16 had been reviewed. She stated she did not know if the orders had been checked. After reviewing the orders from the ER visit on 12/29/16, the DON stated the dosage of Coumadin had been changed to a rotating dose of 5 mg and 7.5 mg. The DON was asked if the resident had received the correct dosage of Coumadin. She stated he had not received the correct dosage since it was changed on 12/31/16.

Based on observation, interview and record review, it was determined the facility failed to ensure: a) supervision/cueing/assistance with eating was provided for one (#40), b) assistance was provided with grooming, oral hygiene and incontinent care for one (#62), c) assistance was provided with bathing and grooming for one (#30) of four sampled residents who required assistance with ADLs and d) assistance was provided with positioning for three (#56, 62 and #84). The facility's failure to provide assistance with positioning contributed to the development of avoidable pressure ulcers for residents #56, 62 and #84, resulting in harm. The 'Resident Census and Condition of Residents Report' dated 01/11/17, documented 37 residents required assistance with dressing/grooming, 55 residents required assistance with bathing, 10 residents required assistance with eating and seven residents with pressure ulcers. Findings: 1. Resident #62 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, updated 06/20/16, documented, .Focus; (Resident) requires assistance with bathing, oral care, dressing, grooming, hygiene, toileting and has a visual deficit r/t recent [MEDICAL CONDITION]. At risk for skin integrity r/t decreased mobility incontinence and required ADLs assistance . Goal; I will have my needs anticipated and met on a daily basis while being clean, dry and odor free thru next review date. I will have no alteration in skin integrity thru next review date . Interventions; assist with bathing, scheduled and prn, dressing in clothing of choice, assist with performance of ADLs as needed in order to maintain a clean neat appearance. Assist with grooming hair and establish a daily routine. Assist and remind me to wear my glasses daily and keep them clean. Float heels while in bed, monitor skin for red or open area, provide peri care after each episode of incontinence . A hospice care plan, dated 12/08/16, documented, .Problems; oral care/pt has bad breath and lips that are chapped and dry. Goal; comfort care. Interventions; Requested oral care from aides . A quarterly assessment, dated 12/20/16, documented the resident was cognitively intact, able to make her needs known and used glasses to correct impaired vision. The assessment documented the resident was totally dependant on staff for bed mobility, transfers, dressing, toilet use, bathing and eating. The assessment documented the resident required extensive assistance from staff for on the unit locomotion and personal hygiene, and was always incontinent of bowel and bladder. The range of motion portion of the assessment documented the resident was only able to stabilize with staff assistance when moving from a seated to standing position, moving on and off the toilet and for surface to surface transfers. The resident was also impaired on both sides of the upper and lower extremities. The assessment documented the resident was at risk for developing pressure ulcers, had one stage II pressure ulcer. A wound care physician's note dated 12/28/16 documented the wound had been resolved. Monthly physician's orders [REDACTED].Oral hygiene at least twice daily, AM care; Wash face and hands brush teeth and hair dress in day clothes. Turn and reposition Q 2 hours and PRN . On 01/09/17 at 12:15 p.m., the resident was observed at a meal table in the south dining room. The resident was not observed to eat any of her pureed diet as she sat at the table with staff. The DON removed the resident from the meal table at 12:32 p.m., and positioned her in front of the television in the center foyer. The DON was not observed to assist the resident with washing her face, after the meal, or offer her to toilet prior to placing her wheelchair in front of the television. At 12:52 p.m., the resident was asked how her lunch was. She stated it was ok. She then stated she had asked three people to take her to the bathroom and no one had come to take her yet. The resident's face was observed to have a white substance on the side of her chin, and her lips appeared to be dry with small pieces of skin standing out. Both eyes were observed to be teary and contained a green matter in the corners. She was not observed to wear glasses. She was asked if she could see the television without her glasses and she stated she could not. At 3:52 p.m., the resident was again observed in the center foyer near the television. She was not observed to wear her glasses, her eyes remained matted and teary. The resident had not been assisted with repositioning since 12:15. On 01/10/16 at 08:50 a.m. to 1:23 p.m. (four hours and 33 minutes), the resident was observed in her bed on her back. At 1:23 p.m., the resident was asked how she was feeling today and she stated, My butt hurts! CNA #3 entered the room and was asked to assist the resident onto her side for her skin to be observed. On her left buttock a nickel sized, round shaped, dried area with a small opening was observed. The area did not have any exudate, bleeding or other drainage. The CNA positioned the resident on her back and exited the room. On 01/11/17 at 8:36 a.m., the resident was observed in her room, in bed. She responded appropriately when spoken to, her left eye was observed to have a green matter in the corner, her television was on and she was not observed to wear her glasses. She was observed in a supine position wearing a hospital gown. At 10:26 a.m., the resident remained unchanged, in the same position in bed. The television remained on, she was not observed to wear her glasses. She was observed to watch as people passed her door. She remained positioned on her back. At 11:08 a.m., she was observed to visit with family at her bedside as she lay in bed. The resident remained dressed in a hospital gown. She was not observed to wear her glasses and remained on her back. At 12:46 p.m., and again at 2:20 p.m., the resident remained in bed, on her back, in a hospital gown. The resident was not observed to be up and out of bed during the shift. At 3:20 p.m., LPN #1 was interviewed and asked if staff had assisted the resident out of bed today and or repositioned her. The LPN stated, Hospice got her up today and showered her. She was asked when hospice had seen the resident. She stated she didn't know the time, but was sure hospice had provided care and got the resident out of bed. Hospice aide flow sheets were reviewed for January 2017 and documented the resident received care on 01/03/17, 01/05/17, 01/07/17, 01/10/17, 01/12/17, 01/14/17, and 01/17/17. The flow sheet failed to contain documentation which identified the resident as being up and out of bed, or receiving a bath on 01/11/17. The resident was not observed be repositioned or have incontinent care provided during the six hours of observation on 01/11/17. On 01/12/17 at 1:40 p.m., the resident was observed in her room, in bed and wearing bed clothing. The TV was on, she was not wearing her glasses and her eyes were matted. On 01/12/17 at 2:36 p.m., a hospice staff was interviewed as she exited the resident's room. She was asked what care had been provided for the resident and she stated she had provided the resident with a bed bath today. The hospice staff was asked if she had provided the resident with a shower on 01/11/17. She stated she had not provided the resident with a shower on 01/11/17. She was asked what type of care was provided for her on 01/11/17. The hospice staff stated she provided the resident with incontinent care only. She was asked if she had assisted the resident up and out of bed yesterday. She stated she did not get the resident up and had only provided her with care and left her in bed. On 01/12/17 at 4:40 p.m., the resident was observed in her room, in bed and wearing bed clothing. The TV was on, she was not wearing her glasses and her eyes were matted. A nurse's note dated 01/16/17 at 7:15 a.m., documented a small pressure area to the left upper buttock. The area had increased in size since observed on 01/10/17, resulting in harm. On 01/18/17 at 8:11 a.m., and at 10:00 a.m., the resident was observed in bed asleep, resting on her back. She was dressed in bed clothing. At 12:00 p.m., the resident was observed in her chair in the TV area. She was observed to be sitting atop a 'lift' blanket in her reclining positioning chair. She was dressed in a pink house coat, slippers, and was observed to lean to the right side in the chair. She was observed to have her glasses on. The lens in the glasses were observed to have smudges covering both lenses. The resident was observed to have a white dried substance on the left side of her chin and mouth area and both eyes were matted in the corners. She was asked if she had received assistance with washing her face when she was assisted up today. She stated, No one washed my face. She was asked if she had been provided assistance with brushing her teeth today. She stated she had not had her teeth brushed today. She was asked if she needed assistance to brush her teeth. She stated, Yes, I can't do it by myself all the time. LPN #1 and CMA #2 were observed standing at the nurse's station and asked who had assisted the resident out of bed this afternoon. CMA #2 stated she and CNA #3 had assisted the resident into the reclining positioning chair. At 12:45 p.m., CNA #3 was interviewed and asked how much assistance the resident required from the staff for her ADLs. She stated, We do everything for her because she really doesn't use her left arm. She was asked if the resident had been provided with oral care and had her face washed when she was assisted out of bed. She stated she had provided the resident with oral care prior to getting her up. The CNA was taken to where the resident was sitting and asked again if she had provided care for the resident. After looking at the resident, she stated she had forgotten to wash her face, but had provided oral care. The resident was asked again if oral care had been provided for her when she was assisted out of bed. She stated, No. The CNA was asked if the resident could wash her face and or brush her teeth without help. She stated, No, not really. She was asked if she should have washed the resident's face before bringing her out into the foyer. She stated,Yes I should have washed her face. The CNA was then asked if she noticed any other needs the resident may have had. The CNA looked at the resident and after approximately two minutes stated, No. She was directed to the resident's glasses and asked if she thought they looked ok. The CNA looked at the glasses closely and stated, No, they are dirty, I didn't look at them. She was asked if they should have been cleaned before being placed on the resident. She stated, Yes. On 01/18/17 at 12:54 p.m., the DON was interviewed regarding the lack of ADL care by the staff. She was asked to look at the resident's face. After looking at the residents face and glasses, she stated, Oh, I see she has crust on her face and in the corners of her eyes. She was asked if she thought the resident had received assistance with her ADLs prior to being brought out to the foyer. She stated, Nope. She was asked if the resident should have been provided with assistance before being placed in the foyer. She stated, Of course. They should wash her face when they get her up. The DON was asked if it appeared staff had provided the resident with the assistance she required before bringing her out of her room. The DON stated, Nope, not today. The DON was asked about the pressure ulcer and the needs of the resident r/t repositioning. She stated staff was expected to reposition residents every two hours, and as needed. She was asked how she monitored staff to ensure residents were repositioned timely. She stated, By their skin and if something pops up or not. She was advised of the observations and asked if the resident should have been repositioned more frequently. She stated, Yes. 2. Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, with an ARD of 12/13/16, documented the resident had no unhealed pressure ulcers. The assessment documented the resident required limited assistance with bed mobility. No comprehensive care plan had been developed. An 'Initial Plan of Care' documented nursing problems included skin integrity. Interventions included a turning program to meet the resident's needs every one to two hours. An assessment for predicting pressure ulcer risk was completed on 12/08/16 and documented the resident was a moderate risk. There was no documentation staff had comprehensively assessed the resident's skin at any time from the date of admission on 12/08/16 until 01/09/17. A nurse's note dated 12/27/16 at 3:45 a.m., documented, .Notice bottom had a small open area and excoriated. Applied barrier cream . On 01/09/17 at 9:00 a.m., the resident was observed lying in bed on his back with a blanket over his head. From 9:00 a.m. to 12:00 p.m., three hours later, the resident's position remained unchanged. No staff had repositioned the resident. At 4:30 p.m., LPN #3 and CMA #3 observed the resident's skin. The resident, who was unable to turn himself from his back to his side, required two staff to assist him. The coccyx area was observed with two stage 2 pressure ulcers. The CMA stated the areas had been open for several days. The LPN was asked about the open area on the coccyx. She stated charge nurses were to notify the physician and family when a pressure ulcer was identified. She stated treatment orders were to be obtained and implemented when open areas were identified. The LPN was asked about measures to prevent the development of pressure ulcers. She stated the resident should be turned at least every two hours to prevent pressure ulcers from developing. The facility's lack of assistance with repositioning contributed to the development of the avoidable pressure ulcers, resulting in harm. 3. Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 'Skilled Daily Nurses Note', dated 12/14/17, documented the resident required total assistance with bed mobility and . dark unstageable wounds to both heels. Tx ongoing .Coccyx and peri-area red . The facility did not develop a comprehensive assessment to identify the resident's status. An 'Initial Plan of Care' documented a nursing problem included skin integrity. The plan of care documented the resident was at high risk for the development of pressure ulcers. Interventions for the problem of skin integrity included staff were to implement a turning program to meet needs q 1-2 hrs. The initial physician's orders [REDACTED]. The December 2016 and January 2017 TAR documented staff were to float heels while in bed The January 2017 TAR documented staff had not floated the resident's heels on 01/03/17 through 01/06/17 on the 11 p.m. to 7 a.m. shifts and/or the 7 a.m. to 3 p.m. shifts. On 01/09/17 at 10:00 a.m., the resident was observed asleep lying on her right side. At 11:18 a.m., RN #1 (the wound nurse), with the assistance of CNA #1, was observed as she assessed the resident's skin and provided treatments to the buttocks/sacrum area and bilateral heels. As the RN was assessing the resident's skin, the CNA stated the open area to the buttocks had been small, but was getting bigger and had been present for several days. The CNA was asked what type of care residents who were at risk for pressure ulcer development needed to ensure pressure ulcers did not develop or to ensure pressure ulcers healed. She stated residents should be turned every two hours and not left sitting up for longer than one to two hours. After the resident's skin was assessed and treatments were provided as per documentation on the TAR, the resident was again turned to the right side, where she remained until 1:30 p.m. At 1:30 p.m., three hours and 30 minutes after first being observed to be lying on her right side, staff assisted the resident from the bed to the wheelchair. The resident remained sitting in the wheelchair at 5:00 p.m., when the surveyor last observed the resident on that day. The resident was not repositioned for three hours and 30 minutes. On 01/10/17, from 10:45 a.m. to 1:30 p.m., the resident was observed to be sitting in a wheelchair. The resident was not repositioned for two hours and 45 minutes. From 1:30 p.m. to 5:00 p.m., the resident was observed to be lying in bed on her right side. The resident was not repositioned for three hours and 30 minutes. On 01/11/17 at 2:00 p.m., LPN #2 was observed as she prepared to provide treatments to the resident's buttocks/sacral area and heels. When she removed the covers from the resident, the heels were observed propped on a flattened pillow with both heels touching the bed. At 2:50 p.m., the LPN was asked the specific care the resident required. She stated the resident should not be on her buttocks much at all due to the pressure ulcer on her buttocks, and should be turned from side to side at least every two hours. She stated heels were to be floated and weekly skin assessments were to be performed by charge nurses. When she reviewed the record and the surveyor's findings, she stated the staff had not assisted with repositioning and provided the care the resident needed. She stated the CNAs were responsible for repositioning residents, but the nurse was responsible for ensuring the CNAs provided the care as needed for each individual resident. She stated if residents at risk for pressure ulcers did not get repositioned every two hours, they could develop pressure ulcers. When asked if the resident's pressure ulcer could have developed from a lack of consistent repositioning every two hours she stated, Yes. The facility's lack of assistance with repositioning contributed to the development of the avoidable pressure ulcer, resulting in harm. On 01/12/17 at 4:30 p.m., an interview was conducted with a family member. The family member was asked about the staff repositioning the resident. The family member stated he/she would often have to ask the staff to come turn the resident, and at times staff would not reposition the resident for up to four hours. 4. Resident #40 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 10/03/16, documented the resident had moderate cognitive impairment; had not exhibited the behavior of wandering during the seven days prior to the assessment date; required extensive assistance with most activities of daily living; required supervision with eating; and was 65 inches tall and weighed 110 pounds. The care plan, most recently reviewed/revised on 09/21/16, documented the resident had a problem related to her requirement for supervision/setup of meals and with eating and requires frequent reminders/cues to eat during meals. The care plan also addressed a problem related to the resident's refusal of some meals and poor intake. The care plan documented the resident takes meals in the dining room but will frequently leave with her clothing protector on and then come back later .She is at risk for altered nutrition (due to) confusion (related to) dementia and past ([MEDICAL CONDITION]) . On 01/09/17 at 12:25 p.m., during observation of the noon meal in the south dining room, the surveyor observed resident #40 as she self-propelled her wheelchair into the dining room to her assigned place at the end of a table. The residents's meal had already been served and 100% of her health shake had been consumed. Upon arriving at her place, the resident looked at her tray card, took a drink of coffee and left the dining room to go back out into the hallway. At 12:38 p.m., the resident had been in and out of the dining room three times. She had not taken a bite of food from her plate. No staff members had directed/supervised or offered to assist the resident. At 12:50 p.m., the resident had been in and out of the dining room nine times in the past 25 minutes. Each time she wheeled herself to her place at the dining table, the resident would look at her tray card, take a drink of coffee, and leave the dining room. She had still not attempted to take a bite of her meal. No staff member had directed her to eat and/or offered assistance to eat. At 12:53 p.m., the resident was out in the hallway and a staff member pushed the resident to the TV area. Another staff member then pushed the resident to her room. The resident's meal had been left untouched in the dining room. At 12:55 p.m., the surveyor reviewed the above observations with the DON and asked if the resident had received the supervision/assistance she needed to eat. The DON stated, No. On 01/11/17 at 8:30 a.m., the surveyor reviewed the care plan documentation regarding the resident's requirement for supervision with meals with the DON and asked if the resident's care plan had been followed on 01/09/17 during the noon meal. She acknowledged the resident had not been supervised or cued to eat her meal. 5. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 09/14/16, documented the resident had severe cognitive impairment and was totally dependent upon staff with ADLs. The 90 day assessment, dated 12/07/16, documented the resident had no cognitive impairment and required one person limited assistance with ADLs. The December 2016 ADL record was reviewed. The record documented the resident would be bathed and receive nail care on Tuesdays, Thursdays, and Saturdays. The resident did not receive a bath or nail care for 12 days from 12/17/16 through 12/ 28/16. The following days were marked as the resident refused bathing and nail care: 12/16/16, 12/20/16, 12/22/16, 12/24/16 and 12/27/16. On 01/10/17 at 3:50 p.m., the resident was observed in bed holding the call light. The resident's fingernails were observed to have a thick brown discolored substance under the right thumb nail, and the first two fingernails of the right hand. The nails of both hands were observed to be jagged and untrimmed. The resident's hair was observed to be oily. On 01/11/17 at 8:15 a.m., the resident was observed sitting in the dining room waiting for breakfast to be served. The resident's fingernails were observed to have a brown discolored substance under the right thumb nail and the first two fingernails. The resident's nails of both hands were observed to be jagged and untrimmed. The resident's hair was observed to be oily and uncombed. The resident's teeth were unclean with food debris on the front teeth. On 01/17/17 at 12:59 p.m.,the resident was in bed. The resident was asked about assistance she received with bathing and nail care. The resident reported she needed help to shower and to take care of her fingernails. The resident reported her eye sight was very bad and she cold no longer see her nails to clean and trim them. The resident was asked if she refused assistance with bathing and nail care. The resident reported she did not refuse help with her baths or nails. The resident reported she never knows when she will get a bath or someone will clip and clean her fingernails. At 1:10 p.m., the resident's fingernails were observed. The nails were long and had jagged edges. The nails on the resident's right hand were observed to have a thick brown discolored substance under the thumb the first nail and the second and third nail. On 01/18/17, the surveyor reviewed the January 2017 ADL record. The record documented the resident would be bathed and receive nail care on Tuesdays, Thursdays, and Saturdays. The following days were blank and contained no documentation the resident had been provided with bathing or nail care on 01/10/17, 01/13/17 and 01/17/17. The bath and nail care was marked as refused for 01/07/17. At 10:32 a.m., CNA #3 was interviewed regarding how often the resident was assisted with bathing and nail care. The CNA reported the resident was supposed to be bathed three times weekly. The CNA reported the resident's nails were supposed to be cleaned and trimmed when the resident was bathed. The CNA was asked if the resident refused her baths. The CNA reported she didn't refuse, but she slept a lot and had missed baths in the past. The CNA was asked if the resident was offered a bath on another day if she missed the scheduled one. The CNA reported she did not know. At 1:30 p.m., the DON was interviewed regarding assistance with ADLs for residents who were dependent or required assistance. The DON reported CNAs should bathe residents as scheduled, ensure their hair was clean and their teeth were clean. The DON was asked if the staff should assist the residents with nail care. The DON reported the CNAs should be filing, trimming and cleaning the residents' nails each time they observed the resident was in need of nail care. The DON was taken to the resident's room to observe the resident with the surveyor. The DON reported the resident's nails were dirty and observed to have a large amount of brown debris under most of the fingernails. The DON was asked about the resident's teeth. The DON reported the resident's teeth were unclean. The DON reported the resident did require assistance with brushing her teeth. The DON was asked if the resident could get into the bathroom to brush her teeth. The DON reported she was unsure, but thought the resident could not because there was a bsc in the room for the resident to use. ==

Based on observation, record review and interview, it was determined the facility failed to ensure the primary care physician was notified of a change in condition in resident #3 related to two new wounds and the worsening of one wound, which became necrotic and had a foul odor. Also, the facility failed to ensure the physician was notified of a change in condition in resident #2 related to a left lower leg wound which became necrotic, for two (#2 and #3) of four sampled residents. The facility identified eight residents who were receiving wound care. Findings: 1. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly assessment, dated 09/17/15, documented the resident was able to make himself understood and was able to understand others and his cognition was intact. The assessment also documented the resident required limited assistance with transfers, supervision with bathing and was independent with ambulation, dressing, toilet use and personal hygiene. He used a wheelchair for mobility and was continent of bowel and bladder. The assessment documented the resident was at risk of developing pressure ulcers but had no current pressure ulcers, received insulin seven of the seven days of the look back period, and received [MEDICAL TREATMENT] services. The care plan, dated 06/18/15, with a new target date of 12/17/15, documented, Focus: (Resident #3) is at risk for skin breakdown d/t (due to) decreased mobility, diabetes, end stage [MEDICAL CONDITIONS] of CKD ([MEDICAL CONDITION]), [MEDICAL CONDITION] and has hx (history) of [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION] to lower ext's. (extremities) he has AV (arteriovenous) fistula to left forearm for [MEDICAL TREATMENT] which he receives on Tuesday, Thursday and Saturdays. He has old fistula site to rt (right) upper arm. He has left toe amputation. He is currently free of skin breakdown at this time. Goal: (Resident #3) will maintain intact slin (sic) integrity daily this quarter. Interventions: Braden Assessment quarterly to assess risk. Encourage him to report impairments to skin. Monitor skin daily with care and weekly with body audit. Treatments as ordered. A Weekly/Monthly Body Audit dated 10/27/15 and 11/04/15, documented there were no skin issues at that time. A Podiatry Progress Note dated 11/18/15, documented the patient was seen that day with complaints of painful, long, thick nails aggravated from a shoe. A handwritten note at the bottom of the page documented, [MEDICATION NAME] 1% cream to L (left) great toe and L 4th toe q (every) day until healed. The remainder of the note was illegible. A nurse's note, dated 11/18/15 at 4:30 p.m., documented the new order received from the podiatrist. The treatment sheet, dated 11/2015, documented, 11/18/15 [MEDICATION NAME] 1% cream applied to wounds on L great toe and L 4th toe every day until healed. The 7-3 shift was written in when the treatment was to be completed. A nurse's note, dated 12/12/15 at 2:45 a.m., documented the resident complained about concerns to his left 4th toe. The note documented he told the nurse he noticed a wound, which was observed by the nurse to have a foul odor. The note documented the wound was cleaned and that a referral would be made to the wound doctor. No assessment was documented at this time. There was no further documentation of the wound in the nurses' notes. A Weekly/Monthly Body Audit dated 12/12/15, documented there were no skin issues. On 12/16/15 (Wednesday) at 4:00 p.m., the director of nursing (DON) was asked to look at the resident's left 4th toe. She stated it looked better, that it had slough on it Monday. She stated it looked green and wet. The wound to the 4th digit on the left foot was observed to be elongated, necrotic tissue approximately 1.3 cm (centimeters) x 0.7 cm. The DON was asked about the black spot on the tip of the left great toe and the black spot under the nail bed of the right great toe. She stated she was unaware of them. She stated they were probably blood blisters. The DON was asked if those areas had orders for wound care. She stated she thought maybe skin prep. The resident stated the only physician who had observed his toe was the podiatrist. The DON was asked when did the physicians make rounds in the facility. She stated they did full rounds on even months. She further stated the physicians or their assistants also came in two times a week. She was asked when the physicians or their assistants were in the building, would they see a resident who might need attention. She stated, Yes, the staff would just need to go get them. She was asked if she would expect her nurses to inform the doctor of a change in condition while they were in the building. She stated, Yes, she would expect that to happen. On 12/17/15 at 11:21 p.m., licensed practical nurse (LPN) #4 was asked if she was aware of any wounds on the resident. She stated another nurse pointed out to her about a week ago, the fact the resident had a wound. She stated she asked the resident about it and he stated he bumped it in the shower the day before. She was asked if she documented an assessment. She stated she did not, but it was approximately 1.5 cm x 1.5 cm with pin edges. She stated the open area had a slight yellow color on the top. She was asked if she notified anyone. She stated, No. She stated when she researched it, she found out he already had an appointment with wound management for Friday (12/18/15). At 12:15 p.m., LPN#1 was asked about the resident's wound. She stated they applied [MEDICATION NAME] to the toes and skin prep. She was asked if there was an order for [REDACTED]. She was asked when she first observed the wound. She stated on 12/15/15, there was a necrotic area to his left great toe right above the toe nail. She stated he had another place right below the bed of the toe nail, but it was now closed. She was asked about the condition of the wound. She stated the left 4th digit had declined, underneath the skin was yellowish in color. She was asked if she notified anyone of the condition of the toe. She stated when she talked to social services, they told her he had an appointment with the wound clinic for Friday 12/18/15. The necrotic area was never documented in the clinical record, never assessed and the physician was never notified. LPN #1 was asked if she documented any of her assessments on his wounds. She stated she did not document measurements like she should. She was asked if she had observed the right foot. She Stated, No. She was asked if she was aware of any necrotic areas on the right foot. She stated she thought they were putting skin prep on that one. The LPN was shown the orders and the treatment sheet. She stated it looked like there was no order for skin prep, that she made a mistake. She further stated she just assumed he had an order for [REDACTED].#3. At 2:10 p.m., LPN #3 was asked when he was informed about the wound for resident #3. He stated a little while ago, not sure when, he just knew the treatment was [MEDICATION NAME], but not sure what else was ordered. He was asked if the wound was improving. He stated, No, not like it should. He was asked if he notified the physician about the wound not getting better. He stated, the physician's assistant was at the facility, but did not tell her the wound was not healing. He was asked if he assessed the resident's toes and asked the resident how it occurred. He stated, the resident had hurt it on a wheelchair and he thought that was an old wound that just re-opened, so he covered it with Band-Aids. LPN #3 was asked where he documented his wound assessments. He stated, on the body audits. He was informed of his documentation, which indicated there were no skin issues. He stated, he did not know why he would document that. On 12/17/15 at 5:15 p.m., the DON was asked if she had notified the physician of the black pin point areas on the resident's two great toes. She stated, No, she had talked to one of the other nurses and they were applying skin prep. 2. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Nursing Evaluation/Data Collection sheet, dated 11/02/15, documented her skin was warm. There were no wounds identified on the sheet. An initial nurse's note, dated 11/02/15, documented the resident was admitted to the facility with [DIAGNOSES REDACTED]. There was no documentation to indicate any wounds on the lower extremities. A nurse's note, dated 11/08/15, documented at 3:25 p.m. the boot was used while transferring. There was no documentation of a wound to the left lower extremety. A care plan, dated 11/09/15, documented, (Resident #2) IS RECEIVING (sic) SKILLED NURSING SERVICES FOLLOWING RECENT hospitalization FOR RT (RIGHT) DISTAL HUMERUS FX (FRACTURE), PELVIC RING FX, LEFT MIDDLE AND RING FINGER FX'S AND LEFT ANKLE SPRAIN D/T (DUE TO) PEDESTRIAN/AUTO ACCIDENT, PAIN R/T INJURIES, [DIAGNOSES REDACTED] AND HAS UTI (urinary tract infection). SHE IS RECEIVING (SIC) PT/OT (PHYSICAL THERAPY/OCCUPATIONAL THERAPY) FOR STRENGTHENING, TO INCREASE ENDURANCE AND ADL (activities of daily living) ABILITIES AND ST (SPEECH THERAPY) FOR COGNITIVE-LINGUISTIC DEFICITS. SHE REQUIRES SUPERVISION/SETUP TO LIMITED ASSIST WITH MEAL/EATING AND EXTENSIVE TO TOTAL ASSIST WITH BATHING, DRESSING, PERSONAL HYGIENE, TOILETING, TRANSFERS, BED AND W/C (wheelchair) MOBILITY. Goal: (Resident #3) WILL HAVE EVIDENCE OF HEALING TO RT (RIGHT) DISTAL HUMERUS FX (fracture), PELVIC RING FX, LEFT MIDDLE AND RING FINGERS AND LEFT ANKLE SPRAIN X 90 DAYS, WILL BE ABLE TO PERFORM MORE OF HER OWN ADL'S DAILY WITH LESS ASSIST, WILL WORK WITH THERAPY AS ORDERED WEEKLY AND WILL BE CLEAN, ODOR FREE AND WELL GROOMED DAILY THIS QUARTER. .JUST TO WEAR CAM BOOT ON LEFT FOOT/ANKLE WHEN OUT OF BED WALKING . Another care plan, dated 11/09/15, documented, (RESIDENT #2) HAS RT DISTAL HUMERUS FX, PELVIC RING FX, LEFT RING AND MIDDLE FINGER FX'S AND LEFT ANKLE SPRAIN D/T AUTO/PEDESTRIAN ACCIDENT (SHE WAS HIT BY A CAR). SHE HAS MULTIBLE (SIC) BRUISES TO FACE AND UPPER/LOWER EXTREMITIES, ABRAISION (sic) TO RT ELBOW, HAS SCABBED AREA TO FOREHEAD, HAS ACE BANDAGES TO BILATERAL UPPER EXT'S, SOFT CAST TO LEFT HAND/FINGERS TO WRIST AND SPLINT TO UPPER ARM, SHE HAS CAM BOOT TO LEFT ANKLE/FOOT TO BE WORN WHEN SHE IS OUT OF BED WALKING/TRANSFERING (SIC) (NOT WALKING AT THIS TIME). SHE HAS APPT'S WITH (NAME-DELETED PHYSICIAN) FOR SPLINT AND SUTURE REMOVAL AND (NAME-DELETED PHYSICIAN) FOR CAST/PIN REMOVAL. SHE IS AT RISK FOR SKIN BREAKDOWN D/T DECREASED MOBILITY, IS FREQUENTLY INCONT (INCONTINENT) OF BOWELS AND BLADDER, WEARS ADULT PULLUPS/BRIEFS DAILY, DIABETES, PSORIASIS, UTI AND D/T CAST/SPLINT USE. Goal: (RESIDENT #2) WILL HAVE EVIDENCE OF HEALING TO RT HUMERUS FX X 90 DAYS, PELVIC RING FX X 90 DAYS, LEFT MIDDLE AND RING FINGERS X 90 DAYS AND LEFT ANKLE SPRAIN X 30 DAYS, WILL BE FREE OF S/SX OF INFECTIONS AT INCISION SITES AND OF S/SX OF HEALING TO INCISIONS, WILL HAVE HEALING OF SCABBED AREA TO FOREHEAD AND OF BRUISES X 30 DAYS AND WILL BE FREE OF SKIN BREAKDOWN DAILY R/T PRESSURE OR MOISTURE DAILY THIS QUARTER. Interventions: .JUST WEAR CAM BOOT WHEN OUT OF BED WALKING . An update to the care plan, dated 11/10/15, documented the resident no longer needs Cam boot, weight bearing at times on bilateral lower extremities. There was no documentation to indicate there was a scab or wound to the left lower extremity. A Weekly/Monthly Body Audit, dated 11/15/15, documented the resident had a scab to her forehead, a cast/ace wrap to bilateral upper extremities was noted in place. A boot was on the left leg and no open skin was noted at the time of assessment. A nurse's note, dated 11/27/15 at 3:00 p.m., documented the physician was at the bedside making rounds. A new order was received for [MEDICATION NAME] lotion to back and left leg twice daily. There was no documentation of a left leg wound. A nurse's note, dated 11/28/15 at 11:45 a.m., documented the resident had 2+ [MEDICAL CONDITION] to the left lower extremity with a scabbed area on the ankle. No s/sx (signs/symptoms) of infection were noted. There was no documentation to indicate the physician was notified of the scabbed area. A nurse's note, dated 11/29/15 at 1:00 p.m., documented the scabbed area on the lower left extremity was dry and intact with rash/itching. A Weekly/Monthly Body Audit, dated 11/29/15, documented no open skin noted at the time of assessment. The 14 day comprehensive assessment, dated 12/04/15, documented the resident's cognition was intact. She required extensive assistance with transfers, dressing, personal hygiene and bathing. The assessment documented she was totally dependent on staff for mobility and impairment on both sides to her upper extremety and impairment on one side for her lower extremety. The resident had surgical wounds and was receiving surgical wound care. A Weekly/Monthly Body Audit, dated 12/06/15, documented the boot to the left leg was off at the time of the assessment. Noted black scab/eschar to the left shin 2 cm diameter at the time of the assessment. A nurse's note, dated 12/06/15 at 11:30 p.m., documented a skin assessment was performed and eschar was noted to the left hand and left lower leg. The note documented the eschar was 2 cm in diameter on the left lower leg. Another care plan for the resident related to hearing abilities documented at the bottom of the page, 12/06/15 [MEDICATION NAME] to left hand and lower left leg as ordered. A physician's telephone order, dated 12/06/15, documented, [MEDICATION NAME] spray to L (left) hand and L lower leg eschar twice daily and as needed. Dx: to debride eschar to L hand an L lower leg (2 cm diameter). This was the first time the physician had been contacted. An update, dated 12/11/15, documented to discontinue the [MEDICATION NAME] and start skin prep for seven days then re evaluate. A nurse's note, dated 12/11/15 at 8:10 a.m., documented [MEDICATION NAME] spray applied to left lower extremity as ordered. A patient progress note, dated 12/11/15, documented the resident had a wound to the left medial lower leg 3 cm x 2 cm irregular shape and was unstageable. The current treatment was [MEDICATION NAME]. At 1:30 p.m., the nurse practioner ordered to discontinue the [MEDICATION NAME] and start skin prep to the left medial lower extremity three times a day for seven days and then re evaluate. There was no documentation of an assessment to describe the wound. A Nurse's Note Monthly, dated 12/13/15, did not document a wound on the left leg. A nurse's note, dated 12/14/15 at 4:00 p.m., documented the nurse practitioner was at the bedside. A new order was received to increase the skin prep to the left medial ankle from twice a day to three times a day. A nurse's note, dated 12/15/15 at 9:30 a.m., documented a new order was received for the left bilateral lower extremity to clean with normal saline or DWC (dermal wound cleanser) pat dry crush [MEDICATION NAME] (antibiotic), sprinkle to area 2 x 2 cm necrotic tissue cover wound with Santyl nickel thick cover dry dressing for two days then discontinue [MEDICATION NAME] and re evaluate the wound. On 12/16/15 at 10:00 a.m., the resident was interviewed. She stated she had a wound to her left lower leg about the size of a nickle. She stated it smelled like a rotten potato. She further stated she was a diabetic and was told the dressing had an antibiotic on it. A nurse's note, dated 12/16/15 at 10:30 a.m., documented a wound measurement to the left lower extremity of 2.2 cm x 2.3 cm with 0.1 depth noted to peri wound, 95% of dark eschar noted in center of wound bed with 5% of yellow slough noted to peri wound with slight redness noted. On 12/17/15 at 11:30 a.m. LPN #6 was asked about the wound on the left lower extremity. She stated she documented about it 3 days ago. She stated the resident's left leg had necrotic tissue and a new order was received from the nurse practitioner. She was asked if she documented the observations of the wound. She stated, No. She was asked if she measured the wound. She stated, No. The LPN was asked when should wounds be assessed and documented. She stated, they should be documented and measured upon entry. At 11:35 a.m., LPN #7 was asked about the wound to the resident's left lower leg. She stated that LPN #2 admitted the resident. She was asked when she first observed the area. She stated she really did not remember. She stated she thought it was a scabbed area. She was asked if she could locate any assessment data identifying the wound. She identified the weekly/monthly body audit, dated 12/06/15. At 1:10 p.m., LPN #2 was asked about the wound. She stated she was working when the resident was admitted . She stated she thought she was admitted with the wound to the left leg. She was asked if she performed any wound care on the left leg. She stated, No, she did not see the wound, the resident told her it was there upon admission. She was asked when she was made aware of the wound. She stated about a day or two after the resident was admitted , but she did not think there was a treatment ordered for the wound. She was asked if she performed an assessment when the resident arrived. She stated, No, there were a lot of people in the room and she never got back to it. At 1:35 p.m., LPN #8 was asked about the wound for resident #2. She stated she did not perform wound care and did not remember when the area was first noticed. She stated she thought the resident came in with the wound. She was asked if the area had improved or declined. She stated the last time she observed the wound, they were putting [MEDICATION NAME] on it to debride the eschar. She further stated the treatment changed to two days of [MEDICATION NAME] and Santyl due to the [MEDICATION NAME] not [MEDICATION NAME] the eschar. The LPN was asked why there was no documentation of an assessment of the wound from 11/02/15 through 12/06/15. She stated she did not have an answer. She was asked to review the clinical record for documentation on the admission note and the nurses' notes. She stated she was not able to locate any documentation. At 2:45 p.m., LPN #9 was asked about the wound. She stated she only worked on weekends, but she thought the resident was admitted to the facility with the wound. She stated the resident wore boots in bed so she did not actually see her legs. She was asked if she completed skin assessments on the resident. She stated, Yes. She was asked how she could document the resident had no concerns with her skin if she did not actually look at her legs. She stated she was wrong in doing so. She was asked if she was aware the physician ordered the boot to be worn only while up and that on 11/10/15, the physician documented the resident no longer needed to wear the boot. She stated, No, I missed that. She was shown the nurses' notes and assessment on 11/29/15. She was asked if there was any assessment documented regarding the wound or if the physician had been notified. She stated, No, the documentation is incorrect. She stated the first time she noticed and documented the wound was on 12/06/15, when she contacted the physician. At approximately 3:15 p.m., the DON was asked to observe the wound of the resident's left lower leg. She stated the wound had a black center and a foul odor.

Based on observations, record review and interview, it was determined the facility failed to ensure wounds were thoroughly assessed and monitored for four (#1- #4) of four sampled residents with wounds. This resulted in harm to residents #2 and #3. The facility identified eight residents currently being treated for [REDACTED]. Findings: 1. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly assessment, dated 09/17/15, documented the resident was able to make himself understood and was able to understand others and his cognition was intact. The assessment documented the resident required limited assistance with transfers, supervision with bathing and was independent with ambulation, dressing, toilet use and personal hygiene. He used a wheelchair for mobility and was continent of bowel and bladder. The resident was at risk of the development of pressure ulcers, but did not have a current pressure ulcer, received insulin seven of the seven days of the look back period, and received [MEDICAL TREATMENT] services. The care plan, dated 06/18/15, with a new target date of 12/17/15, documented, Focus: (Resident #3) is at risk for skin breakdown d/t (due to) decreased mobility, diabetes, end stage [MEDICAL CONDITIONS] of CKD ([MEDICAL CONDITION]), [MEDICAL CONDITION] and has hx (history) of [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION] to lower ext's. (extremities) he has AV (arteriovenous) fistula to left forearm for [MEDICAL TREATMENT] which he receives on Tuesday, Thursday and Saturdays. He has old fistula site to rt (right) upper arm. He has left toe amputation. He is currently free of skin breakdown at this time. Goal: (Resident #3) will maintain intact slin (sic) integrity daily this quarter. Interventions: Braden Assessment quarterly to assess risk. Encourage him to report impairments to skin. Monitor skin daily with care and weekly with body audit. Treatments as ordered. A Weekly/Monthly Body Audit form, dated 10/27/15 and 11/04/15, documented there were no skin issues at that time. A Podiatry Progress Note dated 11/18/15, documented the patient was seen this day with complaints of painful, long, thick nails aggravated with a shoe. A handwritten note at the bottom of the page documented, [MEDICATION NAME] 1% cream to L (left) great toe and L 4th toe q (every) day until healed. The remainder of the note was illegible. A nurse's note, dated 11/18/15 at 4:30 p.m., documented the new order received from the podiatrist. The treatment sheet, dated 11/2015, documented, 11/18/15 [MEDICATION NAME] 1% cream applied to wounds on L great toe and L 4th toe every day until healed. A nurse's note, dated 12/12/15 at 2:45 a.m., documented the resident complained about concerns to his left 4th toe. The note documented he told the nurse he noticed a wound. The nurse observed the wound and noted it had a foul odor. She documented the wound was cleaned and that a referral would be made to the wound doctor. There was no further documentation of the wound in the nurses' notes. A Weekly/Monthly Body Audit form, dated 12/12/15, documented there were no skin issues. On 12/16/15 at 4:00 p.m., the director of nursing (DON) was asked to observe the wound on the resident's left 4th toe. She stated it looked better, that it had slough on Monday. She stated it looked green and wet. The wound to the 4th digit on the left foot was observed to be elongated, necrotic tissue approximately 1.3 centimeters (cm) x 0.7 cm. The DON was asked about the black spot on the tip of the left great toe and the black spot under the nail bed of the right great toe. She stated she was unaware of them. She stated they were probably blood blisters. The DON was asked if those areas had orders for wound care. She stated she thought maybe skin prep. The resident stated the only physician who had observed his toe was the podiatrist. The DON was asked when physicians make rounds in the facility. She stated they do full rounds on even months. The physicians or their assistants came in two times a week. She was asked when the physicians or their assistants were in the building, would they see a resident who might need attention. She stated, Yes, staff would just need to go get them. She was asked if she would expect her nurses to inform the doctor of a change in a resident's condition while they were in the building. She stated, Yes, she would expect that to happen. The DON was asked about his shoes. She stated she talked to the resident about them due to his [MEDICAL CONDITION], regarding the fact he may not be able to feel if the shoe was too tight. She stated the resident told her he ordered new shoes. At 4:30 p.m., the DON and the administrator were asked if there were any additional skin assessments for the resident. The DON stated, Well, the nurse documented the resident's skin was clean dry and intact, obviously the nurse did not really assess the resident's skin. On 12/17/15 at 11:21 p.m., licensed practical nurse (LPN) #4 was asked if she was aware of any wounds on the resident. She stated another nurse pointed it out to her about a week ago. She asked the resident about the wound and he stated he bumped it in the shower the day before. She was asked if she documented an assessment. She stated she did not, but it was approximately 1.5 cm x 1.5 cm with pink edges. She stated the open area had a slight yellowish color on the top. She was asked if she notified anyone. She stated, No. She stated when she researched it, she found out the resident already had an appointment with wound management for Friday (12/18/15). She was asked if the resident was to have skin assessments performed. She stated he was supposed to have an assessment completed weekly. She further stated residents were assigned to the nurses by room. She was asked who was responsible for the skin assessment for the resident. She stated she thought it was LPN #3. At 12:15 p.m., LPN#1 was asked about the wound for the resident. She stated they applied [MEDICATION NAME] to the toes and skin prep. She was asked if she had an order for [REDACTED]. She was asked when she observed the wound. She stated on 12/15/15, there was a necrotic area to his left great toe right above the toe nail. She stated he had another place right below the bed of the toe nail but it was now closed. She was asked about the condition of the wound. She stated the left 4th digit had declined, underneath the skin was a yellowing. She stated when she talked to social services, they told her he had an appointment with the wound clinic (12/18/15). LPN #1 was asked if she documented any of her assessments on his wounds. She stated she did not document measurements like she should. She was asked if she had observed the right foot. She Stated, No. She was asked if she was aware of any necrotic areas on the right foot. She stated she thought they were putting skin prep on one. The LPN was shown the orders and the treatment sheet. She stated it looks like there are no orders for skin prep, it looks like she made a mistake. She further stated she just assumed he had an order for [REDACTED].#3. At 2:10 p.m., LPN #3 was asked when he was informed about the wound for resident #3. He stated a little while ago, not sure when, he just knew the treatment was [MEDICATION NAME], but not sure of what else was ordered. He was asked if the wound was progressing. He stated, No, not like it should. He was asked if he notified the physician about the wound not getting better. He stated, the physician's assistant was at the facility, but he did not tell her the resident's wound was not healing. He was asked if he assessed the resident's toes. He stated, the resident hurt his toes on a wheelchair and he thought that was an old wound that just re-opened, so he covered it with Band-Aids. LPN #3 was asked where he documented his wound assessments. He stated, on the body audits. He was informed of his documentation which indicated there were no skin issues. He stated, he did not know why he would document that. On 12/17/15 at 5:15 p.m., the DON was asked if she had notified the physician of the two black areas on the resident's two great toes. She stated, No, she had talked to one of the other nurses and they were applying skin prep. On 12/18/15, a call was placed to the podiatrist's office. The surveyor explained the podiatrist's note of 11/18/15, was not able to be fully deciphered and needed to know the condition of the resident's left 4th toe at that time. At 5:38 p.m., the office manager from the podiatrist's office called and stated she had talked to the physician concerning the resident's left 4th toe. She stated the physician identified the area to the left 4th toe as an abrasion and ordered the [MEDICATION NAME] 1% cream. 2. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Nursing Evaluation/Data Collection form, dated 11/02/15, documented the resident's skin was warm. There were no wounds identified on the form. An initial nurse's note, dated 11/02/15, documented the resident was admitted to the facility with [DIAGNOSES REDACTED]. There was no documentation to indicate any wounds on the lower extremities. A nurse's note, dated 11/08/15, documented at 3:25 p.m., the boot was used while transferring. There was no documentation of a wound to the left lower extremity. A care plan, dated 11/09/15, documented, (Resident #2) IS RECEIVING (sic) SKILLED NURSING SERVICES FOLLOWING RECENT hospitalization FOR RT (RIGHT) DISTAL HUMERUS FX (FRACTURE), PELVIC RING FX, LEFT MIDDLE AND RING FINGER FX'S AND LEFT ANKLE SPRAIN D/T (DUE TO) PEDESTRIAN/AUTO ACCIDENT, PAIN R/T INJURIES, [DIAGNOSES REDACTED] AND HAS UTI (urinary tract infection). SHE IS RECEIVING (SIC) PT/OT (PHYSICAL THERAPY/OCCUPATIONAL THERAPY) FOR STRENGTHENING, TO INCREASE ENDURANCE AND ADL (activities of daily living) ABILITIES AND ST (SPEECH THERAPY) FOR COGNITIVE-LINGUISTIC DEFICITS. SHE REQUIRES SUPERVISION/SETUP TO LIMITED ASSIST WITH MEAL/EATING AND EXTENSIVE TO TOTAL ASSIST WITH BATHING, DRESSING, PERSONAL HYGIENE, TOILETING, TRANSFERS, BED AND W/C (wheelchair) MOBILITY. Goal: (Resident #3) WILL HAVE EVIDENCE OF HEALING TO RT DISTAL HUMERUS FX (fracture), PELVIC RING FX, LEFT MIDDLE AND RING FINGERS AND LEFT ANKLE SPRAIN X 90 DAYS, WILL BE ABLE TO PERFORM MORE OF HER OWN ADL'S DAILY WITH LESS ASSIST, WILL WORK WITH THERAPY AS ORDERED WEEKLY AND WILL BE CLEAN, ODOR FREE AND WELL GROOMED DAILY THIS QUARTER. .JUST TO WEAR CAM BOOT ON LEFT FOOT/ANKLE WHEN OUT OF BED WALKING . Another care plan, dated 11/09/15, documented, (RESIDENT #2) HAS RT DISTAL HUMERUS FX, PELVIC RING FX, LEFT RING AND MIDDLE FINGER FX'S AND LEFT ANKLE SPRAIN D/T AUTO/PEDESTRIAN ACCIDENT (SHE WAS HIT BY A CAR). SHE HAS MULTIBLE (SIC) BRUISES TO FACE AND UPPER/LOWER EXTREMITIES, ABRAISION (sic) TO RT ELBOW, HAS SCABBED AREA TO FOREHEAD, HAS ACE BANDAGES TO BILATERAL UPPER EXT'S, SOFT CAST TO LEFT HAND/FINGERS TO WRIST AND SPLINT TO UPPER ARM, SHE HAS CAM BOOT TO LEFT ANKLE/FOOT TO BE WORN WHEN SHE IS OUT OF BED WALKING/TRANSFERING (SIC) (NOT WALKING AT THIS TIME). SHE HAS APPT'S WITH (NAME-DELETED PHYSICIAN) FOR SPLINT AND SUTURE REMOVAL AND (NAME-DELETED PHYSICIAN) FOR CAST/PIN REMOVAL. SHE IS AT RISK FOR SKIN BREAKDOWN D/T DECREASED MOBILITY, IS FREQUENTLY INCONT (INCONTINENT) OF BOWELS AND BLADDER, WEARS ADULT PULLUPS/BRIEFS DAILY, DIABETES, PSORIASIS, UTI AND D/T CAST/SPLINT USE. Goal: (RESIDENT #2) WILL HAVE EVIDENCE OF HEALING TO RT HUMERUS FX X 90 DAYS, PELVIC RING FX X 90 DAYS, LEFT MIDDLE AND RING FINGERS X 90 DAYS AND LEFT ANKLE SPRAIN X 30 DAYS, WILL BE FREE OF S/SX OF INFECTIONS AT INCISION SITES AND OF S/SX OF HEALING TO INCISIONS, WILL HAVE HEALING OF SCABBED AREA TO FOREHEAD AND OF BRUISES X 30 DAYS AND WILL BE FREE OF SKIN BREAKDOWN DAILY R/T PRESSURE OR MOISTURE DAILY THIS QUARTER. Interventions: .JUST WEAR CAM BOOT WHEN OUT OF BED WALKING . An update to the care plan, dated 11/10/15, documented the resident no longer needed the Cam boot, weight bearing at times on bilateral lower extremities. A Weekly/Monthly Body Audit form, dated 11/15/15, documented the resident had a scab to her forehead, a cast/ace wrap to bilateral upper extremities was noted in place. A boot was on the left leg and no open skin was noted at the time of the assessment. A nurse's note, dated 11/27/15 at 3:00 p.m., documented the physician was at the bedside making rounds. A new order was received for [MEDICATION NAME] lotion to the back and left leg twice daily. There was no documentation of a left leg wound. A nurse's note, dated 11/28/15 at 11:45 a.m., documented the resident had 2+ [MEDICAL CONDITION] in the left lower extremity with a scabbed area on the ankle. No s/sx (signs/symptoms) of infection were noted. There was no documentation to indicate the physician was notified of the scabbed area. A nurse's note, dated 11/29/15 at 1:00 p.m., documented the scabbed area on the lower left extremity was dry and intact with rash/itching. A Weekly/Monthly Body Audit form, dated 11/29/15, documented no open skin was noted at the time of the assessment. The 14 day comprehensive assessment, dated 12/04/15, documented the resident's cognition was intact. She required extensive assistance with transfers, dressing, personal hygiene and bathing. The assessment documented she was totally dependent on staff for mobility and had impairment on both sides to her upper extremity and impairment on one side for her lower extremity. The resident had surgical wounds and was receiving surgical wound care. A Weekly/Monthly Body Audit form, dated 12/06/15, documented the boot to the left leg was off at the time of the assessment. Noted black scab/eschar to the left shin 2 cm diameter at the time of the assessment. A nurse's note, dated 12/06/15 at 11:30 p.m., documented a skin assessment was performed and eschar was noted to the left hand and left lower leg. The note documented the eschar was 2 cm in diameter on the left lower leg. Another care plan for the resident related to hearing abilities documented at the bottom of the page, 12/06/15 [MEDICATION NAME] to left hand and lower left leg as ordered. A physician's telephone order, dated 12/06/15, documented, [MEDICATION NAME] spray to L hand and L lower leg eschar twice daily and as needed. Dx: to debride eschar to L hand an L lower leg (2 cm diameter). This was the first time the physician had been notified. An update, dated 12/11/15, documented to discontinue the [MEDICATION NAME] and start skin prep for seven days then re-evaluate. A nurse's note, dated 12/11/15 at 8:10 a.m., documented, [MEDICATION NAME] spray applied to left lower extremety as ordered. A patient progress note, dated 12/11/15, documented the resident had a wound to the left medial lower leg 3 cm x 2 cm irregular shape and was unstageable. The current treatment was [MEDICATION NAME]. At 1:30 p.m., the nurse practioner ordered to discontinue the [MEDICATION NAME] and start skin prep to the left medial lower extremity three times a day for seven days and then re evaluate. There was no documentation of an assessment to describe the wound. A Nurse's Note Monthly, dated 12/13/15, had no documentation concerning the wound to the left leg. A nurse's note, dated 12/14/15 at 4:00 p.m., documented the nurse practitioner was at the bedside. A new order was received to increase the skin prep to the left medial ankle from twice a day to three times a day. A nurse's note, dated 12/15/15 at 9:30 a.m., documented a new order was received for the left bilateral lower extremity to clean with normal saline or DWC (dermal wound cleanser), pat dry, crush [MEDICATION NAME] (antibiotic), sprinkle to area 2 x 2 cm necrotic tissue cover wound with Santyl nickel thick cover dry dressing for two days then discontinue [MEDICATION NAME] and re-evaluate the wound. On 12/16/15 at 10:00 a.m., the resident was interviewed. She stated she had a wound to her left lower leg about the size of a nickle. She stated it smelled like a rotten potato. She further stated she was a diabetic and was told the dressing had an antibiotic on it. A nurse's note, dated 12/16/15 at 10:30 a.m., documented a wound measurement to the left lower extremity to be 2.2 cm x 2.3 cm with 0.1 depth noted to peri wound, 95% of dark eschar noted in center of the wound bed with 5% of yellow slough noted to peri wound with slight redness noted. On 12/17/15 at 11:30 a.m., LPN #6 was asked about the wound on the left lower extremity. She stated she documented about it 3 days ago. She stated the resident's left leg had necrotic tissue and a new order was received from the nurse practitioner. She was asked if she documented any observations of the wound. She stated, No. She was asked if she measured the wound. She stated, No. The LPN was asked when should wounds be assessed and documented. She stated, they should be documented and measured upon entry. At 11:35 a.m., LPN #7 was asked about the wound to the resident's left lower leg. She stated that LPN #2 admitted the resident. She was asked when she first observed the area. She stated she really did not remember, she thought it was a scabbed area. She was asked if she could locate any assessment data identifying the wound. She identified the weekly/monthly body audit, dated 12/06/15. At 1:10 p.m., LPN #2 was asked about the wound. She stated she was working when the resident was admitted . She stated she thought she was admitted with the wound to the left leg. She was asked if she provided any wound care to the resident's left leg. She stated, No, she did not see the wound, the resident told her it was there upon admission. She was asked when she was made aware of the wound. She stated about a day or two after the resident was admitted , but she did not think there was a treatment ordered for the wound. She was asked if she performed an assessment when the resident arrived. She stated, No, there were a lot of people in the room and she never got back to it. At 1:35 p.m., LPN #8 was asked about the wound for resident #2. She stated she did not provide wound care and did not remember when the area was first noticed. She stated she thought the resident came in with it. She was asked if the area had improved or declined. She stated the last time she observed the wound, they were putting [MEDICATION NAME] on it to debride the eschar. She further stated the treatment was changed to two days of [MEDICATION NAME] and Santyl due to the [MEDICATION NAME] not [MEDICATION NAME] the wound. The LPN was asked why there was no documentation of an assessment of the wound from 11/02/15 through 12/06/15. She stated she did not have an answer. She was asked to review the clinical record for documentation on the admission note and in the nurses' notes. She stated she was not able to locate any assessment documentation of the wound. At 2:45 p.m., LPN #9 was asked about the wound. She stated she only worked on weekends, but she thought the resident was admitted to the facility with the wound. She stated the resident wore boots in bed so she did not actually see the resident's legs. She was asked if she completed skin assessments on the resident. She stated, Yes. She was asked how she could document the resident had no concerns with her skin, if she did not actually look at the resident's legs. She stated she was wrong in doing so. She was asked if she was aware the physician ordered the boot to be worn only while up and that on 11/10/15, the physician documented the resident no longer needed to wear the boot. She stated, No, I missed that. She was shown the nurses' notes and assessment on 11/29/15. She was asked if there was any assessment documented regarding the wound. She stated, No, the documentation is incorrect. She stated the first time she noticed and documented the wound was on 12/06/15, when she contacted the physician. At approximately 3:15 p.m., the DON was asked to observe the wound of the resident's left lower leg. She stated the wound had a black center and a foul odor. 3. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A Nurse's Note Monthly dated 10/20/15, documented None in the section for Skin Conditions. A Weekly/Monthly Body Audit form, documented the following: 10/29/15 - No redness/breakdown noted. No areas of concern. A quarterly assessment, dated 11/17/15, documented the resident had severe cognitive deficits and exhibited signs and symptoms of [MEDICAL CONDITION] to include continuous inattention and disorganized thinking. The assessment documented the resident required extensive staff assistance with dressing and was at risk for the development of pressure ulcers, had no current pressure ulcers and had no other current skin problems. A Podiatry Progress Note, dated 11/18/15, documented, Patient see today c (with) long, thick painful nails (indecipherable) . The note described the resident as having a dried blister to the tip of the 3rd toe on the right foot and a thick dried blister to the right great toe. The podiatrist further described the resident's toe as being a little swollen. He recommended the resident wear tennis shoes or flats only. The note documented the resident's toenails were debrided in length and thickness down to the nail bed until patients tolerance in order to reduce prominence of the nail and relieve pain. He further recommended the resident have her toes cleaned and dried between the toes daily and for the resident to wear socks and change them daily. He described the resident's nails and feet as follows: Nail thickening, skin discoloration, temperature changes, [MEDICAL CONDITION], and parasthesia. A nurse's note, dated 11/18/15 at 2:45 p.m., documented, Called to resident's room by CNA (certified nurse aide). Pressure sore noted to 3rd toe on R foot. Shoes were too tight. Family notified regarding sore & unfitting shoes. Dr. (Name withheld) notified regarding pressure sore/deep tissue sore. New order received. Apply skin prep to 3rd toe on R foot Q shift until deep tissue injury resolved. Family notified regarding new orders. A Weekly/Monthly Body Audit form, documented the following: 11/19/15 - Redness to 3rd toe of R foot. Skin prep Q shift. A nurse's note dated 11/22/15 at 5:00 p.m., documented, Spoke c/ (with) son (Name withheld) they took all of resident's shoes, & brought 2 new pairs of bigger shoes . A nurse's note, dated 11/24/15, documented, .N.O. (new order) wound care consult 3rd toe right foot monitor wound if S/S if starts to drain/becomes warm call (Name withheld-nurse practitioner) or Dr. (Name withheld) 1 DC (discontinue) Skin prep to R 3rd toe 2 Clean R 3rd toe c/ (with) NS (normal saline) or DWC (dermal wound cleanser) pat dry apply Iodosorb Cover c/ 4 x 4 secure c/ Coban change q 3 days & PRN (as needed) orders noted . A physician's progress note, dated 11/24/15, documented the resident had a wound to the R 3rd toe. The note further documented, .noted blood blister 3rd toes reddened. No warmth no visibly crusted areas Start on Iodosorb today (negative pain) @ (at) time - pain med (medication) on board Staff have weeded out ill fitting shoes .Impression/Plan: 1) wound continue current Meds/Treatment - See Chart Orders Meds/Treatment Change: Monitor Call me if worse . A nurse's note, dated 11/25/15, ( no time) documented, Notified Dr. (Name withheld)/(Name withheld-nurse practitioner) of s/s of infection in toe. New order received. Bactrim DS 1 PO (by mouth) BID (twice daily) x (times) 7 D (days), [MEDICATION NAME] 1 PO BID x 10 D. Not to be given within 1 hour of each other. A nurse's note, dated 11/26/15 at 4:55 p.m., documented, Antibiotic received & started. Family notified regarding new orders. Will cont. (continue) to monitor. A nurse's note, dated 11/26/15 at 1:45 p.m. (late entry), documented, .c/o (complained of) wet foot. Upon arrival observed resident up via recliner in rm (room) c/ dry drsg (dressing) to R foot wet. Removed drsg to R foot noted 5cm x 3.1cm red area noted to 3rd digit, warmth to touch. ABT (antibiotic) cont (continues) for infection to R foot 3rd digit s/ (without) s/s of adverse reaction noted. Cleanse 3rd digit to R foot c/ NS & Tx (treatment) performed as ordered. Resident denies discomfort/pain voiced @ this time . A nurse's note, dated 11/27/15 at 3:45 p.m., documented, .Resident c/o R toe pain. Removed dsg to R foot noted dark discoloration c/ small ant (amount) of yellow drainage noted c/ [MEDICAL CONDITION] noted & foul odor noted. Resident states They ran over my foot. Redness noted to top of toe. PRN pain med given. Dr. (Name withheld) arrived @ bedside to assess 3rd digit to right foot. New order received - Transfer to ER (emergency room ) for further evaluation, Resident and (Name withheld), son notified re: (regarding) new order . A Discharge Summary from the hospital, dated 12/03/15, documented, .Date of admission:11/27/15 Date of discharge: 12/03/15 Admitting Diagnoses: [REDACTED]. 2. History of hypertension. 3. History of dementia. Discharge Diagnoses: [REDACTED].#2 day, stable. Hospital Course: .Cultures were taken of the wound and were remarkable for Staph aureus, Staph glaciate and [MEDICATION NAME] aim . A nurse's note, dated 12/03/15 at 2:40 p.m., documented, Resident returned from (Name withheld) hospital .Skin W/D (warm and dry) c/ dsg to R foot C/D/I (clean/dry/intact) c/ surgical shoe intact. 3-11 (3:00 p.m. to 11:00 p.m.) charge nurse to do complete skin assessment . A nurse's note, dated 12/03/15 at 4:00 p.m., documented, .Skin W/D/I (warm/dry/intact) Bandage to R foot C/D/I. No complaints . A nurse's note, dated 12/04/15 (no time) documented, Call placed to (Name withheld) hospital in regards to clarifying order for wound care to R 3rd toe NS/O received to use Conform daily & PRN dressing changed resident tolerates well site is clean and free of s/s of infection. There were no other assessments completed describing the condition of the new amputation site after the resident returned from the hospital. On 12/16/15 at 2:35 p.m., the resident was observed sitting in the therapy room. The resident was observed to have a gauze dressing around the right foot with an orthopedic type boot over the dressing. The resident was wearing a soft house slipper on the left foot. The resident made no verbal response when asked about her right foot. On 12/16/15 at 4:30 p.m., the administrator and DON were asked for any additional wound assessments for the resident related to the amputation of the 3rd toe of the right foot. After review of the resident's clinical record, they both stated there were no additional skin assessments or nursing notes describing the condition of the wound. 4. Resident #4 was admitted to the facility on [DATE], with a new left below knee amputation, end stage [MEDICAL CONDITION] stage V, hypertension, recent pneumonia, type II diabetes mellitus, [MEDICAL CONDITIONS] in [MEDICAL CONDITION], and [MEDICAL CONDITION]. The resident also had an ulcer to the second toe of her right foot. Admission physician orders, documented the wound to the second toe of the right foot was to be cleansed with saline, pat dry, apply [MEDICATION NAME], secure with a dry dressing and change Monday, Wednesday and Friday and as needed. An initial care plan, dated 12/11/15, documented, .#6 Skin integrity Braden scale = (blank) 1) pressure reduction mattress. 2) Pressure reduction cushion to w/c (wheelchair) or chair. 3) Turning program to meet elder's needs Q 1-2 hours. 4) Notify physician for treatments to any wounds identified. 5) Notify wound nurse for evaluation. 6) Provide incontinent care at least Q 2 hours and PRN. 7) Assist to toilet before meals, bedtime, and PRN. 8) Notify responsible party of admission, wounds, or risk of wounds and POC (plan of care). #7 Other 1) 12/13/15 Wound care as ordered to Rt foot 2nd (second) toe . A Nursing Evaluation/Data Collection form, dated 12/11/15, documented in the section for skin condition, Comments: L BKA (below knee amputation) DRSG change to (See orders) R foot great toe see orders . A Pressure Ulcer Risk Evaluation form, dated 12/11/15, documented a score of 7. The form indicated a score of 8 or above represented a high risk for pressure ulcer development. This was inaccurate related to documentation the resident only had two predisposing diseases. The resident had admission [DIAGNOSES REDACTED]. These were all included in the predisposing diseases. An admission nurse's note, dated 12/11/15 at 3:45 p.m., documented, .Resident is a L BKA with daily Dressing changes and PRN . There was nothing documented about the ulcer to the right second toe. A Skilled Daily Nurses Note, dated 12/12/15 at 11:40 p.m., had no documentation of the ulcer to the right second toe. A Skilled Daily Nurses Note, dated 12/13/15 at 4:30 a.m., had no documentation of the ulcer to the right second toe. A Skilled Daily Nurses Note, dated 12/13/15 at 9:00 a.m., had no documentation of the ulcer to the right second toe. A Skilled Daily Nurses Note, dated 12/13/15 at 11:25 p.m., had no documentation of the ulcer to the right second toe. A Skilled Daily Nurses Note, dated 12/14/15 at 5:30 a.m., had no documentation of the ulcer to the right second toe. A Skilled Daily Nurses Note, dated 12/14/15 for the 7:00 a.m. to 11:00 p.m. shift, documented, .treatment to her foot done as ordered and clarification written in regards to drsg See note. A Skilled Daily Nurses Note, dated 12/14/15 at 8:30 a.m., documented, .Skin W/D c/ drsg to R foot C/D/I . A Skilled Daily Nurses Note, dated 12/14/15 at 6:00 p.m., had no documentation of the ulcer to the right second toe. A Skilled Daily Nurses Note, dated 12/15/15 at 4:30 a.m., had no documentation of the ulcer to the right second toe. A Skilled Daily Nurses Note, dated 12/15/15 (no time), had no documentation of the ulcer to the right second toe. A Skilled Daily Nurses Note, dated 12/15/15 (no time), had no documentation of the ulcer to the right second toe. A Skilled Daily Nurses Note, dated 12/16/15 (no time), had no documentation of the ulcer to the right second toe. A Skilled Daily Nurses Note, dated 12/16/15 at 2:30 p.m., documented, .Skin W/D c/ drsg to L AKA (above knee amputation) (supposed to be BKA) & R foot C/D/I . A Skilled Daily Nurses Note, dated 12/16/15 at 9:00 p.m., documented, .New drsg applied to R toe C/D/I . None of the above notes described the condition of the ulcer to the resident's right second toe. On 12/17/15 at 4:35 p.m., an interview was conducted with the resident. She was asked about the ulcer on the second toe of her right foot. She stated she had been at the facility for a week and had the diabetic sore before she arrived at the facility. She further stated she had just had the amputation of her left leg, below the knee. An observation was made of the resident's right second toe. The right great toe was missing due to a

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to notify the physician of the resident's change in condition related to signs and symptoms of a urinary tract infection and a decreased level of consciousness first documented on [DATE]. The resident's change in condition was not reported to a physician until [DATE]. The resident was admitted to a hospital on [DATE]. The resident was intubated upon admission. physician progress notes [REDACTED]. Coli UTI. The resident expired at the nursing facility on [DATE]. On [DATE] the Oklahoma State Department of Health (OSDH) was notified and verified the Immediate Jeopardy Situation. At 11:20 a.m., the administrator and the ADON were notified of the IJ situation. At 2:44 p.m., the facility presented an acceptable plan of removal to the survey team. The Plan of Removal documented: "Plan of Removal for Immediate Jeopardy for Failure to Notify Physician for Decreased LOC and Signs (and) Symptoms of UTI. Failure to Assess/Monitor/Intervene for Signs (and) Symptoms of UTI. 1. All Licensed Nurses/Registered Nurses will be in-serviced regarding following P (and) P for Change of Condition of Resident to his or her Attending Physician, and representative (sponsor) of changes in medical/mental condition and/or status. In-servicing will be completed by 4:30 PM [DATE]. In-service will include review of Policy and Procedure in relation to Change of Condition to include assessment, monitoring, and interventions. All staff that cannot be contacted for in-service will be in-serviced prior to working the floor. 2. All Nursing staff to include LPNs/RNs, CMAs/CNAs will be in-serviced by 4:30PM [DATE] on recognizing signs and symptoms of UTI to include complaints of pain/burning upon urination, change in frequency/amount, odor, consistency, color, and any change in LOC. CMAs/CNAs will report any/all signs and symptoms to charge nurse immediately. All staff that cannot be contacted for in-service will be in-serviced prior to working the floor. 3. Nurses will be in-serviced on [DATE] by 4:30 PM regarding Change in Condition including Assessment, Monitoring, and Interventions Policy (and) Procedure. Facility will continue to monitor daily to include review of all telephone orders and documentation supporting resident, Physician, and family/representative notification. All staff that cannot be contacted for in-service will be in-serviced prior to working the floor. 4. Change of Condition including Assessment, Monitoring, and Interventions will be reviewed Monday thru Friday by D.O.N./designee validating compliance of policy and procedure. Change of Condition including Assessment, Monitoring, and Interventions will be reviewed during the weekend by RN/designee on duty. Any non-compliance will be addressed immediately with written counseling and/or termination. Beginning [DATE] and on-going until continued compliance has been established. 5. Continued Compliance of Change of Condition including Assessment, Monitoring, and Interventions will be validated during IDT Monday thru Friday Morning Clinical Meeting and documented. Beginning [DATE] and on-going until continued compliance has been established. 6. All supporting documentation for continued compliance of Change of Condition including Assessment, Monitoring, Interventions and Physician Notification including signs/symptoms of UTI will be reviewed in IDT QA meeting x 1 month, then quarterly thereafter until the IDT determines compliance has been established." On [DATE] at 8:22 p.m., the Immediate Jeopardy was removed after all staff had been in-serviced in regards to how to recognize signs and symptoms of a UTI, reporting signs and symptoms of a UTI, proper documentation of signs and symptoms of a UTI and who to report signs and symptoms of a UTI. The deficient practice remained at an isolated level of actual harm. At 3:30 p.m., the facility day and evening nursing staff who attended the in-service were interviewed. All staff were knowledgeable concerning notifying the physician/family/POA or charge nurse of a resident's change in condition in regards to signs and symptoms of a UTI and proper documentation related to signs and symptoms of a UTI. Staff were also knowledgeable when questioned about the assessment, monitoring and intervention of a resident with signs and symptoms of a UTI and/or decreased levels of consciousness. On [DATE] at 7:58 a.m., the facility night nursing staff who attended the in-service were interviewed. All staff were knowledgeable concerning notifying the physician/family/POA or charge nurse of a resident's change in condition in regards to signs and symptoms of a UTI and proper documentation related to signs and symptoms of a UTI. Staff were also knowledgeable when questioned about the assessment, monitoring and intervention of a resident with signs and symptoms of a UTI and/or decreased levels of consciousness. Based on observation, record review, staff interviews, and review of facility policy and procedure, it was determined the facility failed: a. to notify the physician or interested party of a resident's change in condition related to decreased level of consciousness and signs and symptoms of a urinary tract infection for one (#6) of six sampled residents with a history of a urinary tract infections. This deficient practice resulted in an actual harm to the resident and an immediate jeopardy to the resident's health and well-being. This had the potential to affect 21 residents identified by the facility with a history of a urinary tract infection in the last three months. b. to notify the physician or interested party of a resident's change in condition related the development of a stage two pressure ulcer for one (#5) of four sampled residents who were reviewed for pressure ulcers. This had the potential to affect six residents identified by the facility with pressure ulcers. Findings: A facility policy titled, Change in a Resident's Condition or Status, documented: "Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status... Policy Interpretation and Implementation: 1. The Nurse Supervisor/Charge Nurse will promptly notify the resident's Attending Physician or On-Call Physician when there has been: ...d. A significant change in the resident's physical/emotional/mental condition... 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting)... 3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when: ...b. There is a significant change in the resident's physical, mental, or psychosocial status... 6. The Nurse Supervisor/Charge Nurse will record in the resident's clinical record information relative to changes in the resident's medical/mental condition or status..." A facility policy titled, Urinary Tract Infections/Bacteriuria- Clinical Protocol, documented: "...2. The staff and practitioner will identify individuals with signs and symptoms suggesting a possible UTI. a. Nurses should observe, document, and report signs and symptoms (for example, fever or hemturia) in detail and avoid premature diagnostic conclusions. b. There is no consistent, clear presentations of symptomatic UTIs. New onset of nonspecific symptoms alone (change in mental status, decline in appetite, etc.) is not a reliable indicator of a UTI, unless there are other general or localized symptoms. Urine odor and cloudiness do not necessarily indicate bacteriuria or a UTI. c. According to the CDC...three of the following symptoms must be present to make an empiral [DIAGNOSES REDACTED]. 1. fever of at least...100.4... 2. new or increased frequency, urgency or burning on urination. 3. new flank or suprapubic pain or tenderness. 4. change in character of urine. 5. worsening of mental or functional status... e. Acute deterioration in previously stable chronic symptoms may indicate an acute infection... Treatment/Management: 1. The physician will order appropriate treatment for [REDACTED]. a. Empirical treatment should be based on a documented description of an individual's symptoms and on consideration of relevant test results, co-existing illnesses and conditions, and pertinent risk factors. b. Generally, symptomatic UTIs should be treated... c. In select situations, empirical antimicrobial therapy may be warranted for afebrile individuals with non-specific symptoms... Monitoring: ...2. Decisions should be made primarily on the basis of clinical signs and symptoms..." A policy, titled, "Pressure Ulcers/Skin Breakdown - Clinical Protocol", documented: "Assessment and Recognition 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support services; and e. All active diagnoses 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin. 4. The physician will help identify factors contributing to determine etiology (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of the skin alteration..." Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented: "...Urinary Tract Infection: Urinary tract infection will resolve with minimal discomfort to resident... Monitor for increased confusion, fall risk related to presence of UTI... [DATE] Amoxicillan...750 mg (1) po q 12 hrs x 14 days... [DATE] [MEDICATION NAME] 1 gm IM daily x 7 days... [DATE] Amoxicillan 500 mg (1) po TID x 10 days..." A care plan, dated [DATE] and last updated [DATE], documented: "...Focus: (named resident) is occasionally incontinent of urine. She receives diuretic daily and has history of recurring UTI... Interventions: ...Monitor for s/s of UTI... Note any changes in amount, frequency, color or odor. Report any abnormalities to Registered Staff... [DATE] (illegible) 750 mg (1) po daily x 5 days UTI... [DATE] [MEDICATION NAME] 100 mg (1) po BID x 10 days..." A quarterly assessment, dated [DATE], documented the resident was moderately impaired in cognitive skill for daily decision making. The assessment documented she required extensive assistance from staff with transfers, dressing, hygiene and bathing. The assessment documented she was occasionally incontinent of bowel and bladder. A nurse's note, dated [DATE] at 6:10 a.m., documented, "Resident has been awake on and off during the night. Has extreme confusions (sic). Believes she is upstair (sic) (at) (named facility). Has also been worried about loosing her coin purse c money in it will pass on info about coin purse to next shift. Resident also believes she has a UTI. Urine has strong odor c burning during urination..." There were no additional nurses' notes documented until [DATE] at 12:40 a.m. A nurse's note, dated [DATE] at 12:40 a.m., documented, "Noted (decreased) LOC from res though still rouses to verbal stimuli. C/o burning c urination when asked (named physician #1) notified via message." A nurse's note, dated [DATE] at 3:30 a.m., documented, "N/o for UA c C (and) S." A physician's orders [REDACTED]. Dx: s/sx UTI..." A nurse's note, dated [DATE] at 3:45 a.m., documented, "Straight cath UA obtained...Urine cloudy yellow c strong odor." A nurse's note, dated [DATE] at 6:50 a.m., documented, "Notified (named family member) of UTI s/sx...Expressed concern over waiting for C (and) S to start meds. Passed on to oncoming nurse to contact (named physician #2) in am regarding starting abt tx before C (and) S." A nurse's note, dated [DATE], documented, "Spoke c (named physician #2) N.O for [MEDICATION NAME] 100 mg BID x 10 day for s/sx of UTI pending C (and) S. Notified (named family member) of new orders." A nurse's note, dated [DATE], documented, "Focused assessment r/t LOC. Monitor VS/LOC q 2 h. Hold meds if sedated." A nurse's note, dated [DATE] at 01:45 a.m., documented, "...awake very upset/confused continues to yell for help..." A nurse's note, dated [DATE] at 1:00 a.m., documented, "Late entry...(increased) levels of confusion. Alert to person only..." A nurse's note, dated [DATE] at 3:15 a.m., documented, "...O2 (at) 92 (percent) RA. Still continues to have increased levels of confusion alert to person only..." A nurse's note, dated [DATE] at 5:20 a.m., documented, "...Still has (increased) level of confusion..." A nurse's note, dated [DATE] at 6:55 a.m., documented, "...Still (increased) confusion..." A laboratory result, dated [DATE], documented, "...Urine culture pending...Urinalysis...Protein...2 (plus)...Blood...3 (plus)...Leukocyte...3 (plus)...Bacteria...4 (plus)..." A nurse's note, dated [DATE], documented, "Resident remains confused. Asking for babies..." A laboratory result, dated [DATE], documented, "...Urine culture...Result status...Partial...Colony count greater than 100,000 CFU/ML...Gram negative rods sensitivities to follow...Notified (named physician #2)..." A nurse's notes, dated [DATE], documented, "Resident cont to be confused...Spoke c (named physician #2) concerning residents confusion. N.O. for CBC and BMP..." A physician's orders [REDACTED]. A laboratory result, dated [DATE], documented, "...Urine Culture... Preliminary...Colony count greater than 100,000 CFU/ML... Possible other gram negative rod...Heavy escherichia coli... Sensitivity [MEDICATION NAME] N.O. (named physician #2) [MEDICATION NAME] 500 mg TID x 10 [MEDICATION NAME] 10 mg TID 10 days..." A nurse's note, dated [DATE], documented, "Resident lethargic unable to take scheduled medications. Notified (named family member) and (named physician #2)." A laboratory result, dated [DATE], documented, "...CBC... WBC...16.6... RBC...2.50... HGB...7.4... HCT...24.7... (increase) [MEDICATION NAME] sulfate to 325 mg BID. Recheck CBC in one week..." A laboratory result, dated [DATE], documented, "...Basic Metabolic Panel... BUN...104 H... Creatinine...5.6 H... Potassium...5.3 H... Chloride...112 H... Carbon [MEDICATION NAME](less than) 10 L Calcium...8.3 L... GFR...8 L... Stat nephrology consult hold order...IV fluids 40cc/hr NS...Recheck BMP (at) first bag...Encourage PO fluids...Monitor q shift fluid overload..." A physician's orders [REDACTED]. "...1. IV fluids 40cc/hr NS 2. Recheck BMP after (first) bag ran 3. Encourage PO fluids 4. Monitor q shift for fluid overload..." A nurse's note, dated [DATE] at 11:00 a.m., documented, "...Respirations remain deep and quick. O2 sat 90 (percent) on room air..." A nurse's note, dated [DATE] at 12:15 p.m., documented, "Resident HOB (up) 30 (degrees). Respirations very labored. O2 sat 86 (percent) on room air. O2 added via N/C O2 sat 93 (percent) on 2LPM. Resident no longer drinking out of straw." A nurse's note, dated [DATE] at 12:30 p.m., documented, "Notified daughter of condition and paged (named physician #2)..." A nurse's note, dated [DATE] at 12:50 p.m., documented, "Spoke c (named physician #2) concerning O2 sat (decreasing) LOC and diminished lower lobes. N.O. to send to (named hospital) ER for eval and treat." A physician's orders [REDACTED]. A nurse's note, dated [DATE] at 1:00 p.m., documented, "(named EMS) here for transfer." A hospital laboratory result, dated [DATE], documented, "...BUN...106 H Creatinine...7.5 H...Potassium...7.3 H...Chloride...119 H...carbon [MEDICATION NAME](less than) 5...Calcium...8.2 L...Phosphorus...12.5 H..." A hospital laboratory result, dated [DATE], documented, "...WBC...16.4 H...RBC...2.57 L...Hemoglobin...7.7 L...Hematocrit...22.8 L..." An hospital nephrology consult note, dated [DATE], documented, "...presented from (named nursing facility) home via EMS with altered mental status... Fluid status: Difficult to assess. Skin dry but CXR shows [MEDICAL CONDITION] and she is hypertensive. Problems: Acute on [MEDICAL CONDITION] [MEDICAL CONDITION] Hypertensive urgency... Metabolic acidosis... [MEDICAL CONDITION] [MEDICATION NAME] [MEDICAL CONDITION] I placed temporary [MEDICAL TREATMENT] catheter and will plan to dialyse (sic) her for 2.5 hrs today with 2 k, 2.5 ca, and 40 [MEDICATION NAME] bath. Will remove 1 litre (sic) on [MEDICAL TREATMENT]. Will again dialyse (sic) her tomorrow. Continue [MEDICATION NAME] drip but decrease rate to 50ml/hr. Continue [MEDICATION NAME]. Will dose 1 gm [MEDICATION NAME] and check level in am. (named physician) discussed with daughter and she is agreeable to [MEDICAL TREATMENT]..." A hospital consultation note, dated [DATE], documented, "Reason for consult: Acute on chronic kidney injury and severe [MEDICAL CONDITION]. History or present illness: ...Apparently she was recently diagnosed with [REDACTED]. Over the last few days she has been feeling more and more weak, had decreased po intake, and now had significant altered mental status which made them send her to the emergency room . While in the ER she was found to have significant abnormalities in her labs with potassium as high as 7.3, creatinine around 7.3, pH of 6.9, and [MEDICATION NAME] of less than 5. She was very tachypneic and so was intubated while in the ER was then sent to intensive care unit. She did receive medical management for her [MEDICAL CONDITION] including insulin, [MEDICATION NAME] boluses and was started on [MEDICATION NAME] drip...The patient was currently intubated and sedated. Regarding her kidney function, it appears that her creatinine had been running around 2 to 2.4 in 2013. It is 7.6 on admission today... There is no history of similar presentations in the past... Assessment and Plan: ...1. Acute on chronic kidney injury. This is most likely acute tubular necrosis [MEDICAL CONDITION] on combination with NSAID use. As of now she is hypercalcemic, severely acidotic, so I have placed a temporary [MEDICAL TREATMENT] catheter and I am planning to dialyze her for 2-,[DATE] hours today... 2. [MEDICAL CONDITION]. Likely due to urinary tract infection. I agree with [MEDICATION NAME]. We will dose 1 gm [MEDICATION NAME] and recheck level in the morning... 3. Metabolic acidosis. [MEDICATION NAME] drip was started. We will continue at this time. We will plan to hold it off after [MEDICAL TREATMENT]. 4. Hypertensive urgency. Blood pressure is settling down with propofol at this time... The patient is currently a full code. (named physician) discussed with the patient's daughter, who wanted everything to be done at this time..." A hospital laboratory result, dated [DATE], documented, "...Urine Culture... Organism 1...Gram negative rod (greater than) 100,000 CFU/ML... Organism 2...Gram negative rod #2 (greater than) 100,000 CFU/ML..." A hospital laboratory result, dated [DATE], documented, "WBC...26.7 H..." A hospital laboratory result, dated [DATE], documented, "...Urine culture...Organism 1...Escherichia Coli...(greater than) 100,000 CFU/ML..." An emergency room progress note, dated [DATE], documented, "...Subjective: Intubated and sedated... Objective: ...sedated, intubated, mechanically ventilated... Assessment/Plan: ...1. Acute on [MEDICAL CONDITION] on [MEDICAL TREATMENT]: Unclear etiology. Likely ATN [MEDICAL CONDITION] vs prerenal from intravascular volume depletion. She was dialysed (sic) yesterday and on admission. Lytes stable. Plan to hold off HD until Monday and recheck if any renal recovery. 2. [MEDICAL CONDITION]: Likely UTI. Urine c/s growing gram neg rods. She is on [MEDICATION NAME]. She is also started on [MEDICATION NAME] and will continue until c/s ar (sic) negative. 3. Hypertensive urgency resolved. Bp stable. 4. Anion gap Metabolic acidosis. [MEDICATION NAME] 18. Start [MEDICATION NAME] drip at 50 cc per hr. 5. [MEDICAL CONDITION]; Resolved with [MEDICAL TREATMENT]. 6. [MEDICATION NAME]: Resolved with [MEDICAL TREATMENT]. 7. [MEDICAL CONDITION]: Hb stable post 2 units transfusion. Discussed her care with her daughter. Her prognosis is guarded. Will contineu (sic) current treatment for [REDACTED]. A hospital progress note, dated [DATE], documented, "...Patient is lying in bed, remains on the ventilator. Patient continues to receive care by nephrology, had undergone 2 [MEDICAL TREATMENT]. (named physician) is going to hold today and probably tomorrow. He had a long conversation with the family today, and they have elected to make her a Do Not Resuscitate. At this point we are going to continue with current medical regimen. We will not withdrawal any care. We will see how she responds to treatment and continue to check on her on a frequent basis...She did have a temperature last night with a temperature of 100.9... Assessment: 1. Acute on top of [MEDICAL CONDITION] 7. [MEDICAL CONDITION] 8. Urinary tract infection growing Escherichia coli which shows sensitivity to current antibiotic regimen... Plan: ...If patient does not show improvement in the next couple of days, family may elect to consider withdrawal of care..." A hospital progress note, dated [DATE], documented, "...Patient continue to be intubated and sedated. She opens her eyes but not following commands... Assessment/Plan: 1. Acute on [MEDICAL CONDITION] on [MEDICAL TREATMENT]. Likely ATN [MEDICAL CONDITION]. Cr more or less stable compared to yesterday. We had long discussion with the patients daughter. I explained her (sic) the there are few signs to suggest her renal function may be recovering, but we are not sure how long it takes to improve back to her baseline. Her daughter doesn't want her life to be prolonged, if no significant improvement quality of life accepted, So we decided to hold off [MEDICAL TREATMENT]/extubate her and the family will decide on further care based on how she does off ventilator... 2. [MEDICAL CONDITION]: Likely ecoli UTI. She is on [MEDICATION NAME] 3...Metabolic acidosis...resolved... 4. [MEDICAL CONDITION]: Plan to extubate today... Family is planning (question) hospice..." A hospital discharge summary, dated [DATE], documented, "...Send back on oxygen at 2 liters/minute to keep sats (greater than) 92 (percent)... Problem List: Acute on [MEDICAL CONDITION] (acute) Acute [MEDICAL CONDITION] (acute) Altered mental status (acute)... [MEDICAL CONDITION] (acute) Metabolic acidosis (acute) Pneumonia (acute) [MEDICAL CONDITION] (acute) Sepsis (acute) UTI (lower urinary tract infection) (acute) Acute [MEDICAL CONDITION] (Resolved)... Arrangements: Hospice Care..." A nurse's note, dated [DATE], documented, "Resident arrived back from (named hospital) via (named EMS)..." A nurse's note, dated [DATE], documented, "Resident in bed c eyes open, unresponsive to speech/touch. Respirations even/unlabored..." On [DATE] at 4:05 p.m., the resident was observed to lay in her bed with her eyes open. A hospice aide was observed to cover the resident with her blanket. The hospice aide was observed to speak to the resident. The resident did not respond. She made no movements physically and was nonverbal. The resident's breathing had periods of apnea. A nurse's note, dated [DATE], documented, "Resident beginning to mottle and periods of apnea...spoke c (named family member)" A nurse's note, dated [DATE], documented, "...Called into resident's room by hospice staff...Resident had (no) apical pulse was not breathing (no) b/p noted...notified (named physician #2)...Spoke c (named family member)." A physician's orders [REDACTED]. A nurse's note, dated [DATE], documented, "Late entry for [DATE]...notified PCP regarding residents earlier statements about being upstairs at (named facility), vs/wnl for resident, afebrile is oriented to person and place. Communicated to PCP residents thoughts of having a UTI completed ABT therapy in April per chart review. No new orders (at) this time." On [DATE] at 8:00 a.m., a facility communication log was reviewed for [DATE]. There was no documentation which stated the physician/family or interested party was contacted in regards to the resident's decreased level of consciousness and signs and symptoms of a urinary tract infection. On [DATE] at 8:55 a.m., LPN #1 was asked how often she cared for the resident. She stated, "Most of the time I've been here I've worked on north so I've cared for her most of the time." She was then asked why a late entry was written in the resident's chart for [DATE]. She stated, "I was told you wanted to talk to me so I went back over everything I had written." She was asked which physician she contacted on the morning of [DATE]. She stated, "Talked to (named physician #1)." She was then asked if she notified the physician of the resident's signs and symptoms of a UTI. She stated she spoke with the physician and informed him all the resident's vital signs were normal and the resident was afebrile. She stated no new orders were given. At 9:06 a.m., LPN #2 was asked how often she was assigned to care for the resident. She stated, "Monday through Friday typically." She was then asked if she was familiar with the resident's baseline. She stated, "Yes. She has intermittent confusion. Has since I worked here." She further stated, "In the past when she has UTIs she gets more confused." She was asked if the resident exhibited increased confusion when she assumed her care on [DATE]. She stated, "Yes. She was asking for babies. Normally not this confused." On [DATE] at 9:40 a.m., physician #1 was asked when he was first notified the resident had increased confusion and signs and symptoms of a urinary tract infection. He stated, "She's (named physician #2) patient. I know her pretty well. Haven't care for her at all." He was then asked if he was on call for physician #2 on [DATE] or [DATE]. He stated, "No." He further stated the facility texts from time to time if they need something. He stated, "I don't normally get called for (named physician #2) patients." He stated, "I can't remember if they called or text." He further stated, "There's no way staff would have called me and I would not have addressed this. I would have ordered a UA with C and S. I think going from [DATE]nd to [DATE]th is too long. (named resident) was chronically ill and could not tolerate much." At 10:05 a.m., physician #2 was asked when he was first informed of the resident's increased confusion and signs and symptoms of a urinary tract infection. He stated, "I don't remember." He was then asked if he felt the resident's urinary tract infection could have contributed to her outcome. He stated, "Of course it could have contributed to it. You can become septic very easily from a UTI." On [DATE] at 11:25 a.m., LPN #1 was asked how she determined in the past the resident was showing signs of a urinary tract infection. She stated, "I can remember one instance she was talking about her dog and her dog wasn't here. As far as her thinking she was upstairs. She commented on that a lot." She was then asked what were some signs and symptoms of a urinary tract infection. She stated, "Fever, burning, smell, pain upon urination, color, clarity." She was asked what action she would take if she noticed any of these signs or symptoms. She stated, "If I notice this I call doctor and ask for UA to be obtained with culture." On [DATE] at 12:10 p.m., the MDS coordinator was asked what the resident's level of consciousness was when she last assessed her. She stated, "She answered questions appropriately. She was awake and alert. Nothing stood out cognitive wise." She further stated, "Every time I saw and talked to her she answered my questions appropriately. Saw her at least once a week." At 12:18 p.m., LPN #2 was asked what was the resident's usual cognitive status. She stated, "Intermittent confusion. She had dementia. Wasn't really bad. She would forget time of day or if she ate dinner." She was then asked if she cared for the resident when she had symptoms of a urinary tract infection in the past. She stated, "With her she would become lethargic. She rarely ran a temp with UTI." On [DATE] at 12:19 p.m., CNA #1 was asked how often she was assigned to take care of the resident. She stated, "Monday through Friday. Every day I worked." She was then asked what was the resident's usual cognitive status. She stated, "She was very alert. Knew what she wanted when she wanted it. I've been here three years. I think this was only the second time I noticed her to have increased confusion." At 12:22 p.m., CMA #1 was asked how often she was assigned to care for the resident. She stated, "Monday through Friday I took care of (named resident)." She was then asked what was the resident's usual cognitive status. She stated, "She was rarely confused. She could tell me what pills she took every day. She always wanted to take big pills first." 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented, "Focus (Resident) has the potential for impaired skin integrity r/t incontinence and impaired mobility. Goals Maintain intact skin integrity Interventions Description - Cleanse perineal area well with each incontinence episode - Ensure linens are dry and wrinkle free. - Lotion to be applied to hands and fingers bid per CNA's - Monitor skin daily with care and weekly body audit. - Take extra care and time transferring, use palms of hands or arms to support. Ensure safety around sharp objects i.e. toilet paper holders, w/c peddles (sic), etc. - Treatment as ordered. - Turn and reposition with skin care q2hr - Use two person transfer and use turn sheet to avoid friction/shearing of resident skin - CNA's to apply lotion to hands fingers bid (written in)..." A weekly body audit, dated [DATE], documented the resident's skin was clean, dry and intact. A weekly body audit, dated [DATE] documented, "Redd (sic) bottom Tx c A&D q shift..." A physician's telephone order, dated [DATE] at 4:00 p.m., documented, "Comment:..A&D ointment to coccyx q shift until resolve (sic) Dx: Reddened coccyx..." A weekly body audit, dated [DATE], documented, "...Comment: 0.5cm stage II noted to (R) buttock reddened area noted to (R) heel..." A weekly body audit, dated [DATE], documented, "...Comment: CDI" A weekly body audit, dated [DATE], documented, "...Comment: ,[DATE] cm rounded pressure sore beginning. 1st layer of s

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to assess, monitor and intervene appropriately and timely for a resident who exhibited a change in condition related to signs and symptoms of a urinary tract infection and decreased level of consciousness first documented on [DATE]. The resident's change in condition was not reported to a physician until [DATE]. The resident was admitted to an acute care facility on [DATE]. The resident was intubated on admission. physician progress notes [REDACTED]. Coli UTI. The resident expired on [DATE]. On [DATE], the Oklahoma State Department of Health (OSDH) was notified and verified the Immediate Jeopardy Situation. On [DATE] at 11:20 a.m., the administrator and the ADON were notified of the IJ situation. At 2:44 p.m., the facility presented an acceptable plan of removal to the survey team. The Plan of Removal documented: "Plan of Removal for Immediate Jeopardy for Failure to Notify Physician for Decreased LOC and Signs (and) Symptoms of UTI. Failure to Assess/Monitor/Intervene for Signs (and) Symptoms of UTI. 1. All Licensed Nurses/Registered Nurses will be in-serviced regarding following P (and) P for Change of Condition of Resident to his or her Attending Physician, and representative (sponsor) of changes in medical/mental condition and/or status. In-servicing will be completed by 4:30 PM [DATE]. In-service will include review of Policy and Procedure in relation to Change of Condition to include assessment, monitoring, and interventions. All staff that cannot be contacted for in-service will be in-serviced prior to working the floor. 2. All Nursing staff to include LPNs/RNs, CMAs/CNAs will be in-serviced by 4:30PM [DATE] on recognizing signs and symptoms of UTI to include complaints of pain/burning upon urination, change in frequency/amount, odor, consistency, color, and any change in LOC. CMAs/CNAs will report any/all signs and symptoms to charge nurse immediately. All staff that cannot be contacted for in-service will be in-serviced prior to working the floor. 3. Nurses will be in-serviced on [DATE] by 4:30 PM regarding Change in Condition including Assessment, Monitoring, and Interventions Policy (and) Procedure. Facility will continue to monitor daily to include review of all telephone orders and documentation supporting resident, Physician, and family/representative notification. All staff that cannot be contacted for in-service will be in-serviced prior to working the floor. 4. Change of Condition including Assessment, Monitoring, and Interventions will be reviewed Monday thru Friday by D.O.N./designee validating compliance of policy and procedure. Change of Condition including Assessment, Monitoring, and Interventions will be reviewed during the weekend by RN/designee on duty. Any non-compliance will be addressed immediately with written counseling and/or termination. Beginning [DATE] and on-going until continued compliance has been established. 5. Continued Compliance of Change of Condition including Assessment, Monitoring, and Interventions will be validated during IDT Monday thru Friday Morning Clinical Meeting and documented. Beginning [DATE] and on-going until continued compliance has been established. 6. All supporting documentation for continued compliance of Change of Condition including Assessment, Monitoring, Interventions and Physician Notification including signs/symptoms of UTI will be reviewed in IDT QA meeting x 1 month, then quarterly thereafter until the IDT determines compliance has been established." On [DATE] at 8:22 p.m., the Immediate Jeopardy was removed after all staff had been in-serviced in regards to how to recognize signs and symptoms of a UTI, reporting signs and symptoms of a UTI, proper documentation of signs and symptoms of a UTI and who to report signs and symptoms of a UTI. The deficient practice remained at an isolated level of actual harm. Based on observation, record review, staff interviews, and review of facility policy and procedure, it was determined the facility failed to assess, monitor and intervene for a resident who exhibited a decreased level of consciousness and signs and symptoms of a urinary tract infection for one (#6) of six sampled residents with a history of a urinary tract infection. This deficient practice resulted in an immediate jeopardy situation for the resident who was hospitalized , required immediate intubation with ventilatory support. The resident was diagnosed with [REDACTED]. The resident expired. The facility identified 21 residents with a history of a urinary tract infection in the last three months. Findings: A facility policy titled, Change in a Resident's Condition or Status, documented: "Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status... Policy Interpretation and Implementation: 1. The Nurse Supervisor/Charge Nurse will promptly notify the resident's Attending Physician or On-Call Physician when there has been: ...d. A significant change in the resident's physical/emotional/mental condition... 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting)... 3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when: ...b. There is a significant change in the resident's physical, mental, or psychosocial status... 6. The Nurse Supervisor/Charge Nurse will record in the resident's clinical record information relative to changes in the resident's medical/mental condition or status..." A facility policy titled, Urinary Tract Infections/Bacteriuria- Clinical Protocol, documented: "...2. The staff and practitioner will identify individuals with signs and symptoms suggesting a possible UTI. a. Nurses should observe, document, and report signs and symptoms (for example, fever or hemturia) in detail and avoid premature diagnostic conclusions. b. There is no consistent, clear presentations of symptomatic UTIs. New onset of nonspecific symptoms alone (change in mental status, decline in appetite, etc.) is not a reliable indicator of a UTI, unless there are other general or localized symptoms. Urine odor and cloudiness do not necessarily indicate bacteriuria or a UTI. c. According to the CDC...three of the following symptoms must be present to make an empiral [DIAGNOSES REDACTED]. 1. fever of at least...100.4... 2. new or increased frequency, urgency or burning on urination. 3. new flank or suprapubic pain or tenderness. 4. change in character of urine. 5. worsening of mental or functional status... e. Acute deterioration in previously stable chronic symptoms may indicate an acute infection... Treatment/Management: 1. The physician will order appropriate treatment for [REDACTED]. a. Empirical treatment should be based on a documented description of an individual's symptoms and on consideration of relevant test results, co-existing illnesses and conditions, and pertinent risk factors. b. Generally, symptomatic UTIs should be treated... c. In select situations, empirical antimicrobial therapy may be warranted for afebrile individuals with non-specific symptoms... Monitoring: ...2. Decisions should be made primarily on the basis of clinical signs and symptoms..." A policy, titled, "Pressure Ulcers/Skin Breakdown - Clinical Protocol", documented: "Assessment and Recognition 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support services; and e. All active diagnoses 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin. 4. The physician will help identify factors contributing to determine etiology (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of the skin alteration..." Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented: "...Urinary Tract Infection: Urinary tract infection will resolve with minimal discomfort to resident... Monitor for increased confusion, fall risk related to presence of UTI... [DATE] Amoxicillan...750 mg (1) po q 12 hrs x 14 days... [DATE] [MEDICATION NAME] 1 gm IM daily x 7 days... [DATE] Amoxicillan 500 mg (1) po TID x 10 days..." A care plan, dated [DATE] and last updated [DATE], documented: "...Focus: (named resident) is occasionally incontinent of urine. She receives diuretic daily and has history of recurring UTI... Interventions: ...Monitor for s/s of UTI... Note any changes in amount, frequency, color or odor. Report any abnormalities to Registered Staff... [DATE] (illegible) 750 mg (1) po daily x 5 days UTI... [DATE] [MEDICATION NAME] 100 mg (1) po BID x 10 days..." A quarterly assessment, dated [DATE], documented the resident was moderately impaired in cognitive skill for daily decision making. The assessment documented she required extensive assistance from staff with transfers, dressing, hygiene and bathing. The assessment documented she was occasionally incontinent of bowel and bladder. A nurse's note, dated [DATE] at 6:10 a.m., documented, "Resident has been awake on and off during the night. Has extreme confusions (sic). Believes she is upstair (sic) (at) (named facility). Has also been worried about loosing her coin purse c money in it will pass on info about coin purse to next shift. Resident also believes she has a UTI. Urine has strong odor c burning during urination..." There were no additional nurses' notes documented until [DATE] at 12:40 a.m. A nurse's note, dated [DATE] at 12:40 a.m., documented, "Noted (decreased) LOC from res though still rouses to verbal stimuli. C/o burning c urination when asked (named physician #1) notified via message." A nurse's note, dated [DATE] at 3:30 a.m., documented, "N/o for UA c C (and) S." A physician's orders [REDACTED]. Dx: s/sx UTI..." A nurse's note, dated [DATE] at 3:45 a.m., documented, "Straight cath UA obtained...Urine cloudy yellow c strong odor." A nurse's note, dated [DATE] at 6:50 a.m., documented, "Notified (named family member) of UTI s/sx...Expressed concern over waiting for C (and) S to start meds. Passed on to oncoming nurse to contact (named physician #2) in am regarding starting abt tx before C (and) S." A nurse's note, dated [DATE], documented, "Spoke c (named physician #2) N.O for [MEDICATION NAME] 100 mg BID x 10 day for s/sx of UTI pending C (and) S. Notified (named family member) of new orders." A nurse's note, dated [DATE], documented, "Focused assessment r/t LOC. Monitor VS/LOC q 2 h. Hold meds if sedated." A nurse's note, dated [DATE] at 01:45 a.m., documented, "...awake very upset/confused continues to yell for help..." A nurse's note, dated [DATE] at 1:00 a.m., documented, "Late entry...(increased) levels of confusion. Alert to person only..." A nurse's note, dated [DATE] at 3:15 a.m., documented, "...O2 (at) 92 (percent) RA. Still continues to have increased levels of confusion alert to person only..." A nurse's note, dated [DATE] at 5:20 a.m., documented, "...Still has (increased) level of confusion..." A nurse's note, dated [DATE] at 6:55 a.m., documented, "...Still (increased) confusion..." A laboratory result, dated [DATE], documented, "...Urine culture pending...Urinalysis...Protein...2 (plus)...Blood...3 (plus)...Leukocyte...3 (plus)...Bacteria...4 (plus)..." A nurse's note, dated [DATE], documented, "Resident remains confused. Asking for babies..." A laboratory result, dated [DATE], documented, "...Urine culture...Result status...Partial...Colony count greater than 100,000 CFU/ML...Gram negative rods sensitivities to follow...Notified (named physician #2)..." A nurse's notes, dated [DATE], documented, "Resident cont to be confused...Spoke c (named physician #2) concerning residents confusion. N.O. for CBC and BMP..." A physician's orders [REDACTED]. A laboratory result, dated [DATE], documented, "...Urine Culture... Preliminary...Colony count greater than 100,000 CFU/ML... Possible other gram negative rod...Heavy escherichia coli... Sensitivity [MEDICATION NAME] N.O. (named physician #2) [MEDICATION NAME] 500 mg TID x 10 [MEDICATION NAME] 10 mg TID 10 days..." A nurse's note, dated [DATE], documented, "Resident lethargic unable to take scheduled medications. Notified (named family member) and (named physician #2)." A laboratory result, dated [DATE], documented, "...CBC... WBC...16.6... RBC...2.50... HGB...7.4... HCT...24.7... (increase) [MEDICATION NAME] sulfate to 325 mg BID. Recheck CBC in one week..." A laboratory result, dated [DATE], documented, "...Basic Metabolic Panel... BUN...104 H... Creatinine...5.6 H... Potassium...5.3 H... Chloride...112 H... Carbon [MEDICATION NAME](less than) 10 L Calcium...8.3 L... GFR...8 L... Stat nephrology consult hold order...IV fluids 40cc/hr NS...Recheck BMP (at) first bag...Encourage PO fluids...Monitor q shift fluid overload..." A physician's orders [REDACTED]. "...1. IV fluids 40cc/hr NS 2. Recheck BMP after (first) bag ran 3. Encourage PO fluids 4. Monitor q shift for fluid overload..." A nurse's note, dated [DATE] at 11:00 a.m., documented, "...Respirations remain deep and quick. O2 sat 90 (percent) on room air..." A nurse's note, dated [DATE] at 12:15 p.m., documented, "Resident HOB (up) 30 (degrees). Respirations very labored. O2 sat 86 (percent) on room air. O2 added via N/C O2 sat 93 (percent) on 2LPM. Resident no longer drinking out of straw." A nurse's note, dated [DATE] at 12:30 p.m., documented, "Notified daughter of condition and paged (named physician #2)..." A nurse's note, dated [DATE] at 12:50 p.m., documented, "Spoke c (named physician #2) concerning O2 sat (decreasing) LOC and diminished lower lobes. N.O. to send to (named hospital) ER for eval and treat." A physician's orders [REDACTED]. A nurse's note, dated [DATE] at 1:00 p.m., documented, "(named EMS) here for transfer." A hospital laboratory result, dated [DATE], documented, "...BUN...106 H Creatinine...7.5 H...Potassium...7.3 H...Chloride...119 H...carbon [MEDICATION NAME](less than) 5...Calcium...8.2 L...Phosphorus...12.5 H..." A hospital laboratory result, dated [DATE], documented, "...WBC...16.4 H...RBC...2.57 L...Hemoglobin...7.7 L...Hematocrit...22.8 L..." An hospital nephrology consult note, dated [DATE], documented, "...presented from (named nursing facility) home via EMS with altered mental status... Fluid status: Difficult to assess. Skin dry but CXR shows [MEDICAL CONDITION] and she is hypertensive. Problems: Acute on [MEDICAL CONDITION] [MEDICAL CONDITION] Hypertensive urgency... Metabolic acidosis... [MEDICAL CONDITION] [MEDICATION NAME] [MEDICAL CONDITION] I placed temporary [MEDICAL TREATMENT] catheter and will plan to dialyse (sic) her for 2.5 hrs today with 2 k, 2.5 ca, and 40 [MEDICATION NAME] bath. Will remove 1 litre (sic) on [MEDICAL TREATMENT]. Will again dialyse (sic) her tomorrow. Continue [MEDICATION NAME] drip but decrease rate to 50ml/hr. Continue [MEDICATION NAME]. Will dose 1 gm [MEDICATION NAME] and check level in am. (named physician) discussed with daughter and she is agreeable to [MEDICAL TREATMENT]..." A hospital consultation note, dated [DATE], documented, "Reason for consult: Acute on chronic kidney injury and severe [MEDICAL CONDITION]. History or present illness: ...Apparently she was recently diagnosed with [REDACTED]. Over the last few days she has been feeling more and more weak, had decreased po intake, and now had significant altered mental status which made them send her to the emergency room . While in the ER she was found to have significant abnormalities in her labs with potassium as high as 7.3, creatinine around 7.3, pH of 6.9, and [MEDICATION NAME] of less than 5. She was very tachypneic and so was intubated while in the ER was then sent to intensive care unit. She did receive medical management for her [MEDICAL CONDITION] including insulin, [MEDICATION NAME] boluses and was started on [MEDICATION NAME] drip...The patient was currently intubated and sedated. Regarding her kidney function, it appears that her creatinine had been running around 2 to 2.4 in 2013. It is 7.6 on admission today... There is no history of similar presentations in the past... Assessment and Plan: ...1. Acute on chronic kidney injury. This is most likely acute tubular necrosis [MEDICAL CONDITION] on combination with NSAID use. As of now she is hypercalcemic, severely acidotic, so I have placed a temporary [MEDICAL TREATMENT] catheter and I am planning to dialyze her for 2-,[DATE] hours today... 2. [MEDICAL CONDITION]. Likely due to urinary tract infection. I agree with [MEDICATION NAME]. We will dose 1 gm [MEDICATION NAME] and recheck level in the morning... 3. Metabolic acidosis. [MEDICATION NAME] drip was started. We will continue at this time. We will plan to hold it off after [MEDICAL TREATMENT]. 4. Hypertensive urgency. Blood pressure is settling down with propofol at this time... The patient is currently a full code. (named physician) discussed with the patient's daughter, who wanted everything to be done at this time..." A hospital laboratory result, dated [DATE], documented, "...Urine Culture... Organism 1...Gram negative rod (greater than) 100,000 CFU/ML... Organism 2...Gram negative rod #2 (greater than) 100,000 CFU/ML..." A hospital laboratory result, dated [DATE], documented, "WBC...26.7 H..." A hospital laboratory result, dated [DATE], documented, "...Urine culture...Organism 1...Escherichia Coli...(greater than) 100,000 CFU/ML..." An emergency room progress note, dated [DATE], documented, "...Subjective: Intubated and sedated... Objective: ...sedated, intubated, mechanically ventilated... Assessment/Plan: ...1. Acute on [MEDICAL CONDITION] on [MEDICAL TREATMENT]: Unclear etiology. Likely ATN [MEDICAL CONDITION] vs prerenal from intravascular volume depletion. She was dialysed (sic) yesterday and on admission. Lytes stable. Plan to hold off HD until Monday and recheck if any renal recovery. 2. [MEDICAL CONDITION]: Likely UTI. Urine c/s growing gram neg rods. She is on [MEDICATION NAME]. She is also started on [MEDICATION NAME] and will continue until c/s ar (sic) negative. 3. Hypertensive urgency resolved. Bp stable. 4. Anion gap Metabolic acidosis. [MEDICATION NAME] 18. Start [MEDICATION NAME] drip at 50 cc per hr. 5. [MEDICAL CONDITION]; Resolved with [MEDICAL TREATMENT]. 6. [MEDICATION NAME]: Resolved with [MEDICAL TREATMENT]. 7. [MEDICAL CONDITION]: Hb stable post 2 units transfusion. Discussed her care with her daughter. Her prognosis is guarded. Will contineu (sic) current treatment for [REDACTED]. A hospital progress note, dated [DATE], documented, "...Patient is lying in bed, remains on the ventilator. Patient continues to receive care by nephrology, had undergone 2 [MEDICAL TREATMENT]. (named physician) is going to hold today and probably tomorrow. He had a long conversation with the family today, and they have elected to make her a Do Not Resuscitate. At this point we are going to continue with current medical regimen. We will not withdrawal any care. We will see how she responds to treatment and continue to check on her on a frequent basis...She did have a temperature last night with a temperature of 100.9... Assessment: 1. Acute on top of [MEDICAL CONDITION] 7. [MEDICAL CONDITION] 8. Urinary tract infection growing Escherichia coli which shows sensitivity to current antibiotic regimen... Plan: ...If patient does not show improvement in the next couple of days, family may elect to consider withdrawal of care..." A hospital progress note, dated [DATE], documented, "...Patient continue to be intubated and sedated. She opens her eyes but not following commands... Assessment/Plan: 1. Acute on [MEDICAL CONDITION] on [MEDICAL TREATMENT]. Likely ATN [MEDICAL CONDITION]. Cr more or less stable compared to yesterday. We had long discussion with the patients daughter. I explained her (sic) the there are few signs to suggest her renal function may be recovering, but we are not sure how long it takes to improve back to her baseline. Her daughter doesn't want her life to be prolonged, if no significant improvement quality of life accepted, So we decided to hold off [MEDICAL TREATMENT]/extubate her and the family will decide on further care based on how she does off ventilator... 2. [MEDICAL CONDITION]: Likely ecoli UTI. She is on [MEDICATION NAME] 3...Metabolic acidosis...resolved... 4. [MEDICAL CONDITION]: Plan to extubate today... Family is planning (question) hospice..." A hospital discharge summary, dated [DATE], documented, "...Send back on oxygen at 2 liters/minute to keep sats (greater than) 92 (percent)... Problem List: Acute on [MEDICAL CONDITION] (acute) Acute [MEDICAL CONDITION] (acute) Altered mental status (acute)... [MEDICAL CONDITION] (acute) Metabolic acidosis (acute) Pneumonia (acute) [MEDICAL CONDITION] (acute) Sepsis (acute) UTI (lower urinary tract infection) (acute) Acute [MEDICAL CONDITION] (Resolved)... Arrangements: Hospice Care..." A nurse's note, dated [DATE], documented, "Resident arrived back from (named hospital) via (named EMS)..." A nurse's note, dated [DATE], documented, "Resident in bed c eyes open, unresponsive to speech/touch. Respirations even/unlabored..." On [DATE] at 4:05 p.m., the resident was observed to lay in her bed with her eyes open. A hospice aide was observed to cover the resident with her blanket. The hospice aide was observed to speak to the resident. The resident did not respond. She made no movements physically and was nonverbal. The resident's breathing had periods of apnea. A nurse's note, dated [DATE], documented, "Resident beginning to mottle and periods of apnea...spoke c (named family member)" A nurse's note, dated [DATE], documented, "...Called into resident's room by hospice staff...Resident had (no) apical pulse was not breathing (no) b/p noted...notified (named physician #2)...Spoke c (named family member)." A physician's orders [REDACTED]. A nurse's note, dated [DATE], documented, "Late entry for [DATE]...notified PCP regarding residents earlier statements about being upstairs at (named facility), vs/wnl for resident, afebrile is oriented to person and place. Communicated to PCP residents thoughts of having a UTI completed ABT therapy in April per chart review. No new orders (at) this time." On [DATE] at 8:00 a.m., a facility communication log was reviewed for [DATE]. There was no documentation which stated the physician/family or interested party was contacted in regards to the resident's decreased level of consciousness and signs and symptoms of a urinary tract infection. On [DATE] at 8:55 a.m., LPN #1 was asked how often she cared for the resident. She stated, "Most of the time I've been here I've worked on north so I've cared for her most of the time." She was then asked why a late entry was written in the resident's chart for [DATE]. She stated, "I was told you wanted to talk to me so I went back over everything I had written." She was asked which physician she contacted on the morning of [DATE]. She stated, "Talked to (named physician #1)." She was then asked if she notified the physician of the resident's signs and symptoms of a UTI. She stated she spoke with the physician and informed him all the resident's vital signs were normal and the resident was afebrile. She stated no new orders were given. At 9:06 a.m., LPN #2 was asked how often she was assigned to care for the resident. She stated, "Monday through Friday typically." She was then asked if she was familiar with the resident's baseline. She stated, "Yes. She has intermittent confusion. Has since I worked here." She further stated, "In the past when she has UTIs she gets more confused." She was asked if the resident exhibited increased confusion when she assumed her care on [DATE]. She stated, "Yes. She was asking for babies. Normally not this confused." On [DATE] at 9:40 a.m., physician #1 was asked when he was first notified the resident had increased confusion and signs and symptoms of a urinary tract infection. He stated, "She's (named physician #2) patient. I know her pretty well. Haven't care for her at all." He was then asked if he was on call for physician #2 on [DATE] or [DATE]. He stated, "No." He further stated the facility texts from time to time if they need something. He stated, "I don't normally get called for (named physician #2) patients." He stated, "I can't remember if they called or text." He further stated, "There's no way staff would have called me and I would not have addressed this. I would have ordered a UA with C and S. I think going from [DATE]nd to [DATE]th is too long. (named resident) was chronically ill and could not tolerate much." At 10:05 a.m., physician #2 was asked when he was first informed of the resident's increased confusion and signs and symptoms of a urinary tract infection. He stated, "I don't remember." He was then asked if he felt the resident's urinary tract infection could have contributed to her outcome. He stated, "Of course it could have contributed to it. You can become septic very easily from a UTI." On [DATE] at 11:25 a.m., LPN #1 was asked how she determined in the past the resident was showing signs of a urinary tract infection. She stated, "I can remember one instance she was talking about her dog and her dog wasn't here. As far as her thinking she was upstairs. She commented on that a lot." She was then asked what were some signs and symptoms of a urinary tract infection. She stated, "Fever, burning, smell, pain upon urination, color, clarity." She was asked what action she would take if she noticed any of these signs or symptoms. She stated, "If I notice this I call doctor and ask for UA to be obtained with culture." On [DATE] at 12:10 p.m., the MDS coordinator was asked what the resident's level of consciousness was when she last assessed her. She stated, "She answered questions appropriately. She was awake and alert. Nothing stood out cognitive wise." She further stated, "Every time I saw and talked to her she answered my questions appropriately. Saw her at least once a week." At 12:18 p.m., LPN #2 was asked what was the resident's usual cognitive status. She stated, "Intermittent confusion. She had dementia. Wasn't really bad. She would forget time of day or if she ate dinner." She was then asked if she cared for the resident when she had symptoms of a urinary tract infection in the past. She stated, "With her she would become lethargic. She rarely ran a temp with UTI." On [DATE] at 12:19 p.m., CNA #1 was asked how often she was assigned to take care of the resident. She stated, "Monday through Friday. Every day I worked." She was then asked what was the resident's usual cognitive status. She stated, "She was very alert. Knew what she wanted when she wanted it. I've been here three years. I think this was only the second time I noticed her to have increased confusion." At 12:22 p.m., CMA #1 was asked how often she was assigned to care for the resident. She stated, "Monday through Friday I took care of (named resident)." She was then asked what was the resident's usual cognitive status. She stated, "She was rarely confused. She could tell me what pills she took every day. She always wanted to take big pills first."

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the failure of the facility to provide immediate cardio [MEDICAL CONDITION] resuscitation (CPR) to resident #1, whose family had requested her be on full code status, and failure to notify the physician for orders in response to a finger stick blood sugar of 34. The staff waited until an AMBU bag (bag valve mask) was located to initiate rescue breathing, due to the emergency cart not containing an AMBU bag. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 10:43 a.m., the Administrator and the Director of Nursing were notified of the IJ situation. At 11:45 a.m., an acceptable plan of removal was presented to the survey team. The Plan of removal documented: "1. Nurses will be inserviced on Management of Symptomatic [DIAGNOSES REDACTED] per facility policy by 2 p.m. on [DATE]. Inservice will include administration of an oral form of rapidly absorbed glucose for lethargic an non-lethargic residents and rechecking of blood glucose. 2. Nursing staff will be inserviced on Emergency Cardiopulmonary Resuscitation to include, rescue breathing per facility policy by 2 p.m. on [DATE]. 3. The Nurses were inserviced on [DATE] in regards to the maintenance of the Emergency Cart and contents. Facility will continue to maintain an Ambu bag on the North Crash Cart and the South Crash Cart. In addition, the facility will place Ambu bags at the North Nurse Station, Center Nurse Station, and South Nurses Station. The ,[DATE] Shift Nurse will continue to check the Crash carts in their assigned area for compliance of contents. 4. Nurses will be inserviced on checking of additional Ambu bag in each Nurses Station by 2 p.m. on [DATE]. 5. Nursing staff will be inserviced on location of additional Ambu bags by 2 p.m. on [DATE]." On [DATE] at 1:45 p.m., thru 2:10 p.m., nursing staff from all shifts who attended the inservices were interviewed. They were knowledgeable in regard to management of symptomatic [DIAGNOSES REDACTED]. All staff were knowledgeable of emergency cardiopulmonary resuscitation. All staff were knowledgeable of management of emergency carts. All staff were knowledgeable of locations of ambu bags. At 2:10 p.m., the Immediate Jeopardy was removed after the staff had been in-serviced and ambu bags were located in all identified locations. The deficient practice remained at an isolated level of actual harm. Based on interview, record review and review of facility policy and procedure, it was determined the facility failed to: ~ ensure rescue breathing was started in a timely manner for one (#1) of two sampled residents who experienced a cardiopulmonary arrest. This had the potential to affect 35 residents identified as full codes by the facility; and ~ promptly notify the physician of a low glucose reading for one (#1) of five sampled diabetic residents. This had the potential to affect 18 diabetic residents identified by the facility. Findings: A facility policy, titled Nursing Care of the Resident with Diabetes Mellitus documented, "...Management of [DIAGNOSES REDACTED]... 4. For symptomatic and unresponsive residents with [DIAGNOSES REDACTED] (<70 mg/dl or less than the physician-ordered parameter): a. immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME], per facility protocol and notify the physician for further orders; b. if resident remains unresponsive, call 911 (in accordance with resident's advance directives)..." A facility policy, titled Emergency Procedure - Cardiopulmonary Resuscitation documented, "... Policy Interpretation and Implementation... Symptoms 3. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. Training in BLS (basic life support) includes recognizing the atypical presentation of SCA (sudden [MEDICAL CONDITION])... Preparation for Cardiopulmonary Resuscitation... Equipment and Supplies 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times... Emergency Procedure - Cardiopulmonary Resuscitation... Compression-Ventilation Ratio 7. Trained rescuers should also provide ventilations with compression-ventilation ratio of 30:2..." Resident # 1 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident was understood, understood others, and she was independent in cognitive skills for daily decision making. She required extensive assistance from staff with bed mobility, transfers, locomotion on and off the unit, dressing, hygiene and bathing. She was occasionally incontinent of bladder and always continent of bowel. A care plan, dated [DATE], documented, "Focus: (named resident) has dx of Diabetes Mellitus... Goal: (named resident will have no complications related to diabetes through the review date... Interventions:...Monitor/document/report to MD PRN for s/sx of [DIAGNOSES REDACTED]: Sweating, Tremor, Increased heart rate ([MEDICAL CONDITION], Pallor, Nervousness, Confusion, Increased heart rate, slurred speech, lack of coordination, staggering gait..." A telephone order, dated [DATE] documented, "...Send to (named hospital) ER for eval and tx [DIAGNOSES REDACTED] A nurse's note, dated [DATE] at 3:50 p.m., documented,"This nurse was asked by RA to go to res room per daughter request daughter stated to RA she was clammy" A nurse's note, dated [DATE] at 3:53 p.m., documented, "FSBS 34 res in recliner daughter stated that she felt clammy just before she told RA to get me and that res was was talking but was not acting like herself. Res was nonresponsive I summoned for CNA & I asked daughter to tell staff to call 911. I cont to monitor res approx 2 mins res had a [MEDICAL CONDITION] but continued to breath pulse had to palpate & was thready res stopped breathing CNA, this nurse & daughter transferred res to floor. I told daughter there was no pulse & asked if she was a DNR she stated yes I asked if she wanted me to start CPR daughter stated 'yes' I asked 2 more times to make sure that she wanted to revoke DNR. She said yes I want you to do CPR I'm not ready for her to go. This nurse started chest compressions & told CNA to get ambu bag now." A nurse's note, dated [DATE] at 4:05 p.m., documented, "This nurse cont CPR until relieved by ADON at this time I took daughter in hallway daughter stated, 'your doing all you can & I thank you' I then made copies of face sheet drs orders prepared transfer sheet/bedhold policy." A nurse's note, dated [DATE] at 4:15 p.m., documented, "React arrived..." An EMS patient care report, dated [DATE], documented, "...times... recvd: 16:10 (4:10 p.m.)... dispatch: 16:11 (4:11 p.m.)... At patient 16:19 (4:19 p.m.)..." A hospital EDM (emergency department) Summary, dated [DATE], documented, "...Discharge Disposition: Expired Clinical Impression [MEDICAL CONDITION]" On [DATE] at 8:05 a.m., CNA #1 was asked to describe the events of the CPR event on [DATE]. She stated, I was on the North hall to put weights in the patients charts. The daughter of the resident told me her mom was in her room clammy and sweaty and she thought her blood sugar was low. I ran and got the LPN and she went to the room. When I got to the room the resident was on the floor and the LPN was over her with her hands on her chest area. She yelled for me to get the crash cart. I ran to the crash cart on the North hall and (named CMA #1) was at the cart already and said there was no ambu bag. I ran down to the South hall to the other crash cart. I pulled the plastic off and grabbed the ambu bag and headed back to the room. (Named LPN #2) was in the hall about half way to the resident's room and I gave her the ambu bag. She started to go to the room and fell so (named CMA#1) took it on to the room. She was then asked how long she felt it took to get the ambu bag. She stated, "I would have to guess, I was going as fast as I could. I would think it took one to two minutes but it seemed like it took a long time." On [DATE] at 8:20 a.m., PT staff #1 was asked to describe what she observed when she entered the resident's room during the CPR. She stated, "The charge nurse (named LPN #1) was working on (named resident) doing CPR." She was then asked what she was doing. She stated, "Chest compressions, I don't think she was doing mouth to mouth." She was then asked if anyone else was in the room. She stated, "Several people, I was very upset and don't remember who." She was then asked if she observed any rescue breathing. She stated, "I didn't see any breathing mouth to mouth, they were gone to get the ambu bag. I know (named DON) came in at some point." At 8:35 a.m., LPN #2 was asked what she observed when she got to the room. She stated, they were doing CPR, chest compressions and rescue breathing. EMT came in right after I got in the room. She was then asked how long it had taken to get the ambu bag from the far end of the building on the other hall. She stated, "I'm not sure how long it took to get it from the time I heard (named LPN #1) yell, but (named CMA #1) was running and it took about 90 seconds after I fell ." At 8:50 a.m., PT staff #2 was asked if she observed any of the CPR. She stated, yes. She was asked what she observed. She stated, "They had her on the floor doing CPR. She was then asked who was doing CPR. She stated the charge nurse. She was then asked was she doing chest compressions or rescue breathing. She stated, "There was no ambu bag, they had sent for it." She then stated, I'm not 100% sure about what was happening. I am positive someone was doing chest compressions but not the rescue breathing. I offered to help and they said they were ok. On [DATE] at 9:15 a.m., the DON was interviewed and asked about what happened during the CPR. She stated, I heard down the hall her blood sugar was low and then I heard we needed to call 911. I then called 911 and went down to the room and they were asking for an ambu bag. When I walked in (named ADON) was doing chest compressions. They were gone to the South hall to get an ambu bag. The room was full so I came out into the hall. Once the ambu bag got there they started the rescue breathing. She was then asked how long it took to get the ambu bag. She stated, "I was on the phone for awhile with 911. It was a new dispatcher and there was a delay." On [DATE] at 9:40 a.m., LPN #1 was interviewed and asked how long it took to get the ambu bag. She stated, "Five minutes or longer." She was then asked if any rescue breathing was performed prior to the ambu bag arriving. She stated, "No rescue breathing until I got the ambu bag." She then stated, I did not have a pocket shield so I waited for the ambu bag." LPN#1 was asked what interventions she did for the low blood sugar. She stated, I did not feel it was safe to give oral [MEDICATION NAME]. Shortly after I got the finger stick she had a [MEDICAL CONDITION] and was unresponsive. She was then asked who was in the room during the CPR. She stated, "Me, (named ADON), (named therapy #1 and therapy #2)." At 9:50 a.m., the ADON was interviewed and asked about her observations during the CPR. She stated, When I went into the room they were doing chest compressions on her but no rescue breathing. I took over chest compressions and they got an ambu bag. she was then asked how long it took to get the ambu bag. She stated, "I'd say about five minutes." She was then asked about the low blood sugar. She stated, "I wasn't aware until after of the low finger stick." At 10:15 CMA #1 was asked what she observed during the CPR. She stated, I was there at the very end. I took the ambu bag in. She was then asked how long it took to get the ambu bag. She stated, "I took about one or two minutes to get the bag." On [DATE] at 2:45 p.m., the DON was asked for a copy of physician #1's standing [DIAGNOSES REDACTED] orders. She stated, "I will go get them." At 3:00 p.m., the DON gave the surveyor a copy of physician #2's sliding scale insulin orders and stated, "We use (named physician #2) sliding scale orders." Physicians #2's standing sliding scale orders documented, "...<60 call (physician #2)..." On [DATE] at 12:30 p.m., a family member of the resident present at the time of the CPR was interviewed and asked about the time frame for the facility to get the ambu bag and for the ambulance to arrive. She stated, I know it was at least 20 minutes for the ambu bag. I know the nurse told the aide to call 911 and she went to tell the DON. When the DON came down to the room she told me it would take 15 minutes for them to get to the facility.

Based on observation, record review and interviews, it was determined the facility failed to have an effective quality assurance program in place to identify problems and implement plans of action to correct deficient practice. The facility failed to identify and implement a plan of action to correct system failures related to recurring falls for five (#1, 3, 11, 12 and #13) of ten sampled residents who had falls. This resulted in actual harm to residents #1, 3, and #12, who had recurring falls with injuries. The DON identified 28 residents that had falls from 07/01/12 through 10/12/12. This had the potential to affect 77 of 77 residents residing in the facility. Findings: "Quality Assessment and Assurance Committee" documented, "...The facility shall establish and maintain a Quality Assessment and Assurance Committee that oversees the identification and handling of quality issues...The primary goals...to monitor and evaluate the appropriateness and quality of care provided within the framework of the quality assessment and Assurance plan...oversee facility systems and processes related to improving quality of care...to help identify negative outcomes relative to resident care...help identify negative outcomes relative to resident care and resolve them appropriately...The committee has the full authority to oversee the implementation of the quality assessment and Assurance Program including...identifying negative and positive outcomes of care and services...establishing quality indicators and identifying pertinent standards practice...committee actions...oversee the development, and implementation of actions to correct quality concerns..." "Quality Assessment and Assurance Plan" documented, "...The primary purpose of the Quality Assessment and Assurance Plan...to provide a means to identify and resolve present and potential negative outcomes related to resident care and safety...to provide a structure and process to correct identified quality deficiencies..." "QA Committee-Role of the Quality Assessment and Assurance Coordinator" documented, "...Duties and responsibilities to the Quality Assessment and Assurance include...assisting, as needed, to develop plans of action to correct identified deficiencies..." 1. The facility failed to identify a problem on the North and Central halls with regard to falls. The facility failed to implement a system that would address all residents who had falls as well as staffing issues on the halls at the time of the falls. The facility also failed to identify residents' care plans for falls were not being followed and implemented. This resulted in actual harm. Refer to F-323 and F-353. An interview was conducted with the Administrator and RN #1 on 10/08/12 at 12:15 p.m. to discuss the facility's QA program. The Administrator stated falls had been identified as a problem in August 2012. When asked what interventions were implemented to address falls and how to prevent them, RN #1 (the former DON) stated they started the Falling Star Program as a means for staff to be able to identify residents who were a high fall risk. She stated they were also tracking and trending falls monthly, but were not tracking if the falls were occurring on a particular hall, shift, day of the week, etc. On 10/11/12 at 8:50 a.m., an interview was conducted with the DON regarding QA. She was asked to describe a quality problem recently identified by the facility QA committee. She stated they identified a problem with falls in August. She stated the interventions they put into place were to start the falling star program after identifying which residents were at risk for falls. She was asked to describe the falling star program. She stated it identified who was at risk for falls and a star would be placed outside the resident's room door. She was asked how staff found out about the falling star program and what the program entailed. She stated an inservice training was provided on 08/15/12, and the program was explained. She stated the part of the falling star program that was not being followed was documentation on the visual check sheets kept in the residents' rooms. The DON was asked if the committee was tracking when the resident falls were occurring, what shift, time of the day and where the falls occurred. She stated she didn't think they were tracking and trending that data yet. An interview was conducted on 10/10/12 at 2:50 p.m., with the DON, care plan/MDS coordinator and RN #1 (the former DON) regarding the residents falls. They were asked what system was put in place to address residents with recurring falls with injuries. RN #1 stated, "I took over the incident reports in May and noticed there was a problem." She then stated a fall program had been implemented to address residents that had five falls in a month. She was asked about residents that did not fit that criteria. She stated the residents were not on the fall program unless they had five falls in one month. On 10/11/12 at 9:15 a.m., an interview was conducted with the MDS coordinator regarding QA. She was asked if she was part of the committee. She stated, "Yes." She was asked if she could describe a problem the committee had recently identified, what interventions had been implemented and if the interventions had been effective. She stated falls had been identified as a problem in August. She stated she and another nurse completed fall risk assessments on each resident in the facility, to see if their risk assessments were current. She stated all the residents with frequent falls were placed on the falling star program, with stars placed outside their doors and on their wheelchairs to identify the resident as a fall risk. She stated all staff were inserviced on the falling star program. On 10/11/12 at 10:10 a.m., CMA #1 was interviewed regarding how to access the QA committee. The CMA stated she didn't know what "QA" meant. The surveyor explained to the CMA the committee was a group of facility employees who identified problems within the facility, implemented interventions to address the problems and reevaluated the effectiveness of the interventions to see if the problem had been corrected. She stated if she saw a problem, she would take it to her charge nurse. The CMA was asked if she knew what was on the residents' care plans, she stated she did not. She was asked if the facility had provided any inservice training regarding resident falls. She stated there had been training on falls, about "two months ago" but she was unable to recall what the program was called. She stated they were told what the stars placed outside the residents' doors and on their wheelchairs meant. At 10:25 a.m., an interview was conducted with a housekeeping employee regarding the QA committee, what it's function was and how to access the committee. She stated she didn't know what the QA committee was or how to access it. She was asked if the facility had provided staff with training on resident falls. She stated an inservice on falls was recently given. She was asked what the staff had been told about resident falls. She stated they (staff) were told if they see a resident on the floor, to go get someone. She stated she would take any problems she identified to (Name withheld-SS Director). At 10:40 a.m., an interview was conducted with CNA #2 regarding the QA committee, what it's function was and how to access the committee. She stated she didn't know what the QA committee was or how to access it. She was asked how she would report any problems she identified and who would she report to. She stated she would take any problem related to resident rights to the SS Director. She stated if the problem was related to a resident such as falls, she would take the problem to the charge nurse. She was asked if the facility provided staff with training regarding resident falls. She stated they (staff) had recently been given inservice training related to falls, she couldn't remember when it was given, but the staff was told about the falling star program and what it meant. An interview was conducted on 10/12/12 at 11:40 a.m., with RN #1, the former DON, regarding falls. She was asked to clarify when she took over the fall program. She stated she took over incident reports in April and addressed a problem related to falls as a QA problem in August. She then stated that was when the fall program was implemented. She was asked if the fall program included frequent falls of one or two a month for several months with injuries. She stated, "No. It needs to be improved. It only is for those resident's that had four or five falls in one month." She was asked if she trended falls from dates prior to April when she took over the incident reports. She stated, "I did not trend back, I didn't think of that." She was asked if the interventions had been evaluated for each resident with falls and changes made. She stated, "No, they all seem to be the same." She was asked if the care plans for the resident's had been followed for fall interventions. She stated, "Not if the interventions aren't being done." She was asked if the facility trended falls for staffing issues and interventions not being implemented. She stated, "No, they are going to start that." She was asked how effective the falls program was as implemented through the QA process. She stated, "Not very, I didn't think to do all that."

Based on observation, record review and interview, it was determined the facility failed to ensure there was sufficient staff on the North and Central hall to prevent recurring falls that resulted in several of the residents sustaining injuries, for five (#1, 3, 11, 12 and #13 ) of five sampled residents on the North and Central hall. This deficient practice resulted in actual harm to residents #1, 3 and #12. The DON identified a potential of 39 residents who could have resided in rooms 33 through 49 and 111 through 119 on the North/Central hall. Findings: "Staffing" policy, documented, "Our facility provides adequate staffing to meet needed care and services for our resident population...Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met..." The facility day (7:00 a.m. to 3:00 p.m.) and evening shift (3:00 p.m. to 11:00 p.m.) has staff assigned on each of the halls, North, Central and South. On the night shift (11:00 p.m. to 7:00 a.m.) staff are assigned to the North/Central and South/Central hall. The North/Central hall consisted of rooms 33 through 49 and 111 through 119. 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan dated 10/03/11, documented, "Focus: (Resident) has a history of falls prior to admission. She has a fall risk assessment score of 13. She has the potential for further falls. Continues to be impulsive and doesn't ask for assist.... Goals: No injury from falls. Ensure safety during fall... Interventions: Ensure call light within reach...environment is free of clutter...have commonly used articles within easy reach...reinforce need to call for assistance...resident to wear proper and non slip footwear...transfer and change position slowly..." Hand written notes under focus documented, "10/30/11 fall, , 10/30/11 fall, refusing therapy @ this time. 12-5-11 transferring to recliner & lost footing 0 injuries, 12-22-11 fall in room, 0 injuries cont /c therapy, 12-27-11- fall bruise to forehead blanket removed slide out of chair, 12-28-11- reaching for something in floor and fell out of WC, 1-7-11- fall- unassisted transfer doesn't use call light for assist, 1-21-12- fall- laceration to backhead (sic) Started one hour checks... 1-17-12- discussed /c (Resident) the potential for falls /c injury. Possibly using personal alarm she refused..." Undated hand written notes under interventions documented, "Therapy as ordered...med changes/reviews...instruct to use call light for assist...instruct to use reacher for items out of reach...UA ABT therapy 12-12-11...removed blanket...reinforce to use call light and reacher...Q hours checks...encourage use of reacher if items are on the floor." An incident report dated 10/30/11, documented, "Time of incident 1405 p.m. (2:05 p.m.)...what happened: res observed sitting on floor in bathroom. States she fell trying to transfer self to wc from toilet...steps taken to prevent recurrence: inst to ask for assist..." A second incident report dated 10/30/11, documented, " Time of incident 4:05 p.m...what happened: upon entering res room noted res sitting on buttocks on floor in front of recliner. Res stated I tried to transfer from recliner to w/c & fell ...type of injury (R) shoulder pain...steps taken to prevent recurrence encourage res to use call light when needing assistance /c transfers." A pain evaluation completed at the time of the fall documented the resident had pain at a level of three on a scale of one to ten, ten being the worst pain. A "Skilled Daily Nurses Note" dated 10/30/11 at 10:00 a.m., documented, "Visited and discussed recent falls and what happened. Reported weakness and no strength. Interventions discussed; need for call light usage, educated on importance of assistance and ill affects, possibility breaking a hip or other fractures. Voices understanding..." A review of the "Nursing Department Schedule as Worked" for 10/30/11, for the evening shift (3:00 p.m. to 11:00 p.m.) documented two certified nurse aides were working on the central hall at the time of the fall. There was no charge nurse or certified medication aide assigned to the central hall on the evening shift. An incident report dated 12/22/11 at 6:15 a.m., documented, "Resident stated she leaned forward in w/c to pick up item on floor & fell forward striking head on recliner arm cushion 0 injury...steps taken to prevent recurrence: all interventions in place PT continues to work /c res, has grabber in room- meds (changed) pt request for therapy." A pain evaluation completed at the time of the fall documented the resident had pain at a level of six on a scale of one to ten, ten being the worst. A review of the "Nursing Department Schedule as Worked" for 12/21/11, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two certified nurse aides were working on the North/Central hall at the time of the fall on 12/22/11. The staff was responsible for rooms 33 through 49 and 111 through 119, for a potential of 39 residents. An incident report dated 12/28/11 at 7:00 a.m., documented, "CNA (Name deleted) answered res call light & observed her in the floor. Res was in wheel chair reaching for something on the floor when she fell ...type of injury: bumped forehead ...steps taken to prevent recurrence: Instructed res to use grabber to p/u objects on floor or use call light for staff assistance..." An incident report dated 12/28/11 at 11:30 p.m., documented, "Resident stated I was trying to get up & slid out. Blanket in chair. Res said the blanket caused her to slide out...type of injury: bruise to forehead...steps to prevent recurrence: removed blanket..." A pain evaluation completed at the time of the fall documented the resident had pain at a level of seven on a scale of one to ten, ten being the worst. A review of the "Nursing Department Schedule as Worked" for 12/28/11, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two certified nurse aides were working on the North/Central hall at the time of the fall on 12/28/11. The staff was responsible for rooms 33 through 49 and 111 through 119, for a potential of 39 residents. An incident report dated 01/07/12 at 6:45 a.m., documented, "Nurse was informed by CNA...she found resident in the floor lying down and she helped her up to the wheelchair. Nurse found resident sitting down on her wheelchair...(right side) part of head that according to resident is tender to touch....steps taken to prevent recurrence: advise to use call light for assistance especially after she takes her pain meds in the morning-refuses to use call light..." A pain evaluation completed at the time of the fall documented the resident had pain at a level of eight on a scale of one to ten, ten being the worst. A review of the "Nursing Department Schedule as Worked" for 01/06/12, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two certified nurse aides were working on the North/Central hall at the time of the fall on 01/07/12. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, for a potential of 39 residents. An incident report dated 01/19/12 at 8:00 a.m., documented, "Res sitting on her bottom in front of her door stated I was reaching for my door knob...steps to prevent recurrence: waiting on C & S results, check res more frequently q 1 hour (checks)." There was no documentation the facility completed the hourly checks of the resident as written on the incident report and care plan dated 10/03/11. A review of the "Nursing Department Schedule as Worked" for 01/19/12, for the day shift (7:00 a.m. through 3:00 p.m.) documented one charge nurse and two certified nurse aides were working on the Central hall at the time of the fall on 01/19/12. An incident report dated 01/21/12 at 3:00 a.m., documented, "Resident sitting on the floor by her wheelchair /c her forehead bleeding up to the top of the head. Nurse cleaned the residents forehead and top of head to find where injury site, after resident was helped by 2 nurses and 2 aids to her recliner lift chair. Nurse noted injury was to forehead below hair line the size & shape of fingernail tip. Cleaned & cold compress applied. c/o the injury site is tender to touch. Also c/o pain to the back of neck where touched....hot compress applied to and pain meds given. Back of neck hurts when she moves her head.... type of injury: laceration gash, swelling slightly...steps to prevent recurrence: advised to sleep in her recliner/lift chair or better in bed. Advise to use call light for help. x-ray 1/23/12..." A pain evaluation completed at the time of the fall documented the resident had pain at a level of eight on a scale of one to ten, ten being the worst, when the neck had been moved. It also documented the resident had pain at a level of six when touching the right side of her face. A review of the "Nursing Department Schedule as Worked" for 01/20/12, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two certified nurse aides were working on the North/Central hall at the time of the fall on 01/21/12. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, for a potential of 39 residents. A "Skilled Daily Nurses Note" dated 01/22/12 at 2:50 p.m., documented, "...reminded res she needs help with transfers..." A "Computerized Tomography Report" dated 01/23/12, documented, "CT imaging of the cervical spine...history: injury, fall... readings: There is a fracture through the base of the odontoid extending bilaterally into the upper portion of C 2 about 2 to 3 mm separates the major fragments. There is a [MEDICAL CONDITION] arch of C 1... Impression: C 2 and C 1 fractures as described..." A final report dated 01/24/12, documented, "...Findings: Fractures of the C 1 ring anteriorly, with 3 mm of separation, and posteriorly on both sides. Type II odontoid fracture with 25 degree posterior angulation of the odontoid process relative to the C 2 body...mild prevertebral soft swelling anterior to C 1-C 2... impression: Anterior and bilateral posterior C 1 ring fractures...fracture through base of the odontoid process with 25 degree posterior angulation of the odontoid relative to the C 2 base." A "CT Head wo Infusion" dated 01/26/12, documented, "...findings:...Anterior C 1 ring fracture is redemonstrated...impression...Anterior C 1 ring fracture is redemonstrated..." A discharge summary dated 01/27/12, documented, "...discharge diagnose...cervical spine C 1 vertebral fracture, closed..." The resident resided in room [ROOM NUMBER] located on the central hall through her hospital stay for the fractured neck. Upon return from the hospital the resident was moved to room [ROOM NUMBER] where she currently resides. A significant change assessment dated [DATE], documented the resident was able to understand others, could be understood by others, had adequate vision, hearing, disorganized thinking and had moderately impaired cognitive skills for daily decision making. The assessment also documented the resident required extensive assistance with transfers, toilet use, personal hygiene and bathing. The resident had impairment to both sides on the upper extremities and one side on the lower extremities and required assistance to stabilize self while moving from a seated to standing position, on and off the toilet and surface to surface transfers. The "Care Area Assessment (CAA) Summary" dated 02/01/12, documented falls had triggered and would be care planned due to CAA triggers, balance, and history of falls." An incident report dated 03/30/12 at 3:30 a.m., documented, "...property involved: personal recliner- sit to stand chair...what happened: resident stated she put chair (arrow up) to adjust self & slid from chair to floor... level of consciousness: alert, oriented, speech slurred...steps to prevent recurrence: remind res to call for assist for repositioning..." A review of the "Nursing Department Schedule as Worked" for 03/29/12, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two certified nurse aides were working on the North/Central hall at the time of the fall on 03/30/12. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, for a potential of 39 residents. An incident report dated 06/01/12 at 2:45 p.m., documented, "Resident was sitting in her recliner when she reached for something in the floor and fell out of chair. Resident very disoriented and argumentive (sic). Res states the sheet in her chair slipped and that's why she fell . Sheet was tucked into chair tight... level of consciousness: AAO X 3, very groggy...steps to prevent recurrence: Resident to use call light when needing assistance. Staff informed to do frequent checks. Medications decreased..." A pain evaluation completed at the time of the fall documented the resident had pain at a level of six on a scale of one to ten, ten being the worst. It also documented the resident was not administered pain medications. A review of the "Nursing Department Schedule as Worked" for 06/01/12, for the day shift ( 7:00 a.m. a.m. to 3:00 p.m.) documented one charge nurse and two certified nurse aides were working on the North hall at the time of the fall, for the potential of 33 residents. An incident report dated 06/17/12 at 1:35 a.m., documented, "Resident was sleeping in her recliner/lift chair but noted by CNA (name deleted) on the floor. Nurse asked resident what happened and resident told nurse that she was trying to reach her water jug that she put on the floor beside her lift chair and got outbalance (sic) and fell to the floor. C/O hurting her upper (R) rib... steps to prevent recurrence: x-ray of rt ribs, maintenance to eval recliner for proper balance & proper functioning..." A "Final X-Ray Report" dated 06/17/12, documented, "Exam reason: pain from fall; exam type portable RT ribs...impression: No acute displaced fracture or dislocation of right ribs..." A review of the "Nursing Department Schedule as Worked" for 06/16/12, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and one certified nurse aide were working on the North/Central hall at the time of the fall on 06/16/12. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, for a potential of 39 residents. A quarterly assessment dated [DATE], documented the resident required a two person extensive assistance with bed mobility, transfers, toilet use, personal hygiene and bathing. The resident also had an active [DIAGNOSES REDACTED]. The assessment also documented the resident had one fall without injury since the last assessment or discharge. A care plan last updated 07/24/12, documented, Focus: "(Resident) uses call light continuously. Staff assist her /c her needs and will turn call light on again as soon as staff leave room...States she is unable to sleep R/T pain...upon observation of staff during rounds she is asleep in recliner and is easily aroused. 7-24-12 - 0 change... Goal: To ensure safety for resident... Focus: (Resident) presents with short term memory loss. 4-3-12 ST to eval & tx. 7-24-12 - 0 change... Goal: display appropriate response to situation... Interventions...observe and report changes in cognitive status...provide cueing & prompting to ensure resident makes attempts at own care before offering assistance, provide reality orientation..." Focus: "(Resident) has a history of falls. 3-30-12 slid out of her lift chair. 6-1-12 fell out of recliner. 7-24-12 - 0 further falls. Goals: will have decreased number of falls... Interventions: ensure call light within reach...environment is free of clutter, have commonly used articles within easy reach, reinforce need to call for assistance, resident to wear proper and non slip footwear, transfer and change positions slowly..." An incident report dated 07/30/12 at 10:10 p.m., documented, "Res leaning over while in w/c looking in laundry hamper began sliding out & brakes on w/c were not locked. Observed lying on (R) side in bathroom... steps to prevent recurrence: educated resident on importance of locking w/c...encouraged res to ask for assistance..." A pain evaluation completed at the time of the fall documented the resident had pain at a level of seven on a scale of one to ten, ten being the worst. There was no documentation to indicate pain medication was provided in response the resident's pain. An incident report dated 08/02/12 at 8:00 p.m., documented, "Res stated she was trying to reach something off bedside table & slide from w/c to floor. Sheet folded between w/c of cushion...type of injury: 2 cm X .3 cm s/t... steps to prevent recurrence: remind res, not to stretch for things that are not in easy reach- therapy to assist /c reach thing..." A pain evaluation completed at the time of the fall documented the resident had pain at a level of eight on a scale of one to ten, ten being the worst. There was no documentation to indicate pain medication was provided in response to the resident's pain. A review of the "Nursing Department Schedule as Worked" for 08/02/12, for the evening shift (3:00 p.m. to 11:00 p.m.) documented one certified medication aide and three certified nurse aides were working on the North hall at the time of the fall. No charge nurse was working in the facility at the time of the incident. The North hall consisted of rooms 40 through 49 and 111 through 119, for a potential of 33 residents. An incident report dated 10/07/12 at 10:30 a.m., documented, "Resident appeared to have fallen out of w/c to floor...I was called to room [ROOM NUMBER] A by CNA...on floor face down on (L) arm (R) leg twisted beside her sm skin tear above (L) eyebrow res states (R) knee hurt and hip... type of injury: laceration, (R) knee warm to touch...steps to prevent recurrence: asked to not lean forward to call for help & use reacher sent to ER..." A nurse's note dated 10/07/12 at 10:30 a.m., documented, "CNA (name deleted) came to me and stated (Resident) was on the floor. CNA stated she was just in the room [ROOM NUMBER] min prior...and res was going through her drawers fidgeting /c her things stated she did not want to lay down @ this time...CNA left room and instructed res to press call light if she needed anything...aprox 20 min later CNA (name deleted) walked by after hearing help me, found res on floor on stomach face down...I came in assessed res tried to roll on to side res screamed in pain..." A nurse's note at 6:00 p.m., documented, "Res returned from ER /c...two steri strips to eyebrow...instructed next time to please call us to help her verbalized understanding..." A care plan last updated 10/07/12, documented, "07/30/12 - slid out of w/c...10-7-12 - fall from w/c ST (L) eyebrow, pain to (R) knee sent to ER..." The following interventions were hand written and undated on the care plan: educate of call light for assist, frequent (checks), educated on importance of locking brakes on w/c and to ask for assist." A physician's telephone order dated 10/08/12, documented "Xray (B) hips, necks & (R) knee c/o pain/fall." Thee was no documentation the facility was completing the frequent checks as written on the resident's care plan. The resident had fourteen falls from 10/30/11 through 10/07/12, seven of the falls resulted in the following injuries: hematoma to the forehead X 2; fractured C 1 and C 2 (neck); bruising to the ribs; skin tears; laceration to the eye; and one additional injury to the right side of the head. There was no documentation the facility assessed the resident's falls and implemented different interventions to aide in the prevention of falls. During the initial tour of the facility on 10/08/12 from 9:40 a.m. through 11:00 a.m., LPN #3 indicated resident #1 was a risk for falls and had a fracture as a result of the falls. She also indicated the resident was able to be interviewed and had a grabber to assist with picking items up. The nurse stated the resident had an ADL decline and had deficits in range of motion, which included an above the knee amputation. The nurse was asked how the resident got around the facility. She indicated the resident required staff assistance with propelling her wheel chair. The resident was observed in her room in her wheel chair. The call light was located approximately three feet away on the back of her recliner. The resident was not able to easily access the call light. The grabber was visible in the room. The resident had steri-strips over the left eyebrow. The nurse indicated it was from a fall over the weekend. On 10/09/12 at 9:30 a.m., the resident's room was observed. The resident's grabber was located on the floor at the head of the bed. The resident's recliner sits at a 45 degree angle and the resident did not have access to the grabber. At 2:20 p.m., the resident was observed in her room in the wheel chair. The resident's grabber continued to be on the floor at the head of the bed. The grabber was not accessible to the resident. An interview was conducted on 10/10/12 at 1:25 p.m., with the resident. She was asked about her falls. The resident was located in her wheel chair at the foot of her bed. The call light was at the head of her bed and the grabber remained on the floor. The resident was asked if she had any falls. She stated, "I have had a lot of falls." She was asked how often staff come and check on her. She stated, Two hours, sometimes longer." She then added, "I see the therapist in the room two doors down more then other staff." An interview was conducted on 10/10/12 at 1:55 p.m., with CNA #3. She was asked how she knew what care the resident needed. She stated, "You find the information on the care plan." 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Facility "SKILLED DAILY NURSES NOTES, and corresponding Incident Reports, documented the following: 11/02/11 at 10:45 p.m., "Res sitting in BR floor in front of toilet on her buttocks, bruise R inner thigh small scratch. A corresponding incident report documented steps to prevent recurrence as: "Instruct res to ask for help when going to BR or any transfers." A review of the "Nursing Department Schedule as Worked" for 11/02/12, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two CNAs were working on the North/Central hall at the time of the fall on 11/02/11. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, with a potential of 39 residents. 11/26/11 at 7:30 p.m., "Noted res sitting on floor on buttock in closet in room stated 'I fell forward out of w/c as I was looking for some clothes." A corresponding incident report documented steps to prevent recurrence as: "Encourage res to use call light when needing assistance." A review of the "Nursing Department Schedule as Worked" for 11/26/11, for the evening shift (3:00 p.m. to 11:00 p.m.) documented one charge nurse, one CMA and three CNAs were working on the North hall at the time of the fall on 11/26/11. The North hall consisted of rooms 40 through 49 and 111 through 119, with a potential of 33 residents. 11/27/11 at 11:15 p.m., "Resident attempted to go to toilet s/ assistance, and fell forward out of chair onto knees hitting her face on toilet seat. Lacerations noted between eyes w/ swelling and deviation of nose noted." A corresponding incident report documented steps to prevent recurrence as: "w/c removed from bedside to remind resident to use call light for assistance." A review of the "Nursing Department Schedule as Worked" for 11/27/11, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two CNAs were working on the North/Central hall at the time of the fall on 11/27/11. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, with a potential of 39 residents. 12/14/11 at 8:20 p.m.,"This nurse called to res room, res lying face 1st into shower...stated I stood (arrow up) to get a dress and lost my balance." A corresponding incident report documented steps to prevent recurrence as: "Res instructed to ask for help." A review of the "Nursing Department Schedule as Worked" for 12/14/11, for the evening shift (3:00 p.m. to 11:00 p.m.) documented one charge nurse, one CMA and two CNAs were working on the North hall at the time of the fall on 12/14/11. The North hall consisted of rooms 40 through 49 and 111 through 119, with a potential of 33 residents. 03/27/12 at 12:00 a.m., "this nurse called to res room observed res lying on floor in bathroom in front of toilet on back c head in shower stall, had trash can under her L arm & pants at ankles." A corresponding incident report documented steps to prevent recurrence as: "Instructed to ask for help (res is working with therapy for strengthening and endurance)." A review of the "Nursing Department Schedule as Worked" for 03/27/12 for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two CNAs were working on the North/Central hall at the time of the fall on 03/27/12. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, with a potential of 39 residents. 03/30/12 at 1:45 p.m., "Res had an assisted fall she was lowered to the floor by therapy while attempting to transfer from the toilet seat to the wheelchair." 03/30/12 at 4:30 p.m., "res called nurse into room, res had pinhole opening L inner ankle-upon touch, res cried out in pain." A corresponding incident report documented steps to prevent recurrence as: "(X-ray of L ankle done Resid (resident) sent to ER at (local hospital) & transferred to (second local hospital) on 3/31/12, ORIF done.)" 04/12/12, un-timed late entry, "At 6:35 a.m., resident called out from her room ...resident lay in the floor on her right side in front of her wheelchair." A corresponding incident report documented steps to prevent recurrence as: "-cushion removed from w/c PT assessed for positioning new w/c and new cushion were given." A review of the "Nursing Department Schedule as Worked" for 04/12/12, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two CNAs were working on the North/Central hall at the time of the fall on 04/12/12. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, with a potential of 39 residents. 04/22/12 at 8:45 p.m., "Attempted to transfer self from wheelchair to the toilet, While doing this she received two skin tears on her R calf..." A corresponding incident report documented steps to prevent recurrence as: "reminded resident to use call light and wait for assistance. ... " A review of the "Nursing Department Schedule as Worked" for 04/22/12, for the evening shift (3:00 p.m. to 11:00 p.m.) documented one charge nurse one CMA and two CNAs were working on the North hall at the time of the fall on 04/22/12. The North hall consisted of rooms 40 through 49 and 111 through 119, with a potential of 33 residents. 06/06/12 at 2:30 a.m., "Res found sitting on BR floor with boot on L foot and R foot w no socks on. A corresponding incident report documented steps to prevent recurrence as: "toilet Q 2 hr, tab alarm @ times request. staff in-serviced on toileting when res. arise in am." A review of the "Nursing Department Schedule as Worked" for 06/06/12, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse one and two CNAs were working on the North/Central hall at the time of the fall on 06/06/12. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, with a potential of 39 residents. 08/24/12 at 8:00 p.m., "Res in bathroom floor in room after being being put on toilet by CNAs, res state's she sat there forever!" A review of the "Nursing Department Schedule as Worked" for 08/24/12, for the evening shift (3:00 p.m. to 11:00 p.m.) documented one LPN for all halls, one CMA and one CNA working on the South hall at the time of the fall. The south hall consisted of rooms 1 through 10, with a potential of 22 residents. A corresponding incident report documented steps to prevent recurrence as: "educate resident of use of call light and to wait for staff assistance." 08/25/12 at 8:15 p.m., "Res observed sitting in front of w/c in the floor of her room leaning against her dresser. A corresponding incident report documented steps to prevent recurrence as: "Reiterated pt teaching regarding call light use, room changed, put on fall program Q 1 hr ck." A care plan last updated 08/25/12, documented; "Problem (Resident) is at risk for falls due to weakness and psychoactive medications. She has a history of falls over the past six months. Goals; (Resident) will have no injury due to fall or other accident through next review. Approach; ...place call light within reach and answer promptly. review; reinforce use of call light and assist." 09/07/12 at 2:30 p.m., "took herself to bathroom /c out waiting for staff and tore skin on R arm." The clinical record did not contain an incident report for the injury. The clinical record contained six facility forms titled "Hourly Observations" dated 08/27/12, 09/08/12, 09/09/12, 09/30/12, 10/06/12 and 10/07/12. The record did not contain any additional "Hourly Observation" forms for 08/26/12, 08/28/12 through 09/07/12, 09/10/12 through 09/29/12 and 10/01/12 through 10/05/12. A quarterly assessment dated [DATE], documented the resident was cognitively intact, required extensive assistance to stabilize during transfers, dressing, hygiene, toileting and was unable to transfer on/off the toilet without assistance. There was no documentation in the clinical record or on the care plan to indicate the facility assessed the resident's falls and implemented different interventions to aide in the prevention of falls. On 10/10/12 at 9:40 a.m., CNA #1 was interviewed and asked if the resident was known to be on every one hour monitoring, she stated, "No, she puts on her call light when she needs assistance with toileting. She was then asked if the resident had a toileting checklist on her bathroom door. She stated, no (resident #3) did not, but identified two other residents who did have the checklist in their rooms. At 9:42 a.m., CMA #1 was asked if the resident was considered to be a fall risk. She stated, "She is considered a fall risk but I don't know if she's on a fall program. At 10:00 a.m., LPN #1 was asked if the resident required assistance with her toileting needs. She stated the resident required one person assistance with all of their ADLs and toileting needs. When asked if the resident was considered a fall risk she stated, "No, the resident has had a lot of falls while on the north hall by none since transferring to the south hall. She is not on a fall program." At 10:15 a.m., an interview was conducted with RN #1 and the DON. They were asked if resident #3, had been placed on the fall program. RN #1, stated the resident is at risk for falls and is on the fall program. She further stated when a resident is placed on the program, in addition to every hour rounding, they have a star placed on their door, on their wheelchairs and a toileting check list is placed in the resident bathrooms. At 10:20 a.m., surveyors observed the resident's room for signs of the falling star program. The bathroom door did not contain a toileting checklist for the documentation of every two hours toileting. On 10/11/12 at 10:45 am., an interview was conducted with resident #3. When asked if the staff answered her call light promptly, she stated, "Usually, but once in a while when they are short staffed, it takes longer." She was then asked if she usually waited for the staff to assist her, she stated, "I try to but some

Based on observation, record review and interviews, it was determined the facility failed to ensure residents who had recurring falls with injuries were provided with adequate supervision to prevent falls, were assessed and had interventions in place to aid in the prevention of falls for five (#1, 3, 11, 12 and #13) of ten sampled residents who had falls. This deficient practice resulted in actual harm to residents #1, #3 and #12. The DON identified 28 residents who had sustained falls from 07/01/12 through 10/12/12. Findings: The "Falls-Clinical Protocol" documented, "...staff will evaluate and document falls that occur while the individual is in the facility...falls should be categorized as: those that occur while trying to rise...upright and attempting to ambulate and other circumstances such as sliding out of a chair or rolling from a low bed to the floor...staff will try various relevant interventions, based on assessment of the nature or category of falling...if the individual continues to fall , the staff and physician will re-evaluate situation and continued relevance of current interventions..." The "Fall Risk Assessment" policy documented, "The nursing staff in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify...risk factors for falls...the staff will seek to identify environmental factors that may contribute to falling...address modifiable fall risk factors and interventions to try to minimize the consequences..." The "Falls and Fall Risk, Managing" policy documented, "...if falling recurs despite initial interventions staff will implement additional or different interventions, or indicate why the current approach remains relevant...if resident continue to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions..." 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan dated 10/03/11, documented, "Focus: (Resident) has a history of falls prior to admission. She has a fall risk assessment score of 13. She has the potential for further falls. Continues to be impulsive and doesn't ask for assist.... Goals: No injury from falls. Ensure safety during fall... Interventions: Ensure call light within reach...environment is free of clutter...have commonly used articles within easy reach...reinforce need to call for assistance...resident to wear proper and non slip footwear...transfer and change position slowly..." Hand written notes under focus documented, "10/30/11 fall, , 10/30/11 fall, refusing therapy @ this time. 12-5-11 transferring to recliner & lost footing 0 injuries, 12-22-11 fall in room, 0 injuries cont /c therapy, 12-27-11- fall bruise to forehead blanket removed slide out of chair, 12-28-11- reaching for something in floor and fell out of WC, 1-7-11- fall- unassisted transfer doesn't use call light for assist, 1-21-12- fall- laceration to backhead (sic) Started one hour checks... 1-17-12- discussed /c (Resident) the potential for falls /c injury. Possibly using personal alarm she refused..." Undated hand written notes under interventions documented, "Therapy as ordered...med changes/reviews...instruct to use call light for assist...instruct to use reacher for items out of reach...UA ABT therapy 12-12-11...removed blanket...reinforce to use call light and reacher...Q hours checks...encourage use of reacher if items are on the floor." An incident report dated 10/30/11, documented, "Time of incident 1405 p.m. (2:05 p.m.)...what happened: res observed sitting on floor in bathroom. States she fell trying to transfer self to wc from toilet...steps taken to prevent recurrence: inst to ask for assist..." A second incident report dated 10/30/11, documented, " Time of incident 4:05 p.m...what happened: upon entering res room noted res sitting on buttocks on floor in front of recliner. Res stated I tried to transfer from recliner to w/c & fell ...type of injury (R) shoulder pain...steps taken to prevent recurrence encourage res to use call light when needing assistance /c transfers." A pain evaluation completed at the time of the fall documented the resident had pain at a level of three on a scale of one to ten, ten being the worst pain. A "Skilled Daily Nurses Note" dated 10/30/11 at 10:00 a.m., documented, "Visited and discussed recent falls and what happened. Reported weakness and no strength. Interventions discussed; need for call light usage, educated on importance of assistance and ill affects, possibility breaking a hip or other fractures. Voices understanding..." There was no documentation in the clinical record or on the care plan to indicate the facility assessed the resident's fall and implemented different interventions to aide in the prevention of falls. A review of the "Nursing Department Schedule as Worked" for 10/30/11, for the evening shift (3:00 p.m. to 11:00 p.m.) documented two certified nurse aides were working on the central hall at the time of the fall. There was no charge nurse or certified medication aide assigned to the central hall on the evening shift. An incident report dated 12/22/11 at 6:15 a.m., documented, "Resident stated she leaned forward in w/c to pick up item on floor & fell forward striking head on recliner arm cushion 0 injury...steps taken to prevent recurrence: all interventions in place PT continues to work /c res, has grabber in room- meds (changed) pt request for therapy." A pain evaluation completed at the time of the fall documented the resident had pain at a level of six on a scale of one to ten, ten being the worst. A review of the "Nursing Department Schedule as Worked" for 12/21/11, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two certified nurse aides were working on the North/Central hall at the time of the fall on 12/22/11. The staff was responsible for rooms 33 through 49 and 111 through 119, for a potential of 39 residents. An incident report dated 12/28/11 at 7:00 a.m., documented, "CNA (Name deleted) answered res call light & observed her in the floor. Res was in wheel chair reaching for something on the floor when she fell ...type of injury: bumped forehead ...steps taken to prevent recurrence: Instructed res to use grabber to p/u objects on floor or use call light for staff assistance..." An incident report dated 12/28/11 at 11:30 p.m., documented, "Resident stated I was trying to get up & slid out. Blanket in chair. Res said the blanket caused her to slide out...type of injury: bruise to forehead...steps to prevent recurrence: removed blanket..." A pain evaluation completed at the time of the fall documented the resident had pain at a level of seven on a scale of one to ten, ten being the worst. A review of the "Nursing Department Schedule as Worked" for 12/27/11, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two certified nurse aides were working on the North/Central hall at the time of the fall on 12/28/11. The staff was responsible for rooms 33 through 49 and 111 through 119, for a potential of 39 residents. An incident report dated 01/07/12 at 6:45 a.m., documented, "Nurse was informed by CNA...she found resident in the floor lying down and she helped her up to the wheelchair. Nurse found resident sitting down on her wheelchair...(right side) part of head that according to resident is tender to touch....steps taken to prevent recurrence: advise to use call light for assistance especially after she takes her pain meds in the morning-refuses to use call light..." A pain evaluation completed at the time of the fall documented the resident had pain at a level of eight on a scale of one to ten, ten being the worst. A "Skilled Daily Nurses Note" dated 01/07/12 at 11:55 a.m., documented, "...Fall on 1-7-12. cont to not use call light for assist, participates /c therapy when she chooses...cont to encourage participation /c therapy and to use call light for assist..." A review of the "Nursing Department Schedule as Worked" for 01/06/12, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two certified nurse aides were working on the North/Central hall at the time of the fall on 01/07/12. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, for a potential of 39 residents. A "Skilled Daily Nurses Note" dated 01/17/12 at 11:00 a.m., documented, "Meeting held to discuss upcoming discard (sic) from therapy and progress made...Falls and unsafe transfers to bathroom or recliner. Refuses to ask for assistance /c transfers...resident voiced understanding of all areas discussed..." An incident report dated 01/19/12 at 8:00 a.m., documented, "Res sitting on her bottom in front of her door stated I was reaching for my door knob...steps to prevent recurrence: waiting on C & S results, check res more frequently q 1 hour (checks)." There was no documentation the facility completed the hourly checks of the resident as written on the incident report and care plan dated 10/03/11. A review of the "Nursing Department Schedule as Worked" for 01/19/12, for the day shift (7:00 a.m. through 3:00 p.m.) documented one charge nurse and two certified nurse aides were working on the Central hall at the time of the fall on 01/19/12. An incident report dated 01/21/12 at 3:00 a.m., documented, "Resident sitting on the floor by her wheelchair /c her forehead bleeding up to the top of the head. Nurse cleaned the residents forehead and top of head to find where injury site, after resident was helped by 2 nurses and 2 aids to her recliner lift chair. Nurse noted injury was to forehead below hair line the size & shape of fingernail tip. Cleaned & cold compress applied. c/o the injury site is tender to touch. Also c/o pain to the back of neck where touched....hot compress applied to and pain meds given. Back of neck hurts when she moves her head.... type of injury: laceration gash, swelling slightly...steps to prevent recurrence: advised to sleep in her recliner/lift chair or better in bed. Advise to use call light for help. x-ray 1/23/12..." A pain evaluation completed at the time of the fall documented the resident had pain at a level of eight on a scale of one to ten, ten being the worst, when the neck had been moved. It also documented the resident had pain at a level of six when touching the right side of her face. A review of the "Nursing Department Schedule as Worked" for 01/20/12, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two certified nurse aides were working on the North/Central hall at the time of the fall on 01/21/12. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, for a potential of 39 residents. A "Skilled Daily Nurses Note" dated 01/22/12 at 2:50 p.m., documented, "...reminded res she needs help with transfers..." A "Computerized Tomography Report" dated 01/23/12, documented, "CT imaging of the cervical spine...history: injury, fall... readings: There is a fracture through the base of the odontoid extending bilaterally into the upper portion of C 2 about 2 to 3 mm separates the major fragments. There is a fracture of the anterior arch of C 1... Impression: C 2 and C 1 fractures as described..." A final report dated 01/24/12, documented, "...Findings: Fractures of the C 1 ring anteriorly, with 3 mm of separation, and posteriorly on both sides. Type II odontoid fracture with 25 degree posterior angulation of the odontoid process relative to the C 2 body...mild prevertebral soft swelling anterior to C 1-C 2... impression: Anterior and bilateral posterior C 1 ring fractures...fracture through base of the odontoid process with 25 degree posterior angulation of the odontoid relative to the C 2 base." A "CT Head wo Infusion" dated 01/26/12, documented, "...findings:...Anterior C 1 ring fracture is redemonstrated...impression...Anterior C 1 ring fracture is redemonstrated..." A discharge summary dated 01/27/12, documented, "...discharge diagnose...cervical spine C 1 vertebral fracture, closed..." A significant change assessment dated [DATE], documented the resident was able to understand others, could be understood by others, had adequate vision, hearing, disorganized thinking and had moderately impaired cognitive skills for daily decision making. The assessment also documented the resident required extensive assistance with transfers, toilet use, personal hygiene and bathing. The resident had impairment to both sides on the upper extremities and one side on the lower extremities and required assistance to stabilize self while moving from a seated to standing position, on and off the toilet and surface to surface transfers. The "Care Area Assessment (CAA) Summary" dated 02/01/12, documented falls had triggered and would be care planned due to CAA triggers, balance, and history of falls." A "Fall Risk Evaluation" dated 03/29/12, documented the resident was a high risk for falls with a score of 12. A score of ten or greater indicated the resident was a high risk for falls. An incident report dated 03/30/12 at 3:30 a.m., documented, "...property involved: personal recliner- sit to stand chair...what happened: resident stated she put chair (arrow up) to adjust self & slid from chair to floor... level of consciousness: alert, oriented, speech slurred...steps to prevent recurrence: remind res to call for assist for repositioning..." A review of the "Nursing Department Schedule as Worked" for 03/29/12, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two certified nurse aides were working on the North/Central hall at the time of the fall on 03/30/12. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, for a potential of 39 residents. There was no documentation to indicate the facility assessed the resident's fall's and implemented changes to interventions to aide in the prevention of further falls. A "Fall Risk Evaluation" dated 05/27/12, documented the resident was a high risk for falls with a score of 12. A score of ten or greater indicated the resident was a high risk for falls. An incident report dated 06/01/12 at 2:45 p.m., documented, "Resident was sitting in her recliner when she reached for something in the floor and fell out of chair. Resident very disoriented and argumentive (sic). Res states the sheet in her chair slipped and that's why she fell . Sheet was tucked into chair tight... level of consciousness: AAO X 3, very groggy...steps to prevent recurrence: Resident to use call light when needing assistance. Staff informed to do frequent checks. Medications decreased..." A pain evaluation completed at the time of the fall documented the resident had pain at a level of six on a scale of one to ten, ten being the worst. It also documented the resident was not administered pain medications. A review of the "Nursing Department Schedule as Worked" for 06/01/12, for the day shift ( 7:00 a.m. a.m. to 3:00 p.m.) documented one charge nurse and two certified nurse aides were working on the North hall at the time of the fall, for the potential of 33 residents. An incident report dated 06/17/12 at 1:35 a.m., documented, "Resident was sleeping in her recliner/lift chair but noted by CNA (name deleted) on the floor. Nurse asked resident what happened and resident told nurse that she was trying to reach her water jug that she put on the floor beside her lift chair and got outbalance (sic) and fell to the floor. C/O hurting her upper (R) rib... steps to prevent recurrence: x-ray of rt ribs, maintenance to eval recliner for proper balance & proper functioning..." A "Final X-Ray Report" dated 06/17/12, documented, "Exam reason: pain from fall; exam type portable RT ribs...impression: No acute displaced fracture or dislocation of right ribs..." A review of the "Nursing Department Schedule as Worked" for 06/16/12, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and one certified nurse aide were working on the North/Central hall at the time of the fall on 06/16/12. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, for a potential of 39 residents. A "Fall Risk Evaluation" dated 07/20/12, documented the resident was a high risk for falls with a score of 19. A score of ten or greater indicated the resident was a high risk for falls. A quarterly assessment dated [DATE], documented the resident required a two person extensive assistance with bed mobility, transfers, toilet use, personal hygiene and bathing. The resident also had an active [DIAGNOSES REDACTED]. The assessment also documented the resident had one fall without injury since the last assessment or discharge. A care plan last updated 07/24/12, documented, Focus: "(Resident) uses call light continuously. Staff assist her /c her needs and will turn call light on again as soon as staff leave room...States she is unable to sleep R/T pain...upon observation of staff during rounds she is asleep in recliner and is easily aroused. 7-24-12 - 0 change... Goal: To ensure safety for resident... Focus: (Resident) presents with short term memory loss. 4-3-12 ST to eval & tx. 7-24-12 - 0 change... Goal: display appropriate response to situation... Interventions...observe and report changes in cognitive status...provide cueing & prompting to ensure resident makes attempts at own care before offering assistance, provide reality orientation..." Focus: "(Resident) has a history of falls. 3-30-12 slid out of her lift chair. 6-1-12 fell out of recliner. 7-24-12 - 0 further falls. Goals: will have decreased number of falls... Interventions: ensure call light within reach...environment is free of clutter, have commonly used articles within easy reach, reinforce need to call for assistance, resident to wear proper and non slip footwear, transfer and change positions slowly..." The residents care plan had not been updated with new interventions since being implemented on 02/02/12. The resident had three falls since the care plan had been written. An incident report dated 07/30/12 at 10:10 p.m., documented, "Res leaning over while in w/c looking in laundry hamper began sliding out & brakes on w/c were not locked. Observed lying on (R) side in bathroom... steps to prevent recurrence: educated resident on importance of locking w/c...encouraged res to ask for assistance..." A pain evaluation completed at the time of the fall documented the resident had pain at a level of seven on a scale of one to ten, ten being the worst. There was no documentation to indicate pain medication was provided in response the resident's pain. An incident report dated 08/02/12 at 8:00 p.m., documented, "Res stated she was trying to reach something off bedside table & slide from w/c to floor. Sheet folded between w/c of cushion...type of injury: 2 cm X .3 cm s/t... steps to prevent recurrence: remind res, not to stretch for things that are not in easy reach- therapy to assist /c reach thing..." A pain evaluation completed at the time of the fall documented the resident had pain at a level of eight on a scale of one to ten, ten being the worst. There was no documentation to indicate pain medication was provided in response to the resident's pain. A "Fall Risk Evaluation" dated 08/15/12, documented the resident was a high risk for falls with a score of 19. A score of ten or greater indicated the resident was a high risk for falls. An incident report dated 10/07/12 at 10:30 a.m., documented, "Resident appeared to have fallen out of w/c to floor...I was called to room 48 A by CNA...on floor face down on (L) arm (R) leg twisted beside her sm skin tear above (L) eyebrow res states (R) knee hurt and hip... type of injury: laceration, (R) knee warm to touch...steps to prevent recurrence: asked to not lean forward to call for help & use reacher sent to ER..." A nurse's note dated 10/07/12 at 10:30 a.m., documented, "CNA (name deleted) came to me and stated (Resident) was on the floor. CNA stated she was just in the room 20 min prior...and res was going through her drawers fidgeting /c her things stated she did not want to lay down @ this time...CNA left room and instructed res to press call light if she needed anything...aprox 20 min later CNA (name deleted) walked by after hearing help me, found res on floor on stomach face down...I came in assessed res tried to roll on to side res screamed in pain..." A nurse's note at 6:00 p.m., documented, "Res returned from ER /c...two steri strips to eyebrow...instructed next time to please call us to help her verbalized understanding..." A care plan last updated 10/07/12, documented, "07/30/12 - slid out of w/c...10-7-12 - fall from w/c ST (L) eyebrow, pain to (R) knee sent to ER..." The following interventions were hand written and undated on the care plan: educate of call light for assist, frequent (checks), educated on importance of locking brakes on w/c and to ask for assist." "The Golden Rule Fall Tracking Log" for the resident documented each of the resident's fourteen falls sustained from 10/30/11 through 10/07/12. The form listed all the same interventions as on the care plan and the incident reports. A physician's telephone order dated 10/08/12, documented "Xray (B) hips, necks & (R) knee c/o pain/fall." There was no documentation the facility was completing the frequent checks as written on the resident's care plan. The "Sign in sheet for Call Light Response" had the following dated entries: 04/23/12, 04/24/12, 04/25/12, 04/26/12, 04/27/12, 04/28/12, 04/29/12, 04/30/12, 05/04/12, 05/05/12, 05/06/12, 05/07/12, 05/08/12, 05/09/12, 05/10/12, 05/11/12, 05/12/12, 05/13/12, 05/14/12, 05/15/12, 05/16/12, 05/17/12, 05/17/12, 05/18/12, 05/19/12 and 05/20/12. The documented times on the sign in sheet ranged from twenty minutes to over four hours. The sign in sheet had no documentation to indicate the resident had been checked on every hour as indicated on the resident's care plan. There was no additional documentation to indicate the resident had hourly checks as implemented on the care plan dated 10/03/11. The resident had fourteen falls from 10/30/11 through 10/07/12, seven of the falls resulted in the following injuries: hematoma to the forehead X 2; fractured C 1 and C 2 (neck); bruising to the ribs; skin tears; laceration to the eye; and one additional injury to the right side of the head. There was no documentation the facility assessed the resident's falls and implemented different interventions to aide in the prevention of falls. During the initial tour of the facility on 10/08/12 from 9:40 a.m. through 11:00 a.m., LPN #3 indicated resident #1 was a risk for falls and had a fracture as a result of the falls. She also indicated the resident was able to be interviewed and had a grabber to assist with picking items up. The nurse stated the resident had an ADL decline and had deficits in range of motion, which included an above the knee amputation. The nurse was asked how the resident got around the facility. She indicated the resident required staff assistance with propelling her wheel chair. The resident was observed in her room in her wheel chair. The call light was located approximately three feet away on the back of her recliner. The resident was not able to easily access the call light. The grabber was visible in the room. The resident had steri-strips over the left eyebrow. The nurse indicated it was from a fall over the weekend. On 10/09/12 at 9:30 a.m., the resident's room was observed. The resident's grabber was located on the floor at the head of the bed. The resident's recliner sits at a 45 degree angle and the resident did not have access to the grabber. At 2:20 p.m., the resident was observed in her room in the wheel chair. The resident's grabber continued to be on the floor at the head of the bed. The grabber was not accessible to the resident. An interview was conducted on 10/10/12 at 1:25 p.m., with the resident. She was asked about her falls. The resident was located in her wheel chair at the foot of her bed. The call light was at the head of her bed and the grabber remained on the floor unaccessible to the resident. The resident was asked if she had had any falls. She stated, "I have had a lot of falls." She was asked how often staff checked on her. She stated, "Two hours, sometimes longer." She then added, "I see the therapist in the room two doors down more then other staff." She was asked if she had a grabber to assist with picking items up from the floor. She stated, "Yes, it's next to my recliner." The grabber was once again observed at the head of the bed. The grabber was in the same location since the initial observation on 10/09/12. An interview was conducted on 10/10/12 at 1:55 p.m., with CNA #3. She was asked if the resident was a risk for falls. She stated, "No, she is not a risk for falls." She was asked how long she had been employed at the facility. She stated, "End of July." She was asked how many falls the resident had since her employment started. She stated, "The resident had one fall over the weekend." She was asked how often the resident was to be checked. She stated, 'Every two hours." She was asked if the resident was checked on more frequently such as hourly. She stated, "Fall risk residents have one hour checks, but she isn't a fall risk. We don't have to check on her as often." She was asked how she knew what care the resident needed. She stated, "You find the information on the care plan." An interview was conducted on 10/10/12 at 2:07 p.m., with CMA #2. She was asked if the resident used her call light to ask for assistance. She stated, "She has no problems using her call light." She was asked how often the resident is to be checked on to ensure her safety. She stated, "Every two hours." She was asked if the resident was checked more frequently such as every hour. She stated, "Ones that are an extreme fall risk is checked more frequently. (Resident) is checked every two hours she is not every one hour." She was asked if the resident was a fall risk. She stated, "To an extent, she has fallen." An interview was conducted on 10/10/12 at 2:18 p.m., with CNA #4. She was asked if the resident was a risk for falls. She stated, 'Yes the resident is a risk for falls." She was asked how often the resident had to be checked on. She stated, "She is checked on every two hours." She was asked if the resident had to be checked on more frequently then every two hours. She stated, "She is a two hour check, she doesn't need to be checked hourly." She was asked if the resident had a number of falls. She stated, "She had a lot of falls and hurt her head the last time." She was asked how she knew what the resident's needs were. She stated, "The care plan tells how the resident is to be cared for." An interview was conducted on 10/10/12 at 2:25 p.m., with LPN #3. She was asked if the resident was a fall risk. She stated, "Yes, she is a fall risk." She was asked if the resident had a grabber. She stated, "She had a gabber, but don't know if she still has it." She was asked how often the resident was checked on. She stated, "Every two hours." She was asked if the resident was checked on every hour as indicated in the care plan. She stated, "No, she is not checked on every hour." She was asked where staff were able to locate information on how to care for the resident. She stated, "Care plan indicates the needs and care of the resident." An interview was conducted on 10/10/12 at 2:50 p.m., with the DON, care plan/MDS coordinator and RN #1 regarding the resident's falls. They were asked if the resident was a high risk for falls. The DON stated, "Yes she falls. She has had multiple recurring falls." RN #1 agreed with the DON. They were asked what interventions were put into place to prevent recurring falls with injuries. RN #1 stated, "The incident report has interventions on them that had been attempted." She was asked if the interventions were on the care plan. She stated, "They should be on the care plan." They were asked what frequent checks would be for a resident. RN #1 stated, "Every hour because everyone gets checked every two hours." The DON agreed with the RN. A request was made for documentation the facility implemented and followed the residents care plans for falls such as frequent hourly checks, and a grabber. No further documentation was provided. The DON stated, "Check every hour is for residents on the program, fall program." She was asked the criteria for being on the fall program. The DON stated a resident who had four or five falls in one month would be placed on the program. If they do not have four or five falls the next month the resident is taken off the fall program. The DON was asked if the resident's care plan interventions for falls was on the care plan and being followed. She stated, "If it's on the care plan it should be followed." An interview was conducted on 10/11/12 at 11:00 a.m., with the certified occupational therapist assistant regarding the resident's falls. She was asked how therapy assisted with the interventions for falls. She stated, "We attempted to educate the resident on using her grabber, call light and asking for assistance." She asked how effective the education was. She stated, "Not very effective due to her cognition being poor." 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Facility "SKILLED DAILY NURSES NOTES, and corresponding Incident Reports, documented the following: 11/02/11 at 10:45 p.m., "Res sitting in BR floor in front of toilet on her buttocks, bruise R inner thigh small scratch. A corresponding incident report documented steps to prevent recurrence as: "Instruct res to ask for help when going to BR or any transfers." A review of the "Nursing Department Schedule as Worked" for 11/02/11, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two certified nurse aides were working on the North/Central hall at the time of the fall on 11/02/11. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, with a potential of 39 residents. 11/26/11 at 7:30 p.m., "Noted res sitting on floor on buttock in closet in room stated 'I fell forward out of w/c as I was looking for some clothes." A corresponding incident report documented steps to prevent recurrence as: "Encourage res to use call light when needing assistance." 11/27/11 at 11:15 p.m., "Resident attempted to go to toilet s/ assistance, and fell forward out of chair onto knees hitting her face on toilet seat. Lacerations noted between eyes w/ swelling and deviation of nose noted." A corresponding incident report documented steps to prevent recurrence as: "w/c removed from bedside to remind resident to use call light for assistance." A review of the "Nursing Department Schedule as Worked" for 11/27/11, for the night shift (11:00 p.m. to 7:00 a.m.) documented one charge nurse and two certified nurse aides were working on the North/Central hall at the time of the fall on 11/27/11. The North/Central hall consisted of rooms 33 through 49 and 111 through 119, with a potential of 39 residents. 12/14/11 at 8:20 p.m.,"This nurse called to res room, res lying face 1st into shower...stated I stood (arrow up) to get a dress and lost my balance." A corresponding incident report documented steps to prevent recurrence as: "Res instructed to ask for help." A fall risk assessment dated [DATE], documented the resident was a high risk for falls AEB a fall risk score of 16. A score of ten or greater indicated the resident was a high risk. 03/27/12 at 12:00 a.m., "t