Every finding on record at The King's Daughters & Sons Nursing Home

Based on record review and interview, the facility failed to administer the 2024 influenza vaccine and the pneumococcal vaccine for 1 (#27) of 5 residents whose records were reviewed for immunizations. The facility's policy Influenza Vaccine, dated March 2022, and the facility's policy Pneumococcal Vaccine, dated October 2023, showed the date of the vaccine, lot number, expiration date, person administering, and the site of vaccination were documented in the resident's medical record. Resident #27's immunization record was missing their 2024 influenza and their pneumoccocal immunization. On 06/19/25 at 12:25 p.m., the infection preventionist stated there was no documentation of Resident #27 receiving their 2024 influenza or their pneumococcal immunization.

Based on observation, record review, and interview, the facility failed to ensure that the advanced and planned menu was available for review for 32 residents who received meals from the facility kitchen. A revised facility policy titled Menus dated October 2017, read in part, 2. Menus for regular and therapeutic diets are written at least two (2) weeks in advance, and are dated and posted in the kitchen at least one (1) week in advance.11. Copies of menus are posted in at least two (2) resident areas, in positions and in print large enough for residents to read them. On 06/17/25 at 11:39 a.m., it was observed no weekly menus were posted for resident to review. On 06/18/25 at 9:08 a.m., the dietary manager stated according to company policy the menu's were supposed to be posted in places throughout the building for residents to review. On 06/17/25 at 11:27 a.m., the dietary manger stated they did not have to post rotating schedules with the dates. On 06/18/25 at 9:04 a.m., Resident #1 stated, I have never seen menus posted.

On 02/01/24 an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who had fallen had interventions in place to prevent the recurrence of falls. The facility failed to monitor and evaluate the effectiveness of the interventions and modify the care plan with each fall. The facility failed to conduct a root cause analysis and/or evaluate the cause for each fall. The facility did not have a fall prevention program, nor have the staff received education regarding falls and fall prevention in the last 12 months. Res #36 had 26 falls from 05/17/23 to 01/27/24. Res #36 had 19 falls prior to sustaining a left hip fracture on 11/19/23 and six falls after sustaining the fracture. 13 of the 26 falls did not have updated interventions to help prevent future falls. On 02/01/24 at 4:52 p.m., the OSDH verified the existence of the IJ situation. On 02/01/24 at 5:00 p.m., the administrator was notified of the IJ situation. On 02/01/24 at 8:04 p.m., the facility submitted a plan of removal. On 02/02/24 at 10:10 a.m., the facility amended the plan of removal. On 02/02/24 at 10:18 a.m., the facility submitted an acceptable plan of removal to OSDH. The facility's plan of removal documented the following: King's Daughters and Sons Plan to remove Immediacy 1. Ad Hoc QAPI meeting regarding falls/interventions and care plans. Completed 1-31-24 2. Reviewed all residents and identified residents to implement the Falling Star Program. Completed 1-31-24 3. Placed stars on name tags and any assistive device they use for every resident identified for the Falling Star Program. Attached is a list of residents identified for the Falling Star Program. Completed 1-31-24 4. Reviewed January incident reports for fall interventions. Ensured they were appropriate, and care planned. Completed 1-31-24 5. Implemented fall communication book located at the nurse's station. Completed 1-31-24 6. Employees will be in-serviced either in person or via phone and for any staff unable to be reached they will not return to work until in-serviced. Completed 2-1-24 7. Daily fall meetings M-F to review previous days falls, interventions and update care plan. Will coordinate with weekend charge nurse to review incident reports, interventions and care plans. Implemented 2-1-24 and ongoing. 8. Continuation of monitoring. On 02/02/24 at 12:00 p.m., the immediacy was removed after the plan of removal was verified and facility met the requirements of their plan. The deficient practice remained at an isolated level at a potential for harm. Based on observation, record review, and interview, it was determined the facility failed to provide supervision to prevent accidents for one (#36) of three sampled residents reviewed for falls. Res #36 had 26 falls in 8 months with the 20th fall resulting in a fractured hip, 13 of the 26 falls did not have any new fall interventions in place to prevent future falls. The facility failed to: a) Thoroughly investigate falls to determine root causes of falls. b) Determine frequency of needed supervision to prevent falls. c) Modify/revise interventions as necessary to prevent falls. d) Monitor effectiveness of interventions to prevent falls. The administrator identified 31 residents who had fallen in the last 3 months. Findings: The facility fall policy Falls - Clinical Protocol, revised March 2018, read in part, .For an individual who has fallen, the staff ad practitioner will begin to try to identify possible causes within 24 hours of the fall .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .If underlying causes cannot be identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of or in addition to those that have already been identified) and also reconsider the current interventions . Res #36 had diagnoses which include left femoral neck fracture, dementia, urgency of urination, and anxiety. An incident report, dated 05/17/23 at 6:45 p.m., documented the resident had a fall in their room. An incident report, dated 05/17/23 at 9:15 p.m., documented the resident fell in their room. The resident was observed to have bruising to the left lateral forehead. The care plan, initiated on 05/17/23, documented the resident will be assisted by staff for all of their transfers, will be assisted/supervised by staff with all ambulation, and staff will attempt to anticipate the resident's needs. An incident report, dated 05/19/23 at 3:11 p.m., documented the resident fell from the wheelchair. A care plan, initiated on 05/19/23, did not document any new interventions to prevent falls. A care plan, initiated on 05/25/23, documented the resident had two falls on 05/17/23. The interventions were to assist the resident to bed when she was tired. The staff will check on the resident frequently throughout the day when in room, keep call light within reach, and assist with transfers. An incident report, dated 05/27/23 at 10:08 a.m., documented the resident fell from the wheelchair in the dining room. The intervention was to bring the resident to the nurse station for closer monitoring. The care plan documented a witnessed fall on 05/29/23 and the intervention was to check on the resident every two hours for toileting and changing positions, staff will monitor and assist with all transfers, and the resident will stay seated till staff can assist with care. An incident report, dated 06/22/23 at 5:30 a.m., documented an un-witnessed fall in the dining room. There were no new interventions documented. An incident report, dated 06/26/23 at 1:10 a.m., documented the resident fell in another resident's room. There were no new interventions documented to help prevent future falls. A care plan, initiated on 06/26/23, documented the resident would be placed in view of staff while in the lobby. An incident report, dated 07/07/23 at 1:15 a.m., documented the resident was found in their room on the floor next to the bed. There were no new interventions documented to prevent future falls. An incident report, dated 07/29/23 at 3:30 p.m., documented the resident's roommate called for help. The resident was found in the room on the floor beside the bed. The resident had a small scalp hematoma. No new interventions documented. An incident report, dated 07/30/23 at 12:00 a.m., documented the resident was in another resident's room on the floor with bruising to left side and lower back and buttocks noted. No new interventions documented. Incident reports, dated 07/31/23 at 3:06 a.m., was blank and the fall at 4:08 a.m., documented the resident was laying on their left side and stated they were using the restroom. A fall at 10:00 p.m., documented the resident was lying on the floor. A care plan, initiated on 07/31/23, documented the resident's bed would be in low position at all times. A fall mat will be place next to the bed, and toilet and meet all needs prior to assisting resident to bed. An incident report, dated 08/01/23 at 9:50 p.m., documented the resident was observed sitting on their buttocks in their room. A care plan initiated on 08/01/23, documented the staff will ambulate with resident when awake. An incident report, dated 08/03/23 at 5:52 p.m., documented staff observed resident standing up from wheelchair and fell to the floor. A care plan, initiated on 08/03/23, documented to give the resident something eat or drink prior to bed which was not a relevant intervention. A quarterly assessment, dated 08/25/23, documented the resident was severely cognitively impaired, required extensive assistance of one for transfers and supervision with assistance of one for ambulating. An incident report, dated 09/21/23 at 3:42 p.m., documented the resident was found on the floor in the bathroom. No new interventions were documented to prevent falls. An incident report, dated 09/22/23 at 12:15 a.m., documented resident was found on the floor between bed an closet. No new interventions were documented to help prevent falls. An incident report, dated 09/24/23 at 6:18 a.m., documented the resident was sitting in wheelchair at the nurse station, before staff could interviene, the wheel chair slipped out from under the resident and they fell back onto the floor. A care plan, initiated 09/24/23, documented staff will monitor the resident's where-abouts when up and ambulatory, which was not a relevant intervention. An incident report, dated 10/1/23 at 1:22 p.m., documented the resident stood up in the dining room and fell to the floor. The report documented the resident hit her right knee, hip, and head with a loud thump. The resident complained of right knee and hip pain. The resident sent to the hospital for evaluation. No new interventions were documented. An incident report, dated 11/19/23 at 6:15 p.m., documented the nurse was notified that the resident fell in their room. The resident was sitting upright on her buttocks. The resident complained of their hip hurting at a 2 on pain scale for the cognitively impaired. No new interventions were documented. Left hip x-ray was ordered. A nurse note, dated 11/19/23 at 10:00 p.m., called EMS to transport resident to the hospital for evaluation. A nurse note, dated 11/20/23 at 3:21 a.m., documented they called to check on the resident, found that the resident was admitted to the hospital for fractured left hip. Called sooner mobile to cancel x-ray. The hospital discharge instructions, dated 11/28/23, read in part, .Activity, ambulate with assist, maintain or improve current level of function, and maintain safe living environment . A significant change assessment, dated 12/11/23, documented the resident was severely impaired with cognition and was dependent with most ADLs. Res #36 was currently totally dependent for transfers with assistance of two and required extensive assistance of two for ambulating. The assessment documented the resident had two or more falls since prior assessment. The assessment documented one fall with a major injury that required surgery. An incident report, dated 01/03/24 at 3:30 p.m., documented the resident's room mate was yelling for help. The report documented the resident was found on the floor on her fall mat. The resident was assisted to bed and no injuries observed. A care plan, dated 01/03/24, documented the fall and the resident would be monitored for any verbal as well as non-verbal signs of pain or discomfort. An incident report, dated 01/05/24 at 3:33 p.m., documented the resident was sitting in the floor on the fall mat. The report documented the resident was confused and did not know what happened. A care plan, dated 01/05/24, documented the staff will assist the resident to the front when awake, the staff will set the resident where they can easily be monitored by staff when they are up. There were no new interventions to prevent reoccurrence of falls. An incident report, dated 01/08/24 at 11:25 p.m., the resident room mate yelled out for help. The incident report documented the resident was observed sitting in the floor on their buttocks. The resident was assisted to the wheel chair and taken to the nurse station. The incident report documented the resident was encouraged to refrain from ambulating self without assistance due to unsteady gait. The intervention was not appropriate for cognitively impaired resident. A care plan, dated 01/08/24, documented staff will not leave the resident in her wheelchair without staff present in the room. An incident report, dated 01/17/24 at 5:45 p.m., documented a visitor notified the nurse the resident was lying face down on the floor in the dining room. The incident report documented the resident had a bruise on the left cheek. The incident report documented the resident had been attempting to ambulate without assistance multiple times. A care plan, dated 01/17/24, documented the resident fell in the dining room and had bruising to the resident's cheek. The care plan did not documented new interventions to prevent falls. An incident report, dated 01/20/24 at 1:00 p.m., documented the resident was in the dining room in their wheelchair. The resident leaned forward to stand up and the chair slid out from under the resident. The resident landed on their bottom on the floor. The incident report documented no injury. The resident was assisted back to the wheelchair and taken up by the nurses station. A care plan, dated 01/20/24, documented the resident fell from the wheel chair in the dining room. The care plan documented the staff would monitor the resident and assist her with locking the wheelchair when seated. An incident report, dated 01/27/24 at 7:31 p.m., documented the resident was found face down on the floor beside the bed and had an incontinent episode. The resident complained of neck pain. EMS called and transported to the hospital. A care plan, dated 01/27/24, documented the resident fell in their room and had an incontinent episode. The care plan documented the resident would wear an adult brief to assist in preventing incontinent episodes resulting in a fall. On 01/31/24 at 10:00 a.m., at this time there was not any fall prevention posted in the resident's room. On 01/31/24 at 4:30 p.m., the administrator was asked if they had a fall prevention program and they stated not at this time. The administrator stated unless the staff was told in report there was no way for the staff to know which residents were at high fall risk. On 01/31/24 at 5:05 p.m., the administrator stated they would implement the falling star program today. On 02/01/24 at 10:40 a.m., the resident was observed in their wheelchair in front of the nurse station. The wheelchair was not in the locked position. On 02/01/24 at 10:42 a.m., LPN #1 stated they just initiated the toileting intervention last night. They stated they did not have previous documentation for toileting the resident. On 02/05/24 at 12:45 p.m., the MDS/care plan coordinator stated all of the resident interventions were not appropriate and some were not new for the resident on the care plan. They stated about 50% were appropriate interventions for the resident.

Based on observation, record review, and interview, the facility failed to have an effective administration to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident. The facility failed to ensure: a. to follow their abuse policy and ensure background checks were completed for new hires; b. MDS assessments accurately reflected the residents' status; c. care plans were updated and revised; d. physician orders were followed; e. supervision was provided to help prevent accidents, falls were thoroughly investigated to determine root causes, fall interventions were modified/revised, and to monitor effectiveness of interventions to prevent falls; f. staff demonstrated competency in skills to care for residents; g. a registered nurse served as the DON; h. required daily staffing information was posted; i. the physician responded to and dated the MRRs; j. significant medication errors did not occur; k. certifications were not expired; and l. the Legionnaires prevention policy was implemented. The administrator identified 42 residents who resided in the facility. Findings: 1. On [DATE] at 1530, the director of staff services reported they could not find a criminal background check for CNA #1 or DA #1 and reported neither employee should be working without a criminal background check. 2. On [DATE] at 1:31 p.m., the MDS coordinator stated they missed coding the antiplatelet on the resident's admission MDS. On [DATE] at 12:34 p.m., the MDS coordinator stated the Abilify was missed on the resident's quarterly assessment. On [DATE] at 11:30 a.m., the MDS Coordinator reported they believe they finished the MDS and signed it prior to the catheter being inserted that day. MDS Coordinator reported they should have documented the catheter since they had until midnight to complete the MDS. 3. On [DATE] at 12:00 p.m., the MDS /care plan coordinator stated they failed to change the ABT on the resident's care plan to the one the resident was taking. She stated she did get the physician orders and she usually updates the care plan. On [DATE] at 12:45 p.m., the MDS/care plan coordinator stated all of the resident interventions were not appropriate and some were not new for the resident on the care plan. They stated about 50% were appropriate interventions for the resident. 4. On [DATE] at 3:28 p.m., RN #1 (nurse on duty when the medication error occurred) reported they should have written a physician's order when they received orders from the PA but didn't because they had several things happening at once and must have forgotten. RN #1 reported her monitoring of Res #27 consisted of vital signs. RN #1 reported they were unsure why they didn't complete or document an assessment of Res #27. On [DATE] at 3:33 p.m., LPN #1 stated they did not think Res #10's clonidine order was PRN anymore. After looking in the resident's orders the LPN stated the clonidine order was now given TID. The order was changed to TID on [DATE]. The LPN stated the PRN order should have been removed from the metoprolol order. LPN #1 stated if they were following the metoprolol order and the residents blood pressure was out of parameter the staff should have given a PRN clonidine which was not ordered. On [DATE] at 2:45 p.m., LPN #1 (nurse who completed the Drug Incident Report), reported a physician's order should have been written for anything the physician instructed the nurse to do when they were notified of the medication error. LPN #1 reported the physician should have been notified of Res #27's out of parameter vital signs and the nurse should have assessed Res #27 after the medication error occurred. 5. On [DATE] at 4:30 p.m., the administrator was asked if they had a fall prevention program and they stated not at this time. The administrator stated unless the staff was told in report there was no way for the staff to know which residents were at high fall risk. 6. On [DATE] at 3:49 p.m., CMA #1 reported dispensing medication for two residents who were roommates in separate cups with the intention to administer medication to both residents at the same time. CMA #1 reported they went to administer the medication and mixed up the medication cups and gave one resident their roommate's medication. CMA #1 reported knowing they should only dispense and administer medication for one resident at a time. CMA #1 denied nursing administration ever completing a skills observation on them. 7. On [DATE] at 9:40 a.m., during entrance conference, the administrator stated their DON was an LPN. The administrator stated they had emails where they had contacted the state and was informed an LPN could serve as the DON. The administrator stated they did not have a current waiver for the LPN to serve as the DON. On [DATE] at 2:19 p.m., LPN #1 stated they had been employed as the DON of the facility since their start date of [DATE]. 8. On [DATE] at 1:25 p.m., LPN #1 reported they were not aware of the requirements regarding posted staffing information. 9. On [DATE] at 12:59 p.m., LPN #1 stated there were not a response from the physician on the November or December MRR for the resident. LPN #1 stated sometimes it took three or four months to get the MRRs back from the physician. LPN #1 stated they took a folder to the physician's office and they were supposed to pick up the folder with the signed documents the next week but the MRRs are not always in the folder. On [DATE] at 12:28 p.m., LPN #1 stated the MRR for October was not dated by the physician. LPN #1 stated they noted the form when they get them back from the physician. LPN #1 stated she did not know when the physician signed the form. On [DATE] at 12:02 p.m., RN #2 stated the 159 blood sugar held on [DATE]st she would have given the full dose of medication. RN #2 stated the nurse who administered the ,d+[DATE] dose of insulin did not chart the physician was notified. The RN stated they should not have given ,d+[DATE] of the dose without calling the physician. On [DATE] at 11:54 p.m., RN #1 stated the 5:00 a.m., FSBS would be the same as the 6: a.m., FSBS because they only obtain it once in the morning. RN #1 stated they did not know why there were blanks on the sliding scale insulin. The RN stated they did not know if the insulin was given or not by looking at the MAR. The RN stated if the FSBS was below 100 they thought the LPN would call the physician. The RN looked at the notes and stated there was no documentation the physician was notified of the insulin being held on the 29th they stated if its not documented it was not done. 10. On [DATE] at 11:00 a.m., the administrator reported CMA #1 did not complete their required eight hour class so that they could renew their certification. The administrator reported they completed random checks of certification and if any employee's certification was set to expire they put a reminder by the time clock for the employee. The administrator reported they didn't have a system in place to verify the employees had renewed their certifications. 11. On [DATE] at 2:22 p.m., the plant operations director was asked what were some things in place regarding their Legionnaires policy. The plant operations director stated they were not aware of a Legionella water management program. The stated they only did water temperatures. On [DATE] at 2:33 p.m., the plant operations director present with a water management plan for Legionella. They stated the plan was contracted and the contractors had not shown up to map the blue print of the water pipes yet. They were unaware if the plan was in operation at this time. On [DATE] at 2:42 p.m., the administrator stated the contract company will come and put the plan in place and the facility will maintain the Legionella program. The contract company had not been in to map the water supply.

Based on record review and interview, the facility failed to follow their abuse policy and ensure background checks were completed for new hires. The administrator identified 42 residents who resided in the facility. Findings: The Abuse Prohibition/Unusual Occurrence Policy and Procedure policy, undated, read in part, .Screening All potential employees will be screened for a history of abuse, neglect or mistreatment of residents as defined by the applicable requirements .Nursing Home will obtain OSBI checks, attempt to obtain information from prior employers, current employers and licensing boards and registries . The Employee Seniority Report, dated 01/30/24, documented the following: a. CNA #1 was hired on 02/11/23. b. DA #1 was hired on 10/27/23. On 02/01/24 at 1530, the Director of Staff Services reported they could not find a criminal background check for CNA #1 or DA #1 and reported neither employee should be working without a criminal background check.

Based on record review and interview, the facility failed to implement their Legionnaires prevention policy. The administrator identified 42 residents who resided in the facility. Findings: A Legionella Water Management Program dated September 2022, read in parts, .Our facility is committed to prevent, detection and control of water-borne contaminants, including Legionella .As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team .The water management team consists of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; and e. The director of environmental services .The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease . On 02/06/24 at 2:20 p.m., a Legionnaires water management program policy was provided by LPN #1. On 02/06/24 at 2:22 p.m., the plant operations director was asked what were some things in place regarding Legionnaires management. The plant operations director stated they were not aware of a Legionnaires water management program. The stated they only did water temperatures. On 02/06/24 at 2:33 p.m., the plant operations director presented a water management plan for legionella. They stated the plan was contracted and the contractors had not shown up to map the blue print of the water pipes yet. They were unaware if the plan was in operation at this time. On 02/06/24 at 2:42 p.m., the administrator stated the contract company will come and put the plan in place and the facility will maintain the Legionnaires program. The contract company had not been in to map the water supply.

Based on record review and interview, the facility failed to ensure significant medication errors did not occur for four (#1, 14, 24, and #27) of six sampled residents whose medications were reviewed. The administrator identified 42 residents who resided in the facility. Findings: A facility policy Diabetes-Clinical Protocol, dated November 2020, read in part, .The Physician will order desired parameters for monitoring and reporting information related to blood sugar management. a. The staff will incorporate such parameters into the Medication Administration Record and care plan . 1. Res #1 had diagnoses which included diabetes mellitus, hypertension, and bradycardia. A physician order, dated 12/20/23, documented Basaglar KwikPen (insulin glargine) administer 20 units subcutaneously two times a day for diabetes mellitus. A physician order, dated 12/20/23, documented Lisinopril 20 mg administer one tablet by mouth in the evening for HTN. An admission assessment, dated 12/27/23 documented the resident was severly impaired with cognition and was dependent with ADLs. The assessment documented the resident had received insulin, antipsychotic medication, antidepressant medication, and hypoglycemic medication during the look back period. A care plan, last revised 12/28/23, documented the resident had a diagnoses of HTN and received medication to manage. The care plan documented to administer the hypertensive medication as ordered. The care plan, documented Res #1 had a diagnosis of diabetes and received routine insulin two times a day and to check the resident's FSBS prior to administering any insulin. The resident was monitored for signs and symptoms of hypo/hyperglycemia issues. The care plan documented to administer the diabetic medication as ordered. Res #1's January 2023 MAR was reviewed and documented on 01/01/23 the resident was administered a partial dose of insulin. The a.m. insulin was held five more times on the MAR. The resident's evening insulin was held on 01/01/23 and 01/09/23. An administration note, dated 01/01/24, documented insulin held in a.m., partial administration. An administration note, dated 01/06/24, documented insulin held due to behaviors and the provider was aware. An administrative note, dated 1/31/24, documented the resident's FSBS was 80 and the insulin was held. The notes did not document the physician was notified. The January 2024 MAR documented the Lisinopril 20 mg was held on 01/03/23, 01/08/24, 01/10/24, 01/12/24, 01/14/24, and 01/20/24. An administration note, dated, 1/10/24 documented the resident blood pressure was 99/70 and the medication was held. The note did not document the physician was notified. This was the only note observed to document why the blood pressure medication was held for the listed days. On 02/05/24 at 12:02 p.m., RN #2 stated the 159 blood sugar held on January 1st she would have given the full dose of medication. RN #2 stated the nurse who administered the 1/2 dose of insulin did not chart the physician was notified. The RN stated they should not have given 1/2 of the dose without calling the physician. RN #2 observed the order for Lisinopril and stated there were no parameters on the order to hold the blood pressure medication. 2. Res #14 had diagnoses which included diabetes mellitus. A physician order dated 07/22/23, documented Humalog (insulin) administer per sliding scale. The sliding scale documented administer if FSBS is 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 if >400 notified physician, subcutaneously before meals and at bedtime related to diabetes mellitus. A physician order, dated 11/30/23, documented Basaglar KwikPen (insulin glargine) administer 70 units subcutaneously in the evening related to diabetes mellitus. A physician order, dated 12/01/23, documented Basaglar KwikPen (insulin glargine) administer 35 unit subcutaneously in the morning for diabetes mellitus. A quarterly assessment, dated 01/24/24 documented the resident was intact with cognition and was independent to moderate assist with most ADLs. The assessment documented the resident had received insulin, an antidepressant, diuretic, and an opioid medication during the look back period. A care plan, revised 07/05/23, documented the resident had a diagnosis of diabetes and received insulin. The care plan documented to administer the medication as ordered by the physician and monitor for side effects. The care plan documented to administer the Humalog insulin per sliding scale and if the FSBS result was below 150 do not administer sliding scale insulin and if the FSBS was greater than 400 administer 12 units and notify the physician. The January 2024 MAR was observed, the Humalog sliding scale insulin had blank administration times, one on 01/12/24 at 4:30 p.m., and two blanks on 01/13/24 at 11:30 a.m., and at 4:30 p.m. There was not documentation of insulin being administered on these times. The Basaglar KwickPen (insulin glargine) 35 units did not have FSBS documented on the am dose and on the 01/29/24 the insulin was held. An administration note, dated 1/29/2024 at 4:35 a.m., documented Basaglar KwikPen insulin 35 unit subcutaneously in the morning for diabetes mellitus was held for a FSBS of 79. The note did not document the physician was notified. On 02/05/24 at 11:54 p.m., RN #1 stated the 5:00 a.m., FSBS would be the same as the 6: a.m., FSBS because they only obtain it once in the morning. RN #1 stated they did not know why there were blanks on the sliding scale insulin. The RN stated they did not know if the insulin was given or not by looking at the MAR. The RN stated if the FSBS was below 100 they thought the LPN would call the physician. The RN looked at the notes and stated there was no documentation the physician was notified of the insulin being held on the 29th they stated if its not documented it was not done. 45913 3. Res #24 had diagnoses which included diabetes with hyperglycemia. A physician's order, dated 10/10/23, read in part, Lantus (insulin) Subcutaneous Solution Inject 60 unit subcutaneously in the morning for hyperglycemia. The Insulin Administration Record for January 2024, documented no insulin was administered on 01/03/24 at 5:00 a.m. The resident should have received Lantus 60u. There was no order written to hold the insulin. A progress note, dated 01/16/24 at 3:11 p.m. documented Res #24's blood sugar was 99 and their insulin (Lantus 60u) was held. There was no documentation the physician was notified, nor was a physician's order written to hold the insulin. A progress note, dated 01/17/24 at 6:25 a.m. documented Res #24's blood sugar was 126 and they received 40u of Lantus due to hypoglycemia in the past. Resident should have received 60u of Lantus as ordered. There was no documentation the physician was notified, nor was a physician's order written to administer a partial amount of insulin. 02/05/24 at 2:50 p.m. LPN #1 reported the insulin should not have been held without obtaining a physician's order. LPN #1 reported the nurse should not have given a different dose of insulin without notifying the physician. LPN #1 reported they couldn't find any documentation the physician was notified of the insulin being held or partially administered. LPN #1 could not explain why insulin as not administered on 01/03/24. 4. Res #27 had diagnoses which included quadriplegia, anxiety, depression, muscle spasms, GERD, insomnia, neuromuscular dysfunction of the bladder, and convulsions. A Drug Incident Report dated, 12/23/23, documented Res #27 received their roommate's 18 morning medications in error which included, Carafate (antacid) 1 gm, Neurontin (anti-convulsant) 600mg, Robaxin (muscle relaxer) 750mg, Norco (opioid) 10mg, dicyclomine (anti-spasmotic for the gastrointestinal system) 20mg, allopurinol (uric acid reducer) 300mg, digoxin (anti-arrhythmic) 125 mcg, ferrous sulfate (iron) 325mg, multivitamin, Paxil (anti-depressant) 20mg, potassium 20mEq, prednisone (steroid) 5mg, probiotic, spironalactone (diuretic) 25mg, torsemide (diuretic) 100mg, amiodarone (anti-arrhythmic) 200mg, buspirone (anti-anxiety) 7.5mg, and Eliquis (blood thinner) 5mg. The PA was notified and ordered Res #27's vital signs to be taken every hour for 24 hours; monitor heart rate and blood pressure; and hold a.m. Valium (sedative) and Norco (opioid) with routine meds. Vital sign flow sheets and nursing notes for 12/24/24, documented six out-of-parameter blood pressures ranging from 77-98/52-58 and one out of parameter pulse of 57. On 01/31/24 at 3:49 p.m., CMA #1 reported dispensing medication for two residents who were roommates in separate cups with the intention to administer medication to both residents at the same time. CMA #1 reported they went to administer the medication and mixed up the medication cups and gave one resident their roommate's medication. CMA #1 reported knowing they should only dispense and administer medication for one resident at a time. CMA #1 stated, There was a lot going on and the residents were demanding their medication and I was trying to hurry.

Based on record review and interview, the facility failed to ensure there was a registered nurse serving as the DON on a full time basis. The administrator identified 42 residents resided in the facility. Findings: On 01/30/24 at 9:40 a.m., during entrance conference, the administrator stated their DON was an LPN. The administrator stated they had emails where they had contacted the state and was informed an LPN could serve as the DON. The administrator stated they did not have a current waiver for the LPN to serve as the DON. The administrator stated the facility had RN coverage eight hours a day seven days a week. On 02/06/24 at 2:19 p.m., LPN #1 stated they had been employed as the DON of the facility since their start date of 01/16/20.

Based on record review, observation, and interview, the facility failed to follow physician orders for two (#10 and #27) of five sampled residents reviewed for unnecessary medications. The administrator identified 42 residents resided in the facility. Findings: 1. Res #10 had diagnoses which included vascular dementia, chronic pain syndrome, anxiety disorder, and hypertension. A physician order, dated 09/22/23, documented to administer metoprolol tartrate 50 mg BID related to hypertension. The order documented if the systolic was above 160 or the diastolic was above 90 to administer PRN clonidine. A physician order, dated 12/04/23, documented clonidine 0.1 mg to administer three times a day for HTN. A current order was not found for PRN clonidine in the EHR. The January 2024 MAR was reviewed and the following blood pressures were documented: 01/07/24 in the a.m., BP was 167/102, 01/08/24 in the evening, BP was 164/79, 01/09/24 in the evening, BP was 165/93, 01/13/24 in the a.m., BP was 155/92, in the evening BP was 162/89, 01/14/24 in the a.m., BP was 159/97, 01/16/24 in the a.m., BP was 168/105, and 01/17/24 in the a.m., BP was 173/112. The February MAR documented on 02/02/24 the resident's BP was 173/90 and on 02/03/24 in the a.m., the BP was 151/97. On 01/30/24 at 11:00 a.m., Res #10 was walking from the bathroom to the recliner in their room. On 02/05/24 at 3:33 p.m., LPN #1 stated they did not think the resident's clonidine order was PRN anymore. After looking in the resident's orders the LPN stated the clonidine order was now given TID. The order was changed to TID on 12/4/23. The LPN stated the PRN order should have been removed from the metoprolol order. LPN #1 stated if they were following the metoprolol order and the residents blood pressure was out of parameter the staff should have given a PRN clonidine which was not ordered. 45913 2. Res #27 had diagnoses which included quadriplegia, anxiety, depression, muscle spasms, GERD, insomnia, neuromuscular dysfunction of the bladder, and convulsions. A physician order, date 08/31/21, read in part, .Notify PCP if systolic B/P is >160 or <90, or if pulse >100 or <60 . A Drug Incident Report dated, 12/23/23, documented Res #27 received their roommate's 18 morning medications in error which included, but was not limited to, an anti-depressants, anti-anxiety, two anti-arrthymics, two diuretics, an anticoagulant, antihistamine, antispasmotic for the gastrointestinal system, a steroid, anticonvulsant, and uric acid reducer. The report documented the PA was notified and ordered Res #27's vital signs to be taken every hour x 24 hours; monitor heart rate and blood pressure; and hold a.m. Valium (sedative) and Norco (opioid) with routine medications. A physician order was not written to check vital signs every hour x 24 hours; monitor heart rate and blood pressure; and hold am Valium and Norco with routine a.m. medications. Vital sign flow sheets and nursing notes for 12/24/24 documented six out-of-parameter blood pressures ranging from 77-98/52-58 and one out of parameter pulse of 57. The physician/PA was not notified of out of parameter vital signs. A review of Res #27's nursing notes for 12/24/24 did not include an assessment of Res #27's condition other than vital signs. On 01/31/24 at 2:45 p.m., LPN #1 (nurse who completed the Drug Incident Report), reported a physician order should have been written for anything the physician instructed the nurse to do when they were notified of the medication error. LPN #1 reported the physician should have been notified of Res #27's out-of-parameter vital signs and the nurse should have assessed Res #27 after the medication error occurred. On 01/31/24 at 3:28 p.m., RN #1 (nurse on duty when the medication error occurred) reported they should have written a physician order when they received orders from the PA but didn't because they had several things happening at once and must have forgotten. RN #1 reported their monitoring of Res #27 consisted of vital signs. RN #1 reported they were unsure why they didn't complete or document an assessment of Res #27.

Based on record review and interview, the facility failed to ensure MDS assessments accurately reflected the residents' status for three (#1, 6, and #14) of 15 residents whose assessments were reviewed. The administrator identified 42 residents resided in the facility. Findings: 1. Res #1 had diagnoses which included atherosclerotic heart disease, old myocardial infarction, and cerebral infarction. A physician order, dated 12/20/23, documented Brilinta (an antiplatelet medication) administer 90 mg BID for MI/CVA prevention. An admission assessment dated [DATE], documented the resident was severly impaired with cognition and required extensive assistance with ADLs. The assessment did not document the resident was receiving an antiplatelet medication. On 02/01/24 at 1:31 p.m., the MDS coordinator stated they missed coding the antiplatelet on the resident's admission MDS. 2. Res #14 had diagnoses which included depression, anxiety disorder, insomnia, and bipolar disorder. A physician order, dated 07/18/23, documented Abilify (an antipsychotic medication) administer 5 mg in the evening related to bipolar disorder and depression. A quarterly assessment, dated 01/21/24, documented the resident was intact with cognition, had no behaviors. The assessment documented the resident had received insulin, antidepressant, diuretic, and opioid medications. The assessment documented an antipsychotic was not received. On 02/05/24 at 12:34 p.m., the MDS coordinator stated the Abilify was missed on the resident's quarterly assessment. 45913 3. Res #6 had diagnoses which included cerebral infarction, chronic obstructive pulmonary disease, and hypertension. A nursing note, dated 10/08/23 at 4:09 p.m., read in part, #18 french foley catheter (indwelling urinary catheter) placed sterile technique .obtained 2000 cc total initially .foley left in place as ordered . An admission assessment, dated 10/08/23, did not document Res #6 had an indwelling urinary catheter in place. On 02/06/24 at 11:30 a.m., the MDS coordinator reported they believed they finished the MDS and signed it prior to the catheter being inserted that day. MDS Coordinator reported they should have documented the catheter since they had until midnight to complete the MDS.

Based on interview and record review, the facility failed to ensure staff were able to demonstrate competency in skills necessary to care for residents' needs for one (CMA #1) of six staff reviewed for competency skills. The administrator identified 42 residents who resided in the facility. Findings: The employee file for CMA #1 was reviewed and the certification for CMA #1 expired on [DATE]. The payroll records were reviewed and CMA #1 worked as a CMA 18 days without certification, from [DATE] through [DATE]. A Drug Incident Report dated, [DATE], documented Res #27 received their roommate's 18 morning medications in error which included, Carafate (antacid) 1 gm, Neurontin (anti-convulsant) 600mg, Robaxin (muscle relaxer) 750mg, Norco (opioid) 10mg, dicyclomine (anti-spasmotic for the gastrointestinal system) 20mg, allopurinol (uric acid reducer) 300mg, digoxin (anti-arrhythmic) 125 mcg, ferrous sulfate (iron) 325mg, multivitamin, Paxil (anti-depressant) 20mg, potassium 20mEq, prednisone (steroid) 5mg, probiotic, spironalactone (diuretic) 25mg, torsemide (diuretic) 100mg, amiodarone (anti-arrhythmic) 200mg, buspirone (anti-anxiety) 7.5mg, and Eliquis (blood thinner) 5mg. On [DATE] at 3:49 p.m., CMA #1 reported dispensing medication for two residents who were roommates in separate cups with the intention to administer medication to both residents at the same time. CMA #1 reported they went to administer the medication and mixed up the medication cups and gave one resident their roommate's medication. CMA #1 reported knowing they should only dispense and administer medication for one resident at a time. CMA #1 stated, There was a lot going on and the residents were demanding their medication and I was trying to hurry. CMA #1 denied nursing administration ever completing a skills observation on them. On [DATE] at 11:00 a.m., the administrator reported CMA #1 did not complete her required eight hour class so that they could renew their certification. The administrator reported they complete random checks of certification and if any employee's certification is set to expire they put a reminder by the time clock for the employee. The administrator reported they didn't have a system in place to verify the employees had renewed their certifications.

Based on record review and interview, the facility failed to ensure certifications were not expired for one (CMA # 1) of six employee files reviewed for certifications/licenses. The administrator identified 42 residents resided in the facility. Findings: The employee file for CMA #1 was reviewed and the certification for CMA #1 expired on [DATE]. The payroll records were reviewed and CMA #1 worked as a CMA 18 days without certification, from [DATE] through [DATE]. On [DATE] at 11:00 a.m., the administrator reported CMA #1 did not complete her required 8 hour class so that they could renew their certification. The administrator reported they complete random checks of certification and if any employee's certification is set to expire they put a reminder by the time clock for the employee. The administrator reported they didn't have a system in place to verify the employees had renewed their certifications.

Based on observation, interview, and record review, the facility failed to document required daily staffing information. The administrator identified 42 residents who resided in the facility. Findings: On 01/30/24 and throughout the survey a window behind the nursing station was observed to include the date, census, staff names and titles. There was no documentation of the facility name or staffing hours worked. On 02/06/24 at 1:25 p.m. LPN #1 reported they were not aware of the requirements regarding posted staffing information.

Based on record review and interview, the facility failed to ensure the physician responded to or dated the MRRs for two (#10 and #14) of five sampled residents reviewed for unnecessary medications. The administrator identified 42 residents resided in the facility. Findings: A Drug Regimen Review policy, dated 2020, read in part, .The physician provides a written response of the report to the facility within one month after the report is sent . 1. Res #10 had diagnoses which included generalized anxiety disorder, depression, bipolar disorder, and vascular dementia. A MRR, dated 11/27/23, documented a recommendation for the following labs, CBC and CMP every six months and a Lipid yearly. The physician did not respond to the request. A MRR, dated 12/18/23, documented a request a GDR be attempted for Trazodone 100 mg QHS or Venlafaxine 150 mg daily. The physician did not respond to the GDR request. On 02/05/24 at 12:59 p.m., LPN #1 stated there were not a response from the physician on the November or December MRR for the resident. LPN #1 stated sometimes it took three or four months to get the MRRs back from the physician. LPN #1 stated they took a folder to the physician's office and they were supposed to pick up the folder with the signed documents the next week but the MRRs are not always in the folder. 2. Res #14 had diagnoses which included other reactions to severe stress, bipolar disorder, insomnia, and anxiety disorder. A MRR, dated 10/30/23, documented a request for a reduction in Trazodone 100 mg QHS and/or Zoloft 100 mg daily. The physician documented a reduction would likely worsen or destabilize the resident's condition. The physician did not date the form. On 02/05/24 at 12:28 p.m., LPN #1 stated the MRR for October was not dated by the physician. LPN #1 stated they noted the form when they get them back from the physician. LPN #1 stated she did not know when the physician signed the form.

Based on record review and interview, the facility failed to ensure care plans were updated and revised for two (#31 and #36) of 15 residents whose care plans were reviewed. The administrator identified 42 residents resided in the facility. Findings: 1. Res #31 had diagnoses of urinary tract infection. A quarterly assessment, dated 01/21/24, documented the resident was moderately impaired with cognition and was dependent with most ADLS. A care plan, dated 01/22/24, documented the resident developed a UTI and to administer Bactrim 1 tablet by mouth two times a day for 10 days for UTI. A physician order, dated 01/27/24, documented to administer Keflex 500 MG (Cephalexin) three times a day related to UTI for seven days. On 02/06/24 at 12:00 p.m., the MDS /care plan coordinator stated they failed to change the ABT on the resident's care plan to the one the resident was taking. She stated she did get the physician orders and she usually updates the care plan. 2. Res #36 had diagnoses which include left femoral neck fracture, dementia, urgency of urination, and anxiety. An incident report, dated 05/27/23 at 10:08 a.m., documented the resident fell from the wheelchair in the dining room. The intervention was to bring the resident to the nurse station for closer monitoring. The care plan was not updated with new intervention. An incident report, dated 08/03/23 at 5:52 p.m., documented staff observed resident standing up from wheelchair and fell to the floor. A care plan, initiated on 08/03/23, documented to give the resident something eat or drink prior to bed which was not a relevant intervention. A quarterly assessment, dated 08/25/23, documented the resident was severely cognitively impaired, required extensive assistance of one for transfers and supervision with assistance of one for ambulating. A care plan, initiated 09/24/23, documented falls for 09/21/23, 09/22/23, and 09/24/23. the care plan did not document any new interventions for falls except the staff will monitor the resident's where-abouts when up and ambulatory, which was not a relevant intervention for the falls. An incident report, dated 10/1/23 at 1:22 p.m., documented the resident stood up in the dining room and fell to the floor. The report documented the resident hit her right knee, hip, and head with a loud thump. The resident complained of right knee and hip pain. The resident sent to the hospital for evaluation. No new interventions were documented in the care plan. An incident report, dated 11/19/23 at 6:15 p.m., documented the nurse was notified that the resident fell in their room. The resident was sitting upright on her buttocks. The resident complained of their hip hurting at a 2 on pain scale for the cognitively impaired. No new interventions were documented in the care plan. A significant change assessment, dated 12/11/23, documented the resident was severely impaired with cognition and was dependent with most ADLs. Res #36 was currently totally dependent for transfers with assistance of two and required extensive assistance of two for ambulating. The assessment documented the resident had two or more falls since prior assessment. The assessment documented one fall with a major injury that required surgery. An incident report, dated 01/05/24 at 3:33 p.m., documented the resident was sitting in the floor on the fall mat. The report documented the resident was confused and did not know what happened. The care plan was not updated with new interventions. An incident report, dated 01/17/24 at 5:45 p.m., documented a visitor notified the nurse the resident was lying face down on the floor in the dining room. The incident report documented the resident had a bruise on the left cheek. The incident report documented the resident had been attempting to ambulate without assistance multiple times. The care plan was not updated with any new interventions to prevent falls. On 02/01/24 at 10:40 a.m., the resident was observed in their wheelchair in front of the nurse station. The wheelchair was not in the locked position. On 02/01/24 at 10:42 a.m , LPN #1 stated they just initiated the toileting intervention last night. They stated they did not have previous documentation for toileting the resident. On 02/05/24 at 12:45 p.m., the MDS/care plan coordinator stated all of the resident interventions were not appropriate and some were not new for the resident on the care plan. They stated about 50% were appropriate interventions for the resident.

Based on record review, observation, and interview, the facility failed to lock unattended treatment and medication carts. The Resident Census and Conditions of Residents documented a census of 45. Findings: A policy and procedure titled Security of Medication Cart, revised 04/07, documented in part Medication carts must be securely locked at all times when out of the nurse's view. On 01/04/23 at 7:40 a.m., the treatment cart on rodeo hall was observed unlocked. LPN #1 was in room [ROOM NUMBER] and the treatment cart was not in LPN #1's view. On 01/04/23 at 7:45 a.m., LPN #1 reported the treatment cart contained medications and should not have been unlocked while unattended. On 01/04/23 at 8:00 to 8:03 a.m., the medication cart on abstract hall was observed unlocked and CMA #1 was in room [ROOM NUMBER]. On 01/04/23 at 8:06 a.m., CMA #1 reported the medication cart should not have been unlocked while unattended. On 01/05/23 at 10:23 a.m., the DON reported the medication and treatment carts should not have been unlocked while unattended. On 01/05/23 at 10:30 a.m., the administrator reported the medication and treatment carts should have been locked while unattended.

Based on record review, observation, and interview the facility failed to develop a comprehensive person centered care plan for one (# 3) of three residents reviewed for care plans. The Resident Census and Conditions of Residents, dated 01/03/23, documented a census of 45. Findings: Res # 3 was admitted with diagnoses which included respiratory failure, dysphasia, and multiple sclerosis. A policy and procedure titled Care Plan, Comprehensive Person-Centered, revised 3/22, documented in part A comprehensive, person centered care plan that includes measurable objectives and time tables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. A physician's order, dated 11/25/22, read in part may place 02 at 2 lpm . An annual assessment, dated 12/19/22, documented Res #3 was mildly impaired in cognition and requires extensive assistance with activities of daily living. A care plan, dated 12/22/22, did not have oxygen therapy documented. On 01/03/23 at 10:55 a.m., Res #3 was observed lying in bed with 02 in place at 2 lpm/nc. On 01/04/23 at 12:34 p.m., the MDS coordinator reported the oxygen was not care planned and should have been. On 01/04/23 at 12:39 p.m., the administrator reported the oxygen was not care planned and should have been.

Based on record review, observation, and interview, the facility failed to provide services to have a hearing aid repaired for one (#9) of one residents reviewed for hearing aids. Findings: The administrator documented two residents required hearing aids. Res #9 was admitted with diagnoses which included chronic obstructive pulmonary disease, dementia, and hypertension. A quarterly assessment, dated 10/17/22, documented Res #9 was cognitively intact and required hearing aids. A progress note, dated 10/20/22 at 11:39 a.m., read in parts .came to SSD and stated a piece broke off .hearing aids . needs to schedule an appointment. SSD contacted (name with held) clinic .stated appointment is not needed for this .drop off and fix in office . On 01/03/23 at 10:34 a.m., Res #9 was observed in their room. Res #9 reported their hearing aids had a broken piece and the SSD had called the clinic to have the hearing aids repaired but arrangements had not been made. On 01/04/23, at 2:31 p.m., the SSD reported the hearing aids should have been taken to the clinic for repair. On 01/04/23 at 2:39 p.m., the administrator reported the facility should have followed up with the audiologist and had the hearing aids repaired.

Based on observation, interview, and record review, it was determined the facility failed to implement an abuse policy to ensure residents were free from abuse for one (#38) of one resident reviewed for an allegation of abuse. The facility staff failed to report an allegation of abuse to administration for eight days. The facility identified 37 residents who resided in the facility. Findings: An abuse policy and procedure, titled Reporting Abuse to Facility Management, stated, Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report the incident to the administrator or director of nursing. A review of resident #38 records showed an incident report form, dated 06/10/20, stated, On 06/18/20 an employee reported to the director of nursing and administrator that two certified nurse aides (CNA) #1 and #2 were in resident #38 room getting her up for breakfast on 06/10/20 and she was refusing but they were making her get up anyways. Resident #38 to [CNA #1] to get the hell out. That is when CNA #1 and #2 got mad and began to call resident #38 names saying fine [OBSCENITY] , and was a little aggressive with the wheelchair when she put it in from of her. They then went on to say, let that whore dress herself, and they left the room. A little after that they returned shortly after CNA #1 asking, you're still helping that [OBSCENITY] ? and she just stood there while we got her up. Resident #38 family, the police, the physician, department of human services, and the nurse aide registry were notified on 06/18/20. Upon completion of the investigation allegations were substantiated. Staff witness statements and resident interviews by administration dated 06/18/20 were reviewed. Reviewed documentation confirmed CNA #1 and #2 were terminated on 06/18/20. On 08/03/21 at 9:30 AM, resident #38 was observed lying in bed with her eyes closed. The resident was determined not able to be interviewed after three attempts. The facility staff were interviewed and reported any abuse allegations were to be reported to the director of nursing (DON) and administrator immediately. Staff reported abuse prohibition training and in-service had been attended. Residents were interviewed and reported no allegations of abuse. On 08/04/21 at 10:04 AM, the administrator reported the staff were required to report any allegations of abuse immediately to the DON and administrator. The administrator reported the abuse prohibition policy and procedures were trained to all new staff and twice a year for all staff and back ground checks were conducted before hire. The administrator stated the staff should have reported the allegation immediately per the abuse prohibition policy and procedure. On 08/04/21 at 10:30 AM, the DON reported staff were to report any allegation of abuse immediately to the administrator and DON and a full investigation would be conducted and reported. The staff did not report the allegation of abuse to administration per the policy and procedure.

Based on observation, interview, and record review, it was determined the facility failed to develop a comprehensive care plan to include smoking safety for one (#140) of one resident who was reviewed for smoking safety. The facility failed to ensure supervision was provided during smoking. The facility identified six residents who smoked. Findings: A comprehensive care plan, last updated 07/13/21, did not address resident #140 was a supervised smoker. Smoking assessments for resident #140, dated 07/12/21 and 07/20/21, stated, Resident #140 smoked and was to be supervised while smoking. The resident had dexterity problems (difficulty performing tasks especially with hands) and the facility would store the resident's lighter and cigarettes. On 08/02/21 at 9:30 AM, resident #140 was identified as a supervised smoker by the facility administration. On 08/02/21 at 11:07 AM, resident #140 reported he didn't know if he was supposed to be supervised by staff or not and smoked when he so desired. On 08/02/21 at 12:01 PM, resident #140 was observed outside at the designated smoking area smoking a cigarette unsupervised by staff. On 08/02/21 at 3:23 PM, resident #140 was observed outside at the designated smoking area smoking a cigarette unsupervised by staff. On 08/03/21 at 2:09 PM, certified nurse aide (CNA) #1 reported resident #140 was to be supervised during smoking and wear a smoking apron. On 08/03/21 at 2:35 PM, licensed practical nurse (LPN)#3 reported the comprehensive care plan for resident #140 did not include he was to be supervised while smoking. On 08/03/21 at 3:15 PM, the director of nursing (DON) reported resident #140 should not have been smoking unsupervised by staff. The DON reported the comprehensive care plan for resident #140 did not include he was a supervised smoker due to impaired hand dexterity.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (#23) of two residents sampled for pressure ulcers received appropriate treatment and services necessary to promote healing, prevent infection, and prevent new pressure ulcers from forming. The facility failed to: a) Notify the physician and receive an order for [REDACTED]. On the third day the wound was assessed by a nurse and met the description of a stage III pressure ulcer. Five days later the wound was assessed and was described as an unstageable pressure ulcer. Orders were written by nursing for vitamins without first consulting the physician. b) Ensure the physician directly examined the resident's wounds in order to diagnose, order effective treatments, and/or monitor and evaluate the effectiveness of the wound treatments ordered for resident #23. The wound stayed at a shear/friction status for six weeks. The wound then progressed from a shear/friction wound to a stage III pressure ulcer within three days, according to the nurse's description of the wound documented on the assessment. The wound then progressed from a stage III pressure ulcer to an unstageable pressure ulcer within five days. The facility identified a second wound as a stage III pressure ulcer, according to the nurse's description of the wound documented on the assessment. The stage III pressure ulcer progressed to an unstageable pressure ulcer within two weeks. The facility identified a third wound, which was assessed as an unstageable pressure ulcer, the day the surveyor observed the treatments. physician progress notes [REDACTED]. c) Ensure pressure ulcer treatment was performed in a way to help prevent infection related to not performing hand hygiene and changing gloves between cleansing multiple pressure ulcers. The director of nursing (DON) identified 31 residents who resided at the facility. Findings: Resident #23 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A nurse note, dated 04/05/18 at 1:44 p.m., documented the resident had arrived at the facility by emergency medical service. A skin observation tool for wound #2, dated 04/09/18, documented the resident had friction/shear areas on her left buttock which measured 0.5 x 0.5 centimeter (cm) and 2.0 x 3.0 cm. A quarterly assessment, dated 04/09/18, documented the resident was severely cognitively impaired and had no rejection of care behaviors. The assessment documented the resident required extensive assistance with bed mobility, transfers, toilet use, and did not walk. The assessment documented the resident had one fall with major injury, [DIAGNOSES REDACTED]. The assessment documented the resident was frequently incontinent of urine, occasionally incontinent of bowel, was 67 inches ('') in height, and weighed 126 pounds (#). The assessment documented the resident was at risk for pressure ulcers, had surgical wounds, and did not have any pressure ulcers or open [MEDICAL CONDITION]. The assessment documented the resident had received surgical wound care and pressure reducing devices for her bed and chair. The assessment documented the resident had not received any applications of ointments and the physician or the authorized assistant or practitioner had not examined the resident in the last 14 days. A nurse note, dated 04/11/18, documented the physician assistant (PA) was at the facility for nursing home rounds and no orders were obtained for the resident. The note did not document the PA had a direct visit with the resident. The resident's medical record did not document any other visits or exams by the P[NAME] The resident's record did not contain physician progress notes [REDACTED]. The resident's record did not document an order for [REDACTED]. A significant change assessment, dated 04/12/18, documented the resident was severely cognitively impaired and had no rejection of care behaviors. The assessment documented the resident required extensive assistance with bed mobility, transfers, toilet use, and did not walk. The assessment documented the resident had a [DIAGNOSES REDACTED]. The assessment documented the resident was frequently incontinent of urine, occasionally incontinent of bowel, was 67'' in height, and weighed 126#. The assessment documented the resident was at risk for pressure ulcers, had surgical wounds, and did not have any pressure ulcers or open [MEDICAL CONDITION]. The assessment documented the resident had received surgical wound care, applications of ointments, and pressure reducing devices for her bed and chair. The assessment documented the physician or the authorized assistant or practitioner had not examined the resident in the last 14 days. The care plan, dated 04/12/18, documented the resident had friction/shear areas observed on her buttocks which were to be treated daily and monitored both daily and weekly. The care plan documented the resident had developed a stage II pressure ulcer to her coccyx due to her limited mobility status, recent right [MEDICAL CONDITION], and incontinence. The care plan documented the resident did not like to go to bed to stay off her back, would sit in her recliner most of the day, and was up in her wheelchair for meals and therapy. The care plan documented her skin was to have been monitored daily during care by the certified nursing aides (CNAs), weekly by a licensed nurse, and any abnormalities were to have been reported to the charge nurse. The care plan documented the resident would deny any issues with her skin. The care plan documented the staff were to administer vitamin C 500 milligrams (mg) twice a day and zinc 220 mg by mouth twice a day to promote wound healing. The care plan documented the staff were to assist the resident with turning and repositioning every two hours when in bed and monitor her nutritional status each meal. The care plan documented the staff were to encourage the resident to shift her weight every 15 minutes when up in the wheelchair. The care plan documented the resident was to be assisted with incontinent care as needed, to keep the resident's skin clean and dry, and to apply a barrier cream as she was at risk for pressure ulcers due to her incontinence. A skin observation tool for wound #2, dated 04/16/18, documented the resident had friction/shear areas on her left buttock which measured 0.5 x 0.5 cm and 2.0 x 3.0 cm. A prospective payment system (PPS) 14 day assessment, dated 04/18/18, documented the resident was moderately cognitively impaired and had no rejection of care behaviors. The assessment documented the resident required extensive assistance with bed mobility, was occasionally incontinent of urine, and was frequently incontinent of bowel. The assessment documented the resident attended PT and OT and was 67'' in height and weighed 126#. The assessment documented the resident was at risk for pressure ulcers but did not have any pressure ulcers or open [MEDICAL CONDITION]. The assessment documented the resident had moisture associated skin damage (MASD) and received applications of ointments. The assessment documented the physician or the authorized assistant or practitioner had not examined the resident in the last 14 days. A skin observation tool for wound #2, dated 04/23/18, documented the resident had friction/shear areas on her left buttock which measured 0.5 x 0.5 cm and 2.0 x 3.0 cm. A nurse note, dated 04/26/18, documented the resident had sheared areas to her left buttock/coccyx and treatment orders were obtained. A physician order [REDACTED]. A skin observation tool for wound #2, dated 04/30/18, documented the resident had friction/shear areas on her left buttock which measured 0.5 x 0.5 cm and a 2.0 x 3.0 cm. A PPS 30 day assessment, dated 05/03/18, documented the resident was moderately cognitively impaired and had rejection of care behaviors one to three days of the seven day look back period. The assessment documented the resident required extensive assistance with bed mobility, attended PT and OT, and was 67'' in height and weighed 114#. The assessment documented the resident was at risk for pressure ulcers but did not have any pressure ulcers or open [MEDICAL CONDITION]. The assessment documented the resident was frequently incontinent of urine and bowel, had MASD, and received applications of ointments. The assessment documented the physician or the authorized assistant or practitioner had not examined the resident in the last 14 days. A skin observation tool for wound #2, dated 05/07/18, documented the resident had a 2.0 x 1.0 cm friction/shear area on her left buttock. A skin observation tool for wound #2, dated 05/14/18, documented the resident had a 2.0 x 1.0 cm friction/shear area on her left buttock. A weekly wound assessment for wound #1, dated 05/14/18, documented the resident had a 2.0 x 2.0 cm stage II pressure ulcer on her coccyx. The assessment documented the pressure ulcer had granulation tissue and a moderate amount of serosanguinous drainage. The assessment documented the edges of the wound were well defined and irregular. A physician order [REDACTED]. A physician order [REDACTED]. A weekly wound assessment for wound #1, dated 05/21/18, documented the resident had a 2.0 x 2.0 cm stage II pressure ulcer on her coccyx. The assessment documented the pressure ulcer had granulation tissue and a small amount of serosanguinous drainage. The assessment documented the edges of the wound were well defined and the shape was oblong. A skin observation tool for wound #2, dated 05/21/18, documented the resident had a 2.0 x 1.0 friction/shear area on her left buttock. The assessment document the left buttock area had worsened. The assessment did not document any details relating to the wound. A physician order, dated 05/22/18, documented to administer zinc-220 50 mg two times a day to promote wound healing. A physician order, dated 05/22/18, documented to administer vitamin C 500 mg two times a day to promote wound healing. On 05/23/18 at 9:48 a.m., the resident was observed sitting in her recliner. The resident was asked if she had been to the hospital recently. She said, No. The resident was asked if she had any sores on her body. She said, No. The resident was asked if she was in pain. She said, No. On 05/23/18 at 12:15 p.m., the resident was observed sitting in her wheelchair in the dining room. The resident was observed to not eat well. The resident was observed to receive and consume a health shake after her meal as a new intervention for recent weight loss. A physician order [REDACTED]. A weekly wound assessment for wound #2, dated 05/24/18, documented the resident had a 2.0 x 1.0 cm stage II pressure ulcer on her left buttock. The assessment documented the pressure ulcer wound bed was made up of granulation tissue with a small amount of serous drainage. The assessment documented the wound had well defined edges and an irregular shape. The assessment documented the wound was initially a friction/shear area but had worsened to a stage II pressure ulcer. A physician order [REDACTED]. A physician order [REDACTED]. On 05/29/18 at 9:48 a.m., licensed practical nurse (LPN) #1 was observed preparing supplies for the pressure ulcer treatment for [REDACTED]. The LPN commented the resident had two pressure ulcers and an additional new opened area on her right upper buttock. She stated she had just received orders for the new wound. The LPN said she had not been at the facility since Thursday the 24th and had not seen the resident's skin since for the last five days. She was asked if the pressure ulcers looked the same as they had on Thursday. She said they did except for the new one on the right buttock which was not there the last time she saw the resident. The LPN was then asked how she would classify the pressure ulcers. She said the wounds were stage II pressure ulcers. The LPN said the new one looked like an abscess or blister and was not sure if it was a pressure ulcer. The LPN was asked when the pressure ulcer measurements were obtained. She said LPN #2 assessed and measured wounds on Mondays. LPN #1 stated she did not think it had been done the past Monday because of the holiday. The LPN sent CNA #2 to get LPN #2. LPN #1 stated there was a wound consultant who came to the facility but she did not see the resident because the resident was on medicare at that time. On 05/29/18 at 9:53 a.m., LPN #2 entered the resident's room and measured and assessed the resident's pressure ulcers. The resident was observed to have three unstageable pressure ulcers. LPN #2 measured the largest pressure ulcer (#1), which was located on the resident's sacrum area, as 3.5 X 3.0 cm. She measured a thin line of brown necrotic tissue which she said was not there the last time. The LPN did not mention the slough on the ulcer as being a new characteristic of the wound. The pressure ulcer was observed to have rolled edges and a small amount of undermining along top portion. The wound bed was covered with approximately 80% slough. The wound bed, which was not covered with slough, was light pink and smooth. The pressure ulcer was observed to have some depth but was not measured. LPN #2 then measured pressure ulcer (#2), which was located in the coccyx region, as 2.0 x 3.0 cm with a thin line of necrotic tissue. The LPN did not mention the slough in the wound as being a new characteristic. She stated the pressure ulcer started out as two shear/friction areas which came together to form one wound. The LPN said the wound started out to the left of center on the resident's coccyx and was the reason she had identified the location of the wound as the left buttock. The wound bed of the pressure ulcer was observed to be approximately 50% slough. The ulcer had rolled edges. The portion of the ulcer which was not covered in slough was smooth and light pink. The pressure ulcer was observed to have depth but was not measured. After LPN #2 measured and assessed the pressure ulcers, LPN #1 provided the treatment to the pressure ulcer. LPN #1 and CNA #2 were then observed to position the resident on her right side with a pillow. The resident was asked by the surveyor if she had any pain, and she said she did not. LPN #2 then measured pressure ulcer (#3), which was located on the resident's upper right buttock, as 1.0 x 1.0 cm. The pressure ulcer was observed to be 100% covered with slough. The LPN was asked if the two larger pressure ulcers had changed since last week. She said they looked about the same except for the small areas of brown necrotic tissue. She said the necrosis was not there last week. The LPN did not mention the slough which was in the wounds. She was asked how she would stage the pressure ulcers. She said, They are all stage II pressure ulcers, they have no depth. On 05/29/18 at 11:34 a.m., after the surveyor reviewed the pressure ulcer assessments, LPN #2 was asked if the wounds had slough the last time she assessed them. She said they had no slough. The weekly assessments for pressure ulcers #1 and #2 documented the ulcers had granulation tissue. LPN #2, who also completed the minimum data set (MDS) assessments, was asked if she was aware the regulations and the MDS guidelines related to pressure ulcers documentation in which pressure ulcers which have granulation tissue are stage III pressure ulcers. She said she thought ulcers could have granulation and still be a stage II ulcer. The LPN was asked when a pressure ulcer is unstageable. She said when it has necrotic tissue or slough. She said all the ulcers were unstageable. A weekly wound assessment for wound #1, dated 05/29/18, documented the resident had a 3.5 x 3.0 cm unstageable pressure ulcer on her coccyx. The assessment documented the pressure ulcer had slough, necrotic tissue, and a small amount of serosanguinous drainage. The assessment documented the edges of the wound were well defined and irregular. The assessment documented the pressure ulcer had worsened. A weekly wound assessment for wound #2, dated 05/29/18, documented the resident had a 2.0 x 3.0 cm unstageable pressure ulcer on her coccyx. The assessment documented the pressure ulcer contained 75% slough, 1% necrotic tissue, and a small serosanguinous drainage. The assessment documented the wound had well defined edges and an irregular shape. The assessment documented the wound had progressed to an unstageable pressure ulcer since last week. A weekly wound assessment for wound #3, dated 05/29/18, documented the resident had a 1.0 x 1.0 cm unstageable pressure ulcer on her upper right buttock. The assessment documented this was the initial assessment. The assessment documented the pressure ulcer contained 100 % slough. The assessment documented the edges of the wound were well defined edges and irregular. A facimille (fax) to resident's physician, dated 05/29/18, documented, During routine wound care this am, noted slough to wound bed to coccyx & sacral area. Also small amount of necrotic to wound bed. (MONTH) we have an order for [REDACTED].! Thank you! Signed by LPN #1. The physician response documented, Yes, may use Santyl daily with dressing change. Attempt to position patient in such a way as to avoid weight bearing on affected area. The fax was signed by the physician. A physician order [REDACTED]. A physician order [REDACTED]. The order did not document interventions for the slough. On 05/29/18 at 2:59 p.m., LPN #1 was asked if the resident's wounds had slough or necrosis last week. She said they did not. She said she called the doctor and received new orders on 05/24/18 when the shear/friction had worsened and changed to a pressure ulcer. She was asked how she notified the physician. She said by phone or fax. On 05/30/18 at 10:54 a.m., the DON was asked if there was a physician order [REDACTED]. On 05/30/18 at 10:57 a.m., LPN #2 was asked if the physician was notified at the time the resident received the shear/friction areas on her coccyx. The LPN reviewed the record and said she could not find an order until 04/26/18. She said the CNAs had used a barrier cream on the resident as a preventative had continued to use it. She was asked how she knew the CNAs were using it on a regular basis. She stated there was not a place to document it's use. On 05/30/18 at 11:06 a.m., LPN #2 was asked if she contacted the physician on 05/21/18 concerning the resident's shear/friction wound which was documented as being worse. The LPN said she did not. She was asked why she thought the wound had worsened. The LPN said she could not remember why she thought it was worse. She said it just looked worse or was not improving. The LPN said she did not call the physician to inform him of the worsening wound. She said she wrote the order for the zinc and vitamin C. She said the physician and the PA did not care if the nurses wrote orders for vitamins. She was asked if the order for the vitamins had been signed by the physician. She looked for the orders and came back and said the orders had not been returned from physician's office. On 05/30/18 at 3:21 p.m., LPN #2 was asked if she knew if the resident's physician or his PA had seen the resident's wounds. She said they had not. She said the resident had only been out to see her orthopedic physician. She was asked how she notified the physician. She said either by calling or faxing him. On 05/30/18 at 3:22 p.m., LPN #1 was asked over the phone if she knew if the resident's physician or his PA had seen the resident's wounds. She said they had not. On 05/30/18 at 3:24 p.m., LPN #3 was asked if she knew if the resident's physician or his PA had seen the resident's wounds. She said not to her knowledge. The resident's medical record did not document any progress notes from the resident's physician or the PA after the resident returned from the hospital on [DATE]. The orthopedic physician, who was treating her [MEDICAL CONDITION], had notes present in the chart relating to the [MEDICAL CONDITION]. A telephone order, dated 04/26/18, regarding the treatment for [REDACTED]. on 04/28/18. No other documentation from the physician or the PA was documented in the resident's medical record after her return on 04/05/18. On 05/30/18 at 3:30 p.m., the DON said the resident's physician was not available at that time, but the PA would call for an interview regarding the resident. On 05/30/18 at 4:09 p.m., the PA was interviewed by phone regarding the resident wounds. The PA was asked if he had visualized the resident's pressure ulcers. He said he had not. He said if there was something significant about the wounds, he would want the nurses to tell him and he would look at the resident, otherwise he would depend on the nurse to describe the area to him. The PA was asked about nurses writing orders for vitamins without calling him first. He said he gave the nurses some leeway involving pressure ulcers. He said he was fine with them writing this order. He said he would not perform a head to toe assessment on a resident unless a problem came up which was significant. He was asked if he would expect the nurses to call him if a wound had not improved or had become worse. He said, Absolutely! He said if it was significant he wanted them to give him a call or schedule an appointment at the office. The PA was asked if he knew how often the physician saw the resident. The PA said he did not know. The PA was asked if he was aware the shear/friction area on the resident's coccyx was now an unstageable pressure ulcer. He said he was not aware. He said the resident could be difficult at times and was not cooperative. On 05/29/18 at 4:23 p.m., the DON was asked about the physician's involvement in treating and diagnosing the resident's wounds. She said the nurses were responsible for calling the physician and describing the wounds to receive orders for treatments. The DON did not comment on the physician not examining the resident's skin since her re-admission.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' medical care was supervised by a physician for two (#23 and #31) of four residents sampled for wound care. The facility failed to ensure the physician directly examined the resident's wounds in order to diagnose, order effective treatments, and/or monitor and evaluate the effectiveness of the wound treatments ordered for resident #23. The wound stayed at a shear/friction status for six weeks. The wound then progressed from a shear/friction wound to a stage III pressure ulcer within three days, according to the nurse's description of the wound documented on the assessment. The wound then progressed from a stage III pressure ulcer to an unstageable pressure ulcer within five days. The facility identified a second wound as a stage III pressure ulcer, according to the nurse's description of the wound documented on the assessment. The stage III pressure ulcer progressed to an unstageable pressure ulcer within two weeks. The facility identified a third wound, which was assessed as an unstageable pressure ulcer, the day the surveyor observed the treatments. Resident #23 was re-admitted to the facility on [DATE] for skilled services after fracturing her hip. physician progress notes [REDACTED]. The director of nursing (DON) identified 31 residents who resided at the facility. Findings: 1. Resident #23 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A nurse note, dated 04/05/18 at 1:44 p.m., documented the resident had arrived at the facility by emergency medical service. A skin observation tool for wound #2, dated 04/09/18, documented the resident had friction/shear areas on her left buttock which measured 0.5 x 0.5 centimeter (cm) and 2.0 x 3.0 cm. A quarterly assessment, dated 04/09/18, documented the resident was severely cognitively impaired and had no rejection of care behaviors. The assessment documented the resident required extensive assistance with bed mobility, transfers, toilet use, and did not walk. The assessment documented the resident had one fall with major injury, [DIAGNOSES REDACTED]. The assessment documented the resident was frequently incontinent of urine, occasionally incontinent of bowel, was 67 inches ('') in height, and weighed 126 pounds (#). The assessment documented the resident was at risk for pressure ulcers, had surgical wounds, and did not have any pressure ulcers or open [MEDICAL CONDITION]. The assessment documented the resident had received surgical wound care and pressure reducing devices for her bed and chair. The assessment documented the resident had not received any applications of ointments and the physician or the authorized assistant or practitioner had not examined the resident in the last 14 days. A nurse note, dated 04/11/18, documented the physician assistant (PA) was at the facility for nursing home rounds and no orders were obtained for the resident. The note did not document the PA had a direct visit with the resident. The resident's medical record did not document any other visits or exams by the P[NAME] The resident's record did not contain physician progress notes [REDACTED]. The resident's record did not document an order for [REDACTED]. A significant change assessment, dated 04/12/18, documented the resident was severely cognitively impaired and had no rejection of care behaviors. The assessment documented the resident required extensive assistance with bed mobility, transfers, toilet use, and did not walk. The assessment documented the resident had a [DIAGNOSES REDACTED]. The assessment documented the resident was frequently incontinent of urine, occasionally incontinent of bowel, was 67'' in height, and weighed 126#. The assessment documented the resident was at risk for pressure ulcers, had surgical wounds, and did not have any pressure ulcers or open [MEDICAL CONDITION]. The assessment documented the resident had received surgical wound care, applications of ointments, and pressure reducing devices for her bed and chair. The assessment documented the physician or the authorized assistant or practitioner had not examined the resident in the last 14 days. The care plan, dated 04/12/18, documented the resident had friction/shear areas observed on her buttocks which were to be treated daily and monitored both daily and weekly. The care plan documented resident had developed a stage II pressure ulcer to her coccyx due to her limited mobility status, recent right [MEDICAL CONDITION], and incontinence. The care plan documented the resident did not like to go to bed to stay off her back, would sit in her recliner most of the day, and was up in her wheelchair for meals and therapy. The care plan documented her skin was to have been monitored daily during care by the certified nursing aides (CNAs), weekly by a licensed nurse, and any abnormalities were to have been reported to the charge nurse. The care plan documented the resident would deny any issues with her skin. The care plan documented the staff were to administer vitamin C 500 milligrams (mg) twice a day and zinc 220 mg by mouth twice a day to promote wound healing. The care plan documented the staff were to assist the resident with turning and repositioning every two hours when in bed and monitor her nutritional status each meal. The care plan documented the staff were to encourage the resident to shift her weight every 15 minutes when up in the wheelchair. The care plan documented the resident was to be assisted with incontinent care as needed, to keep the resident's skin clean and dry, and to apply a barrier cream as she was at risk for pressure ulcers due to her incontinence. A skin observation tool for wound #2, dated 04/16/18, documented the resident had friction/shear areas on her left buttock which measured 0.5 x 0.5 cm and 2.0 x 3.0 cm. A prospective payment system (PPS) 14 day assessment, dated 04/18/18, documented the resident was moderately cognitively impaired and had no rejection of care behaviors. The assessment documented the resident required extensive assistance with bed mobility, was occasionally incontinent of urine, and was frequently incontinent of bowel. The assessment documented the resident attended PT and OT and was 67'' in height and weighed 126#. The assessment documented the resident was at risk for pressure ulcers but did not have any pressure ulcers or open [MEDICAL CONDITION]. The assessment documented the resident had moisture associated skin damage (MASD) and received applications of ointments. The assessment documented the physician or the authorized assistant or practitioner had not examined the resident in the last 14 days. A skin observation tool for wound #2, dated 04/23/18, documented the resident had friction/shear areas on her left buttock which measured 0.5 x 0.5 cm and 2.0 x 3.0 cm. A nurse note, dated 04/26/18, documented the resident had sheared areas to her left buttock/coccyx and treatment orders were obtained. A physician order [REDACTED]. A skin observation tool for wound #2, dated 04/30/18, documented the resident had friction/shear areas on her left buttock which measured 0.5 x 0.5 cm and a 2.0 x 3.0 cm. A PPS 30 day assessment, dated 05/03/18, documented the resident was moderately cognitively impaired and had rejection of care behaviors one to three days of the seven day look back period. The assessment documented the resident required extensive assistance with bed mobility, attended PT and OT, and was 67'' in height and weighed 114#. The assessment documented the resident was at risk for pressure ulcers but did not have any pressure ulcers or open [MEDICAL CONDITION]. The assessment documented the resident was frequently incontinent of urine and bowel, had MASD, and received applications of ointments. The assessment documented the physician or the authorized assistant or practitioner had not examined the resident in the last 14 days. A skin observation tool for wound #2, dated 05/07/18, documented the resident had a 2.0 x 1.0 cm friction/shear area on her left buttock. A skin observation tool for wound #2, dated 05/14/18, documented the resident had a 2.0 x 1.0 cm friction/shear area on her left buttock. A weekly wound assessment for wound #1, dated 05/14/18, documented the resident had a 2.0 x 2.0 cm stage II pressure ulcer on her coccyx. The assessment documented the pressure ulcer had granulation tissue and a moderate amount of serosanguinous drainage. The assessment documented the edges of the wound were well defined and irregular. A physician order [REDACTED]. A physician order [REDACTED]. A weekly wound assessment for wound #1, dated 05/21/18, documented the resident had a 2.0 x 2.0 cm stage II pressure ulcer on her coccyx. The assessment documented the pressure ulcer had granulation tissue and a small amount of serosanguinous drainage. The assessment documented the edges of the wound were well defined and the shape was oblong. A skin observation tool for wound #2, dated 05/21/18, documented the resident had a 2.0 x 1.0 friction/shear area on her left buttock. The assessment document the left buttock area had worsened. The assessment did not document any details relating to the wound. A physician order, dated 05/22/18, documented to administer zinc-220 50 mg two times a day to promote wound healing. A physician order, dated 05/22/18, documented to administer vitamin C 500 mg two times a day to promote wound healing. On 05/23/18 at 9:48 a.m., the resident was observed sitting in her recliner. The resident was asked if she had been to the hospital recently. She said, No. The resident was asked if she had any sores on her body. She said, No. The resident was asked if she was in pain. She said, No. On 05/23/18 at 12:15 p.m., the resident was observed sitting in her wheelchair in the dining room. The resident was observed to not eat well. The resident was observed to receive and consume a health shake after her meal as a new intervention for recent weight loss. A physician order [REDACTED]. A weekly wound assessment for wound #2, dated 05/24/18, documented the resident had a 2.0 x 1.0 cm stage II pressure ulcer on her left buttock. The assessment documented the pressure ulcer wound bed was made up of granulation tissue with a small amount of serous drainage. The assessment documented the wound had well defined edges and an irregular shape. The assessment documented the wound was initially a friction/shear area but had worsened to a stage II pressure ulcer. A physician order [REDACTED]. A physician order [REDACTED]. On 05/29/18 at 9:48 a.m., licensed practical nurse (LPN) #1 was observed preparing supplies for the pressure ulcer treatment for [REDACTED]. The LPN commented the resident had two pressure ulcers and an additional new opened area on her right upper buttock. She stated she had just received orders for the new wound. The LPN said she had not been at the facility since Thursday the 24th and had not seen the resident's skin since for the last five days. She was asked if the pressure ulcers looked the same as they had on Thursday. She said they did except for the new one on the right buttock which was not there the last time she saw the resident. The LPN was then asked how she would classify the pressure ulcers. She said the wounds were stage II pressure ulcers. The LPN said the new one looked like an abscess or blister and was not sure if it was a pressure ulcer. The LPN was asked when the pressure ulcer measurements were obtained. She said LPN #2 assessed and measured wounds on Mondays. LPN #1 stated she did not think it had been done the past Monday because of the holiday. The LPN sent CNA #2 to get LPN #2. LPN #1 stated there was a wound consultant who came to the facility but she did not see the resident because the resident was on medicare at that time. On 05/29/18 at 09:53 a.m., LPN #2 entered the resident's room and measured and assessed the resident's pressure ulcers. The resident was observed to have three unstageable pressure ulcers. LPN #2 measured the largest pressure ulcer (#1), which was located on the resident's sacrum area, as 3.5 X 3.0 cm. She measured a thin line of brown necrotic tissue which she said was not there the last time. The LPN did not mention the slough on the ulcer as being a new characteristic of the wound. The pressure ulcer was observed to have rolled edges and a small amount of undermining along top portion. The wound bed was covered with approximately 80% slough. The wound bed, which was not covered with slough, was light pink and smooth. The pressure ulcer was observed to have some depth but was not measured. LPN #2 then measured pressure ulcer (#2), which was located in the coccyx region, as 2.0 x 3.0 cm with a thin line of necrotic tissue. The LPN did not mention the slough in the wound as being a new characteristic. She stated the pressure ulcer started out as two shear/friction areas which came together to form one wound. The LPN said the wound started out to the left of center on the resident's coccyx and was the reason she had identified the location of the wound as the left buttock. The wound bed of the pressure ulcer was observed to be approximately 50% slough. The ulcer had rolled edges. The portion of the ulcer which was not covered in slough was smooth and light pink. The pressure ulcer was observed to have depth but was not measured. After LPN #2 measured and assessed the pressure ulcers, LPN #1 provided the treatment to the pressure ulcer. LPN #1 and CNA #2 were then observed to position the resident on her right side with a pillow. The resident was asked by the surveyor if she had any pain, and she said she did not. LPN #2 then measured pressure ulcer (#3), which was located on the resident's upper right buttock, as 1.0 x 1.0 cm. The pressure ulcer was observed to be 100% covered with slough. The LPN was asked if the two larger pressure ulcers had changed since last week. She said they looked about the same except for the small areas of brown necrotic tissue. She said the necrosis was not there last week. The LPN did not mention the slough which was in the wounds. She was asked how she would stage the pressure ulcers. She said, They are all stage II pressure ulcers, they have no depth. On 05/29/18 at 11:34 a.m., after the surveyor reviewed the pressure ulcer assessments, LPN #2 was asked if the wounds had slough the last time she assessed them. She said they had no slough. The weekly assessments for pressure ulcers #1 and #2 documented the ulcers had granulation tissue. LPN #2, who also completed the minimum data set (MDS) assessments, was asked if she was aware the regulations and the MDS guidelines related to pressure ulcers documentation in which pressure ulcers which have granulation tissue are stage III pressure ulcers. She said she thought ulcers could have granulation and still be a stage II ulcer. The LPN was asked when a pressure ulcer is unstageable. She said when it has necrotic tissue or slough. She said all the ulcers were unstageable. A weekly wound assessment for wound #1, dated 05/29/18, documented the resident had a 3.5 x 3.0 cm unstageable pressure ulcer on her coccyx. The assessment documented the pressure ulcer had slough, necrotic tissue, and a small amount of serosanguinous drainage. The assessment documented the edges of the wound were well defined and irregular. The assessment documented the pressure ulcer had worsened. A weekly wound assessment for wound #2, dated 05/29/18, documented the resident had a 2.0 x 3.0 cm unstageable pressure ulcer on her coccyx. The assessment documented the pressure ulcer contained 75% slough, 1% necrotic tissue, and a small serosanguinous drainage. The assessment documented the wound had well defined edges and an irregular shape. The assessment documented the wound had progressed to an unstageable pressure ulcer since last week. A weekly wound assessment for wound #3, dated 05/29/18, documented the resident had a 1.0 x 1.0 cm unstageable pressure ulcer on her upper right buttock. The assessment documented this was the initial assessment. The assessment documented the pressure ulcer contained 100 % slough. The assessment documented the edges of the wound were well defined edges and irregular. A facimille (fax) to resident's physician, dated 05/29/18, documented, During routine wound care this am, noted slough to wound bed to coccyx & sacral area. Also small amount of necrotic to wound bed. (MONTH) we have an order for [REDACTED].! Thank you! Signed by LPN #1. The physician response documented, Yes, may use Santyl daily with dressing change. Attempt to position patient in such a way as to avoid weight bearing on affected area. The fax was signed by the physician. A physician order [REDACTED]. A physician order [REDACTED]. The order did not document interventions for the slough. On 05/29/18 at 2:59 p.m., LPN #1 was asked if the resident's wounds had slough or necrosis last week. She said they did not. She said she called the doctor and received new orders on 05/24/18 when the shear/friction had worsened and changed to a pressure ulcer. She was asked how she notified the physician. She said by phone or fax. On 05/30/18 at 10:54 a.m., the DON was asked if there was a physician order [REDACTED]. On 05/30/18 at 10:57 a.m., LPN #2 was asked if the physician was notified at the time the resident received the shear/friction areas on her coccyx. The LPN reviewed the record and said she could not find an order until 04/26/18. She said the CNAs had used a barrier cream on the resident as a preventative had continued to use it. She was asked how she knew the CNAs were using it on a regular basis. She stated there was not a place to document it's use. On 05/30/18 at 11:06 a.m., LPN #2 was asked if she contacted the physician on 05/21/18 concerning the resident's shear/friction wound which was documented as being worse. The LPN said she did not. She was asked why she thought the wound had worsened. The LPN said she could not remember why she thought it was worse. She said it just looked worse or was not improving. The LPN said she did not call the physician to inform him of the worsening wound. She said she wrote the order for the zinc and vitamin C. She said the physician and the PA did not care if the nurses wrote orders for vitamins. She was asked if the order for the vitamins had been signed by the physician. She looked for the orders and came back and said the orders had not been returned from physician's office. On 05/30/18 at 3:21 p.m., LPN #2 was asked if she knew if the resident's physician or his PA had seen the resident's wounds. She said they had not. She said the resident had only been out to see her orthopedic physician. She was asked how she notified the physician. She said either by calling or faxing him. On 05/30/18 at 3:22 p.m., LPN #1 was asked over the phone if she knew if the resident's physician or his PA had seen the resident's wounds. She said they had not. On 05/30/18 at 3:24 p.m., LPN #3 was asked if she knew if the resident's physician or his PA had seen the resident's wounds. She said not to her knowledge. The resident's medical record did not document any progress notes from the resident's physician or the PA after the resident returned from the hospital on [DATE]. The orthopedic physician, who was treating her [MEDICAL CONDITION], had notes present in the chart relating to the [MEDICAL CONDITION]. A telephone order, dated 04/26/18, regarding the treatment for [REDACTED]. on 04/28/18. No other documentation from the physician or the PA was documented in the resident's medical record after her return on 04/05/18. On 05/30/18 at 3:30 p.m., the DON said the resident's physician was not available at that time, but the PA would call for an interview regarding the resident. On 05/30/18 at 4:09 p.m., the PA was interviewed by phone regarding the resident wounds. The PA was asked if he had visualized the resident's pressure ulcers. He said he had not. He said if there was something significant about the wounds, he would want the nurses to tell him and he would look at the resident, otherwise he would depend on the nurse to describe the area to him. The PA was asked about nurses writing orders for vitamins without calling him first. He said he gave the nurses some leeway involving pressure ulcers. He said he was fine with them writing this order. He said he would not perform a head to toe assessment on a resident unless a problem came up which was significant. He was asked if he would expect the nurses to call him if a wound had not improved or had become worse. He said, Absolutely! He said if it was significant he wanted them to give him a call or schedule an appointment at the office. The PA was asked if he knew how often the physician saw the resident. The PA said he did not know. The PA was asked if he was aware the shear/friction area on the resident's coccyx was now an unstageable pressure ulcer. He said he was not aware. He said the resident could be difficult at times and was not cooperative. On 05/29/18 at 4:23 p.m., the DON was asked about the physician's involvement in treating and diagnosing the resident's wounds. She said the nurses were responsible for calling the physician and describing the wounds to receive orders for treatments. The DON did not comment on the physician not examining the resident's skin since her re-admission. 2. Resident #31 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A prospective payment schedule (PPS) five day assessment, dated 04/24/18, documented the resident was cognitively intact. The assessment documented the resident required supervision to extensive assistance with most activities of daily living and did not walk. The assessment documented the resident had two stage II pressure ulcers which were present on admission. A weekly wound observation tool, dated 5/21/18, documented the top of the resident's right leg was observed to have a scabbed area without signs or symptoms of infection. The tool documented the staff were to clean the wound with normal saline, apply calcium alginate, and a dry dressing daily for 14 days and then reevaluate the wound. A weekly wound observation tool, dated 5/21/18, documented the resident had a stage II wound on the back of her right leg which measured two centimeters (cm) by two cm with a small amount of serosanguinous drainage. The tool documented the staff were to clean the area with normal saline, apply calcium alginate, and a dry dressing daily for 14 days then reevaluate the wound. On 05/30/18 at 3:40 p.m., the resident's wounds were observed. The wound on the front of her right leg was scabbed and the wound on the back of her right leg was moist in appearance. Measurements of the wounds were not obtained with this observation. On 05/30/18 at 4:09 p.m., the resident's primary care provider was interviewed and reported he had not seen the resident's leg wounds. On 05/30/18 at 4:22 p.m., the resident was interviewed about the wounds on her right leg. The resident reported she obtained the wounds the previous year from limbs of a tree which fell in her yard. She stated she scrapped her legs in two places and they had not healed. On 05/30/18 at 4:52 p.m., the minimum data set (MDS) coordinator and the director of nursing (DON) were interviewed about the resident's leg wounds. The DON reported the wounds were non-healing wounds and were complicated by the resident's poor circulation. The DON and the MDS reported, to their knowledge, neither the resident's physician or the resident's physician assistant had examined the resident's wounds.

Based on record review, observation and interview, it was determined the facility failed to: a. Ensure adequate supervision was provided and new interventions were implemented to prevent falls for three (#4, 6 and #14) of nine residents sampled for falls. This resulted in harm to residents #6 and #14. This had the potential to affect seven residents at risk for falls per the DON. b. Ensure surface to surface transfers were conducted in a safe manner for (#6) of six sampled residents who were observed being transferred. This had the potential to affect 33 residents who needed assistance with transfers per the DON. Findings: 1. Resident #6 had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A 'Fall Risk Assessment' dated 04/17/13, scored the resident as a high fall risk. An admission assessment, dated 04/30/13, documented the resident had moderately impaired cognition, was depressed, had a problem concentrating, required extensive assist with transfers, bed mobility, dressing, hygiene, toileting and bathing, had one sided ROM deficiency, was frequently incontinent of bowel and bladder, and did not identify any falls in the past. The resident's original care plan documented the resident was at risk for falls r/t the use of anti-depressants, anti- anxiety and anti-psychotic medications. The interventions included the resident was to have assist with transfers, keep call light within reach and be encouraged to use it, and to answer her call light in a timely manner. Interventions included she would be monitored daily for side effects and behaviors, would have a pharmacist review her medications monthly, would be monitored for the effectiveness of medications, would have assist with transfers as needed, would have her call light within reach and be encouraged to use it, and staff would answer her call light in a timely manner. The resident's medications included Remeron (anti-depressant), Xanax (anti-anxiety), Seroquel (anti-psychotic), and Zyprexa (anti-psychotic). These medications could cause an increase in falls as documented in the resident's care plan. On 06/14/13 at 11:00 p.m., an incident report documented the resident was found sitting on the floor at bedside. (L) knee abrasion 1 x 1. "Suggested Safety Precautions To Prevent Recurrence: Monitor freq. Ensure call light within reach." On 06/19/13 at 12:30 a.m., the resident fell from the bed. She was not injured. On 06/25/13, the resident was discharged from OT and placed on restorative services. An incident report, dated 07/21/13 at 10:00 a.m., documented the resident had fallen out of her W/C in the living room area. "Resident wheeled self into living room area, attempted to transfer self from wheelchair to recliner. Slid onto floor. VS taken condition assessed. No injuries found. Suggested Safety Precautions To Prevent Recurrence: Check on resident frequently. Have resident sit within." A temporary care plan, dated 07/21/13, documented, "Attempted to transfer self fell from W/C. (Intervention) Cont c falling star. *Freq checks." An incident report, dated 07/23/13 at 6:30 a.m., documented the resident had fallen out of her W/C in the living area. "CNA called CN to L/R. Resident lying on floor on Lt side hit Lt side of forehead. C/O Lt shoulder, head and neck. Sm 1/2 cm abrasion on Lt frontal lobe...Sent to ER... Suggested Safety Precautions To Prevent Recurrence: Instructed staff to insure resident has proper body arrangement while in chair. Encouraged resident not to lean forward in W/C." A nurse's note, dated 07/23/13, documented EMS had arrived at 6:50 a.m., and placed a C-collar on the resident's neck...C/O pain when moved. A temporary care plan, dated 07/23/13, documented, "fell on to floor causing abrasion on (L) side frontal lobe. (Interventions included) Proper body alignment in bed. Monitor when resident is up in W/C not leaning forward. *On falling star program." These were the same interventions. There were no new interventions attempted since the last fall. An incident report, dated 07/23/13 at 4:00 p.m., documented the resident had fallen out of her W/C in her room. "As nurse was walking past residents room she was trying to get up out of W/C et (and) fell to the floor...Skin tear to Lt lower ext. noted. 2.5 cm x 2.0 cm..." Suggest Safety Precautions To Prevent Recurrence: None A nurse's note, dated 07/23/13 at 4:00 p.m., documented the resident trying to get out of her W/C, fell on to (R) hip. Received a LE skin tear, 2.5cm x 2.0cm. The physician ordered an X-ray to the right hip and knee. A temporary care plan, dated 07/23/13, documented, "Attempting to get ^ OOF W/C (L) lower ext S/T 2.5cm x 2.0cm. (Intervention) Cont with falling star*" There were no new interventions attempted to prevent falls. A 'Fall Risk Assessment' dated 07/31/13, scored the resident as a high risk for falls. On 07/31/13, the risk for falls care plan was revised. "(Resident's Name deleted) has had a fall in the last 30 days. Cont c medications as ordered..." There were no new interventions attempted to prevent falls. An incident report, dated 08/10/13 at 9:15 p.m., documented the resident had fallen out of her W/C in the living room area. "Was up in W/C & tried to transfer self. Setting on edge of W/C & slipped out. Sat on floor. 0 injuries noted 2 present time... Suggested Safety Precautions To Prevent Recurrence: Cont to monitor frequently. Toileting q 2 hrs." An acute temporary care plan, dated 08/10/13, documented the resident had a fall. Interventions were to "visually monitor the resident when she is up in W/C, remind resident to call for assist for transfers, visually monitor if resident is amb, monitor gait, and provide assist if resident appears unsteady or fatigued including safety issues, and toilet PRN and provide incont/peri care accordingly offer snack or other diversion to provide resident interaction. Cont c falling star program." She was in the living room when she fell which was next to the nurses' station. Anyone at the nurses' station could see out into the living room where the resident was sitting. The resident's cognition was moderately impaired and she was unable to remember things, so the reminder for her to call for assistance was not an appropriate intervention. The resident was non-ambulatory. Monitoring her gait and providing assistance if she appeared unsteady was not an appropriate intervention. An incident report, dated 10/14/13 at 8:00 p.m., documented the resident had fallen out of her W/C in the living room. "Slid out of W/C onto the floor grabbed ahold of the leg of the W/C and obtained a skin tear. ROM WNL. 0 other apparent injuries noted... Suggested Safety Precautions To Prevent Recurrence: Staff to do more freq visual checks to make sure she is toileted & positioned properly in her chair..." An acute temporary care plan, dated 10/14/13, documented, "...visually monitor the resident when she is up in W/C, remind resident to call for assist for transfers, visually monitor if resident is amb, monitor gait, and provide assist if resident appears unsteady or fatigued including safety issues, and toilet PRN and provide incont/peri care accordingly offer snack or other diversion to provide resident interaction." The past interventions had been ineffective at preventing further falls. New interventions had not been attempted. Another acute temporary care plan, dated 10/14/13, documented, "Slid out of W/C. Obtained S/T palm of (R) hand app 3 cm. Visually monitor the resident when she is up in W/C, remind resident to call for assist for transfers, visually monitor if resident is amb, monitor gait, and provide assist if resident appears unsteady or fatigued including safety issues, and toilet PRN and provide incont/peri care accordingly offer snack or other diversion to provide resident interaction." The past interventions had been ineffective at preventing further falls. New interventions had not been attempted. A 'Fall Risk Assessment' dated 10/31/13, scored the resident as a high risk for falls. The care plan for falls was revised on 10/31/13. "Cont @ risk for falls. Cont c meds as ordered..." An acute temporary care plan, dated 11/22/13, documented, "Slid out of W/C (R) side ST (R) elbow 0.8cm. Tx in place & ordered. Visually monitor. Make sure (Resident's Name deleted) is properly positioned." A physician's telephone order, dated 01/09/14, documented, P.T. evaluate and treat. P.T. clarification: Physical therapy services 3-5 x wk x 30 days for training in bed mobility, transfers, balance & gait (if possible) & therapeutic ex for strengthening." A physician's telephone order, dated 01/10/14, documented, "OT clarification. Pt. to be seen 3-5/week..." On 01/25/14 at 2:30 a.m., an incident report documented the resident had fallen out of bed. Suggested Safety Precautions To Prevent Recurrence: Encourage to use the call light. An acute temporary care plan, dated 01/25/14, documented, "Sitting beside bed. No injuries. Remind resident to call for assist for transfers. Cont on falling star program. A 'Fall Risk Assessment' dated 01/30/14, scored the resident as a high fall risk. The care plan at risk for falls was revised on 01/30/14, "Has had a fall in the last quarter. Cont meds as ordered." A quarterly assessment, dated 01/31/14, identified the resident with moderately impaired cognition, short and long term memory loss, required extensive assistance of one person for bed mobility, transfers, dressing, hygiene/bathing, and toileting. The resident had falls and one fall had caused injury. An incident report, dated 02/04/14 at 6:10 a.m., documented the resident fell out of her W/C in the TV room beside the nurse's station. "fell forward out of W/C & hit face first on floor in TV room c head injury noted Lt knuckles skinned/swollen... Suggested Safety Precautions To Prevent Recurrence: ^ visual checks for safety precautions to prevent a fall. admitted to hospital this am." A temporary care plan, dated 02/04/14, documented, "fell forward out of W/C hit face on floor (L) forehead laceration, skint (Lt) knuckles. Sent out to ER." A temporary care plan, dated 02/04/14, documented, "Rolled out of bed thought she had more room. Make frequent visual checks & position correctly in bed." A care plan, dated 02/10/14, documented the resident had fallen and had, "Laceration forehead sutures x 2. Remove sutures 2-19-14." On 02/28/14 at 9:30 p.m., an incident report documented the resident had rolled out of bed and received a skin tear. "Suggested Safety Precautions To Prevent Recurrence: Frequent visual checks for positioning in bed." A temporary care plan, dated 03/06/14, documented, "fell forward out of W/C hit head on floor (L) S/T elbow & ^ (L) arm. Tx in place... Cont neuro's until complete report any abnormalities. Cont falling star program. On 03/14/14/at 3:30 p.m., the resident's W/C was observed setting in the resident's room. A regular cushion was on the W/C seat. A temporary care plan, dated 04/13/14, documented, "fell out of bed hitting (L) side forehead 1.0 x 3.0 hematoma. Visually monitor. Neuro's started." On 04/16/14 at 9:05 a.m., the ADM and DON were interviewed regarding the numerous falls and the subdural hematoma experienced by the resident. They were asked for documentation for any interventions other than to monitor the resident when the falls continued to occur. The DON reported the facility had requested a PT/OT referral after the resident had experienced some falls. The medical record documented the resident had already experienced 7 falls before the referral to PT/OT was requested, and another fall had occurred after the referral. The DON was asked if any other interventions were attempted after the resident began having repeated falls. The DON replied they had not tried any new interventions. The DON was asked if she had reported falls to the QA committee in order to identify repeated falls, to investigate common causes, and to implement and change corrective actions. She stated, "No." The ADM was asked if the QA committee had been involved in determining if new interventions were warranted in an attempt to prevent repeated falls and/or further injuries. The ADM reported the QA committee had not discussed repeated falls or interventions to prevent repeated falls. At 2:45 p.m., the QA nurse was asked what she thought about all the resident's falls. The QA nurse reported she thought they had tried a slanted cushion for the resident's W/C. She was asked to bring documentation to support the attempts tried. No other documentation was brought to the surveyor to show attempts had been tried to prevent the resident from slipping out of the W/C. The resident had fallen out of her W/C a total of seven times, with four different times causing a head injury to the resident. The resident had fallen out of her bed a total of five times causing injuries, one being a head injury. 2. Resident #14 was admitted to the facility, on 10/19/13, with [DIAGNOSES REDACTED]. and Fractured R foot. An incident report, dated 10/20/13, documented the resident was sitting on the floor at her bedside and said she wanted to get up. No injury. The preventive measures documented to place a safety mat on the floor at the bedside and place the bed in the low position. An IR, dated 10/20/13, documented the resident was sitting on the edge of her bed and tried to stand and slid off the bed onto the floor mat. No injury. The preventive measures documented for the staff to make frequent visual checks, toilet her and teach her to use the call light. An IR, dated 10/25/13, documented the resident was sitting in the W/C in the living room and tried to get out of her W/C and fell on the floor. No injury. The preventive measures documented for the staff to toilet her before and right after meals and put her to bed if she wanted. Resident on the Falling Star Program. An IR, dated 11/10/13, documented the resident was in her W/C in the Living Room area. She attempted to get out of the W/C and fell on the floor. The resident received a (R) hip fracture. The preventive measures documented to keep the resident within sight of the nurses station when up in the W/C and to visually monitor the resident frequently. An IR, dated 12/09/13, documented the resident was in the Living Room in the W/C and attempted to get up without assistance and fell on to right side. No injury. The preventive measures were to encourage the resident to call for assistance for help with all transfers and remind her that she had a hip fracture. PT working with resident to help strengthen. An IR, dated 12/30/13, documented the resident was in the Living Room, got out of her W/C without assist, was unable to stand and fell to the floor. No injury. The preventive measures documented to visually check more frequently and to toilet after meals and implemented the Bowel & Bladder program. A recommendation for the physician to look at her psychoactive medications was made. The physician did not agree to attempt a reduction. An IR, dated 01/14/14, documented the resident was in the living area and the resident said she fell out of her W/C trying to get up and walk. No injury. The preventive measures documented to visually monitor when up in the W/C and offer a midmorning snack. A care plan, dated 01/30/14, documented, "(Res name deleted) is at risk for falls due to the use of antianxiety, antidepressant and antipsychotic medications...She has had a recent fall and fracture in the last 90 days...She is sometimes able to verbalize her needs..." A quarterly assessment, dated 02/01/14, documented the resident was cognitively impaired, needed the extensive assistance of two people with transfers and did not ambulate or propel herself in the W/C. An IR, dated 02/17/14, documented the resident was sitting in her W/C in the living room and slid out onto the floor. No injury. The preventive measures documented for the staff to make sure she was positioned properly and continue to lock the W/C. Apply a no-glide cushion in chair. An IR, dated 04/08/14, documented the resident was sitting in the W/C in the living room and leaned forward and fell on the floor. The preventive measures documented to increase visual checks and involve in activities. On 04/18/14, at 10:55 a.m., the resident was observed participating in a group activity in the dining room. At 4:40 p.m., the DON was asked if there was any documentation of increased visual monitoring of the resident. She said she did not have any. The DON was asked if reminding the resident to remember to call for assistance is an effective preventive measure if the resident has dementia. She said it wasn't. 3. Resident #4 was admitted to the facility, on 05/01/13, with CHF, weakness/deconditioning and dementia. An admission assessment, dated 05/14/13, documented the resident had moderately impaired cognition, needed extensive assistance with bed mobility and transfers and had falls prior to admission. An incident report (IR), dated 06/04/13, documented the resident was sitting on the floor in front of the bed and stated she wanted to go to the bathroom. The preventive measures documented to monitor closely and assist with transfer and toilet every two hours. An IR, dated 06/22/13, documented the resident tried to stand and slipped during a shower. The resident received a 3 cm skin tear to her RUE. The preventive measures documented to notify PT of falls, work with safety awareness and continue the Falling Star Program. An IR, dated 06/23/13, documented the resident was beside the bed on the floor and stated she was trying to go to the dining room. The IR report documented the wheelchair was not locked. The preventive measures documented to bring her to the living room for monitoring, anticipate needs, and visually monitor. An IR, dated 07/01/13, documented the resident was found on the floor beside her bed. No new preventive measures were documented. An IR, dated 07/08/13, documented the resident was sitting on the edge of the W/C and fell on the floor. The preventive measures documented to position the resident properly in the W/C and lock the W/C. An IR, dated 07/14/13, documented the resident was attempting to transfer from the chair to the W/C and the W/C rolled and the resident fell in the floor. No new preventive measures were documented. An IR, dated 08/08/13, documented the resident was transferring herself to the chair and the W/C rolled and she fell on her bottom. No new preventive measures were documented. An IR, dated 08/15/13, documented the resident fell out of her W/C. No new preventive measures were documented. An IR, dated 08/23/13, documented the W/C rolled out from the resident in the living room. The resident received a skin tear to her RUE. No new preventive measures were documented. An IR, dated 09/02/13, documented the resident slipped out of her W/C in the bathroom. No new preventive measures were documented. An IR, dated 09/07/13, documented the resident was found on her right side beside her W/C in the living room. No new preventive measures were documented. An IR, dated 09/08/13, documented the resident fell while transferring herself. No new preventive measures were documented. An IR, dated 09/21/13, documented the resident was found on the floor in the living room in front of her W/C. The resident received a skin tear to her elbow. The preventive measures documented to lie the resident down if she seemed tired. An IR, dated 10/05/13, documented the resident slid off her W/C. No new preventive measures were documented. An IR, dated 01/29/14, documented the resident slipped down on the bathroom floor while transferring from her W/C to the commode. The preventive measures documented to encourage her to call for assistance for transfers and ADLs. A quarterly assessment, dated 02/22/14, documented the resident had moderately impaired cognition, needed limited assistance with bed mobility and transfers and had one fall with no injury since the last assessment. On 04/14/14, at 3:30 p.m., the resident was observed sitting in a chair in the Living Room. On 04/15/14, at 4:40 p.m., the DON was asked if there was any documentation of increased visual monitoring of the resident. She said she did not have any. On 04/18/14, at 4:25 p.m., the DON was informed the resident had fallen a total of 15 times from June 2013 thru January 2014. She was asked why the steps to prevent reoccurrence were not changed or modified after the resident continued to fall. She said she didn't know why. 4. The quarterly assessment, dated 01/31/14, documented resident #6 had poor cognition skills, required the extensive assistance of one person for bed mobility, transferring, hygiene and toileting. On 04/14/14 at 3:30 p.m., CNA #6 and CNA #7 were observed providing incontinent care for the resident. The resident was in her W/C requesting to sit on the BSC. The CNAs placed a gait belt around the resident and also placed their arms underneath the residents arms and had her stand. This also placed the resident's weight on her arms. On 04/17/14 at 3:30 p.m., the DON was informed of the transfer placing weight on the resident's arms. She reported they know better.

Based on observation, record review and staff interview, it was determined the facility was not being administered in an effective manner to: Ensure adequate supervision was provided and new interventions were implemented to prevent falls for three (#4, 6 and #14) of nine residents sampled for falls. This resulted in harm to residents #6 and #14. This had the potential to affect seven residents at risk for falls per the DON. Please refer to F323.

Based on record review and staff interview, it was determined the facility failed to ensure an effective quality assurance program was in place to: Ensure adequate supervision was provided and new interventions were implemented to prevent falls for three (#4, 6 and #14) of nine residents sampled for falls. This resulted in harm to residents #6 and #14. This had the potential to affect seven residents at risk for falls per the DON. Please refer to F323.

Based on observation, interview and record review, it was determined the facility failed to: a. Provide psychological services for a resident who had grief about the loss of his mother, had anxiety about the possibility of having to leave the facility in the future after his grandmother expires and anxiety about using the toilet for one (#16) of four sampled residents whose social service records were reviewed. b. Provide psychological services for a resident who was emotionally distraught after she experienced changes in a family relationship for one (#6) of four sampled residents whose social service records were reviewed. This had the potential to affect all 39 residents residing in the facility. Findings: 1. Resident #16 was [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated [DATE], documented, "Neighbor has been upset over the past few days, increased anxiety, call was place to (physician's name deleted) with NO for [MEDICATION NAME] 0.5 mg 1 po BID x 5 days, anxiety." A quarterly assessment, dated [DATE], documented the resident was cognitively intact, had no mood indicators or behaviors, had unclear speech and always understands, needed extensive assist with transfers and toilet use, did not ambulate, needed set-up and supervision help only with eating, always continent of bladder and always incontinent of bowel. The care plan, dated [DATE], documented, "...He is usually continent of bladder using a urinal. He is incontinent of bowels. (Res name deleted) will be checked q 2 hours and changed as needed...will have incontinent care after each incontinent episode...He has some sensory impairment of his lower extremities...He is unable to ambulate due to his weakness in his lower ext. He uses a wheelchair as his primary mode of transport. Staff will allow (Res name deleted) to perform adl's independently as tolerated...(Res name deleted) is alert and oriented x 3. He is usually able to verbalize his needs. He sometimes has trouble with expressing himself due to his impaired speech. He is pleasant and cooperative with care..." On [DATE], at 11:00 a.m., at the end of the group meeting, resident #16 requested to meet with the surveyors privately. The resident said (QA nurse name deleted) told him he would be kicked out if he went to the bathroom in his pants instead of the commode. The resident said, "I don't have a place to go." The resident was observed to be distraught and stressed when speaking to the surveyors. His face was flushed and he was out of breath. The resident continued to talk about his mother dying and about his cousin who lived and worked in Texas and could not take care of him. The resident was asked if he had reported this to anyone. He said he had told his aunt, but had not told anyone in the facility. On [DATE], at 1:34 p.m., CNA #4 was asked if she had aver heard any staff tell residents they were going to be kicked out. She said, "You must be talking about (Resident name deleted). He worries. He wants to be good and accepted. Doesn't want to be a problem. He gets on the light and says I don't want to be a problem. He has a bowel movement in his underwear occasionally. I have heard him say it a time or two. He says it in a kidding or joking way. He has never said someone told him he was getting kicked out. He was not upset or tearful when he said 'don't want to get kicked out'. He has been occasionally tearful about death of his mother." On [DATE], at 2:30 p.m., CMA #3 was met in the hall after she had taken the resident to his room after the resident was asked by the surveyor if she could ask him a few questions. She said the resident was crying. He thinks he is in trouble. The surveyors walked in the room and observed the resident in his W/C, wiping his red eyes. The resident asked, "Am I in trouble?" The surveyors assured him he was not in trouble. On [DATE], at 3:40 p.m., the DON was asked if the resident had ever been upset. She said he was tearful on occasion, but not due to any one event. The DON was asked why he was tearful. She reported the resident's mother had passed away about a year ago. She said DHS had told him he would only be able to live there while his grandmother was there. On [DATE], at 3:40 p.m., the DON was asked if she remembered the resident coming into her and the QA nurse's office recently. She said she did. She said, we discussed the need for him to try to use the toilet instead of his underwear. The DON was asked if the QA nurse had told the resident he would be kicked out if he continued using the bathroom in his pants. She said she did not hear the QA nurse say that. At 3:45 p.m., the DON was asked if the facility ever referred him to psychological services. She said the Social Service person, who is on maternity leave at the present time, referred him to Inspirations. The DON reported the resident attended once and was denied services. The DON said the facility had not pursued any counseling for him because he was not upset very often. She said he had an order for [REDACTED]. On [DATE], at 6:00 p.m., LPN #5 was asked about the bowel habits of the resident. She said the aides would position him on the toilet and sometimes he would have a bowel movement and sometimes he wouldn't. She said he was used to using the floor because that's what he did while he lived with his mother. After his mother died he lived with his cousin for a little while, and it was during that time he fell off the toilet. The LPN was asked if the resident was fearful of using the toilet. She said he was at first, then they put hand rails on the toilet, a walker for him to lean on, and the aides always stayed with him. She was asked if he ever said he didn't want to use the toilet or refused. She said he had not. The LPN was asked if the resident was ever anxious or tearful about anything. She said, "He is occasionally. I got an order for [REDACTED]." The LPN was asked if she ever heard the resident talk about having to leave the facility. She said she had not. On [DATE], at 11:00 a.m., the resident was asked if he was afraid to use the toilet. He said it made him nervous. He said he had a fall from a toilet while living with his cousin before coming to the facility. He was asked if the facility had done anything to help him not feel nervous. He said they had put hand rails on the toilet, a walker in front of him for him to lean on and someone always stayed with him. He was asked if those things helped him. He said, "Sometimes." He said he would rather use the floor than the toilet. He was asked if he had told anyone he did not want to use the toilet, and he said no. He was asked if he knew when he had to have a bowel movement. He said he did. He was asked if he let the staff know before he had to have a BM or after he had already had one in his underwear. He said sometimes I let them know before and sometimes after. The social service notes for the resident were reviewed. The social service person did not identify or address the fact the resident was grieving about the loss of his mother. The social service person did not identify the issue of the DHS worker telling the resident he would have to leave the facility after his grandmother expired and the anxiety he was feeling about it. The social service person did not identify the nervous feelings he had of using the toilet. The Social Service person was on maternity leave and unavailable for interview. On [DATE], at 3:07 p.m., the ADM was asked why the psychological needs of the resident were not identified in the social service notes. She said they should have been. She was asked if she was aware of the psychosocial needs of the resident. She said the resident is being set up with a counselor and will see him Saturday. On [DATE], at 5:00 p.m., the DON was asked if she or the staff had ever asked him if he wanted to use the toilet. She said, "No, I just asked him how the toileting was going and he said ok." An assessment of the resident's usual routines before coming to the facility and the evidence the facility made accommodations for the resident's customary routines were not found in the resident's records. 2. Resident #6 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident's medications included [MEDICATION NAME] 45 mg one PO at bedtime for depression, and [MEDICATION NAME] 0.5 mg one PO two times a day for anxiety. The care plan, dated [DATE], documented, "(Resident's Name deleted) is at risk for psychosocial well being and decreased activity participation due to her occ confusion. She is estranged from her spouse whom she reports is seeing another younger woman and took all her money." She is tearful at times and verbalizes her story frequently. Her son visits rarely. She is up and out of her room daily. She eats in the dining room. She is frequently in the phone booth attempting to call friends and family but no one usually answers which upsets her. The resident's medical record was reviewed for Social Services notes to see if the problems had been addressed pertaining to her family issues. It was two months since the resident's admission when the first Social Service note had been written. There was no Social Services note for April or [DATE]. On [DATE], the first 'Social/Activities' note documented, "(Resident's Name deleted) has moments when she will participate in some activities. She tends to cry at times and when asked what is wrong, she tells staff nothing. She likes to visit with other neighbors in the LR. She is up in a W/C. She eats her meals in the DR. Her son visits on occasion. She is still adjusting to being in the facility. She was transferred from another facility. Seen daily by Soc services." On [DATE], a 'Social/Activities' note documented, "(Resident's Name deleted) is alert. She gets confused at times and is reoriented as needed. She likes to talk with others. She visits the activities office often. She is very sweet. She has moments when she will break down and cry and staff tries to comfort her. She is up in a W/C. She eats her meals in the DR. She loves to have a cup of coffee throughout the day. She visits the LR frequently. She also likes to flip through the phone books. She has calmed down about trying to leave. She seems to be adjusting better to the facility. Seen daily by SOC services." On [DATE], a nurse's note documented the resident was experiencing increased anxiety and crying for her kids. On [DATE], a revision to the care plan documented, "(Resident's Name deleted) is @ risk for psychosocial well being & decreased act. participation secondary confusion & general debility. Cont c occ episodes of tearfulness. Redirection successful. ^ daily in common areas. No change in tx or poc." On [DATE], a 'Social/Activities' note documented, "(Resident's Name deleted) is alert and cooperates with staff. At times she becomes frustrated and will repeat herself continuously. She is calmed and reoriented as needed. She eats her meals in the DR. She visits the LR frequently throughout the day. She likes to wear her sunglasses. She is up in a W/C. She participates in some activities. She enjoys karaoke. Her family checks on her from time to time. Seen daily by SOC services." On [DATE], a 'Social/Activities' note documented, "(Resident's Name deleted) is alert. She gets confused at times and is reoriented as needed. She likes to talk with others. She visits the activities office often. She is very sweet. She has moments when she will break down and cry and staff tries to comfort her. She is up in a W/C. She eats her meals in the DR. She loves to have a cup of coffee throughout the day. She visits the LR frequently. She also likes to flip through the phone books. She has calmed down about trying to leave. She seems to be adjusting better to the facility. Seen daily by SOC services." On [DATE], a revision to the care plan documented, "(Resident's Name deleted) is up in common areas daily. Some periods of tearfulness @ times. Redirection successful usually. Cont current tx & poc." On [DATE], a 'Social/Activities' note documented, "(Resident's Name deleted) participates in some activities. She has confusion at times and will start crying. She is brought to the LR for activities and socialization. She likes to talk with staff on her good days. She is up in a W/C. She enjoys getting her hair done in the beauty shop. She eats her meals in the DR with assistance at times. She enjoys sitting in the DR and drinking a cup of coffee. Seen daily by SOC services." On [DATE], a 'Social/Activities' note documented, "(Resident's Name deleted) is alert and cooperates with staff and other neighbors. She participates in some activities. At times she gets upset and hollers out. She is calmed and reoriented as needed. She does like to socialize with others. She often calls out for her son and others she knows. She is up in a W/C. She eats meals in the DR. She loves to drink coffee in the LR. She is brought to the LR throughout the day. Seen daily by SOC services." On [DATE], a revision to the care plan, documented, "^ daily in common areas daily. Some periods of tearfulness. Redirection successful usually compliant c tx & poc..." There were no psychosocial interventions to address the family issues the resident had problems with, which had increased her anxiety and depression. One of the interventions was for the resident to receive in house counseling services. There was no documentation the resident had ever received in house counseling services. The comprehensive assessment dated [DATE], documented the resident had a severe cognitive impairment and had no behavioral symptoms. On [DATE] at 2:50 p.m., the ADM was interviewed regarding the social service needs of the resident and how there had been no interventions put into place to fully meet the resident's psychosocial needs. The ADM was informed the documentation related to the resident getting upset over family not answering the telephone and son not visiting, but nothing had been documented about what Social Services had done to help with that problem. The ADM said it did upset the resident. The ADM was asked if counseling had been offered to the resident. She replied she did not know for sure, but would print out all the Social Services notes for the past two years. The ADM said she would print out all the 2013, Social Services notes to see if there were some answers to the problems in the notes. There was nothing to answer those questions in the 2013 and 2014, Social Services notes.

On 03/22/12, an Immediate Jeopardy (IJ) situation was determined to exist in regard to the failure to contact a physician, to obtain a physician's intervention for the swelling, redness and pain to the side of a resident's face and jaw area that the facility had been aware of for three days. The staff failed to follow their policy and procedure to notify the physician for any significant change in a resident's condition. On 03/22/12, at 10:50 a.m., the Oklahoma State Department of Health was notified and the Immediate Jeopardy situation was verified. At 10:55 a.m., the Administrator and the Director of Nursing were notified of the IJ situation. On 03/22/12, at 2:20 p.m., the 2nd and final revised plan of removal was accepted. The final plan of removal documented the following: "Failure to Assess/Documentation Failure to complete RN assessment Plan of Removal Plan of Correction Plan of Removal: 1. Pt was immediately assessed by RN and staff LPN. 2. Medical Director was notified of situation and pt is being seen in his office under his care or late day physician for reddened area on face with itching. (3/22/2012) During activity pt is noted to have experienced de-satting and facility failed to address pain expressed by patient and provide effective pain control. 3. Any orders rec'd following Dr. visit will be followed by this facility as her healthcare provider. 4. All licensed staff (RN/LPN) meeting describing deficient practice was held at 12:20 pm and 1:20 pm. 5. Patient has been admitted to hospital. (Dx: Facial abscess). Plan of Correction: Facility Administrator/ADON will monitor all new admissions/re-admissions to ensure pt is properly assessed upon admission/return and required documentation re:condition of admission is accurate. Director of Nurses or Staff RN will complete admission assessments. This deficient practice will be referred to our quality assurance program. Our quality assurance team will also monitor to ensure the deficient practice does not reoccur. This facility will revise communication reports to ensure all nurses reporting for duty will be alerted to any resident condition change or changes. Licensed Staff have been informed to contact the Medical Director at anytime if attending physician/physician assistant is not available. Licensed Staff members have been instructed to inform Assistant Director of Nurses/Administrator any change of condition in the patient, should be after hours, they will place notification in communication box on office door." A special in-service was held by ADM, addressing the following: "Subject: Failure to properly assess, tx, document. March 22,2012 Effective immediately, no new admits will be accepted to the facility except on a Monday-Friday basis. We will no longer accept new admits on Saturday and Sunday. The only exception to this policy is if the patient in question is a regular patient who is returning to the facility. We are implementing this new policy to improve quality of care of our patients. Thank you for your consideration and cooperation in this manner." The IJ was removed on 03/22/12, at 4:00 p.m. after all licensed staff were inserviced and then interviewed to verify their knowledge. The deficient practice will remain at no actual harm with potential for more than minimal harm, at a pattern. Based on record review, observation and staff interviews, it was determined the facility failed to: a) Ensure the resident's physician had been notified when swelling was observed to the side of a resident's face and jaw, including complaints of pain from the resident for one (#2) of six sampled residents identified with pain. This had the potential to affect all 44 residents identified by the DON, that could experience a change in condition. This failed practice caused harm to the resident, who suffered from pain and swelling to her jaw for three days before the facility notified the physician the resident was having pain, but did not inform the physician of the swelling to the resident's jaw. b) Ensure the physician had been contacted for an order to obtain a urine culture prior to obtaining the sample for one (#2) of four sampled residents identified with UTIs. This had the potential to affect six residents identified by the DON, as having a UA specimen collected in the month of March 2012. Findings: The facility policy 'Facility Responsibility to Physician Policy', documented the following: "Policy: The facility shall be responsible to the physician for practices concerning a resident under his/her care while in the facility. Procedure: The facility shall be responsible for providing the best possible care to each resident of the facility. No medication or treatment shall be given except on the order of the physician. The physician shall be notified of any significant change in the resident conditions... Charting Guidelines: New admits or hospital returns are to be charted on every shift for 72 hours whether they are skilled or not with documentation on condition..." The admitting physician's orders [REDACTED]. An admission nursing evaluation, dated 03/18/12, documented, "Pt AO x 3 denies need for SNF expresses wants for short stay agrees for need to increase strength- has generalized weakness- multiple skin breakdown- [MEDICAL CONDITION] to lower feet bilateral 2+ - denies pain in peri area @ X's- very cooperative, poor appetite on arrival, poor turgor... Weight 100 lbs." The assessment did not identify any swelling to the right side of the resident's face and jaw area, any shortness of breath or problems with swallowing. A 'Pain Interview and Assessment' form dated 03/18/12, documented, "Denies pain & no s/sx pain noted." A 'Daily Skilled Nurse's Note', dated 03/18/12 at 11:00 p.m., documented, "Resting in bed. Alert & oriented X 3. [MEDICAL CONDITION] noted to (R) side of face & jaw. She did c/o pain to the face & jaw & inability to sleep @ this time. LCTA resp even & unlabored." A shift change report, dated 03/19/12, documented the resident had been admitted to the facility. There was no other documentation. A 'Daily Skilled Nurse's Note', dated 03/19/12, at 11:45 p.m., documented, "...lungs clear resp even/unlabored... denies pain @ this time." A shift change report, dated 03/20/12, for the day shift, documented, "C/O pain to face, slightly swollen, (PA's name deleted) called." A urine culture dated 03/19/12, at 8:42 a.m., documented, "Escherichia coli." A handwritten note on the report documented, "Faxed to (Name deleted PA) 03/21/12, [MEDICATION NAME] 875 mg 1 po BID X 10 days. F/U UA when ABT completed." A telephone physician's orders [REDACTED]. F/U UA when ABT completed. Dx: UTI." A telephone physician's orders [REDACTED]. Dx: pain to side of face." The resident had complained of pain on the night of admission on 03/18/12, documented in a nurse's note. A daily shift charting sheet documented: On 03/21/12, on the '6-2 shift', at 2:00 p.m., "...A&O x3. Cont c [MEDICAL CONDITION] to (R) side of face. (PA's Name deleted) returned call. Received N/O for Tylenol 500 mg 1 po q 6 hrs prn..." At 5:00 p.m., "...(R) jaw continues to be [MEDICAL CONDITION] & sli (slight) redden, c/o itching, c tenderness...Will continue to monitor." At 7:40 p.m., "Tylenol 500 mg given for pain." The back of the MAR indicated [REDACTED] On 03/21/12, at 11:50 a.m., the LPN treatment nurse was observed to provide pressure sore treatment to the resident's buttocks. The resident was observed lying on her (L) side. The resident's (R) ear and jaw area were observed to be very [MEDICAL CONDITION] and red. After the care had been completed, the resident was asked what had happened to her jaw. The resident reported she did not know. The resident was asked if her jaw hurt. The resident said, "Yes, it hurts." She rated the pain at a '5' on a scale of '1 to 10' with a '10' being the worst. The resident was asked if she had received any medication for the pain. The resident reported she had received one pill twice, but it had not been enough to make it quit hurting. She was then asked if the staff had asked her if she was hurting. The resident reported no one had asked her about the pain or any relief she may have had from the Tylenol. On 03/21/12, at 12:30 p.m., the resident was observed sitting up in her bed eating her noon meal. The resident was observed to eat only 25% of her meal. The resident was asked if she liked the food. She said her jaw hurt when she tried to chew. On 03/21/12, at 3:00 p.m., LPN #3 was interviewed regarding the resident's condition. The LPN had reported she had received new physician's orders [REDACTED]. The LPN was asked when the UA had been obtained. The LPN reported LPN #1 had obtained the urine specimen when the resident was admitted . The resident's medical record was reviewed. The record did not contain documentation of the resident having signs or symptoms of a UTI, or that the physician had been informed of any urinary problems. There was no order for the UA. At 3:15 p.m., LPN #3 was asked why the Tylenol had been ordered. The LPN reported the resident's physician was out of town, so she had left a message on the PA's cell phone on 03/20/12, (the previous day) asking for something for pain for the resident. The PA had just returned her call that day. On 03/21/12, at 3:30 p.m., LPN #1 was interviewed regarding any symptoms of a UTI. The LPN was asked if the resident had been having symptoms of a UTI when she obtained the UA, or if the physician had been contacted. The LPN reported the resident's urine had been concentrated and had an odor when the resident had been admitted . The LPN then stated, "I thought I wrote an order somewhere, but I can't find it." On 03/21/12, at 3:45 p.m., LPN #1, LPN#3 and the DON were interviewed regarding the swelling and redness on the right side of the resident's face and jaw area. The DON reported she had been present when the resident was admitted on Sunday afternoon (03/18/12). She reported the swelling had not been there when the resident had been admitted . A nurse's note, dated 03/22/12, at 2:30 a.m., documented, "Resident requested 'something for pain' and pointed to her (R) jaw- gave Tylenol 500 mg 1 po per prn protocol." The MAR indicated [REDACTED]. At 3:30 a.m., the nurses' notes documented, "Resident resting quietly @ this time- 0 s/s pain noted." On 03/22/12, at 9:20 a.m., CNA #1 and CNA #2 were observed providing incontinent care for the resident. The CNAs were observed to lower the head of the resident's bed to provide the care. The resident was heard asking the CNAs to raise her head because she felt like she was going to choke on her saliva. The resident said she was unable to swallow when her head was laying flat. The CNAs raised her head but did not address why the resident was feeling like she was going to choke. After the incontinent care had been provided, the resident was asked by the surveyor, how her pain had been that day. The resident rated her pain at a '5-6'. She was asked if she had received anything for the pain that day. The resident reported she had not asked for a Tylenol, because the Tylenol had not relieved the pain in the past. Tylenol was the only medication that had been ordered for the resident's pain. At that time, the resident's swelling and redness was observed to extend down the (R) side of the face including the jaw and down the (R) side of her neck. The resident's (R) ear was now observed to have a light purple discoloration. On 03/22/12, at 9:30 a.m., LPN #4 was interviewed. The LPN had been the charge nurse on the night shift on 03/18/12, the night the resident was noted as having the swelling and pain to the (R) side of her face/jaw, which had been documented in the nurse's notes. The LPN reported she thought it was a stopped up salivary gland. She reported she had not contacted the physician. She reported she watched the resident through the night and had told the day shift to contact the physician for pain medication and an antibiotic. On 03/22/12 at 9:45 a.m., LPN #3 was identified as the charge nurse on the day shift on 03/19/12, following the identified swelling/pain to the (R) side of the resident's face. She was asked if she had been informed of the swelling and pain. The LPN reported there had been nothing in the shift report notes and nothing had been said to her that morning. The LPN reported she had observed the swelling when she did her shift assessment that day. The LPN was asked what steps she took when she saw the swelling. She reported the resident was complaining of it itching, but it was red and swollen. The LPN was asked if she had contacted the physician. She reported the physician had been out of town, but she had left a message on the PA's answering machine on 03/20/12, and the PA had called back the 21st and ordered the Tylenol. On 03/22/12 at 10:35 a.m., the PA that was responsible for the resident's care since the resident's primary physician was out of town, was interviewed by phone. The PA was asked what she had been told about the resident's pain. She reported the staff had just said the resident was having pain to the side of her face. The PA was then asked if she had been told anything else about the resident's face. The PA reported she had not. She reported she would be seeing the resident next week when she made her rounds at the facility. The PA was asked if she had been contacted by the facility regarding the resident's pain relief with the use of the pain medication. She reported she had not been contacted regarding the pain relief. She reported she had started with one Tylenol and if that did not work the facility would contact her and it would be changed to something stronger. The PA was asked if she had been contacted about the resident needing a UA when she had been admitted . She reported she had not been contacted regarding the resident needing a UA. She reported the facility had contacted her with the results and she had ordered the resident an antibiotic. On 03/22/12, at 12:30 p.m., the ADM reported the medical director had requested the resident be sent to his office for evaluation. At 2:30 p.m., the ADM reported the resident had been admitted to the hospital with [REDACTED].

On 03/22/12, an Immediate Jeopardy (IJ) situation was determined to exist in regard to the failure to assess, monitor and contact the physician for interventions pertaining to swelling, redness and pain to the side of a resident's face and jaw area. There was a lack of communication between the staff to identify residents experiencing changes in conditions and requiring possible physician notifications. The nursing staff failed to assess the resident's jaw and the side of the resident's face, that was red and inflamed and was causing pain, and failed to contact the physician for three days for an effective treatment for [REDACTED]. The staff failed to follow their policy and procedure for physician notification for any significant change in the resident's condition. On 03/22/12 at 10:50 a.m., the Oklahoma State Department of Health was notified and the Immediate Jeopardy situation was verified. At 10:55 a.m., the Administrator and the Director of Nursing were notified of the IJ situation. On 03/22/12, at 2:20 p.m., the 2nd revised plan of removal was accepted. The plan of removal documented the following: "Failure to Assess/Documentation Failure to complete RN assessment Plan of Removal Plan of Correction Plan of Removal: 1. Pt was immediately assessed by RN and staff LPN. 2. Medical Director was notified of situation and pt is being seen in his office under his care or late day physician for reddened area on face with itching. (3/22/2012) During activity pt is noted to have experienced de-satting and facility failed to address pain expressed by patient and provide effective pain control. 3. Any orders rec'd following Dr. visit will be followed by this facility as her healthcare provider. 4. All licensed staff (RN/LPN) meeting describing deficient practice was held at 12:20 pm and 1:20 pm. 5. Patient has been admitted to hospital. (Dx: Facial abscess). Plan of Correction: Facility Administrator/ADON will monitor all new admissions/re-admissions to ensure pt is properly assessed upon admission/return and required documentation re:condition of admission is accurate. Director of Nurses or Staff RN will complete admission assessments. This deficient practice will be referred to our quality assurance program. Our quality assurance team will also monitor to ensure the deficient practice does not reoccur. This facility will revise communication reports to ensure all nurses reporting for duty will be alerted to any resident condition change or changes. Licensed Staff have been informed to contact the Medical Director at anytime if attending physician/physician assistant is not available. Licensed Staff member have been instructed to inform Assistant Director of Nurses/Administrator any change of condition in the patient, should be after hours, they will place notification in communication box on office door." A special in-service was held by ADM, addressing the following: "Subject: Failure to properly assess, tx, document. March 22,2012 Effective immediately, no new admits will be accepted to the facility except on a Monday-Friday basis. We will no longer accept new admits on Saturday and Sunday. The only exception to this policy is if the patient in question is a regular patient who is returning to the facility. We are implementing this new policy to improve quality of care of our patients. Thank you for your consideration and cooperation in this manner." The IJ was removed on 03/22/12, at 4:00 p.m. after all licensed staff were inserviced and then interviewed to verify their knowledge. The deficient practice will remain at no actual harm with potential for more than minimal harm, at a pattern. Based on record review, observation and staff and resident interview, it was determined the facility failed to: a) Ensure a resident's physician was notified when swelling and redness were observed to the side of a resident's face, along the jaw line for one (#2) of one sampled resident identified with redness and swelling. This had the potential to affect all 44 residents identified by the DON, that could experience a change in condition. b) Ensure the resident's jaw was assessed when redness and swelling were observed and when the resident was voicing complaints of pain for one (#2) of six sampled residents identified with pain. This had the potential to affect 44 residents identified by the DON as residing in the facility that could experience a change in condition. These failed practices caused harm to the resident, who suffered from pain and swelling to her jaw for three days before the facility notified the physician the resident was having pain, but did not inform the physician of the swelling and redness to the resident's jaw. Findings: The admitting physician's orders [REDACTED]. An admission nursing evaluation, dated 03/18/12, documented, "Pt AO x 3 denies need for SNF expresses wants for short stay agrees for need to increase strength- has generalized weakness- multiple skin breakdown- [MEDICAL CONDITION] to lower feet bilateral 2+ - denies pain in peri area @ X's- very cooperative, poor appetite on arrival, poor turgor... Weight 100 lbs." The assessment did not identify any swelling to the right side of the resident's face and jaw area, any shortness of breath or problems with swallowing. A 'Pain Interview and Assessment' form dated 03/18/12, documented, "Denies pain & no s/sx pain noted." A 'Daily Skilled Nurse's Note', dated 03/18/12 at 11:00 p.m., documented, "Resting in bed. Alert & oriented X 3. [MEDICAL CONDITION] noted to (R) side of face & jaw. She did c/o pain to the face & jaw & inability to sleep @ this time. LCTA resp even & unlabored." A shift change report, dated 03/19/12, documented the resident had been admitted to the facility. There was no other documentation. A 'Daily Skilled Nurse's Note', dated 03/19/12, at 11:45 p.m., documented, "...lungs clear resp even/unlabored... denies pain @ this time." A shift change report, dated 03/20/12, for the day shift, documented, "C/O pain to face, slightly swollen, (PA's name deleted) called." A telephone physician's orders [REDACTED]. Dx: pain to side of face." The resident had complained of pain on the night of admission on 03/18/12, documented in a nurse's note. A daily shift charting sheet documented: On 03/21/12, on the '6-2 shift', at 2:00 p.m., "...A&O x3. Cont c [MEDICAL CONDITION] to (R) side of face. (PA's Name deleted) returned call. Received N/O for Tylenol 500 mg 1 po q 6 hrs prn..." At 5:00 p.m., "...(R) jaw continues to be [MEDICAL CONDITION] & sli (slight) redden, c/o itching, c tenderness...Will continue to monitor." At 7:40 p.m., "Tylenol 500 mg given for pain." The back of the MAR indicated [REDACTED] On 03/21/12, at 11:50 a.m., the LPN treatment nurse was observed to provide pressure sore treatment to the resident's buttocks. The resident was observed lying on her (L) side. The resident's (R) ear and jaw area were observed to be very [MEDICAL CONDITION] and red. After the care had been completed, the resident was asked what had happened to her jaw. The resident reported she did not know. The resident was asked if her jaw hurt. The resident said, "Yes, it hurts." She rated the pain at a '5' on a scale of '1 to 10' with a '10' being the worst. The resident was asked if she had received any medication for the pain. The resident reported she had received one pill twice, but it had not been enough to make it quit hurting. She was then asked if the staff had asked her if she was hurting. The resident reported no one had asked her about the pain or any relief she may have had from the Tylenol. On 03/21/12, at 12:30 p.m., the resident was observed sitting up in her bed eating her noon meal. The resident was observed to eat only 25% of her meal. The resident was asked if she liked the food. She said her jaw hurt when she tried to chew. On 03/21/12, at 3:00 p.m., LPN #3 was interviewed regarding the resident's condition. The LPN had reported she had received new physician's orders [REDACTED]. The resident's medical record was reviewed. The record did not contain documentation of the resident having signs or symptoms of a UTI, or that the physician had been informed of any urinary problems. There was no order for the UA. At 3:15 p.m., LPN #3 was asked why the Tylenol had been ordered. The LPN reported the resident's physician was out of town, so she had left a message on the PA's cell phone on 03/20/12, (the previous day) asking for something for pain for the resident. The PA had just returned her call that day. On 03/21/12, at 3:45 p.m., LPN #1, LPN#3 and the DON were interviewed regarding the swelling and redness on the right side of the resident's face and jaw area. The DON reported she had been present when the resident was admitted on Sunday afternoon (03/18/12). She reported the swelling had not been there when the resident had been admitted . A nurse's note, dated 03/22/12, at 2:30 a.m., documented, "Resident requested 'something for pain' and pointed to her (R) jaw- gave Tylenol 500 mg 1 po per prn protocol." The MAR indicated [REDACTED]. At 3:30 a.m., the nurses' notes documented, "Resident resting quietly @ this time- 0 s/s pain noted." On 03/22/12, at 9:20 a.m., CNA #1 and CNA #2 were observed providing incontinent care for the resident. The CNAs were observed to lower the head of the resident's bed to provide the care. The resident was heard asking the CNAs to raise her head because she felt like she was going to choke on her saliva. The resident said she was unable to swallow when her head was laying flat. The CNAs raised her head but did not address why the resident was feeling like she was going to choke. After the incontinent care had been provided, the resident was asked by the surveyor, how her pain had been that day. The resident rated her pain at a '5-6'. She was asked if she had received anything for the pain that day. The resident reported she had not asked for a Tylenol, because the Tylenol had not relieved the pain in the past. Tylenol was the only medication that had been ordered for the resident's pain. At that time, the resident's swelling and redness was observed to extend down the (R) side of the face including the jaw and down the (R) side of her neck. The resident's (R) ear was now observed to have a light purple discoloration. On 03/22/12, at 9:30 a.m., LPN #4 was interviewed. The LPN had been the charge nurse on the night shift on 03/18/12, the night the resident was noted as having the swelling and pain to the (R) side of her face/jaw, which had been documented in the nurse's notes. The LPN reported she thought it was a stopped up salivary gland. She reported she had not contacted the physician. She reported she watched the resident through the night and had told the day shift to contact the physician for pain medication and an antibiotic. On 03/22/12 at 9:45 a.m., LPN #3 was identified as the charge nurse on the day shift on 03/19/12, following the identified swelling/pain to the (R) side of the resident's face. She was asked if she had been informed of the swelling and pain. The LPN reported there had been nothing in the shift report notes and nothing had been said to her that morning. The LPN reported she had observed the swelling when she did her shift assessment that day. The LPN was asked what steps she took when she saw the swelling. She reported the resident was complaining of it itching, but it was red and swollen. The LPN was asked if she had contacted the physician. She reported the physician had been out of town, but she had left a message on the PA's answering machine on 03/20/12, and the PA had called back the 21st and ordered the Tylenol. On 03/22/12 at 10:35 a.m., the PA that was responsible for the resident's care since the resident's primary physician was out of town, was interviewed by phone. The PA was asked what she had been told about the resident's pain. She reported the staff had just said the resident was having pain to the side of her face. The PA was then asked if she had been told anything else about the resident's face. The PA reported she had not. She reported she would be seeing the resident next week when she made her rounds at the facility. The PA was asked if she had been contacted by the facility regarding the resident's pain relief with the use of the pain medication. She reported she had not been contacted regarding the pain relief. She reported she had started with one Tylenol and if that did not work the facility would contact her and it would be changed to something stronger. On 03/22/12, at 12:30 p.m., the ADM reported the medical director had requested the resident be sent to his office for evaluation. At 2:30 p.m., the ADM reported the resident had been admitted to the hospital with [REDACTED].