Every finding on record at The Lakes

Based on observation, record review, and interview, the facility failed to prevent a resident from a fall resulting in a close head injury during the provision of care for one (#3) of three sampled residents reviewed for accidents. The administrator identified 67 residents resided in the facility and 34 residents required assistance with activities of daily living. Findings: The Safety and Supervision of Residents policy, revised 07/2017, read in part, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident #3 had diagnoses which included vascular dementia and Alzheimer's disease. Resident #3's care plan for ADLs and falls, revised 10/29/24, documented the resident: a. was dependent on staff for bed mobility, b. was totally dependent on staff for repositioning and turning in bed, c. required total assistance with transfers, and d. was at risk for falls. Resident #3's quarterly resident assessment, dated 10/30/24, documented the resident had severe cognitive impairment and was dependent on staff for toileting hygiene. The assessment documented the resident weighed 222 lbs. A nursing note, dated 12/08/24 at 8:05 a.m., read in part, while given peri care the Resident rolled out of the other side of the bed on to the floor. Nurse noted the Resident lying supine on the floor on the left side of the bed. A knot about the size of a quarter was noted on the right side of the forehead. An After Visit Summary, dated 12/08/24, documented diagnoses of closed head injury and contusion of forehead An Initial State Reportable Incident form, dated 12/09/24, documented certain injuries. It documented Resident #3 rolled out the other side of the bed on to the floor during peri care. It documented a knot about the size of a quarter was noted on right side of the resident's forehead. It documented the resident was sent to the ER due to head injury and being on Eliquis (blood thinner). It documented the resident returned within hours with a diagnosis of closed head injury. A Final State Reportable Incident form, dated 12/13/24, documented certain injuries. It documented Resident #3 had completed neuro checks. It documented knot resolving to right side of forehead with slight discoloration. It documented staff were educated to use two person assist when the resident was in bed. On 12/17/24 at 8:39 a.m., Resident #3 was observed receiving peri care by CNA #2 and CNA #3. The resident was dependent on staff for turning during the provision of peri care. There was no effort from the resident. On 12/17/24 at 1:07 p.m., CNA #3 stated Resident #3 was incontinent and required two staff assistance with peri care. They stated they always had another staff to assist with peri care. On 12/17/24 at 1:07 p.m., the CNO stated they educated staff on using two person assist with Resident #3 on the day of the incident, but did not have signatures or documentation for the education. On 12/17/24 at 2:58 p.m., CNA #1 stated they were completing peri care when the resident rolled out of the bed onto the floor. They stated they had turned the resident on their left side and their left hand was on the resident to hold them. They stated the resident was slippery due to having a bowel movement. CNA #1 stated everything happened so fast. They stated they tried to pick up the wipes with their right hand and the resident rolled out of the bed onto the floor. They stated there were no rails to prevent the fall. They stated they were informed the resident was a one person assist with peri care. On 12/17/24 at 3:06 p.m., CMA #4 stated they were educated after the incident that Resident #3 would now be a two person assist with peri care. They stated they always used two person assist with the resident because they were obese, used a lift for transfers, shook during care, and there was no support in front of the resident so another staff had to be in front to hold them. They stated sometimes if the resident was shaking badly, it could take up to three staff to assist in the care. On 12/17/24 at 3:21 p.m., LPN #1 stated Resident #3 was a one or a two person assist with peri care, but every time they completed peri care on the resident they got another staff to assist. They stated the resident was a two person transfer with the lift. On 12/17/24 at 3:27 p.m., observation of Resident #3's bed was made. There was no supporting device for the resident to hold on to during the provision of care. On 12/18/24 at 2:21 p.m., MDS Coordinator #1 stated totally dependent on staff meant the staff did 75% or more of the effort. They stated it could require one staff or two staff assistance.

Based on record review and interview, the facility failed to ensure a resident was free from abuse for one (#2) of three sampled residents reviewed for abuse. The administrator identified 67 residents resided in the facility. Findings: The Abuse and Neglect Clinical Protocol policy, revised 07/2017, read in part, Sexual abuse is defined .as non-consensual sexual contact of any type with a resident. Resident #2 had diagnoses which included dementia and senile degeneration of brain. Resident #2's quarterly resident assessment, dated 10/23/24, documented the resident had severe cognitive impairment. An Initial State Reportable Incident form, dated 12/02/24, documented an allegation of abuse/mistreatment. It documented Resident #4 was witnessed putting their hand on Resident #2's crotch while sitting at the TV area. It documented Resident #4 was immediately removed from the area and placed on one on one with staff. It documented no injury noted to Resident #2 who was unable to answer any questions regarding the situation. On 12/17/24 at 9:57 a.m., Housekeeper #1 stated they observed Resident #4's hand over Resident #2's crotch over their clothing on their way to the vending machine. They stated they went to get help and it took about five to eight minutes to get help to separate the two residents. On 12/17/24 at 1:23 p.m., the administrator stated they were the abuse coordinator. On 12/17/24 at 1:24 p.m., the administrator and the CNO stated sexual abuse was any unwanted physical contact or any report where a resident felt they were sexually abused. On 12/17/24 at 1:33 p.m., the administrator stated they had completed a safe survey of all residents on 12/01/24 for a different incident and did not complete a safe survey specific to this incident. On 12/17/24 at 1:39 p.m., the administrator and the CNO stated the incident could be considered sexual abuse and that was why it was reported as abuse to the Department.

Based on record review and interview, the facility failed to ensure a resident with a new diagnosis of a serious mental health condition had a pre-admission screening and resident review updated for one (#1) of one sampled resident reviewed for PASARR level two. The DON identified 28 residents with serious mental health diagnoses. Findings: The facility policy titled, Admission Criteria, read in part, Nursing and medical needs of individuals with mental disorders, intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission and Resident Review program (PASARR) to the extent possible. Resident # 1 had diagnoses which included psychosis, anxiety, and recurrent depression. Resident #1's Nursing Level of Care Assessment, dated 01/23/18, did not document they had any serious mental health conditions. The primary diagnosis was listed as multiple sclerosis. A review of the order summary medical diagnoses list documented Resident #1 had the following new diagnoses after the initial PASARR was completed in 2018: a. anxiety with an onset date of 09/11/18; b. psychosis not due to a substances or known psychological condition with an onset date of 11/10/23; and c. recurrent depression disorder with an onset date of 11/10/23. An annual MDS assessment, ARD date 07/30/24, docuented Resident #1 did not have a serious mental illness. The assessment further documented Resident #1 had psychiatric mood disorders of anxiety, depression, and psychotic disorder. A care plan, last revised 11/05/24, documented Resident #1 had a diagnoses of anxiety, depression, and psychosis. The documented interventions for all focused areas was for Resident #1 were to be provided their psychoactive medications as ordered by the doctor. Resident #1's physician's orders, dated November 2024, documented Risperdal (antipsychotic medication) 0.5 mg give one tablet by mouth one time a day related to psychosis. The order was first written on 11/17/23. There was no documentation the facility had completed an updated PASARR with the onset of serious mental health diagnoses of recurrent depression, anxiety, and psychosis. On 11/19/24 9:40 a.m, MDS coordinator #1 stated pre-admission screening and resident review was to be completed on admission, when they got referrals, or as soon as they got to the facility. MDS Coordinator #1 stated schizophrenia, recurrent depression, bipolar, and anxiety were all serious mental health diagnoses. They stated Resident #1 had recurrent depression, anxiety, and psychosis which were serious mental health diagnoses. MDS Coordinator #1 stated the diagnoses onset dates were 11/10/23 for recurrent depression and psychosis and 11/20/18 for anxiety. They stated the intital screening occurred on 01/24/18 and it did not list any serious mental health conditions. MDS Coordinator #1 further stated no other screening had been completed after the initial assessment in 2018 and there should have been a new screening to know if there was the need for a level two PASARR. They stated all of Resident #1's serious mental health diagnoses should have had a screen completed. On 11/19/24 at 9:57 a.m., the DON stated a PASARR had to be submitted on admission and if there was a new psychological diagnosis. They stated schizophrenia, recurrent depression, bipolar, and anxiety were all serious mental health diagnoses that would require a screen with the onset of the new diagnosis. The DON stated Resident #1's diagnoses onset dates were 11/10/23 for recurrent depression and psychosis and 11/20/18 for anxiety. They stated a screen should have been completed if they were not on the original screening.

Based on record review and interview, the facility failed to develop a comprehensive care plan for: a. IV and antibiotic usage for one (#20); b. visual function for one (#6); and c. antipsychotic medication use for one (#35) of 18 sampled residents whose care plans were reviewed. The DON identified 71 residents who resided in the facility. Findings: A Care Plans, Comprehensive Person-Centered policy, revised 12/16, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Resident #20 had diagnoses which included metabolic encephalopathy, chronic kidney disease, and urinary tract infection. A progress note, dated 11/03/24 at 2:31 p.m., documented they received a urine culture report and the resident would need a midline or PICC placement for IV antibiotic. It documented the resident was sent to the emergency room for a long term access device placement and to receive their first dose of antibiotic for monitoring related to a drug allergy to penicillin. A physician's order, dated 11/04/24, documented normal saline flush intravenous solution with 10 cc intravenously every 8 hours related to urinary tract infection. A care plan focus for urinary tract infection, dated 11/04/24, did not include any documentation or interventions for an IV or antibiotic. The medical record was reviewed and revealed the resident completed their antibiotic on 11/17/24. A physician's order, dated 11/22/24, documented to change the PICC line dressing every seven days. On 11/21/24 at 12:08 p.m., MDS coordinator #2 stated the IV and antibiotic for the recent UTI were not on the care plan and they normally were on the care plan. 2. Resident #6 had diagnoses which included anxiety disorder, essential hypertension and tremor. An Annual Resident Assessment, dated 10/25/24, documented Resident #6's cognition was intact and they had impaired vision and used corrective lenses. The CAA documented visual function had triggered and the care plan decision was yes. Resident #6's care plan did not address their visual function. On 11/18/24 at 9:35 a.m., Resident #6 reported they broke their glasses yesterday. On 11/18/24 at 9:36 a.m., Resident #6's glasses were observed with tape on the right upper frame. The right lens was also observed out of the frame. On 11/21/24 at 10:00 a.m., MDS coordinator #2 stated MDS coordinator #1 had completed Resident #6's annual resident assessment. They stated MDS coordinator #1 was not at the facility and MDS coordinator #2 stated they would be able to answer questions about it. On 11/21/24 at 10:02 a.m., MDS coordinator #2 stated visual concerns were captured on a residents MDS assessment if they had glasses or reading glasses. They stated it was documented under section b. They stated the CAA summary was where they got their information for that section. They stated Resident #6's CAA summary did trigger visual function. On 11/21/24 at 10:03 a.m., MDS coordinator #2 stated anything that triggered should be put on the care plan. They reviewed Resident #6's care plan and stated they were not seeing it on the care plan. 3. Resident #35 had diagnoses which included psychotic disorder with delusions due to known physiological condition. A Physician Order, dated 06/29/24, documented Seroquel (antipsychotic medication) 25 mg one tablet by mouth at bedtime related to unspecified insomnia and psychotic disorder with delusions due to know physiological condition. An Admission Resident Assessment, dated 07/06/24, documented Resident #35 had severe cognitive impairment and was taking antipsychotic medication and had an indication for use. The CAA documented psychotropic drug use was trigger and was addressed in the care plan. Resident #35's care plan did not address their antipsychotic medication use or interventions in place to address their psychotic disorder with delusions. On 11/20/24 at 1:34 p.m., LPN #4 stated Resident #35 received Seroquel for psychotic disorder with delusions with known physiological condition. On 11/20/24 at 1:36 p.m., LPN #4 stated Resident #35 occasionally wandered from room to room when their anxiety was high. They stated the resident exhibited restlessness and disorganized thinking. On 11/20/24 at 1:39 p.m., LPN #4 stated staff redirected the resident, provided a calm environment, and would reproach the resident when they exhibited behaviors. They stated medications including antipsychotic medication was monitored and put in resident care plans. On 11/20/24 at 1:41 p.m., LPN #4 reviewed Resident #35's care plan and stated they were not seeing the resident's antipsychotic medication addressed in the care plan. On 11/20/24 at 1:47 p.m., MDS coordinator #2 stated diagnoses, medication, ADLs, and discharge plan interviews were used when developing a resident care plan. On 11/20/24 at 1:48 p.m., MDS coordinator #2 stated if a resident was taking psychotropic medications they would all be in a group. They stated they would click on mental health disorder, they would click on depression, and the program would load any behaviors, psychoactive medications, and side effects they would watch for. On 11/20/24 at 1:51 p.m., MDS coordinator #2 stated Resident #35 was on Seroquel for psychotic disorder with delusions. They stated they would need to research where the diagnosis came from and update the resident's care plan. On 11/20/24 at 1:52 p.m., MDS coordinator #2 stated the antipsychotic was coded on the resident assessment and they did not see it on the care plan. 45583

Based on observation, record review and interview, the facility failed to ensure wound treatments were provided for one (#18) of two sampled residents reviewed for pressure ulcers. The DON identified three residents had been admitted to the facility with wounds since 10/01/24. Findings: An undated facility policy, Guidelines for Notifying Physician of Clinical Problems, read in part, These guidelines are to help ensure that .medical problems are communicated to the medical staff in a timely efficient manner .The charger nurse or supervisor should contact the attending physician at anytime if they feel a clinical situation requires immediate discussion and management .the nurse should have the the following information available .active medical problems. The Admission Assessment and Follow Up: Role of the Nurse, last revised September 2012, read in part, conduct a physical assessment including .skin .contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. The Pressure Ulcer/Injury Risk Assessment policy, last revised July 2017, read in part, documentation in medical record addressing MDS notification if new skin altercation notes with change of plan of care, if needed. The Admission Notes policy , last revised September 2012, read in part, When a resident is admitted to the nursing unit, the admitting Nurse must document the following .the general condition of the resident upon admission .the time the attending physician was notified of the admission .the time the physician's orders were received and verified. Resident #18 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure Parkinson's disease, acute kidney failure, atrial fibrillation, displaced bimalleolar fracture of left lower leg, and disorder of the skin and subcutaneous tissue. Resident #18's Admission Summary, dated 11/08/24, documented they had surgical wounds, bruises, skin tears/cuts, and other open lesions on their foot. Resident #18's skin and wound progress note, dated 11/08/24, documented their right heel had eschar and they were admitted to the facility with it. It documented the wound was unstageable and measured 3 cm X 3 cm with no depth. Resdient #18's Baseline Care Plan, dated 11/08/24, documented they had pain to their right heel and had a wound on their right heel. The care plan documented Resident #18's wound measured 3 cm X 3 cm with black eschar on the heel and redness around the outer heel. There were no documented orders for a treatment to the right heel on admission. An Order Summary for Resident #18, dated 11/11/24, documented they had the following treatment order for the right heel. Cleanse right heel with hibiclens and pat dry. Apply calcium alginate to wound bed, cover with optifoam heel protector, secure with kerlix every day and prn one time a day related to disorder of the skin. The order was written three days after Resident #18 was admitted . Resident #18's admission MDS assessment, ARD date 11/12/24, documented they had one unhealed pressure ulcer due to slough or eschar on admission. Resident #18's care plan, dated 11/13/24, documented they had a focus area of potential for impairment to skin integrity. The interventions were documented as assist as needed with tranfers with caution to prevent injury, document skin condition weekly, encourage good nutrition and pressure relieving mattress on the bed. The care plan did not address the wound to the right heel. The November 2024 TAR documented the first treament to the right heel was on 11/11/24. There were no documented treatments on 11/08/24, 11/09/24, or 11/20/24. On 11/18/24 at 1:09 p.m., Resident #18 stated they had a hole in their heel. Resident #18 was observed with a heel protector boot in place and a bandage dated 11/17/24 on the right foot and heel. On 11/20/24 at 9:34 a.m., LPN #3 stated they were the admitting nurse for Resident #18. LPN #3 stated Resident #18 had orders from a previous facility that was reviewed for orders. On 11/20/24 at 10:33 a.m., LPN #3 stated there were no orders for treatments on the admitting paperwork. They stated after completing the admission assessment they left for the day without contacting the physician. LPN #3 stated the physician should have been notified and they were not notified until 11/11/24. LPN #3 stated the ADON was the one that notified the physician and got the order for a treatment on the wound. They stated the order was not until 11/11/24 and prior to that there were no orders for treatments. On 11/20/24 at 11:01 a.m., Resident #18 stated they had their wound since admission on their right heel. Resident #18 stated they just started doing a treatment on the right heel about a week ago and have since been doing them everyday. On 11/20/24 at 12:54 p.m., the ADON stated Resident #18 was admitted with a wound to their right heel, and LPN #3 would know what the treatment order was on admission. After looking through the clinical record they stated there were no orders on admission and the physician should have been notified of the wound to get a treatment order. The ADON indicated no treatment was provided for three days after admission when the order was obtained. On 11/20/24 at 1:09 p.m., the DON stated the admitting nurse was to assess's the resident in all areas including the skin. They stated they received orders from the facility they are admitting from and use them as a basis for their orders. The DON stated if there were identified skin issues without orders it was the expectation of the facility to notify the physician and get orders. They stated Resdient #18 was admitted to the facility with a wound to the right heel, and did not have an order from the previous facility for th wound. The DON stated there were no treatments that had been completed until 11/11/24 and Resident #18 went three days without a treatment. The DON stated the facility policy for admission and notification were not followed and it should be been completed on the first day Resident #18 was admitted the facility.

Based on observation, record review and interview, the facility failed to: a. ensure an insulin label indicated the order had changed for one (#41); and b. ensure medications were administered following standards of practice for one (#41) of ten sampled residents observed during medication pass. The DON identified five residents with orders for a lidocaine patch. The Resident Matrix, dated 11/18/24, documented 16 residents received insulin. Findings: An Administering Topical Medications policy, revised 10/10, read in part, The purpose of this procedure is to provide guidelines for the safe administration of topical medications .Apply glove to your dominant hand .assess area for .debris .Clean the skin. Remove old medication residue .Don clean gloves if necessary .Trans-dermal patches .Clean and dry a selected area that is approved for application of the patch. Rotate sites with each new application, if possible. An Insulin Administration policy, revised 09/2014, read in part, To provide guidelines for the safe administration of insulin to residents with diabetes .The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order .The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies, before giving the insulin . 1. Resident #41 had diagnoses which included chronic pain and type two diabetes mellitus with diabetic neuropathy. A Physician Order, dated 06/25/24, documented lidocaine (local anesthetic medication) external patch five percent apply to right front upper thigh topically one time a day. A Physician Order, dated 09/27/24, documented Lantus (insulin) 100 u/ml inject 55 units subcutaneously one time a day. On 11/19/24 at 9:37 a.m., LPN #3 obtained Resident #41's Lantus from the treatment cart and dialed it to 55 units. The label on the Lantus pen documented inject 45 units subcutaneously once daily with a fill date of 09/09/24. LPN #3 stated, It's 55 in out system. On 11/19/24 at 9:47 a.m., LPN #3 stated the facility had a sticker for change of medication for when the label of the medication did not match the order. LPN #3 stated there was not one on Resident #41's Lantus. They stated the order had recently changed to 55 and they would have to get with the pharmacy to have it changed. LPN #3 removed a lidocaine patch five percent from the treatment cart and obtained a pair of scissors from the top drawer of the cart. On 11/19/24 at 9:50 a.m., LPN #3 cut the lidocaine patch container open, removed the patch and dated and initialed the patch. LPN #3 removed the old patch, dated 11/18/24, from Resident #41's right upper thigh, threw it in the trash, and placed a new patch on the same general area of the resident's right upper thigh. LPN #3 did not clean the site prior to placing a new lidocaine patch on the resident's thigh. On 11/19/24 at 10:22 a.m., LPN #3 stated staff were to move lidocaine patches to different areas of the resident's thigh when administering. They stated staff should probably use alcohol to clean the area first. They stated with Resident #41 they at least tried to move the patch in an area a little different from where it was. On 11/19/24 at 11:47 a.m., the DON stated staff were to wash their hands with soap and water or use alcohol based had rub, verify the order with the label on the lidocaine patch, check expiration, verify the resident's identity, apply glove to dominant hand, and assess the area of skin for debris when administering the lidocaine patch. The DON stated staff were to apply clean gloves if necessary, clean and dry the selected area and rotate sites when possible with each new application. On 11/19/24 at 11:51 a.m., the DON stated there was a change of direction sticker staff used when a medication order changed from what was documented on the label. They stated the sticker was supposed to be applied to the medication itself or the container for it.

Based on record review and interview, the facility failed to: a. maintain a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system; b. adhere to enhanced barrier precautions for one (#18) of 18 sampled residents reviewed for infection control; c. remove gloves and/or wash or sanitize hands in order to prevent cross contamination for six (#2, 22, 23, 26, 41, and #49); and d. clean out the nebulizer canister after use for one (#26) of ten sampled residents observed during medication pass. The DON identified 71 residents resided in the facility and eight residents with orders for nebulizer treatments. The Resident Matrix, dated 11/18/24, documented 16 residents received insulin. Findings: A Pulse Oximetry policy, revised 10/2010, read in part, Steps to procedure .Perform hand antisepsis .Remove probe when monitoring is complete .Perform hand antisepsis. The Respiratory Therapy Prevention of Infection policy, revised 11/2011, read in part, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy .Infection Control Considerations Related to Medication Nebulizers .After completion of therapy .Remove the nebulizer container .Rinse with fresh tap water .Dry on a clean paper towel or gauze sponge. An Insulin Administration policy, revised 09/2014, read in part, Steps in the procedure .Wash hands .Check Blood Glucose per physician order .Depress the plunger and remove the needle after approximately five (5) seconds .Dispose of the needle in a designated container .Wash hands. A Handwashing/Hand Hygiene policy, revised 08/2015, read in part, This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents .Wash hands with soap .and water for the following situations .When hands are visibly soiled .After contact with a resident with infectious diarrhea .Use alcohol-based hand rub .or .soap .and water for the following situations .Before and after direct contact with residents .Before preparing or handling medications .After contact with a resident's intact skin .After contact with blood or body fluids .After contact with objects in the immediate vicinity of the resident .After removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment. A Legionella Water Management Program policy, dated 07/2017, read in part, As part of the infection prevention and control programs, our facility has a water management program, which is overseen by the water management team. The water management team will consist 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. A Legionella Surveillance and Detection policy, dated 07/2017, read in part, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Legionnaire's disease will be included as part of our infection surveillance activities. 1. Resident #18 had diagnoses which included Parkinson's and a-fib. Resident #18s skin and wound progress note, dated 11/08/24, documented their right heel had eschar and they were admitted to the facility with it. It documented the wound was unstageable and measured 3 cm X 3 cm with no depth. Resdient #18's Baseline Care Plan, dated 11/08/24, documented they had pain to their right heel and had a wound on their right heel. The care plan documented Resident #18's wound measured 3 cm X 3 cm with black eschar on their heel and redness around the outer heel. On 11/20/24 at 10:55 a.m., LPN #1 stated the PPE for EBP was a gown and gloves and they were kept in the shower room. On 11/20/24 at 3:37 p.m., LPN #2 was observed to begin performing the treatment on Resident #18's right heel wound. There was no observation of LPN #2 wearing a gown during the provision of wound care. There was no observation of signage to indicate EBP for Resident #18. On 11/20/24 at 1:13 p.m., the ADON stated the EBP policy was for residents that had a peg tube, wound, nebulizer treatment, all Foleys, trachs, and gastric tube. They stated not skin tears. The ADON stated Resident #18 should have been on EBP. They stated the PPE required was a gown, gloves, and mask if airborne. The ADON stated the policy was not followed if the staff did not wear PPE and there was no signage. 2. On 11/20/24 at 1:52 p.m., the maintenance supervisor stated the city came out annually and if they called them to test if someone got sick. They stated they would need to request the documentation. On 11/20/24 at 8:39 a.m., the maintenance supervisor stated they had not received the Legionella testing results and were still waiting. On 11/21/24 at 8:58 a.m., the maintenance supervisor was shown the facility's policy for Legionella. They stated they did not know they had to do the elements listed in the policy. There was no documentation provided by the facility Legionella monitoring had been completed. 3. Resident #26 had diagnoses which included COPD. A Physician Order, dated 11/11/24, documented Ipratropium-albuterol inhalation solution 0.5-3 ml/ 3 ml one vial inhale orally four times a day. 4. Resident #23 had diagnoses which included shortness of breath. A Physician Order, dated 03/26/22, documented combivent respimat aerosol solution 20-100 mcg/act one puff inhale orally three times a day. 5. Resident #41 had diagnoses which included chronic pain and type two diabetes mellitus with diabetic neuropathy. A Physician Order, dated 06/25/24, documented lidocaine external patch five percent apply to right front upper thigh topically one time a day. A Physician Order, dated 09/27/24, documented Lantus 100 u/ml inject 55 units subcutaneously one time a day. On 11/19/24 at 9:11 a.m., LPN #3 removed one vial of Ipratropium-albuterol inhalation solution 0.5-3 ml/ 3 ml from the treatment cart, sanitized their hands, donned gloves, picked up the vial, locked the cart, opened the resident's nebulizer mask with tubing that was in a bag in their room, connected it to the nebulizer machine, placed the mask on the resident's face, opened the vial, poured it into the canister, connected it to the mask, plugged the tubing into the machine, and turned the machine on. LPN #3 removed the nasal cannula tubing in the room, wrapped it up, and threw it in the trash on the treatment cart located in the hall with their gloves hands. They picked up the pulse oximeter off the top of the treatment cart and placed it on Resident #26's finger. On 11/19/24 at 9:21 a.m., LPN #3 removed the pulse oximeter and placed it back on top of the treatment cart with the same gloved hands. On 11/19/24 at 9:24 a.m., Resident #26's treatment was completed. LPN #3 removed the mask from their face, and placed the mask on the resident's bedside table, removed their gloves, left the room and went to the treament cart and pushed it down the hallway. LPN #3 did not clean out the nebulizer canister after use, wash or sanitize their hands, or clean the pulse oximeter after use. On 11/19/24 at 9:30 a.m., LPN #3 moved the treatment cart down to room [ROOM NUMBER]. Without washing or sanitizing their hands from the last treatment they walked into room [ROOM NUMBER] with a thermometer and took Resident #49's temperature and exited the room without washing or sanitizing their hands. On 11/19/24 at 9:32 a.m., LPN #3 opened the treatment cart, obtained Resident #23's combivent respimat 20 mcg/100 mcg inhaler, entered the room, donned gloves, took the resident's temperature, and watched Resident #23 administer the inhaler. LPN #3 used the same pulse oximeter previously used and without cleaning it, obtained Resident #23's oxygen saturation at 94 percent. LPN #3 returned to the treatment cart with one gloved hand that they had written on and placed the pulse oximeter on the cart. On 11/19/24 at 9:37 a.m., LPN #3 removed the glove and placed the inhaler back in the treatment cart. LPN #3 did not clean the pulse oximeter. On 11/19/24 at 9:37 a.m., LPN #3 sanitized their hands, took out two lancets, two alcohol prep pads, a glucometer, placed a test strip in the glucometer, and a cotton ball. They entered Resident #41's room pricked their finger, wiped the first blood off, obtained their FSBS to be 226, cleaned off their finger, threw the disposable items away, and removed their gloves. Without washing or sanitizing their hands, they documented the FSBS in the computer, obtained Resident #41's Lantus from the treatment cart and dialed it to 55 units. LPN #3 donned gloves, cleaned Resident #41's left arm with alcohol, administered the insulin, threw sharps in the sharps container on the treatment cart, and placed the lid back on the insulin pen all while wearing the same pair of gloves. LPN #3 accessed the computer with the same gloved hands to document the FSBS. On 11/19/24 at 9:47 a.m., with the same gloved hands, LPN #3 removed keys from their pocket, unlocked the treatment cart, and obtained a lidocaine patch five percent from the treatment cart, and obtained a pair of scissors from the top drawer of the cart. On 11/19/24 at 9:50 a.m., with the same gloved hands, LPN #3 cut the lidocaine patch container open, removed the patch and dated and initialed the patch. Wearing the same pair of gloves, LPN #3 removed the old patch, dated 11/18/24, from Resident #41's right upper thigh, threw it in the trash, and placed a new patch on the same general area of the resident's right upper thigh. LPN #3 removed their gloves and threw them in the trash. Without washing or sanitizing their hands, LPN #3 moved back to the treatment cart, obtained keys from their pocket, opened the cart, and started using the computer. LPN #3 obtained the thermometer, took Resident #41's temperature and scratched the resident's left upper back through their gown. LPN #3 went back to the treatment cart and started charting on the computer without washing or sanitizing their hands. On 11/19/24 at 9:55 a.m., without washing or sanitizing their hands, LPN #3 walked into Resident #2's room and took their temperature which read 97.6. Without washing or sanitizing their hands, LPN #3 walked over to the other resident in the room, Resident #22, and took their temperature which read 96.8. Without washing or sanitizing their hands, LPN #3 went out to the treatment cart and documented the readings. On 11/19/24 at 9:56 a.m., LPN #3 stated staff were to turn on water, use soap, lather a good 30 seconds, scrub between fingernails and fingers for 25 to 30 seconds, and rinse the soap off when washing their hands. They stated staff would dry their hands with a paper towel and use the paper towel to turn off the water. LPN #3 stated it was best to sanitize before going into each room, even when using gloves. They stated staff should sanitize anytime they went from room to room. On 11/19/24 at 9:58 a.m., LPN #3 stated staff were to use gloves for each resident. They stated they were not to use the same pair of gloves on two different residents. They stated they would remove gloves when visibly soiled. On 11/19/24 at 9:59 a.m., LPN #3 stated they should clean the pulse oximeter after each use. They stated they did not clean it in between uses and that was their fault. On 11/19/24 at 10:01 a.m., LPN #3 stated they did not clean out the canister after administering the nebulizer treatment to Resident #26. They stated they did not know the process for cleaning out the canister. They stated, I don't keep it on there for a whole week or anything like that. They stated sometimes if it got foggy from the temperature, they would switch it out just to be safe. They stated they did not ever date the tubing, but they should. On 11/19/24 at 11:35 a.m., the DON stated staff were to physically wash their hands with soap and water anytime they were visibly soiled. The ADON stated staff were to clean their hands before and after care and could use either sanitizer or soap if not visibly soiled. The DON stated after three uses of sanitizer, staff were supposed to wash their hands. On 11/19/24 at 11:36 a.m., the DON stated staff were clean the nebulizer machine after use per protocol, use soap and water, and allow it to air dry on a paper towel. They stated once it was dry they were to store it in a sanitary manner and change it out every seven days per policy. On 11/19/24 at 11:44 a.m., the DON stated staff would provide hand antiseptics, place probe on the resident's finger, turn on the pulse oximeter, and compare the pulse reading to the radial pulse when obtaining a pulse oximeter reading. They stated staff would perform hand antiseptics afterwards. On 11/19/24 at 11:47 a.m., the DON stated staff would clean the pulse oximeter if they dropped it on the floor, a resident put it in their mouth, or anytime it was dirty. 45583

Based on record review and interview, the facilty failed to provide documentation the facility administered the pneumococcal vaccine for two (#62 and #69) of five sampled residents reviewed for immunizations. The DON identified 71 residents who resided in the facility. Findings: A Pneumococcal Vaccine policy, dated 8/2016 read in part, Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility. 1. Resident #62 was admitted to the facility on [DATE]. The pneumococcal consent was signed on 12/04/23. The immunization record for the resident did not document the pneumococcal vaccine was administered. 2. Resident #69 was admitted to the facility on [DATE]. The pneumococcal consent was signed on 05/02/24. The immunization record for the resident did not document the pneumococcal vaccine was administered. On 11/21/24 8:38 a.m., the DON stated they were not able to locate any documentation either resident received the pneumococcal vaccine. They stated they had started at the facility in September of this year and they had not administered any vaccines. On 11/21/24 at 9:00 a.m., the DON stated neither Resident #62 nor #69 had received the pneumonia vaccine.

Based on observation, record review and interview, the facility failed to notify the attending physician of a wound without a treatment order for one (#18) of two sampled residents with wounds. The DON identified three residents had been admitted to the facility with wounds since 10/01/24. Findings: An undated facility policy, Guidelines for Notifying Physician of Clinical Problems, read in part, These guidelines are to help ensure that .medical problems are communicated to the medical staff in a timely efficient manner .The charger nurse or supervisor should contact the attending physician at anytime if they feel a clinical situation requires immediate discussion and management .the nurse should have the the following information available active medical problems. The Admission Assessment and Follow Up: Role of the Nurse, last revised September 2012, read in part, conduct a physical assessment including skin .contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. The Admission Notes policy , last revised September 2012, read in part, When a resident is admitted to the nursing unit, the admitting Nurse must document the following .the general condition of the resident upon admission .the time the attending physician was notified of the admission .the time the physician's orders were received and verified. Resident #18 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure, Parkinson's disease, acute kidney failure, atrial fibrillation, displaced bimalleolar fracture of left lower leg, and disorder of the skin and subcutaneous tissue. Resident #18's Admission Summary, dated 11/08/24, documented they had surgical wounds, bruises, skin tears/cuts and other open lesions on the foot. Resident #18's skin and wound progress note, dated 11/08/24, documented their right heel had eschar and they were admitted to the facility with it. The wound was unstageable and measured 3 cm X 3 cm with no depth. There was no documentation Resident #18's physician had been notified on admission of the right heel wound and no treatments. On 11/20/24 at 9:34 a.m., LPN #3 stated they were the admitting nurse for Resident #18. LPN #3 stated Resident #18 had orders from a previous facility that was reviewed for orders. On 11/20/24 at 10:33 a.m., LPN #3 stated there were no orders for treatment. They stated after completing the admission assessment they left for the day without contacting the physician. LPN #3 stated the physician should have been notified and they were not notified until 11/11/24 when the ADON contacted the physician. On 11/20/24 at 12:54 p.m., the ADON stated Resident #18 was admitted with a wound to their right heel and LPN #3 would know what the treatment order was on admission. After looking through the clinical record they stated there were no orders on admission and the physician should have been notified of the wound to get a treatment order. On 11/20/24 at 1:09 p.m., the DON stated it was the expectation of the facility to notify the physician of any wounds on admission and get orders if needed.

Based on record review and interview, the facility failed to ensure a MDS was coded accurately for one (#30) of 18 sampled residents reviewed for accuracy of MDS assessments. The DON identified 71 residents resided in the facility. Findings: Resident #30 had diagnoses which included spondylosis and peripheral vascular disease. An admission assessment, dated 10/31/24, documented the resident had an indwelling catheter. On 11/20/24 at 12:45 p.m., MDS coordinator #2 stated Resident #30 did not have a catheter. They stated for some reason the system auto populates. MDS Coordinator #1 stated they would do a correction and that was not the only one. They stated they needed to pay better attention and it was not coded accurately.

Based on record review and interview, the facility failed to complete a discharge summary for one (#72) of one sampled resident reviewed for discharge. The Admission/Discharge To/From Report, dated 05/01/24 through 11/18/24, documented 10 residents discharged from the facility within the last six months. Findings: Res #72 discharged from the facility on 09/03/24 after a respite stay since 08/26/24. A communication note, dated 09/03/24 at 4:37 p.m., documented, Resident picked up by transport to be taken home. Wife, Hospice, ADON and PA aware. Personal belongings and medications given to transport. There was no documentation a discharge summary had been completed. On 11/19/24 at 11:16 a.m., LPN #3 stated they did not see the summary. They stated the policy was to document where the resident was going, how they discharged , any teaching, medications, a brief summary, who picked them up, and details of the stay.

Based on observation, record review and interview, the facility failed to ensure: a. oxygen tubing was changed; and b. oxygen was administered as ordered for one (#6) of one sampled resident reviewed for oxygen. The DON identified six residents with orders for oxygen resided in the facility. Findings: An Oxygen Administration policy, revised 10/2010, read in part, The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify there is a physician's order for this procedure .After completing the oxygen setup .the following information should be recorded in the resident's medical record .The date and time that the procedure was performed .The rate of oxygen. The Respiratory Therapy Prevention of Infection policy, revised 11/2011, read in part, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy .Check water levels of refillable humidifier units daily when humidified O2 is used .Change the reservoir every forty-eight (48) hours when humidified O2 is used. Resident #6 had diagnoses which included chronic respiratory failure with hypoxia and chronic respiratory failure with hypercapnia. A discontinued order, dated 10/18/23, documented oxygen via nasal cannula at two liters continuous three times a day. A discontinued order, dated 09/19/24, documented oxygen via nasal cannula at two liters continuous three times a day. The September 2024 TAR documented the oxygen tubing and humidifier bottle was to be changed weekly on Saturdays. The last documented oxygen tubing change was on the 7th. A Physician Order, dated 10/09/24, documented oxygen via nasal cannula at two liters continuous three times a day. An Annual Resident Assessment, dated 10/25/24, documented Resident #6 utilized oxygen therapy while a resident at the facility. The October 2024 TAR did not document Resident #6's oxygen tubing had been changed during the month. The November 2024 TAR did not document Resident #6's oxygen tubing had been changed for the month. There was no order to change oxygen tubing located in Resident #6's current physician orders. On 11/18/24 at 9:19 a.m., Resident #6 was observed with oxygen in place via nasal cannula. Resident #6 stated they wore oxygen continuously. The humidifier bottle on the oxygen concentrator was observed with a date of 08/31/24 and the oxygen tubing was not connected to the humidifier bottle. There was no date observed on the oxygen tubing. Resident #6 stated they did not use the humidifier because they did not notice much of a difference with it. They stated their oxygen was to be at three liters. The oxygen was observed running at four liters. On 11/18/24 at 9:25 a.m., LPN #4 entered Resident #6's room and administered an inhaler to the resident. LPN #4 did not observed the flow rate of the resident's oxygen that was running. On 11/19/24 at 10:03 a.m., LPN #3 stated staff dated oxygen tubing. When asked how often it was changed, LPN #3 stated, You do what's best for you. They stated if it looked like moisture or a kink was forming, they would switch it out. They stated sometimes it could have discoloration along the nasal part or ear part and they would throw it away. On 11/21/24 at 10:10 a.m., Resident #6 was observed wearing oxygen via nasal cannula running at four liters. There was no date observed on the oxygen tubing. The humidifier bottle on the oxygen concentrator was observed with a date of 08/31/24 and the oxygen tubing was not connected to the humidifier bottle. On 11/21/24 at 10:15 a.m., LPN #4 stated if a resident was on continuos oxygen, staff would ensure the resident had oxygen on, kept pressures, and monitored oxygen every shift. They stated the humidifying component depended on the physician orders and dryness of the mucosa. On 11/21/24 at 10:16 a.m., LPN #4 stated the rate at which the oxygen was to be set would be included in the orders. They stated the night shift would change out the oxygen tubing weekly and most of the residents were scheduled to have it changed every Saturday at bedtime. On 11/21/24 at 10:19 a.m., LPN #4 stated Resident #6 had and order for continuous oxygen at two liters. On 11/21/24 at 10:21 a.m., LPN #4 stated they did not see an order for changing the tubing. On 11/21/24 at 10:22 a.m., LPN #4 walked into Resident #6's room visualized their oxygen concentrator and stated, Oh my goodness. They stated it was running at four liters. They stated they did not see a date sticker on the tubing. They stated the humidifier part was old because the resident did not use it. They stated it was dated August 31st and removed it from the concentrator. On 11/21/24 at 10:26 a.m., the DON stated staff were to verify the physician order, facility protocol, care plan, and assemble equipment and supplies when providing oxygen to residents. On 11/21/24 at 10:28 a.m., the DON stated residents had specific orders for how many liters to put the oxygen at. On 11/21/24 at 10:29 a.m., the DON stated oxygen tubing was supposed to be changed weekly. On 11/21/24 at 10:31 a.m., the DON stated Resident #6 had an order for continuous oxygen at two liters. They stated there was a spot to document checking the oxygen saturation each shift attached to the order.

Based on observation, record review, and interview, the facility failed to ensure treatment carts were secured when not in use for one observation observed on hall 500 for medication storage. The DON identified 71 residents resided in the facility. Findings: A Storage of Medication policy, dated 4/2007, read in part, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy also read, Compartment (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On 11/19/24 at 3:30 p.m., LPN #2 was observed preparing to do wound care. They were observed to walk away from the unlocked treatment cart and walk up the hall towards the nurses station. On 11/19/24 at 3:32 p.m., LPN #2 returned to the cart. They stated they left the cart unlocked and the policy for securing medications was to lock the cart when they walk away from it.

On 10/09/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide adequate supervision to prevent elopement for Resident #1 with severe cognitive impairment, daily wandering behaviors, and a history of elopement. An initial State Reportable Incident, dated 10/06/24, documented the facility charge nurse was called and notified by the local church Resident #1 was at their facility. It documented the resident was assessed and noted to have bruising to left and right lower extremities, and bilateral knees. It documented the resident reported they fell but did not hit their head. It documented the resident was sent to the ER and would be placed on 1:1 with staff to ensure safety. An Incident Note, dated 10/06/24 at 1:29 p.m., documented Resident #1 returned to the facility from the hospital with no new orders. Staffing assignment sheets were reviewed from 10/06/24 through 10/09/24. There was no documentation 1:1 was completed by staff on 10/06/24 for the day and evening shift. On 10/09/24 at 4:58 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 10/09/24 at 5:05 p.m., the administrator and DON were notified of the IJ situation. On 10/10/24 at 11:25 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal documented: .Identification of total number of residents at risk for the same failed practice: 105 Actions to remove the immediacy of the alleged failed practice: . There are (four) residents at risk for this alleged deficient practice including this resident. Resident (initials removed) intentionally hides from the staff thinking it is a joke, Resident (initials removed) and (initials removed) occasionally exit seek and are easily redirected. .The identified resident was placed on 1:1 supervision on 10/06/24 1:29 PM upon return from the hospital check-up post incident and will remain on 1:1 if (the resident) remains as a resident at the facility. .Identified resident's family is seeking placement in a secure dementia unit which is a more appropriate setting for meeting this resident's needs and with the help of facility staff, the (family) found placement in a secure dementia facility and is planning to admit identified resident there on Friday, [DATE]. .Training of all staff in the areas of elopement risk including identification of those at risk for elopement, protection measures to prevent elopement, and dementia care including documentation of 1:1 when provided and lasted for 30 minutes for all current staff by the Nursing Leadership Team staff at 7PM October 9, 2024 and no other staff will be permitted to work until they have been in-serviced before their next scheduled shift by phone contact or in-person. .The facility will monitor resident (current and future) behaviors to observe for exit seeking, verbalization of needing to go home and/or unsafe wandering. New admits will be screened through interview and record review for at risk behavior including potential elopement or unsafe wandering. If a resident is determined to be at risk, then this information will be care planned with individualized interventions for that resident will be determined and implemented. This information will be captured on the initial baseline care plan for new admissions and on regular care plans for current residents. Any behaviors exhibited would be captured in the behavior notes and screened daily by the DON or designee to identify behaviors that might lead to elopement or unsafe wandering. The staff will also notify the DON or Administrator for residents that are wandering or exit seeking at the time of the event so an immediate intervention can be placed. Actions taken to prevent recurrence of alleged failed practice: DON or designee will: .Daily review of all incidents and behavior notes to identify residents at risk for elopement. .Review will include protection of residents from elopement or unsafe wandering and interventions to reduce potential elopement or unsafe wandering in residents with dementia. .Training for staff will continue re: dementia including protective measures from unsafe wandering and elopement as well as dementia care and behaviors prevention/management and including documentation for 1:1 Care when provided, on an on-going basis by the DON, ADON, MDS, Corporate staff or Administrator and will include new hires on 10/09/2024 and on-going. .The facility will monitor resident (current and future) behaviors to observe for exit seeking, verbalization of needing to go home and/or unsafe wandering. New admits will be screened through interview and record review for at risk behavior including potential elopement or unsafe wandering. If a resident is determined to be at risk, then this information will be care planned with individualized interventions for that resident will be determined and implemented. This information will be captured on the initial baseline care plan for new admission and on regular care plans for current residents. Any behaviors exhibited would be captured in the behavior notes and screened daily by the DON or designee to identify behaviors that might lead to elopement or unsafe wandering. The staff will also notify the DON or Administrator for residents that are wandering or exit seeking at the time of the event so an immediate intervention can be placed. Actions will be completed by: 10-10-2024 3:00 PM and no staff will be permitted to work until they have completed training, and this training will be completed before the start of their next worked shift. All current staff will be in-serviced about this as of 7PM on 10-09-2024 . The IJ was lifted, effective 10/10/24 at 3:00 p.m., when all components of the plan of removal had been verified as completed. The deficient practice remained isolated with the potential for more than minimal harm. Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment, daily wandering behaviors, and a history of elopement for one (#1) of three sampled residents reviewed for elopement. The ADON identified four residents at risk for elopement resided in the facility. Findings: An Elopement policy, revised 12/07, read in part, .Staff shall investigate and report all cases of missing residents . A Wandering policy, revised 08/14, read in part, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will offer corrective interventions that may minimize risk .The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included . Resident #1 had diagnoses which included mood disorder, vascular dementia, parkinsonism, and repeated falls. A State Reportable Incident, dated 01/07/23, documented Resident #1 had eloped from the facility and was self-propelling in a wheelchair in the street to the shopping center next to the facility. A Quarterly Resident Assessment, dated 10/04/24, documented Resident #1's cognition was severely impaired. It documented the resident exhibited the behavior of wandering daily. Resident #1's Care Plan, revised 07/06/24, read in part, I wander often and at times am exit seeking. It documented the following interventions. a. 10/06/24 staff to provide 1:1 care date initiated 10/09/24, b. change door code as needed to prevent the resident from memorizing it. Date initiated 04/08/24, c. encourage the resident to attend activities for diversion. Date initiated 04/06/24, and d. observe the resident's movements and redirect away from the door as needed. Date initiated 04/08/24. Resident #1's care plan did not document the resident was at risk for elopement or that the resident had eloped in the past. August 2024 behavior monitoring records documented no behaviors were observed for Resident #1 for the month. September 2024 behavior monitoring records documented Resident #1 exhibited elopement/exit seeking behaviors on the 7th and the 15th. They documented no behaviors were observed any other days of the month. October 2024 behavior monitoring records documented Resident #1 exhibited elopement/exit seeking behaviors on 10/03/24. An Incident Note, dated 10/06/24 at 8:52 a.m., documented LPN #3 was notified by a member of the local church that Resident #1 was at their facility. It documented the nurse walked to the facility with two other staff members to bring Resident #1 back to the building. It documented upon assessment the resident had bruising to their left and right lower extremity and bilateral knees. It documented the resident reported they fell , but did not hit their head. It documented the DON, ADON, POA, and NP were notified. An Incident Note, dated 10/06/24 at 8:58 a.m., documented Resident #1 was picked up by emergency transport and taken to a local hospital for further evaluation. An initial State Reportable Incident, dated 10/06/24, documented the facility charge nurse was called and notified by the local church Resident #1 was at their facility. It documented the resident was assessed and noted to have bruising to left and right lower extremities, and bilateral knees. It documented the resident reported they fell , but did not hit their head. It documented the resident was sent to the ER and would be placed on 1:1 with staff to ensure safety. An Incident Note, dated 10/06/24 at 1:29 p.m., documented Resident #1 returned to the facility from the hospital with no new orders. Staffing assignment sheets were reviewed from 10/06/24 through 10/09/24. There was no documentation 1:1 was completed by staff on 10/06/24 for the day and evening shift. The hospital after visit summary, dated 10/06/24, documented Resident #1 was diagnosed with a closed head injury and accidental fall. On 10/09/24 at 8:23 a.m., CNA #4 was observed seated in a chair in Resident #1's room. Resident #1 was observed lying in bed. CNA #4 stated they were assigned to Resident #1. They stated wherever the resident went, they went. They stated they believed Resident #1 had gotten out of the building, but that was all they knew. They stated they believed the resident had fallen and experienced scratches. They stated the resident could foot propel themselves in a wheelchair. On 10/09/24 at 10:15 a.m., CNA #4 stated Resident #1 exhibited the behavior of kicking the door. They stated the resident was not able to use the key pad because it was too high. They stated the resident did not wear any monitor for wandering. On 10/09/24 at 12:50 p.m., an interview attempt was made with family member #1. Family Member #1 reported they did not want to be interviewed without council for themselves. On 10/09/24 at 1:15 p.m., CNA #2 stated staff had to redirect Resident #1 and keep an eye on them to ensure they were not by the door. They stated the resident went everywhere in the building. They stated staff would redirect the resident. On 10/09/24 at 1:18 p.m., CNA #2 stated they believed Resident #1 had left the building within the last year. They stated the resident was found by the trash can looking for a cigarette. They stated they were not at the facility when Resident #1 eloped on 10/06/24. They stated now someone was sitting with the resident for safety. They stated the door to exit the facility was coded and only staff knew the code. On 10/09/24 at 1:45 p.m., LPN #3 stated if a resident was known to wander the doors to the facility were locked. They stated a code had to be used to exit. They stated there was a door to the gated patio that was not locked. On 10/09/24 at 1:47 p.m., LPN #3 stated they did not know the policy for identifying residents at risk for elopement. They stated they believed they completed an elopement assessment and it was care planned. On 10/09/24 at 1:48 p.m., LPN #3 stated Resident #1 liked to move around freely and go up and down halls and tried to get out of the facility often. They stated staff would take the resident out back to get fresh air. On 10/09/24 at 1:50 p.m., LPN #3 stated Resident #1 headed to the front door pretty often. They stated staff would redirect the resident when they experienced this behavior. On 10/09/24 at 1:51 p.m., LPN #3 stated they really did not know what happened on 10/06/24. They stated the church had called them and reported Resident #1 was there. They stated the door would alarm if someone was trying to get out without the key pad. They stated they did not hear an alarm sounding. LPN #3 stated they were down the hall doing blood sugars at the time. They stated no staff observed Resident #1 leave the building. LPN #3 stated they completed a head to toe assessment of the resident and looked for bruising, pain, and obtained vital signs. They stated the DON, NP, emergency transport company, and family were notified. LPN #3 stated they were not sure how Resident #1 got to the church, but they thought the resident might have fallen because of the resident's knees. They stated the resident was sent out and returned to the facility shortly after with no new orders. On 10/09/24 at 1:56 p.m., LPN #3 stated as soon as the resident came back the facility had a sitter with the resident 24 hours a day. LPN #3 stated they had not received any additional education regarding elopement since the incident occurred. On 10/09/24 at 2:30 p.m., the DON and administrator were asked the policy for wandering. The administrator read the policy word for word. The DON stated the facility did not have an assessment tool, but monitored resident behaviors. On 10/09/24 at 2:35 p.m., the administrator stated staff were to promptly report elopement concerns to the charge nurse and DON. The DON stated staff monitored residents for exit seeking behaviors. The DON stated 1:1 was not part of the policy, but the facility felt it was needed for Resident #1. On 10/09/24 at 2:40 p.m., the DON reviewed Resident #1's behavior monitoring forms and Resident #1's quarterly resident assessment that documented the resident experienced the behavior of wandering daily. The DON stated they could not explain the discrepancy. The DON stated Resident #1 did wander around everyday and even went towards the door. On 10/09/24 at 2:49 p.m., the DON stated there was not an assessment completed on residents for elopement. They stated there was an option on the behavior monitoring form for elopement. On 10/09/24 at 2:53 p.m., the DON provided the behavior monitoring forms for Resident #1. They stated when everything was marked no for Resident #1's behaviors, You don't have to verify a lot. On 10/09/24 at 2:55 p.m., the administrator stated Resident #1 liked to smoke. The DON stated that was generally when the resident would go to the door. The DON stated in the past month they had noticed the resident going to the front door and they would redirect them. The DON stated they had never seen the resident go to the door at the end of the halls. The DON stated Resident #1 was quick at foot propelling themselves in a wheelchair. On 10/09/24 at 2:59 p.m., the DON stated Resident #1 had a history of exit seeking behaviors. On 10/09/24 at 3:01 p.m., the DON stated Resident #1 had eloped from the facility on 10/06/24. They stated no one saw the resident leave the building because staff were on the halls providing treatments to residents. The DON stated they were still investigating and getting statements. The DON stated no one knew Resident #1 had left until they received a call from the church. The DON stated the resident got out of the building and went across the street to the church. The DON stated the resident had apparently fallen and reported getting themselves back into their wheelchair. On 10/09/24 at 3:04 p.m., the DON stated the resident was sent out to the hospital because the fall was unwitnessed and the resident had experienced scrapes. The DON stated when the resident returned they were placed on 1:1. The DON stated 1:1 was documented in nurse notes and on the schedule with a 1:1 next to the name. On 10/09/24 at 3:06 p.m., the DON stated the resident had eloped on 05/30/22 to the facility parking lot but did not leave facility grounds. The administrator stated Resident #1 also eloped from the facility on 01/07/23. They stated the facility had encouraged family to transfer the resident to a more secure facility in the past and the family refused. They stated this time the family was willing to transfer the resident to a sister facility. On 10/09/24 at 3:08 p.m., the DON stated they did not know how Resident #1 exited the building. They stated there was about a 30 second delay of when the door would relock. They stated they facility did not believe the resident pushed the door the 30 seconds because the alarm was not sounding. The DON stated they do not know if the resident followed behind someone to exit the building. On 10/09/24 at 3:12 p.m., the DON reviewed Resident #1's care plan and stated there was nothing that stated the resident had eloped from the facility. The DON stated the facility had not in-serviced any staff related to Resident #1's elopement on 10/06/24. On 10/09/24 at 3:15 p.m., the DON stated the facility did not conduct any additional assessments of residents at risk for elopement after this elopement occurred because the facility did not use an actual assessment. The administrator stated QA was involved in the incident. The administrator was observed looking through documentation for the facility stand up meetings and stated nothing was written down. They stated it was discussed via phone and in text messages. On 10/09/24 at 3:28 p.m., the administrator was observed pushing on the front door for several seconds. The door alarmed and the lock released. On 10/09/24 at 3:29 p.m., the surveyor stood in the common area by the nurses' station. The administrator pushed on the front door sounding the alarm. The alarm was faintly heard in the common area. On 10/09/24 at 3:40 p.m., the DON stated staff did not document 1:1 was completed on 10/06/24 when Resident #1 returned to the facility. On 10/09/24 at 3:52 p.m., the administrator provided three staff interviews related to the 10/06/24 elopement of Resident #1.

Based on record review and interview, the facility failed to implement their abuse policy for three (#2, 5, and #6) of three sampled residents reviewed for abuse. The DON identified 70 residents resided in the facility. Findings: An Abuse Investigation and Reporting policy, revised 07/17, read in part, .All reports of resident abuse, neglect .shall be promptly reported to local, state and federal agencies .and thoroughly investigated by facility management .The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation .Role of the Investigator .The individual conducting the investigation will, as a minimum .Interview the person reporting the incident .Interview any witnesses to the incident .Interview the resident (as medically appropriate) .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate, family members, and visitors .Interview other residents .Review all events leading up to the alleged incident .Witness reports will be obtained in writing . 1. Resident #5 had diagnoses which included dysphagia following cerebral infarction and osteoporosis. A Quarterly Resident Assessment, dated 06/10/24, documented Resident #5 had moderate cognitive impairment. A Quarterly Resident Assessment, dated 09/10/24, documented Resident #5's cognition was intact. 2. Resident #6 had diagnoses which included unspecified dementia without behavioral disturbances, Alzheimer's disease, and psychotic disorder with delusions. An Admission Resident Assessment, dated 07/06/24, documented Resident #6 had severe cognitive impairment. A Combined Initial and Final State Reportable Incident, dated 08/14/24, documented an allegation of abuse/mistreatment. It documented Resident #5 slapped the hand of Resident #6. It documented the residents were separated. It documented no staff observed the incident, but overheard commotion from other residents in the area. It documented the physician and family were notified. It documented no reports of the action had previously been received. It documented staff were educated to redirect Resident #5 and to increase frequent checks while the resident was in the public area around others. It documented relocation for Resident #6 had occurred since they were previously roommates. There was no documentation of interviews with Resident #5, witnesses, visitors, staff, or family members conducted in conjunction with this abuse allegation per the facility policy. On 10/10/24 at 10:15 a.m., Resident #5 stated the staff were good to them. The only concern the resident shared when asked about abuse/neglect was the price they were charged for a haircut and to have their eyebrows done and a resident who followed them sometimes had bumped into their wheelchair. They stated they would speak with staff if they had any concerns. On 10/10/24 at 10:57 a.m., an attempt was made to interview Resident #6. The resident did not respond. On 10/10/24 at 1:35 p.m., CNA #1 stated the policy for abuse was to report any concerns to the charge nurse or DON. They stated they were not aware of any incidents of abuse involving Resident #5 or Resident #6. On 10/10/24 at 1:45 p.m., CNA #2 stated any signs of abuse were to be reported to the administrator, DON, and ADON. They stated they were not aware of any incidents of abuse involving Resident #5 or Resident #6. On 10/10/24 at 1:48 p.m., CMA #1 stated if they saw abuse they were to immediately report it to the nurse. They stated they were aware of an incident of hitting involving Resident #5 and Resident #6. They stated Resident #5 did not like roommates. They stated the resident could get physically aggressive at times. On 10/10/24 at 2:00 p.m., LPN #1 stated abuse was to be reported to the administrator/abuse coordinator. They stated if they observed a resident to resident altercation they would remove the residents and report to the DON and administrator. They stated if they were injured, depending on the severity, they would be sent to the hospital. They stated the authorities would typically be called, they would complete behavior monitoring, and an investigation would be completed. LPN #1 stated they had heard there was an incident involving Resident #5 and Resident #6. They stated they believed Resident #5 slapped Resident #6. They stated Resident #6's cognition was not intact. They stated Resident #5 rambled and it was difficult to get a detailed report from them. On 10/10/24 at 2:04 p.m., the administrator stated staff worked on abuse concerns together. On 10/10/24 at 2:10 p.m., the administrator stated an investigation would be completed. The DON stated an incident report and state reportable would be completed. The administrator stated they would provide supporting documentation, notify the family, and would conduct interviews in a private location. They stated they would interview witnesses, the resident, and roommate to get the story of what had occurred. The DON stated when it was a resident to resident incident, staff would separate them to ensure safety was maintained and would need to monitor them. The administrator stated the physician and police would be notified. On 10/10/24 at 2:15 p.m., the administrator stated if abuse was witnessed, reported, or suspected, staff were to report it. The DON stated a CNA or medication aide could separate the residents and notify the charge nurse. On 10/10/24 at 2:17 p.m., the DON stated they would notify the physician, police, family, APS, the State, proper licensing board as needed, the DON, administrator and corporate. On 10/10/24 at 2:19 p.m., the administrator reviewed the state reportable incident involving Resident #5 and Resident #6 dated 08/14/24, and stated they did not have any good answers. They stated it happened in the television area. They stated there was a commotion and they separated the residents. The administrator stated staff did not witness the event. They stated since they were roommates the facility separated them. On 10/10/24 at 2:25 p.m., the administrator stated they did not interview any witnesses because there were not any. The administrator stated Resident #6 was not interviewable and Resident #5 was not interviewed. The administrator stated Resident #5 had a wonderful imagination. The DON stated Resident #5's communication was hard to understand. On 10/10/24 at 2:27 p.m., the administrator stated they did not remember interviewing any staff regarding this incident. On 10/10/24 at 2:28 p.m., the administrator stated they did not interview other residents, family members, or visitors regarding the incident. On 10/10/24 at 2:30 p.m., the administrator stated Resident #5 was kept in an area where they could be closely monitored by staff. They stated they did not have any documentation of staff completing additional monitoring of the resident during this time. The DON stated they had already looked for additional monitoring and did not find it. On 10/10/24 at 2:31 p.m., the administrator stated they did not have any documentation of QAPI having been involved in this allegation of abuse. On 10/10/24 at 2:32 p.m., the administrator stated they did not have any documentation of any education with staff regarding this abuse investigation. 3. Resident #2 had diagnoses which included closed fracture of right distal femur, osteoarthritis, and osteopenia. An Admission Resident Assessment, dated 02/26/24, documented Resident #2's cognition was moderately impaired. A Facility Incident Report, dated 08/24/24, documented the nurse had received report from the CNA Resident #2 had complained of their leg hurting when they were turned. It documented Resident #2's description was I don't know, it just hurts. I haven't done anything. It documented the resident was taken to the hospital. Resident #2's x-ray results, dated 08/24/24, documented acute displaced femur fracture. A Combined Initial and Final State Reportable Incident, dated 08/24/24, documented certain injuries and Resident #2 complained of pain in their right leg upon staff trying to assist them out of bed. It documented the x-rays from the hospital documented acute mildly displaced fracture of the distal femoral diametaphysis. It documented the resident did not complain of falling. A Follow-up State Reportable Incident, faxed 08/26/24, documented the facility was seeking updated notes. It documented Resident #2's hospital paperwork stated the resident felt they were handled roughly by nursing staff during a transfer and an investigation was initiated. Resident #2's hospital records, dated 08/26/24, read in part, .It is reported that patient was aggressively moved causing pain . It documented the resident thought they were handled roughly by nursing staff and had worsening pain since. There was no additional documentation of the facility investigating this allegation of abuse. A Quarterly Resident Assessment, dated 09/02/24, documented Resident #2's cognition was intact. On 10/09/24 at 8:40 a.m., Resident #2 stated they believed staff had dropped them in the shower or going to the shower. They stated they could not remember who was helping them. They stated they had no concerns of abuse or mistreatment. Resident #2 denied going to the hospital and stated they had gone to doctor appointments. They stated they knew they were supposed to call staff for help to get up, but sometimes they tried to get up on their own. On 10/11/24 at 9:07 a.m., CNA #3 stated they knew Resident #2's fracture had happened over the weekend. They stated when they came in on Monday the resident had been to the hospital. CNA #3 stated the facility was taking extra precautions with the resident when utilizing the lift. On 10/11/24 at 9:09 a.m., LPN #2 was observed reviewing the incident report for Resident #2 dated 08/24/24, and stated it lacked a description. They stated they knew the resident had a history of fractures. LPN #2 stated the resident had not fallen at the facility in the last six months. They stated the resident had osteoarthritis and they were not aware of the cause of the fracture. On 10/11/24 at 9:11 a.m., LPN #2 stated they were not aware of any reports of abuse, neglect, or mistreatment involving Resident #2. On 10/11/24 at 9:16 a.m., the administrator stated the incident involving Resident #2 happened on 08/24. They stated the resident was sent to the hospital for evaluation and treatment. They stated the x-ray results showed a fracture. The administrator stated different stories were coming out and they believed the resident told a family member staff had transferred them weird. On 10/11/24 at 9:18 a.m., the administrator stated on the follow-up state reportable, there were notes in the hospital portal that documented the resident reported they felt they were handled roughly by staff. The administrator stated according to what the facility had been told the resident reported leg pain. On 10/11/24 at 9:20 a.m., the administrator stated they had spoken to staff regarding this information. They stated they did not believe anything was completed on paper. They stated they would speak with the ADON to see if there was any additional documentation. On 10/11/24 at 9:55 a.m., the administrator stated there was a care plan meeting with the resident's family member. The administrator provided a copy of the social service note, dated 10/03/24, that documented the family discussed concerns with the facility related to the fracture and the resident possibly being manually lifted or dropped. The administrator stated they could not locate any additional documentation of the facility investigating the above allegation.

Based on record review and interview, the facility failed report an allegation of abuse to APS and local law enforcement for two (#5 and #6) of three sampled residents reviewed for abuse. The DON identified 70 residents resided in the facility. Findings: An Abuse Investigation and Reporting policy, revised 07/17, read in part, .All reports of resident abuse, neglect .shall be promptly reported to local, state and federal agencies .All alleged violations involving abuse .will be reported by the facility Administrator .to the following persons or agencies .Adult Protective Services .Law enforcement officials . 1. Resident #5 had diagnoses which included dysphagia following cerebral infarction and osteoporosis. A Quarterly Resident Assessment, dated 06/10/24, documented Resident #5 had moderate cognitive impairment. A Quarterly Resident Assessment, dated 09/10/24, documented Resident #5's cognition was intact. 2. Resident #6 had diagnoses which included unspecified dementia without behavioral disturbances, Alzheimer's disease, and psychotic disorder with delusions. An Admission Resident Assessment, dated 07/06/24, documented Resident #6 had severe cognitive impairment. A Combined Initial and Final State Reportable Incident, dated 08/14/24, documented an allegation of abuse/mistreatment. It documented Resident #5 slapped the hand of Resident #6. It documented the residents were separated. It documented no staff observed the incident, but overheard commotion from other residents in the area. It documented the physician and family were notified. It documented no reports of the action had previously been received. It documented staff were educated to redirect Resident #5 and to increase frequent checks while the resident was in the public area around others. It documented relocation for Resident #6 had occurred since they were previously roommates. There was no documentation this allegation of abuse was reported to APS or local law enforcement. On 10/10/24 at 10:15 a.m., Resident #5 stated the staff were good to them. The only concern the resident shared when asked about abuse/neglect was the price they were charged for a haircut and to have their eyebrows done, and that a resident who followed them sometimes had bumped into their wheelchair. They stated they would speak with staff if they had any concerns. On 10/10/24 at 10:57 a.m., an attempt was made to interview Resident #6. The resident did not respond. On 10/10/24 at 1:35 p.m., CNA #1 stated the policy for abuse was to report any concerns to the charge nurse or DON. They stated they were not aware of any incidents of abuse involving Resident #5 and Resident #6. On 10/10/24 at 1:45 p.m., CNA #2 stated any signs of abuse were to be reported to the administrator, DON and ADON. They stated they were not aware of any incidents of abuse involving Resident #5 and Resident #6. On 10/10/24 at 1:48 p.m., CMA #1 stated if they saw abuse they were to immediately report it to the nurse. They stated they were aware of an incident of hitting involving Resident #5 and Resident #6. They stated Resident #5 did not like roommates. They stated the resident could get physically aggressive at times. On 10/10/24 at 2:00 p.m., LPN #1 stated abuse was to be reported to the administrator/abuse coordinator. They stated if they observed a resident to resident altercation they would remove the residents and report it to the DON and administrator. They stated if they were injured, depending on the severity, they would be sent to the hospital. They stated the authorities would typically be called, they would complete behavior monitoring, and an investigation would be completed. LPN #1 stated they had heard there was an incident involving Residents #5 and Resident #6. They stated they believed Resident #5 slapped Resident #6. They stated Resident #6's cognition was not intact. They stated Resident #5 rambled and it was difficult to get a detailed report from them. On 10/10/24 at 2:04 p.m., the administrator stated staff worked on abuse concerns together. On 10/10/24 at 2:17 p.m., the DON stated they would notify the physician, police, family, APS, the State, proper licensing board as needed, the DON, administrator, and corporate. On 10/10/24 at 2:19 p.m., the administrator reviewed the state reportable incident involving Resident #5 and Resident #6 dated 08/14/24, and stated they didn't have any good answers. They stated it happened in the television area. They stated there was a commotion and they separated the residents. The administrator stated staff did not witness the event. They stated since they were roommates the facility separated them. On 10/10/24 at 2:29 p.m., the administrator and DON stated APS was not notified of the event. The administrator stated law enforcement was not notified of the incident of abuse.

Based on record review and interview, the facility failed to ensure wound and skin assessments were completed for one (#1) of three sampled residents reviewed for wounds and skin assessments. The director of nursing identified 26 residents with skin issues and/or wounds. Findings: Resident #1 was admitted to the facility on [DATE] with diagnosis to include pressure ulcer to right heel, diabetes mellitus with polyneuropathy, congestive heart failure, cerebral infarction, and hemiplegia and hemiparesis. Resident #1 wound and skin noted dated 06/07/24 at 10:34 p.m., documented the resident had wounds to the right heel and great toe. The note indicated the measurements of the heel wound was 8 cm X 3.5 cm with a depth of 0.1 cm. The heel was dry, hard to touch with a white center and the outer wound was black. There was no additional documentation of the wound to the great toe. Resident #1 admission Summary, dated 06/07/24, read in part, .Pressure injury noted to R heel 8cmx3.5 cm, dry and hard to touch, center white, outer wound black, peri wound reddened and border uneven . There was no documented assessment or descriptions of the residents great toe and second toe on the right foot that was observed on admission. Resident's #1 wound and skin notes dated 06/10/24 documented the resident had the following wounds on admission: great right toe, right heel, and right second toe. The note provided measurements and description of all the wounds the resident had including skin tears and abrasions. Resident #1 care plan, dated 06/11/24, documented the resident had an unstageable pressure ulcer with an intervention to document skin condition weekly. Resident #1 wound and skin note, dated 07/18/24, was the only other assessments and descriptions of all wounds and skin issues the resident had. There were no additional assessment and/or descriptions of Resident #1s wounds to his right heel and toes weekly for Resident #1. On 08/08/24 at 2:44 p.m., Licensed Practical Nurse #2, stated they were the nurse working the night Resident #1 was admitted . They stated the resident had wounds to the right great toe, right second toe and on the heel. They stated they were there on admission and they did not provide any descriptions of the wounds on the toes. On 08/12/24 at 8:18 a.m., the Director of nursing, who identified themselves as the wound nurse, a resident with wounds should have an assessment weekly which would include measurements, stage, signs and symptoms of infection, drainage, a full description. The director of nursing was asked how often this should be completed. The director of nursing stated at least weekly. They were asked to review the clinical record and progress notes dated 06/22/24, 06/28/24, 07/04/24 and 07/17/24. After the review they were asked if these notes were weekly assessments of the residents skin and wounds. The director of nursing stated they were notes about the wounds and skin but they were not assessments. She was asked if there were any additional assessments of the wound and skin for Resident #1. They stated the only complete assessments were 06/10/24 and 07/18/24.

Based on record review and interview, the facility failed to ensure medical records were provided within two working days for one (#1) of one sampled residents reviewed for medical records request. The administrator identifed only one record request since 06/01/24, and 64 residents who resided in the facility Findings: An undated policy, Release of Information, read in part, .A resident may obtain photocopies/electronic versions of their records by providing the facility with at least a forty-eight (48) hour (excluding weekends and Holidays) advance notice of such request .it may require additional time produce up to 5 business days based on the volume . Resident #1 was admitted to the facility on [DATE] with diagnosis to include pressure ulcer to right heel, diabetes mellitus with polyneuropathy, congestive heart failure, cerebral infarction, and hemiplegia and hemiparesis. Resident #1 face sheet documented their spouse was the power of attorney and responsible party. An Authorized to Use or Disclose Health Information form, docuented Resident #1 power of attorney had filled out and signed the form requesting medical records on 07/30/24. There was no documentation the facility had provided the medical record within the two working days. On 08/07/24 at 4:50 p.m., Resident #1 family stated they had requested the medical records on 07/30/24 and they had not received them within two working days. They stated they still had not received them. On 08/12/24 at 7:00 a.m., the administrator stated the family filled out the request for medical records and it was sent to the corporate office. The administrator then stated the attorney mailed them out to the family on Monday, 08/05/24. They stated they do not know when the family received the records. After reviewing the regulation, the administrator stated the facility policy did not match the regulation because it says five business days. The administrator stated the family should have received the medical records no later then 08/01/24.

Based on observation and interview, the facility failed to ensure stored and opened food items were dated or labeled inside of the refrigerator. The Resident Census and Conditions of Residents report, dated 09/26/23, documented 59 residents resided in the facility. The DON identified 54 residents received their meals from the kitchen and three residents receive nothing by mouth. Findings: A Date Marking policy, dated 12/22, read in part, All food and supply items in the Dietary Department should be date [sic] and marked with received date, Items removed from the master case must be marked individually with received date .Once items are removed from the original packaging and placed in alternate storage containers, the alternate storage container must have received date and transfer date .Commercially prepared products that have been individually marked with a receipt date should be marked once opened with an open date .Once product is removed from original package, product should be .marked with open date .Cooked, prepared food should be sealed and marked with prep date .if product is left over and will not be served that same day, items must be individually dated with service date .if items are opened but not dished, this product should be placed in a sealed container, labeled with the open date . On 09/26/23 at 11:01 a.m., the initial tour of the kitchen was conducted with the CDM. The refrigerator was observed to have the following items undated and unlabeled: a. An opened plastic bag of biscuits located inside the original box was undated and unlabeled. The CDM verified no date or label. b. An opened plastic bag of pancakes located inside the original box was undated and unlabeled. The CDM verified no date or label. c. One metal sheet pan of sausage links was undated and unlabeled. The CDM verified no date or label of placement. The CDM stated they were for tomorrow's breakfast. d. Three metal sheet pans of bacon were undated and unlabeled. The CDM verified no date or label of placement. The CDM stated they were for tomorrow's breakfast. e. One metal container of liquid eggs covered with plastic wrap was undated and unlabeled. The CDM verified no date or label. On 09/26/23 at 11:04 a.m., the CDM was asked what the policy and procedure was for food storage. They stated items were to be dated. They stated when staff opened it, they were to date it.

Based on observation, record review and interview, the facility failed to ensure a call light was in reach for one (#25) of 24 sampled residents reviewed for call lights. The Resident Census and Conditions of Residents report, dated 09/26/23, documented 59 residents resided in the facility. Findings: The facility's Answering the Call Light policy, revised 10/10, read in part, .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Resident #25 had diagnoses which included hemiplegia and hemiparesis. Resident #25's quarterly resident assessment, dated 07/26/23, documented the resident was cognitively intact and required two person physical assist for transfers. It documented the resident had a functional limitation in range of motion impairment on one side for the upper and lower extremity. Resident #25's care plan for fall, dated 07/28/23, documented Resident #25 was at risk for falls with interventions that included to ensure the Resident's call light was in reach. On 09/26/23 at 1:49 p.m., Resident #25 was in a wheelchair eating their lunch and their call light was out of reach. On 09/26/23 at 1:57 p.m., Resident #25 pointed to their call light on the bed behind two stacked pillows and stated they could not reach it. On 09/26/23 at 1:59 p.m., Resident #25 stated they would holler if they needed help. On 09/26/23 at 2:38 p.m., CNA #1 entered Resident #25's room. On 09/26/23 at 2:39 p.m., CNA #1 left Resident #25's room with the resident's lunch tray. The call light remained out of reach. On 09/26/23 at 2:44 p.m., CNA #1 stated they were not sure if Resident #25 was a fall risk. CNA #1 stated residents should have their call light in reach. On 09/26/23 at 2:45 p.m., CNA #1 stated Resident #25 could use their call light and the call light was out of the resident's reach. On 09/27/23 at 1:29 p.m., the DON stated dependent residents should always have their call light in reach.

Based on record review and staff interviews, it was determined the facility failed to provide the assistance required and that was indicated in the resident's assessment, to ensure personal care was provided in a manner to prevent a resident from falling out of bed and receiving a head injury for one (#1) of three sampled residents reviewed for falls. This resulted in actual harm to the resident. He sustained a head injury with facial lacerations, which required being sent to the emergency room . The facility identified 136 residents resided in the facility. Findings: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Resident-Data Collection sheet, dated 06/20/15, documented the resident required Total assist under the Transfers-Able To Transfer section, was Non-weight bearing under the Weight Bearing- Able To Bear section and was documented as being on Bedrest under the Ambulation- Able to Ambulate section. The admission minimum data set (MDS), dated [DATE], documented resident #1 was cognitively intact and required extensive two person physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. It documented the resident required total dependence of two person physical assistance for locomotion on the unit. A care plan, dated 07/01/15, documented, .Focus .I have bladder incontinence .Interventions .Incontinent care/toileting q (every) 2 hours and prn (as needed) .Focus .I require assistance with adls (activities of daily living) . An employee witness statement completed by certified nurse aide (CNA) #1, dated 07/06/15, documented, .I was in the process of changing the resident and he was holding on to (sic) his bed rail, (I thought bed rail was secure) his weight shifted and he went over on the floor. The side rail was not secure and it moved causing the resident's shift in weight Ubar not secure to side of bed . An incident report completed by licensed practical nurse (LPN) #1, dated 07/06/15, documented, .Pt (patient) fall out of the bed during bed check at 0200 (2 a.m.) .Neuro (checks) Implemented sent to ER (emergency room ) for eval . An Oklahoma State Department of Health (OSDH) incident report form, dated 07/06/15, documented, .Resident had a fall out of bed during care by cna. Resident hit head on bedside table causing a laceration to right eye lid and left side of nose. Resident was sent to ER for evaluation/treatment and returned the same day with new treatment orders. Bruising noted to right eye and nose area. New intervention resident bed changed to bariatric bed with attached u-bars. Neuro (neurological) checks implemented . Investigation reveals resident fell out of bed during incontinent care when u-bar became dislodged while receiving care by cna. resident sustained [REDACTED]. Bruising noted to both areas. Resident was sent to ER for eval (evaluation) and treatment. New intervention resident bed changed to bariatric bed with attached u-bars . A physician's orders [REDACTED].clean laceration to the nose c (with) NS (normal saline) cover laceration c bandaid q (every) shift .Monitor s/s (signs/symptoms) of infection q shift .cleanse laceration to the left eye c NS, pat dry, apply bacitracin 500 units/g (gram) opth (ophthalmic) ointment . A care plan, dated 07/08/15, documented, .Focus .I have a laceration to my nose/ above left eye r/t (related/to) fall 07/06/15 .Interventions .keep areas clean and dry .monitor for s/s infection .treatment as ordered . A resident status sheet, undated, documented resident #1 required two person assistance for locomotion and position changes. It documented the resident required total care for dressing, grooming, bathing and bowel and bladder care. On 11/12/15 at 11:30 a.m., CNA #2 was asked how many staff were needed to assist in turning a resident. She stated if the resident needed a lift, obviously you need two people. At 11:46 a.m., the director of nursing (DON) was interviewed and asked to describe the events surrounding resident #1's fall on 07/06/15. She stated resident #1 fell out of his bed during care. She stated the resident had a facial laceration and was sent to the emergency room for treatment. She stated she was unsure of what exactly happened to the U bar on the resident's bed the date the fall occurred. She stated after the incident the facility ordered the resident a new bed with a U bar attached to the bed. The DON was asked to review the MDS data sheet, admission Resident Data Collection sheet and the resident status sheet. She was asked what assistance resident #1 required. She stated resident #1 used a hoyer lift for transfers. She stated he was a 1-2 person assist for bed mobility. She stated the resident was able to turn himself at times with 1 person assistance. She stated when he was in pain he required 1-2 person assistance. At 12:50 p.m., CNA #4 was interviewed and asked to describe the events surrounding resident #1's fall on 07/06/15. She stated the nurse who usually helped her turn the resident was busy and told her to go ahead and turn resident #1 by herself. She stated she was never aware that the U bar on the bed was loose. She stated when the resident's weight shifted onto the bar during the turn, the bar moved and the resident fell out of the bed. She stated she reported the fall to the charge nurse on duty. She stated the office nurses were also informed of the fall. At 1:00 p.m. corporate nurse #1 was asked if the facility had discovered any malfunction in resident #1's bed/U bar. She stated the facility did not find anything wrong with the resident's U bar or bed. She stated when the facility was made aware that the resident was returning from the hospital the same day, a whole new bed was ordered for the resident. She stated all U bars in the facility were checked the same day for safety.

Based on record review and interview, it was determined the facility failed to supervise, monitor, assess and develop specific and appropriate interventions for a resident with 20 falls which resulted in injury and actual harm for one (#1) of four residents whose clinical records were reviewed for falls. The facility roster matrix dated [DATE], documented 12 residents had falls with injuries. Findings: Resident #1 had [DIAGNOSES REDACTED]. The significant change in status assessment, dated [DATE], documented the resident was severly cognitively impaired and required limited to extensive assistance with all activities of daily living. The resident's clinical record documented she had 20 falls between [DATE] and [DATE]. The care plan, last updated [DATE], documented the resident's physician was to review her medications to determine if her medications were a factor in the number and severity of her falls. The clinical record did not indicate the reviews had been performed. The incident reports frequently documented the resident's blood pressure was low after many of her falls. The facility did not regularly monitor the resident's blood pressure to ensure her blood pressure medications were therapeutic and were not a contributing factor to her falls. A fall on [DATE], resulted in a subdural and subarachnoid hemorrhage. She had an additional fall on [DATE]. The resident died on [DATE]. The facility's fall risk policy documented: "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Policy Interpretation and Implementions (sp) ...Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture. If a medication is suspected as a possible cause of the resident's falling, the initial intervention might be to taper or stop that medication. ...and nursing staff, the Attending Physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. ..If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevent (sic). ...If underlying causes cannot be readily identified, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for continuation of the falling is identified as unavoidable. Monitoring Subsequent Falls and Fall Risk The staff will monitor and document each resident's response to interventions intended to reduce falling or risks of falling. ...If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions..." The resident's care plan for falls, dated [DATE], documented: "Interventions . assess my need for therapy/restorative due to weakness . Assist me as needed with transfers . Avoid clutter in my room or hallways . hipsters/protective helmet to be worn as i will allow . Pharmacy consult to evaluate my medications monthly . provide me wheelchair when weakness present." Hand written notes on the care plan documented: [DATE] 1. Redirect me to activity area after meals [DATE] 1.) Resident sent to ER (emergency room ) for head laceration 2.) Encourage proper foot wear [DATE] 1. was sent to ER for head laceration 2. Helmet to be worn as I will allow [DATE] w/c (wheelchair) provided for increased weakness Encourage staff to re-direct me when cleaning table and remove clutter from my hands [DATE] 1.) labs as ordered 2) close monitoring [DATE] I have had recent falls c (with) injury IDT (interdisciplinary team) continue to investigate falls and implement new interventions c each fall... [DATE] therapy part B to continue will check on HGB (hemoglobin) [DATE] ensure proper foot wear while ambulating or non skid socks [DATE] redirect me from pulling at blinds labwork: CBC (complete blood count), CMP (complete metabolic profile) pre-alb (albumin) [DATE] at 1845 (6:45 p.m.) 1) ensure halls and isles are free of clutter 2) ensure resident sits at 1st table near entrance as she will allow [DATE] at 11:25 a.m., 1) ensure floors are clean and dry during mealtimes, wipe up spill immediately Place me @ (at) entry table @ mealtime assist me back to my room q (every) after meal is done Sent to ER for eval (evaluation) and treat (treatment) At 1925 (7:25 p.m.) collaborate with hospice for X-tra (extra) visits ,[DATE] (resident) has had recent fall hx (history), Injury noted c 2 or more falls, has been sent to ER for tx (treatment) then return. IDT continue to investigate fall and add new interventions c each fall... (Resident) cont (continue) to amb (ambulate) s (without) assist (assistance)/devices -unsteady gait/balance, very impulsive. [DATE] due lab work to r/o (rule out) blood levels. [DATE] Attempt lab. draw (CBC) to r/o decreased HGB r/t (related to) increased falls [DATE] medication to ensure therapeutic medication regimen [DATE] Remove bedside table from room [DATE] Injury to face noted was sent to ER for eval, has not returned as of [DATE], IDT will re-assess resident and fall interventions to accommodate resident and enhance safety. [DATE] Moved closer to nurses station for safety [DATE] Encourage me to use w/c at mealtime." Incident Reports/Investigations/Nurses' Notes: Incident reports, investigative reports, and nurses' notes were reviewed for the period of [DATE] through [DATE]. 1. An incident report (IR) dated [DATE] at 7:00 a.m., documented an unwitnessed injury. The resident was found to have a bruise to the left forehead of unknown origin. The report documented the resident was confused. Vital signs were not obtained. No interventions were documented on the IR. A fall investigation worksheet dated [DATE], documented the resident required supervision and that safety interventions were in use at the time of the fall. The interventions in use were not described. The portion of the worksheet which asked, "Did the resident require supervision?" was answered, "yes." There was no documentation of increased supervision found in the clinical record. A fall risk evaluation dated [DATE] documented the resident was a high risk for falls with a score of 17. The fall intervention plan dated [DATE] documented the following interventions: a. the resident was to be monitored for changes in anxiety, sleep patterns, behaviors, or mood; and, b. there was to be increased staff assistance to and from the toilet and during ambulation. There was no documentation of increased supervision found in the clinical record. 2. An IR dated [DATE] at 1:25 p.m., documented an unwitnessed fall in the dining room. The report documented the resident was confused/disoriented and that an identified bruise had been acquired previous to this fall. No new injuries were identified. Vital signs of blood pressure (b/p) - ,[DATE], pulse - 61, respirations (resp) - 17, and temperature (temp) - 98.1 (degrees Fahrenheit), were obtained immediately after the fall. Documented interventions were to decrease the resident's stimuli, provide one-on-one (1:1) supervision at the nurses station, and redirection to the activities area after meals. There was no documentation in the clinical record that supervision at the nurses' station had been done. A fall intervention plan dated [DATE], documented the resident was to receive increased staff assistance to decrease stimuli and to provide 1:1 supervision at the nurses station. The portion of the worksheet which asked, "Did the resident require supervision?" was left blank. 3. An IR dated [DATE] at 6:30 p.m., documented the resident had an observed fall which resulted in a laceration to the upper left eye and complaints of pain to the left arm and left shoulder. Vital signs of b/p - ,[DATE], pulse - 72, resp - 18, and temp - 97.5, were obtained immediately after the fall. The documented interventions were to ensure the resident wore proper fitting shoes. The fall investigation worksheet dated [DATE], recommended as an intervention to supervise the resident while ambulating to prevent further falls. The portion of the worksheet which asked, "Did the resident require supervision?" was left blank. There was no documentation supervision had been done while ambulating. A fall intervention plan dated [DATE], documented increased staff assistance in the early morning, to and from the toilet, and during ambulation. Unsafe behaviors interventions included increased staff assistance for bathroom safety, use of a low bed and floor mat, a non-slip mat, and non-skid socks. Interventions for increased comfort included pain management and frequent rest periods. A nurse's note dated [DATE] on ,[DATE] (3:00 p.m. to 11:00 p.m. shift) did not document the resident had any safety equipment (helmet, hipsters, non-skid footwear) in use at the time of the fall. 4. An IR dated [DATE] at 7:00 p.m., documented the resident miss-stepped and fell in the hallway. The resident was disoriented and had a decreased level of conscience (LOC). She sustained a laceration to the right side of her face and was bleeding from the laceration and from her nose. Vital signs were unobtainable. The resident was sent to the emergency room (ER). The documented interventions were to offer a safety helmet and hipsters as the resident would allow. There was no fall investigation worksheet or fall intervention plan attached to the documentation. A communication form dated [DATE], documented the resident finished her meal, left the dining room and fell in the hallway. There was no documentation to indicate the resident had any safety equipment in use at the time of the fall or that the resident was assisted from the dining room by staff. 5. An IR dated [DATE] at 10:41 a.m., documented the resident had an unobserved fall in the hallway, the resident was confused, and there was swelling noted to the left cheek area. Vital signs of b/p - ,[DATE], pulse - 65, resp - 14, and temp - 97.4 were obtained immediately after the fall. The resident was sent to the ER for evaluation and treatment. The documented interventions were to have her physician perform a review of the resident's medications, send to the ER for evaluation, and offer wheelchair assistance for increased weakness related to chronic anemia. An incident report in regard to an incident dated [DATE], to the Oklahoma State Department of Health (OSDH) documented the resident had a safety helmet on at the time of the fall. An ER discharge report dated [DATE] at 2:41 p.m., documented the resident fractured a bone on the right side of the face. There was no fall investigation worksheet or fall intervention plan attached to the IR documentation. A nurse's note dated [DATE] at 11:00 a.m., did not document any safety equipment was in use at the time of the fall. 6. An IR dated [DATE] at 6:30 p.m., documented the resident had an unobserved fall in the dining room and the resident was confused/disoriented. Vital sign of b/p - ,[DATE], pulse - 91, resp - 18, and temp - 98.2, were obtained immediately after the fall. Documented interventions were to provide close monitoring and to draw labwork to identify possible causes of the fall. There was no fall investigation worksheet or fall intervention plan attached to the IR documentation. A nurse's note dated [DATE] at 6:50 p.m., documented the resident was not supervised as she sat at a dining room table. A progress note written on [DATE] at 3:34 p.m., by the resident's psychiatrist documented the resident's strength and muscle tone were decreased, and documented, "Reported fall, wears helmet." 7. An IR dated [DATE] at 7:10 p.m., documented the resident had a witnessed fall in the hallway. The resident tripped on her right foot. No injuries were apparent and the resident was disoriented. Vital sign of b/p - ,[DATE], pulse - 70, resp - 16, and temp - 98.2, were obtained immediately after the fall. Documented interventions were to monitor labwork. A fall investigation worksheet dated [DATE], documented the resident was wearing a safety helmet at the time of the fall. There were no recommended interventions documented. The portion of the worksheet which asked, "Did the resident require supervision?" was answered, "No." There was no fall intervention plan attached to the IR documentation. A nurse's note dated [DATE] at 9:15 p.m., did not document the resident was being assisted while ambulating in the hall, or that the safety helmet or non-skid footwear were in use at the time of the fall. 8. An IR dated [DATE] at 11:00 a.m., documented a witnessed fall in the dining room. The resident fell on her bottom and then picked herself up off the floor without assistance. The resident was disoriented and there were no apparent injuries. Vital signs of b/p - ,[DATE], pulse - 70, resp - 16, and temp - 97.4, were obtained immediately after the fall. The documented intervention was to ensure the resident wore proper footwear. The fall investigation worksheet dated [DATE], documented the resident was wearing a safety helmet at the time of the fall and required supervision. The portion of the worksheet which asked, "Did the resident require supervision?" was answered, "Yes." A fall intervention plan dated [DATE], documented interventions to reduce the risk of injury were the use of a helmet and hip protectors and the use of non-skid socks. A nurse's note dated [DATE] at 11:00 a.m., documented the resident was ambulating in the dining room unassisted and her gait was unsteady. The note does not document the use of of non-skid footwear at the time of the fall. 9. An IR dated [DATE] at 11:40 a.m., documented a witnessed fall in the dining room. The resident fell back on her bottom after attempting to hold herself up with window blinds. The resident was confused/disoriented. Vital signs of b/p - ,[DATE], pulse - 94, resp - 14, and temp - 97.4, were obtained immediately after the fall. Documented interventions were to redirect the resident when pulling at the blinds, and draw labwork to identify possible causes of the resident's fall. A fall investigation worksheet dated [DATE], documented the resident had a safety helmet and hipsters on at the time of the fall. The portion of the worksheet which asked, "Did the resident require supervision?" was left blank. A fall intervention plan dated [DATE], documented interventions to reduce the risk of injury were the use of a helmet and hip protectors and the use of non-skid socks. A nurse's note dated [DATE] at 12:00 p.m., did not document the resident had non-skid socks on at the time of the fall or that the resident was assisted as she wandered around the dining room. A progress note dated [DATE], was written by the resident's primary care physician. It documented the resident was at high risk for falls due to poor safety awareness, had impaired cognition and was confused. The note continued with documentation that the resident's gait was very unstable and the facility needed to "...continue to actively observe..." the resident. 10. An IR dated [DATE] at 6:15 p.m., documented the resident fell while ambulating in the dining room. The resident hit her head on a wheelchair. She had a safety helmet on and was disoriented. The resident refused to allow vital signs to be taken immediately after the fall. The documented intervention was to seat the resident near the dining room entrance/exit to reduce the distance and obstructions between the resident and the entrance/exit. Vital signs of b/p - ,[DATE], pulse - 86, resp - 19, and temp - 97.9, were obtained at 7:30 p.m. A fall investigation worksheet dated [DATE], documented the resident had a safety helmet on at the time of the fall. The recommended intervention was to use non-skid footwear. The portion of the worksheet which asked, "Did the resident require supervision?" was left blank. An employee witness statement dated [DATE], documented the employee did not witness the entire fall but did observe the resident's helmet fell off her head as she fell . There was no fall intervention plan attached to the IR documentation. A nurse's note dated [DATE] at 6:57 p.m., documented the resident did not have non-skid footwear on at the time of the fall. There was no documentation to indicate the resident had been assisted as she ambulated in the dining room. A neurological assessment flowsheet, dated [DATE], documented the residents b/p at follows: ,[DATE] at 7:30 p.m. - ,[DATE] at 7:45 p.m. - ,[DATE] at 9:45 p.m. - ,[DATE] at 11:45 p.m. - ,[DATE] 11. An IR dated [DATE] at 11:05 a.m., documented the resident had a witnessed fall in the dining room. The resident slipped in some water as she tried to rise from a stationary chair. There were no apparent injuries. Vital sign of b/p - ,[DATE], pulse - 80, resp - 17, and temp - 98.6, were obtained immediately after the fall The documented intervention was to educate staff to wipe up spills immediately. A fall investigation worksheet dated [DATE] at 11:05 a.m., documented the resident had a safety helmet on at the time of the fall. Recommended interventions were environmental modifications. The portion of the worksheet which asked, "Did the resident require supervision?" was answered, "yes." There was no fall risk assessment or fall intervention plan attached to the IR documentation. A nurse's note dated ,[DATE] at 11:35 a.m., did not document assistance was provided to the resident as she rose from her chair. 12. An IR dated [DATE] at 7:25 a.m., documented a witnessed fall in the hallway. The resident was ambulating with an unsteady, shuffling gait and fell . She hit her head on a door frame causing a hematoma to her right forehead. Vital signs were unobtainable. The resident was sent to the ER for evaluation and treatment of [REDACTED]. There was no documentation in the clinical record hospice had been contacted in regard to increased visits. There was no fall investigation worksheet, fall risk assessment, or fall intervention plan attached to the IR documentation. A nurse's note dated [DATE] at 8:15 p.m., documented the resident was walking unassisted with an unsteady, shuffled gait and was not wearing a safety helmet. There was no documentation to indicate the resident was wearing non-skid footwear or hipsters at the time of the fall. A neurological assessment flowsheet dated [DATE], documented the residents b/p at follows: ,[DATE] at 7:55 a.m. - ,[DATE] at 9:45 a.m. - ,[DATE] at 11:45 a.m. - ,[DATE] at 1:45 p.m. - ,[DATE] at 5:45 p.m. - ,[DATE] The entry timed 7:45 p.m., documented the resident had been sent to the emergency room . 13. An IR dated [DATE] at 6:45 p.m., documented the resident fell in the dining room as she tried to sit in an empty chair. The resident was confused/disoriented. Vital signs of b/p - ,[DATE], pulse - 89, resp - 20, and temp - 98.4, were obtained immediately after the fall. The documented intervention was to assist resident to her room as the resident will allow. A fall investigation worksheet dated [DATE], documented a safety helmet and hipsters were in use at the time of the fall. No interventions were recommended. The portion of the worksheet which asked, "Did the resident require supervision?" was left blank. There was no intervention plan attached to the IR documentation. A nurse's note dated [DATE] at 9:00 p.m., did not document the resident had on non-skid footwear or that she was assisted as she wandered around the dining room. 14. An IR dated [DATE] at 12:00 p.m., documented the resident fell in the dining room as she attempted to rise from her chair. There was no documentation of the resident's mental status at the time of the fall. Vital signs of b/p - ,[DATE], pulse - 70, resp - 18, and temp - 97.6, were taken after the fall. The documented interventions were to draw labwork to measure the resident's hemoglobin level which may have caused the fall. A fall intervention worksheet dated [DATE], documented the resident was disoriented, did not require supervision, and had a safety helmet on at the time of the fall. The portion of the worksheet which asked, "Did the resident require supervision?" was answered, "No." A fall intervention plan, dated [DATE], documented interventions to be implemented were the use of a helmet and hip protectors, and non-skid socks, which had already been addressed previously. 15. An IR dated [DATE] at 5:10 p.m., documented a witnessed fall in the dining room. The resident stood up and sat on the floor. Vitals signs of b/p - ,[DATE], pulse - 77, resp - 19, and temp - 97.9, were obtained immediately after the fall. The intervention documented was to increase activities involvement. A fall investigation worksheet, dated [DATE], did not document a safety helmet, hipsters, or non-skid socks had been in use at the time of the fall. The portion of the worksheet which asked, "Did the resident require supervision?" was left blank. A fall intervention plan, dated [DATE], documented interventions were to increased activities involvement, and use a helmet, hip protectors, and non-skid socks, again these interventions had already been addressed. A nurse's note dated [DATE] at 5:40 p.m., did not document the resident had on non-skid footwear at the time of the fall or that the resident was assisted when she tried to rise from her chair. 16. An IR dated [DATE] at 8:00 a.m., documented a witnessed fall as the resident was leaving her room. The resident was confused. Vital signs of b/p-,[DATE], pulse - 74, resp - 18, and temp - 97.2, were taken immediately after the fall. The documented intervention was to draw labwork to rule out a low hemoglobin level, which may have contributed to the fall. A fall investigation worksheet dated [DATE], documented the resident did not require supervision and had a safety helmet and hipsters on at the time of the fall. The portion of the worksheet which asked, "Did the resident require supervision?" was answered, "No." A nurse's note dated [DATE] at 8:48, did not document the resident had any safety equipment in use at the time of the fall. 17. An IR dated [DATE] at 2:30 p.m., documented an unobserved fall in the hallway. The resident's condition was normal. Vital signs of b/p - ,[DATE], pulse - 81, resp - 18, and temp - 97.0 were obtained immediately after the fall. The documented intervention was to review medications to ensure a therapeutic medication regimen. A fall investigation worksheet dated [DATE], documented the fall was unwitnessed. It documented safety interventions were in use at the time of the fall but did not document which interventions. The portion of the worksheet which asked, "Did the resident require supervision?" was left blank. An employee witness statement dated [DATE], documented aides reported the resident fell to the floor while walking in the hall. There was no documentation to indicate the resident had been assisted while ambulating. A fall interventions plan dated [DATE], documented a helmet, hipsters, and non-skid socks were to be used to prevent further falls. A nurse's note dated [DATE] at 7:00 a.m., did not document the resident had a safety helmet on at the time of the fall. 18. An IR dated [DATE] at 6:45 a.m., documented the resident was found sitting on the floor in her room with dried blood on her nose, hands, and fingers. Vital signs of b/p - ,[DATE], pulse, 72, resp - 18, and temp - 97.3, were obtained as soon as the incident was discovered. The interventions documented were to obtain a urinalysis (UA) with a culture and sensitivity (C&S) test and to remove the bedside table from the room. An OSDH incident report form dated [DATE], documented the facility's investigation of the incident determined the resident, "hit her nose on the bedside table while attempting to get up out of bed unassisted." The form documented the bedside table was removed from the room to prevent further injuries related to falls and the physician ordered a UA with C&S test, if indicated, to rule out infection as the cause of the fall. The form also documented the resident was independent with ambulation but had unsteady gait at times. A fall investigation sheet dated [DATE], documented the resident did not have any safety interventions in use at the time of the fall. The portion of the worksheet which asked, "Did the resident require supervision?" was left blank. 19. An IR dated [DATE] at 2:00 p.m., documented an unobserved fall in the hallway. The resident sustained [REDACTED]. The report did not indicate where the laceration was located. Vital signs of b/p - ,[DATE], pulse - 69, resp - 18, and temp - 97.4, were obtained immediately after the fall. The documented intervention was to move the resident to a room closer to the nurses' station. An OSDH incident report form dated [DATE], documented the resident hit her head, was independent with ambulation but was unsteady and had received blood transfusions for anemia in the past. A fall investigation worksheet dated [DATE], documented two lacerations to the face and also documented the resident had taken the safety helmet off. The portion of the worksheet which asked, "Did the resident require supervision?" was left blank. There was not a fall prevention plan attached to the IR investigation documentation. A nurse's note dated [DATE] at 2:28 p.m., did not document any safety measures were in use at the time of the fall. A neurological assessment flowsheet dated [DATE], documented at 10:30 a.m., the resident's b/p was ,[DATE]; at 11:30 a.m., the residents b/p was ,[DATE]; and at 2:15 p.m., the residents b/p was ,[DATE]. 20. An IR dated [DATE] at 2:50 p.m., documented an unobserved fall in the dining room. Vital signs of b/p - ,[DATE], pulse - 88, resp - 20, and temp - 99.5, were obtained immediately after the fall. The documented intervention was to encourage the resident to use a wheelchair at meal times. A fall investigation worksheet dated [DATE], documented the resident had removed her safety equipment prior to the fall. The portion of the worksheet which asked, "Did the resident require supervision?" was left blank. A fall intervention plan dated [DATE], documented a helmet, hip protectors and non-skid socks were to be used to prevent future falls. A nurse's note dated [DATE] at 2:58 p.m., did not document the resident had any safety measures in place at the time of the fall. There was no documentation found to indicate the physician had reviewed the resident's medications to determine if medications had contributed to the resident's falls. On [DATE] at 3:00 p.m., the administrator, director of nurses (DON), and a corporate nurse were interviewed in regard to the resident's supervision and number of falls. They were asked if they were aware of the number of falls the resident had. The corporate nurses stated they were very aware of them. They stated they had talked about the falls everyday in stand up, but there was no documentation of the discussions. The clinical record contained no documentation of the resident's falls having been discussed or re-evaluated. They were asked if new interventions were put in place after each fall. The corporate nurse stated they did and they were documented on the care plan. They were asked if they had attempted to get the resident to use a wheelchair (W/C) as indicated on the care plan. They stated they had not. The care plan documented one intervention had been to have the resident use a W/C as necessary for weakness. The administrator, DON and corporate nurse were asked if there was documentation the staff ambulated the resident to the dining room, activity room, or in the hallways. They stated staff did assist the resident with ambulation. The care plan did not address ambulation. They were asked if staff provided the resident with assistance to sit in her dining room chair. They stated the resident would just fall in front of them. They were asked if it was care planned and they said, "No." The clinical record contained no documentation staff assisted the resident to sit in a chair at the dining room table. They were asked if there was documentation the resident was on frequent visual checks while she was in her room, in the halls or the dining room. They stated staff did watch her. They were asked if it was documented and they said, "No." The clinical record documented the resident resided in a room where the roommate would not allow the door to remain open. She was moved to a new room after her fall on [DATE]. The clinical record documented the resident was moved to a room where the resident could be more closely monitored. This was done on [DATE]. The administrator, DON and corporate nurse were asked if the resident wore a helmet or non-skid socks. They stated she was able to remove the helmet and non-skid socks and frequently did so. They were asked if there was documentation of when the resident removed the safety equipment and if it was reapplied by staff. They stated the documentation would be found in the nurses' notes. They were asked if it was care planned or documented, and they stated they would have to look. The care plan and clinical record did not address the resident's refusal to wear a helmet or non-skid socks and/or when the resident removed the safety equipment and if it was reapplied by staff. They were asked if the resident's blood pressure had been obtained prior to the administration of B/P (blood pressure) medications. They stated that it was not taken prior to the administration of B/P medications unless there was a physician's orders [REDACTED]. The administrator, DON and corporate nurse were asked if orthostatic hypotension had ever been evaluated as a possible cause of falls. They stated they had not because sometimes she refused to let them take her B/P. They were asked if her refusal to allow it had been care planned. They stated it had not been care planned. They were asked if the resident was assisted to and from the dining room or supervised while in the dining room to prevent falls. They stated they kept an activities person in the dining room to supervise residents while other staff was serving trays. The corporate nurse stated it was not possible to assign 1:1 supervision for the resident; that all staff assisted with keeping an eye on her while in the dining room and ambulating in the hall. The corporate nurse stated that as the resident's condition declined the goal was to get the resident into a wheelchair and off her feet. She was asked if this was done successfully. She stated, "Yes, the resident is using a wheelchair-after the last fall." On [DATE] at 3:35 p.m., licensed practical nurse (LPN) #1 was interviewed in regard to fall precautions. He stated he was informed of a resident being placed on fall precautions by the person from the transferring facility who called report. He stated if he did not get the information from them, new residents were observed by staff for 72 hours and assessments were completed. He stated it would come out at that time. LPN #1 stated standard fall precautions included: pink helmets, hipsters, non-skid socks, low beds, fall mats (in some cases), assistance from staff with ambulation, and increased staff observation-approximately every 30 minutes to 1 hour. He stated alarms were not used. When asked specifically about the resident, LPN #1 stated she was a fall risk. He stated she was to use a safety helmet, hipsters, non-skid s

Based on observation, record review and interview, it was determined the facility failed to ensure medical social services were provided to obtain an admission to a gero-psych unit for one (#12) of one sampled resident requiring a gero-psych unit admission. This caused mental and physical harm due to the lack of assessment and intervention of the resident's loud excessive yelling. The Census and Conditions report, dated 08/19/13, documented 123 residents resided in the facility. Findings: Resident #12 was readmitted to the facility on [DATE] following a hip fracture with repair. She had [DIAGNOSES REDACTED]. Shortly after admission, it was documented the resident began having episodes of yelling which were easily redirected. Documentation showed these episodes progressively became more frequent and severe. She was no longer able to be redirected. It was also documented she began experiencing hallucinations. The physician's orders [REDACTED]. Celexa 10 mg daily (an antidepressant), Depakote Sprinkles 125 mg twice a day (a mood stabilizer), Ativan 0.25 mg every 12 hours and every eight hours as needed (an antianxiety medication) and Norco 5-325 mg one every six hours as needed (a narcotic pain medication.) A care plan, dated 05/21/13, documented, "...Focus - I have impaired cognitive function/dementia c behaviors: yelling out loudly... Goals - Staff will anticipate and meet my needs during this review period... Interventions - I require locked unit - Keep my routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion - medication as my dr ordered - Identify yourself to me... (in handwriting) Focus - 8/15/13 I was slapped by another resident in face R/T my yelling out behavior... Goals... I will be kept safe from physical abuse from others this review period... Interventions - 1. Other resident removed from my room 2. Visual cue provided to my door to cue other resident not to enter my room 3. diversional activity provided to resident @ time of incident... (in handwriting) Focus - 8/19/13 -I was kicked by another resident on my leg no injury R/T my yelling out behavior... Goals - I will be kept safe from physical abuse from others... Interventions - 1. Redirect other residents away from my area 2. provide diversional activity to residents at time of incident..." On 06/18/13, the Depakote was increased to 125 mg three times a day due to increased behaviors. On 06/21/13, an in-house psychiatric consult was ordered due to increased agitation and anxiety. On 06/25/13, the Norco was increased to one tablet three times a day routinely due to pain. An activity progress note, dated June 2013, documented, "...She has shown a big decline, shes (sic) becoming very agitated toward staff and to other residents. She is becoming more and more agigtated (sic), she is becoming more disruptive and toother (sic) residents are getting very aggressive with her when she gets irritated..." On 07/02/13, the in-house psychiatric services evaluated the resident. The Depakote was increased to 250 mg twice a day due to behaviors. On 07/12/13, the Depakote was increased to 250 mg at 8:00 a.m., 125 mg at 2:00 p.m. and 250 mg at 8:00 p.m. On 07/21/13, the Depakote was increased to 250 mg three times a day due to dementia with behaviors. A nurse's note, dated 07/23/13, documented, "(12:19 p.m.) ...continued anxiety and yelling out noted c no relief. PRN ativan (and) norco given. 1 on 1 attention attempted, redirection, removing from group, all s relief. contacted (Physician's name) received n/o to refer to geriatric psych ward to eval and tx ...(9:30 p.m.)...continuously yelling and screaming. Redirected as needed s relief..." A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's progress note, dated 07/26/13, documented, "...She has had a lot of behaviors recently, yelling out, being repetitive and disruptive with other residents. We have a UA ...ordered. For anxiety we are going to go ahead and increase her Ativan to 0.5 mg Q.8H. routinely and one Q.6H. P.R.N. If her symptoms persist and the UA is negative, she may need an inpatient geropsych stay for medication adjustments..." An activity progress note, dated July 2013, documented, "...(Resident) has shown a huge decline, shes (sic) becoming very agitated toward staff and to other residents, She is becoming more and more agigtated (sic), she is becoming more disruptive and too their (sic) residents are getting very aggressive with her when she gets irritated,..." A physician's progress note, dated 07/30/13, documented, "...psych eval when abx completed..." A social services resident assessment, dated 07/31/13, documented, "...Behavioral problems/concerns: continues to yell out often: anxiety... Relationship with roommate: moved her roommate due to continuous yelling... Summation: nursing checking for UTI and doing lab work. may need other interventions if all clear - possible inpatient admission - constant yelling/anxiety without being able to be redirected..." A physician's orders [REDACTED]. On 08/08/13, the Depakote was increased to 500 mg twice a day. The Celexa was discontinued and Remeron 15 mg at bedtime was initiated due to depression with anorexia. A social service monthly summary, dated for August 2013, documented, "...8/6/13 Made phone calls to (gero-psych unit #1). Left message. To return call for (representative) regarding possible admission to inpt. 8/8/13 Called (gero-psych unit #2) to see if they have any available beds. Left message to return call. 8/9/13 No response from either hospital. Will continue to check. Also, per family they would like resident to stay within city for treatment. So, unable to call (gero-psych unit #3) or (gero-psych unit #4). 8/12/13 Called (gero-psych unit #5). Left message to return call. Late entry 08/20/13 On 08/15/13 Spoke with (family member). Advised of denial from (gero-psych unit #1). When speaking with him, found that he did not understand that the inpatient referral is only for a specific short amount of time, not a temporary placement. He states he is okay with resident going to treatment centers outside of Oklahoma city." A social services progress note documented, "08/12/13 -Spoke with (family members) about possible inpatient admission for resident. After many interventions from nursing/doctor, resident is still constantly yelling out without interruption, and is constantly agitated and anxious. She can not be redirected. It disturbs other residents, and puts resident at danger for resident to resident abuse. Resident has to be assisted eating, but is unable to remain in the dining area, so she is usually assisted by the nurse's station. So, the constant yelling has isolated her socially. Doctor has written order for inpatient admission, but that was before it was found out that she had a UTI. Now that her UTI is cleared, the behaviors remain. Charge nurse has advised this SW that she has seen resident have difficulty eating and swallowing (almost choking) because of her yelling. She will rarely calm down enough even to eat. Explained all this to (family members), and they agree that inpatient evaluation and care is appropriate. I had given inpatient referral to (gero-psych unit #1) representative while she was here. She will have the team there review and will let me know. 08/14/13 -Received call from (Representative) with (gero-psych unit #1). She states they will not be able to admit resident mainly due to her only symptom is yelling out. Will continue to look for other facilities who have possible openings..." A nurse's note, dated 08/14/13, documented, "...(2:06 p.m.)...Res noted c (increased) anxiety. Routine med given. Res cont to yell. Res was given her PRN Ativan -Res was calm an hour after it was given but was yelling again later...(9:20 p.m.)...Had a call from (gero-psych unit #1) regarding prospective transfer to psych unit. Cont to have hallucinations and (increased) anxiety..." A nurse's note, dated 08/15/13, documented, "...(1:26 p.m.) Res noted with (increased) anxiety... (7:00 p.m.)...Continues with (increased) anxiety, yelling and hallucinations... (7:05 p.m.) Res was observed being slapped by another resident who wandered into her room while she was yelling and hallucinating..." On 08/19/13 at 8:55 a.m., resident #12 was observed in the dining room of Memory Lane (the secured dementia unit). She was sitting at the table being assisted to eat. She was sitting in a wheel chair repetitively yelling as loudly as she could, "I want to go home...where's my sister...come here, come here...shut up, shut up..." She pushed away the hand of the CNA who was attempting to assist her with the meal several times. Resident #28 was observed quietly saying, "Shut her up." At 9:15 a.m., resident #12 was moved to the hallway in front of the nurse's desk. She continued to yell. At 9:20 a.m., resident #12 was repetitively yelling, "Come here, Faye. Come here Faye." Resident #17 was observed by two surveyors to walk up to resident #12 and strike her on the lower leg with his cane. CNA #3 turned the corner and redirected resident #17 to his room by stating, "Oh, no. You can't do that." At this same time, resident #25 and resident #26 were observed to walk by resident #12 and say. "Shut up." At 9:25 a.m., resident #12 was taken to her room and placed in bed. A large velcro 'Stop' sign was placed across the doorframe. The resident continued yelling. At 9:35 a.m., resident #12 was still yelling loudly "Get out, get out." No one was in the room. Resident #27 walked by the room, looked in and stated, "No." At 10:05 a.m., resident #12 was still yelling. She was in the bed pulling and tugging at the blankets. An activity was in progress in the dining room/lobby area and resident #12 could be heard yelling from her room down and around the hallway. At 11:00 a.m., resident #12 was still in her bed yelling loudly. The stop sign was in place. At 12:10 p.m., resident #12 was outside in the courtyard with a CNA. She was yelling loudly. At 12:20 p.m., resident #12 was brought to the dining room to await lunch. She drank a half a glass of orange juice and then started yelling loudly again. A CNA removed the resident from the dining room and pushed her in the halls. She continuously yelled. At 12:48 p.m., resident #12 was still yelling in the hallways. She was taken to her room at this time for the lunch meal. She continued to yell throughout the meal and pushed the CNA's hand away numerous times. Occasionally she would take a bite and then continue yelling. The stop sign was in place. At 1:50 p.m., resident #12 was outside with a CNA. She continued to yell. At 3:00 p.m., resident #12 was in her bed asleep. The stop sign was in place. At 4:10 p.m., resident #12 was in the wheel chair in her room yelling loudly. Her voice was beginning to sound a little raspy. The stop sign was in place. A nurse's note, dated 08/19/13, documented, "...(2:02 p.m.)...(increased) agitation noted...Res cont to yell...This res was sitting in w/c when other res came down hallway and other res foot hit this res leg...very disoriented with disorganized thinking. Keeps screaming and yelling c some hallucinations.." On 08/20/13, at 7:40 a.m., resident #12 was in bed repetitively yelling, "Come here, go away." She could be heard in the dining room where the other residents were gathering for breakfast. The stop sign was in place. At 9:00 a.m., resident #12 had been placed in her wheel chair and was still yelling. Her breakfast tray was taken to her room. She continued to yell throughout the meal and was observed pushing away the hands of the CNA as bites of food were offered. The stop sign was in place. At 9:15 a.m., resident #12 was still yelling. Resident #15 had also begun a repetitive yelling. Resident #25 and resident #26 were observed walking down the hall. Resident #25 was overheard telling resident #26, "I wish they would both shut up!" At 10:15 a.m., an activity was in progress in the dining room/lobby area. Resident #12 could be heard yelling from her room. The room door was partially shut and the stop sign was in place. At 11:20 a.m., resident #12 was still yelling. At 1:40 p.m., the SSD was asked about resident #12. She stated she was trying to get her into a gero-psych unit. She stated they won't accept her because her only behavior is yelling. She stated she had tried to tell them the yelling was now effecting her eating. She was asked if she had told them the resident was disruptive to the unit and was in potential danger due to her behaviors. She stated she thought she had. She was asked if she had documented this information. She stated, "Probably not," but would check the monthly summary notes. At 1:55 p.m., the SSD presented the monthly summary note for August 2013. She stated the resident's POA had not wanted the resident placed in a facility out of town, so was limited to only metro facilities. She was asked if she had called a facility on 07/23/13. After she reviewed the note, she stated the facilities would not accept the resident if she had a UTI. She stated she had told nursing and the resident was treated for [REDACTED]. She was asked if she was told this by a facility on the 07/23/13. She stated, "No", she just knew this from other referrals. She was asked when was the first time she had contacted a gero-psych unit. She stated it looked like the first call was placed on 08/06/13 to (gero-psych unit #1). She was asked if she had informed the unit of the resident having hallucinations, disrupting the unit, being in potential danger due to her yelling and swallowing difficulties. She stated LPN #2 had talked to them so he would have told them all that. At 4:00 p.m., the resident's POA was interviewed. He was asked if he was aware a gero-psych referral order had been given for the resident. He stated, "Yes." He was asked when he first knew of the referral. He stated, "Seven to ten days ago." He was asked if he had been notified on 07/23/13 when the first order was given. He stated, "No, it definitely was not that long ago." He was asked if he knew of any behaviors resident #12 may have. He stated, "Yes, she yells all the time." He was asked if he was aware the yelling could possibly be aggravating the other residents. He stated, "I'm sure it does, probably even the staff that have to listen to it." He stated he had been called yesterday about another resident hitting her with his cane. He was asked if he was aware another resident had slapped her. He stated, "No, I didn't know she had been slapped." He was asked if he had told the facility to only make referrals in the metro area. He stated he had at first, but when they met a few days ago, he told them to do whatever they had to. At 5:30 p.m., the SSD was asked if, on 07/23/13, a facility had told her they would not accept the resident if she had a UTI. She stated, "No, they had told me that before so I told nursing that." At 5:50 p.m., the DON was interviewed. She was asked if she knew if a 'hold' order had been written for the 07/23/13 gero-psych referral when the resident needed a UA. She stated the resident had to finish the antibiotics before a referral could be made. She was asked who told her the resident needed a UA. She stated, "(SSD name) told us." She stated that's why she was hired, to guide us in what we need to do. She was asked if the family had been notified of the 07/23/13 gero-psych referral order. She stated the SSD had been visiting with the family about placement. She was asked if she was aware of any other residents mistreating resident #12 because of her yelling. She stated she knew resident #17 had kicked her with his foot on 08/19/13. She was asked if she knew resident #17 had hit the resident on the leg with his cane. She stated, "No." She was asked if she was aware of any other incidents. She stated another resident slapped resident #12. She stated they had placed the 'stop' sign on her door after this happened. She was asked how the resident was being protected while outside her room. She stated the staff kept her where they could see her and redirected other residents away from her. She was asked if she was aware the nurses were documenting resident #12 was having trouble swallowing and eating because of the constant yelling. She stated they had asked the nurses to start documenting about that and any aggressive behaviors she might have. She was asked if she was aware the SSD had only contacted a couple of gero-psych units with the referral. She stated, "She has been having trouble getting her placed." She was asked if she had ever tried to help the SSD obtain an admission. She stated, "No, she handles all the referrals." At 6:10 p.m., the administrator was interviewed. She was asked if a referral to a gero-psych unit was made for resident #12 on 07/23/13. She stated she had a dirty UA and had to finish the antibiotic before she could be referred. She was asked if she was aware of any incidents where other residents had mistreated the resident because of her yelling. She stated, "Yes, she was kicked by a male resident yesterday, or maybe even hit her with his cane. She was asked if she was aware of any more incidents. She stated a resident slapped her a few days ago. She stated that was when they put up the 'stop' sign on her doorframe. She was asked how the resident was protected when outside her room. She stated the staff keep her within view and redirect the other residents away from her. She was asked if she was aware the resident's yelling was causing her to have difficulties swallowing and eating. She stated the nurses are supposed to be documenting that so they can show her yelling isn't just yelling to get her admitted . She was asked if she felt resident #12 was safe if she kept yelling. She stated the residents had dementia and wouldn't hurt her intentionally. She was asked if she felt she was disruptive to the unit. She stated the residents had dementia and some of them probably didn't even know she was yelling. She was asked if she had done anything to assist SS in obtaining placement. She stated, "We talk about it in stand-up every morning." She was asked if she had ever made any phone calls to assist with placement. She stated, "No." She was asked if she thought two weeks was an acceptable time frame to still be seeking placement. She stated, "What can you do. They say yelling isn't enough to admit her." She was asked if the gero-psych units had been told of the hallucinations, her safety concerns and how the yelling was affecting her eating. She stated, "(SSD name) should have done that." A nurse' note, dated 08/20/13, documented, "...Res while eating started to cough because of res talking and yelling. Nurse tried to redirect res c (no) success... (7:30 a.m.)...(increased) agitation noted...Agitation cont (increase) also (increased) yelling... (5:08 p.m.)...nail care attempted. Resident won't allow as she becomes very agitated..." On 08/21/13 at 9:15 a.m., the SSD was again interviewed. She was shown the August social service monthly summary. She was asked the following questions about the document: on 08/06/13 did she only call gero-psych unit #1? "Yes"... on 08/08/13 did she only call gero-psych unit #2? "Yes"... did she make any return calls to the units on those days or inbetween? "No"... on 08/09/13 did she talk with the family? "No, nursing had been talking to them." Which nurses? she believed it was LPN #2... on 08/12/13 did she only call gero-psych unit #5? "Yes"... Was this the first date she talked to the family? "Nursing had been talking to them." She was shown the 08/14/13 social service progress note. She was asked if she had told gero-psych unit #1 about the hallucinations, the resident being isolated , the resident's safety being compromised and the resident having swallowing and eating difficulties due to her excessive yelling. She stated LPN #2 had talked to them and she assumed he had told them. She was asked if she had made any other attempts to get her placed since 08/14/13. She stated, "No." She was asked if the ADM or the DON had attempted to help her find placement, such as by making phone calls. She stated, "No, not until last night." She was asked if she knew where resident #12 was. She stated she was sent to the ER last night and was admitted . At 10:10 a.m., resident #29 was asked if she was bothered by resident #12's yelling. She stated, "It did at first, but I've kinda gotten used to it." At 2:40 p.m., LPN #1 and LPN #2 were interviewed. LPN #1 was asked if she was the nurse who documented the incident of resident #17 hitting resident #12 with his foot. She stated, "Yes." They were asked if resident #17 had ever been aggressive towards resident #12 before this incident. Both stated he would go yell at her and then would shut her door. They stated they watched him closely and when he got to close to resident #12 they would redirect him away from her. They were asked if they were aware of any other incidents where other residents mistreated resident #12. LPN #2 stated she had been slapped by resident #18 a few days before. LPN #1 stated the incident shocked them because resident #18 was the 'mother' of the unit. They assumed she went to resident #12's room to console her and when she couldn't get her to stop yelling, she slapped her. LPN #2 stated that was when they placed the stop sign on her door. They were asked what they did to protect her when she was not in her room. Both stated she was kept within view and when they see another resident getting too close to her they redirect the other resident away from her. LPN #1 stated, "She keeps the other residents pretty stirred up." LPN #2 stated, "A lot of them yell at her to 'shut up'. They will even yell at her door." They were asked if they had witnessed her having difficulty swallowing or eating. LPN #2 stated, "Her throat gets sore and she can't swallow. She won't stop yelling long enough to eat sometimes." On 08/23/13 at 9:10 a.m., resident #25 and #26 were asked if they were bothered by resident #12's yelling. Resident #25 stated, "Yes, it drove us crazy." Resident #26 stated, "It just went on and on, it never stopped." At 10:00 a.m., resident #12's physician was interviewed. He was asked about resident #12. He stated, "She screams constantly. I always knew who they were calling me about because I could hear her screaming in the background." He stated he had changed her medications several times but she 'needed a psych consult.' He stated he wasn't sure if this facility was appropriate for her anymore. He was asked if he was aware the facility was having trouble finding placement for the resident. He stated, "No, I didn't know that. First I've heard of it." At 3:15 p.m., LPN #2 was asked if he had contacted resident #12's family on 07/23/13 when the psych eval order was written. After reviewing the record he stated he only talked to the family about the inhouse psychiatric services. He was shown the nurse's note, dated 08/14/13. He stated gero-psych unit #1 had called and asked him if the resident was physically aggressive. He stated he told them 'No, she only yells.' He stated the caller stated 'Ok' and hung up. He was asked if he had ever told any gero-psych unit about the resident having hallucinations, agitating other residents, having difficulty eating or about her safety being compromised because of her yelling. He stated, "No." He was again asked if he had talked to the family about an in-patient gero-psych admission. He stated, "No. Social services was doing that. She takes care of all the referrals."

Based on observation, record review and interview, it was determined the facility failed to promote an environment to enable residents of Memory Lane (a secured dementia unit) to attain their highest practicable well-being for seven (#17, 18 and #25 - #29) of 13 sampled residents who resided on Memory Lane and were exposed to the loud excessive yelling of resident #12. This caused harm through verbal and physical expressions of distress such as repeatedly saying "Shut up" and physically striking the yelling resident. The facility roster identified 37 residents resided on Memory Lane. Findings: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission resident assessment, dated 04/23/13, documented the resident was able to make his needs known and understood others. He had short and long term memory problems and moderately impaired cognitive skills for daily decision making. The resident was ambulatory with a cane. A care plan problem, dated 04/25/13, documented, "Focus I have potential to demonstrate physical behaviors. Goal I will not harm self or others through the review date. Interventions enc my family and friends to visit frequently Give me as many choices as possible about care and activities. Redirect me as needed..." A quarterly resident assessment, dated 07/21/13, documented the resident was able to make his needs known and understood others. He had short and long term memory problems and moderately impaired cognitive skills for daily decision making. The resident was ambulatory with a cane. Resident #18 had [DIAGNOSES REDACTED]. Her resident assessment, dated 06/04/13, documented she had severely impaired decision making skills. Resident #25's quarterly resident assessment, dated 08/06/13, documented her cognitive status was moderately impaired. She was able to understand and was understood. Resident #26's quarterly resident assessment, dated 08/08/13, documented she had severely impaired decision making skills. She was able to understand and was understood. Resident #27's quarterly resident assessment, dated 06/28/13, documented she had severely impaired decision making skills. She was able to understand and was understood. Resident #28's quarterly resident assessment, dated 08/08/13, documented she had severely impaired decision making skills. She was able to understand and was understood. Resident #29's quarterly resident assessment, dated 08/06/13, documented she had severely impaired decision making skills. She was able to understand and was understood. Resident #12 was readmitted to the facility on [DATE] following a [MEDICAL CONDITION] with repair. She had [DIAGNOSES REDACTED]. Shortly after admission, it was documented the resident began having episodes of yelling which were easily redirected. Documentation showed these episodes progressively became more frequent and severe. She was no longer able to be redirected. It was also documented she began experiencing hallucinations. A care plan for resident #12, dated 05/21/13, documented, "...Focus - I have impaired cognitive function/dementia c behaviors: yelling out loudly... Goals - Staff will anticipate and meet my needs during this review period... Interventions - I require locked unit - Keep my routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion - medication as my dr ordered - Identify yourself to me... (in handwriting) Focus - 8/15/13 I was slapped by another resident in face R/T my yelling out behavior... Goals... I will be kept safe from physical abuse from others this review period... Interventions - 1. Other resident removed from my room 2. Visual cue provided to my door to cue other resident not to enter my room 3. diversional activity provided to resident @ time of incident... (in handwriting) Focus - 8/19/13 -I was kicked by another resident on my leg no injury R/T my yelling out behavior... Goals - I will be kept safe from physical abuse from others... Interventions - 1. Redirect other residents away from my area 2. provide diversional activity to residents at time of incident..." An activity progress note, dated June 2013, documented, "...She has shown a big decline, shes (sic) becoming very agitated toward staff and to other residents. She is becoming more and more agigtated (sic), she is becoming more disruptive and toother (sic) residents are getting very aggressive with her when she gets irritated..." The resident assessment, dated 07/08/13, documented the resident had severely impaired decision making skills and had behaviors directed toward others. A nurse's note, dated 07/23/13, documented, "(12:19 p.m.) ...continued anxiety and yelling out noted c no relief. PRN [MEDICATION NAME] (and) [MEDICATION NAME] given. 1 on 1 attention attempted, redirection, removing from group, all s relief. contacted (Physician's name) received n/o to refer to geriatric psych ward to eval and tx ...(9:30 p.m.)...continuously yelling and screaming. Redirected as needed s relief..." A physician's orders [REDACTED]. A physician's progress note, dated 07/26/13, documented, "...She has had a lot of behaviors recently, yelling out, being repetitive and disruptive with other residents. We have a UA ...ordered. For anxiety we are going to go ahead and increase her [MEDICATION NAME] to 0.5 mg Q.8H. routinely and one Q.6H. P.R.N. If her symptoms persist and the UA is negative, she may need an inpatient geropsych stay for medication adjustments..." An activity progress note, dated July 2013, documented, "...(Resident) has shown a huge decline, shes (sic) becoming very agitated toward staff and to other residents, She is becoming more and more agigtated (sic), she is becoming more disruptive and too their (sic) residents are getting very aggressive with her when she gets irritated,..." A physician's progress note, dated 07/30/13, documented, "...psych eval when abx completed..." A social services resident assessment, dated 07/31/13, documented, "...Behavioral problems/concerns: continues to yell out often: anxiety... Relationship with roommate: moved her roommate due to continuous yelling... Summation: nursing checking for UTI and doing lab work. may need other interventions if all clear - possible inpatient admission - constant yelling/anxiety without being able to be redirected..." A physician's orders [REDACTED]. A social service monthly summary, dated for August 2013, documented, "...8/6/13 Made phone calls to (gero-psych unit #1). Left message. To return call for (representative) regarding possible admission to inpt. 8/8/13 Called (gero-psych unit #2) to see if they have any available beds. Left message to return call. 8/9/13 No response from either hospital. Will continue to check. Also, per family they would like resident to stay within city for treatment. So, unable to call (gero-psych unit #3) or (gero-psych unit #4). 8/12/13 Called (gero-psych unit #5). Left message to return call. Late entry 08/20/13 On 08/15/13 Spoke with (family member). Advised of denial from (gero-psych unit #1). When speaking with him, found that he did not understand that the inpatient referral is only for a specific short amount of time, not a temporary placement. He states he is okay with resident going to treatment centers outside of Oklahoma city." A social services progress note documented, "08/12/13 -Spoke with (family members) about possible inpatient admission for resident. After many interventions from nursing/doctor, resident is still constantly yelling out without interruption, and is constantly agitated and anxious. She can not be redirected. It disturbs other residents, and puts resident at danger for resident to resident abuse. Resident has to be assisted eating, but is unable to remain in the dining area, so she is usually assisted by the nurse's station. So, the constant yelling has isolated her socially. Doctor has written order for inpatient admission, but that was before it was found out that she had a UTI. Now that her UTI is cleared, the behaviors remain. Charge nurse has advised this SW that she has seen resident have difficulty eating and swallowing (almost choking) because of her yelling. She will rarely calm down enough even to eat. Explained all this to (family members), and they agree that inpatient evaluation and care is appropriate. I had given inpatient referral to (gero-psych unit #1) representative while she was here. She will have the team there review and will let me know. 08/14/13 -Received call from (Representative) with (gero-psych unit #1). She states they will not be able to admit resident mainly due to her only symptom is yelling out. Will continue to look for other facilities who have possible openings..." A nurse's note, dated 08/14/13, documented, "...(2:06 p.m.)...Res noted c (increased) anxiety. Routine med given. Res cont to yell. Res was given her PRN [MEDICATION NAME] -Res was calm an hour after it was given but was yelling again later...(9:20 p.m.)...Had a call from (gero-psych unit #1) regarding prospective transfer to psych unit. Cont to have hallucinations and (increased) anxiety..." A nurse's note, dated 08/15/13, documented, "...(1:26 p.m.) Res noted with (increased) anxiety... (7:00 p.m.)...Continues with (increased) anxiety, yelling and hallucinations... (7:05 p.m.) Res was observed being slapped by another resident who wandered into her room while she was yelling and hallucinating..." On 08/19/13 at 8:55 a.m., resident #12 was observed in the dining room of Memory Lane (the secured dementia unit). She was sitting at the table being assisted to eat. She was sitting in a wheel chair repetitively yelling as loudly as she could, "I want to go home...where's my sister...come here, come here...shut up, shut up..." She pushed away the hand of the CNA who was attempting to assist her with the meal several times. Resident #28 was observed quietly saying, "Shut her up." At 9:15 a.m., resident #12 was moved to the hallway in front of the nurse's desk. She continued to yell. At 9:20 a.m., resident #12 was repetitively yelling, "Come here, Faye. Come here Faye." Resident #17 was observed by two surveyors to walk up to resident #12 and strike her on the lower leg with his cane. CNA #3 turned the corner and redirected resident #17 to his room by stating, "Oh, no. You can't do that." At this same time, resident #25 and resident #26 were observed to walk by resident #12 and say, "Shut up." At 9:25 a.m., resident #12 was taken to her room and placed in bed. A large velcro 'Stop' sign was placed across the doorframe. The resident continued yelling. At 9:35 a.m., resident #12 was still yelling loudly "Get out, get out." No one was in the room. Resident #27 walked by the room, looked in and stated, "No." At 10:05 a.m., resident #12 was still yelling. She was in the bed pulling and tugging at the blankets. An activity was in progress in the dining room/lobby area and resident #12 could be heard yelling from her room down and around the hallway. At 11:00 a.m., resident #12 was still in her bed yelling loudly. The stop sign was in place. At 12:10 p.m., resident #12 was outside in the courtyard with a CNA. She was yelling loudly. At 12:20 p.m., resident #12 was brought to the dining room to await lunch. She drank a half a glass of orange juice and then started yelling loudly again. A CNA removed the resident from the dining room and pushed her in the halls. She continuously yelled. At 12:48 p.m., resident #12 was still yelling in the hallways. She was taken to her room at this time for the lunch meal. She continued to yell throughout the meal and pushed the CNA's hand away numerous times. Occasionally she would take a bite and then continue yelling. The stop sign was in place. At 1:50 p.m., resident #12 was outside with a CNA. She continued to yell. At 3:00 p.m., resident #12 was in her bed asleep. The stop sign was in place. At 4:10 p.m., resident #12 was in the wheel chair in her room yelling loudly. Her voice was beginning to sound a little raspy. The stop sign was in place. A nurse's note, dated 08/19/13, documented, "...(2:02 p.m.)...(increased) agitation noted...Res cont to yell...This res was sitting in w/c when other res came down hallway and other res foot hit this res leg...very disoriented with disorganized thinking. Keeps screaming and yelling c some hallucinations.." On 08/20/13, at 7:40 a.m., resident #12 was in bed repetitively yelling, "Come here, go away." She could be heard in the dining room where the other residents were gathering for breakfast. The stop sign was in place. At 9:00 a.m., resident #12 had been placed in her wheel chair and was still yelling. Her breakfast tray was taken to her room. She continued to yell throughout the meal and was observed pushing away the hands of the CNA as bites of food were offered. The stop sign was in place. At 9:15 a.m., resident #12 was still yelling. Resident #15 had also begun a repetitive yelling. Resident #25 and resident #26 were observed walking down the hall. Resident #25 was overheard telling resident #26, "I wish they would both shut up!" At 10:15 a.m., an activity was in progress in the dining room/lobby area. Resident #12 could be heard yelling from her room. The room door was partially shut and the stop sign was in place. At 11:20 a.m., resident #12 was still yelling. At 1:40 p.m., the SSD was asked about resident #12. She stated she was trying to get her into a gero-psych unit. She stated they won't accept her because her only behavior is yelling. She stated she had tried to tell them the yelling was now effecting her eating. She was asked if she had told them the resident was disruptive to the unit and was in potential danger due to her behaviors. She stated she thought she had. She was asked if she had documented this information. She stated, "Probably not," but would check the monthly summary notes. At 1:55 p.m., the SSD presented the monthly summary note for August 2013. She stated the resident's POA had not wanted the resident placed in a facility out of town, so was limited to only metro facilities. She was asked if she had called a facility on 07/23/13. After she reviewed the note, she stated the facilities would not accept the resident if she had a UTI. She stated she had told nursing and the resident was treated for [REDACTED]. She was asked if she was told this by a facility on the 07/23/13. She stated, "No", she just knew this from other referrals. She was asked when was the first time she had contacted a gero-psych unit. She stated it looked like the first call was placed on 08/06/13 to (gero-psych unit #1). She was asked if she had informed the unit of the resident having hallucinations, disrupting the unit, being in potential danger due to her yelling and swallowing difficulties. She stated LPN #2 had talked to them so he would have told them all that. At 4:00 p.m., the resident's POA was interviewed. He was asked if he was aware a gero-psych referral order had been given for the resident. He stated, "Yes." He was asked when he first knew of the referral. He stated, "Seven to ten days ago." He was asked if he had been notified on 07/23/13 when the first order was given. He stated, "No, it definitely was not that long ago." He was asked if he knew of any behaviors resident #12 may have. He stated, "Yes, she yells all the time." He was asked if he was aware the yelling could possibly be aggravating the other residents. He stated, "I'm sure it does, probably even the staff that have to listen to it." He stated he had been called yesterday about another resident hitting her with his cane. He was asked if he was aware another resident had slapped her. He stated, "No, I didn't know she had been slapped." He was asked if he had told the facility to only make referrals in the metro area. He stated he had at first, but when they met a few days ago, he told them to do whatever they had to. At 5:30 p.m., the SSD was asked if, on 07/23/13, a facility had told her they would not accept the resident if she had a UTI. She stated, "No, they had told me that before so I told nursing that." At 5:50 p.m., the DON was interviewed. She was asked if she knew if a 'hold' order had been written for the 07/23/13 gero-psych referral when the resident needed a UA. She stated the resident had to finish the antibiotics before a referral could be made. She was asked who told her the resident needed a UA. She stated, "(SSD name) told us." She stated that's why she was hired, to guide us in what we need to do. She was asked if the family had been notified of the 07/23/13 gero-psych referral order. She stated the SSD had been visiting with the family about placement. She was asked if she was aware of any other residents mistreating resident #12 because of her yelling. She stated she knew resident #17 had kicked her with his foot on 08/19/13. She was asked if she knew resident #17 had hit the resident on the leg with his cane. She stated, "No." She was asked if she was aware of any other incidents. She stated another resident slapped resident #12. She stated they had placed the 'stop' sign on her door after this happened. She was asked how the resident was being protected while outside her room. She stated the staff kept her where they could see her and redirected other residents away from her. She was asked if she was aware the nurses were documenting resident #12 was having trouble swallowing and eating because of the constant yelling. She stated they had asked the nurses to start documenting about that and any aggressive behaviors she might have. She was asked if she was aware the SSD had only contacted a couple of gero-psych units with the referral. She stated, "She has been having trouble getting her placed." She was asked if she had ever tried to help the SSD obtain an admission. She stated, "No, she handles all the referrals." At 6:10 p.m., the administrator was interviewed. She was asked if a referral to a gero-psych unit was made for resident #12 on 07/23/13. She stated she had a dirty UA and had to finish the antibiotic before she could be referred. She was asked if she was aware of any incidents where other residents had mistreated the resident because of her yelling. She stated, "Yes, she was kicked by a male resident yesterday, or maybe even hit her with his cane. She was asked if she was aware of any more incidents. She stated a resident slapped her a few days ago. She stated that was when they put up the 'stop' sign on her doorframe. She was asked how the resident was protected when outside her room. She stated the staff keep her within view and redirect the other residents away from her. She was asked if she was aware the resident's yelling was causing her to have difficulties swallowing and eating. She stated the nurses are supposed to be documenting that so they can show her yelling isn't just yelling to get her admitted . She was asked if she felt resident #12 was safe if she kept yelling. She stated the residents had dementia and wouldn't hurt her intentionally. She was asked if she felt she was disruptive to the unit. She stated the residents had dementia and some of them probably didn't even know she was yelling. She was asked if she had done anything to assist SS in obtaining placement. She stated, "We talk about it in stand-up every morning." She was asked if she had ever made any phone calls to assist with placement. She stated, "No." She was asked if she thought two weeks was an acceptable time frame to still be seeking placement. She stated, "What can you do. They say yelling isn't enough to admit her." She was asked if the gero-psych units had been told of the hallucinations, her safety concerns and how the yelling was affecting her eating. She stated, "(SSD name) should have done that." A nurse' note, dated 08/20/13, documented, "...Res while eating started to cough because of res talking and yelling. Nurse tried to redirect res c (no) success... (7:30 a.m.)...(increased) agitation noted...Agitation cont (increase) also (increased) yelling... (5:08 p.m.)...nail care attempted. Resident won't allow as she becomes very agitated..." On 08/21/13 at 9:15 a.m., the SSD was again interviewed. She was shown the August social service monthly summary. She was asked the following questions about the document: on 08/06/13 did she only call gero-psych unit #1? "Yes"... on 08/08/13 did she only call gero-psych unit #2? "Yes"... did she make any return calls to the units on those days or inbetween? "No"... on 08/09/13 did she talk with the family? "No, nursing had been talking to them." Which nurses? she believed it was LPN #2... on 08/12/13 did she only call gero-psych unit #5? "Yes"... Was this the first date she talked to the family? "Nursing had been talking to them." She was shown the 08/14/13 social service progress note. She was asked if she had told gero-psych unit #1 about the hallucinations, the resident being isolated , the resident's safety being compromised and the resident having swallowing and eating difficulties due to her excessive yelling. She stated LPN #2 had talked to them and she assumed he had told them. She was asked if she had made any other attempts to get her placed since 08/14/13. She stated, "No." She was asked if the ADM or the DON had attempted to help her find placement, such as by making phone calls. She stated, "No, not until last night." She was asked if she knew where resident #12 was. She stated she was sent to the ER last night and was admitted . At 10:10 a.m., resident #29 was asked if she was bothered by resident #12's yelling. She stated, "It did at first, but I've kinda gotten used to it." At 2:40 p.m., LPN #1 and LPN #2 were interviewed. LPN #1 was asked if she was the nurse who documented the incident of resident #17 hitting resident #12 with his foot. She stated, "Yes." They were asked if resident #17 had ever been aggressive towards resident #12 before this incident. Both stated he would go yell at her and then would shut her door. They stated they watched him closely and when he got to close to resident #12 they would redirect him away from her. They were asked if they were aware of any other incidents where other residents mistreated resident #12. LPN #2 stated she had been slapped by resident #18 a few days before. LPN #1 stated the incident shocked them because resident #18 was the 'mother' of the unit. They assumed she went to resident #12's room to console her and when she couldn't get her to stop yelling, she slapped her. LPN #2 stated that was when they placed the stop sign on her door. They were asked what they did to protect her when she was not in her room. Both stated she was kept within view and when they see another resident getting too close to her they redirect the other resident away from her. LPN #1 stated, "She keeps the other residents pretty stirred up." LPN #2 stated, "A lot of them yell at her to 'shut up'. They will even yell at her door." They were asked if they had witnessed her having difficulty swallowing or eating. LPN #2 stated, "Her throat gets sore and she can't swallow. She won't stop yelling long enough to eat sometimes." On 08/23/13 at 9:10 a.m., resident #25 and #26 were asked if they were bothered by resident #12's yelling. Resident #25 stated, "Yes, it drove us crazy." Resident #26 stated, "It just went on and on, it never stopped." At 10:00 a.m., resident #12's physician was interviewed. He was asked about resident #12. He stated, "She screams constantly. I always knew who they were calling me about because I could hear her screaming in the background." He stated he had changed her medications several times but she 'needed a psych consult.' He stated he wasn't sure if this facility was appropriate for her anymore. He was asked if he was aware the facility was having trouble finding placement for the resident. He stated, "No, I didn't know that. First I've heard of it." At 3:15 p.m., LPN #2 was asked if he had contacted resident #12's family on 07/23/13 when the psych eval order was written. After reviewing the record he stated he only talked to the family about the inhouse psychiatric services. He was shown the nurse's note, dated 08/14/13. He stated gero-psych unit #1 had called and asked him if the resident was physically aggressive. He stated he told them 'No, she only yells.' He stated the caller stated 'Ok' and hung up. He was asked if he had ever told any gero-psych unit about the resident having hallucinations, agitating other residents, having difficulty eating or about her safety being compromised because of her yelling. He stated, "No." He was again asked if he had talked to the family about an in-patient gero-psych admission. He stated, "No. Social services was doing that. She takes care of all the referrals." On 08/23/13 at 10:00 a.m., LPN #1 was asked if there were any special interventions in regards to resident #17. She stated, "I have only been here three weeks but just to watch him and divert him when he is agitated." She also stated, "He has been a whole lot less agitated without (Resident #12) here."

Based on observation, record review, and interview, it was determined the facility administration did not function effectively to identify possible sources of: ~ psychosocial harm to seven (#17, 18 and #25 - #29) sampled residents on Memory Lane (the secured dementia unit), ~ lack of supervision for two (#12 and #17) sampled residents on the Memory Lane, and ~ lack of supervision of the social services director. The resident room roster, dated 08/18/13, identified 37 residents who resided on Memory Lane. Findings: 1. Social Services failed to obtain a gero-psych admission for resident #12. Refer to F-250. 2. The facility failed to promote an environment to enable residents of Memory Lane (a secured dementia unit) to attain their highest practicable well-being on Memory Lane and were exposed to the loud excessive yelling of resident #12 which caused psychosocial harm, Refer to F-309. 3. The facility failed to provide supervision to prevent resident to resident altercations on Memory Lane, Refer to F-323

Based on observation, record review, and interviews, it was determined the facility failed to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies, which would in turn ensure the staff provided nursing and related services to enable residents to achieve and maintain their highest practicable well-being. The facility failed to identify and implement a plan of action to correct systems failures related to: a. Social Services b. Psychosocial Well-Being c. Supervision of resident #12 d. Administration Findings: The policy, Quality Assessment and Assurance Committee, documented, "Policy Statement This facility shall establish and maintain a quality assessment and assurance committee which identifies and addresses quality issues, and corrective action plans as necessary... Goals of the Committee The primary goals of the Quality Assessment and Assurance Committee are: 1. To monitor and evaluate the appropriateness and quality of care provided within the framework of the Quality Assessment and Assurance Plan; and 2. To provide a means whereby negative outcomes relative to resident care can be identified and resolved through an interdisciplinary approach, and positive outcomes can be reinforced through education and monitoring." 1. Social Services failed to obtain a gero-psych admission for resident #12. Refer to F-250. 2. The facility failed to promote an environment to enable residents of Memory Lane (a secured dementia unit) to attain their highest practicable well-being on Memory Lane and were exposed to the loud excessive yelling of resident #12 which caused psychosocial harm, Refer to F-309. 3. The facility failed to provide supervision to prevent resident to resident altercations on Memory Lane, Refer to F-323 4. The facility administration did not function effectively to identify possible sources of: ~ psychosocial harm to seven (#17, 18 and #25 - #29) sampled residents on Memory Lane (the secured dementia unit), ~ lack of supervision for two (#12 and #17) sampled residents on the Memory Lane, and ~ lack of supervision of the social services director. Refer F-490

On 10/25/12 at 11:00 a.m., an Immediate Jeopardy (IJ) situation was identified related to the failure of the facility to provide supervision for a resident who continued to stand up while in a wheelchair with a lap buddy, pull the W/C over, still positioned in the lap buddy and fall, which resulted in a head injury. At 11:10 a.m., the existence of an IJ was verified with the Oklahoma State Department of Health (OSDH). At 11:30 a.m., the administrator, the DON and two corporate personnel were notified of the existence of an IJ. At 4:00 p.m., the plan of removal was received and accepted. The facility's Plan of Removal documented: "Plan for Removal of IJ regarding Supervision/Accidents involving (Resident and room number). 11:30 a.m. - Notified by team leader that IJ being called regarding above 11:35 a.m. - Removed lap buddy for resident (Resident #20), staff member (RNA #1 (restorative nurses aide)) assigned to be with resident one on one until further notice. 12:45 p.m. - Order clarified to provide a clear lap tray on her wheelchair so that she will remain able to propel self and therapy will evaluate pt. (patient) Until the lap tray arrives, the resident will remain on one-on-one care. 1:00 p.m. - Inservice started with staff regarding restraints, positioners and enablers as well as accidents/hazards prevention (see attached). All staff working on the AU (Alzheimer's Unit) will have this in-service prior to being allowed to work on the unit. There are no lap buddies ordered in the other areas of the facility but training will be conducted for them as well once the in-service on the AU is completed. Sign posted to alert staff not to enter the unit until this training is completed. 1:00 p.m. - all residents with lap buddies have been evaluated for appropriateness of the device. ? (Resident #2) ? (Resident #20) ? (Resident #11) ? (Resident 29) ? (Resident #21) ? (Resident #28) The reviews were completed for these residents by 2:30 p.m. Review of all incidents for (Resident #20) was completed: ? 3/9/12 - resident fall not related to LB (lap buddy) ? 3/23/12 - fell in room (not related to lap buddy) New interventions of alarms ? 4/10/12 - removed her lap buddy - intervention was adjusting lap buddy to size of chair ? 5/8/12 - fell on 11-7 (11p.m. to 7a.m. shift) not related to LB - moved closer to desk ? 6/26/12 sitting in D/R (dining room) and got up and fell - intervention was in-service to staff ? 9-13-12 - Left unattended by hospice - hospice inserviced ? 9-18-12 - removed lap buddy - lap buddy with accessories ordered ? 10-9-12 removed lap buddy - lap buddy D/C (discontinued) and pommel cushion ordered No further falls but on 10-19-2012 recommended that she be placed back on lap buddy. Order clarified 10-25-12 for a clear lap tray and one-on-one until it arrives. PT (physical therapy) to evaluate and treat. This plan demonstrates our allegation of credible compliance and we ask that the immediacy be removed. (Administrator signature) Addendum: 21 people have already been inserviced by 1PM. Staff is not permitted to work in this unit until they have received their in-service. There are 6 more completed by 3PM and 13 are in progress of being in-serviced as of 3:10 PM. The weekend staff will be called today and in-serviced by phone today. There have been 55 people of the 75 were in-serviced by 3:45PM on 10-25-2012. There had been a QA (quality assurance) meeting held on 9-17-2012 that addressed restraints, positioners, enablers and the required evaluations to be done. The plan was to start the monthly evaluations of devices in the next 30-45 days and continue monthly. In addition, we were working to insure all consents, pre-restraint assessments, etc. would be complete as well. (Attachment) In-service 10-25-2012 Restraints, Positioners, Enablers and accident/hazards prevention including information as follows: ? Use of devices, monitoring of devices, reasons for devices, and care of residents using devices ? Fall prevention and measures that can be implemented to reduce falls ? Reporting risky behaviors of residents and interventions to reduce risks of injury to residents using devices that are exhibiting risky behaviors ? Care plan updating to include interventions for fall prevention." Based on observation, record review and interview, it was determined the facility failed to provide supervision for a resident who continued to stand up while in a wheelchair with a lap buddy, pull the W/C over, still positioned in the lap buddy and fall, which resulted in a head injury for one (#20) of six sampled residents with lap buddies. The facility also failed to develop and implement interventions to aid in the prevention of falls for the resident who was placed in the lap buddy and continued to fall. The administrator identified five residents with lap buddies. The survey team identified six residents with lap buddies. Findings: 1. Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She was using a lap buddy upon admission to the facility. A nurse's note, dated 03/07/12, documented, "12:30 p.m., ...uses w/c c lap buddy on... 2100 (9:00 p.m.) continues to attempt to get out of her wheelchair despite lap buddy order for fall prevention..." The comprehensive resident assessment, dated 03/19/12, documented the resident's cognitive ability was severely impaired as she rarely or never made decisions. The assessment documented she required limited assistance of one person with her ADL's, including walking, as the resident was highly involved in the tasks. The assessment documented no physical restraints were used in the bed or in the chair. The comprehensive care plan, dated 03/27/12, documented, "...Problem: I have a dx (diagnosis) and hx (history) of recent falls... Approach: Lap buddy when in wheelchair... chair alarm when in wheel chair to cue me of safety chair parameters (this was marked through with a date of 3/23/12)... (these next approaches were handwritten) Lap buddy/wc assessed for proper fit ( this was marked through and dated 4/10/12 and documented done )... Relocate closer to nurse station for closer observation of resident ( this was marked through and dated 5/8/12 and documented done )... staff education on lap buddy @ dining table (dated 6/26/12)... RNA (restorative nursing aide) for ambulation (dated 7/10/12)... Hospice education to staff placement of resident not to be left alone (dated 9/13/12)..." The care plan did not address when the lap buddy was to be used or how often and how long the restraint was to be released. An incident/accident report, dated 04/10/12, documented, "...sitting in dining room for lunch...removed her lap buddy, stood up and fell against the wall...has an abrasion on her forehead..." A nurse's note, dated 04/10/12, documented, "...still trying to take lap buddy off and also trying to stand..." The monthly physician's orders [REDACTED].) A Medical Device Monthly Evaluation form, dated 04/29/12, documented, "...Device: Lap buddy Diagnoses: [REDACTED]. Does resident have a current device order? Yes Does order reflect diagnosis? Yes Does device enable activity? Yes If yes, is device the most effective enabler? (left blank) Activity enabled: mobilizing in chair safely Does device prohibit activity? No... Activity level: moderate Weight bearing status: stands c assistance X1, can walk assisted Bed mobility: fair Sitting balance: fair Physical limitations: CAO X1 Mentation: poor Comprehension: poor Medication that may affect balance, muscle tone, or motor performance: Ativan, Trazadone Recent decline in condition? No... Safety awareness: poor Recommendation (sic): cont. current plan" A nurse's note, dated 06/26/12 at 12:00 noon, documented, "...Resident was in the dining room getting ready to eat lunch when suddenly she tried getting up and fell on floor, hitting head on floor, (L) (left) upper head is swollen...Pt (patient) had lab (sic) body(sic) and alarm on @ (at) the time of fall..." A nurse's note, dated 06/28/12 at 8:20 a.m., documented, "...resting well from 0200 (2:00 a.m.) until 7am - was awake and rolling about hall until that time - would keep standing up et (and) walk c w/c et lap buddy would be in place - was medicated with c 1 mg of ativan for anxiety and agitation... 2020 (9:20 p.m.)...continues to try to stand and pull her wheelchair along..." A nurse's note, dated 07/10/12 at 8:20 a.m., documented, "...Resident cont's (continues) to stand up c lap buddy on and drag wheelchair..." A physician's orders [REDACTED]. A Restorative Nursing Care Program sheet, dated for July 2012, documented, "...Date initiated: 7/10/12... Goals: 1. Maintain or (increase) ability to ambulate 2. Maintain LE (lower extremity) strength... Approaches: 1. Ambulate c gait belt 100+ feet daily 5 days/wk (week) 2. Restorator 5 min (minutes) LE... Week 1- Response: Resident maintaining (and) succeeding in program. Resident goal 100 ft. 5 days/wk. She can walk 650 ft or more. Restorative trying to exceed her walking ability...7/13/12 Week 2 - Response: Continue c program to (increase) strength and endurance. gait belt c ambulation due to unsteady gait. She walks fast and forward @ X's. Continue c ambulation (and) (increase) as tolerated...7/21/12... Week 3 - Response: Continues to improve but still so disoriented she will always remain a high fall risk and asst X 1 but she loves to walk and loves the social aspect...7/28/12" The restorative notes documented the resident was walked three times the first week, four times the second week and three times the third week of therapy. A nurse's note, dated 07/14/12 at 1:15 a.m., documented, "...in w/c c lappy (sic) buddy in place. Cont attempts to stand c lap buddy in place; when redirected pt strikes out at staff pt was given prn (as needed) med (medications) Trazadone, morphine (and) Ativan (and) effective pt in w/c at desk asleep..." A nurse's note, dated 09/13/12 at 10:00 p.m., documented an unwitnessed fall: "...was sitting in wc (wheelchair) by the nurse's station with her lap buddy in place. Hospice personal who came visiting took resident down to the dining room. Shortly after he left, resident was found on the floor laying on the left side, bleeding from the left side of her head c lap buddy off from wc.." The comprehensive resident assessment, dated 09/15/12, documented the resident was able to understand and was understood. Her cognitive ability was moderately impaired as she made poor decisions and required cueing and supervision. She had long and short term memory problems. The assessment also documented she had disorganized thinking, inattention and delusions. The assessment documented she required extensive assistance of one person with her ADL's, including walking. The assessment documented no physical restraints were used in the bed or in the chair. A nurse's note, dated 09/18/12, documented an unwitnessed fall: "...Resident was found sitting in room (room number) in the floor..." A nurse's note, dated 10/9/12, documented an unwitnessed fall: "...resident was observed on the floor by the feeder's table by her wc. Observed to have taken her lap buddy off her wc. found laying on L side..." The monthly physician's orders [REDACTED]...04/07/12 (date of origin) - Lap Buddy while in wheelchair..." A physician's orders [REDACTED]. A nurse's note, dated 10/10/12, documented, "...Resident is ambulatory with asst (assist) X 1 and UTA (unable to ambulate) without assistance, however she is unaware of her limitations due to dementia. Concluding resident may be safer c a pommel cushion...d/c lap buddy @ this time..." A nurse's note, dated 10/11/12, documented, "(1:20 p.m.) ...Resident on pommel cushion as ordered. Keeps trying to get out of wc. Res assisted with walking Q (every) 2 (hours)... (9:15 p.m.)...Observed to have tried to get out of wc 5X and actually out of wc 4 times. Redirected to sit down to prevent fall.." A nurse's note, dated 10/19/12 at 2:25 p.m., documented, "Resident most part of this shift has been getting out of wc and walking by herself. Her gait very unsteady and @ an increased risk of falling. She is also agitated @ this pt. Ativan 0.5mg given prn per MD orders. Called (physician) about residents actions and increased fall risk. Recommended lap buddy to be reinstated for safety and positioning and Dr. asked the nurse to talk to the POA (power of attorney) ...about it. If she is okay, then order should be reinstated...She was okay with order. Lap buddy therefore reinstated..." A physician's orders [REDACTED]. A Restorative Nursing Care Program sheet, dated for October 2012, documented, "...Date initiated: 7/10/12... Week 1 - Response: Resident was ambulated by (CNA#4) this week and tolerated well. Restorative was unavailable this week...10/6/12 Week 2 - Response: Doing well with ambulation, wanting to stand a lot more. Residents lap buddy D/C'd due to fall and pommel wedge cushion used for her positioning (and) safety...10/14/12 Week 3 - Response: RNA able to work with resident 5 days this week (and) FMP ambulated daily Resident loves to walk (and) exercise, continue program...10/21/12 ..." On 10/21/12 at 4:25 p.m., resident #20 was observed in the AU dining room seated at an assisted feeding table. She was in a wheelchair with a lap buddy in place. She was observed pushing and pulling at the lap buddy attempting to remove it from the wheelchair. On 10/24/12 at 9:50 a.m., resident #20 was observed in the AU television lobby in a wheelchair with a lap buddy in place. She was observed pulling at the lap buddy trying to remove it from the wheelchair. She stood up with the lap buddy in place, leaned over the lap buddy and pulled a high backed chair, which had been positioned against the wall, up to the wheelchair. While standing and holding onto the high backed chair, she began trying to turn the wheelchair. The wheel chair was unstable and was tipping forward. She then sat back down and started pulling at the lap buddy again. CNA #5 went to the resident and lowered the foot rests on the wheelchair. She pushed the high backed chair back against the wall, placed the resident's feet on the footrests and stated, "(Resident), you have to stay seated." At 9:58 a.m., the resident lifted the footrests with her feet and stood up. She leaned over the lap buddy and tried to pull it off the wheelchair. At 10:10 a.m., the resident continued to stand up in the wheelchair with the lap buddy in place. While standing up she pulled up on the lap buddy and all four wheels of the wheelchair left the floor. The resident then took 3 steps while dragging the wheelchair by the lap buddy. The staff member leading the group exercise had the resident sit down and attempted to redirect her to participate in the exercises. The resident would move her arms or clap her hands for a few seconds then would begin pulling and pushing at the lap buddy again. After about 20 seconds of working at the lap buddy she would stand up again. The staff member would get her to sit down and the process would start all over. At 10:20 a.m., the resident was still trying to stand up. CNA #2 removed and replaced the footrests on the wheelchair. While she was replacing them, the resident was pushing at the CNA and pulling at her clothes. At 10:40 a.m., the resident was still pulling at the lap buddy but had stopped attempting to stand. At no time had she been observed getting the lap buddy to release from the wheelchair. On 10/25/12 at 8:50 a.m., the resident was in the hallway by the nurses' station in the wheelchair with the lap buddy in place. She had a cup of coffee in her hand. No staff members were present. She was observed to push and pull at the lap buddy. While holding the coffee cup in one hand, she stood up and would hold onto the lap buddy. The wheelchair's front wheels would rise up off the floor. She was observed to take two steps during one of the times she stood. She would sit down, work at getting the lap buddy off and stand up again. At 9:00 a.m., CNA #3 came down the hall and took the resident to the television lobby. At 9:30 a.m., the administrator was asked if she knew where the restraint documentation, eg. consent forms, pre-screenings, monthly evaluations were located. She stated she was unsure but would find out. At 9:45 a.m., the administrator presented two consent forms, both for lap trays. She was asked if she had any documentation on the lap buddies. She stated they were not restraints but positioning devices and didn't need any paperwork. At 10:30 a.m., LPN #1 was asked if resident #20 often tried to get out of the wheelchair or stood up with the lap buddy in place. He stated, "She does quite often." He was asked if restorative was working with the resident. He stated he wasn't sure, but the staff walked her when she tried to get up. He was asked where they documented walking the resident. He stated he wasn't sure and asked CNA #6 where they documented walking resident #20. She stated they didn't document it, they just walked her when she tried to get up and then she got tired. At 10:45 a.m., CNA #3 was informed of the observations of resident #20 standing up with the lap buddy in place and asked her if this was usual. She stated, "Yes, all the time." She was asked what she would do when she saw this behavior. She stated she would tell the resident to sit down and watch her. She stated sometimes she walked her. She was asked if she knew why the resident had the lap buddy. She stated it kept her from getting up and falling. At 10:50 a.m., CNA #2 and CNA #5 were asked if the resident trying to stand in the wheelchair with the lap buddy in place was usual. Both stated, "Yes." They were asked if they have anything special they did when they saw her doing this. CNA #5 stated sometimes they walked her and it tired her out so she quit trying to get up. They kept reminding her to leave the lap buddy alone and to sit down and not get up. CNA #5 stated the lap buddy was for her safety. It kept her from getting up and walking and possibly falling. They were asked where they documented when they walked the resident. CNA #5 stated, "We don't. We tell the nurse and they document it, I guess." They were asked if she ever got the lap buddy off. CNA #5 stated, " She mainly picks it up and walks with it." At 10:55 a.m., RNA #1 was asked if she worked with resident #20. She stated she walked her five days a week. She stated the resident was still a little weak and her gait was a little wobbly, but she was doing really well with walking and liked to walk. At 10:55 a.m., while interviewing the RNA, LPN #1 was observed walking with resident #20 in the hallway leading to the dining room. She was only holding his hand while walking, no gait belt was required. Her gait was a little slow and her posture was slightly stooped forward. She was observed to wobble slightly when she looked up to talk to another staff member she passed in the hall. She was observed to be smiling, laughing and talkative throughout the walk. This was the first time the resident was observed ambulating with assist. At 4:00 p.m., when interveiwed, the administrator was unable to provide any documentation on a plan, intervention or assessment in regard to the safety of the resident with continued use of the lap buddy. The facility failed to address the continued use of the lap buddy for this resident who was able to stand up, walk and pull the W/C behind her, resulting in injurys. At 5:00 p.m., the administrator was informed the IJ had been lifted as of 10/25/12 at 4:00 p.m. The deficiency remained at the level of actual harm that was not an immediate jeopardy with more than a very limited number of residents affected.

Based on record review and interview, it was determined the facility failed to ensure: ~ pain medications were administered in a timely manner for a new fracture for one (#8) of one sampled residents with new narcotic pain medication orders. No other residents in the facility had recently received orders for new narcotic pain medication. ~ pain assessments were conducted by a RN (registered nurse) upon admission, quarterly, annually, and with a change in condition for one (#8) of one sampled residents with new onset pain. The Resident Census and Condition identified 125 residents lived at the facility. ~ the staff provided wound care as ordered by the physician for one (#13) of two sampled residents for whom wound care was observed. The Resident Census and Condition, dated 07/25/11, documented one pressure ulcer. Findings: 1. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. The comprehensive resident assessment, dated 03/15/11, documented the resident was able to make herself understood and was able to understand others. She required extensive assistance with ADLs (activities of daily living). She has limitation with range of motion on one side with a lower extremity. The care plan, dated 11/28/10, documented, "Problem: *Resident is at risk for fall or fall related injuries [MEDICAL CONDITION] subsequent right sided [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Also has [DIAGNOSES REDACTED]. Goal: Resident will be without falls during this 90 day review period 2/28/11... Approach: Please note that resident is able to wheel self somewhat in wheelchair, but cognitively is unable to consistently follow independent locomotion." The care plan was not updated to include the fall on 02/17/11 with investigation of why the fall occurred or new approaches. An INCIDENT/ACCIDENT REPORT, documented, "02/17/11 - 9 pm - dining room. Resident slide out of chair, received skin tear to R forearm...confused... Additional comments and/or steps taken to prevent recurrence: Informed staff to monitor closely alarm was in place." A nurse's note, dated 02/17/11, documented, "9:45 p.m. Resident slide out of chair, received skin tear to R forearm..." A nurse's note, dated 02/18/11, documented, "0610 (6:10 a.m.) Resident holding and guarding R (right) leg. (name-deleted physician) office called...N.O. (new order) Recd (received) for X-Ray of R (right) hip (and) pelvic area..." A (name-deleted) mobile x-ray report, date of service 02/18/11, documented, "IMPRESSION: 1. Findings highly compatible with an undisplaced oblique fracture proximal lateral aspect of right femoral diaphysis. A CT scan (cat scan) would be helpful for definite confirmation." A nurses's medication note (on back of MAR) documented, "2/19 - 1600 (4:00 p.m.) Tylenol ii/ii (two) 650 mg. Res (resident) c/o (complains of) pain (right leg and shoulder) - no help. 2/20 - 1130 (11:30 a.m.) Tylenol ii/ii 650 mg. Pain on leg and shoulder - very little help. 1900 (7:00 p.m.) Tylenol ii/ii 650 mg for intense pain on right leg - no help." A physician's telephone order, dated 02/20/11 documented, "0730 (7:30 a.m.) [MEDICATION NAME] 2.5 mg i PO q 8 hrs. [MEDICATION NAME] 2.5 mg i PO q 4 hrs PRN DX Pain. X Ray R hip (and) pelvic Monday 2-21-11." A nurse's note, dated 02/20/11, documented, "1900 (7:00 p.m.) Res c/o R side hurting called for X Ray results. Told by X Ray tech (technician) proximal lateral aspect diaphysis were results done...called (name-deleted physician assistant) for pain med (medication) (and) notify of results. N.O. [MEDICATION NAME] 2.5 mg (milligrams) i (one) PO (by mouth) q (every) 8 hrs (hours), [MEDICATION NAME] 2.5 mg i PO q 4 hrs PRN (as needed) DX (diagnosis) Pain." A PAIN EVALUATION completed by LPN (licensed practical nurse) #2, dated 2/20/11, documented, "Does the resident have any diagnosis(es) which would give reason to believer he/she would be in pain: x - yes. If yes, describe cause, origin of pain, [MEDICAL CONDITION] of pain, and prior treatment: fx (fracture) femur, [MEDICAL CONDITION] (arthritis). Does the resident verbalize pain? x - yes. If yes, date of pain onset: "I'm not sure." As the patient describes it, what does the pain feel like: (check all that apply) x - aching, x - heavy, x -sharp... Pain is increased by: moving... Time when pain is worse; x - morning x - evening... Pain location/type/frequency/intensity/duration...C = Constant, at present - 8, 1 hour after medication - 4, 3 hours after medication - 8, worst it gets - 10, best it gets - 2 (0 - no pain, 2 - hurts little bit, 4 - hurts little more, 6 - hurts even more, 8 - hurts whole lot, 10 - hurts worse)... ADLs - N/A (not applicable) Nonverbal / Noncognitive signs of pain... (a check mark was placed beside yes for the following) Grimacing/distorted face, frowning/scowling, wrinkled brow, turned down mouth, moaning, crying/whimpering... Relief of pain - Pain is relieved by (check all that apply): x - Medication, x - deep relaxation, x - frequent position changes, x - heat... x - unable to express (acceptable level of pain). Does the resident receive scheduled medications? x - yes. If yes, pain medication(s) in use: [MEDICATION NAME] 2.5 mg (milligram) i (one) q (every) 8 hrs. Does the resident receive a PRN medication? x - yes. If yes, pain medication(s) in use: Tylenol 325 mg 1-2 q 6 hrs PRN, [MEDICATION NAME] 2.5 mg i q 4 hr PRN. Is pain medication effective: x - yes. Time elapsed until pain relief: 1 hr. Conclusion - x - No pain, intervention is not necessary. Re-assess quarterly or with onset of pain...." The MAR (medication administration record), dated February 2011, documented the resident received the first dose of [MEDICATION NAME] on 02/22/11 at 8:00 a.m. The MAR indicated [REDACTED]. A nurse's medication note (the back of the MAR), dated 2/21/11, documented, "0915 (9:15 a.m.) Tylenol 325 mg x (times) 2 PO R leg pain per CN - helped." A nurse's note, dated 02/21/11, documented, "7-3 (no time) (name-deleted physician) in today to see resident. X-Ray done 2/18/11. rec'd (received) N.O. for CT scan. Will have (name-deleted transportation person) schedule CT scan... 2/22/11 7-3 (a.m.) (name-deleted transportation person) scheduled CT scan at earliest date which was for Tuesday March 1, 2011...." A nurse's note, dated 02/22/11, documented, "0930 (9:30 a.m.) Pt laying in bed c (with) eyes open. Pt's AM meal still sitting in front of pt only ate 25 %, tried to feed her more she refused. Pt has multi (multiple) bruises on all extremities... CNA (certified nurse aide) helped roll pt on side. Pt has non-verbal s/s (signs symptoms) of pain by guarding R side. Pt has dark purple upper extremities, has large bruises." A nurse's note, no date, documented, "Resident resting in bed turned q 2 hrs grimaces when being turned..." The clinical record did not contain a pain assessment completed by a RN. The clinical record did not contain nurses' notes from 02/25/11 through 02/28/11. A nurse's note, dated 03/01/11, documented, "At 8:30 p.m., received a call from (name-deleted hospital) requesting (name-deleted physician) number. Stated (Resident #8) hip was broken..." A nurse's note, dated 03/02/11, documented, "1100 (a.m.) Nurse from (name-deleted hospital) called and stated that res needs to be sent to (name-deleted hospital) ER (emergency room ) d/t (due to) (no) beds are open and they can give res pain meds in ER..." On 07/27/11 at 1:00 p.m., LPN #3 was asked if there was documentation to show the nurse contacted the physician to let him know of the length of time the resident waited for the CT scan. She said the length of time was on the hospital because we schedule around the resident and could have sent another staff member if it conflicted with the transportation person. She stated she would go look for the documentation. None was provided by the end of the survey. At 2:45 p.m., the transportation person was asked about making the appointment for the CT scan for resident #8. He stated he called the hospital preferred by the family. He didn't remember if he called any other hospital when he couldn't get the scan scheduled any earlier. He was asked if he informed the charge nurse of the date. He stated he told whoever was the charge nurse at that time and did not know what happened after that. At 4:15 p.m., the DON was asked why it took so long for the pain medication to arrive. She stated it was because the pharmacy would not accept over the phone or faxed orders from the charge nurses anymore. The original script has to have the physician signature before (name deleted pharmacy) will deliver. On 07/28/11 at 2:35 p.m., the resident's attending physician was interviewed. He was asked about the delay in the receiving the pain medication. He stated he would have been upset if he knew how long it took. He stated the DEA played a role in the delay. You would have to talk to the pharmacy. 08/01/11 at 4:00 p.m., the administrator stated the pain assessments have been brought to their attention and they have been inserviced on that. Wound Care: 2. Resident #13 had [DIAGNOSES REDACTED]. The resident was observed to have a wound on the right heel. A physician's orders [REDACTED]. On 07/26/11 at 11:45 a.m., LPN #1 was observed performing the dressing change to the right heel. She stated this was the first day the new dressing had been applied. LPN #1 was observed to cut a piece of the calcium alginate rope and place it in normal saline. She was asked if the orders stated to place the rope in normal saline. She stated she didn't know but had been told it needed to be placed in the saline to activate it. After a conversation about the uses of calcium alginate, LPN #1 discarded the dampened alginate. She stated since it wasn't ordered to wet the alginate she would place it dry. LPN #1 was then observed to cut a piece of the alginate rope and roll it into a ball before placing it in the wound. The LPN then placed a large piece of Meplex tape over the wound without placing a protective dressing first. She was asked if a protective dressing should have been applied before placing the tape. She stated they had been using [MEDICATION NAME] but didn't know if it was ordered now. She was asked if the tape would hurt the wound or surrounding skin when it was removed. She stated it didn't seem to bother it because they had been using skin prep. On 07/27/11 at 8:50 a.m., the wound care RN was asked if LPN #1 had asked her about resident #13's wound care. She stated, "No." The wound care RN was asked if calcium alginate needed to be activated with normal saline. She stated, "No, it should be used dry." After informing the wound care RN about the observations during resident #13's dressing change, she stated the alginate should not be rolled into a ball and the order was to place a [MEDICATION NAME] pad on the wound for protection under the tape. She stated she needed to do some instruction with the nurses because the wound care was not performed according to physician's orders [REDACTED].

Based on record review and interview, it was determined the facility failed to ensure: ~ pain medications were received in a timely for new onset of pain for one (#8) of one sampled residents with new narcotic pain medication orders. No other residents in the facility had recently received orders for new narcotic pain medication. ~ physician ordered antidepressant medications were administered for one (#22) of twelve sampled residents who received anti-depressant medications. The Resident Census and Condition, dated 07/25/11, documented 70 residents received anti-depressant medications. Findings 1. A nurse's note for resident #8 documented the resident had a fall on 02/17/11 at 9:00 p.m. A nurse's note, dated 02/18/11, documented, "0610 (6:10 a.m.) Resident holding and guarding R (right) leg. (name-deleted physician) office called...N.O. (new order) Recd (received) for X-Ray of R (right) hip (and) pelvic area..." A nurses's medication note documented, "2/19 - 1600 (4:00 p.m.) Tylenol ii/ii (two) 650 mg (milligrams). Res (resident) c/o (complains of) pain (right leg and shoulder) - no help. 2/20 - 1130 (11:30 a.m.) Tylenol ii/ii 650 mg. Pain on leg and shoulder - very little help. 1900 (7:00 p.m.) Tylenol ii/ii 650 mg for intense pain on right leg - no help." A physician's telephone order, dated 02/20/11 documented, "0730 (7:30 a.m.) Lortab 2.5 mg i PO q 8 hrs (hours). Lortab 2.5 mg i PO (by mouth) q (every) 4 hrs PRN DX (diagnosis) Pain. X Ray R hip (and) pelvic Monday 2-21-11." A nurse's note, dated 02/20/11, documented, "1900 (7:00 p.m.) Res c/o R side hurting called for X Ray results. Told by X Ray tech (technician) proximal lateral aspect diaphysis were results done...called (name-deleted physician assistant) for pain med (medication) (and) notify of results. N.O. Lortab 2.5 mg i (one) PO q 8 hrs, Lortab 2.5 mg i PO q 4 hrs PRN (as needed) DX Pain." A nurse's medication note, dated 2/21/11, documented, "0915 (9:15 a.m.) Tylenol 325 mg x (times) 2 PO R leg pain per CN - helped." The MARs (medication administration record) for February 2011, documented the resident received the first dose of Lortab 2.5 mg on 02/22/11 at 8:00 a.m. The MAR indicated [REDACTED]. A nurse's note, dated 02/22/11, documented, "0930 (9:30 a.m.) Pt (patient) laying in bed c (with) eyes open. Pt's AM meal still sitting in front of pt only ate 25 %, tried to feed her more she refused. Pt has multi (multiple) bruises on all extremities...CNA (certified nurse aide) helped roll pt on side. Pt has non-verbal s/s (signs symptoms) of pain by guarding R side. Pt has dark purple upper extremities, has large bruises." A nurse's note, no date, documented, "Resident resting in bed turned q 2 hrs grimaces when being turned..." The clinical record did not contain a pain assessment by a registered nurse on this change in condition. On 07/27/11 at 4:15 p.m., the DON (director of nursing) was asked why it took so long for the pain medication to arrive. She stated it was because the pharmacy would not accept over the phone or faxed orders from the charge nurses anymore. The original script has to have the physician signature before (name deleted pharmacy) will deliver. On 07/28/11 at 2:35 p.m., the resident's attending physician was interviewed. He was asked about the delay in the receiving the pain medication. He stated he would have been upset if he knew how long it took. He stated the DEA played a role in the delay. You would have to talk to the pharmacy. 2. Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission orders ...Welbutrin (sic) SR (slow release) 150mg PO Bid (twice a day), Lexapro 10mg PO QD (every day)...Citalopram 20 mg PO QD..." A telephone order, dated 10/08/10, documented, "D/C (discontinue) Lexapro -- Cont (continue) Citalopram 20mg QD." A telephone order, dated 10/29/10, documented, "...DC Citalopram - depression...Start Lexapro 10mg PO QD - depression." A telephone order, dated 11/08/10, documented, "...D/C Wellbutrin...Start Celexa 20mg q day DX: Depression." The January 2011 monthly physician's orders [REDACTED]...11/08/10 Celexa 20mg 1 tab (tablet) by mouth every day...10/29/10 Lexapro 10mg 1 tab by mouth every day..." The January 2011 MARs documented the resident received three doses of Lexapro from 01/01/11 through 01/03/11. On 01/04/11, "DC'd 10-18-10" was hand written across the documentation area of the MAR. A telephone order, dated 02/07/11, documented, "Lexapro 10mg PO QD." The February 2011 monthly physician's orders [REDACTED]...11/08/10 Celexa 20mg 1 tab by mouth every day..." The February 2011 MARs documented the Lexapro was restarted on 02/08/11. The resident did not receive the anti-depressant medication Lexapro for 35 days, from 01/04/11 through 02/07/11. An interview was conducted on 08/01/11 at 9:55 a.m., with the DON. She was asked about the Lexapro which was discontinued on 01/04/11 and then restarted on 02/08/11. She stated, "Those were confusing orders because of the daughter." She was asked if a medication error report had been completed. After looking through a desk drawer, she stated, "There is no medication error report in here."

Based on record review and interview, it was determined the facility failed to ensure: ~ a physician's order was obtained prior to medications being administered for one (#2) of three sampled residents, and ~ physician ordered medications were administered for one (#2) of three sampled residents with medication orders. Findings: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Medication Administration Record, [REDACTED]." There was no documentation on the facility's 'ADMISSION / START-UP' to include the medication. A nurse's note, dated 05/15/11, documented, "Nurse informed res (resident) supply of Cymbalta was last taken yesterday, pharmacy called no order for Cymbalta 30 mg. found in chart as order from other facility (and) was not written on start up on admission. Spoke with (Spouse) want Cymbalta 30 mg cont (continued) as should have on arrival from (Name-deleted facility) order written (and) faxed stat to (Name-deleted pharmacy) spouse informed." A physician's telephone order, dated 05/15/11, documented, "Cymbalta 30 mg cap DR i cap PO daily. DX (diagnosis) Depressive Disorder..." A nurse's note, dated 06/09/11, documented, "0810 (8:10 a.m.) (Name-deleted physician) in facility and shown chest x-ray results. N.O. (new order) rec'd (received) for Avelox (an antibiotic) x (times) 10 days for pneumonia.." A nurse's note, dated 06/11/11, documented, "1730 (5:30 p.m.)...CMA (certified medication aide) missed giving res (resident) ABT (antibiotic) (at) 0800 (8:00 a.m.)... On 06/28/11 at 10:15 a.m., the ADON was asked about the missed dose of antibiotic. She stated there was not a count sheet in place for the medicine. "We filled out a medication error report." The ADON stated the resident's spouse was aware of the incident. The ADON was also asked about the Cymbalta. She stated, "We filled out a medication error report on that as well. We didn't have an order. When the CMA ran out, she notified the nurse and she called the doctor and got the order to administer the medication. The spouse was also called."