Every finding on record at The Springs Skilled Nursing and Therapy

Based on observation and interview, the facility failed to ensure food was served in accordance with professional standards for food service safety for 1 of 1 meal service observed. The administrator identified 86 residents ate meals prepared in the kitchen. Findings: On 09/18/25 at 11:57 a.m., the cook was observed obtaining food temperatures for the lunch meal. The chicken patty was 192 degrees Fahrenheit, and the ground chicken patty was 141 degrees Fahrenheit.On 09/18/25 at 12:16 p.m., the dietary aide was observed tempting food in the main bistro dining area. The chicken patty was 95.6 degrees Fahrenheit.On 09/18/25 at 1:38 p.m., the dietary aide stated the steam table was turned on every morning around 6:00 a.m. and it remained on until dinner was served. They stated food was tempted before it left the main kitchen and transferred into a hot box to the bistro. They stated food was then placed onto the steam table and the temperature should be recorded again. The dietary aide stated they should take the food back to the main kitchen to be reheated if the food was not at the desired temperature. The dietary aide stated the chicken patty should be at least 130 degrees. When asked if they knew what the problem was with the significant drop in temperature the dietary aide stated it may be due to the food not being covered while serving.On 09/18/25 at 1:50 p.m., the dietary manager stated the significant change in temperature could be due to the food not being covered while serving. They stated the dietary aide should have brought the food back to the main kitchen. They dietary manager stated they did not have a facility policy on maintaining warm foods. They stated their own personal policy was to temp the food before, during, and after serving.

Based on observation and interview, the facility failed to securely store medicated creams for 1 of 1 treatment carts located on the 400 hall and failed to label an open date on a multi-dose vial of tuberculin protein derivative used to check residents and facility staff for the possible presence of the tuberculin virus and stored in the 300/400 medication room. The DON identified three medication rooms and three treatment carts in the facility. Findings: On 09/17/25 at 11:58 a.m., the 400 hall treatment cart was observed unlocked and unattended. The treatment cart contained lidocaine 2.5%/Prilocaine 2.5% medicated cream, cadexomer lodine gel (antimicrobial gel to clean wounds), Vashe wound solution, Santyl cream (topical medicine), mupirocin ointment (topical medicine), and coloplast cream (moisture barrier). On 09/23/2025 at 3:38 p.m., the 300/400 hall medication room was observed with RN #1. An open multi-dose vial of tuberculin protein derivative was observed in the refrigerator bin. There was no open date observed on the vial and no box present for the multi-dose vial. On 09/23/25 at 3:38 p.m., the open multi-dose vial of tuberculin protein derivative showed to discard the vial 30 days after opening. On 09/23/25 at 3:39 p.m., RN #1 stated the multi-dose vial of tuberculin protein derivative did not have a documented open date. RN #1 stated the multi-dose vial read to discard the vial 30 days after it was opened. On 09/23/25 at 4:45 p.m., the DON stated if the vial was opened, it had to have a date it was opened. The DON stated tuberculin protein derivative was to be discarded 30 days after it was opened. The DON stated medication carts and treatment carts were to be locked before stepping away from the cart and were not to be left unattended and unsecured.

Based on observation, record review, and interview, the facility failed to secure cleaning chemicals in 1 of 1 shower rooms on the 400 hall. The nurse consultant identified one shower room on the 400 hall. Findings: On 09/17/25 at 9:10 a.m., the 400 hall shower room door was observed ajar. No residents were observed wandering on the 400 hall. The 400 hall shower room was unsecured and unattended. The door handle locked automatically, had a passcode lock for entry, and the door spring tension was adequate to pull the door closed. Upon entering the shower room, an opaque spray bottle was observed hanging from the whirlpool lift. The spray bottle contained a clear liquid and was labelled with QUAT STAT 5 (disinfectant) in permanent marker. On 09/17/25 at 2:30 p.m., the 400 hall shower room door was observed ajar. No residents were observed wandering on the 400 hall. The 400 hall shower room was unsecured and unattended. The door handle locked automatically, had a passcode lock for entry, and the door spring tension was adequate to pull the door closed. Upon entering the shower room, an opaque spray bottle was observed hanging from the whirlpool lift. The spray bottle contained a clear liquid and was labelled with QUAT STAT 5 in permanent marker. A safety data sheet for QUAT-STAT 5, dated 02/04/21, read in part, Signal word: Danger. Hazard statements: Combustible liquid. Harmful if swallowed or in contact with skin. Causes severe skin burns and eye damage. Storage: Store locked up. Store in a well-ventilated place. Keep cool. On 09/23/25 at 4:45 p.m., the DON stated chemicals were to be stored locked away where residents could not access them. On 09/24/25 at 5:42 p.m., the administrator stated the last safety check performed was in August. The administrator stated chemicals were to be secured away from residents. The administrator stated if the shower room door was closed, the chemical would have been secured.

Based on observation, record review, and interview, the facility failed to ensure the care plan had been revised to include the use of bed rails for 1 (#11) of 1 sampled resident reviewed for bed rails.Quality Manager Nurse #2 identified 25 residents utilized bed rails. Findings:On 09/17/25 at 10:46 a.m., a bed rail was observed on the right side of Resident #11's bed in the up position.A significant change assessment, dated 08/19/25, showed Resident #11 had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of depression.A care plan, updated 09/08/25, did not show the Resident #11 utilized a bed rail to the right side of the bed.On 09/24/25 at 2:32 p.m., quality manager nurse #2 reviewed the care plan for Resident #11 and stated since they utilized a bed rail, the care plan should have been revised. On 09/24/25 at 2:56 p.m., the MDS coordinator stated they had reviewed the care plan and the bed rail had not been addressed. On 09/24/25 at 3:45 p.m., the DON stated Resident #11 had utilized a bed rail for approximately 1.5 years. They stated the bed rail had not been included in the resident's care plan.

Based on record review and interview, the facility failed to provide a written summary of the baseline care plan to the resident/resident representative for 1 (#30) of 2 residents sampled for the development, implementation, and dissemination of the baseline care plan to the resident/resident representative.The administrator identified 86 residents resided in the facility. Findings: A baseline care plan, dated 11/15/24, showed Resident #30 was admitted on [DATE]. The baseline care plan showed a copy of the admission orders were given to the resident/resident representative other and listed the resident's contact representative as the resident's caregiver and emergency contact. There was no documentation the resident/resident representative received a summary of the baseline assessment/care plan or a copy of the medication administration record or treatment record. On 09/22/25 at 4:22 p.m., the MDS coordinator reviewed the resident's clinical record and stated they did not see documentation the resident or resident representative were given a copy of the baseline care plan. On 09/24/25 at 4:20 p.m., the DON reviewed the baseline care plan and the resident's clinical record and stated there was no documentation the resident or resident representative were given a copy of the baseline care plan.

Based on record review and interview, the facility failed to ensure level 2 PASARR recommendations were incorporated into the plan of care for 1 (#11) of 1 sampled resident reviewed for PASARR.The BOM identified four residents had a level 2 PASARR.Findings: Review of the scanned documents in the electronic clinical record, dated 01/01/25 - 09/01/25, showed Resident #11 had been seen by psychiatric services on 03/01/25, 04/09/25, 07/09/25, and 08/13/25. A progress note, dated 01/17/25 at 11:21 a.m., showed a PASARR meeting had been completed for Resident #11. A PASRR-MI [mental illness] Summary of Findings, dated 01/18/25, showed recommendations for psychiatric follow up services monthly and individual counseling/psychotherapy 45 minutes a week minimum to be provided by a licensed mental health provider. A significant change assessment, dated 08/19/25, showed Resident #11 had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making, and had diagnoses of depression and psychotic disorder other than schizophrenia. A care plan, updated 09/08/25, showed Resident #11 had a mood disorder with visual hallucinations and psychiatric services was to evaluate and treat as indicated. A review of Resident #11's electronic clinical record did not show a level 2 PASARR. On 09/24/25 at 12:10 p.m., the administrator stated they had to call to get a copy of the level 2 PASARR for Resident #11 because they did not have it in the facility or in the electronic clinical record. They stated the corporate quality manager nurse had requested the level 2 PASARR. On 09/24/25 at 12:13 p.m., quality manager nurse #1 stated they had not received the level 2 PASSAR for Resident #11. They stated it was the BOM or their responsibility to obtain the results of the level 2 PASSAR for implementation of the recommendations. On 09/24/25 at 2:56 p.m., the care plan coordinator stated the level 2 PASSAR recommendations had not been implemented onto the care plan because it had just been received earlier on this day. On 09/24/25 at 2:58 p.m., the administrator stated they were unaware they had not had the level 2 PASSAR summary to implement the recommendations until earlier on this day.

Based on record review and interview, the facility failed to ensure a discharge summary with a recapitulation of the resident's stay was completed for 1 (#99) of 1 sampled resident reviewed for discharge.The BOM identified 27 residents discharged in the past 30 days.Findings: A care plan, dated 06/30/25, showed Resident #99 had a diagnosis of congestive heart failure and planned to return to the community with family. An admission assessment, dated 07/06/25, showed Resident #99 had a BIMS score of 13, which indicated the resident's cognition was intact, and planned to return to the community upon discharge. A physician order, dated 07/29/25, showed Resident #99 was discharging with home health on 07/30/25. A progress note, dated 07/30/25, showed Resident #99 discharged home with family with home health services. On 09/24/25 at 1:13 p.m., the DON stated usually the MDS coordinators completed discharge summaries. They stated a discharge summary with a recapitulation of the resident's stay had not been completed for Resident #99's planned discharge.

Based on observation, record review, and interview, the facility failed to ensure regular inspection of bed rails as part of their maintenance program for 1 (#11) of 1 sampled resident reviewed for bed rails.Quality Manager Nurse #2 identified 25 residents utilized bed rails. Findings:On 09/17/25 at 10:46 a.m., a bed rail was observed on the right side of Resident #11's bed in the up position.A significant change assessment, dated 08/19/25, showed Resident #11 had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of depression.On 09/24/25 at 3:04 p.m., the maintenance supervisor stated they applied bed rails to beds as indicated by the DON, but they did not regularly inspect them after installation. On 09/24/25 at 3:11 p.m., the administrator stated they did not have a policy related to bed rails, bed safety, or inspection of resident beds. They stated maintenance installed bed rails, but did not regularly inspect them as part of the maintenance program. The administrator stated Resident #11 had an enabler bar and they did not consider enabler bars to be bed rails. On 09/24/25 at 3:33 p.m., the administrator stated if they had put an order in for the use of bed rails for Resident #11 the nursing staff would have monitored every shift to ensure the bed rails were in place. On 09/24/25 at 3:45 p.m., the DON stated Resident #11 had utilized a bed rail for approximately 1.5 years.

Based on observation, record review, and interview, the facility failed to ensure an assessment for the use of bed rails had been completed for 1 (#11) of 1 sampled resident reviewed for bed rails.Quality Manager Nurse #2 identified 25 residents utilized bed rails. Findings:On 09/17/25 at 10:46 a.m., a bed rail was observed on the right side of Resident #11's bed in the up position.A significant change assessment, dated 08/19/25, showed Resident #11 had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of depression.A care plan, updated 09/08/25, did not show Resident #11 utilized a bed rail to the right side of the bed.Review of the electronic clinical record, dated 09/01/24 through 09/24/25, did not show Resident #11 had been assessed for the use of bed rails or consent had been obtained.On 09/24/25 at 2:12 p.m., quality manager nurse #2 stated they did not have a policy for the use of bed rails, but they were to complete an assessment, obtain consent, obtain a physician order, update the care plan and document a progress note. On 09/24/25 at 2:32 p.m., quality manager nurse #2 stated they had not completed an assessment, obtained consent or obtained a physician order for the use of bed rails for Resident #11. On 09/24/25 at 3:45 p.m., the DON stated Resident #11 had utilized a bed rail for approximately 1.5 years. They stated they had reviewed the electronic clinical record and it did not show an assessment had been completed, a physician order, or a consent had been obtained for the use of the bed rail.

Based on record review and interview, the facility failed to ensure weights were obtained as ordered by the physician for 1 (#52) of 4 sampled residents reviewed for nutrition.The administrator identified 86 residents resided in the facility.Findings: A physician order, dated 02/05/25, showed Resident #52 was to be weighed monthly. Review of the weights in the electronic health record, dated 03/01/25 through 09/17/25, showed the last weight obtained was dated 06/10/25. The electronic health record did not show a weight had been obtained in July 2025 or August 2025. A quarterly assessment, dated 09/19/25, showed Resident #52 had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of depression. A care plan, updated 09/22/25, showed Resident #52 was at risk for weight fluctuations. The care plan, read in part, weigh per physician orders/facility protocol. On 09/24/25 at 9:49 a.m., LPN #1 stated the nurses and CNAs were responsible to obtain resident weights and document in the electronic clinical record. LPN #1 reviewed the electronic clinical record and stated they did not know why a weight for Resident #52 had not been obtained in July 2025 or August 2025. On 09/24/25 at 9:54 a.m., the DON stated the MDS coordinator provided a list of residents to the nurse for the CNA to obtain weights. The DON stated it was the MDS coordinator's responsibility to ensure weights were obtained per physician orders. They stated the MDS coordinator was new to the position. They stated Resident #52 likely refused to be weighed in July 2025 and August 2025 and there should have been a progress note made if the resident refused. On 09/24/25 at 10:46 a.m., the DON stated they followed the physician orders regarding weights. The DON stated they had reviewed the electronic clinical record and did not find documentation of weights or the resident refusing weights in July 2025 or August 2025.

Based on record review and interview, the facility failed to ensure a conveyance of funds within 30 days of death for 1 (#101) of 2 sampled residents reviewed for personal funds.The BOM identified 32 residents in the facility trust account. Findings: An undated policy titled Resident Trust Policies and Procedures - Nursing Facilities, read in part, A discharged or expired resident's trust account should be closed within 30-60 days. (30 days per Oklahoma State guidelines) A Trust-Transaction History form, dated [DATE] through [DATE], showed Resident #101 had a remaining balance of $920.09 in the facility trust account.A nurse note, dated [DATE], showed Resident #101 had been sent to the emergency room for evaluation.A nurse note, dated [DATE], showed two family members had come to the facility and gathered Resident #101's personal belongings. A letter on facility letter head, to the SSA, dated [DATE], showed the facility inquired about a check which had been applied to the trust account for Resident #101 on [DATE], and the resident had expired on [DATE] at the hospital.A Trust Statement, dated [DATE], showed Resident #101 had a closing balance of $1,282.09.A Social Security Administration [NAME] Statement, dated [DATE], showed an overpayment of benefits had been paid to Resident #101. The billing statement showed a balance of $362.00 was due by [DATE].A Trust Statement, dated [DATE], showed Resident #101 had a closing balance of $1,282.09.An Activity Report, dated [DATE], showed a call had been placed to the SSA by the BOM. The representative for the SSA informed them to return the funds dated [DATE].A Social Security Administration Electronic Payment Reminder, dated [DATE], showed a payment of $362.00 was due to be paid back to the SSA.A letter on facility letter head, to the Social Security Administration, dated [DATE], showed a check for $362.00 had been made payable to the SSA.A Transfer/Discharge Report, dated [DATE], showed Resident #101 had a diagnosis of dementia and was discharged from the facility on [DATE].On [DATE] at 9:05 a.m., the BOM stated they had attempted to find out about overpayment from the SSA for Resident #101. They stated they would look for their documentation regarding conversations with the SSA and the family of Resident #101. On [DATE] at 4:22 p.m., the BOM stated they had made calls with the SSA between [DATE] and [DATE] but did not have documentation of the calls. They stated they would need to convey funds to the resident's family. On [DATE] at 4:33 p.m., the administrator stated funds were typically conveyed within 30 days of death by the home office. They stated the BOM had attempted to work out the overpayment from the SSA, but did not have documentation.

Based on observation, record review and interview, the facility failed to perform post dialysis assessments for 1 (#94) of 1 resident sampled for dialysis care. The nurse consultant identified two dialysis residents residing in the facility. Findings: On 09/17/25 at 11:30 a.m., the right chest wall of Resident #94 was observed to have a dialysis port with a clean and dry dressing covering the port site and distal ends of the port. The August 2025 treatment sheet showed the following for Resident #94:a. dialysis ordered every Tuesday, Thursday, and Saturday;b. orders to weigh the resident on dialysis days;c. the resident's arteriovenous fistula (for dialysis) was to be assessed for thrill/bruit every shift;d. assessed for signs of trauma or infection every shift;e. no blood pressure, labs, or lifting with the arm containing the arteriovenous fistula;f. dialysis port site was to be assessed for trauma and/or infection every shift and;g. no lab drawn, blood pressure, or lifting in the right arm due to the presence of the dialysis port on the right side of the resident's chest wall. The September 2025 treatment sheet, dated 09/01/25 to 09/22/25, did not show the following for Resident #94:a. dialysis was ordered/scheduled;b. an order to weigh the resident on dialysis days;c. the arteriovenous fistula was assessed for thrill/bruit, signs of trauma, or infection;d. not to perform blood pressure, lab draws, or lifting with the arm containing the arteriovenous fistula;e. to assess the resident's dialysis port for signs of trauma/infection; andf. not to obtain blood pressure, lab draws, or lifting in the right arm due to the presence of the dialysis port on the right side of the resident's chest wall. On 09/22/25 at 4:42 p.m., the MDS coordinator stated they worked as the floor nurse on 400 hall until recently. The floor nurse documented the pre dialysis assessment on a form and sent a copy of the form to dialysis with the resident. The MDS coordinator stated when the resident returned from dialysis, the nurse received the form and typed the written information into the resident's electronic medical record that the dialysis center provided. The MDS coordinator stated the post dialysis vital signs typed into the pre/post dialysis assessment were obtained by the dialysis provider prior to the resident returning to the facility and did not automatically populate in the resident's electronic medical record. The MDS coordinator stated the post dialysis assessment was documented on the treatment record. The MDS coordinator reviewed the resident's clinical record and stated they did not see where the facility staff assessed the resident post dialysis but would consult with the director of nurses. On 09/23/25 at 10:50 a.m., the MDS coordinator stated they consulted with the DON and resumed all the previous dialysis orders. The MDS coordinator stated the resident was hospitalized at the end of August and when the resident returned to the facility, the admitting nurse failed to resume the orders related to dialysis. On 09/24/25 at 4:20 p.m., the DON stated when Resident #94 was re-admitted to the facility at the end of August, the admitting nurse failed to resume orders related to dialysis. The DON stated the staff knew to perform the pre/post assessment, but failed to tell anyone the orders were not in place to document their findings. The DON stated the nurse documented the pre dialysis assessment on the dialysis assessment form, but the form did not have space for the facility's post assessment, and they should have documented the post assessment in the progress notes.

Based on record review and interview, the facility failed to provide adequate staffing to ensure residents received their baths as scheduled for two (#34 and #71) of three sampled residents whose bathing documentation was reviewed. The administrator identified 79 residents who resided in the facility. Findings: 1. Res #34 had diagnoses which included end stage renal disease and congestive heart failure. The Inventory/Task Schedule documented Res #34 was scheduled to receive a bath on Monday and Wednesday each week. The Documentation Survey Report v2 for May 2024 documented Res #34 only received a bath on the following days: 05/01, 05/06, 05/15, 05/20 and 05/29/24. Res #34 did not receive a bath on the following scheduled days: 05/08, 05/13, 05/22, and 05/27/24. On 05/28/24 at 11:41 a.m., Res #34 reported they don't get baths when they are scheduled. Res #34 reported they were supposed to have a bath yesterday (05/27/24) and asked for one but was told by staff no one working could give them a bath. Res #34 reported the staff always say there aren't enough people when needing assistance with activities of daily living. 2. Res #71 had diagnoses which included COPD, history of falling and left hip replacement. The Inventory/Task Schedule documented Res #71 was scheduled to receive a bath on Wednesday and Saturday each week. The Documentation Survey Report v2 for May 2024 documented Res #71 only received a bath on the following days: 05/01, 05/04, 05/08, 05/15, 05/18, and 05/29/24. Res #71 did not receive a bath on the following scheduled days: 05/11, 05/22, and 05/25/24. On 05/28/24 at 11:40 a.m., Res #71 reported they were supposed to get two showers a week and stated tomorrow makes two weeks since I have had a shower. Res #71 reported they don't have enough staff to give everyone their baths when they are supposed to get them. Res #71 reported the staff do not attempt to make up missed showers. On 05/31/24 at 11:23 a.m., the DON reported their expectation is for any missed baths to be made up on another day. The DON reported our staffing problems are not the residents' problems. The DON reported the process of accounting for baths and documenting baths has not been organized and could not explain the lack of documented baths for Res #71. 45913

Based on observation, record review, and interview, the facility failed to ensure oxygen and humidifier tubing was changed monthly for three (#11, 40, and #78) of three sampled residents whose respiratory care was reviewed. The Administrator identified six residents who require oxygen. Findings: The Respiratory Equipment Changeout Schedule policy, last revised on 11/11/19, read in part, .Changeout Schedule .O2 Humidifier one time per month, Cannulas one time per month . 1. Res #11 had diagnoses which included COPD A physician's order, dated 06/09/23, documented oxygen nasal cannulas/tubing and humidifiers should be changed on the 15th of each month and as needed. On 05/28/24 at 10:45 a.m., Res #11's oxygen was in use with their cannula/tubing dated 02/13/24. Res #11's oxygen humidifier was empty and dated 04/30/24. On 05/29/24 at 11:02 a.m., Res #11's oxygen was in use with their cannula/tubing dated 05/28/24. Res #11's oxygen humidifier was empty and dated 04/30/24. 2. Res #40 had diagnoses which included COPD A physician's order, dated 08/25/23, documented oxygen 2-4 liters via nasal cannula if oxygen saturation less than 90%. On 05/28/24 at 11:35 a.m., Res #40's oxygen tubing was dated 02/13/24 and humidifier bottle was empty and dated 04/10/24. On 05/29/24 at 9:35 a.m., Res #40's oxygen tubing was dated 05/28/24 and humidifier bottle was empty and dated 04/10/24. 3. Res #78 had diagnoses which included COPD A physician's order, dated 08/05/23, documented oxygen 2-4 liters via nasal cannula is oxygen saturation less than 90%. On 05/28/24 at 1:05 p.m., Res #78's oxygen tubing was dated 02/13/24. On 05/29/24 at 2:21 p.m., Res #78's oxygen tubing was dated 05/28/24. Res #78 reported the staff changed the oxygen tubing last night. On 05/31/24 at 11:28 a.m., the DON reported the tubing should be changed at least monthly. The DON reported the changing of oxygen tubing has been a problem but reported with a full administrative team they should be able to monitor tubing changes better.

Based on record review and interview, the facility failed to ensure resident assessment were completed within the required timeframe for 10 (#11, 12, 15, 17, 33, 55, 59, 62, 64 and #78) of 11 residents whose transmission reports were reviewed. The Administrator identified 79 residents who resided in the facility Findings: The CMS Transmission Report, dated 05/28/24 documented the following resident assessments were completed late/more than 14 days after the assessment reference date. a. Res #11's quarterly assessment dated [DATE]. b. Res #12's quarterly assessment dated [DATE]. c. Res #15's quarterly assessment dated [DATE]. d. Res #17's quarterly assessment dated [DATE]. e. Res #33's annual assessment dated [DATE] and quarterly assessment dated [DATE]. f. Res #55's admission assessment dated [DATE] and end of skilled assessment dated [DATE]. g. Res #59's quarterly assessment dated [DATE] and 01/21/24. h. Res #62's quarterly assessment dated [DATE]. i. Res #64's quarterly assessment dated [DATE] and 01/23/24. j. Res #78's quarterly assessment dated [DATE] On 05/31/24 at 11:16 a.m., the MDS Coordinator reported they have been pulled to the floor to cover staffing and during those times they weren't able to complete resident assessments.

Based on record review and interview, the facility failed to ensure a medication was administered as ordered for one (#83) of five sampled residents reviewed for medications. The Administrator identified 79 residents resided in the facility. Findings: A Specific Medication Administration procedure, date January 2022, read in part, .To administer oral medications in a safe, accurate, and effective manner . A Physician's Order, dated 02/08/24, documented to administer Levothyroxine Sodium Oral Tablet 88 MCG one tablet by mouth one time a day related to hypothyroidism. An April 2024 MAR documented blanks for the 6:00 a.m. Levothyroxine 88 mcg on 04/09, 04/10, 04/12, 04/16, 04/19, 04/20, 21, 04/23, 04/25, 04/27, and 04/28/24. A May 2024 MAR documented blanks for the 6:00 a.m. Levothyroxine 88 mcg on 05/04, 05/09, 05/13, 05/18, 05/21, 05/22, 05/26, 05/27, and on 05/31/24. On 05/30/24 at 10:09 a.m., CMA #1 was asked what the process was for administering medications. They stated they would look at the medication card and check it against the MAR. CMA #1 was asked how they documented when a medication was administered. They stated they pushed yes or no on the computer. CMA #1 stated if they pushed no, they would document a reason why the medication wasn't given. CMA #1 was asked what blanks on the MAR indicated. They stated it meant it wasn't given. CMA #1 was shown Resident #83's April and May MARs. They stated the night shift nurse should be giving the 6:00 a.m. medications. 45913

Based on observation, interview, and record review, the facility failed to: a. monitor food cooking and holding temperatures to ensure safe temperatures were maintained in the kitchen and on steam table during a meal service. b. the facility servings sizes were appropriate for each item served. c. food served to residents was palatable. The Resident Census and Conditions of Residents form documented 91 residents resided in the facility. Findings: On 08/23/23 at 4:55 p.m., staff were observed delivering plates of food to residents. The plates were stacked on an open cart and had plastic wrap to cover them. Multiple plates were observed stacked together as a staff member was working delivering them on the 300 hall. The plates had no mechanism to prevent heat loss from the food being served which appeared to be a ravioli dish. On 08/24/23 at 10:00 a.m., Res #1 stated if it was not for friends bringing the resident food they would starve because of the palatability, quality, and serving sizes. On 08/24/23 at 12:40 p.m., the DM was asked how the staff delivered meals to the residents who ate in their rooms. The DM stated the staff delivered them one at a time to ensure the meals were delivered hot. The DM was asked about the observation of meals being delivered on a cart with plates covered with plastic wrap. The DM stated depending on how much floor staff were available to deliver meals, sometimes the facility had to take the plates out all at once. The DM was asked how the facility ensured the food was delivered at the resident's preferred temperature. The DM stated they did not know. The temperature logs for the kitchen and the main serving area were reviewed. The logs for both did not documented temperatures were obtained for breakfast or lunch on 08/24/23. On 08/24/23 at 1:38 p.m., the DM stated the staff obtained the temperature of the food today and they must have documented on yesterday's documentation slot because they did not obtain the temperatures of the food yesterday. The DM stated the residents' can order from the alternate menu anytime. The DM stated they wanted the residents to eat in the dining room but had a lot of residents who ate in their rooms. At that time, the alternate menu items were reviewed for availability and all items were present with the exception of peanut butter. The DM stated a truck was to deliver food, including the peanut butter, tomorrow. On 08/24/23 at 3:48 p.m., Res #7 stated they did not like the food as it did not have a lot of flavor. Res #7 stated they did not eat it most of the time and would instead just eat ham and cheese sandwiches and sometimes for breakfast would have the bacon if it was cooked right and a banana. On 08/24/23 at 3:49 p.m., Res #6 stated the portions were not very big and they had ran out of food before. Res #6 stated they have an alternate menu to choose from and have those foods available if they wanted. Res #6 stated the temperature of the food was always cool. On 08/24/23 at 3:54 p.m., Res #8 stated the food was so-so and cold most of the time. On 08/24/23 at 3:56 p.m., Res #9 stated the food was cool to warm and the servings sizes varied depending on who was serving. The resident stated they were not made aware there was an alternate menu and when shown the alternate menu the resident stated they wanted a chef salad for dinner. 34945

Based on observation, record review, and interview, the facility failed to ensure medications were available for one (#10) of 15 residents observed for medication pass and failed to administer medications as ordered for two (#1 and #5) of four residents reviewed for medication administration. The Census and Conditions of Residents report, documented 91 residents resided in the facility. Findings: 1. Res #1 had diagnoses which included atrial fibrillation, seizures, and GERD. A quarterly assessment, dated 05/24/23, documented the resident was intact with cognition and required limited assistance with most ADLs. On 08/24/23 at 9:50 a.m., Res #1 was observed sitting in their wheelchair in their room and stated they had missed nine pills and the nurse, after finishing on the 100 and 200 halls, came and gave them their medication. Res #1 stated they would have stayed at the nurses station all night to get the medication if they had to. The review of the resident MAR for August, 2023 reveled on 08/03/23 one medication was not marked as administered. On 08/08/23 the MAR documented 11 medications were not marked as administered and on 08/21/23 the MAR documented three medications not marked as administered. On 08/24/23 at 2:04 p.m., the corporate RN stated they were unable to know if the resident received medications on the days which were blank on the August MAR. On 08/24/23 at 2:52 p.m., the corporate RN stated the resident had not been out of the facility on the days the MAR documentation was blank. On 08/24/23 at 4:17 p.m., the quality manager stated they only new about the 21st because of MAR recorded the medications in red which indicated the medication had not been administered. They were not aware of the other days in August with blanks on the MAR. The quality manager stated if the medications were not documented on the MAR then they were not administered. 46909 2. Res #10 had diagnoses which included chronic pain, human immunodeficiency virus, and unspecified convulsions. A physicians order, dated 04/20/22 documented the resident was prescribed divalproex sodium tablets delayed release 500 mg to be given three times a day. The resident's MAR for August 2023 documented the divalproex 500 mg was to be given between 7:00 a.m. to 11:00 a.m., again at 3:00 p.m., and 6:00 p.m. to 10:00 p.m. On 08/24/23 at 3:50 p.m., during a medication pass, the 3:00 p.m. dose of divalproex 500 mg was observed to not have been available for Res #10. On 08/24/23 at 3:52 p.m., an interview was conducted with the ADON on the medication availability and they stated they would call the pharmacy and ask about the medication. The ADON stated if the medication was not shipped then they would request the medication to be drop shipped to the facility. On 08/24/23 at 4:05 p.m., an interview was conducted with LPN #3 on the medication not being available and they stated they had spoken to the pharmacy about the medication and it should be in the facility by 7:00 p.m. to 8:00 p.m. tonight. 34945 3. Res #5 had diagnoses which included insomnia, depression, and neuropathy. An annual assessment, dated 07/28/23, documented the resident was moderately impaired in cognition and required supervision to limited assistance with ADLs. A review of the resident's MAR for August 2023 was reviewed and did not document the resident's doses of melatonin, gabapentin, or Trazodone were administered on 08/08/23. On 08/24/23 at 4:18 p.m., the Quality Manager was asked about blanks on the MAR. The Quality Manager reported if it was not documented it was not given.

Based on observation, record review, and interview, it was determined the facility failed to ensure residents received supervision to prevent falls for three (#10, 15, and #33) of five residents who were reviewed for accidents related to falls. Res #15 had a fall on 03/17/23. Hospital records related to this fall documented the resident sustained a right femoral neck fracture. The DON reported 68 residents had fallen in the previous six months. Findings: A facility policy, titled Fall Awareness Program, revised on 02/28/23, read in part, .11. Review the fall at the next Safety committee meeting and gain input for interdisciplinary team meeting members for other possible interventions to prevent falls. Make sure to update and revise plan of care as indicated. 1. Res #15 had diagnoses which included vascular dementia, senile degeneration of the brain, and history of falling. A care plan, initiated on 07/16/21, documented the resident was at risk for falls. The care plan documented the following interventions: a. a fall mat at bed side, b. staff were to anticipate the resident's needs, c. ensure the call light was in reach and encourage the resident to use it, d. staff were to respond quickly to all requests for assistance, e. utilize a bolster cover to the resident's mattress, f. ensure the resident was wearing appropriate footwear, g. keep frequently used items in reach, h. keep the pathways clear, dry, and clutter free, i. lock the wheelchair brakes prior to attempting a transfer, j. place non-skid strips at the bedside, k. keep the bed in the lowest position, and l. apply positioning bars to the bed. An incident report, dated 11/20/22, documented Res #15 had experienced an unwitnessed fall and was found on the floor in her room sitting on the fall mat. The incident report documented the resident had no apparent injuries and no steps to prevent the recurrence of falls. The care plan did not document any new fall interventions. An incident report, dated 11/23/22, documented the resident was found on the floor on the fall mat. The incident report documented the resident had not been injured and was assisted to a wheelchair and taken to the nurses station for a meal. The care plan did not reveal any new interventions to prevent falls. Another fall incident report, dated 11/23/22, documented the resident had been found on the floor lying on her back. The incident report documented the resident had no visible injuries and a CNA remained with the resident until she became restful. The incident report did not document interventions to prevent the recurrence of falls and the care plan did not reveal any new fall interventions. An annual assessment, dated 11/27/22, documented Res #15 was severely impaired in cognition, required extensive assistance with most ADLs, and had experienced two or more falls since the previous assessment. The care area assessment documented falls triggered for care planning. An incident report, dated 11/29/22, documented the resident had been found on the floor next to the fall mat. The incident report documented the resident had no apparent injury and did not document any steps to prevent the recurrence of falls. The care plan did not reveal any new fall interventions. An incident report, dated 12/05/22, documented the resident was found laying on the floor in her room. The report documented the staff found no apparent injuries. The interventions documented were previously documented on the care plan and no new interventions were added. The care plan was not updated. An incident report, dated 12/05/22, documented a second fall where the resident was found laying on the floor in her room. The incident report documented the resident was checked and did not appear to have been injured. The immediate intervention was to place the resident in a wheelchair and set her next to the nurse station. The care plan did not reveal any new fall interventions. An incident report, dated 12/13/22, documented the nursing staff were notified the resident was on the floor in her room. The immediate intervention was to place the resident in a wheelchair and bring her near the nursing station. No new interventions were documented in the care plan. An incident report, dated 12/15/22, documented the resident was on the floor in her room. The report documented the resident was assisted to her wheelchair. No new interventions were documented and the care plan did not reveal any new interventions to prevent falls. An incident report, dated 12/19/22, documented the nurse was notified the resident was on the floor. The report documented the resident was assisted to her wheelchair. The care plan was updated with previously used interventions on 12/19/22 to place the resident in a wheelchair and set her next to the nurse station. No new interventions to prevent falls were documented in the care plan. An incident report, dated 12/22/22, documented the resident was found on the floor in the dining area. The report documented an intervention to keep the resident near the staff when up in a wheelchair. A nurse note for this fall documented the resident was sent to the emergency room after appearing to lose consciousness several times after the fall. The care plan was not updated with any new interventions to prevent falls. An incident report, dated 12/25/22, documented the resident had been found on the floor next to her bed. The report documented the resident was assisted back to bed. No new interventions to prevent falls were documented on the care plan. An incident report, dated 12/28/22, documented the resident was found crawling on the floor in her room and she was stating she was trying to get a drink of water. The care plan was reviewed and did not document a new intervention to prevent falls. A significant change assessment, dated 01/02/23, documented Res #15 was severely impaired in cognition, required limited to extensive assistance with most ADLs, and had experienced two or more falls since the previous assessment. The care area assessment documented falls had been triggered for care planning. A significant change assessment, dated 01/18/23, documented Res #15 was severely impaired in cognition, required limited to extensive assistance with most ADLs, and had experienced two or more falls since the previous assessment. The care area assessment documented falls had triggered for care planning. An incident report, dated 01/28/23, documented the resident was found on the floor with a pillow under her head and a blanket over her. No steps to prevent the recurrence of falls was documented on the report and the care plan was not updated to address any new fall interventions. An incident report, dated 02/06/23, documented the resident was found on the floor on her right side. The note documented the resident complained of left hip pain and was sent to the emergency room . The incident report did not document steps to prevent falling and the care plan did not document any new interventions to prevent falling. An incident report, dated 02/17/23, documented the resident was found on the floor on a fall mat. No interventions were documented and the care plan was not updated to reflect any new interventions to prevent falls. An incident report for a second fall on 02/17/23 documented the resident was found on the floor next to the bed. No interventions were documented and the care plan was not updated to reflect any new interventions to prevent falls. An incident report, dated 02/19/23, documented the resident was found lying on the floor in her room. The report documented the resident complained that she hit her head. The report documented the resident was sent to the emergency room for evaluation. No steps to prevent the recurrence of falls was documented in the report. The care plan did not document any new interventions to prevent falls. A quarterly assessment, dated 02/20/23, documented Res #15 was severely impaired in cognition, required supervision to extensive assistance with ADLs, and had experienced two or more falls since the previous assessment. An incident report, dated 03/04/23, documented the resident was found on the floor next to her bed and the call light had been pulled out of the wall. The incident report did not document any interventions and the care plan was not updated to reflect any new fall prevention interventions. An incident report, dated 03/07/23, documented the resident slid out of her chair and sat on the floor. The report did not document interventions to prevent the recurrence of falls and the care plan did not document a fall intervention update. An incident report, dated 03/08/23, documented the resident had been sitting between the table and the medication carts and when the staff returned the resident was on the floor. The report did not document interventions to prevent the recurrence of falls and the care plan did not document a fall intervention update. An incident report, dated 03/11/23, documented the resident was found on the floor next to the bed. The report documented the resident complained of hip pain and an order for hip and pelvis X-rays were obtained from the practitioner. The report did not document interventions to prevent the recurrence of falls. The care plan did not document any new interventions to prevent falls. An incident report, dated 03/17/23, documented the resident was found on the floor in front of her wheelchair in her room. The report documented the resident complained of pain in her lower extremities and was sent to the emergency room for evaluation. The report did not document interventions to prevent the recurrence of falls. The care plan was reviewed and was found to not document any new interventions to prevent falls. Hospital records were reviewed related to this fall and documented the resident had fractured her hip. On 04/12/23 at 12:11 p.m., the DON stated, regarding the fall on 12/05/23, the facility had asked the consultant pharmacist to review the resident's medications as a possible contributor to falls and the review occurred on 12/12/22. He stated the resident's medication Remeron was discontinued several days later. The DON stated the care plan was not updated to include a medication review as a fall prevention intervention. On 04/12/23 at 12:16 p.m., the DON stated, regarding the fall on 12/13/22, he was waiting for hospice to get back to him if they had approved a restart of the resident's dose of Ativan as a medicinal intervention for falls. On the same date at 3:31 p.m., the DON confirmed the Ativan was added again but was not documented on the resident's fall care plan as a fall intervention. On 04/12/23 at 12:28 p.m., the DON stated, regarding the fall on 02/20/22, the resident had been sent to the emergency room and was diagnosed with a urinary tract infection. He stated this may have been the cause of the fall and confirmed the diagnosis of a urinary tract infection was not documented on the resident's care plan as a fall intervention. On 04/12/23 at 12:35 p.m., the DON stated, regarding the fall on 03/08/23, the facility had again requested the consultant pharmacist to review the resident's medications as a cause of the falls. He stated this occurred on 03/14/23 and the physician declined to reduce any medications. The DON confirmed the care plan had not been updated to include a review of the resident's medications as a fall prevention intervention. On 04/12/23 at 3:29 p.m., the DON reported the incident report for the fall on 03/11/23 documented placing bright colored tape on the resident's call light for ease of locating the call light by the resident. He stated he knew the tape had been applied as he did it himself. The DON confirmed the application of bright colored tape to the call light was not added to the care plan as a fall intervention. For the other falls, the DON was interviewed on 04/12/23 between 12:20 p.m. and 12:33 p.m., and stated he could find no further documentation or interventions placed on the incident reports or documented in the notes or care plan. 2. Res #33 had diagnoses which included dementia with behavioral disturbance, anxiety disorder, unspecified psychosis, and osteoporosis. A fall care plan, initiated on 08/03/21, documented the resident was at risk for falls with injuries. The care plan documented the following interventions: a. evaluate all falls and intervene as necessary to reduce the potential of significant injury, b. get the resident up when he was restless, c. keep the bed in the low position, d. anticipate the resident's needs, e. keep the call light close and answer it promptly, f. keep personal items in reach, g. bolster cover to the resident's mattress, h. staff to assist him to bed after meals and activities, i. ensure resident was wearing appropriate footwear, j. Dycem to his wheelchair, k. monitor the resident for attempting to put himself to bed, l. the falling star program and facility fall policy, m. positioning bars, m. physical therapy and occupational therapy as ordered, and o. a safety (beveled) fall mat. An incident report, dated 12/06/22, documented the resident was on the floor in the hallway. The report did not contain documentation of any interventions to prevent further falls. The care plan documented the resident was currently near the nursing station in a wheelchair but did not reveal any documentation of new interventions to prevent falls. An annual MDS assessment, dated 12/21/22, documented the resident was severely impaired in cognition, required limited to extensive assistance with most ADLs, and had experienced two or more falls since the previous assessment. The care area assessment documented falls were triggered to care plan. An incident report, dated 12/28/22, documented the resident was observed standing in his doorway with only an adult brief on. The report documented the resident lost his balance and fell . The report documented the resident stated he was hungry and a snack was provided to him. The report documented to ensure the resident was wearing proper footwear. The care plan had already documented appropriate footwear and no new interventions to prevent falls were documented. An incident report, dated 01/07/23, documented the resident was found on the floor in his room. The report and the resident's care plan did not contain documentation of any new steps to prevent falls. An incident report, dated 01/22/23, documented the resident was found sitting on his fall mat on the floor. The incident report documented the resident had on appropriate footwear and an adult brief. The incident report and the care plan documented safety measures were already in place and did not contain documentation of any new interventions to prevent falls. An incident report, dated 01/23/23, documented the resident was found sitting on the floor and scooting himself across the hallway. The report documented the resident was assisted to his wheelchair and brought near the nursing station. The care plan documented an intervention of every two hour safety checks. An incident report, dated 01/29/23, documented the resident was found on his bottom and was scooting himself across the floor. The report and the care plan did not contain documentation of any new interventions to prevent falls. An incident report, dated 02/24/23, documented the resident was observed crawling from his bed and onto the floor. An intervention documented on the report was to place the resident in his wheelchair and bring him to the common area when he was awake. The care plan did not reveal documentation of the intervention. An incident report, dated 02/27/23, documented the resident was observed sitting on the floor outside of his room. The report documented to add the resident to the morning get up list where CNAs were to assist the resident to get up before the end of their shift. The care plan did not contain documentation of this intervention. An incident report, dated 03/03/23, documented the resident was found sitting on the floor in his doorway. The incident report did not document any interventions and the care plan was not updated. A quarterly MDS assessment, dated 03/17/23, documented the resident was severely impaired in cognition, required extensive with most ADLs, and had experienced two or more falls since the previous assessment. On 04/07/23 at 10:36 p.m., Res #33 was observed sitting on the side of the bed, with his and legs over the side, pulling on the mattress and grab bar, attempting to stand up. A fall mat was observe at the side of the bed and the bed was observed to have a bolstered mattress cover. On 04/07/23 at 10:39 a.m., a staff member was passing by in the hall, saw the resident attempting to stand, and entered the room and closed the resident's door. On 04/07/23 at 12:09 p.m., a family member of Res #33 was interviewed and stated the resident fell frequently when attempting to get out of bed. On 04/12/23 from 5:03 p.m. to 5:13 p.m., the DON was interviewed regarding these falls. He confirmed there had been no new fall preventions added to the resident's care plan related to the resident's falls listed above. He stated every two hour checks was not an appropriate intention to prevent falls as the staff were to do this anyway. 38495 3. Res #10 had diagnoses which included chronic respiratory failure with hypoxia, COPD, atrial fibrillation, and HTN. A care plan for falls, initiated on 12/09/22, documented the resident had the potential for falls related to muscle weakness. The care plan documented the following interventions: a. keep the call light in reach and encourage the resident to use it, b. encourage the resident to participate in activities which promoted physical activity for strengthening and mobility, c. ensure the resident was wearing non skid footwear before ambulation, before transfers, and when up in the wheelchair. d. toilet the resident frequently, e. keep the high low bed in the low position, f. lock the wheelchair before transfers, g. assess the environment for potential hazards such as wetness, clutter, and newly waxed floors, h. keep personal and frequently used items in reach, i. anticipate the resident's needs, and j. follow the facility's fall protocol. A nurse incident note, dated 02/28/23, documented a CNA called the nurse to the resident's room. The note documented resident was setting on the edge of her bed. The note documented Res #10 stated she fell in the bathroom and hit her head on the cabinet and then she got up and walked back to her bed. The note documented the resident was observed to have a quarter sized hematoma to right side of her forehead with two abrasions on top of the raised area. The note documented the resident was sent to the ER for evaluation and the intervention to prevent falls was the resident would be checked hourly for three days upon return from hospital. The fall care plan, revised 02/28/23, documented the intervention for hourly checks for three days upon return from the hospital. The resident's medical record did not document the hourly checks for three days as completed. A nurse incident note, dated 03/03/23, documented Res #10 was sitting on the floor. The note documented the resident was assessed and was assisted up into a wheelchair and no injuries were observed. The note documented the resident refused to go to the emergency room . The note documented a fall intervention of the resident was educated to use the call light before transfers which was already documented on the initial fall care plan. A significant change assessment, dated 03/20/23, documented the resident was severely impaired with cognition, required limited assistance with most ADLs, and total assistance with bathing. The assessment documented no falls since reentry or last assessment. On 04/10/23 at 11:27 a.m., Res #10 was observed sitting on the side of her bed which was in the low position. A nurse incident note, dated 04/11/23 at 6:08 a.m., documented the resident was found sitting on the floor in her room leaning forward to the box fan in her room. The note documented the resident had placed herself on the floor to be near to the box fan and was not injured. The note documented the resident's box fan was to be kept in reach. On 04/11/23 at 11:32 a.m., Res #10 was observed asleep sitting on the side of the bed with one foot on the floor and lying on her right side. The bed was observed in the low position. The box fan was observed on the floor under the over the bed table out of reach of the resident. On 04/11/23 at 11:43 a.m., CNA #2 stated Res #10 had been out to the hospital after a fall but not fallen recently that she was aware of. The CNA stated the yellow paper on the resident's wall was to identify the resident as a fall risk. The CNA stated the nurses had not instructed the staff on any interventions to prevent falls for the resident. On 04/11/23 at 2:18 p.m., the DON stated the hourly checks should have been documented in a physician order and then would have been on the TAR for the staff to document checking on the resident. On 04/11/23 at 3:59 p.m., the DON stated he was not able to find where the hourly checks were documented for the three days upon return from hospital.

Based on observation, record review, and interview, it was determined the facility failed to ensure residents' care plans were reviewed and revised for six (#5, 10, 15, 33, 69, and #86) of 27 residents whose care plans were reviewed. The facility failed to update the residents' care plans: a. with new interventions in response to position and mobility for residents #69 and #86. b. with new interventions in response to the residents' falls for #5, 10, 15, and #33. c. with ADL cares and oxygen for resident #10. The Resident Census and Conditions of Residents documented 86 residents resided in the facility. Findings: 38495 1. Res #5 had diagnoses which included history of falling, COPD, diabetes mellitus, and schizophrenia. A nurse note, dated 03/12/23, documented the resident had a fall in the dining room. The intervention was to place the resident on PRN incontinent care checks. A care plan, revised 03/12/23, documented an intervention was in place for incontinent care checks as needed. A Medicare 5 day assessment, dated 03/20/23, documented the resident was severely impaired with cognition and required extensive assistance with a two person assist for walking. A significant change assessment dated [DATE], documented the resident was independent in cognition and required supervision to limited assistance with most ADLs. The assessment documented walking occurred only once or twice during the look back period. On 04/10/23 at 6:58 a.m., Res #5 was observed sitting in a wheelchair at a table in the dining room. The resident was observed to have been a double amputee of the lower extremities. The DON was asked where the incontinent checks were documented for Res #5. On 04/13/23 at 9:30 a.m., the DON stated the intervention of incontinent checks was changed to watch for things on the ground which the resident might have leaned over to pick up. He stated the resident was observed for the fall and was leaning to retrieve something from the ground. He stated the resident had an incontinent episode after she fell . The DON stated the care plan had not been updated with the new intervention. 2. Res#10 had diagnoses which included chronic respiratory failure with hypoxia, COPD, atrial fibrillation, and HTN. A nurse incident note, dated 03/03/23, documented Res #10 was sitting on the floor. The resident was assessed and was assisted up into a wheelchair. The nurse incident note documented no injuries observed and the resident refused to go to the emergency room . The nurse incident note documented an intervention was the resident was educated to use the call light before transfers. A significant change assessment, dated 03/20/23, documented the resident was severely impaired with cognition and required limited assistance with most ADLs and total assistance with bathing. The assessment documented no falls since reentry or last assessment. The assessment documented the resident received oxygen. A care plan, revised 03/21/23 for falls, documented minor injury fall in room, bruising and bleeding from both elbows. The care plan documented an intervention for hourly safety checks for seven days. The care plan was updated with the fall from 03/03/23 and already contained the intervention for the call light being in reach and encourage to use. A care plan, last revised 03/24/23, for respiratory care, documented the resident had altered respiratory status related to COPD and acute and chronic respiratory failure with hypoxia. The care plan did not include oxygen therapy or the amount of oxygen the resident was to receive. A care plan, last revised 03/30/23, for ADL care documented when bathing the resident to avoid scrubbing and pat dry sensitive skin, check nail length, and trim and clean the nails on bath day. The care plan documented the resident required limited staff participation with bathing and the resident would be provided a sponge bath when a full bath or shower could not be tolerated. The care plan for personal care documented the resident required limited staff participation with personal hygiene and oral care. On 04/06/23 at 11:12 a.m., the resident stated she had facial hair and she would like it gone. The resident was observed to have facial hair on her chin which was approximately 1/2 inch long and curled. On 04/10/23 at 11:27 a.m., Res #10 stated she received showers but the staff did not take care of her facial hair. Res #10 rubbed her chin and stated she would like them to. The resident facial hair was observed to be long on the resident's chin. The resident was observed receiving four liters of oxygen per nasal cannula. On 04/11/23 at 11:32 a.m., Res #10 was asleep sitting on the side of the bed with her feet on the floor and lying over on her right side. The bed was in a low position. The resident was observed with facial hair present on her chin and on four liters of oxygen per nasal cannula. On 04/11/23 at 2:53 p.m., MDS coordinator #2 stated the 03/03/22 fall was not captured on the care plan and should have been updated with a new intervention. She stated the CNA who bathed the resident should have known to address shaving during the bath when shaving was needed or wanted. She stated she thought there was an option to make sure the shaving was on the care plan. She stated the care plan should have been updated after the significant change for the resident's ADLs. On 04/13/23 at 11:24 a.m., MDS coordinator #2 stated on 04/11/23 oxygen and the flow amount were added to the care plan. 3. Res #86 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, and Parkinson's Disease. A care plan, last revised 12/03/22 for transfer and mobility, documented the resident had an ADL self care performance deficit. The care plan documented the resident was independent to limited assist of one with transfers and bed mobility. A significant change assessment, dated 02/16/23, documented the resident was intact with cognition and required limited assistance with bed mobility and transfer. The assessment documented the resident had limited ROM impairment with both upper and lower extremities on both sides. On 04/17/23 at 3:06 p.m., Res #86 stated she was not able to reposition herself in the bed. CNA #1 stated the resident was total care for positioning. CNA #1 was providing care for the resident at that time and confirmed the resident was unable to turn and reposition herself. On 04/18/23 at 8:45 a.m., MDS coordinator #1 stated the resident's care plan needed to be updated to limited to extensive with one to two staff for assistance. 34945 4. Res #15 had diagnoses which included vascular dementia, senile degeneration of the brain, and history of falling. A care plan, initiated on 07/16/21, documented the resident was at risk for falls. The care plan documented a fall mat had been placed at the side of the bed. The care plan documented staff were to anticipate the resident's needs, ensure the call light was in reach and encourage the resident to use it. The care plan documented staff were to respond quickly to all requests for assistance. The care plan documented the facility was to utilize a bolster cover to the resident's mattress, to ensure the resident was wearing appropriate footwear, to keep frequently used items in reach, keep the pathways clear, dry, and clutter free, and to lock the wheelchair brakes prior to attempting a transfer. The care plan documented to place non-skid strips at the bedside and to keep the bed in the lowest position. The care plan documented to apply positioning bars to the bed. An incident report, dated 11/20/22, documented Res #15 had experienced an unwitnessed fall and was found on the floor in her room sitting on the fall mat. The incident report documented no steps to prevent the recurrence of falls and the care plan did not document any new fall interventions. An incident report, dated 11/23/22, documented the resident was found on the floor on the fall mat. The incident report documented the resident had not been injured and was assisted to a wheelchair and taken to the nurses station for a meal. The care plan was reviewed and did not reveal any new interventions to prevent falls. Another fall incident report, dated 11/23/22, documented the resident had been found on the floor lying on her back. The incident report did not document interventions to prevent the recurrence of falls and the care plan did not reveal any new fall interventions. An annual assessment, dated 11/27/22, documented Res #15 was severely impaired in cognition, required extensive assistance with most ADLs, and had experienced two or more falls since the previous assessment. The care area assessment documented falls were to have been care planned. An incident report, dated 11/29/22, documented the resident had been found on the floor next to the fall mat. The incident report did not document any steps to prevent the recurrence of falls. The care plan did not reveal any new fall interventions. An incident report, dated 12/05/22, documented the resident was found laying on the floor in her room. The interventions documented were previously documented on the care plan and no new interventions were added. The care plan was not updated. An incident report, dated 12/05/22, documented a second fall where the resident was found laying on the floor in her room. The immediate intervention was to place the resident in a wheelchair and set her next to the nursing station. The care plan did not reveal any new fall interventions. An incident report, dated 12/13/22, documented the nursing staff were notified the resident was on the floor in her room. The immediate intervention was to place the resident in a wheelchair and bring her near the nursing station. No new interventions were documented in the care plan. An incident report, dated 12/15/22, documented a CNA notified the nurse the resident was on the floor in her room. No new interventions were documented and the care plan did not reveal any new interventions to prevent falls. An incident report, dated 12/19/22, documented the nurse was notified the resident was on the floor. The care plan was updated with previously used interventions on 12/19/22 to place the resident in a wheelchair and set her next to the nursing station. No new interventions to prevent falls were documented in the care plan. An incident report, dated 12/22/22, documented the resident was found on the floor in the dining area. The report documented an intervention to keep the resident near the staff when up in a wheelchair. A nurse note for this fall documented the resident was sent to the emergency room after appearing to lose consciousness several times after the fall. The care plan was not updated with any new interventions to prevent falls. An incident report, dated 12/25/22, documented the resident had been found on the floor next to her bed. No new interventions to prevent falls were documented on the care plan. An incident report, dated 12/28/22, documented the resident was found crawling on the floor in her room and she was stating she was trying to get a drink of water. The care plan was reviewed and did not document a new intervention to prevent falls. A significant change assessment, dated 01/02/23, documented Res #15 was severely impaired in cognition, required limited to extensive assistance with most ADLs, and had experienced two or more falls since the previous assessment. The care area assessment documented falls had been triggered for care planning. A significant change assessment, dated 01/18/23, documented Res #15 was severely impaired in cognition, required limited to extensive assistance with most ADLs, and had experienced two or more falls since the previous assessment. The care area assessment documented falls had triggered for care planning. An incident report, dated 01/28/23, documented the resident was found on the floor with a pillow under her head and a blanket over her. No steps to prevent the recurrence of falls was documented on the report and the care plan was not updated to address any new fall interventions. An incident report, dated 02/06/23, documented the resident was found on the floor on her right side. The note documented the resident complained of left hip pain and was sent to the emergency room . The incident report did not document steps to prevent falling and the care plan did not document any new interventions to prevent falling. An incident report, dated 02/17/23, documented the resident was found on the floor on a fall mat. No interventions were documented and the care plan was not updated to reflect any new interventions to prevent falls. An incident report for a second fall on 02/17/23 documented the resident was found on the floor next to the bed. No interventions were documented and the care plan was not updated to reflect any new interventions to prevent falls. An incident report, dated 02/19/23, documented the resident was found lying on the floor in her room. The report documented the resident complained that she hit her head. The report documented the resident was sent to the emergency room for evaluation. No steps to prevent the recurrence of falls was documented in the report. The care plan did not document any new interventions to prevent falls. A quarterly assessment, dated 02/20/23, documented Res #15 was severely impaired in cognition, required supervision to extensive assistance with ADLs, and had experienced two or more falls since the previous assessment. An incident report, dated 03/04/23, documented the resident was found on the floor next to her bed and the call light had been pulled out of the wall. The incident report did not document any interventions and the care plan was not updated to reflect any new fall prevention interventions. An incident report, dated 03/07/23, documented the resident slid out of her chair and sat on the floor. The report did not document interventions to prevent the recurrence of falls and the care plan did not document a fall intervention update. An incident report, dated 03/08/23, documented the resident had been sitting between the table and the medication carts and when the staff returned the resident was on the floor. The report did not document interventions to prevent the recurrence of falls and the care plan did not document a fall intervention update. An incident report, dated 03/11/23, documented the resident was found on the floor next to the bed. The report documented the resident complained of hip pain and an order for hip and pelvis X-rays were obtained from the practitioner. The report did not document interventions to prevent the recurrence of falls and the care plan did not document any new interventions to prevent falls. An incident report, dated 03/17/23, documented the resident was found on the floor in front of her wheelchair in her room. The report documented the resident complained of pain in her lower extremities and was sent to the emergency room for evaluation. The report did not document interventions to prevent the recurrence of falls. The care plan was reviewed and was found to not document any new interventions to prevent falls. Hospital records were reviewed related to this fall and documented the resident had fractured her hip. On 04/12/23 at 12:11 p.m., during an interview with the DON regarding the fall on 12/05/23, he reported the facility had asked the consultant pharmacist to review the resident's medications as a possible contributor to falls and the review occurred on 12/12/22. He stated the resident's medication Remeron was discontinued several days later. The DON stated the care plan was not updated to include a medication review as a fall prevention intervention. On 04/12/23 at 12:16 p.m., the DON stated, regarding the fall on 12/13/22, he was waiting for hospice to get back to him if they had approved a restart of the resident's dose of Ativan as a medicinal intervention for falls. On the same date at 3:31 p.m., the DON confirmed the Ativan was added again but was not documented on the resident's fall care plan as a fall intervention. On 04/12/23 at 12:28 p.m., during an interview with the DON regarding the fall on 02/20/22, he stated the resident had been sent to the emergency room and was diagnosed with a urinary tract infection. He stated this may have been the cause of the fall and confirmed the diagnosis of a urinary tract infection was not documented on the resident's care plan as a fall intervention. On 04/12/23 at 12:35 p.m., during an interview with the DON regarding the fall on 03/08/23, he stated the facility had again requested the consultant pharmacist to review the resident's medications as a cause of the falls. He stated this occurred on 03/14/23 and the physician declined to reduce any medications. The DON confirmed the care plan had not been updated to include a review of the resident's medications as a fall prevention intervention. On 04/12/23 at 3:29 p.m., the DON reported the incident report for the fall on 03/11/23 documented placing bright colored tape on the resident's call light for ease of locating the call light by the resident. He stated he knew the tape had been applied as he did it himself. The DON confirmed the application of bright colored tape to the call light was not added to the care plan as a fall intervention. For the other falls, the DON was interviewed on 04/12/23 between 12:20 p.m. and 12:33 p.m., and stated he could not find any further documentation or interventions placed on the incident reports or documented in the notes or care plan. 5. Res #33 had diagnoses which included dementia with behavioral disturbance, anxiety disorder, unspecified psychosis, and osteoporosis. A fall care plan, initiated on 08/03/21, documented the resident was at risk for falls with injuries. The care plan documented the staff were to evaluate all falls and intervene as necessary to reduce the potential of significant injury. The care plan documented interventions prior to 11/01/22 which included getting the resident up when he was restless, keep the bed in the low position, anticipate the resident's needs, keep the call light close and answer it promptly, keep his personal items in reach, bolster cover to the resident's mattress, staff to assist him to bed after meals and activities, ensure he was wearing appropriate footwear, Dycem to his wheelchair, monitor the resident for attempting to put himself to bed, the falling star program, facility fall policy, positioning bars, physical therapy and occupational therapy as ordered, and a safety (beveled) fall mat. An incident report, dated 12/06/22, documented the resident was on the floor in the hallway. The report did not contain documentation of any interventions to prevent further falls. The care plan documented the resident was currently near the nursing station in a wheelchair but did not reveal any documentation of new interventions to prevent falls. An annual MDS assessment, dated 12/21/22, documented the resident was severely impaired in cognition, required limited to extensive assistance with most ADLs, and had experienced two or more falls since the previous assessment. The care area assessment documented falls were triggered to care plan. An incident report, dated 12/28/22, documented the resident was observed standing in his doorway with only an adult brief on. The report documented the resident lost his balance and fell . The report documented the resident stated he was hungry and a snack was provided to him. The report documented to ensure the resident was wearing proper footwear. The care plan had already documented appropriate footwear and no new interventions to prevent falls were documented. An incident report, dated 01/07/23, documented the resident was found on the floor in his room. The report and the resident's care plan did not contain documentation of any new steps to prevent falls. An incident report, dated 01/22/23, documented the resident was found sitting on his fall mat on the floor. The incident report documented the resident had on appropriate footwear and an adult brief. The incident report and the care plan documented safety measures were already in place and did not contain documentation of any new interventions to prevent falls. An incident report, dated 01/23/23, documented the resident was found sitting on the floor and scooting himself across the hallway. The report documented the resident was assisted to his wheelchair and brought near the nursing station. The care plan documented an intervention of every two hour safety checks. An incident report, dated 01/29/23, documented the resident was found on his bottom and was scooting himself across the floor. The report and the care plan did not contain documentation of any new interventions to prevent falls. An incident report, dated 02/24/23, documented the resident was observed crawling from his bed and onto the floor. An intervention documented on the report was to place the resident in his wheelchair and bring him to the common area when he was awake. The care plan did not reveal documentation of the intervention. An incident report, dated 02/27/23, documented the resident was observed sitting on the floor outside of his room. The report documented to add the resident to the morning get up list where CNAs were to assist the resident to get up before the end of their shift. The care plan did not contain documentation of this intervention. An incident report, dated 03/03/23, documented the resident was found sitting on the floor in his doorway. The incident report did not document any interventions and the care plan was not updated. A quarterly MDS assessment, dated 03/17/23, documented the resident was severely impaired in cognition, required extensive with most ADLs, and had experienced two or more falls since the previous assessment. On 04/07/23 at 10:36 p.m., Res #33 was observed sitting on the side of the bed, with his and legs over the side, pulling on the mattress and grab bar, attempting to stand up. A fall mat was observe at the side of the bed and the bed was observed to have a bolstered mattress cover. On 04/07/23 at 10:39 a.m., a staff member was passing by in the hall, saw the resident attempting to stand, and entered the room and closed the resident's door. On 04/07/23 at 12:09 p.m., a family member of Res #33 was interviewed and stated the resident fell frequently when attempting to get out of bed. On 04/12/23 from 5:03 p.m. to 5:13 p.m., the DON was interviewed regarding these falls. He confirmed there had been no new fall prevention added to the resident's care plan related to the resident's falls listed above. He stated every two hour checks was not an appropriate intention to prevent falls as the staff were to do this anyway. 6. Res #33 had diagnoses which included GERD. A care plan, updated on 08/26/22, documented the resident had a diagnosis of GERD and to administer naloxegol as ordered by the physician. A physician order, dated 08/30/22, documented the facility was to administer naloxegol oxalate (a medication used to counteract the action of opioids and treat constipation), 25 mg daily for a diagnosis of GERD. An annual MDS assessment, dated 12/21/22, documented the resident was severely impaired in cognition, required limited to extensive assistance with most ADLs and was always incontinent of bowel. A quarterly MDS assessment, dated 03/17/23, documented the resident was severely impaired in cognition, required extensive assistance with most ADLs, and was always incontinent of bowel and bladder. On 04/12/23 at 3:35 p.m., the DON stated he checked with the pharmacist and the medication naloxegol was not used to treat GERD. He stated the medication was used to treat constipation caused by opioid medication. He stated he would have to correct the care plan. 7. Res #69 had diagnoses which included hemiplegia and hemiparesis. An annual MDS assessment, dated 11/08/22, documented the resident was intact in cognition; required extensive to total assistance with ADLs; and had range of motion impairment on both sides of his upper and lower extremities. A care plan, dated 02/07/23, documented the resident had an ADL self care performance deficit. The care plan documented Res #69 was to maintain his current level of function in ADLs through the next review date. The care plan documented the restorative aide was to do passive range of motion with the resident's left hand daily. On 04/10/23 at 9:18 a.m., the resident was observed in his room in bed. The resident stated he did not receive any therapy or restorative. His left hand was observed with his fingers curved at the first joint. He stated he could not fully open his hand but worked with it daily to try to keep it movable. On 04/17/23 at 12:14 p.m., the DON was asked why this resident was not receiving restorative on his hand. He stated this facility did not have a restorative aide or restorative program at that time. On 04/18/23 at 8:43 a.m., MDS coordinator #2 stated the care plan did not address his range of motion and the facility did not have a restorative program.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from neglect when it failed to: ~ Provide supervision to prevent resident to resident altercations for one (#3) of two residents reviewed for supervision. This had the potential to affect 50 residents who resided on the 300 and 400 halls; and ~ Carry the resident call light system pagers for the 300 and 400 halls. This had the potential to affect 42 of 50 residents who resided on the 300 and 400 halls. Findings: The facility's policy on abuse and neglect, revised 12/28/17, documented, . The facility will not tolerate mistreatment, neglect, or abuse of residents . Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas . 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, revised 08/23/20, documented the resident had a focus concern of impaired cognitive function related to [MEDICAL CONDITION]. The goal was the resident would be able to communicate her basic needs. Interventions included to monitor the resident for wandering and to check her Wanderguard for placement and functionality. Another focus concern was the resident had the potential to demonstrate physical behaviors such as kicking and hitting residents and staff. The goal was the resident would not harm herself or others. Interventions included to document behaviors and attempted interventions and to guide away from sources of distress. Another focus concern was the resident was a wanderer and this significantly intruded on the privacy of others. The goal was the resident's safety would be maintained. Interventions included to distract the resident from wandering by offering pleasant diversion, hourly safety checks, and a Wanderguard to her right ankle. A quarterly assessment, dated 11/12/20, documented the resident was severely impaired in cognitive skills for daily decision making. It was documented the resident required supervision for transfers and locomotion throughout the unit. It was documented the resident had physical symptoms directed to others, other behavioral symptoms not directed towards others, and wandering on one to three days during the previous seven days. It was documented the resident rejected care daily. A progress note, dated 11/26/20 at 1:12 p.m., documented, . redirect resident from other resident room. Resident will go into other resident room to take stuff, lay (sic) in their bed. Redirect resident to her room . A progress note, dated 12/08/20 at 5:59 p.m., documented, . she has refused to have her v/s (vital signs) taken gritting her teeth and slapping at this nurse . A progress note, dated 12/13/20 at 3:11 p.m., documented, . wandered over to 300 hall, approached another resident and forcefully grabbed her by the wrist, leaving a thumb shaped bruise. Resident was taken back to her room . A progress note, dated 12/15/20 at 3:13 p.m., documented, . Resident on hourly checks for aggressive behavior on 12/13/20 . Staff kept resident involved with diversional activities . A behavior note, dated 12/15/20 at 9:53 p.m., documented, . has been roaming up and down the hallways and going into other resident's (sic) rooms . She went in another resident's room and got on the toilet. She becomes very agitated and angry when staff tries to redirect her . An incident note, dated 12/16/20 at 10:54 a.m., documented, . Called to another resident (Resident #12) room. Resident stated, 'Another resident wheeled into his door, pulled back curtain. He asked her not to come in because this is not her room. Your room is down the hall way. Other resident continue to wheel up to me. Other resident stood up moved bedside table. Asked resident to leave again this is not your room. Other resident said, 'I don't have to do jack[***]' Other resident got blank stare then hit me on side of head, shoulder on RT (right) side. Then sat in her wheelchair and left room' . N/O (new order) obtain UA (urinalysis) with C&S (culture and sensitivity) . place on one hour checks . A behavior note, dated 12/16/20 at 12:46 p.m., documented, . wondering (sic) 300 and 400 hall in wheelchair. Stopping at resident doors. At times goes into rooms, has taken stuff from room. When staff redirects resident does come (sic) combative by attempting to hit and scratch at times. Staff assist with returning belongs (sic) . A quality manager progress note, dated 12/16/20 at 1:05 p.m., documented, . spoke with (family member) regarding resident's aggressive behavior . A physician's orders [REDACTED]. A behavior note, dated 12/17/20 at 11:54 a.m., documented, . Resident up in wheelchair self propelling about facility without incident. 1:1 (one to one) staff with resident today. Resident has attempted multiple times to go in other resident room but redirected by staff . A progress note, dated 12/17/20 at 3:16 p.m., documented, . Resident was pulling things off her wall, breaking objects, hitting and kicking staff refusing her medication, crying out and unable to verbalize wants or needs . 1:1 staff is unable to redirect her or calm her. Her (family member) wants her to have a mental health eval (evaluation) at the hospital. Resident was transferred . slapping, kicking . punched one of the female paramedics in the face and scratched her with her fingernail . An admission note, dated 12/31/20 at 7:45 p.m., documented the resident returned to the facility. A behavior note, dated 01/01/21 at 1:06 p.m., documented, . Self propelling about facility up and down halls. Continue going into other residents room. Resident always picks up stuff out of other resident room. staff returns to other residents. Other resident yelling for resident to get out of their rooms. Staff assist with redirecting resident . A behavior note, dated 01/13/21 at 9:07 p.m., documented, . noted to go in other residents rooms. On several occasions resident is noted in residents beds, has taken food out of residents rooms, took another residents wheelchair/walker . can be difficult to redirect. At times resident does become combative with staff . A behavior note, dated 01/14/21 at 12:50 p.m., documented, . went into another female resident room while she was in the bathroom on the toilet. They were yelling at each other. I went in and removed this resident and took her back to her room on the other hallway. Staff to monitor . A behavior note, dated 01/14/21 at 12:55 p.m., documented, . Late entry from 01/13/21, resident was found in a male resident room on the other hallway asleep in his bed. He was very upset and started yelling at her to get our his room. Staff to monitor . A behavior note, dated 01/14/21 at 1:54 p.m., documented, . raised her arm and threatened to slap another resident . was redirected by staff . will continue to monitor . A behavior note, dated 01/14/21 at 2:48 p.m., documented, . observed taking another resident's coloring materials from them. Resident asked this nurse to retrieve materials and remove resident from the area as she states she is afraid of resident (resident #3) because she hits . A behavior note, dated 01/14/21 at 11:27 p.m., documented, . found in another resident's room on another hall. Resident told (resident #3) this is not your room and she left . will continue to monitor . A progress note, dated 01/15/21 at 10:13 a.m., documented, . came onto 300 hall and took another resident breakfast from them and started eating it. I attempted to take her back to dinning (sic) area and she started hitting me and yelling curse words at me. I did notify the nurse for her hall and she was taken back to her hall . A behavior note, dated 01/19/21 at 1:32 p.m., documented, . is observed going into other residents room, she will lay (sic) in their beds, get into their clothes and carry them around. This nurse observed her eating food that other residents didn't eat after lunch, she was redirected but becomes combative, offered her more food of her own but she refuses, she is refusing her medications, she will throw them or hit at the CMA (certified medication aide), unable to redirect. Giving her food helps with her behaviors at times if she likes the food given to her . A progress note, dated 01/21/21 at 1:41 p.m., documented, . has been up self propelling in wheelchair about facility without incident. has had to redirect multiple times throughout shift. Continue to go in other resident room and take other residents personal belongings . An incident note, dated 01/21/21 at 10:09 p.m., documented, . fell on buttocks in hall next to her room . appears she was trying to go to the restroom because her pants were pulled down to her knees . A behavior note, dated 01/25/21 at 1:19 p.m., documented, . resident up walking with wheelchair in hallway. Got end (sic) of hall dropped her pants, small bowel movement . A behavior note, date 01/25/21 at 6:28 p.m., documented, . Resident without walker or wheelchair, she would get upset if she was escorted to her chair. She attempted to strike another resident without cause, staff stopped . A behavior note, dated 01/27/21 at 7:33 a.m., documented, . Upon arriving to room noted whole room was flooded. Water going in bathroom. Had moved faucet to over counter instead of sink . A behavior note, dated 01/27/21 at 9:56 p.m., documented, . was found going through other residents things. She also got in a heated exchange when a resident was trying to get her out of her room . A behavior note, dated 01/28/21 at 10:41 p.m., documented, . residenering (sic) was up waundering (sic) frequently through out day . She does not like to be approached by staff . A behavior note, dated 02/02/21 at 10:03 p.m., documented, . found covered in fecal material. All over hand and sheets. She becomes easily agitated . A behavior note, dated 02/05/21 at 5:53 a.m., documented, . Up most of the night . going in and out of other resident's (sic) rooms. Resident difficult to redirect and becomes combative with staff hitting and kicking at them when being redirected. Staff has offered snacks and fluids and offered assistance with toileting and addressed pain . A behavior note, dated 02/12/21 at 5:50 a.m., documented, . was reported to me that pt (patient) when (sic) into another pt room and grab her wrist L (left) and cause pt to have 2 small scratches on her wrist . will cont (continue) to try and keep pt away from other pt . A behavior note, dated 02/15/21 at 8:53 p.m., documented, . remains easily irritated. Often goes into other residents room. She is also incont (incontinent) of bowel and bladder. She was spreading feeces (sic) all over facility . tried to strike out at staff . A behavior note, dated 02/21/21 at 9:52 a.m., documented, . went into another resident's room and sat in recliner . attempted to escort resident out of room resident became agitated . A behavior note, dated 02/24/21 at 4:43 a.m., documented, . noted to be finger painting and refusing care. Not allowing staff to change sheets or clean the mess. Fecal material covering walls in room and all over the bathroom . continues to roam the halls and attempts to enter other resident's rooms . hits and kicks at staff . A physician's orders [REDACTED]. A progress note, dated 02/25/21 at 3:16 p.m., documented, . care plan meeting requested at this time with family . A progress note, dated 03/01/21 at 10:31 a.m., documented, . spoke to (family member) regarding care plan meeting . will talk to his (family member) and call me back . A behavior note, dated 03/03/21 at 3:15 p.m., documented, . took luch (sic) that was spagetti (sic) and has all over her bed . A care plan meeting note, dated 03/05/21 at 10:50 a.m., documented, . Concerns: Memory care unit more appropriate for resident at this time . (family member) agreeable to finding alternate placement for resident at this time . A physician's orders [REDACTED]. Review of the clinical record revealed no documentation of one to one supervision for the resident from 01/01/21 through 03/09/21, as per physician's orders [REDACTED]. On 03/09/21 at 9:00 a.m., resident #3 was observed propelling herself from the 400 hall living room area to the dining and down the 400 hall. Her room was not on this part of the hall. Registered nurse (RN) #1 was on the hall. Resident #3 stopped near the entry to the room for resident #4. The resident's pants were pulled down to the mid thigh, and her incontinent brief was exposed. She did not have a Wanderguard on her ankle. At 9:06 a.m., resident #3 placed her right hand in her brief and began to pull the brief upward. At 9:09 a.m., resident #3 approached the door of resident #4. Resident #4 blew a [MEDICATION NAME], and resident #3 stopped. Using a firm tone, resident #4 told resident #3, Go back to your room. RN #1 approached the residents and asked resident #4 what the problem was. Resident #4 told her resident #3 was attempting to enter her room. RN #1 asked resident #3 if she wanted to go back to her room. RN #1 stated the resident needed to be cleaned up. At 10:35 a.m., it was reported the resident was in the shower because she had a bowel accident in the hallway and needed to be cleaned. At 11:50 a.m., the resident was observed in the hallway near her room. No staff were present. Throughout the rest of the day, the resident was observed on multiple occasions, propelling herself through the 400 halls and dining room with no staff present. On 03/10/21 at 11:01 a.m., the resident was observed lying on her bed. The resident's pants were stained, and the room smelled of urine. The clothes were the same the resident had worn on the previous day. At 12:23 p.m., she was observed in the dining room. She was wearing the same clothes. At 12:53 p.m., the resident was observed leaving the dining room and propelling towards her room. No staff were present. At 1:04 p.m., the resident was observed propelling to the dining room. She had a small Snickers candy bar with the wrapper on it. A staff member walked by and did not assist the resident with the candy bar. The resident then went back to her room, then left again, going on the part of 400 hall where resident #4 lived. On 03/11/21 at 8:51 a.m., resident #4, an alert and oriented resident, stated she was scared to death of resident #3. She stated the resident had been outside her door this morning. She stated, You never know what she is going to do. She could hit or kick you for no reason. The resident stated her family member brought her a [MEDICATION NAME], and she used it when she needed assistance because she could not get anyone to answer the call light. She stated she tried to talk firm to resident #3 and tried to keep her at a distance until help came. She stated a male nurse had to come into her room and got resident #3 off her couch the other night. The resident stated, (Resident #3) is very strong and you just never know when or where she will be. She reported the facility had a nurse aide stay with the resident for three days. She stated it was not an extra CNA (certified nurse aide), and that was taking away from all the other residents. The resident stated, (Resident #6) is very violent also and she wanders. I am very scared of her. She stated she had observed resident #6 hit, kick, and pinch an aide before. She stated resident #6 was more violent talking and she was more afraid of resident #3. She stated, You hear about nursing home abuse, but I feel like I'm living it. On 03/11/21 at 9:25 a.m., resident #7, an alert and oriented resident, stated she was scared of resident #3. She stated she did not want the resident in her room because she tried to hit people. On 03/11/21 at 9:33 a.m., resident #19, an alert and oriented resident, stated she was afraid of resident #3 because she had tried to slap her once. She stated resident #3 came into her room about six weeks ago and scattered cereal and pecans all over the floor. She stated resident #3 got on her bed and would not leave. She stated resident #3 told her she wanted this room and would get rid of her. Resident #19 stated she would give resident #3 something to get her to leave her room, and it worked most times, until that day. She stated, (Resident #3) does things like that to everyone. On 03/11/21 at 10:20 a.m., CNA #1 stated staff tried to redirect the resident out of other residents' rooms. She stated if the resident became aggressive, she would get the nurse. She stated she had witnessed resident #3 in the room of resident #6 approximately two months earlier. She stated resident #6 was pointing her finger at resident #3 and pacing the floor. She stated resident #3 got out of her wheelchair and was going towards resident #6. CNA #1 stated she got between the residents and stopped the situation from escalating. She stated she reported the incident to assistant director of nursing (ADON) #2. On 03/11/21 at 10:25 a.m., CMA #1 stated she had witnessed an incident between resident #3 and resident #6 on the previous day. She stated resident #3 had a bag of Snickers candy bars, and resident #6 stated resident #3 had stole them out of her room. CMA #1 stated she was trying to take resident #3 back to her room when resident #6 grabbed the arm of resident #3 to get the bag of Snickers. CMA #1 stated she did not report the incident to anyone. She stated she should have, but it was an ongoing thing with resident #3. She stated she had observed resident #3 going in others rooms, but not resident #6. On 03/11/21 at 10:32 a.m., CMA #2 stated they tried to redirect resident #3. She stated she would get the nurse, and if the nurse was unsuccessful, they would get the ADON. CMA #2 stated she had not received any education or inservices on how to deal with resident #3's behaviors. On 03/11/21 at 10:40 a.m., CNA #2 stated resident #3 had to be watched. She stated they tried to guide the resident out of other residents' rooms. She stated snacks worked best for redirecting the resident. She stated she had been given a piece of paper with information on behaviors as an inservice. On 03/11/21 at 10:41 a.m., RN #1 stated resident #3 went into other resident rooms. She stated the resident took things. She stated the resident had slapped her on the previous day. She stated she had no knowledge of the resident hitting or slapping other residents. She stated she was not aware of the incident between residents #3 and #6 on the previous day in relation to the Snickers candy bars. RN #1 stated resident #3 had been in the room of resident #6. She stated when she walked by the room, resident #3 was getting into resident #6's bed. She stated she went to get the resident out of the bed, and resident #3 slapped her at that time. RN #1 stated she left to get help from the CNA, and when she returned, they were able to get resident #3 out of the room. RN #1 stated the CNA was to try and separate the resident and then get help if they could not redirect the resident. She stated the CNAs were to report any actual incident, and the nurse would start an incident report. On 03/11/21 at 10:57 a.m., RN #1 stated she tried to do hourly checks on the resident. She stated it was like watching a toddler. On 03/11/21 at 11:20 a.m., the director of nursing (DON) stated the facility was trying to transfer the resident to some type of locked unit. She stated they had sent out referrals and had a meeting with the family. She stated they were trying to transfer the resident because she had a family member tell her the resident was wandering around. She stated that is when she found out resident #3 was going into other residents' rooms. She stated the resident would yell out and show aggression. She stated the resident had to be watched a lot when she was out on the floor. She stated she thought it was difficult to have her out with the other residents. The DON stated the aggression the resident was showing was yelling out. She stated she thought the resident had scratched someone on the arm. She stated the resident had the behavior of having feces on her hands. The DON stated the facility was protecting the other residents by monitoring the resident when she was out and about on the unit. She stated she thought all staff knew to monitor the resident. She stated the only physically aggressive incident she knew of was when the resident scratched another resident. The DON was asked how long they had been doing the same interventions for the resident's behaviors. She stated she would have to look at the dates. The DON stated she was not aware the resident had slapped a nurse on the previous day. She stated she did not know the resident had been involved in an incident with another resident on the previous day. She stated any incident should be reported to her. She stated staff had been instructed to monitor the resident and make sure she was not going into other rooms. She stated she knew resident #4 had a concern with the resident coming into her room, but she did not know if any other resident had concerns with it. She stated she had found out about resident #4's concern approximately a week and one-half earlier. The DON stated the resident's needs could not be met at the facility. She stated she had talked with the administrator about it during her first month of being at the facility. She stated she started work on 12/21/20. She stated monitoring was the changes she had made related to the resident's behaviors. She stated, I can't do one on one because we don't have the staff to do that here. She stated, I do not think this facility is where she needs to be. It isn't fair to her or the residents. She stated she did not know why contact was not made with the family before 02/25/21. She stated she knew they had talked about it a lot. She stated there were some phone calls made to the family, but they were not returned. She stated she did not send a letter to the family. She stated the issue had to go through the corporate offices. She stated it was not something she could just make happen. The DON stated she had not provided any education to staff related to behaviors. She stated she did not know what had been trained on before her arrival. On 03/15/21 at 2:00 p.m., the administrator was asked for the facility's policy related to supervision of residents. He reported there was no policy related to supervision. 2. On 03/09/21 at 5:10 a.m., there was no staff observed on the 400 hall of the facility. On 03/09/21 at 5:15 a.m., resident #1, an alert and oriented resident who resided in room [ROOM NUMBER], was heard saying, Help. The resident was sitting on the side of her bed, holding onto the grab bar. The resident stated, I had the call light on for quite a while. She stated she needed help to the rest room and to get up for the day. A red light was on where the resident's call light cord was attached to the wall. On 03/09/21 at 5:32 a.m., licensed practical nurse (LPN) #7 was observed in the dining room. She stated the call light system was a pager system. She stated the call light communication board at the nurses' station also showed what call lights were being paged. She stated the board showed rooms [ROOM NUMBER] had their call lights on. She started she was the nurse, and there had been a CMA and a CNA on the 300 and 400 halls on this shift for 56 residents. She stated she and the CMA both stayed over and worked the night shift. She stated the CMA was working as a CNA for the shift. LPN #7 did not have her call light pager on her. LPN #7 retrieved the pager from a basket on the nurses' desk. At 5:40 a.m., LPN #7 went to assist resident #1. No other staff had been observed at this time. On 03/09/21 at 5:48 a.m., CMA #5 was observed on the 300 hall with her medication cart. She stated she had worked last night. She was asked if she had her pager, and she stated yes, but she was not able to find it on the medication cart. She stated most nights there were two CNAs that work on the 300 and 400 halls. On 03/09/21 at 5:49 a.m., the call light communication board at the nurses' station behind the bistro was observed. The following was noted: ~ room [ROOM NUMBER] had pushed the call light at 5:29 a.m. The call had been re-paged three times; ~ room [ROOM NUMBER] had pushed the call light at 5:11 a.m. The call had been re-paged six times; ~ room [ROOM NUMBER] had pushed the call light at 4:57 a.m. The call had been re-paged nine times; and ~ room [ROOM NUMBER] had pushed the call light at 4:56 a.m. The call had been re-paged nine times. At 5:50 a.m., LPN #7 entered room [ROOM NUMBER]. She asked the resident if she was alright.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent resident to resident altercations for two (#3 and #6) of two residents reviewed for supervision. From 12/13/20 through 03/09/21, resident #3 had physical altercations with other residents that resulted in bruising, scratching, and hitting. Three residents expressed fear of physical aggression from resident #3. This had the potential to affect 50 residents who resided on the 300 and 400 halls. Findings: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, revised 08/23/20, documented the resident had a focus concern of impaired cognitive function related to [MEDICAL CONDITION]. The goal was the resident would be able to communicate her basic needs. Interventions included to monitor the resident for wandering and to check her Wanderguard for placement and functionality. Another focus concern was the resident had the potential to demonstrate physical behaviors such as kicking and hitting residents and staff. The goal was the resident would not harm herself or others. Interventions included to document behaviors and attempted interventions and to guide away from sources of distress. Another focus concern was the resident was a wanderer and this significantly intruded on the privacy of others. The goal was the resident's safety would be maintained. Interventions included to distract the resident from wandering by offering pleasant diversion, hourly safety checks, and a Wanderguard to her right ankle. A quarterly assessment, dated 11/12/20, documented the resident was severely impaired in cognitive skills for daily decision making. It was documented the resident required supervision for transfers and locomotion throughout the unit. It was documented the resident had physical symptoms directed to others, other behavioral symptoms not directed towards others, and wandering on one to three days during the previous seven days. It was documented the resident rejected care daily. A progress note, dated 11/26/20 at 1:12 p.m., documented, . redirect resident from other resident room. Resident will go into other resident room to take stuff, lay (sic) in their bed. Redirect resident to her room . A progress note, dated 12/08/20 at 5:59 p.m., documented, . she has refused to have her v/s (vital signs) taken gritting her teeth and slapping at this nurse . A progress note, dated 12/13/20 at 3:11 p.m., documented, . wandered over to 300 hall, approached another resident and forcefully grabbed her by the wrist, leaving a thumb shaped bruise. Resident was taken back to her room . A progress note, dated 12/15/20 at 3:13 p.m., documented, . Resident on hourly checks for aggressive behavior on 12/13/20 . Staff kept resident involved with diversional activities . A behavior note, dated 12/15/20 at 9:53 p.m., documented, . has been roaming up and down the hallways and going into other resident's (sic) rooms . She went in another resident's room and got on the toilet. She becomes very agitated and angry when staff tries to redirect her . An incident note, dated 12/16/20 at 10:54 a.m., documented, . Called to another resident (Resident #12) room. Resident stated, 'Another resident wheeled into his door, pulled back curtain. He asked her not to come in because this is not her room. Your room is down the hall way. Other resident continue to wheel up to me. Other resident stood up moved bedside table. Asked resident to leave again this is not your room. Other resident said, 'I don't have to do jack[***]' Other resident got blank stare then hit me on side of head, shoulder on RT (right) side. Then sat in her wheelchair and left room' . N/O (new order) obtain UA (urinalysis) with C&S (culture and sensitivity) . place on one hour checks . A behavior note, dated 12/16/20 at 12:46 p.m., documented, . wondering (sic) 300 and 400 hall in wheelchair. Stopping at resident doors. At times goes into rooms, has taken stuff from room. When staff redirects resident does come (sic) combative by attempting to hit and scratch at times. Staff assist with returning belongs (sic) . A quality manager progress note, dated 12/16/20 at 1:05 p.m., documented, . spoke with (family member) regarding resident's aggressive behavior . A physician's orders [REDACTED]. A behavior note, dated 12/17/20 at 11:54 a.m., documented, . Resident up in wheelchair self propelling about facility without incident. 1:1 (one to one) staff with resident today. Resident has attempted multiple times to go in other resident room but redirected by staff . A progress note, dated 12/17/20 at 3:16 p.m., documented, . Resident was pulling things off her wall, breaking objects, hitting and kicking staff refusing her medication, crying out and unable to verbalize wants or needs . 1:1 staff is unable to redirect her or calm her. Her (family member) wants her to have a mental health eval (evaluation) at the hospital. Resident was transferred . slapping, kicking . punched one of the female paramedics in the face and scratched her with her fingernail . An admission note, dated 12/31/20 at 7:45 p.m., documented the resident returned to the facility. A behavior note, dated 01/01/21 at 1:06 p.m., documented, . Self propelling about facility up and down halls. Continue going into other residents room. Resident always picks up stuff out of other resident room. staff returns to other residents. Other resident yelling for resident to get out of their rooms. Staff assist with redirecting resident . A behavior note, dated 01/13/21 at 9:07 p.m., documented, . noted to go in other residents rooms. On several occasions resident is noted in residents beds, has taken food out of residents rooms, took another residents wheelchair/walker . can be difficult to redirect. At times resident does become combative with staff . A behavior note, dated 01/14/21 at 12:50 p.m., documented, . went into another female resident room while she was in the bathroom on the toilet. They were yelling at each other. I went in and removed this resident and took her back to her room on the other hallway. Staff to monitor . A behavior note, dated 01/14/21 at 12:55 p.m., documented, . Late entry from 01/13/21, resident was found in a male resident room on the other hallway asleep in his bed. He was very upset and started yelling at her to get our his room. Staff to monitor . A behavior note, dated 01/14/21 at 1:54 p.m., documented, . raised her arm and threatened to slap another resident . was redirected by staff . will continue to monitor . A behavior note, dated 01/14/21 at 2:48 p.m., documented, . observed taking another resident's coloring materials from them. Resident asked this nurse to retrieve materials and remove resident from the area as she states she is afraid of resident (resident #3) because she hits . A behavior note, dated 01/14/21 at 11:27 p.m., documented, . found in another resident's room on another hall. Resident told (resident #3) this is not your room and she left . will continue to monitor . A progress note, dated 01/15/21 at 10:13 a.m., documented, . came onto 300 hall and took another resident breakfast from them and started eating it. I attempted to take her back to dinning (sic) area and she started hitting me and yelling curse words at me. I did notify the nurse for her hall and she was taken back to her hall . A behavior note, dated 01/19/21 at 1:32 p.m., documented, . is observed going into other residents room, she will lay (sic) in their beds, get into their clothes and carry them around. This nurse observed her eating food that other residents didn't eat after lunch, she was redirected but becomes combative, offered her more food of her own but she refuses, she is refusing her medications, she will throw them or hit at the CMA, unable to redirect. Giving her food helps with her behaviors at times if she likes the food given to her . A progress note, dated 01/21/21 at 1:41 p.m., documented, . has been up self propelling in wheelchair about facility without incident. has had to redirect multiple times throughout shift. Continue to go in other resident room and take other residents personal belongings . An incident note, dated 01/21/21 at 10:09 p.m., documented, . feel on buttocks in hall next to her room . appears she was trying to go to the restroom because her pants were pulled down to her knees . A behavior note, dated 01/25/21 at 1:19 p.m., documented, . resident up walking with wheelchair in hallway. Got end (sic) of hall dropped her pants, small bowel movement . A behavior note, date 01/25/21 at 6:28 p.m., documented, . Resident without walker or wheelchair, she would get upset if she was escorted to her chair. She attempted to strike another resident without cause, staff stopped . A behavior note, dated 01/27/21 at 7:33 a.m., documented, . Upon arriving to room noted whole room was flooded. Water going in bathroom. Had moved faucet to over counter instead of sink . A behavior note, dated 01/27/21 at 9:56 p.m., documented, . was found going through other residents things. She also got in a heated exchange when a resident was trying to get her out of her room . A behavior note, dated 01/28/21 at 10:41 p.m., documented, . residenering (sic) was up waundering (sic) frequently through out day . She does not like to be approached by staff . A behavior note, dated 02/02/21 at 10:03 p.m., documented, . found covered in fecal material. All over hand and sheets. She becomes easily agitated . A behavior note, dated 02/05/21 at 5:53 a.m., documented, . Up most of the night . going in and out of other resident's (sic) rooms. Resident difficult to redirect and becomes combative with staff hitting and kicking at them when being redirected. Staff has offered snacks and fluids and offered assistance with toileting and addressed pain . A behavior note, dated 02/12/21 at 5:50 a.m., documented, . was reported to me that pt (patient) when (sic) into another pt room and grab her wrist L (left) and cause pt to have 2 small scratches on her wrist . will cont to try and keep pt away from other pt . A behavior note, dated 02/15/21 at 8:53 p.m., documented, . remains easily irritated. Often goes into other residents room. She is also incont (incontinent) of bowel and bladder. She was spreading feeces (sic) all over facility . tried to strike out at staff . A behavior note, dated 02/21/21 at 9:52 a.m., documented, . went into another resident's room and sat in recliner . attempted to escort resident out of room resident became agitated . A behavior note, dated 02/24/21 at 4:43 a.m., documented, . noted to be finger painting and refusing care. Not allowing staff to change sheets or clean the mess. Fecal material covering walls in room and all over the bathroom . continues to roam the halls and attempts to enter other resident's rooms . hits and kicks at staff . A physician's orders [REDACTED]. A progress note, dated 02/25/21 at 3:16 p.m., documented, . care plan meeting requested at this time with family . A progress note, dated 03/01/21 at 10:31 a.m., documented, . spoke to (family member) regarding care plan meeting . will talk to his (family member) and call me back . A behavior note, dated 03/03/21 at 3:15 p.m., documented, . took luch (sic) that was spagetti (sic) and has all over her bed . A care plan meeting note, dated 03/05/21 at 10:50 a.m., documented, . Concerns: Memory care unit more appropriate for resident at this time . (family member) agreeable to finding alternate placement for resident at this time . A physician's orders [REDACTED]. Review of the clinical record revealed no documentation of one to one supervision for the resident from 01/01/21 through 03/09/21, as per physician's orders [REDACTED]. On 03/09/21 at 9:00 a.m., resident #3 was observed propelling herself from the 400 hall living room area to the dining and down the 400 hall. Her room was not on this part of the hall. RN #1 was on the hall. Resident #3 stopped near the entry to the room for resident #4. The resident's pants were pulled down to the mid thigh, and her incontinent brief was exposed. She did not have a Wanderguard on her ankle. At 9:06 a.m., resident #3 placed her right hand in her brief and began to pull the brief upward. At 9:09 a.m., resident #3 approached the door of resident #4. Resident #4 blew a [MEDICATION NAME], and resident #3 stopped. Using a firm tone, resident #4 told resident #3, Go back to your room. RN #1 approached the residents and asked resident #4 what the problem was. Resident #4 told her resident #3 was attempting to enter her room. RN #1 asked resident #3 if she wanted to go back to her room. RN #1 stated the resident needed to be cleaned up. At 10:35 a.m., it was reported the resident was in the shower because she had a bowel accident in the hallway and needed to be cleaned. At 11:50 a.m., the resident was observed in the hallway near her room. No staff were present. Throughout the rest of the day, the resident was observed on multiple occasions, propelling herself through the 400 halls and dining room with no staff present. On 03/10/21 at 11:01 a.m., the resident was observed lying on her bed. The resident's pants were stained, and the room smelled of urine. The clothes were the same the resident had worn on the previous day. At 12:23 p.m., she was observed in the dining room. She was wearing the same clothes. At 12:53 p.m., the resident was observed leaving the dining room and propelling towards her room. No staff were present. At 1:04 p.m., the resident was observed propelling to the dining room. She had a small Snickers candy bar with the wrapper on it. A staff member walked by and did not assist the resident with the candy bar. The resident then went back to her room, then left again, going on the part of 400 hall where resident #4 lived. On 03/11/21 at 8:51 a.m., resident #4, an alert and oriented resident, stated she was scared to death of resident #3. She stated the resident had been outside her door this morning. She stated, You never know what she is going to do. She could hit or kick you for no reason. The resident stated her family member brought her a [MEDICATION NAME], and she used it when she needed assistance because she could not get anyone to answer the call light. She stated she tried to talk firm to resident #3 and tried to keep her at a distance until help came. She stated a male nurse had to come into her room and get resident #3 off her couch the other night. The resident stated, (Resident #3) is very strong and you just never know when or where she will be. She reported the facility had a nurse aide stay with the resident for three days. She stated it was not an extra CNA and that was taking away from all the other residents. The resident stated, (Resident #6) is very violent also and she wanders. I am very scared of her. She stated she had observed resident #6 hit, kick, and pinch an aide before. She stated resident #6 was more violent talking and she was more afraid of resident #3. She stated, You hear about nursing home abuse, but I feel like I'm living it. On 03/11/21 at 9:25 a.m., resident #7, an alert and oriented resident, stated she was scared of resident #3. She stated she did not want the resident in her room because she tried to hit people. On 03/11/21 at 9:33 a.m., resident #19, an alert and oriented resident, stated she was afraid of resident #3 because she had tried to slap her once. She stated resident #3 came into her room about six weeks ago and scattered cereal and pecans all over the floor. She stated resident #3 got on her bed and would not leave. She stated resident #3 told her she wanted this room and would get rid of her. Resident #19 stated she would give resident #3 something to get her to leave her room, and it worked most times, until that day. She stated, (Resident #3) does things like that to everyone. On 03/11/21 at 10:20 a.m., certified nurse aide (CNA) #1 stated staff tried to redirect the resident out of other residents' rooms. She stated if the resident became aggressive, she would get the nurse. She stated she had witnessed resident #3 in the room of resident #6 approximately two months earlier. She stated resident #6 was pointing her finger at resident #3 and pacing the floor. She stated resident #3 got out of her wheelchair and was going towards resident #6. CNA #1 stated she got between the residents and stopped the situation from escalating. She stated she reported the incident to assistant director of nursing (ADON) #2. On 03/11/21 at 10:25 a.m., CMA #1 stated she had witnessed an incident between resident #3 and resident #6 on the previous day. She stated resident #3 had a bag of Snickers candy bars, and resident #6 stated resident #3 had stole them out of her room. CMA #1 stated she was trying to take resident #3 back to her room when resident #6 grabbed the arm of resident #3 to get the bag of Snickers. CMA #1 stated she did not report the incident to anyone. She stated she should have, but it was an ongoing thing with resident #3. She stated she had observed resident #3 going in others rooms, but not resident #6. On 03/11/21 at 10:32 a.m., CMA #2 stated they tried to redirect resident #3. She stated she would get the nurse, and if the nurse was unsuccessful, they would get the ADON. CMA #2 stated she had not received any education or inservices on how to deal with resident #3's behaviors. On 03/11/21 at 10:40 a.m., CNA #2 stated resident #3 had to be watched. She stated they tried to guide the resident out of other residents' rooms. She stated snacks worked best for redirecting the resident. She stated she had been given a piece of paper with information on behaviors as an inservice. On 03/11/21 at 10:41 a.m., RN #1 stated resident #3 went into other resident rooms. She stated the resident took things. She stated the resident had slapped her on the previous day. She stated she had no knowledge of the resident hitting or slapping other residents. She stated she was not aware of the incident between residents #3 and #6 on the previous day in relation to the Snickers candy bars. RN #1 stated resident #3 had been in the room of resident #6. She stated when she walked by the room, resident #3 was getting into resident #6's bed. She stated she went to get the resident out of the bed, and resident #3 slapped her at that time. RN #1 stated she left to get help from the CNA, and when she returned, they were able to get resident #3 out of the room. RN #1 stated the CNA was to try and separate the resident and then get help if they could not redirect the resident. She stated the CNAs were to report any actual incident, and the nurse would start an incident report. On 03/11/21 at 10:57 a.m., RN #1 stated she tried to do hourly checks on the resident. She stated it was like watching a toddler. On 03/11/21 at 11:20 a.m., the director of nursing (DON) stated the facility was trying to transfer the resident to some type of locked unit. She stated they had sent out referrals and had a meeting with the family. She stated they were trying to transfer the resident because she had a family member tell her the resident was wandering around. She stated that is when she found out resident #3 was going into other residents' rooms. She stated the resident would yell out and show aggression. She stated the resident had to be watched a lot when she was out on the floor. She stated she thought it was difficult to have her out with the other residents. The DON stated the aggression the resident was showing was yelling out. She stated she thought the resident had scratched someone on the arm. She stated the resident had the behavior of having feces on her hands. The DON stated the facility was protecting the other residents by monitoring the resident when she was out and about on the unit. She stated she thought all staff knew to monitor the resident. She stated the only physically aggressive incident she knew of was when the resident scratched another resident. The DON was asked how long they had been doing the same interventions for the resident's behaviors. She stated she would have to look at the dates. The DON stated she was not aware the resident had slapped a nurse on the previous day. She stated she did not know the resident had been involved in an incident with another resident on the previous day. She stated any incident should be reported to her. She stated staff had been instructed to monitor the resident and make sure she was not going into other rooms. She stated she knew resident #4 had a concern with the resident coming into her room, but she did not know if any other resident had concerns with it. She stated she had found out about resident #4's concern approximately a week and one-half earlier. The DON stated the resident's needs could not be met at the facility. She stated she had talked with the administrator about it during her first month of being at the facility. She stated she started work on 12/21/20. She stated monitoring was the change she had made related to the resident's behaviors. She stated, I can't do one on one because we don't have the staff to do that here. She stated, I do not think this facility is where she needs to be. It isn't fair to her or the residents. She stated she did not know why contact was not made with the family before 02/25/21. She stated she knew they had talked about it a lot. She stated there were some phone calls made to the family, but they were not returned. She stated she did not send a letter to the family. She stated the issue had to go through the corporate offices. She stated it was not something she could just make happen. The DON stated she had not provided any education to staff related to behaviors. She stated she did not know what had been trained on before her arrival. On 03/15/21 at 2:00 p.m., the administrator was asked for the facility's policy related to supervision of residents. He reported there was no policy related to supervision. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/22/21, documented the resident was mildly impaired in cognitive skills for daily decision making and required only supervision with ambulation. The resident's care plan, dated 02/15/21, documented a focus concern related to [MEDICAL CONDITION] medications. The goal was the resident would be free of drug related complications. Interventions included to monitor and record occurrences of target behavior symptoms, such as wandering, inappropriate responses to verbal communication, and violence or aggression towards staff and others. The care plan did not address supervision for the resident related to her behaviors. A behavior note, dated 02/26/21 at 9:55 p.m., documented, . Resident up in facility, cursing at everyone that walks by, paranoid speech, talking about killing people and going to get her knives, walking very close to other residents, pointing her plastic fork at their face, calling them '(expletives withheld)' . A behavior note, dated 03/04/21 at 5:37 p.m., documented, . Resident in hall this shift, pacing in and out of room, cursing at various staff, calling this SN (skilled nurse) a stupid incompetent nurse. Threatening to call the cops . stating there is a woman in 'there' with a baby that is on drugs. Following CNA to the spa room and banging on the door screaming she better let me in or I'm going to beat her 'ass.' Resident is not easy to redirect and only gets further agitated if you speak to her to try to redirect her in any way . On 03/11/21 at 8:51 a.m., resident #4, an alert and oriented resident, stated, (Resident #6) is very violent also and she wanders. I am very scared of her. She stated she had observed resident #6 hit, kick, and pinch an aide before. On 03/11/21 at 9:33 a.m., resident #19, an alert and oriented resident, stated she was afraid of resident #6. She stated she would come to her door and just stand. She stated she would give her something like candy if she had it so the resident would leave. She stated, She can be aggressive. On 03/11/21 at 10:20 a.m., CNA #1 stated she had witnessed resident #3 in the room of resident #6 approximately two months earlier. She stated resident #6 was pointing her finger at resident #3 and pacing the floor. She stated resident #3 got out of her wheelchair and was going towards resident #6. CNA #1 stated she got between the residents and stopped the situation from escalating. She stated she reported the incident to assistant director of nursing (ADON) #2. From 03/09/21 through 03/15/21, throughout the survey, the resident was observed on multiple occasions to be out of her room, on the hall with no supervision. On 03/15/21 at 1:35 p.m., the DON stated she was unaware of any supervision problems with resident #6.

Based on observation, interview, and record review, it was determined the facility failed to have sufficient staff to meet the needs of the residents. The failure to have adequate staff contributed to actual harm situations related to neglect, supervision to prevent resident to resident altercations, pain management, and pharmacy services. This had the potential to affect 89 of 89 residents who resided at the facility. Findings: 1. The facility failed to provide supervision to prevent resident to resident altercations for two (#3 and #6) of two resident reviewed for supervision. From 12/13/20 through 03/09/21, resident #3 had physical altercations with other residents that resulted in bruising, scratching, and hitting. Three residents expressed fear of physical aggression from resident #3. This had the potential to affect 50 residents who resided on the 300 and 400 halls. The findings at F-689 are incorporated here by reference. 2. On 03/09/21 at 5:03 a.m., upon entry to the facility, licensed practical nurse (LPN) #2 stated there were 26 residents on the 100 hall and 15 residents on the 200 hall. He stated he was in charge of the 100 and 200 halls. LPN #2 stated there was one aide assigned to each hall, certified nurse aides (CNA) #3 and #4. CNA #4 was assigned to the 100 hall, and CNA #3 was assigned to the 200 hall. At 5:15 a.m., CNAs #3 and #4 were observed providing care for the resident in room [ROOM NUMBER]. No other staff was observed on the 100 hall. CNA #4 stated the nurse was usually on the 200 hall and the aides switched back and forth. At 5:20 a.m., Resident #2, who resided on the 100 hall, was heard calling out, Pleases help me. The resident was observed to have her call light in her hand. The resident continued to call out, Help me, please, in Jesus' name, help me. At 5:22 a.m., the resident stated she needed to be taken to the bathroom. She stated she had pushed her call button. She stated she had been ringing it for a long time, over an hour. She stated, If I don't get help, I'm gonna wet the bed. She stated she did not want to do that. She stated it was terrible when you wet the bed and had to lie in it. At 5:24 a.m., the surveyor requested the resident push the call button again. From 5:24 a.m. until 5:42 a.m., the resident continued to call out for assistance. At 5:42 a.m., LPN #2 was observed to enter the resident's room and close the door. On 03/10/21 at 3:20 p.m., resident #2 stated it took a while to answer call lights. She stated she felt like sometimes the facility needed more help. She stated if she felt the urge to go to the bathroom, she would go ahead and push the call light right then because she knew it took a while to get help. 3. On 03/09/21 at 5:10 a.m., there was no staff observed on the 400 hall of the facility. On 03/09/21 at 5:15 a.m., resident #1, an alert and oriented resident who resided in room [ROOM NUMBER], was heard saying, Help. The resident was sitting on the side of her bed, holding onto the grab bar. The resident stated, I had the call light on for quite a while. She stated she needed help to the rest room and to get up for the day. A red light was on where the resident's call light cord was attached to the wall. On 03/09/21 at 5:32 a.m., licensed practical nurse (LPN) #7 was observed in the dining room. She stated the call light system was a pager system. She stated the call light communication board at the nurses' station also showed what call lights were being paged. She stated the board showed rooms [ROOM NUMBER] had their call lights on. She started she was the nurse, and there was a CMA and a CNA on the 300 and 400 halls on this shift for 56 residents. She stated she and the CMA both stayed over and worked the night shift. She stated the CMA was working as a CNA for the shift. LPN #7 did not have her call light pager on her. LPN #7 retrieved the pager from a basket on the nurses' desk. At 5:40 a.m., LPN #7 went to assist resident #1. No other staff had been observed at this time. On 03/09/21 at 5:48 a.m., CMA #5 was observed on the 300 hall with her medication cart. She stated she had worked last night. She was asked if she had her pager, and she stated yes, but she was not able to find it on the medication cart. She stated most nights there were two CNAs that work on the 300 and 400 halls. On 03/09/21 at 5:49 a.m., the call light communication board at the nurses' station behind the bistro was observed. The following was noted: ~ room [ROOM NUMBER] had pushed the call light at 5:29 a.m. The call had been re-paged three times; ~ room [ROOM NUMBER] had pushed the call light at 5:11 a.m. The call had been re-paged six times; ~ room [ROOM NUMBER] had pushed the call light at 4:57 a.m. The call had been re-paged nine times; and ~ room [ROOM NUMBER] had pushed the call light at 4:56 a.m. The call had been re-paged nine times. At 5:50 a.m., LPN #7 entered room [ROOM NUMBER]. She asked the resident if she was alright. The facility identified 42 resident on the 300 and 400 halls who were able to use their call lights. 4. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A progress note, dated 10/31/20 at 10:55 a.m., documented, . Medications verified and clarified through physician. MAR (medication administration record) updated. Resident received all morning meds. PRN (as needed) [MEDICATION NAME] on order from pharmacy pending order clarification . A nurse's note, dated 10/31/20 at 1:50 p.m., documented, . Family with complaints in regards to care provided during brief stay to facility. Resident family has decided to take resident from facility and utilized (sic) home health . On 03/10/21 at 12:49 p.m., an electronic document was provided by the resident's family member. It was documented, . October 30, 2020 8:51 p.m. (resident #8) called me to let me know that she had been settled in her room at The Springs. She did tell me that when she advised her nurse that she had not had any medications before being transported from (hospital name withheld). The nurse told her that 'she didn't have any orders for medications'. I told (resident #8) to give the nurse a little bit to get things in the computer and to have the nurse call me so that we could discuss (resident #8)'s medications . October 31, 2020 8:13 a.m. I called (resident #8). She said that she never received her night time medicines from the night before nor her morning meds. She said that her heart was beating very fast and that she had not slept but 30 minutes. She also said that she had set (sic) on a bed pan for an extended period of time and that she had called the nurses station several times asking them to remove it but that no one ever came. She said that she removed it herself. I told her that I would call The Springs and talk to her nurse. 8:16 a.m. I called The Springs two times and the phone just rang . No one ever answered . 8:25 a.m. (Resident #8)'s nurse from The Springs returned my call. I do not remember her name but she told me that 'she had an IV on another patient that she was working on putting in' and then she assured me 'that (resident #8) was next on her list.' She apologized that the medications had not been put into the system the night before and said that she didn't know why it had happened . 9:51 a.m. I called (resident #8) to check in. She still had not had any medications and also had not had any breakfast. She said that her heart was racing and felt like it was going to 'beat out of her chest' . 10:27 a.m. (Physician name withheld) called and said he spoke to someone at The Springs . He said he was told that they were giving (resident #8) her medication 'as soon as we speak' . 11:57 a.m. (Resident #8) called and said that she had finally received her medications . In review: (Resident #8) asked for her medication 3-5 times throughout the night of 10/30 to which the reply from the nurse was always 'they are putting it in the computer and it will be a few minutes.' Her pain level reached an eight (8) on the pain level scale (scale of zero to 10). Her last pain medication had been at 7:35 p.m. on 10/30 at (hospital name withheld) before transportation to The Springs. She stated that when she would press the nurses' button, it would take between 30-45 minutes before they would respond to (resident #8)'s room. On one occasion, she had the bed pan under her and she pressed the red button, after 15 minutes of waiting on a nurse, she removed the bed pan herself. When the nurse finally responded (approximately 30 minutes after the button was pushed) (resident #8) requested that they leave the bed pan next to her bed and she would take care of her own bathroom needs . 5. The facility failed to provide physician ordered medications for one (#8) of three sampled residents whose medications were reviewed and document the administration of medications per nursing standards of practice for one (#4) of three sampled residents whose medications were reviewed. The facility identified 86 residents as receiving medications. The findings at F-755 are incorporated here by reference. 6. On 03/09/21 at 7:28 a.m., resident #4, an alert and oriented resident who resided on the 400 hall, stated, We didn't have an aide last night; a CMA was working both halls. She stated, I got help one time last night after the call light was on 45 minutes. She stated, I don't know why they have the call lights because they won't answer them. On 03/15/21 at 10:56 a.m., resident #4 stated there was one CNA for the day so that meant no showers would be given. The resident stated she used her call light on 03/13/21 after wetting her bed. She stated she waited an hour for someone to come. She stated the nurse finally came and helped her change her clothes and her bed. Staffing sheets, dated 03/15/21 for the day shift, documented there was one nurse, one CMA and one CNA assigned to the 400 hall for 21 residents. 7. On 03/09/21 at 9:17 a.m., Resident #14, and alert and oriented resident, stated it took about an hour for call lights to be answered. She stated approximately two or three weeks ago, she had slipped from her recliner. She stated she crawled to the bathroom and pull the call cord. She stated staff did not come. She stated she was able to pull herself up using the grab bars in the bathroom and managed to get herself back to her recliner. She stated she was already back in her recliner when staff finally came to the room. 8. On 03/09/21 at 7:45 a.m., Resident #15, an alert and oriented resident, stated, Sometimes at night they don't answer the call light. She stated, They don't even come or I've forgot what I wanted before they come. She stated she was usually needing something to drink when she used the call light. 9. On 03/10/21 at 8:38 a.m., Resident #16, an alert and oriented resident, stated sometimes it took 45 minutes for staff to answer the call light. He stated it was worse at night. He stated he had messed the bed waiting on staff to come. 10. On 03/11/21 at 9:04 am, resident #25, an alert and oriented resident, stated it took from one and one-half hours to two hours for staff to answer his call light. 11. On 03/11/21 at 9:12 am, resident #27, an alert and oriented resident, stated there had been times it took over an hour for her call light to be answered. 12. On 03/15/21 at 10:06 a.m., assistant director of nursing (ADON) #1 stated he was in charge of staffing. He stated the facility staffed to or exceeded the nurse staffing ratios in the Oklahoma State Nursing Care Act. He stated, We staff above that. He stated they used PPD or personnel per day. He stated they looked at the census and there was a formula to go by. He stated it was above the minimums. ADON #1 stated the facility ensured there was enough staff to meet the residents needs by looking at the census daily and by shift. He stated depending on fluctuations in residents, they could move staff. He stated they looked at acuity as well. He stated they looked at the number of skilled residents, and if there were more skilled residents, they would need more staff. On 03/15/21 at 12:30 p.m., the administrator and director of nursing (DON) were interviewed. The administrator stated there was not a visual path between the 300 and 400 halls nor for the 100 and 200 halls. He stated the call light communication boards for each hall were located at the respective nursing desks and they could not be seen from the halls themselves. He stated staff would know call lights were ringing because the calls went to the paging system. He stated each staff had a pager. He stated staff should always have their pager on. He stated staff would not know if a call light was going off if they did not have their pager with them. He stated staff should always have their pager with them. He stated the paging system was specific to each hall, but all call lights throughout the facility showed on each call light communication board. The administrator stated each hall operated on as a stand-alone unit. He stated sounds from the 300/400 halls and 100/200 halls could not be heard on the other halls. The administrator stated he monitored to ensure call lights were answered in a timely manner by making random audits. He stated he would go down to a room, ring the call light, and wait for staff to show up. He stated concerns related to answering call lights timely would come up from time to time. He stated when they did, he would do his own audit, and staff did not go over 15 minutes in answering a call light. The administrator was asked if he had identified a concern related to staffing. He stated he never felt it was a concern to the extent it was affecting patient care. He was asked if there was enough staff to meet the needs of resident #3. He stated there would not be any one monitoring her if the two CNA/CMAs assigned on night shift were providing care and the nurse was on the other hall.

Based on interview and record review, it was determined the facility failed to: ~ provide physician ordered medications for one (#8) of three sampled residents whose medications were reviewed. Resident #8 suffered a femur fracture with subsequent surgical repair, and while at the facility, experienced pain of eight out of 10, on a zero to 10 scale, and was not provided any pain medication; and ~ document the administration of medications per nursing standards of practice for one (#4) of three sampled residents whose medications were reviewed. The facility identified 86 residents as receiving medications. Findings: The facility's policy on medication ordering and receiving, revised 12/01/12, documented, . Medications and related products are received from the provider pharmacy on a timely basis . New medications . If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery . Timely delivery of new orders is required to that (sic) medication administration is not delayed . Nurse.com Blog. 2021. Understanding the basics of medication administration. (online) Available at: <https://www.nurse.com/blog/2015/12/16/understanding-the-basics-of-medication-administration/> (Accessed 19 March 2021) documented, . the nurse . is also responsible for the proper, accurate and truthful documentation of the medication administered. This responsibility speaks to a nurse's accountability when preparing, administering and documenting medications given . 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital discharge orders, dated 10/30/20, documented the resident was to receive medications including: ~ Atorvastatin (a high cholesterol medication) 80 milligrams (mg) one tablet nightly; ~ [MEDICATION NAME] (a medication used for [MEDICAL CONDITION]) 15 microgram (mcg)/2 milliliters (ml) via nebulizer twice daily, morning and night; ~ [MEDICATION NAME]-aetaminophen ([MEDICATION NAME], a pain medication) 7.5 mg/325 mg one tablet every six hours as needed for pain; ~ [MEDICATION NAME] (a cardiac medication) 30 mg twice daily, morning and night; ~ [MEDICATION NAME] 0.01% ophthalmic solution (a [MEDICAL CONDITION] medication) one drop every night to the left eye; ~ [MEDICATION NAME] (a cardiac medication) 50 mg twice daily, morning and night; ~ Quetiapine (an anti-psychotic medication) 50 mg every night; ~ Ranolazine (a cardiac medication) 500 mg twice daily, morning and night; and ~ [MEDICATION NAME] (an anti-depressant) 50 mg every night. A facility admission note, dated 10/30/20 at 9:34 p.m., documented, . focused assessment r/t (related to) new admit . is here for therapy r/t right femur fx (fracture) . Dr (doctor) notified orders verified and clarified . Medication administration records (MARs), dated 10/30/20, contained no documentation to show the resident received any of the above medications for the night time dose on 10/30/21; including any as needed pain medication. A progress note, dated 10/31/20 at 10:55 a.m., documented, . Medications verified and clarified through physician. MAR updated. Resident received all morning meds. PRN (as needed) [MEDICATION NAME] on order from pharmacy pending order clarification . A nurse's note, dated 10/31/20 at 1:50 p.m., documented, . Family with complaints in regards to care provided during brief stay to facility. Resident family has decided to take resident from facility and utilized (sic) home health . On 03/10/21 at 12:49 p.m., an electronic document was provided by the resident's family member. It was documented, . October 30, 2020 8:51 p.m. (resident #8) called me to let me know that she had been settled in her room at The Springs. She did tell me that when she advised her nurse that she had not had any medications before being transported from (hospital name withheld). The nurse told her that 'she didn't have any orders for medications.' I told (resident #8) to give the nurse a little bit to get things in the computer . October 31, 2020 8:13 a.m. I called (resident #8). She said that she never received her night time medicines from the night before nor her morning meds. She said that her heart was beating very fast and that she had not slept but 30 minutes . I told her that I would call The Springs and talk to her nurse. 8:16 a.m. I called The Springs two times and the phone just rang . No one ever answered. I then called (physician name withheld)'s office (the surgeon who performed (resident #8) surgery). It was a Saturday so the office was closed but I was connected to the (hospital name withheld) desk. I told the (hospital name withheld) operator my concerns about (resident #8) not receiving her medications and that I would like to talk to (physician name withheld). She suggested allowing her to try and reach The Springs. 8:23 a.m. The operator from (hospital name withheld) called and said that she was able to get through to The Springs and that (resident #8)'s nurse would be calling me . 8:25 a.m. (Resident #8)'s nurse from The Springs returned my call . She apologized that the medications had not been put into the system the night before and said that she didn't know why it had happened . 8:27 a.m. I called (resident #8) back and told her that the nurse should be in soon and I would give her about an hour and check back in. 9:51 a.m. I called (resident #8) to check in. She still had not had any medications . She said that her heart was racing and felt like it was going to 'beat out of her chest.' 9:51 a.m. I called (hospital name withheld) desk and told the operator that I wanted to speak with (physician name withheld). 10:22 a.m. (Physician name withheld) called. I told him exactly what was going on with (resident #8) not receiving any medications since she had arrived at The Springs the night before. I talked to him concerning her medical conditions that require medications on time, including that she had not had any pain medication from her leg fracture surgery on the previous Tuesday. He said that although he was not her attending physician, or the one who discharged her, he would contact The Springs for us to see what he could do . 10:27 a.m. (Physician name withheld) called and said he spoke to someone at The Springs . He said he was told that they were giving (resident #8) her medication 'as soon as we speak.' 11:28 a.m. (Resident #8) called and said that she still had not received her medications but the nurse had come to take her blood pressure and said that 'it was high.' (Resident #8) stated, 'I'm afraid that I am going to have a stroke.' I told her that I was waiting on a call from the Director of The Springs. 11:39 a.m. (Director of Nursing (DON) #2), the Director from The Springs called me. I told him all of the above information . He . did state 'I have just been back there and they have assured me that (resident #8) has had her medications.' My reply was, 'so are you saying that (resident #8) is lying to me?' He said, 'I will go back there when we get off of the phone and make sure' . 11:57 a.m. (Resident #8) called and said that she had finally received her medications . 1:25 p.m. We arrived to pick (resident #8) up from the facility . I had to sign that (resident #8) was leaving 'AMA (against medical advice)' . we are removing the patient because she has not received any medications since arriving the night before . The nurse . apologized and said 'I'm sorry, this should have never happened.' She also said that because (resident #8) was leaving 'AMA' she could not give me any of her medications. In review: (Resident #8) asked for her medication 3-5 times throughout the night of 10/30 to which the reply from the nurse was always 'they are putting it in the computer and it will be a few minutes.' Her pain level reached an eight (8) on the pain level scale (scale of zero to 10). Her last pain medication had been at 7:35 p.m. on 10/30 at (hospital name withheld) before transportation to The Springs . On 03/10/21 at 3:52 p.m., the admissions coordinator stated the facility was supposed to receive hospital records, including discharge orders, before a new resident came to the facility. She stated those orders were scanned and sent to the facility's pharmacy. She stated any medications that were ordered would be delivered in the evening. At 4:08 p.m., the admissions coordinator stated the pharmacy had received the orders for resident #8's medications on 10/30/20 at 2:51 p.m. She stated the pharmacy had received an electronic prescription for the resident's [MEDICATION NAME] on 10/31/20 at 3:46 p.m. On 03/11/21 at 2:35 p.m., licensed practical nurse (LPN) #2 stated when a resident was admitted to the facility, the medications were entered into the computer system, and then they were delivered to the facility. She stated medications were not typically at the facility before a resident arrived. She stated if a resident came around midnight, their medications would not come until the next day. She stated if the medications did not come, they could call the on call physician and get orders for a medication that was needed immediately. She stated the facility did have an emergency medication kit, and she believed there were pain medications in the emergency kit. She stated she did not know if there was an emergency pharmacy or local pharmacy used by the facility. On 03/11/21 at 3:48 p.m., the regional nurse consultant stated that in a perfect situation the facility would have a new resident's discharge orders before the resident came to the facility. He stated he did not know if they had the discharge orders for resident #8. The regional nurse consultant stated he could not tell from the documentation when the resident's medications arrived at the facility. He stated the resident did have orders for a [MEDICATION NAME] 7.5 mg/325 mg tablet every six hours for pain, but the resident did not receive any pain medication while at the facility. He stated according to the hospital documents, the resident last received pain medication on 10/30/20 at 1:54 p.m. and had gone approximately 23 hours without pain medication before leaving the facility. The regional nurse consultant stated staff should have requested a first dose of all medications from the local pharmacy. He stated staff should have repeatedly called the physician as necessary in order to get the resident's medications. He stated there was no documentation they did that. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order, dated 10/29/20, documented [MEDICATION NAME], an anti-anxiety medication, 1 mg was to be given every eight hours as needed for anxiety disorder. The resident's narcotic record, dated 01/29/21, documented the times on this day the resident received her [MEDICATION NAME]. One of the times on this day had been marked out and was not legible. Another documented time of administration was 2:46 p.m.; however, the resident's Medication Administration Record [REDACTED]. On 03/15/21 at 10:20 a.m., registered nurse (RN) #1 stated she documented on the narcotic sheet on 01/29/21 at 2:46 p.m. and administered the medication to the resident. She stated she asked the certified medication aide to sign for the medication on the MAR. She stated the CMA signed the MAR indicated [REDACTED]. She stated she did not normally ask the CMA to document when she gave a medication, but the facility was short-staffed. She stated she should have signed off the MAR indicated [REDACTED].

Based on interview and record review, it was determined the facility failed to provide pain management for one (#8) of three sampled residents who were reviewed for pain. The resident had suffered a femur fracture with subsequent surgical repair, and while at the facility, experienced pain of eight out of 10, on a zero to 10 scale, and was not provided any pain medication. The facility identified 26 residents as having pain concerns. Findings: The facility's policy and procedure on pain, revised 09/10/07, documented, . An individualized pain assessment is a vital first step in pain management . Failure to properly assess pain can lead to its under-treatment . Pain complaints may be screened by a licensed practical nurse . Pain should be assessed in all residents . Admission screenings of pain will be done by a licensed nurse and documented . Initiate discussions about pain with the residents . Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital discharge orders, dated 10/30/20, documented the resident was to receive [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 7.5 milligrams (mg)/325 mg one tablet every six hours as needed for pain. It was documented the resident last received the pain medication at 1:54 p.m. on 10/30/20, before leaving the hospital. A facility admission note, dated 10/30/20 at 9:34 p.m., documented, . focused assessment r/t (related to) new admit . is here for therapy r/t right femur fx (fracture) . Dr (doctor) notified orders verified and clarified, resident in bed call light within reach . A progress note, dated 10/31/20 at 10:55 a.m., documented, . Medications verified and clarified through physician. MAR (medication administration record) updated. Resident received all morning meds. PRN (as needed) [MEDICATION NAME] on order from pharmacy pending order clarification . A nurse's note, dated 10/31/20 at 1:50 p.m., documented, . Family with complaints in regards to care provided during brief stay to facility. Resident family has decided to take resident from facility and utilized (sic) home health . Review of the resident's clinical record revealed no documentation a pain screening or pain assessment was completed for the resident. There was no documentation the resident received any pain medication during her stay at the facility. There was no documentation related to pain. On 03/10/21 at 12:49 p.m., an electronic document was provided by the resident's family member. It was documented, . October 30, 2020 8:51 p.m. (resident #8) called me to let me know that she had been settled in her room at The Springs. She did tell me that when she advised her nurse that she had not had any medications before being transported from (hospital name withheld). The nurse told her that 'she didn't have any orders for medications'. I told (resident #8) to give the nurse a little bit to get things in the computer . October 31, 2020 8:13 a.m. I called (resident #8). She said that she never received her night time medicines from the night before nor her morning meds. She said that her heart was beating very fast and that she had not slept but 30 minutes . 8:16 a.m. I called The Springs two times and the phone just rang . No one ever answered. I then called (physician name withheld)'s office (the surgeon who performed (resident #8) surgery). It was a Saturday so the office was closed but I was connected to the (hospital name withheld) desk. I told the (hospital name withheld) operator my concerns about (resident #8) not receiving her medications and that I would like to talk to (physician name withheld). She suggested allowing her to try and reach The Springs. 8:23 a.m. The operator from (hospital name withheld) called and said that she was able to get through to The Springs and that (resident #8)'s nurse would be calling me . 8:25 a.m. (Resident #8)'s nurse from The Springs returned my call. I do not remember her name but she told me that 'she had an IV on another patient that she was working on putting in' and then she assured me 'that (resident #8) was next on her list.' She apologized that the medications had not been put into the system the night before and said that she didn't know why it had happened . 9:51 a.m. I called (resident #8) to check in. She still had not had any medications . She said that her heart was racing and felt like it was going to 'beat out of her chest' . 10:22 a.m. (Physician name withheld) called. I told him exactly what was going on with (resident #8) not receiving any medications since she had arrived at The Springs the night before. I talked to him concerning her medical conditions that require medications on time, including that she had not had any pain medication from her leg fracture surgery on the previous Tuesday . 10:27 a.m. (Physician name withheld) called and said he spoke to someone at The Springs . He said he was told that they were giving (resident #8) her medication 'as soon as we speak' . 11:28 a.m. (Resident #8) called and said that she still had not received her medications . In review: (Resident #8) asked for her medication 3-5 times throughout the night of 10/30 to which the reply from the nurse was always 'they are putting it in the computer and it will be a few minutes.' Her pain level reached an eight (8) on the pain level scale (scale of zero to 10). Her last pain medication had been at 7:35 p.m. on 10/30 at (hospital name withheld) before transportation to The Springs . On 03/10/21 at 3:52 p.m., the admissions coordinator stated the facility was supposed to receive hospital records, including discharge orders, before a new resident came to the facility. She stated those orders were scanned and sent to the facility's pharmacy. She stated any medications that were ordered would be delivered in the evening. At 4:08 p.m., the admissions coordinator stated the pharmacy had received the orders for resident #8's medications on 10/30/20 at 2:51 p.m. She stated the pharmacy had received an electronic prescription for the resident's [MEDICATION NAME] on 10/31/20 at 3:46 p.m. On 03/11/21 at 2:35 p.m., licensed practical nurse (LPN) #2 stated when a resident was admitted to the facility, the medications were entered into the computer system, and then they were delivered to the facility. She stated medications were not typically at the facility before a resident arrived. She stated if a resident came around midnight, their medications would not come until the next day. She stated if the medications did not come, they could call the on call physician and get orders for a medication that was needed immediately. She stated the facility did have an emergency medication kit, and she believed there were pain medications in the emergency kit. She stated she did not know if there was an emergency pharmacy or local pharmacy used by the facility. LPN #2 stated when a resident was admitted , there were specific assessments to be completed, including a pain assessment. On 03/11/21 at 3:48 p.m., the regional nurse consultant stated that in a perfect situation the facility would have a new resident's discharge orders before the resident came to the facility. He stated he did not know if they had received the discharge orders for resident #8 before her arrival. The regional nurse consultant reviewed the resident's clinical record and stated no pain screening or assessment had been completed for the resident. He stated his expectation was for at least a licensed practical nurse pain screening to be completed. He stated there was no documentation in the clinical record related to pain. The regional nurse consultant stated he could not tell from the documentation when the resident's medications arrived at the facility. He stated the resident did have orders for a [MEDICATION NAME] 7.5 mg/325 mg tablet every six hours for pain, but the resident did not receive any pain medication while at the facility. He stated according to the hospital documents, the resident last received pain medication on 10/30/20 at 1:54 p.m., and she had gone approximately 23 hours without pain medication before leaving the facility. The regional nurse consultant stated staff should have requested a first dose of all medications from the local pharmacy. He stated staff should have repeatedly called the physician as necessary in order to get the resident's medications. He stated there was no documentation they did that.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent accidents for one (#300) of three sampled residents reviewed for falls. The facility failed to: a) Thoroughly investigate falls to determine root causes of falls. b) Determine frequency of needed supervision to prevent falls. c) Modify/revise interventions and/or update care plans as necessary to prevent falls. d) Monitor effectiveness of interventions to prevent falls. The resident sustained [REDACTED]. The resident sustained [REDACTED]. The resident complained of hip pain and was sent to the emergency room . The hospital emergency room record, dated 06/14/18, documented the resident had a fractured pelvic with internal bleeding, two left rib fractures, and a left frontal scalp hematoma/laceration. The facility identified 29 residents had falls in the last two months. Findings: The facility policy for the fall prevention documented fall assessments would be completed on all admissions, falls, and significant changes. The policy did not document a specific process to determine the underlying cause of a fall. Resident #300 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall assessment, dated 01/16/18, documented the resident scored 75 indicating the resident was a high fall risk. The care plan, dated 01/16/18, documented the resident was at a risk for falls and fractures. The care plan documented the interventions in place were for staff to keep the call light within reach and answer the resident quickly. The care plan documented the staff were to place an alarm on the residents bed, chair, and to place a fall mat next to resident's bed. The care plan documented the staff were to ensure the resident wore proper footwear and to follow the fall protocol. An incident report, dated 01/20/18, documented the resident was found lying on the floor in a different room. The incident report documented the resident had an injury to the top of her scalp and was sent to the emergency room . The report documented the facility notified the physician, family, and the director of nurses (DON). The facility was not able to provide a completed fall investigation to determine the cause of the fall. The care plan was not updated with a new intervention to prevent falls. An incident report, dated 02/10/18, documented the resident had a fall while being assisted to the bathroom. The report documented the resident slipped, fell on the fall mat, and did not sustain an injury. The report documented the facility notified the physician, family, and the DON. The facility was not able to provide a completed fall investigation to determine the cause of the fall. The care plan documented a repeated intervention. A fall risk assessment, dated 02/10/18, documented the resident scored 80 indicating the resident was a high fall risk. The 14 day assessment, dated 02/22/18, documented the resident was severely impaired for daily decision making. The assessment documented the resident required limited assistance for transfers, walking, dressing, toileting, and hygiene. The assessment documented the resident required a wheelchair for mobility. The assessment did not document the resident had a fall in the last 30 days. The assessment documented the resident was receiving a diuretic. An incident report, dated 03/26/18, documented the resident slipped while being assisted with dressing and was assisted to the floor. The report documented the resident had a small skin tear on her left arm. The report documented the facility notified the physician, administrator, DON, and the unit manager. The facility was not able to provide a completed fall investigation to determine the cause of the fall. The care plan was updated with the new intervention of placing non-skid strips under the fall mat for this fall. A fall risk assessment, dated 04/30/18, documented the resident scored 90 indicating the resident was a high fall risk. An incident report, dated 05/11/18, documented the resident was ambulating in the hallway and fell . The report documented the resident had two hematomas to her left rib and the resident was sent to the emergency room . The report documented the facility notified the physician, family, unit manager, and the DON. The report documented an investigation was completed and the cause of the fall was the resident's loss of balance. The report documented the resident sustained [REDACTED]. A nurse progress note, dated 05/11/18, documented the resident was ambulating in the hallway, turned, grabbed her lower back, lost her balance, and fell into the corner of the wall. The note documented the nurse heard the bed alarm sounding, went to check on the resident, and witnessed the fall. The note documented the resident stated she was looking for her bed. The note documented the resident had two hematomas immediately appear on her left rib cage. The report documented the resident was sent to the emergency room . A fall risk assessment, dated 05/14/18, documented the resident scored 90 and was still a high risk for falls. The physician orders [REDACTED]. An incident report, dated 06/05/18, documented the resident was found on the floor, the wheelchair was turned over, and the resident had a small skin tear on her left hand. The report documented the resident complained of right hip pain. The report documented the facility notified the DON, family, and physician. The report documented the resident was sent to the emergency room . The facility was not able to provide a completed investigation to determine the cause of the fall. The care plan did not document a new intervention to prevent falls. An incident report, dated 06/14/18, documented the resident was found on the floor near her bed. The report documented the resident had a laceration on her left hand and swelling to her forehead. The report documented the resident complained of hip pain. The report documented the resident was sent to the emergency room . The report documented the facility notified the physician, DON, family and the administrator. The report documented an investigation was completed. The report documented the resident did not use her call light as the cause of the fall. Nurse progress notes, dated 06/14/18, documented the CNA found the resident lying on the floor of the resident's room. The notes documented the resident was bleeding from her head and left hand. The notes documented the resident was complaining of hip pain. The notes documented the resident was sent to the emergency room . The hospital emergency department records, dated 06/14/18, documented the resident was admitted to the hospital. The CT reports, dated 06/14/18, documented the resident had a fractured pelvic, internal bleeding, two left rib fractures, and a left frontal scalp hematoma/laceration. The records documented the resident's forehead was sutured. On 09/26/18 at 12:35 PM, the DON was interviewed regarding falls for (MONTH) through (MONTH) (YEAR). The DON stated the she did not have documentation regarding an investigation for falls occurring at that time. On 09/26/18 at 1:10 PM, the DON was interviewed regarding the fall for 05/14/18. The DON stated she was not working at the facility on that date so she was not sure if an investigation was completed. On 09/26/18 at 1:20 PM, the DON was interviewed regarding the fall on 06/05/18. The DON stated the resident was sent the emergency room and an investigation was not completed. On 09/26/18 at 3:00 PM, the nurse who was on duty the night of the 06/14/18 was interviewed by telephone. The nurse stated she did not see the resident fall. The nurse stated she heard the CNA yell for assistance. The nurse stated when she went to the resident's room, the resident was observed lying on her left side on the floor facing the bed. The nurse stated the resident was bleeding from the left side of her face. The nurse stated emergency medical service (EMS) was notified.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent accidents for one (#3) of three sampled residents who were reviewed for falls. The facility failed to consistently identify and implement interventions to aid in the prevention of falls for resident #3. Resident #3 had a history of [REDACTED]. The resident had four head injuries, an elbow fracture, and multiple skin tears. The facility identified 34 residents with falls in the last three months. Findings: The facility policy for falls documented the facility would evaluate the residents fall risk factors, reassess the resident, and implement new intervention on the care plan after each fall. The policy documented a resident with a score of 25 or above on the fall risk assessment would be placed on the falling star program. The policy documented the resident would have a new fall assessment and a new pain assessment after each fall. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 03/16/17, documented the resident was moderately impaired for daily decision making. The assessment documented the resident required extensive assistance with activities of daily living (ADLs). The facility incident report, dated 03/18/17, documented the resident had a fall. The report documented the resident had a skin tear to his right elbow. The report documented the new intervention to prevent falls was to place bright tape on the resident's call light. The care plan, updated 03/18/17, documented a new intervention to prevent falls would be to place bright colored tape on the resident's call light. The care plan documented the intervention would be initiated on 03/20/17. The fall risk assessment, dated 03/18/17, documented the resident was a high risk for falls. The care plan, dated 03/20/17, documented the resident was at risk for falls and fractures related to decreased mobility, weakness, and impaired cognition/poor thought processes. The facility incident report, dated 03/25/17, documented the resident had a fall. The report documented the resident had blood coming from his right shoulder, wrist, and elbow. The report documented an order for [REDACTED]. The report documented the new intervention to prevent falls was to place non skid strips beside the resident's bed. The care plan, updated 03/25/17, documented the new intervention to prevent falls would be to place non skid tape at the resident's bedside. The care plan documented the intervention would be initiated on 03/27/17. The fall risk assessment, dated 03/25/17, documented the resident was a high risk for falls. The facility incident report, dated 04/09/17, documented the resident had a fall. The report documented the resident had a reddened area on his right knee. The report documented the resident had old bruises and healing skin tears on both arms. The report documented the new intervention to prevent falls was to place the resident in the common areas when in his wheel chair. The care plan, updated 04/09/17, documented a new intervention to prevent falls would be to place the resident in the common areas when in his wheelchair. The care plan documented the intervention would be initiated 04/10/17. The fall assessment, dated 04/09/17, documented the resident was a high risk for falls. The facility incident report, dated 04/13/17, documented the resident had a fall. The report documented the resident had skin tears to his right forearm, right wrist, right thumb, left hand, left wrist, and left elbow. The report did not document new interventions to prevent falls. The care plan, updated 04/13/17, documented a new intervention to prevent falls would be to place a fall mat by the resident's bed, place a bed alarm on the resident's bed, and to rearrange the resident's furniture. The care plan documented the intervention would be initiated on 04/14/17. The fall risk assessment, dated 04/13/17, documented the resident was at a high risk for falls. The state incident report, dated 04/29/17, documented the resident had a fall. The report documented the resident had a laceration to his eyebrow and the bridge of his nose. The report documented the resident had skin tears to his right elbow and left upper arm. The report documented the new intervention to prevent falls was to place the resident on scheduled toileting upon awakening, before and after meals, and before bed. The care plan, updated 04/29/17, documented an intervention to prevent falls would be timed toileting when the resident woke up in the morning, before and after meals, and before bedtime. The fall risk assessment, dated 04/29/17, documented the resident was a high risk for falls. The facility incident report, dated 05/01/17, documented the resident had a fall. The report documented the resident had a skin tear on his right hand on the fourth and fifth digit and on his right elbow. The report documented the new intervention to prevent falls was placing pillows in the resident's bed for positioning. The care plan, updated 05/01/17, documented a new intervention to prevent falls would be to place pillows in the resident's bed for positioning. The facility incident report, dated 05/02/17, documented the resident had a fall. The report documented the resident had no new injuries. The report documented the resident had skin tears on both arms from previous falls. The report did not document a new intervention to prevent falls. The care plan, updated 05/02/17, documented a new intervention to prevent falls would be a medication review. The fall risk assessment, dated 05/02/17, documented the resident was a high risk for falls. The fall risk assessment, dated 05/04/17, documented the resident was a high risk for falls. The state incident report, dated 05/05/17, documented the resident had a fall. The report documented the resident had skin tears to his right palm, left palm, and his shoulder. The report documented the resident hit his head. The five day follow up report documented the resident had complained of right elbow pain and an order for [REDACTED]. The x-ray documented the resident had a fracture. The report documented the new intervention to prevent falls was timed toileting upon awakening, before and after meals, and before bed. The care plan, updated 05/05/17, documented an intervention to prevent falls would be timed toileting when the resident woke up in the morning, before and after meals, and before bedtime. The care plan documented the intervention would be initiated 05/08/17. The care plan did not document a new intervenion. The medication administration record (MAR), dated May 2017, documented an order for [REDACTED]. The record documented the resident received the medication 24 times from 05/05/17 thru 05/19/17. The facility incident report, dated 05/11/17, documented the resident had a fall. The report documented the resident had a skin tear on his left elbow. The report did not document a new intervention to prevent falls. The fall risk assessment, dated 05/11/17, documented the resident was a high risk for falls. The state incident report, dated 05/17/17, documented the resident had a fall. The report documented the resident complained of pain to his left elbow. The report documented the resident had a skin tear to his right elbow. The report documented the resident was sent to the emergency room for evaluation and treatment. The report documented the new intervention to prevent falls was to keep the resident's bed in the lowest position and use bright tape to mark the level of the resident's bed. The care plan, updated 05/17/17, documented a new intervention to prevent falls would be to mark the height of the bed with bright colored tape on the wall and not leave the resident's bed above the tape line. The report did not document a new intervention to prevent falls. The facility incident report, dated 06/13/17, documented the resident had a fall. The report documented the resident had no new injuries. The report documented the resident had pre-existing injuries to his left forearm. The care plan, updated 06/13/17, documented a new intervention to prevent falls would be to place a clip alarm onto the residents wheelchair and foam padding would be placed on the furniture. The care plan documented the intervention would be initiated 06/15/17. The state incident report, dated 06/14/17, documented the resident had a fall. The report documented the resident had redness to the back of his head. The report documented the resident was sent to the hospital for evaluation and treatment. The report documented the new intervention to prevent falls was to place padding to the resident's furniture edges. The care plan, updated 06/14/17, did not document a new intervention to prevent falls. The quarterly assessment, dated 06/16/17, documented the resident was moderately impaired for daily decision making. The assessment documented the resident required extensive assistance for activities of daily living (ADLs). The assessment documented the resident had two or more falls with no injury and two or more falls with injuries. The facility incident report, dated 06/18/17, documented the resident had a fall. The report documented the resident had bilateral upper extremity skin tears from a previous fall. The report documented the resident had no new injuries. The report documented the new intervention to prevent falls was to place non skid strips to the resident's bedside. The care plan, updated 06/18/17, did not document a new intervention to prevent falls. The fall risk assessment, dated 06/18/17, documented the resident was a high risk for falls. The state incident report, dated 06/19/17, documented the resident had a fall. The report documented the resident stated his head hurt. The report documented the resident had an abrasion to the top of his scalp and a skin tear to his left elbow. The report documented the resident had pre-existing injuries noted to his right forearm. The report documented the resident was sent to the emergency room for evaluation and treatment. The report documented the new intervention to prevent falls was to have a one on one sitter with the resident. The care plan, updated 06/19/17, documented a new intervention to prevent falls was to offer the resident snacks between meals. The care plan did not document the one on one intervention for the fall on 06/19/17. The fall risk assessment, dated 06/19/17, documented the resident was a high risk for falls. The resident's falling star sheet documented the interventions to prevent falls for the resident were as follows: non-skid strips to the floor beside the bed, a concave mattress, a high/low bed, a safety fall mat, a bed alarm pressure pad, a medication review, a toileting program before and after meals and at bedtime, non skid tape beside the resident's bed, the resident's furniture would be moved, a clip alarm, float the resident's heals when in bed with pillows, pillows with positioning while in bed, a wheel chair cushion, foam padding to the resident's furniture, scheduled toileting, turning and repositioning, a carafoam mattress, have the resident sit in the common areas when in his wheelchair, bright tape to the resident's call light, a lift sheet to the resident's bed, foam padding to the resident's furniture, and offer snacks between meals. The sheet did not document the intervention for a one on one sitter. On 06/21/17 at 10:05 a.m., the resident was observed in his room lying in his bed sleeping. A fall mat was observed beside the resident's bed. The resident's wife was at the bedside. On 06/21/17 at 10:05 a.m., the resident's wife stated the resident fell and hit his head three days ago and was sent to the hospital. The resident's wife stated she was told the resident was put on one on one. The resident's wife stated she did not know what one on one was and had gone into the hall to ask staff what one on one was. The resident's wife stated she had asked licensed practical nurse (LPN) #1 about the one on one when she was leaving the facility on 06/20/17. The resident's wife stated the LPN did not know anything about the one on one. The resident's wife stated the LPN said, If it's not posted around here then no one knows. The resident's wife stated no staff was in the room with the resident when she left the facility. The resident's wife stated at least two times in the last week she had used the call light and staff had not answered. The resident's wife stated she had gone to the nurse station and could not find staff. The resident's wife stated she was told staff was assisting residents on other halls. The resident's wife stated she felt the facility was short staffed. The resident's wife stated staff was always busy and would come by the door two or three times and say they would be back in a minute. The resident's wife stated she hoped no more falls occurred. On 06/21/17 at 1:35 p.m., certified nurse aide (CNA) #2 stated the resident was a fall risk. The CNA stated the resident had fallen several times. The CNA stated the resident was a one on one since 06/19/17. The CNA stated he was notified verbally about the one on one for the resident. On 06/21/17 at 2:40 p.m., LPN #3 and LPN #4 stated the resident was a one on one and prior to that was a frequent check. The LPNs stated the resident couldn't walk and had a bed alarm. On 06/21/17 at 8:15 a.m., the corporate nurse stated the resident was a one on one but did not know who was assigned to him. On 06/21/17 at 8:20 a.m., the director of nurses (DON) stated the CNA assigned to the resident for one on one had gone home during her shift and no one was with the resident during that time. The DON stated the resident was sleeping in his room. On 06/21/17 at 9:58 a.m., the DON stated the staff assigned to one on one for the resident was not included in the staffing schedule. The DON stated one on one meant someone would be with the resident at all times. The DON was asked who was with the resident when the one on one sitter left early during her shift. The DON stated no one. The DON was asked which CNA was assigned to the 300 hall and she stated one CNA was assigned to cover the 300 and 400 halls. The DON stated an LPN was assigned to the residents on the 300 hall. The resident roster documented 56 residents resided on the two halls which included the resident requiring a one on one sitter. No other staff was called in to cover for the CNA who left early during their shift. The charge nurse stated she felt they had sufficient staff to cover both halls and the one on one resident. On 06/21/17 at 4:50 p.m., the DON was asked if the facility had been able to determine the root cause for the resident's falls. The DON stated various reason such as hunger, sometimes the resident stated, I don't know. The DON was asked how the one on one was communicated to the staff. The DON stated it was passed to the staffing coordinator and charge nurses and should have been on the communication board. The DON stated it would have been passed from one shift to the next verbally during report. The DON stated the intervention for the one on one intervention was passed to the care plan coordinator during the morning Q2 meetings.

On 05/02/17 an Immediate Jeopardy (IJ) was determined to exist due to the facility's failure to assess, monitor, and intervene for resident #1 who was experiencing respiratory distress. The resident was in respiratory distress for five hours before being transported to the hospital. A hospital record, dated 10/05/16, documented at 7:32 p.m. the resident was pulseless. The record documented the resident's time of death was 7:36 p.m. The IJ situation was verified with the Oklahoma State Department of Health. On 05/02/17 at 5:01 p.m., the administrator (ADM) and the director of nurses (DON) were notified of the IJ situation regarding the resident not being transported to the hospital when experiencing respiratory distress. On 05/02/17 at 6:47 p.m., the plan of removal was accepted for the Immediate Jeopardy pertaining to [MEDICAL CONDITION]. The Plan of Removal for Immediate Jeopardy documented: All nurses will be inserviced on the respiratory distress policy and procedure. They will also be inserviced to notify the physician of a patient's status and to document. If unable to reach the physician, call the director of nurses (DON). If the resident's condition worsens call emergency management services association (EMSA) for transport to the hospital. Residents receiving oxygen will be assessed to ensure no respiratory distress noted. The facility policy for [MEDICAL CONDITION] will be updated to include: the nurse will remain with the resident when experiencing [MEDICAL CONDITION], the nurse will have staff call the physician, and bring needed items to the nurse. This will be done by midnight 05/02/17. On 05/02/17 the nurse staff who were present in the facility were inserviced on the facility policy for respiratory distress. The nurse staff who were not in the facility were contacted via the telephone. On 05/02/17 at 7:51 p.m., the last resident on oxygen therapy was assessed for respiratory distress. On 05/02/17 at 08:16 p.m., the facility inservice sheet documented the last nurse had been inserviced regarding respiratory distress. On 05/03/17 interviews were conducted with staff regarding inservices for education pertaining to content for Immediate Jeopardy removal. The staff stated an inservice was provided the previous evening in the facility and some staff stated they had been inserviced via the telephone. The staff was able to verbalize understanding of information provided in the inservice pertaining to the plan of removal. On 05/02/17 at 8:16 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a isolated level of actual harm. Based on interview and record review, it was determined the facility failed to provide necessary care and services for one (#1) of five residents reviewed for highest levels of well-being. The facility failed to assess, monitor, and intervene for a resident experiencing respiratory distress. The resident was experiencing respiratory distress with an oxygen saturation of 55%. The resident was in respiratory distress for five hours prior to being transported to the hospital. A hospital record, dated 10/05/16, documented at 7:32 p.m. the resident was pulseless. The record documented the resident's time of death was 7:36 p.m. The facility identified 25 residents who received oxygen therapy resided in the facility. Findings: The facility policy for respiratory distress documented the staff would rapidly assess the resident's respiratory status, lung sounds, and vital signs. The policy documented the resident would be positioned to facilitate breathing and the respiratory therapist would be notified when possible. The policy documented the staff would stay with the resident and have another staff member notify the physician. The policy documented the staff would apply a pulse oximeter and obtain a baseline reading. The policy documented the staff would apply a non-rebreather mask at five to 15 liters per minute providing 100% oxygen. The policy documented the staff would notify the physician of the resident's status for further orders. The policy documented the staff would assess for worsening signs of the resident's condition. The policy documented the staff would call EMSA for transport to the hospital. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 11/19/15, documented the resident was independent for daily decision making. The assessment documented the resident required extensive to limited assistance for ADLs. The care plan, updated 04/20/16, documented the resident had an activity of daily living (ADL) self care performance deficit related to limited mobility, shortness of breath (SOB), and impaired balance. The care plan documented the resident had altered cardiovascular status related to a history of [MEDICAL CONDITION] infarction and [MEDICAL CONDITION] The care plan documented the resident had hypertension. The care plan documented the resident had [MEDICAL CONDITION] and [MEDICAL CONDITION] and was on oxygen therapy. The care plan documented the resident had a history of [REDACTED]. The care plan documented the resident was a full code and if the resident was found in respiratory distress emergency services would be activated immediately. The care plan documented the resident wished to be resuscitated and would receive all available emergency services and aggressive treatments. The quarterly assessment, dated 07/15/16, documented the resident was severly impaired for daily decision making. The assessment documented the resident required extensive to total assistance for ADLs. A physician order, dated 08/02/16, documented the resident was a full code. A physician order, dated 09/16/16, documented an order for [REDACTED]. A nurse note, dated 10/03/16, documented the resident was alert and oriented times three. The note documented the resident's vital signs were within normal limits and wheezes were present in the upper lobes of the resident's lungs upon auscultation. The note documented the resident's oxygen saturation was 97%. No nurse assessment was performed on 10/04/16 related to the resident's respiratory status. A nurse note, dated 10/05/16, documented at 2:00 p.m. licensed practical nurse (LPN) #1 entered the resident's room and found the resident in respiratory distress. The note documented the resident's vital signs were as follows: blood pressure 199/119, respirations 16 and labored, pulse 89, oxygen saturation 55% on 3 liters of oxygen. The note documented the resident's head of the bed was elevated, a breathing treatment was administered, and the physician was contacted. (The note did not document the time the nurse attempted to contact the physician.) The note documented a new order for a STAT chest Xray and a one time dose of [MEDICATION NAME] for the resident's blood pressure. The note documented to continue the breathing treatment and notify the physician of the Xray results. (The note did not document the time the Xray was ordered.) The note documented the feeding tube was disconnected and the medication was administered as ordered. (The note did not document the time the medication was administered to the resident.) The note documented PK Xray arrived at approximately 5:30 p.m. The note documented the results of the Xray were obtained at 6:00 p.m. and no acute pathology was found. (The note did not document if the physician had been contacted with the Xray results.) The note documented the resident's oxygen saturation was reassessed at 78% on three liters of oxygen. (The note did not document the time the assessment was performed.) The note documented at 7:00 p.m. staff asked for assistance to change the resident's linens and stated the resident had thick mucous coming from his mouth. The note documented upon entrance to the resident's room the nurse observed the resident in acute respiratory distress. The note documented the resident was turned to his left side to prevent aspiration and the resident's vital signs were obtained as follows: blood pressure 85/53, respirations 12, pulse 70, oxygen saturation 54%. The note documented the nurse called an ambulance to transport the resident to the hospital. (The note did not document the time the ambulance was called.) The note documented an attempt was made to contact the physician and family related to a change in the resident's condition. (The note did not document the time the nurse attempted to contact the physician and family.) The note documented the DON was notified. (The note did not document the time the DON was contacted.) The note documented the hospital called at 9:00 p.m. to report the resident had passed away while in the emergency room . (The note did not document the time the resident passed away.) The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The facility could not provide an order for [REDACTED]. The emergency management services (EMS) dispatch record, dated 10/05/16, documented at 7:18 p.m. upon arrival to the nursing facility the resident's mental status was altered, the resident was experiencing SOB, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The narrative documented the nurse reported the resident had been experiencing SOB the day before with low oxygen saturation. The narrative documented the nurse had ordered an Xray of the patient's chest and it came back clear. The nurse stated when she arrived at work that day, the resident was again experiencing SOB and low oxygen saturation. The narrative documented upon the resident's initial assessment the resident was unresponsive which was not normal for the resident. The narrative documented the resident's lungs had coarse rhonci bilaterally in the upper lobes. The narrative documented there was a delay on the scene related to getting paperwork from the nurse. The narrative documented the resident was put on four liters of oxygen and the initial pulse oximetry was less than 50%. The resident was intubated and stayed in asystole during transport. The hospital record, dated 10/05/16, documented the resident presented to the emergency department from the nursing home after [MEDICAL CONDITION]. The record documented the resident had been SOB all day and the previous night with oxygen saturations in the 50's and improved to 70 after a breathing treatment. The record documented the resident had an oxygen saturation in the 50's all day and upon arrival to the emergency room the resident was agonal (gasping respirations) and the resident's oxygen saturation was in the 30's. The record documented the resident arrested prior to transport to the emergency department. The record documented the resident was intubated during compressions and the patient was given [MEDICATION NAME]. The record documented the resident was still in asystole ([MEDICAL CONDITION]) upon arrival to the emergency department. The record documented at 7:32 p.m. the resident was pulseless. The record documented the resident's time of death was 7:36 p.m. On 05/02/17 at 12:45 p.m., LPN #1 was interviewed. The LPN stated the resident had been having issues with his oxygen saturation the day before he passed away. The LPN stated the resident was more communicative than normal that day and had asked for a butterfinger. The LPN stated she had tried to contact the physician when the resident started having respiratory distress and had to wait for the physician to call her back with an order. The LPN stated she always had trouble making contact with the physician. The LPN stated she received a verbal order from the physician for a chest Xray, to give the resident an extra [MEDICATION NAME] for his increased blood pressure, and to call the physician with the results of the Xray. The LPN stated the physician was not concerned with a resident having low oxygen saturations with [MEDICAL CONDITION]. The LPN stated the physician stated not to be concerned and just keep monitoring the resident. The LPN stated about an hour after she gave the resident the extra [MEDICATION NAME] his oxygen saturations began to fall. The LPN stated she thought she had to wait for the chest Xray and an order from the physician before the resident could be transported to the hospital. The LPN stated the CNA came to ask for help to change the resident's linens and stated the resident was vomiting. The LPN stated when she entered the room the resident was sweating and vomiting. The LPN stated she turned the resident on his left side to keep him from aspirating, took the resident's vitals, and called the ambulance to transport the resident to the hospital. On 05/02/17 at 1:20 p.m., certified nurse aide (CNA) #1 was interviewed. The CNA stated she arrived to work at 2:00 p.m. and was instructed by the nurse to keep a good eye on the resident. The CNA stated she went in to check on the resident and he was really sweaty and his clothes and bedding were saturated. The CNA stated she had never had a resident act like that before and it really scared her. The CNA stated she asked another CNA for assistance to change the resident's bedding. The CNA stated the resident was really loose and couldn't hold his head up. The CNA stated the resident looked really scary. The CNA stated she notified the nurse. The CNA stated the nurse took the resident's vital signs and they were low. The CNA stated the nurse was on the phone and whoever she was talking to wouldn't let her send the resident to the hospital. The CNA stated foam was coming out of the resident's mouth. The CNA stated the nurse said she had everything under control and that was when she sent the resident to the hospital. On 05/02/17 at 2:30 p.m., the physician was interviewed. The physician was asked if he could tell me about the events leading up to the resident's discharge from the facility. The physician stated October was a long time ago, he would have to review the resident's records, and it may be a week before he could get back with me. On 05/02/17 at 2:35 p.m., CNA #2 was interviewed. The CNA stated he was asked to help another CNA change the resident's linens. The CNA stated he remembered they had to hold the resident's head up to help him breathe. On 05/02/17 at 2:40 p.m., LPN #2 was interviewed. The LPN stated she was working the day of the incident with the resident. The LPN stated the resident's nurse could not get in touch with the physician for an order but had kept trying. The LPN stated the physician had ordered another [MEDICATION NAME] for the resident. The LPN stated the resident's nurse was very frustrated because the physician wouldn't give her orders to do anything. On 05/02/17 at 3:08 p.m., the physician called back to speak with the surveyor. The physician stated the facility had given him some information about the resident. The physician stated, If you have read the nurse note, that's about all I can tell you. The physician stated he gave the nurse an order for [REDACTED]. The physician stated obviously with oxygen saturations of 55%, he wouldn't have wanted the resident to lay there that long without an Xray. On 05/02/17 at 4:15 p.m., the DON was interviewed. The DON stated she was not working at the facility when the incident happened with the resident. The DON was asked if she had problems contacting the physician. The DON stated she didn't usually have a problem making contact with the physician. The DON was asked if the facility had recognized respiratory distress as a problem in their quality assurance (QA) meetings. The DON stated she had just been made aware of QA meetings and one was scheduled for the following week. The DON stated no QA meetings had been performed in 2017. The DON stated respiratory distress had not been recognized as a problem in their morning stand up meetings. The DON was asked how new staff was trained when coming to the facility. The DON stated she had implemented training for new staff as follows: new staff would be put with the most experienced nurse at the facility for two to three days for computer and point click care training. The DON stated the regional nurse also worked with the staff one on one for computer training. The DON stated the new nursing staff would shadow a nurse on the hall for two to three days and once they were comfortable they would run the shift. On 05/03/17 at 10:05 a.m., the quality assurance nurse was asked if the facility had recognized respiratory distress as a problem in the QA meetings. The QA nurse reviewed the meeting notes for 2016 and stated respiratory distress had not been recognized during the QA process.

On 10/06/16, an Immediate Jeopardy (IJ) was determined to exist due to the facility's failure to provide adequate supervision to prevent accidents for residents #1, #2, #3, #4, #5, and #6. Residents #1, #2, #3, #4, #5, and #6 had resided in the facility on the 200 hall behind two locked doors and without supervision or staff present at all times. On 10/06/16 at 8:32 p.m., the IJ situation was verified with the Oklahoma State Department of Health. On 10/06/16 at 8:50 p.m., the director of nurses (DON) stated prior to 10/03/16 she was not aware of dedicated staff assigned to the 200 hall. The DON stated as of 10/03/16 a certified nurse aide (CNA) was assigned to the 200 hall during the day shift only. On 10/06/16 at 9:07 p.m., the administrator and the director of nurses (DON) were notified of the IJ situation related to failure to provide supervision to prevent accidents on the 200 hall. On 10/06/16 at 10:52 p.m., the plan of removal for the Immediate Jeopardy pertaining to supervision to prevent accidents was accepted. The Plan of Removal for the Immediate Jeopardy documented: As of 10-6-16 at 10:00pm, we will keep a staff member assigned to the 200 hall as long as residents are housed on the hall. All existing residents currently on the 200 hall will be moved to other areas of the facility as of 10:00pm on 10-6-16. Facility staff currently in the facility will be inserviced regarding a staff member being assigned to the 200 hall at all times as long as any residents were housed there by 10:30pm on 10-6-16. All other staff members would be inserviced by midnight on 10-6-16. All other staff will not be allowed to work until they have been inserviced. On 10/10/16, interviews were conducted with staff regarding inservices pertaining to content for Immediate Jeopardy removal. The staff stated an inservice was provided the evening of 10/06/16. The staff verbalized information provided in the inservice pertaining to the plan of removal. On 10/06/16 at 11:59 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a pattern level of no actual harm with potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent accidents for six (#1, #2, #3, #4, #5, and #6) of six sampled residents reviewed for supervision to prevent accidents. The facility failed to provide consistent supervision to prevent accidents for the residents who resided on the 200 hall. The facility identified six residents had resided on the 200 hall since the opening of the hall for resident care on 09/22/16. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility identified the resident was admitted to room 216 on the 200 hall. The initial care plan, dated 10/01/16, documented the resident was a full code, was independent with transfers, staff would encourage the resident to use the call light for assistance with activities of daily living (ADLs), and the resident would be assessed/treated for [REDACTED]. A nurse note, dated 10/02/16, documented the resident used a wheelchair for distance ambulation, could stand for short periods of time, and was unsteady of gait. A nurse note, dated 10/03/16, documented the resident ambulated distances in a wheelchair and the resident's gait was unsteady. The note documented the resident required the assistance of one person with activities of daily living. The resident grievance log documented on 10/03/16 resident #1 verbalized a grievance. The log documented the grievance was the facility staff took too long to answer the call light. The log documented the follow up to the grievance was the DON spoke to the resident and verbalized understanding of her concerns. The staffing sheet provided by the facility documented on 10/01/16 a certified nurse aide (CNA) was assigned to the 200 hall for the 10:00 p.m. to 6:00 a.m. shift. The sheet did not document staff was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift or the 2:00 p.m. to 10:00 p.m. shift. The staffing sheet provided by the facility documented on 10/02/16 a licensed nurse was assigned to the 200 hall for the 10:00 p.m. to 6:00 a.m. shift. The sheet did not document staff was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift or the 2:00 p.m. to 10:00 p.m. shift. The staffing sheet provided by the facility, dated 10/03/16, documented no staff was assigned to the 200 hall for any shift. The staffing sheet provided by the facility documented on 10/04/16 a CNA was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift. The sheet did not document staff was assigned to the 200 hall for the 2:00 p.m. to 10:00 p.m. shift or the 10:00 p.m. to 6:00 a.m. shift. The staffing sheet provided by the facility documented on 10/05/16 a CNA was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift. The sheet documented no staff was assigned to the 200 hall for the 2:00 p.m. to 10:00 p.m. shift or the 10:00 p.m. to 6:00 a.m. shift. On 10/06/16 at 5:17 p.m., the resident was observed in her room on the 200 hall. The resident was clean and odor-free. No staff was observed on the 200 hall. On 10/06/16 at 5:17 p.m., resident #1 stated she came to live at the facility the previous week. The resident stated staff was good, but did not always answer the call lights timely. The resident stated she had verbalized the concern to the administrator and staff. The resident stated she was fearful to be on the hall without staff present because she might fall or become ill without someone knowing. The resident stated no staff present on the hall was a dangerous situation. The resident stated she had to be careful in the bathroom to keep from falling. The resident stated she was ill at 2:00 a.m. one morning and was already in the bathroom before staff arrived to help. The resident stated she would obtain her own ice from the dining room and rarely saw staff present. The resident stated she felt alone. A nurse note, dated 10/06/16, documented the resident was moved to room 314 with permanent supervision for her safety. On 10/10/16 at 9:53 a.m., the DON was asked if concerns had been voiced related to supervision on the 200 hall. The DON stated the staff voiced concerns the first day a resident was admitted to the 200 hall due to staff not being present on the hall at all times. The DON stated all staff assigned to the 200 hall had voiced concerns. The DON stated the concerns were taken to the administrator. The DON stated the administrator had no response. On 10/10/16 at 11:27 a.m., the DON was asked if residents were safe when left unsupervised for up to two hours on the 200 hall. The DON stated she had concerns. The DON stated staffing had not changed when residents were admitted to the 200 hall. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility identified the resident was admitted to room 215 on the 200 hall. The staffing sheet provided by the facility, dated 09/23/16, documented no staff was assigned to the 200 hall for any shift. The staffing sheet provided by the facility documented on 09/24/16 a CNA was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift and the 2:00 p.m. to 10:00 p.m. shift. The sheet did not document staff was assigned to the 200 hall for the 10:00 p.m. to 6:00 a.m. shift. The staffing sheet provided by the facility documented on 09/25/16 a CNA was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift and the 2:00 p.m. to 10:00 p.m. shift. The sheet did not document staff was assigned to the 200 hall for the 10:00 p.m. to 6:00 a.m. shift. The staffing sheet provided by the facility documented on 09/26/16 the staff assigned to the 100 hall was to also provide care for the residents who resided on the 200 hall. A physician's orders [REDACTED]. The order documented the resident was on a nothing by mouth (NPO) diet and was receiving enteral feedings. The facility identified the resident was moved to the 400 hall on 09/27/16. A physician's orders [REDACTED]., nutritional intake, or skin integrity. A readmission assessment, dated 09/30/16, documented the resident was severly impaired for daily decision making. The assessment documented the resident needed total assistance with activities of daily living (ADLs). The assessment documented the resident was always incontinent of bowel and bladder. The assessment documented the resident received oxygen therapy via a nasal cannula, was on an anticoagulant, and had a limb restraint which was used daily. The care plan, dated 10/04/16, documented the resident had impaired cognitive function, dementia or impaired thought processes related to difficulty making decisions and multiple disease processes. The care plan documented the resident had a swallowing problem related to a cerebral vascular accident and was dependent on a feeding tube for nutrition. The care plan documented the resident used padded mittens for safety of the peg tube. The care plan documented the resident was at risk for pain related to decreased mobility, left sided [DIAGNOSES REDACTED] , and a new peg tube placement. The care plan documented the resident was dependent on staff for activities, cognitive stimulation, and social interactions related to cognitive deficits. The care plan documented the resident had a communication problem related to aphagia. The care plan documented the resident was at risk for falls related to confusion, poor communication/comprehension, was unaware of safety needs, and had vision and hearing problems. The care plan documented the resident had an ADL self care performance deficit related to left sided [DIAGNOSES REDACTED], decreased mobility and weakness. The care plan documented the resident had a psychosocial well being problem related to distractibility and inability to concentrate. The care plan documented the resident was on oxygen therapy. On 10/06/16 at 6:55 p.m., CNA #1 was asked about the staffing on the 200 hall. The CNA stated she worked the 100 and 200 hall and was assigned to provide supervision most nights. The CNA stated she couldn't just sit over there on the 200 hall. The CNA stated she made rounds on the 200 hall every 2 hours and answered the call lights as soon as she could. The CNA was asked would she be able to hear if a resident residing on the 200 hall called out for help. The CNA stated she would not be able to hear a resident if they called out for help on the 200 hall. The CNA was asked how she would know if a resident had a fall. The CNA stated she would find them when she made rounds. The CNA was asked if she was able to meet resident needs on the 200 hall. The CNA stated not all resident needs may be meet on the 200 hall. The CNA was asked if residents on the 200 hall had voiced any concerns. The CNA stated one resident verbalized she did not like being on the 200 hall alone. The CNA stated staffing was not increased when residents were admitted to the 200 hall. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial plan of care, dated 10/04/16, documented the resident was a full code, a fall risk, had pain, and needed ADL assistance. A nurse note, dated 10/04/16, documented the resident was a smoker, on 3 liters (L) of oxygen, and was able to ambulate short distances but did get short of breath (SOB). The staffing sheet provided by the facility documented on 10/04/16 a CNA was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift and the 2:00 p.m. to 10:00 p.m. shift. The sheet documented no staff was assigned to the 200 hall for the 10:00 p.m. to 6:00 a.m. shift. The staffing sheet provided by the facility documented on 10/05/16 a CNA was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift and the 2:00 p.m. to 10:00 p.m. shift. The sheet documented no staff was assigned to the 200 hall for the 10:00 p.m. to 6:00 a.m. shift. On 10/06/16 at 4:55 p.m., the resident was observed in her room on the 200 hall. The resident was clean and odor free. No staff was observed on the 200 hall. A nurse note, dated 10/06/16, documented the resident was moved to room 114 with permanent supervision for her safety. On 10/06/16 at 4:55 p.m., resident #3 stated she came to live in the facility 2 days before. The resident stated she had lung disease and was oxygen dependent. The resident stated staff was not on the hall at all times. 4. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The five day assessment, dated 09/22/16, documented the resident was severly impaired for daily decision making. The assessment documented the resident needed extensive assistance with ADLs and was always incontinent of bowel and bladder. The admission nurse note, dated 09/22/16, documented the resident was alert and oriented times one. The note documented the resident would require the assistance of two staff members for ADL care. The note documented the resident's speech was unclear. The note documented the resident wore a brace on his right leg, was a high fall risk, and required a wheel chair for mobility with assistance of one staff member. The staffing sheet provided by the facility, dated 09/22/16, documented no staff was assigned to the 200 hall for any shift. The staffing sheet provided by the facility, dated 09/23/16, documented no staff was assigned to the 200 hall for any shift. The care plan, dated 10/04/16, documented the resident was at risk for falls due to decreased mobility and dementia. The care plan documented the resident was NPO and had a nutritional problem. The care plan documented the resident was at risk for pressure ulcers related to decreased mobility and incontinence. The care plan documented the resident was at risk for fractures. The care plan documented the resident had impaired cognitive function related to dementia or impaired thought processes related to dementia. The care plan documented the resident had an ADL self care performance deficit related to a right femur fracture, difficulty walking, lack of coordination, muscle wasting/atrophy and decreased mobility. The care plan documented the resident had oxygen therapy related to sleep apnea. The care plan documented the resident was on intravenous therapy (IV) of normal saline related to fluid deficit. The care plan documented the resident was at risk for adverse reactions related to polypharmacy. The care plan documented the resident was on anticoagulant therapy related to deep vein thrombosis (DVT) of the lower extremity. 5. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial plan of care, dated 10/01/16, documented the resident was a full code, was at risk for falls, was bedfast, and needed assistance with ADLs. The admission nurse note, dated 10/01/16, documented the resident was admitted to room 215. The staffing sheet provided by the facility, dated 10/01/16, documented no staff was assigned to the 200 hall for any shift. The staffing sheets provided by the facility documented on 10/02/16 a licensed nurse was assigned to the 200 hall for the 10:00 p.m. to 6:00 a.m. shift. The sheet documented no staff was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift or the 2:00 p.m. to 10:00 p.m. shift. The staffing sheet provided by the facility, dated 10/03/16, documented no staff was assigned to the 200 hall for any shift. The staffing sheet provided by the facility documented on 10/04/16 a CNA was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift. The sheet documented no staff was assigned to the 200 hall for the 2:00 p.m. to 10:00 p.m. shift or the 10:00 p.m. to 6:00 a.m. shift. The staffing sheet provided by the facility documented on 10/05/16 a CNA was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift. The sheet documented no staff was assigned to the 200 hall for the 2:00 p.m. to 10:00 p.m. shift or the 10:00 p.m. to 6:00 a.m. shift. On 10/06/16 at 6 p.m., resident #5 stated she had been on the 200 hall but had requested to be moved. The resident stated she had to wait a long time for staff assistance. The resident stated it was too quiet on the hall. The resident stated she saw staff during the day but less on evenings and nights. The resident stated she had been incontinent of stool because she did not receive assistance timely. On 10/06/16 at 7:10 p.m., CNA #2 was asked how staff were assigned to the 200 hall. The CNA stated she rotated between the 100 and 200 hall. The CNA was asked how she would know if a resident had a fallen on the 200 hall. The CNA stated she would probably find them when she made rounds on the hall. The CNA stated there was a person assigned to the 200 hall now on the 6:00 a.m. to 2:00 p.m. shift. The CNA stated they could use another CNA to provide coverage to both halls. The CNA stated they were not always able to meet resident needs in a timely manner. 6. Resident #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The staffing sheet provided by the facility, dated 09/23/16, documented no staff was assigned to the 200 hall for any shift. The staffing sheet provided by the facility documented on 09/24/16 a CNA was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift and the 2:00 p.m. to 10:00 p.m. shift. The sheet documented no staff was assigned to the 200 hall for the 10:00 p.m. to 6:00 a.m. shift. The staffing sheet provided by the facility documented on 09/25/16 a CNA was assigned to the 200 hall for the 6:00 a.m. to 2:00 p.m. shift and the 2:00 p.m. to 10:00 p.m. shift. The sheet documented no staff was assigned to the 200 hall for the 10:00 p.m. to 6:00 a.m. shift. The admission assessment, dated 09/29/16, documented the resident was severly impaired for daily decision making. The assessment documented the resident did not ambulate. The assessment documented the resident needed limited assistance of two staff members for toileting, extensive assistance dressing, and total assistance for bathing. The assessment documented the resident had a lower extremity impairment and used a wheelchair for mobility. The assessment documented the resident was always incontinent of bowel and frequently incontinent of urine. The assessment documented the resident was receiving IV therapy. On 10/06/16 at 7:50 p.m., the resident stated he had resided on the 200 hall. The resident stated he did not like being alone on the hall. The resident stated he ate in the dining room alone. The resident stated he had asked to be moved to another hall because he wanted to be around other people. On 10/10/16 at 11:00 a.m., the ADM was interviewed. The ADM stated no concerns had been identified concerning staffing for the 200 hall. The ADM stated he had an open door policy and a daily stand up meeting with department heads. On 10/10/16 at 2:55 p.m., the ADM was asked if staff had brought any concerns to him related to the staffing on the 200 hall. The ADM stated, Not to my memory, nothing specific. The ADM stated he did not go to the Q2 meetings because that was the responsibility of the DON.

Based on observation, record review, and interview, it was determined the facility failed to ensure the resident received adequate supervision to prevent accidents for three (#2, #3, and #7) of four sampled residents reviewed for falls. The facility failed to: a) identify safety factors and functional limitations for resident #2. b) evaluate the effectiveness of interventions and implement new interventions for residents #2, #3, and #7. Resident #2 had a history of [REDACTED]. The resident fell and sustained a fractured ankle. The facility fall log documented 42 falls had occurred in the facility from July 2012 through December 2012. Findings: The facility policy for fall prevention documented fall risk factors including health problems or conditions that could cause a fall would be reviewed and evaluated. Medications and the use of assistive devices would be reviewed and evaluated. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive admission assessment, dated 09/30/11, documented the resident had no cognitive impairment. The assessment documented the resident required extensive assistance for transfers and toilet use. The assessment did not document the resident had a history of [REDACTED]. The care plan, dated 10/10/11, documented the resident was at risk for falls related to multiple diagnoses, balance issues during transfers, and history of a prior fall. The interventions to prevent falls were to complete a fall assessment per facility policy, keep the resident's call light within reach and answer promptly, keep items of frequent use within the resident's reach, and keep pathways well lit and free of clutter. The care plan was updated with non-injury falls that occurred on 01/29/12 and 06/04/12. The care plan interventions for those entries documented the resident was educated to call for assistance with transfers. Restorative progress notes for June 2012 documented the resident walked with assistance two times during the second week of June and refused to walk during the remainder of the month due to pain and/or swelling in her legs. Restorative progress notes for July 2012 documented the resident refused to walk during the month due to pain and/or swelling in her legs. An incident report, dated 07/31/12, documented the resident had been found on the floor in her room and did not have an injury. The report documented the resident stated she stood up trying to reposition herself when the catheter came apart, urine spilled on the floor, and the resident fell . The report documented the resident was instructed to use the call light when assistance was needed and to wait for assistance from the staff. The report did not document new interventions. The care plan, updated 07/31/12, documented the resident had been found on the floor after she reported she had stood to reposition herself and the catheter pulled apart at that time causing urine to spill on the floor. The care plan did not document new interventions to prevent falls. The restorative progress notes for August 2012 documented the resident had done well with range of motion exercises but did not document the resident's progress with ambulation. An incident report, dated 09/09/12, documented the resident stated she had become dizzy and slid down the wall to the floor. The report documented the resident had not been injured. The report documented the resident was instructed to ask for assistance with transfers. The report did not document new interventions. The care plan, updated 09/09/12, documented the resident had been involved in a witnessed fall. The care plan documented the resident stated she got dizzy. The care plan documented the resident was educated to call for assistance with transfers. The care plan did not document new interventions to prevent falls. An incident report, dated 09/12/12, documented the resident was found lying on the floor near the bedside commode. The report documented the resident complained of pain in the left ankle and requested to be sent to the hospital. The report documented the resident stated she needed to use the bathroom and fell . The report documented the call light was in place on the bed. The report documented the resident was educated (but the subject was not identified) and a bed/chair alarm was put into place. A hospital x-ray report, dated 09/12/12, documented the resident had a fractured tibia and fibula near the ankle. The care plan, dated 10/30/12, documented the resident was at risk for falls related to multiple diagnoses, balance issues during transfers, and a history of falls. The interventions to prevent falls were to complete a fall assessment per facility policy, keep the resident's call light within reach and answer promptly, keep items of frequent use within the resident's reach, and keep pathways well lit and free of clutter. On 03/05/13 at 12:20 p.m., the resident was observed sitting in the wheelchair in her room. On 03/06/13 at 6:00 p.m., the resident was observed lying in bed. The resident was interviewed regarding the assistance she required for activities of daily living and previous falls. The resident stated she wanted to be as independent as possible but did require assistance with most activities of daily living because she had arthritis in her hands and pain and swelling in her feet and legs. The resident stated she had not asked for assistance when she needed to go to the bathroom at the time the fracture occurred. On 03/07/13 at 9:50 a.m., the resident was observed during catheter care. The resident had edema in the lower extremities. On 03/07/13 at 2:15 p.m., the assistant director of nurses (ADON) was asked what different interventions had been implemented after each of the resident's falls. The ADON looked at the resident's care plan and stated it looked like the only intervention documented was to instruct the resident to ask for assistance with transfers. The ADON stated the resident had been able to transfer herself from the bed to the wheelchair and the wheelchair to the bedside commode prior to the fracture. The ADON stated reminding the resident to ask for assistance worked for the resident until June 2012 when the resident started getting weaker in her legs. The ADON was asked if the resident had been included in planning care with measures to prevent the resident's falls. The ADON stated they had not discussed measures to prevent falls with the resident. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 11/22/12, documented the resident had a history of [REDACTED]. The care plan documented new interventions to prevent falls were implemented at that time. An incident report, dated 11/27/12, documented the resident had a non-injury fall. The care plan was not updated with new interventions after the fall. An incident report, dated 12/17/12, documented the resident had a fall with a head injury. The care plan was not updated with new interventions after the fall. A significant change assessment, dated 02/20/13, documented the resident was severely impaired for daily decision making, required assistance with activities of daily living, used a walker for mobility, and had falls with injury. On 03/05/13 at 10:25 a.m., the resident was observed ambulating with a Merry walker. On 03/06/13 at 5:30 p.m., the director of nurses (DON) was interviewed. The DON was asked if the resident's care plan documented new interventions after each of the resident's falls and if effectiveness of the interventions had been monitored. The DON stated no new interventions were documented on the care plan for the falls the resident had on 11/27/12 and 12/17/12. The DON stated the effectiveness of the interventions was not monitored. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission fall risk assessment, dated 05/30/12, documented the resident was high risk for falls. The care plan, dated 06/15/12, documented: "Problem I am at risk for falls R/T (related to) multiple Dx (diagnosis), Dx of dementia w/ (with) bx (behavior)(mental confusion/impaired judgement), use of multiple meds (antihypertensives, diuretics, antidepressants, & antipsychotic), unsteady gait, Hx (history) of Fall B/4 (before) coming to GLC... Approaches Please complete fall assessment per policy. Keep call light within reach & answer promptly. Keep items that I frequently use within reach. Notify charge nurse if I have fallen. Keep pathways well lit & free of clutter. Monitor for anything that may be precursor of fall (^confusion, hypotension, ^edema, ^dizziness, lightheadedness, & general weakness). I have a chair & bed alarm for fall prevention measures..." An incident report, dated 11/02/12, documented the resident had a non-injury fall. The care plan was not updated with new interventions after the fall. An incident report, dated 11/15/12, documented the resident had a non-injury fall. The care plan was not updated with new interventions after the fall. An incident report, dated 11/18/12, documented the resident had a fall with minor injury. The care plan was not updated with new interventions after the fall. A quarterly fall risk assessment, dated 03/05/13, documented the resident was at high risk for falls. A quarterly assessment, dated 03/05/13, documented the resident was severely impaired for decision making, had behaviors daily, wandered, required assistance with activities of daily living, and required a wheelchair for mobility. The assessment documented the resident had falls since the previous assessment. On 03/05/13 at 12:15 p.m., the resident was observed seated in her wheelchair. On 03/07/13 at 1:15 p.m., the director of nurses (DON) was interviewed. The DON was asked if the resident's care plan documented new interventions after each of the resident's falls and if the interventions were monitored for effectiveness. The DON stated no new interventions were documented on the care plan for the falls the resident had on 11/02/12, 11/15/12, and 12/18/12. The DON stated the effectiveness of the interventions was not monitored.