Every finding on record at Tidwell Living Center

Based on observation, record review, and interview, the facility failed to ensure assessments were accurate for indwelling catheters for 1 (#26) of 12 sampled residents reviewed for resident assessments. The DON identified 32 residents who resided in the facility. Findings: On 05/06/25 at 3:11 p.m., Res #26 was observed sitting in the lobby in a wheelchair. No indwelling catheter was observed. A diagnoses sheet, dated 03/04/20, showed Res #26 was admitted with diagnoses which included chronic obstructive pulmonary disease and convulsions. A quarterly assessment, dated 04/29/25, showed Res #26 had a brief interview for mental status score of 15 and was cognitively intact. The assessment showed Res #26 had an indwelling catheter. Res #26's medical record did not document an order for an indwelling catheter during the assessment review period of 04/23/25 through 04/29/25. On 05/06/25 at 3:13 p.m., Res #26 stated they did not have a catheter. They stated they had never had an indwelling catheter. On 05/07/25 at 12:57 p.m., LPN #1 stated Res #26 did not have an indwelling catheter recently. On 05/07/25 at 1:00 p.m., the minimum data set coordinator stated Res #26 did not have an indwelling catheter during the assessment review period. They stated the assessment was coded in error.

Based on observation, record review, and interview, the facility failed to implement EBPs during catheter care for 1 (#21) of 2 sampled residents reviewed for EBPs. The DON reported seven residents required EBP. Findings: On 05/07/25 at 1:08 p.m. LPN #1 and certified nurse aide #1 were observed entering Res #21's room to perform catheter care. Neither staff was observed using EBPs when entering the room or while performing care. An undated policy titled Enhanced Barrier Precaution, read in part, Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include; device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator). An undated diagnoses list showed Res #21 had diagnoses of paraplegia and seizure disorder. On 05/07/25 at 1:15 p.m., LPN #1 was asked if they knew what EBPs were. LPN #1 stated a gown, gloves, and a mask. LPN #1 was asked if EBPs applied to performing catheter care. LPN #1 stated they did not think so with catheter care. On 05/07/25 at 1:40 p.m., the DON reported staff did not use EBPs with catheter care.

Based on record review and interview, the facility failed to monitor for side effects of psychotropic medications for two (#12 and #133) of five residents sampled for the use unnecessary medications. The administrator reported the facility census was 31. Findings: An undated policy titled Documentation for Behavioral Medications and Side Effects, read in part, .When medication is ordered by the physician, for a resident to treat a behavioral condition the nurse will initiate the Behavior Drug Monitoring Record . 1. Resident #12 had diagnoses which included bipolar disorder and generalized anxiety disorder. A physician order, dated 07/10/23, documented the resident was to be given 60 mg of Cymbalta by mouth at bedtime. A physician order, dated 11/01/23, documented the resident was to be given 2 mg of Risperdal twice a day. A care plan, dated 12/06/23, documented to monitor for potential side effects of psychotropic medications. A review of the resident's MAR and TAR did not document the resident was being monitored for side effects. 2. Resident #133 had diagnoses which included depression and hypertension. A physician order, dated 01/02/24, documented the resident was to be given 50 mg of Zoloft by mouth every day. A baseline care plan, dated 01/02/24, documented to monitor for side effects of psychotropic medications. A review of Resident #133's MAR and TAR did not document the resident was being monitored for side effects. On 01/10/24 at 10:53 a.m., the DON stated side effect monitoring should be documented in the MAR.

Based on record review and interview, the facility failed to have a program designed to help prevent the development of Legionellosis and Pontiac Fever caused by Legionella Bacteria. The administrator reported the census was 31. Findings: On 01/11/24 at 10:10 a.m., the administrator stated the water management program was a work in progress and they did not currently have a policy in place or a diagram of the facilities water system.

Based on record review and interview, the facility failed to ensure influenza vaccinations were offered for three (#5, #12, and #18) of five residents reviewed for immunizations. The administrator reported the census was 31. Findings: A review of Resident #5, #12, and #18's immunization records did not document the residents had been offered an influenza immunization in 2023. On 01/11/24 at 1015 a.m. the DON stated Residents #5, #12, and #18 were all receiving hospice care and the hospice company was supposed to provide them with vaccinations. They also reported there had been a miscommunication between hospice staff and facility staff and that hospice staff thought the facility had vaccinated all the residents. The Don also reported hospice staff would offer the immunization on their next visit.

Based on record review and interview, the facility failed to implement a baseline care plan that met the professional standards of quality care for one (#133) of one resident reviewed for baseline care plans. The administrator reported the census was 31. Findings: Resident #133 was admitted with diagnoses including a fractured hip and depression. A physician order, dated 01/02/24, documented the resident was to be given 4 mg of warfarin (an anticoagulant) by mouth on Sunday, Wednesday, Friday, and Saturday and 6 mg by mouth on Monday Tuesday and Thursday. The baseline care plan, dated 01/02/24, did address the use of an anticoagulant. On 01/10/24 at 1:18 p.m., the MDS coordinator stated anticoagulant use should be included on the care plan.

Based on record review and interview, the facility failed to ensure accounting ledgers were in accordance with services provided for three (#1, 2 and #3) of three residents reviewed for personal funds. The Administrator reported 14 residents with money held in the trust fund account. Findings: A Management of Resident Funds policy, undated, read in parts .The facility will maintain a precise account of all deposits and withdrawals .and will make all documentation readily available to the residents and/or designee. Res #1 had diagnoses which included heart failure and depression. A Social Security Administration Beneficiary Payee Ledger, dated November 2022, documented Senior Dental insurance for the months of October and November were deducted for Res #1. A Social Security Administration Beneficiary Payee Ledger, dated December 2022, documented the facility expenses for the months of October, November, and December were deducted for Res #1. A Social Security Administration Beneficiary Payee Ledger, dated February 2023, documented the facility expenses for the months of January and February were deducted for Res #1. On 03/02/23 at 9:05 a.m., Res #1 reported the staff did not provide them with accurate statements of their personal funds. Res #1 reported the staff deducted facility expenses for two or three months at a time. Res #2 had diagnoses which included heart failure and hypertension. A Social Security Administration Beneficiary Payee Ledger, dated December 2022, documented the facility expenses for the months of October, November, and December, were deducted for Res #2. A Social Security Administration Beneficiary Payee Ledger, dated February 2023, documented the facility expenses for the months of December and January were deducted for Res #2. On 03/02/23 at 9:50 a.m., Res #2 reported they had no awareness of the amount of money that was in their personal fund. Res #3 was admitted with diagnoses which included hypertension and diabetes. A Social Security Administration Beneficiary Payee Ledger, dated December 2022, documented the facility expenses for the months of October, November, and December, were deducted for Res #3. A Social Security Administration Beneficiary Payee Ledger, dated February 2023, documented the facility expenses for the months of January and February were deducted for Res #3. On 03/02/23 at 2:15 p.m., Res #3 reported the facility waited two or three months before the staff deducted facility expenses and it gets confusing because when they were given a balance they were unaware if the facility expenses had been deducted. On 03/02/23 at 2:50 p.m., the office manager reported the monthly statements were not always accurate. The office manager reported the facility expenses should have been deducted monthly. On 03/02/23 at 2:55 p.m., the Administrator reported the monthly statements should have been accurate and the facility expenses should have been deducted monthly.

Based on record review and interview, the facility failed to maintain a surety bond in a sufficient amount to cover the residents' trust fund account. The administrator reported 14 residents had money held in the trust fund account. Findings: The surety bond, effective 07/10/22 to 07/10/23, was reviewed and the Bond Amount was documented in the amount of $15,000.00. On 03/02/23 at 3:00 p.m., the Administrator provided the trust fund balance of $33,390.55. On 03/02/23 at 3:02 p.m., the Administrator reported the surety bond was not enough to cover the trust fund balance.

Based on record review and interview, the facility failed to ensure one (dietary helper #1) of 45 staff members received their second Covid-19 vaccination within 30 days of their hire date or been granted exemption. The Resident Census and Conditions of Residents, dated 03/02/23, documented a census of 28 residents. Findings: A COVID-19 VACCINE POLICY, undated, read in parts, .1st dose due by start date. 2nd dose- due by day 30 of start date . The Covid-19 Staff Vaccination Status for Providers, read in parts, .dietary helper #1 .hired 11/01/22 .temporary delay/new hire. On 03/02/23 at 2:15 p.m., the DON/IP reported dietary helper #1 was hired on 11/01/22 and should have been completely vaccinated within 30 days of their hire date. The DON/IP reported dietary helper #1 had received one vaccination but had not received the second vaccination. The DON/IP reported dietary helper #1 had not filed exemption and would not be considered a temporary delay. On 03/02/23 at 2:25 p.m., the Administrator reported dietary helper #1 should have been completely vaccinated within 30 days of their hire date.

Based on record review and interview, the facility failed to correct rejected resident assessments for six of 28 resident assessments submitted to CMS. The CMS Submission Report, dated 08/01/22, documented six of 28 resident assessments submitted from 06/19/22 to 07/28/22 were rejected by CMS. Findings: The CMS Submission Report, dated 08/01/22, documented six resident assessments were rejected for the submission period of 06/19/22 to 07/28/22. The MDS coordinator did not correct and resubmit the resident assessments for approval. On 09/21/22 at 10:45 a.m., the MDS coordinator reported the rejected assessments should have been corrected and resubmitted. On 09/21/22 at 11:00 a.m., the administrator reported the rejected assessments should have been corrected and resubmitted. On 09/21/22 at 11:10 a.m., the DON reported the rejected assessments should have been corrected and resubmitted.

Based on record review, observation, and interview, the facility failed to ensure sanitary conditions were maintained during food preparation. The Resident Census and Conditions of Residents, dated 09/19/21, documented 28 residents ate from the kitchen. Findings: A Daily/Weekly Dietary Cleaning Schedule, dated 08/19/22 to 08/25/22, showed no daily cleaning tasks were performed on 08/25/22 and no weekly tasks were performed A Daily/Weekly Dietary Cleaning Schedule, dated 08/26/22 to 09/01/22, showed no daily or weekly cleaning tasks were performed. On 09/19/22 at 9:25 a.m., a dry black substance was observed on a countertop near the hand washing station. On 09/19/22 at 9:25 a.m., a pack of cigarretes, a disposable lighter, and a cellular phone were observed on a countertop near the hand washing station. On 09/19/22 at 9:30 a.m., a brown, sticky, substance was observed on the bottom shelf of refrigerator number three. On 09/19/22 at 9:30 a.m., a brown, sticky, substance was observed on the door handle of freezer number five. On 09/19/22 at 9:35 a.m., a plastic bin labeled sugar was observed to contain three plastic scoops. On 09/19/22 at 9:40 a.m., the range top burner grates were observed to have black and brown chunks of dried food particles. On 09/20/22 at 9:38 a.m. a brown, sticky, substance was observed on the bottom shelf of refrigerator number three. On 09/20/22 at 9:38 a.m., a brown, sticky, substance was observed on the door handle of freezer number five. On 09/20/22 at 9:40 a.m., a plastic bin labeled sugar was observed to contain three plastic scoops. On 09/20/22 at 9:40 a.m., the range top burner grates were observed to have black and brown chunks of dried food particles. On 09/19/22 at 9:30 a.m., Cook #1 reported the brown, sticky, substance on the bottom shelf of refrigerator number three was tea, they reported they did not what the brown, sticky, substance on the door handle of freezer number five was. On 09/19/22 at 9:30 a.m, the administrator reported the cigarettes, lighter, and cellular phone should not have been placed on a countertop near the hand wasing station. On 09/21/22 at 10:35 a.m., Cook #3 reported they had not cleaned the range the day before. On 09/21/22 at 10:40 a.m, the administrator reported the plastic bin labeled sugar should not have contained any scoops and the range was not clean. The administrator also reported the daily/weekly cleaning schedule should have followed.

Based on observation and interview, the facility failed to maintain an effective pest control program. The Resident Census and Conditions of Residents, dated 09/19/22, documented 28 residents resided in the facility. Findings: On 09/19/22 at 9:25 a.m., a brown insect was observed crawling on the countertop beside the hand washing station in the kitchen. On 09/19/22 at 9:25 a.m., three brown insects were observed crawling inside the cabinet beside the hand washing station in the kitchen. On 09/19/22 at 9:30 a.m., approximately five rodent droppings were observed inside the cabinet beside the hand washing station in the kitchen. On 09/19/22 at 9:35 a.m., approximately ten rodent dropping were observed in a plastic bin, in the dry food storage area, labeled jelly/reg jelly. On 09/19/22 at 9:40 a.m., approximately ten rodent droppings were observed on the floor in the corner of the dry food storage area. On 09/20/22 at 9:40 a.m., approximately five rodent droppings were observed inside the cabinet beside the hand washing station in the kitchen. On 09/20/22 at 9:40 a.m. approximately two brown insects were observed inside the cabinet beside the hand washing station in the kitchen. On 09/20/22 at 9:40 a.m., approximately ten rodent dropping were observed in a plastic bin, in the dry food storage area, labeled jelly/reg jelly. On 09/20/22 at 9:45 a.m., approximately ten rodent droppings were observed on the floor in the corner of the dry food storage area. On 09/20/22 at 10:00 a.m., the administrator identified the brown insects as roaches. On 09/21/22 at 9:37 a.m., Cook #1 identified the brown insects as roaches.

Based on record review and interview, the facility failed to ensure 19 resident assessments of 28 resident assessments reviewed were submitted in the required time frame. A CMS Submission Report, dated 08/01/22, documented 28 resident assessments were submitted. Findings: The CMS Submission Report dated, 08/01/22, read in part . Record submitted late. The submission date is more than 14 days . for 19 resident assessments between the dates of 06/18/22 through 07/16/22. On 09/21/22 at 10:45 a.m., the MDS coordinator reported the assessments were not submitted in the right time frame. On 09/21/22 at 11:00 a.m., the administrator reported the resident assessments should have been submitted within the required time frame. On 09/21/22 at 11:10 a.m., the DON reported the expectation was for the resident assessments to be submitted in the required time frame.

Based on observation, record review, and interview, the facility failed to perform bathing as scheduled for one (#20) of two residents reviewed for bathing. The administrator reported 14 residents required assistance with bathing. Findings: Res #20 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #20's care plan, dated 07/27/22, read in part, .I do require assistance with showering. A document titled, ADL Bathing, documented the resident received a bath on 08/13/22 and 08/27/22 for the month of August 2022. A document titled ADL Bathing, documented the resident received a bath on 09/03/22, 09/10/22, and 09/17/22 for the month of September 2022. Res #20's quarterly assessment, dated 09/15/22, documented the resident required assistance with activities of daily living and was cognitively intact. On 09/19/22 at 09:47 a.m., Res #20 was observed in bed. The resident stated they were not being bathed twice a week as scheduled. On 09/20/22 at 8:45 a.m., Res #20 was observed in bed. On 09/20/22 at 12:25 p.m., the DON reported Res #20's showers were scheduled twice a week on Wednesday and Saturday. The DON reported the showers were not given as scheduled.

Based on observation, interview, and record review, it was determined the facility failed to ensure a physician responded to a pharmacist medication regimen review (MRR) for two (#4 and #13) of five residents sampled for unnecessary medications. The facility failed to: a. respond to a request to reduce an anti-anxiety medication for resident #4 and reduce an anti-anxiety and an anti-depessant medication for resident #13, b. provide a rationale for refusal to reduce an anti-anxiety and antidepressant medication for resident #13. The facility reported 22 residents resided in the facility. Findings: The facility policy related to timeliness of pharmacist recommendation and response documented the physician and/or director of nursing (DON) were requested to acknowledge and act upon recommendations within 30 calendar days of the consultant pharmacist's medication regimen review and recommendations. 1. Resident #4 was admitted to the facility with diagnoses which included Alzheimer's disease, anxiety disorder, and depressive disorder. A physician order, dated 12/17/19, documented the facility was to administer [MEDICATION(S)] (an anti-anxiety medication) 10 milligrams (mg) to the resident daily at bedtime. On 06/11/20 a consulting pharmacist MRR documented a request to the physician to reduce the resident's dosage of [MEDICATION(S)] from 10 mg to 5 mg. The MRR did not document a physician's response to the MRR. A quarterly assessment, dated 03/19/21, documented the resident was intact in cognition and required set up to limited assistance with activities of daily living. The assessment documented the resident received anti-anxiety and antidepressant medications seven of seven days during the assessment period. On 04/27/21 at 10:15 AM, the resident was observed in the dining area. The resident was clean, dressed, and interviewable. The resident reported she was aware of which medications she was on and stated they worked well for her depression and anxiety. On 04/27/21 at 3:52 PM, the DON reported she was unable to locate a physician response to the MRR dated 06/11/20. 2. Resident #13 had diagnosis which included chronic obstructive pulmonary disease, anxiety, depression, and [CONDITION(S)]. A physician order, dated 03/18/19, documented [MEDICATION(S)] (an anti-anxiety medication) 0.5 milligrams (mg) 1 tablet (tab) three times a day for anxiety. A physician order, dated 03/28/20, documented [MEDICATION(S)] (an anti-depressant medication) 100 mg 1 1/2 tabs to equal 150 mg every morning. A physician order, dated 04/17/20, documented ([MEDICATION(S)]) lorazepam (an anti-anxiety medication) 2 milligram per milliliter (ml) may give 0.25 ml every 4 hours as needed (prn) for anxiety or restlessness sublingual. A pharmacy medication review, dated 05/16/20, documented a request to discontinue [MEDICATION(S)] since [MEDICATION(S)] was ordered routine. The physician failed to respond to the request. A pharmacy medication review, dated 08/13/20, documented a request to change [MEDICATION(S)] from 150 mg to 100 mg. The physician documented disagreed and failed to document a rationale. A pharmacy medication review, dated 09/21/20, documented a request to discontinue prn [MEDICATION(S)] since [MEDICATION(S)] was ordered routine. The physician documented disagree and failed to document a rationale. A pharmacy medication review, dated 11/12/20, documented a request to change [MEDICATION(S)] from three times a day to two times a day. The physician failed to respond to the request. A pharmacy medication review, dated 02/18/21, documented a request to change [MEDICATION(S)] from 150 mg to 100 mg. The physician documented disagreed and failed to document a rationale. A quarterly assessment, dated 03/02/21, documented the resident required extensive assistance with activities of daily living. The assessment documented the resident required an anti-anxiety and an anti-depressant medication seven of seven days during the assessment period. A care plan, updated 04/13/21, documented the resident had diagnosis of depression and anxiety. The care plan documented pharmacy consult to review medications monthly to ensure the lowest therapeutic dose to help control symptoms. On 04/29/21 at 9:29 AM, the director of nursing (DON) reported the physician should have responded to the pharmacy review request to reduce [CONDITION(S)] medications and should have provided a rationale for disagreeing with the reductions.

Based on observation, interview, and record review, it was determined the facility failed to ensure the temperature of the medication room was monitored and recorded. The facility identified a census of 22 residents who resided in the facility. Findings: A facility policy documented the temperature of the medication room was to be monitored and recorded to ensure proper storage of drugs and biologicals. On 04/28/21 at 11:30 AM, the medication room was observed to be without a method to determine the temperature of the room. On 04/28/21 at 11:35 AM, certified medication aide #1 reported she was unaware the medication room temperature should have been monitored. On 04/28/21 at 1:15 PM, the director of nursing (DON) reported the thermometer to monitor the medication room temperature was placed on top of the refrigerator. Upon searching the medication room, the thermometer was not found, there were no temperatures documented on the room temperature log. The DON reported the temperatures of the medication room should have been monitored and recorded.

Based on interview and record review, it was determined the facility failed to ensure ongoing collaboration, communication, and required documentation between hospice and the facility was maintained in the facility for one (# 13) of two residents reviewed for hospice services. The facility identified two residents who received hospice services. Findings: 1. Resident #13 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 05/17/18, documented hospice to evaluate and treat. A quarterly assessment, dated 03/02/21, documented the resident required extensive assistance with activities of daily living and received hospice services. A care plan, updated 04/13/21, documented the resident received hospice services. The care plan documented nursing home staff and hospice staff was to work together to provide the most optimal care possible. The hospice agreement documented collaboration and communication would be conducted with the facility. The hospice communication book did not document ongoing collaboration and communication between hospice and the facility. The facility nursing progress notes did not document collaboration and communication between hospice and the facility. On 04/27/21 at 2:12 PM, the director of nursing (DON) reported the physician would give the facility new orders and the facility did not know hospice had requested a change in the plan of care. The DON reported hospice had not collaborated and communicated changes to the resident's plan of care. On 04/27/21 at 2:23 PM, licensed practical nurse (LPN) #1 reported hospice did not collaborate or communicate with the facility related to the resident's condition or updates to the resident's plan of care. The LPN reported hospice did not verbally update or document the results of their visits in the hospice communication book. On 04/28/21 at 9:32 AM, a hospice nurse reported communication was conducted thru verbal communication with the facility and was not documented. The hospice nurse reported the facility would receive physician orders. The hospice nurse reported she did not document the results of the hospice visits in the communication book.

Based on observation, interview, and record review, it was determined the facility failed to ensure a quarterly assessment was accurate for falls with major injury for one (#4) of 17 residents whose assessments were reviewed. The facility identified two residents who experienced falls with injury during the past four months. Findings: Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, reviewed on 10/19/20, documented a plan with interventions to prevent falls. A state reportable incident report, dated 02/14/21, documented the resident was found on the floor in her room face down and had received a 4.7 centimeter laceration to her forehead. The incident report documented she was transferred to the hospital and was diagnosed with a facial fracture and concussion. The incident report documented the steps to prevent reoccurrence (STPR) was to institute 30 minute visual checks and recommend to the resident she wear a helmet. The incident report documented the care plan had been updated. The resident's care plan was reviewed and did not document the new STPR. A state reportable incident form, dated 03/09/21, documented the resident was found lying on the floor face down in front of her wheel chair and was bleeding from her head. The report documented the resident was sent to the hospital and received five staples to her scalp. The STPR documented to remind the resident not to lean too far forward in her wheelchair and to encourage her to wear her helmet. The incident report documented the staff had been in-serviced and the care plan had been updated. The resident's care plan was reviewed and did not document the new STPR. A quarterly assessment, dated 03/19/21, documented the resident was cognitively intact, required supervision to limited assistance with most activities of daily living, and had experienced two falls with minor injury. On 04/27/21 at 10:20 AM, resident #4 was observed in the dining area with a helmet, non skid footwear, and a lap buddy. The resident was interviewed at that time and reported she fell frequently. The resident stated the facility had moved her room closer to the nursing station, checked on her frequently, had given her a helmet to protect her head, and provided a lap buddy which she could put on and take off by herself. On 04/27/21 at 3:15 PM, the minimum data set coordinator reported she was unaware the resident has sustained a fall with fracture on 02/14/21. She stated the quarterly assessment, dated 03/19/21, was inaccurate related to falls. She stated she had not updated the care plan to include the new STPR of falls as she had been unaware of the fall with injury.

Based on interview and record review, it was determined the facility failed to ensure a discharge summary was documented for one (#23) of one resident sampled for discharge to the community. The facility identified four residents who had been discharged in the past four months. Findings: The facility policy and procedure documented when the facility discharged a resident, a discharge summary would be developed. The discharge summary would be a recapitulation of the resident's stay at the facility and the health status of the resident upon discharge. Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse note, dated 03/21/21, documented the resident was discharged to another facility per family request so that the resident could be closer to her family. A discharge assessment, dated 03/31/21, documented the resident was cognitively impaired for daily decision making and required moderate assistance with activities of daily living. The resident's clinical record was reviewed. A discharge summary was not included in the documentation. On 04/28/21 at 1:21 P.M., the director of nursing reported the resident should have a discharge summary in the clinical record, but the discharge summary had not been done.

Based on observation, interview, and record review, it was determined the facility failed to ensure the oxygen humidifier and tubing was monitored for one (#13) of one resident reviewed who required oxygen. The facility failed to ensure the oxygen humidifier and tubing were changed per facility policy. The facility identified two residents who required oxygen. Findings: The policy and procedure labeled oxygen therapy documented oxygen tubing was to be changed on the first and fifteenth of each month and were to be labeled with the change date and the nurse's initials. The policy documented to change humidifier bottles every week and prn and was to be labeled with the change date and the nurse's initials. Resident #13 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 05/17/18, documented the resident may wear oxygen at 2 liters per minute (LPM) via nasal cannula for shortness of breath. A quarterly assessment, dated 03/02/21, documented the resident required extensive assistance with activities of daily living. A care plan, updated 03/02/21, documented the resident was at risk for ineffective airway clearance due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/26/21 at 9:11 AM, the resident was observed lying in bed and was not wearing oxygen. The oxygen humidifier and tubing were not dated when last changed. On 04/26/21 at 12:05 PM, the oxygen humidifier and tubing were not dated when last changed. On 04/27/21 at 9:54 AM, the resident was observed wearing oxygen per nasal cannula. The oxygen humidifier and tubing were not dated when last changed. On 04/27/21 at 2:35 PM, the director of nursing (DON) reported the facility failed to date or document when the oxygen humidifier and tubing were last changed. The DON reported the oxygen humidifier and tubing should have be changed weekly. On 04/27/21 at 3:29 PM, the DON reported neither of the two residents' oxygen humidifier and tubing were dated when last changed. The DON reported the residents' medical record did not document when the oxygen humidifier and tubing were last changed.

On 01/23/15 at 2:43 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to consult with the physician regarding a resident's x-ray report which identified a [MEDICAL CONDITION] and the resident's complaint of increased pain. The physician was not consulted regarding the resident's [MEDICAL CONDITION] until the family requested an appointment with an orthopedic surgeon seven days after the facility received notification of the resident's [MEDICAL CONDITION]. On 01/23/15 the OSDH verified an immediate jeopardy situation existed related to the facility's failure to consult with the physician regarding the resident's [MEDICAL CONDITION] and complaints of increased pain. On 01/23/15 at 2:47 p.m., the administrator and director of nursing (DON) were informed of the IJ situation related to the failure to consult with the physician regarding a resident's [MEDICAL CONDITION] and the resident's complaint of increased pain. The administrator and the DON were informed the immediate jeopardy situation constituted substandard quality of care. The administrator and the DON verbalized understanding. On 01/23/15 at 8:10 p.m., the administrator and the DON provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: PLAN OF REMOVAL OF IMMEDIATE JEOPARY (SIC) (IJ) AT TIDWELL LIVING CENTER 1-23-15 at 8:10 P.M. 1. On 01/23/ , (SIC) all Tidwell Living Center Staff, who have resident contact, will receive the following training: a. CHANGE IN A RESIDENT'S CONDITION OR STATUS i. All employees who have contact with residents must know what constitutes a change in a resident's condition or status ii. All employees who witness a change in a resident's condition or status are responsible for notifying the Charge Nurse, on duty at the time of the observance. iii. A change in a resident's condition or status is: 1. Anything out of the ordinary for what the staff normally observes regarding the resident iv. For Licensed Nursing Personnel, additional and more specific information includes those changes identified in CMS Appendix PP F157:483.10(11) and according to Tidwell Living Center's policy, 'Change in a Resident's condition or Status'. (see attached) v. Who the employees should contact, if they do not feel that the Charge Nurse is responding appropriately to their report. vi. For reference, what constitutes a change in a resident's condition or status will be posted and available in all departments. b. If an employee is not available for training on this date, they will be trained at the earliest date possible and will not be allowed to resume duties, until training is received. 2. On 01/23/2015, all Tidwell Living Center Licensed Nursing Staff will receive the following training: a. PROTOCOL FOR NOTIFYING THE ATTENDING PHYSICIAN OF CHANGES IN A RESIDENT'S CONDITION OR STATUS. i. The Charge Nurse is responsible for ensuring that the resident's Attending Physician or On-Call Physician is notified per Tidwell Living Center's policy, 'Change in a Resident's condition or Status'. (see attached) b. EMERGENCY AND/OR ALTERNATIVE PHYSICIAN CARE i. If the resident's Attending Physician or On-Call Physician is not available, the Charge Nurse is responsible for ensuring that physician contact occurs or that the resident is transferred to the ER, per Tidwell Living Center's policies, 'Emergency and/or Alternative Physician Care' and 'Emergency Physician Care'. (see attached) c. ACCIDENTS AND INCIDENTS - INVESTIGATING AND REPORTING i. What constitutes an incident, according OAC 310:6750-7-5.1 (a-1) and OAC 310.675-7-12.1. (see attached) ii. How to investigate and report an incident, according to Tidwell Living Center's policy, 'Accidents and Incidents-Investigating and Reporting'. (see attached) iii. For reference, what constitutes an incident will be posted and available, at the nurse's desk. d. If a Licensed Nursing Staff is not available for training on this date, they will be trained at the earliest date possible and will not be allowed to resume duties, until training is received. 3. All policies referred to in these trainings, were reviewed and updated, as necessary, prior to initiation of this plan. 4. On 01/23/2015, beginning at 18:00 and continuing until complete, all residents of Tidwell Living Center will receive a comprehensive Nursing assessment, including an assessment for pain, utilizing Tidwell Living Center's form, 'Admission Nursing Assessment' (see attached), in order to insure that no unidentified condition exists, which requires physician notification. 5. This plan will be monitored for compliance, by the following: a. Immediately post-training, employees will be individually assessed for understanding of instructions received. b. At the completion of the comprehensive assessments, (Name deleted staff), RN will review the findings and develop a plan of care, to include notification of the physician, for any newly identified, abnormal findings. c. At the end of each shift, beginning on the January 23, 2015 2pm-10pm shift and ending on the January 26, 2015 6am-2pm shift, (Name deleted staff), RN will receive report, from the on-duty Charge Nurses, with emphasis on identifying any significant changes which may have occurred. If any are reported, (Name deleted staff), will review, with the reporting Charge Nurse, that the appropriate interventions were implemented. d. By 5:00 pm, January 26, 2015, (Name deleted staff), RN and or a qualified RN designee will review the residents' charts, for any unreported significant changes or incidents which may have occurred between 2pm, January 23, 2015 and 2pm, January 26, 2015. If any are identified, appropriate interventions will be implemented. Identification of the responsible Charge Nurse will occur, and disciplinary processes will be implemented. 3. (Name deleted staff), RN or designee, will ensure continued monitoring by implementing routine compliance audits, as determined appropriate by Tidwell Living Center's QA committee. Surveyors interviewed staff on all shifts to verify their knowledge of the facility's policy on physician consultation/notification. The staff verbalized an understanding of the facility's policy of physician consultation/notification. On 01/26/15 at 4:00 p.m., the facility was informed the IJ was removed, effective 01/24/15 at 3:45 a.m., when all components of the plan of removal had been implemented and staff verbalized an understanding of physician consultation/notification. The deficiency remained at the level of actual harm that was not an immediate jeopardy at a pattern level. Based on observation, interview, and record review, it was determined the facility failed to consult with residents' physicians for two (#2 and #3) of six residents who were reviewed for physician consultation/notification. The facility identified a census of ten residents. The facility failed to consult with the physician: a. regarding a [MEDICAL CONDITION] and increased pain for resident #2. The facility failed to consult with the physician regarding a resident's x-ray report which identified a [MEDICAL CONDITION] and the resident's complaint of increased pain. The physician was not consulted regarding the resident's [MEDICAL CONDITION] until the family requested an appointment with an orthopedic surgeon seven days after the facility received notification of the resident's [MEDICAL CONDITION]. b. regarding a fall for resident #3. The resident census and condition report documented ten residents lived at the facility. Findings: The facility policy on change in a resident's condition documented the facility would promptly notify the resident, their attending physician, and representative of changes in the resident's medical/mental condition and in the level of care. The policy documented the nursing supervisor and or charge nurse would notify the resident's attending physician or an on-call physician when there had been a discovery of injuries of an unknown source. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 01/30/14, documented the resident had cognitive loss and dementia. The care plan documented the resident had impaired mobility related to right sided [MEDICAL CONDITION] and required assistance with activities of daily living needs. The care plan documented the resident had pain related to right sided [MEDICAL CONDITION]. The care plan documented the resident had impaired verbal communication. A quarterly assessment, dated 11/19/14, documented the resident was moderately impaired with cognition. The assessment documented the resident required extensive assistance with bed mobility and transfers. The assessment documented the resident had impairment on one side of the upper and lower extremity. A nurse note, dated 12/27/14 at 11:50 p.m., documented the resident was crying out in pain and complaining of severe right leg pain. The nurse note documented two [MEDICATION NAME] 50 milligrams were administered. A nurse note, dated 12/28/14 at 7:40 a.m., documented the resident was crying out and complaining of pain to the right leg. The nurse note documented two [MEDICATION NAME] 50 milligrams were administered. A fax report, dated 12/28/14 at 1:40 p.m., documented, For the last three days the resident has been experiencing severe leg pain especially when moved and it appears to be contracting more with the beginning of foot drop. The fax documented, The spouse would like to obtain an actual appointment with physician for evaluation for possible routine medication to help her pain and possibly allow her to be more compliant with restorative exercises. On 12/31/14 at 12:43 p.m., the facility received a x-ray report. The x-ray report documented the resident had a right femoral neck fracture with superior displacement of the femoral shaft in relation to the femoral head. The fax verification report documented the facility sent the x-ray report to the physician via fax at 12:08 a.m. on 12/31/14. A fax transmittal, dated 01/05/15, documented the resident's husband wanted an appointment with the physician to consult regarding the results of the resident's x-ray results from 12/31/14. A nurse note, dated 01/05/15 at 4:00 p.m., documented a telephone call was placed to the physician stating the resident's spouse requested an appointment. The nurse note documented the family requested the x-ray report and written request be sent via fax. The note documented the facility was awaiting a call from the physician. A nurse note, dated 01/06/15, no documented time, documented the resident's spouse wanted an appointment with an orthopedic surgeon. The nurse note documented the resident's spouse reported his daughter was getting the resident an appointment. A nurse note, dated 01/07/15 at 7:00 a.m., documented the resident's family was at the facility to take the resident to the orthopedic surgeon's office for an appointment and a x- ray of the right hip. A nurse note, dated 01/07/15 at 2:15 p.m., documented the facility received a telephone call from the resident's family member. The note documented the family member reported the resident was scheduled for surgery to her right hip on January 15, 2015. On 01/20/15 at 2:50 p.m., the resident was observed sitting in a wheelchair in the front lobby. On 01/23/15 at 10:58 a.m., physician #2 was interviewed regarding notification of the resident's x- ray results, dated 12/31/14, that documented a [MEDICAL CONDITION]. The physician reported his office was closed from 12/31/14 to 01/04/15. The physician reported he had not been made aware of the situation until after an orthopedic surgeon had been consulted. The physician reported he had not been notified of the resident's increased pain until 12/28/14 when he was notified via fax. On 01/23/15 at 11:45 a.m., licensed practical nurse (LPN) #1 was interviewed regarding the facility's policy for assessment and monitoring a resident who complained of pain. The LPN reported if a staff member reported a resident complained of pain she would assess that resident and ask the certified medication aide (CMA) what could be given to the resident. The LPN reported if the resident's pain was not relieved within one hour the resident's physician should be notified. On 01/23/15 at 12:22 p.m., the director of nursing (DON) was interviewed regarding the assessment and monitoring of a resident after the [DIAGNOSES REDACTED]. The DON reported if a resident was diagnosed with [REDACTED]. The DON reported if the facility was unable to contact the resident's physician, the resident should have been sent to the emergency room to be evaluated. The DON reported the facility could have called the medical director. The DON was asked what was done for the resident from the time the facility found out the resident was diagnosed with [REDACTED]. The DON reported she could see how that could be a concern. The DON was interviewed related to the fax report, dated 12/28/14, regarding the resident who had complained of pain for three days. The DON reported if the nurse documented the resident had an increase in pain, there must have been a change in the resident's condition. The DON reported she did not think a fax to notify the physician was a good idea. The DON reported the physician should have been notified. The DON reported this was a problem. The DON reported pain control was important. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, updated 02/13/14, documented the resident had experienced no falls and was dependent on staff for support with transfers. The care plan documented the resident ambulated with the aide of two staff members. A comprehensive assessment, dated 05/13/14, documented the resident ambulated with the assist of two staff members. Nurse notes, dated 07/16/14, documented the resident was found on the floor next to her bed. The nurse notes documented the charge nurse was notified. There was no documentation of physician notification. A comprehensive assessment, dated 09/21/14, documented the resident did not ambulate. The assessment documented the resident propelled self via wheelchair with neck and back support. On 01/20/15 at 12:35 p.m., the resident was observed in the dining room waiting on the noon meal. The resident was observed to roll her wheelchair back and forth from the table. On 01/22/15 at 2:40 p.m., the director of nurses (DON) reported she had reviewed her nursing notes from 07/16/14. The DON stated the physician was not notified at the time of the incident.

On 01/23/15 at 2:43 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to thoroughly assess, monitor, and provide interventions for a resident who had experienced a [MEDICAL CONDITION] and had complaints of increased pain. The physician was not consulted regarding the resident's [MEDICAL CONDITION] until the family requested an appointment with an orthopedic surgeon seven days after the facility received notification of the resident's [MEDICAL CONDITION]. On 01/23/15 the OSDH verified an immediate jeopardy situation existed related to the facility's failure to thoroughly assess, monitor, and provide interventions for a resident who had experienced a [MEDICAL CONDITION] and had complaints of increased pain. On 01/23/15 at 2:47 p.m., the administrator and director of nursing (DON) were informed of the IJ situation related to the the facility's failure to thoroughly assess, monitor, and provide interventions for a resident who had experienced a [MEDICAL CONDITION] and had complaints of increased pain. The administrator and the DON were informed the immediate jeopardy situation constituted substandard quality of care. The administrator and the DON verbalized understanding. On 01/23/15 at 8:10 p.m., the administrator and the DON provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: PLAN OF REMOVAL OF IMMEDIATE JEOPARY (SIC) (IJ) AT TIDWELL LIVING CENTER 1-23-15 at 8:10 P.M. 1. On 01/23/ , (SIC) all Tidwell Living Center Staff, who have resident contact, will receive the following training: a. CHANGE IN A RESIDENT'S CONDITION OR STATUS i. All employees who have contact with residents must know what constitutes a change in a resident's condition or status ii. All employees who witness a change in a resident's condition or status are responsible for notifying the Charge Nurse, on duty at the time of the observance. iii. A change in a resident's condition or status is: 1. Anything out of the ordinary for what the staff normally observes regarding the resident iv. For Licensed Nursing Personnel, additional and more specific information includes those changes identified in CMS Appendix PP F157:483.10(11) and according to Tidwell Living Center's policy, 'Change in a Resident's condition or Status'. (see attached) v. Who the employees should contact, if they do not feel that the Charge Nurse is responding appropriately to their report. vi. For reference, what constitutes a change in a resident's condition or status will be posted and available in all departments. b. If an employee is not available for training on this date, they will be trained at the earliest date possible and will not be allowed to resume duties, until training is received. 2. On 01/23/2015, all Tidwell Living Center Licensed Nursing Staff will receive the following training: a. PROTOCOL FOR NOTIFYING THE ATTENDING PHYSICIAN OF CHANGES IN A RESIDENT'S CONDITION OR STATUS. i. The Charge Nurse is responsible for ensuring that the resident's Attending Physician or On-Call Physician is notified per Tidwell Living Center's policy, 'Change in a Resident's condition or Status'. (see attached) b. EMERGENCY AND/OR ALTERNATIVE PHYSICIAN CARE i. If the resident's Attending Physician or On-Call Physician is not available, the Charge Nurse is responsible for ensuring that physician contact occurs or that the resident is transferred to the ER, per Tidwell Living Center's policies, 'Emergency and/or Alternative Physician Care' and 'Emergency Physician Care'. (see attached) c. ACCIDENTS AND INCIDENTS - INVESTIGATING AND REPORTING i. What constitutes an incident, according OAC 310:6750-7-5.1 (a-1) and OAC 310.675-7-12.1. (see attached) ii. How to investigate and report an incident, according to Tidwell Living Center's policy, 'Accidents and Incidents-Investigating and Reporting'. (see attached) iii. For reference, what constitutes an incident will be posted and available, at the nurse's desk. d. If a Licensed Nursing Staff is not available for training on this date, they will be trained at the earliest date possible and will not be allowed to resume duties, until training is received. 3. All policies referred to in these trainings, were reviewed and updated, as necessary, prior to initiation of this plan. 4. On 01/23/2015, beginning at 18:00 and continuing until complete, all residents of Tidwell Living Center will receive a comprehensive Nursing assessment, including an assessment for pain, utilizing Tidwell Living Center's form, 'Admission Nursing Assessment' (see attached), in order to insure that no unidentified condition exists, which requires physician notification. 5. This plan will be monitored for compliance, by the following: a. Immediately post-training, employees will be individually assessed for understanding of instructions received. b. At the completion of the comprehensive assessments, (Name deleted staff), RN will review the findings and develop a plan of care, to include notification of the physician, for any newly identified, abnormal findings. c. At the end of each shift, beginning on the January 23, 2015 2pm-10pm shift and ending on the January 26, 2015 6am-2pm shift, (Name deleted staff), RN will receive report, from the on-duty Charge Nurses, with emphasis on identifying any significant changes which may have occurred. If any are reported, (Name deleted staff), will review, with the reporting Charge Nurse, that the appropriate interventions were implemented. d. By 5:00 pm, January 26, 2015, (Name deleted staff), RN and or a qualified RN designee will review the residents' charts, for any unreported significant changes or incidents which may have occurred between 2pm, January 23, 2015 and 2pm, January 26, 2015. If any are identified, appropriate interventions will be implemented. Identification of the responsible Charge Nurse will occur, and disciplinary processes will be implemented. 3. (Name deleted staff), RN or designee, will ensure continued monitoring by implementing routine compliance audits, as determined appropriate by Tidwell Living Center's QA committee. Surveyors interviewed staff on all shifts to verify their knowledge of the facility's policy related to assessments, monitoring, and provision of interventions. The staff verbalized an understanding of the facility's policy for assessing, monitoring, and providing interventions for residents who experienced a change in condition. On 01/26/15 at 4:00 p.m., the facility was informed the IJ was removed, effective 01/24/15 at 3:45 a.m., when all components of the plan of removal had been implemented and staff verbalized an understanding inservices related to providing interventions for residents who had experienced a change in conditions. The deficiency remained at the level of actual harm that was not an immediate jeopardy at a pattern level. Based on observation, interview, and record review, it was determined the facility failed to provide care and services to ensure residents' highest levels of well-being for two (#1 and #2) of six residents sampled for well-being. The facility failed to thoroughly assess, monitor, and/or provide interventions for: a. resident #2 after they had received an x ray report of the resident's [MEDICAL CONDITION] and for complaints of increased pain. Resident #2 had experienced a [MEDICAL CONDITION] and had complaints of increased pain. The physician was not consulted regarding the resident's [MEDICAL CONDITION] until the family requested an appointment with an orthopedic surgeon seven days after the facility received notification of the resident's [MEDICAL CONDITION]. b. resident #1 after a documented fall. The resident census and condition report documented ten residents lived at the facility. Findings: The facility policy on accidents and incidents documented all accidents or incidents involving residents would be investigated and reported to the administrator. The policy documented the nurse supervisor or the department director or supervisor would promptly initiate and document investigation of the accident or incident. The facility policy on change in a resident's condition or status documented if a significant change in the resident's physical or mental condition occurred, a comprehensive assessment of the resident's condition would be conducted. The facility policy on pain assessment and management documented the facility would conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain or worsening of existing pain. The policy documented the facility would assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain. The facility policy on pain management documented the facility would re-assess a resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 01/30/14, documented the resident had cognitive loss and dementia. The care plan documented the resident had impaired mobility related to right sided [MEDICAL CONDITION] and required assistance with activities of daily living needs. The care plan documented the resident had pain related to right sided [MEDICAL CONDITION]. The care plan documented the resident had impaired verbal communication. A quarterly assessment, dated 11/19/14, documented the resident was moderately impaired with cognition. The assessment documented the resident required extensive assistance with bed mobility and transfers. The assessment documented the resident had impairment on one side of the upper and lower extremity. A nurse note, dated 12/27/14 at 11:50 p.m., documented the resident was crying out in pain, complaining of severe right leg pain. The nurse note documented two [MEDICATION NAME] 50 milligrams were administered. A nurse note, dated 12/28/14 at 7:40 a.m., documented the resident was crying out in pain of the right leg. The nurse note documented two [MEDICATION NAME] 50 milligrams were administered. A fax report, dated 12/28/14 at 1:40 p.m., documented, For the last three days the resident has been experiencing severe leg pain especially when moved and it appears to be contracting more with the beginning of foot drop. The fax documented, the spouse would like to obtain an actual appointment with physician for evaluation for possible routine medication to help her pain and possibly allow her to be more compliant with restorative exercises. On 12/31/14 at 12:43 p.m., the facility received a x-ray report. The x-ray report documented the resident had a right femoral neck fracture with superior displacement of the femoral shaft in relation to the femoral head. The fax verification report documented the facility sent the x-ray report to the physician via fax at 12:08 a.m. on 12/31/14. A fax transmittal, dated 01/05/15, documented the resident's husband wanted an appointment with the physician to consult regarding the results of the resident's x-ray results from 12/31/14. A nurse note, dated 01/05/15 at 4:00 p.m., documented a telephone call was placed to the physician stating the resident's spouse requested an appointment. The nurse note documented the family requested the x-ray report and written request be sent via fax. The note documented the facility was awaiting a call from the physician. A nurse note, dated 01/06/15, no documented time, documented the resident's spouse wanted an appointment with an orthopedic surgeon. The nurse note documented the resident's spouse reported his daughter was getting the resident an appointment. A nurse note, dated 01/07/15 at 7:00 a.m., documented the resident's family was at the facility to take the resident to the orthopedic surgeon's office for an appointment and a x- ray of the right hip. A nurse note, dated 01/07/15 at 2:15 p.m., documented the facility received a telephone call from the resident's family member. The note documented the family member reported the resident was scheduled for surgery to her right hip on January 15, 2015. On 01/20/15 at 2:50 p.m., the resident was observed sitting in a wheelchair in the front lobby. On 01/23/15 at 10:58 a.m., physician #2 was interviewed regarding notification of the resident's x- ray results, dated 12/31/14, that documented a [MEDICAL CONDITION]. The physician reported his office was closed from 12/31/14 to 01/04/15. The physician reported he had not been made aware of the situation until after an orthopedic surgeon had been consulted. The physician reported he had not been notified of the resident's increased pain until 12/28/14 when he was notified via fax. On 01/23/15 at 11:45 a.m., licensed practical nurse (LPN) #1 was interviewed related to the facility policy regarding assessment and monitoring a resident who complained of pain. The LPN reported if a staff member reported a resident was complaining of pain she would assess that resident and ask the certified medication aide (CMA) what could be given to the resident. The LPN reported if the resident's pain was not relieved within one hour the resident's physician should be notified. On 01/23/15 at 12:22 p.m., the director of nursing (DON) was interviewed regarding the assessment and monitoring of a resident after the [DIAGNOSES REDACTED]. The DON reported if a resident was diagnosed with [REDACTED]. The DON reported if the facility was unable to contact the resident's physician, the resident should be sent to the emergency room to be evaluated. The DON reported the facility could have called the medical director. The DON was asked what was done for the resident from the time the facility found out the resident was diagnosed with [REDACTED]. The DON reported she could see how that could be a concern. The DON was interviewed related to the fax report, dated 12/28/14, regarding the resident who had complained of pain for three days. The DON reported if the nurse documented the resident had an increase in pain, there must have been a change in the resident's condition. The DON reported she did not think a fax to notify the physician was a good idea. The DON reported the physician should have been notified. The DON reported this was a problem. The DON reported pain control was important. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 05/17/14, and a quarterly assessment, dated 11/20/14, documented the resident had severely impaired cognition. The assessment documented the resident required extensive assistance with activity of daily living needs. The quarterly assessment documented the resident had experienced a fall. The care plan, dated 05/28/14, was reviewed. The care plan did not include the resident's falls. An incident report, dated 08/26/14, did not include comments or steps taken to prevent recurrence. Nurse notes, dated 08/26/14, did not include an assessment after the fall. An incident report, dated 10/10/14, documented the resident had experienced a fall. Nurse notes, dated 10/04/14, did not include an assessment after the fall. On 01/20/15 at 10:25 a.m., the resdient was observed sitting in a wheel chair at the nurses' desk. On 01/21/15 at 11:00 a.m., the director of nursing (DON) was interviewed regarding the prevention of recurrence after an incident report was completed. The DON reported the staff should have included steps to prevent recurrence. The DON was asked if the incident reports were complete. The DON stated the incident reports were not complete. The DON was asked if the nursing staff documented in the clinical record after an incident. The DON reported there was no documentation in the clinical record after each of the incidents.