Every finding on record at University Park Skilled Nursing and Therapy Memory

Based on record review and interview, the facility failed to ensure that annual competency reviews were completed for 2 (CNA #2 and CNA #3) of 5 staff members reviewed for annual competency reviews. The administrator identified 49 residents resided in the facility. Findings: 1. CNA #3 was hired on 04/10/03. 2. CNA #2 was hired on 04/11/22. CNA #3 and CNA #2's personnel files were reviewed and did not contain annual competency reviews. On 03/06/25 at 2:37 p.m., the administrator was asked to provide documentation of the annual competency reviews for CNA #3 and CNA #2. On 03/10/25 at 1:20 p.m., the administrator stated they were unable to locate the annual competency reviews for CNA #3 and CNA #2.

Based on record review and interview, the facility failed to perform post fall neurological checks for 1 (#49) of 1 death record reviewed. The administrator identified 49 residents resided in the facility. Findings: The Fall Program policy, revised 05/24, read in part, Complete incident report and include neurological check sheet if suspect or confirmed the resident hit their head. Resident #49 had diagnoses which included epilepsy, history of falling, and unspecified sequelae of cerebral infarction. An Incident Report, dated 01/12/25, read in part, Unwitnessed fall. Resident was found by staff on the floor in prone position in front of his wheelchair in the lobby. Full head to toe assessment completed at the time of incident. Laceration to forehead with moderate bleeding noted. Laceration to right hand with moderate bleeding noted. Pressure dressing applied to both sites and EMS contacted. EMS left with resident at approximately 2000 [8:00 p.m.] Notified DON, administrator and son of transfer. A hospital Patient Discharge Instructions, dated 01/12/25 at 10:27 p.m., showed visit diagnoses of closed head injury, facial laceration, skin tear of right hand without complication, and cervical sprain. There was no documentation 72 hours neurological checks were completed for Resident #49 upon their return to the facility. On 03/06/25 at 11:44 a.m., the DON stated they could not locate neurological checks for Resident #49's fall that occurred on 01/12/25. On 03/06/25 at 2:39 p.m., the ADON stated neurological checks were to be completed for three days if a resident had an unwitnessed fall or if they hit their head. On 03/06/25 at 2:40 p.m., the ADON stated if a resident had a diagnosis of closed head injury post fall, neurological checks will be initiated upon return to the facility. On 03/06/25 at 2:43 p.m., the ADON stated Resident #49 returned to the facility on [DATE]. On 03/06/25 at 2:45 p.m., the ADON stated they could not locate the neurological checks for Resident #49 upon their return to the facility.

Based on observation, record review, and interview, the facility failed to ensure oxygen concentrator filters were sanitary for 1 (#39) of 2 sampled residents reviewed for respiratory care. The administrator identified seven residents received oxygen in the facility. Findings: On 03/04/25 at 2:12 p.m., Resident #39's oxygen concentrator filters were observed to have moderate dust build up. The Cleaning Oxygen Concentrators policy, revised 02/27/20, read in part, Oxygen concentrators are cleaned monthly or every four weeks, and as needed. Resident #39 had diagnoses which included shortness of breath and sleep apnea. On 03/06/25 at 2:08 p.m., LPN #2 stated the filters were dirty and had dust build up. They stated they needed to be cleaned. On 03/06/25 at 2:10 p.m., the DON stated the oxygen concentrator filters were to be cleaned monthly. They stated they put an order in the system for the cleaning to keep track but no order was needed. On 03/06/25 at 2:14 p.m., LPN #2 reviewed Resident #39's orders. They stated there was no order to clean the oxygen concentrator filters. On 03/06/25 at 2:29 p.m., LPN #2 stated they did not remember when Resident #39's oxygen concentrator filters were cleaned.

Based on record review and interview, the facility failed to ensure post dialysis documentation had been completed for 1 (#26) of 1 sampled resident reviewed for dialysis. The facility MDS [minimum data set] Resident Matrix, showed one resident received dialysis. Findings: Resident #26 had diagnoses which included end stage renal disease. The Dialysis Communication forms, read in part, B. Post Dialysis This section to be completed by dialysis unit and returned with the resident: A. Blood pressure B. Pulse C. Respirations D. Temperature E. Pre dialysis weight E1. Post dialysis weight F. Time dialysis started G. Time dialysis ended H. Check all that apply 1. dressing dry and intact 2. ports capped and clamped 3. pain 4. bleeding 5. new orders sent with resident 6. s/s of infection. A physician's order, dated 08/22/22, showed the resident was to receive dialysis weekly Tuesday, Thursday, and Saturday. A quarterly resident assessment, dated 02/20/25, showed the resident was cognitively intact and received dialysis while in the facility. The Dialysis Communication forms dated, 02/19/25, 02/22/25, 02/27/25, and 03/04/25 did not have documentation for post dialysis. On 03/06/25 at 10:20 a.m., LPN #2 stated the process for post dialysis documentation was to get the residents weight when they returned. They stated the night nurse would send the paper and the resident brought it back. LPN #2 stated the assessment was filled out and printed and sent with the resident then uploaded to the electronic medical record after. On 03/06/25 at 10:34 a.m., LPN #2 stated if it was not scanned in then they go back and fill it out. LPN #2 looked in the electronic medical records and verified they did not see documentation for post dialysis on 02/19/25, 02/22/25, 02/27/25, and 03/04/25. They stated they had spoke to the corporate person and provided documents for those dates stating if they were not saved correctly it would not show but would show when printed. Both the LPN #2 and surveyor reviewed the printed documents and there was no documentation for 02/19/25, 02/22/25, 02/27/25, and 03/04/25. On 03/06/25 at 11:44 a.m., the DON stated they were aware of the dialysis documentation issue and had already started and inservice and provided the documents. On 03/06/25 at 11:46 a.m., the DON stated the inservice was 02/17/25. They were informed the missing documentation for post dialysis was after the date of the inservice.

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were implemented for 1 (#30) of 1 sampled resident reviewed for urinary catheters. The DON reported five residents with urinary catheters. Findings: On 03/07/25 at 8:19 a.m., LPN #1 and the ADON were observed providing catheter care for Resident #30, they were not observed to be wearing gowns. An Infection Control and Isolation Policy, revised 03/28/24, read in part, EBP are indicated for residents with any of the following .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO.EBP expands the use of PPE [personal protective equipment] and refer to the use of gown and gloves during high-contact resident care activities. Resident #30 had diagnoses which included benign prostate hyperplasia and diabetes mellitus. A physician's order, dated 10/31/24, showed catheter care was to be completed every shift and as needed. A physician's order, revised 11/01/24, showed enhanced barrier precautions were to be used because Resident #30 had an indwelling catheter. An annual assessment, dated 01/09/25, showed Resident #30 was moderately impaired for daily decision making and had an indwelling urinary catheter. On 03/07/25 at 8:25 a.m., LPN#1 stated they should have been wearing a gown while performing catheter care. On 03/10/25 at 2:50 p.m., the DON stated EBP should be used when providing direct patient care to any resident with an indwelling catheter.

Based on record review and interview, the facility failed to follow the regulatory requirements for transfer and discharge a resident for one (#1) of one sampled resident reviewed for discharge. The charge nurse reported the census was 49. Findings: Resident #1 had diagnoses which included dementia and psychotic disorder. A nurse's note, dated 01/01/25 at 8:30 p.m., documented LPN #1 notified RN #1 that Resident #1 was threatening to leave the facility and stating they could not force them to stay in the facility. The note also documented the on call physician was contacted and they requested a BIMS assessment (an assessment to determine cognitive statue) be completed. The note documented the assessment was completed and the resident was cognitively intact. The note documented if the resident insisted on discharging the discharge would be AMA. A police report #2501T0167, dated 01/01/25, documented a police officer observed Resident #1 standing on the side of the road. The report stated the police officer contacted Resident #1 and they reported they had been kicked out of the motel. The report stated the police officer then transported the resident back to the facility and when the officer went to the door of the facility, they saw a note stating staff had been instructed not to open the door and to contact RN #1 for assistance. The police report documented the police officer contacted RN #1 and a short time later the facility came out and took Resident #1 inside. On 01/24/25 at 11:40 a.m., RN #1 stated the police located Resident #1 and brought them back to the facility. They also stated when Resident #1 arrived at the facility they stated they did not want to go back to the facility, they wanted to go to the hospital or a motel. RN #1 further stated they, along with CMA #1, attempted to take Resident #1 to the hospital. RN #1 stated on the way to the hospital Resident #1 decided they did not want to go to the hospital, but wanted to go to a motel instead. RN #1 stated they explained to the resident the discharge would be against medical advice and they would need to sign an AMA form. They stated the resident refused to sign the AMA form and CMA #1 witnessed the refusal. RN #1 stated they rented Resident #1 a room at the motel and left the resident. On 01/24/25 at 1:18 p.m., LPN #1 stated on 01/01/25 at approximately 8:30 p.m. they entered Resident #1's room to administer medications and discovered the window was open and Resident #1 was missing. LPN #1 stated they notified other staff on duty and searched the facility and the grounds. LPN #1 stated they were unable to locate Resident #1. LPN# 1 stated they contacted the police and RN #1 who was not on duty at the time. LPN #1 stated RN #1 instructed them that RN #1 would enter the documentation into Resident #1's medical record regarding the incident. LPN #1 reviewed the nurse's note dated 01/01/25 at 8:30 p.m. and stated it was not an accurate account of the incident. On 01/24/25 at 1:28 p.m., CMA #1 stated they did not accompany RN #1 to the motel with Resident #1. They also stated they did not witness RN #1 offer an AMA form for Resident #1 to sign. On 01/27/25 at 12:34 p.m., LPN #1 stated on 01/01/25 after RN #1 left Resident #1 at the motel, the other nurse on duty got a call from RN #1 instructing them not to let the resident back in the facility and to have them call RN #1. LPN#1 stated the other nurse on duty then put the note on the door. LPN #1 stated on 01/01/25 at 11:47 p.m., they received a text message from RN #1 that read don't let [them] in, followed a short time later by a text from RN #1 telling them to admit the resident.

Based on record review and interview, the facility failed to provide supervision to prevent elopement for one (#1) of three sampled residents reviewed for elopement. The charge nurse reported the census was 49. Findings: Resident #1 had diagnoses which included dementia and psychotic disorder. A care plan, initiated 12/12/24, documented Resident #1 was at risk for leaving the facility related to confusion and they needed staff to monitor their location. A Medicare five-day assessment, dated 12/13/24, documented Resident #1 was severely impaired for daily decision making. A nurse's note, dated 12/16/24 at 12:40 a.m., documented Resident #1 was going into other resident rooms and required redirection. A nurse's note, dated 12/16/24 at 1:25 a.m., documented Resident #1 had blocked the entrance to their room and Resident #1 had opened their window more than once during this shift. A nurse's note, dated 12/16/24 at 4:43 a.m., documented Resident #1 had been going into other resident rooms. A nurse's note, dated 12/19/24 at 2:49 p.m., documented Resident #1 had been wandering and exit seeking and was moved to the dementia care unit. An elopement risk scale, completed 12/20/24, documented Resident #1 was at high risk for elopement. On 01/27/25 at 11:00 a.m., LPN #2 stated the windows on the memory care unit that open toward the road have alarms. They also stated nursing staff do not routinely monitor the alarms for functionality, but if they notice a problem they reported it to maintenance. On 01/27/25 at 11:38 a.m., the maintenance supervisor reported that they usually checked on the window alarms in the morning, but there was no documentation of routine monitoring or testing. On 01/27/25 at 12:35 p.m., LPN #1 stated on 01/01/25 at approximately 8:30 p.m. they entered Resident#1's room to administer medications and discovered the window was open and Resident #1 was missing. LPN #1 stated they notified other staff on duty and searched the facility and the grounds. They stated they were unable to locate Resident #1. The window alarm was not sounding. The clinical record was reviewed did not document the elopement. On 01/27/25 at 2:38 p.m., the corporate administrator stated they could not say for sure if the alarm was disabled by the resident or was not functioning.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for one (#1) of three sampled residents reviewed for elopement. The charge nurse reported the facility census was 49. Findings: A facility policy titled Content of Resident Medical Records, revised on 08/19/03, read in part, A medical record is to be completed as a confidential medicolegal document containing sufficient data to identify the resident, justify the diagnosis and treatment, and document the end results accurately. Resident #1 had diagnoses which included dementia and psychotic disorder. A nurse's note, dated 01/01/25 at 8:30 p.m., documented LPN #1 notified RN #1 that Resident #1 was threatening to leave the facility and stating that they could not force them to stay in the facility. The note also documented that the on call physician was contacted and they requested a BIMS assessment (an assessment to determine cognitive statue) be completed. The note documented the assessment was completed and the resident was cognitively intact. The note documented that if the resident insisted on discharging the discharge would be AMA. On 01/27/25 at 12:35 p.m., LPN #1 stated on 01/01/25 at approximately 8:30 p.m. they entered Resident #1's room to administer medications and discovered the window was open and Resident #1 was missing. LPN #1 stated they notified other staff on duty and searched the facility and the grounds. They stated they were unable to locate Resident #1. LPN # 1 stated they contacted the police and RN #1 who was not on duty at the time. LPN #1 stated RN #1 instructed them that RN #1 would enter the documentation into Resident #1's medical record regarding the incident. LPN #1 reviewed the nurse's note dated 01/01/25 at 8:30 p.m. and stated it was not an accurate account of the incident.

Based on observation, record review, and interview, the facility failed to ensure food and dishes were stored properly. The administrator identified all residents received services from the kitchen. Findings: A Food Storage policy, dated 04/20/09, read in part, .Storage: Area .floor should be .regularly cleaned .Shelving should be .cleaned .Any opened products should be placed in zip lock bags . On 11/27/23 at 12:28 p.m., a tour of the kitchen was conducted. The following observations were made: a. a blue bag of shredded cheese and a gallon bag of sliced cheese were not sealed or dated in the walk in refrigerator, b. several beans were observed on bottom shelf in dry storage not in a container/bag, c. a container of all purpose mix with the lid not secured in the dry storage, d. one potato on the floor under empty crates in the dry storage area, and e. different sized bowls and plates on multiple shelves next to dishwasher area were faced up and not inverted. On 11/28/23 at 10:00 a.m., a follow up tour of the kitchen was conducted. The following observations were made: a. several beans observed on bottom shelf in dry storage not in a container/bag, b. one potato on the floor under empty crates in the dry storage area, and c. different sized bowls and plates on multiple shelves next to dishwasher area were faced up and not inverted. On 11/28/23 at 10:15 a.m., Cook #1 was observed to obtain and use one of the bowls that had been observed stored up and not inverted. On 11/28/23 at 10:30 a.m., Cook #1 and DA #1 were asked how were items stored in the walk in refrigerator. Cook #1 stated items were covered then dated. DA #1 stated items were placed in a zip lock bag, or covered with aluminum foil or plastic wrap. They were asked if different types of cheese were to be sealed. DA #1 stated, Yes. Cook #1 stated, If it was open, it would dry out and be nasty. DA #1 was asked how were dishes stored. They stated they should be inverted. DA #1 was shown the dishes and was asked if the dishes should be stored inverted. They stated, Yes. Cook #1 was asked how were opened packages of food stored in the dry storage. They stated they should be dated and in a zip lock bag or container. Cook #1 was asked how staff ensured items were stored properly. They stated, I do it if I open it. Cook #1 was shown several beans on the shelf on the shelf in the dry storage. They were asked if the beans were stored properly. They stated, No. Cook #1 was shown the potato on the floor in the dry storage area and was asked if it was stored properly. They stated, They are suppose to move everything and sweep at night.

Based on observation, record review, and interview, the facility failed to ensure activities were provided for two (#52 and #53) of 24 sampled residents reviewed for activities. The administrator identified 52 residents resided in the facility. Findings: An Activities Policy, dated 03/07/01, read in part .It is the policy of this facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each elder . 1. Resident #52 had diagnoses which included, dementia, Alzheimer's disease, anemia, and depressive disorder. Resident #52's admission assessment, dated 06/22/23, documented Resident #52's activity preferences as very important to have books and magazines to read, listen to music, be around animals, keep up with the news, do their favorite activities, go outside when the weather was good, and participate in religious services or practices. On 11/28/23 at 10:17 a.m., Resident #52 was observed sitting in their room watching television and was asked if they participated in activities. They stated no they can't even go outside. They were asked if they would like other activities. They stated, There was nothing to do here except watch tv and sit around, use to be church, quit doing that. 2. Resident #53 had diagnoses which included dementia, anxiety, and high blood pressure. An admission assessment, dated 10/17/23, documented Resident #53's preferences for routine and activities as very important to listen to music, be around animals, do things with groups of people, do their favorite activities, and go outside when the weather was good. A November 2023 activities calendar documented on 11/29/23 there was reading hour at 10:00 a.m., exercise at 11:45 a.m., and movie and popcorn at 3:00 p.m. scheduled. The activities calendar did not correctly document dates for scheduled activities. On 11/27/23 at 1:19 p.m., Resident #53 was observed sitting in their room watching television and was asked about participating in activities. They stated they had not seen any activities that they knew of. On 11/28/23 at 10:28 a.m., LPN #3 was asked what structured activities had been provided. They stated they had not seen any structured activities in the unit for about two months. On 11/28/23 at 2:05 p.m., Resident #53 was observed sitting in the common area in memory unit. There was not a structured activity being conducted at this time in the memory unit. An observation was made of six residents in the non secured units participating in activities. On 11/28/23 at 3:00 p.m., five residents were observed in the common area in the memory care unit watching television and having popcorn. On 11/29/23 at 9:34 a.m., the activities assistant was asked how do they individualize activities to accommodate the residents preferences. They stated there was calendar planning's on what the residents wanted monthly. They were asked if they did individual activities for those who did not like to participate in group settings. They stated Somewhat, most of them who don't like to participate in group settings don't want to do anything at all. They were asked how often residents were assessed for activities preferences. They stated if there was a significant change. They were asked who is responsible to provide activities in the memory care unit. They stated they were, and tried to go there once a day with something. They were asked if they were aware Resident #52 wanted church services. They stated, Yes [Resident #52 name withheld] had told me that on admission. The activities assistant was asked if they had talked to Resident #53 about their activity preferences since admission. They stated, they had talked to Resident #53. They were asked what activities had been provided yesterday in the memory care unit. They stated a movie and popcorn. On 11/29/23 at 2:16 p.m., the administrator was asked if there were church services on the weekends. They stated there were church services. They were asked why Resident #52 would state there were no longer church services. The administrator stated there had been an outbreak of COVID and maybe they stopping bringing the residents out to the main unit from memory care, they were unsure.

Based on observation, record review, and interview, the facility failed to ensure two treatment carts were locked. The administrator identified seven medication/treatments carts were utilized in the facility. Findings: A Storage of Medication policy, dated January 2022, read in part, .Medication .carts .are locked when not attended by persons with authorized access . On 11/27/23 at 1:09 p.m., a treatment cart was observed to be unlocked on hall 100. No staff were observed around the unlocked treatment cart. On 11/27/23 at 1:11 p.m., LPN #1 was observed to notice the cart was unlocked and went to lock the treatment cart. They were asked what the policy was for securing a treatment cart. They stated staff were not to leave it unlocked. On 11/29/23 at 7:18 a.m., LPN #2 was observed to prep an insulin pen for administration. They were observed to go in to the resident's room, close the door, and had left the treatment cart unlocked on hall 200. On 11/29/23 at 7:20 a.m., two other surveyors observed the treatment cart unlocked. On 11/29/23 at 7:22 a.m., LPN #2 was asked how staff secured treatment carts. They stated staff were to lock it. They were asked if the treatment cart was left unlocked when they went into the resident's room. They stated, No, not that I remember.

Based on observation, record review, and interview, the facility failed to maintain a clean, homelike environment for one (#29) of 24 sampled residents reviewed for a homelike environment. The administrator identified 52 residents resided in the facility. Findings: A Housekeeping policy, revised 06/29/12, read in part .Every resident room should undergo complete wet cleaning, disinfection, and deodorizing daily . Resident #29 had diagnoses which included dementia and psychotic disorder. A quarterly assessment, dated 10/12/23, documented Resident #29 had moderate cognitive impairment, and was frequently incontinent of bowel and bladder. On 11/28/23 at 9:50 a.m., Resident #29 was observed in their room sitting in their recliner. A bag of trash was on the floor near the recliner, a towel was observed between the recliner and the wall on the floor. The floor was sticky when walking on it and an old urine odor was noted in the room. On 11/29/23 at 9:19 a.m., an observation was made in Resident #29's room. The resident stated, they had seen bugs and was asked when was the last time they had saw one. They stated today and pointed towards the floor in front of the television. Four dead roaches were observed in the resident's room. One in the closet, one on a can of food on an end table, and one in two corners of the room on the floor. The floor felt sticky when walking. On 11/29/23 at 10:16 a.m., the DON was asked how often were residents' rooms were cleaned. They stated that was housekeeping but everyone was responsible. On 11/29/23 at 10:20 a.m., the DON was asked to observe Resident #29's room. They were asked what they had observed. They stated, the floor was sticky, there were bug problems, the trash needed to be emptied, and the room needed attention. On 11/29/23 at 12:27 p.m., the housekeeping supervisor was asked how often were resident rooms cleaned. They stated every day but not Saturdays and Sundays.

Based on record review and interview, the facility failed to ensure range of motion exercises were completed for one (#39) of one sampled resident reviewed for range of motion. The administrator identified 52 residents resided in the facility. Findings: A Range of Motion policy, dated 10/01/01, read in part .active or passive, range of motion is done to reduce muscle wasting, weakening, and prevents or reduces the development of contractures . Resident #39 had diagnosis which included hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage, gait abnormalities, and unsteadiness on feet. A quarterly assessment, dated 09/21/23, documented a BIMS score of 13, extensive assistance with bed mobility, transfer, and toilet use with one staff assistance and limited assistance with dressing. Resident #39's care plan, dated 09/27/23, read in part, .resident experienced cerebral vascular accident .range of motion exercises several times a day. If resident is able, teach how to do correct active range of motion . 11/29/23 at 9:53 a.m., Resident #39 was asked if they were taught how to perform ROM exercises. Resident #39 stated, No one has ever taught her how to do any kind of exercises. On 11/29/23 at 9:57 a.m., CNA #1 was asked if ROM exercises had been completed on any resident. They stated No. They were asked if ROM exercises were performed on Resident #39. They stated No. Resident #39's clinical record did not document that ROM had been completed. On 11/29/23 at 10:03 a.m., the DON was asked if staff were performing ROM exercises with Resident #39. She stated, When they get [Resident #39] dressed and do ADL's that is ROM. The DON was asked where was the ROM documented. She stated, If it is a task the CNA's would document on it, if is not a task then it's not documented.

Based on observation, record review, and interview, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment was ensured for two (#35 and #52) of four residents reviewed for advanced directives. The facility failed to offer information on advanced directives to Res #35 and failed to ensure the individual who had the authority to sign for resident #52 signed the resident's DNR form. The Resident Census and Conditions of Residents form documented 17 residents with advanced directives resided in the facility. Findings: 1. Res #35 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 07/18/22, documented Res #35 was to be resuscitated in the event of cardio-pulmonary arrest. An annual MDS assessment, dated 08/25/22, documented Res #35 had a serious mental illness, was intact in cognition, and was independent to requiring supervision with most ADLs. On 10/05/22 at 4:36 p.m., Res #35's door was observed and documented their name on a green name tag indicating they were to receive a full resuscitation in the event of cardio-pulmonary arrest. On 10/05/22 at 4:36 p.m., Res #35's records were reviewed and did not contain documentation the facility had discussed whether or not Res #35 had an advanced directive or DNR, provided information to the resident/representative, or if the facility had offered to help the resident or representative formulate one. On 10/06/22 at 10:15 a.m., the DON stated Res #35 had resided in the facility for some time. She confirmed Res #35's records did not contain an acknowledgement of receipt of information regarding advanced directives or DNR. 2. Res #52 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 09/02/22, documented the resident was severely impaired with cognition and required extensive to total assistance with most activities of daily living. The assessment documented the resident had hospice care. A care plan, last reviewed 09/07/22, documented the Res #52 had a DNR. On 10/05/22 at 4:35 p.m., a red name tag was observed by the resident room door indicating Res #52 was not to be resuscitated in the event of cardio-pulmonary arrest. Review of the residents medical record revealed a DNR, dated 05/27/22, signed by [name omitted]. POA paper work or a health care proxy document was not found in the residents chart. On 10/06/22 at 10:10 a.m., the DON stated the resident did not have a POA or proxy and the person who signed the DNR did not have the authority to sign the DNR.

Based on observation, record review, and interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for residents, visitors, and staff. The Resident Census and Conditions of Residents form documented 64 residents resided in the facility. Findings: 1. On 10/05/22 at 3:42 p.m., Res #9 stated the grab bar in the shower on hall 100 was very loose and felt it was an accident waiting to happen. On 10/05/22 at 3:56 p.m., the shower room on hall 100 was observed. The grab bar in the shower was very loose and pulled away from the wall. There was a black substance observed on the ceiling in the shower. On 10/10/22 at 3:43 p.m., the grab bar in the shower room on the 100 hall was observed to be loose and pulled away from the wall approximately an inch. On 10/10/22 at 3:44 p.m., a hospice CNA brought Res #62 into the shower room for his shower. Res #62 was asked if he used the grab bar in the shower. Res #62 stated it would be helpful if he could use the grab bar to stand. On 10/10/22 at approximately 4:50 p.m., CNA #2 was asked about the grab bar in the shower on hall 100. She stated the grab bar had been like that since last week. She stated a nurse either [name omitted] or [name omitted] had reported it and made a work order last week. She stated maintenance had been told about the grab bar. On 10/11/22 at 7:55 a.m., the maintenance supervisor stated he just got a work order for the grab bar in the shower room on 100 hall that morning. He stated he had not been down to check the grab bar as yet. He stated he planned to go to the lumber yard that morning and would have the grab bar fixed that day. The maintenance supervisor was asked if he did routine checks for loose railing and grab bars. He stated he visualized the halls and then checked his work orders more than once a day. He stated he depended on the staff to put in a work order or text him when there were issues in areas where residents received care. On 10/11/22 at 8:07 a.m., the maintenance supervisor went to the shower room on hall 100. He stated the grab bar was loose and he would get it fixed. He stated he would treat the black substance on the ceiling. He stated the window could not be opened for ventilation in shower room. 2. On 10/05/22 at 4:19 p.m., Res #20 complained of staff not emptying her BSC. The resident's room had a smell of urine. On 10/07/22 at 11:30 a.m., the resident complained of her bed side commode being full and not emptied from the day before. She stated she would ask for it to be emptied but the staff would wait till it was full and then empty it. The BSC was observed to be three fourths full of urine and feces. The resident stated that she stuck her hand in the urine when she used her BSC earlier this morning. On 10/07/22 at 12:00 p.m., the DON observed the full BSC and said, That's not right. She stated she would get someone to empty it.

Based on record review and interview, the facility failed to ensure assessments accurately reflected the residents' status for two (#4 and #35) of five residents sampled for medication review. The Resident Census and Conditions of Residents form documented 22 residents on antipsychotic medications. Findings: 1. Res #4 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 04/20/18 and discontinued on 11/02/18, documented [MEDICATION(S)] (an antipsychotic medication) 0.5 mg at bedtime related to impulse disorder. An annual MDS assessment, dated 07/07/22, documented the resident was cognitively intact, had minimal depression, no behaviors, and received antipsychotic and antidepressant medication. The assessment documented a GDR had not been attempted. On 10/07/22 at 10:08 a.m., the MDS coordinator stated she had only looked back through the previous year for any antipsychotic GDRs. 2. Res #35 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MRR, dated 04/20/22, documented no recommendations were made regarding a GDR. A quarterly MDS assessment, dated 05/26/22, documented Res #35 was intact in cognition and received an antipsychotic medication seven days of the seven day assessment period. The assessment documented a physician had documented a GDR was clinically contraindicated on 04/27/22. A MRR, dated 07/19/22, documented no recommendations were made regarding GDR. A MRR, dated 08/22/22, documented no recommendations were made regarding GDR. An annual MDS assessment, dated 8/25/22, documented Res #35 had a serious mental illness and was intact in cognition. The assessment documented Res #35 received an antipsychotic medication for seven days of the seven day assessment period. The assessment documented the physician had documented a GDR of antipsychotic medication was contraindicated on 08/22/22. On 10/07/22 at 9:25 a.m., the MDS coordinator reported she thought when the mental health service documented they reviewed Res #35's medications, this meant they were documenting a GDR was contraindicated. She stated she documented the dates Res #35 was last seen by the mental health service on the MDS assessments.

Based on observation, record review, and interview, the facility failed to provide routine weekly pressure ulcer assessments, failed to provide physician ordered treatments, failed to notify the physician and obtain orders, and failed to perform appropiate hand hygiene during wound care for four (#20, 52, 54, and #56) of four residents sampled for pressure ulcers. The Resident Census and Conditions of Residents form documented three residents with pressure ulcers. Findings: An undated facility policy, titled Pressure Ulcer Policy, read in part, .within eight hours of initial admission or following hospital stay the resident will be assessed for the existence of pressure ulcers. The attending physician will be notified to obtain treatment interventions. Also, the wound care nurse(s) and charge nurse should be notified . 1. Res #20's admission MDS assessment, dated 11/14/21, documented the resident was independent with ADLs and had one pressure ulcer on admission and one surgical wound. A physician order, dated 07/25/22, documented to cleanse sacral wound with wound cleanser and flush undermining, pat dry, pack Biostep AG loosely into wound, apply skin prep to periwound, cover with foam bordered dressing every MWF and PRN related to pressure ulcer of sacral region. A quarterly MDS assessment, dated 08/05/22, documented the resident was cognitively intact, was independent to requiring limited assistance with ADLs, had one pressure ulcer which was present on admission and one surgical wound. The current care plan, read in part, .to assess/record/monitor wound healing. Measure length, width, and depth weekly where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician . A wound assessment, dated 09/13/22, documented the pressure ulcer was 1.7 x 1.0 x UTD cm with slough and moderate purulent drainage. The next wound assessment, dated 10/03/22, documented the pressure ulcer was 1.7 x 1.0 x UTD cm and had slough with moderate purulent drainage. There were no assessments for three weeks from 09/13/22 until 10/03/22. On 10/11/22 at 10:49 a.m., the wound nurse stated she was out with sickness from 09/16/22 until 10/03/22. She stated wound assessments were not conducted while she was out. On 10/11/22 at 2:46 p.m., the DON stated the wound assessments had been re-assigned to the charge nurse while the wound nurse was out, but the assessments were not completed. 2. Res #54 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 7/13/22 , documented the resident was severely impaired in daily decision making and did not have pressure ulcers. The Care Area Assessment documented pressure ulcers triggered for care planning. A nurse note, dated 08/18/22 at 3:36 a.m., read in part, .open areas noted to right hip and lager [sic] red area noted to the left hip. Protective cream applied to area . The note did not document Res #54's physician was notified of the new area of skin breakdown. A weekly skin evaluation assessment, dated 08/18/22, documented new skin issues were identified and an order was obtained. The clinical record did not document a order was obtained on 08/18/22. The assessment did not document a visual assessment or measurements of the wound. A physician order, dated 08/19/22 at 1:30 p.m., documented to cleanse the right hip wound with wound wash, pat dry, and apply Triad to the wound bed and cover with bordered foam dressing daily and as needed for a pressure ulcer of the right hip. A nurse progress note, dated 08/19/22 at 7:18 p.m., documented Res #54 was transferred to the hospital for evaluation of unresponsiveness. A nurse progress note, dated 08/20/22 at 6:00 a.m., documented to cleanse the left hip wound with wound wash, pat dry, paint area with [MEDICATION(S)], cover with a bordered dressing daily and as needed. The resident was hospitalized when this order was documented. A nurse note, dated 08/20/22 at 1:53 p.m., documented the facility was notified Res #54 had been admitted to the hospital for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 08/25/22, documented to cleanse lateral left hip wound with normal saline, pat dry, skin prep periwound, apply Santyl to wound bed, cover with Allevyn foam dressing daily and as needed. A quality manager progress note, dated 08/26/22, documented Res #54 was readmitted to the facility on [DATE] and his wound care treatments had been changed at that time by the wound care nurse. A daily wound charting assessment, dated 08/27/22, documented a wound care assessment. The assessment did not document a visual assessment or measurements of the wound. A visit report from a wound care practitioner, dated 08/29/22, documented weeks in treatment 0 and was the initial visit for wounds. A document, titled Wound Care Status Note, dated 08/30/22, documented the left hip wound was an unstageable wound which started on 08/29/22. At the time of the documentation the wound measured 7 cm by 5 cm with a large amount of necrotic tissue within the wound bed including adherent slough. The note documented the wound was facility acquired. A modification of a significant change assessment, dated 8/31/22, documented the resident was severely impaired in daily decision making and had three unstageable pressure ulcers. On 10/06/22 at 3:14 p.m., wound care was observed being performed by LPN #1. Two unidentified hospice nurses were also in Res #54's room and assisted her with the wound care. The LPN who provided the wound care was observed to frequently change her gloves during the wound care but did not perform hand hygiene except at the beginning and the end of the wound care. On 10/10/22 at 3:32 p.m., the DON stated the facility did not have a policy regarding dressing changes. She stated the facility policy was not to allow the charge nurses to measure or stage the wounds. She stated the charge nurses were to notify the wound care nurse and the physician. If it was not on a time when the wound care nurse was in house they were to call the physician and describe the wound as much as possible. On 10/10/22 at 3:58 p.m., the DON stated hand hygiene should have been performed before the wound care was set up, when the staff removed the dressing, after the cleaning the wound, after the treatment application, after the dressing application, between each wound, after the care was completed, and after the supplies are taken out of the room. She confirmed the wound care nurse should have performed hand hygiene as described. The DON provided documentation of the first wound assessment which was dated on 08/29/22. She stated she told the wound care nurse to come in when Res #54 returned from the hospital on 08/25/22 and assess the wounds. The DON confirmed the first assessment documented was 08/29/22. 3. Res #52 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 09/02/22, documented the resident was severely impaired with cognition and required extensive to total assistance with most activities of daily living. The assessment documented the resident had one stage three pressure ulcer and was on hospice care. A wound care practitioner note, dated 10/03/22, read in parts, .Wound #6 is Open. The wound has been in treatment 2 weeks. The would is currently classified as a Category/Stage III wound with etiology of Pressure Ulcer and is located on Sacrum. The wound measures 0.5cm length x 0.2cm width x 0.1cm depth; 0.079cm^2 area and 0.008cm^3 volume. There is a small amount of serous drainage noted .continue Triad TID due to frequency of bowel incontinence . On 10/06/22 at 2:42 p.m., wound care was observed performed by LPN #2. LPN #2 performed hand hygiene and placed gloves on her hands. She then cleaned the wound and applied cream to the area in the same gloves. The LPN #2 was not observed to remove her gloves and/or perform hand hygiene between the cleansing and the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/11/22 at 9:50 a.m., LPN #2 stated she should have changed gloves between cleaning the wound and applying the treatment. 4. Res #56 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 09/10/22, documented the resident was intact with cognition and was independent with most ADLs. The assessment documented the resident had two unstageable pressure ulcers. Physician orders, dated 09/24/22, documented to cleanse the right and left heel with NS or wound cleanser, pat dry, apply Santyl to wound bed, cover with ABD pad, wrap with Kerlix, secure with tape every day shift. A wound care practitioner note, dated 10/03/22, documented location of wounds were on the right heel, left heel, and left buttock. The measurements for the two pressure ulcers on the left buttock were 1.5 x 1.5 cm and 0.5 x 0.5 cm. The practioner's note documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order documented to cleanse the wounds with saline, protect periwound with skin prep, apply [MEDICATION(S)] to wound bed, and cover wounds with bordered foam every MWF. The October 2022 TAR did not document any treatments for the left buttock from 10/03/22 through 10/07/22. A physician order, dated 10/07/22, documented to cleanse the buttock cheeks with NS or disposable wipes, pat dry, apply Triad to area BID and PRN two times a day for redness and as needed. On 10/10/22 at 4:13 p.m., LPN #2 washed her hands, donned gloves, and cleaned the right heel with NS, then applied treatment and dressing without changing gloves. LPN #2 with same gloves on cleaned the left heel with NS and treated and dressed the left heal without changing gloves. The old bandages were laying on the bed while wound care was being performed. LPN #2 changed her gloves after finishing the heel treatments and did not perform hand hygiene. She then assisted the resident to roll to her right side. On 10/10/22 at 4:33 p.m., LPN #2 went out of the room brought in other supplies for the wound care. LPN #2 placed gloves on her hands no hand hygiene before starting treatment to the bottom was observed. The LPN #2 cleaned the wounds, pat dry, changed gloves, hand hygiene was not performed before changing gloves. The LPN #2 then performed the wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/11/22 at 9:50 a.m. LPN #2 stated hand hygiene should be done before touching the resident and anytime you take your gloves off. She stated she would normally changed gloves between cleaning the wound and the treatment. On 10/11/22 at 10:45 a.m., LPN #2 stated 10/03/22 was the first date she had seen the wounds to the resident's buttock and she believed there were two areas to the buttock. On 10/11/22 at 12:47 p.m., LPN #2 stated she did not have an order in the system for wound care on the resident buttock for 10/03/22. She stated the first order was 10/07/22. She stated she thought there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review,and interview, the facility failed to identify and implement interventions to prevent falls for two (#36 and #54) of four residents reviewed for falls. The Resident Census and Conditions of Residents form documented 64 residents resided in the facility. Findings: A facility policy, titled Fall Awareness Program, revised 11-27-17, read in part, .Fall Occurs: 1. Assess the resident for injuries, .Complete incident report .2. Complete additional fall risk assessment tool .4. develop care plan using appropriate interventions .9. Review and revise the care plan as needed .11. Review the fall at the next Safety committee meeting and gain input for interdisciplinary team members for other possible interventions to prevent falls. Make sure to update and revise plan of care as indicated . 1. Res #36 had diagnoses which included Alzheimer's disease, [CONDITION(S)] disease, and polyneuropathy. An incident note, dated 05/15/22, documented Res #36 had experienced an unwitnessed fall in her room and was found on the floor beside her bed. The note documented the resident had a large contusion on the right side of her forehead and a small red abrasion to her right knee. The note documented the resident was sent to the emergency room for evaluation. The note did not document any interventions were put in place to prevent the recurrence of falls. An annual assessment, dated 06/02/22, documented Res #36 was severely impaired in cognitive skills for daily decision making, required extensive to total assistance with ADLs, and had one non injury fall and one fall with minor injury. The care area assessment documented falls triggered for care planning. An incident note, dated 07/06/22, documented Res #36 experienced a witnessed fall while ambulating without assistance in the common area near the nursing station. The note documented the resident sustained no injuries. The note did not document any interventions were put in place to prevent the recurrence of falls. An incident note, dated 08/14/22, documented Res #36 fell while a CNA was in the resident's room. The note stated after cares were performed, the CNA changed her gloves and the resident attempted to get out of the wheelchair and fell backward into the wall and slid down to the floor. The note documented the resident had a small abrasion to the left lower back approximately two inches in length. The note did not document interventions were put in place to prevent the recurrence of falls. A quarterly MDS assessment, dated 08/25/22, documented the resident was severely impaired in cognitive skills for daily decision making, required extensive assistance with ADLs, and had two or more falls since the prior assessment with one fall causing minor injury. A care plan, initiated on 11/13/19 and last reviewed on 09/05/22, documented Res #36 had potential for falls due to confusion and gait/balance problems. On 10/05/22 at 3:10 p.m., Res #36 was observed sleeping in a recliner in the lobby of the Alzheimer's unit. On 10/05/22 at 4:16 p.m., a family member of Res #36 stated the resident fell frequently. The family member stated the resident had several skin tears and once hit her head and was sent to the hospital for evaluation. On 10/11/22 at 8:15 a.m., the MDS/care plan coordinator reviewed the incident notes for 05/15/22, 07/06/22, and 8/14/22, along with the resident's care plan and stated no new interventions were put in place for these falls. She stated new interventions should have been put in place and the care plan updated with each fall. 2. Res #54 had diagnoses which included dementia, [CONDITION(S)], [CONDITION(S)], and cervical disk disorder. An admission MDS assessment, dated 07/13/22, documented Res #54 was severely impaired in cognitive skills for daily decision making and had not fallen. An incident note, dated 07/31/22, documented Res #54 had been sitting on the side of the bed when he stood up and lost her balance and slid on the floor, falling backwards and landed on the floor with his back on the side of his bed. The note documented to add grip strips to the floor beside the resident's bed to help prevent the recurrence of falls. An incident report, dated 08/10/22, documented the resident was observed on the floor of his room near the sink. The incident report documented the resident complained of pain in his toes. The note documented a x-ray was obtained. The note documented to apply grip strips to the floor near the resident's bed. An incident note, dated 08/18/22, documented Res #54 was found lying on the fall mat next to the bed. The note documented the resident was not injured and no new interventions were documented to prevent the recurrence of falls. A modification of a significant change assessment, dated 8/31/22, documented the resident was severely impaired in cognitive skills for daily decision making and fallen in the two to six months prior to admission, entry, or reentry. The assessment did not document how many times the resident had fallen or if the resident had been injured during the falls. An incident note, dated 09/21/22, documented Res #54 leaned forward in his wheelchair and fell out. The note documented the fall was witnessed and the resident was sent to the emergency room to be checked out. The note documented to monitor the resident's restroom needs more frequently as a step to prevent the recurrence of falls. The resident's care plan was reviewed and did not document this intervention. An incident note, dated 09/25/22, documented Res #54 was found on the floor near the foot of the bed. The note documented the resident was not injured. The note did not document interventions to prevent the recurrence of falls. An incident note, dated 09/30/22, documented Res #54 was found on the floor near the common area in front of the nurses station. The note documented the resident was not injured. The note did not document interventions to prevent the recurrence of falls. On 10/05/22 at 3:36 p.m., Res #54 was observed in bed sleeping. The resident's mattress was observed to be concave and a fall mat was observed at the side of the bed. The floor near the resident's bed was observed to not have grip strips applied. On 10/06/22 at 8:37 a.m., a family member of Res #54 reported the resident fell frequently. On 10/10/22 at 5:10 p.m., the MDS/care plan coordinator reviewed the incident notes and care plan for Res #54 and confirmed no new interventions to prevent falls had been put in place for the falls on 08/18/22, 09/21/22, 09/25/22, or 09/30/22. She stated each time the resident fell a new intervention should have been put in place and the care plan should have been updated. The MDS/care plan coordinator stated she checked the EHR and the facility text system for fall information and new interventions. She stated the charge nurses were to complete the investigation, the incident notes, and institute new interventions. On 10/10/22 at 5:42 p.m., the DON stated the charge nurses should have put new interventions with each resident fall. She stated each resident had a sheet with interventions on it available at the nurses station for the nurses to use. The DON stated the resident's floor was to have grip strips. She stated he had been moved due to a recent COVID-19 outbreak and the staff should have ensured the floor had grip strips applied.

Based on record review and interview, the facility failed to ensure the physician acted upon the MRR in a timely manner and according to the facility's policy. The facility failed to develop policy which addresses the monthly MRRs that include time frames for the different steps in the process for one (#26) of five residents reviewed for unnecessary medications. The Residents Census and Conditions of Residents form documented 64 residents resided in the facility. Findings: 1. The facility's Consultant Pharmacist Reports page 220, read in part, .B. Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. In the event of a problem requiring the immediate attention of the prescriber, the responsible prescriber or physician's designee is contracted by the consultant pharmacist or the facility, and the prescriber is documented on the consultant pharmacist review record or elsewhere in the resident's medical record. C. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. 1) If the prescriber that does not respond is also the Medical Director, the Director of Nursing and the Administrator will address the requirements with the Medical Director and/or pursue more formal actions if necessary to facilitate compliance . On 10/06/22 at 5:25 p.m., the DON and pharmacy consultant were interviewed related to the policy only addressing the physician's timeframe for addressing the MRRs. The DON stated the facility had one step in the timeline for the whole process. When informed the policy did not have a time frame for the facility to act upon the physician's response, the DON stated she felt the policy was correct and did not need to be changed. 2. Res #26 had diagnoses which included Alzheimer's disease, [CONDITION(S)] with delusions, impulse disorder, visual and auditory hallucinations, and recurrent depressive disorder. On 11/18/21, a consultant pharmacist request documented Res #26 received the following [CONDITION(S)] medications, [MEDICATION(S)] 15 mg every HS, [MEDICATION(S)] 100 mg every HS, [MEDICATION(S)] 150 mg BID, [MEDICATION(S)] 1 mg every day, and [MEDICATION(S)] 0.5 mg every four hours as needed. The consultant pharmacist documented a question to the physician if they would like to order a dose reduction to any of the listed medications. A physician response, dated 01/26/22, documented not to change any of the medications except to decrease to [MEDICATION(S)] 7.5 mg every HS. An annual MDS assessments, dated 05/12/22, documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance with ADLs. The assessment documented the resident received antispychotic, antianxiety, and antidepressant medications and a GDR was not attempted. The assessment documented a physician documented a contraindication to GDR on 04/27/22. A quarterly assessment, dated 08/11/22, documented Res #26 was severely impaired in cognitive skills for daily decision making. The assessment documented the resident required extensive to total assistance with ADLs. The assessment documented the resident received antipsychotic, antianxiety, and antidepressant medications daily during the assessment period. The assessment documented a GDR was not attempted and the physician documented a contraindication to a GDR on 06/23/22. A care plan, last reviewed on 8/15/22, documented to consult with pharmacy and the physician to consider dosage reduction when clinically appropriate. On 10/07/22 at 12:58 p.m., the DON stated she did not know why this GDR request was not responded to according to the policy. She stated this GDR was not responded to within the policy time. She stated she had no recollection if she called the medical director.

Based on observation and interview, the facility failed to ensure the dietary supervisor received the certified dietary manager certification within one year of employment. The Resident Census and Conditions of Residents documented 64 residents were served meals from the kitchen. Findings: On 10/05/22 at 9:47 a.m., during the initial tour of the kitchen, cook #1 was asked who the DM was for the facility. Cook #1 stated the DM's name and stated he was not working at that time but was supposed to come in around noon. On 10/10/22 at 10:45 a.m., a return visit to the kitchen was conducted and the DM was observed in the kitchen. On 10/10/22 at 10:48 a.m., the DM stated he had been in the DM position a little over a year. The DM was asked if he had his DM certification. The DM stated he did not. He was asked if he was attending classes. The DM stated he was not enrolled in classes for DM certification. He stated he had completed Servesafe training. On 10/10/22 at 5:57 p.m., the DM stated he had worked in the kitchen for the facility a while and was promoted to DM in April of 2021.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to ensure safe transfers with the mechanical lift and/or transfer residents with the mechanical lift as per the resident's assessment and care plan. Resident #4 was admitted to the facility on [DATE] and was assessed to be dependent on two staff members for transfers. The resident's care plan documented the resident was to be transferred with a mechanical lift using two staff members. On [DATE], the resident was transferred by one staff member with a mechanical lift. The lift sling came off of the lift, resulting in the resident falling. The resident sustained [REDACTED]. Resident #3 was admitted to the facility on [DATE] and was assessed to require extensive assistance of two staff members for transfers. The resident's care plan documented the resident was to be transferred with a mechanical lift. On [DATE], the resident was noted to have bilateral femur fractures. On [DATE], it was revealed the resident had been transferred by one person without the use of a mechanical lift during the week of ,[DATE]-[DATE]. At 3:59 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 4:02 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure to safely transfer residents. On [DATE] at 5:32 p.m., an acceptable plan of removal was provided. The plan of removal documented, . 1) All nursing staff will be inserviced on when to use a hoyer (sic) (mechanical lift) and proper use of a hoyer (sic) lift. Licensed nurses will be inserviced on assessment monitoring and intervening as warranted. Completed by midnight [DATE] 2) Facility will complete competency skills check offs related to appropriate hoyer (sic) lift use with all direct care nursing staff. Completed by midnight [DATE]. 3) DON will be inserviced on developing, implementing and monitoring systems thorough check offs and monitoring clinical outcomes. Completed by midnight [DATE] 4) Facility will monitor, in Q2 (part of the facility's quality assurance program), 5 times a week, related to assessing, monitoring and intervening by monitoring the 24 hour report and random audit of hoyer (sic) lift competency checklists. Completed by midnight [DATE]. 5) All nursing staff will be inserviced on the definition of a fall and reporting criteria. Completed by midnight [DATE] The immediate jeopardy was removed on [DATE] at 10:00 p.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on interview and record review, it was determined the facility failed to ensure safe transfers with the mechanical lift and/or complete transfers as per the assessment and care plan for two (#3 and #4) of four sampled residents who were reviewed for transfers. The facility identified nine residents as requiring the use of a mechanical lift for transfers. Resident #4 was transferred by one staff member instead of two utilizing a mechanical lift. While being transferred the sling came off the lift. The resident fell to the floor and sustained a scalp laceration and fractures to the right clavicle, scapula, and ribs. Resident #3 was transferred without the lift during the week of [DATE] through [DATE]. On [DATE], the resident was found to have bilateral femur fractures. Findings: The facility's policy on lifting and transferring residents, dated [DATE], documented, . Nurses assess and determine lifting and transfer needs and the method used for each resident . All resident(s) must be lifted or transferred according to the method determined by the nurse . The procedure should appear on the resident plan of care . The facility's policy on hydraulic (mechanical) lifts, revised [DATE], documented, . It is Grace Living Centers policy to have two staff members present during transfer to stabilize and support the resident . Remove the hooks or straps from the sling but leave the sling in place under the resident so you'll be able to transfer him (sic) back to the bed from the chair . 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident was dependent on two staff for transfers. The resident's care plan, reviewed [DATE], documented a focus related to the potential for falls. The goal was staff would evaluate all falls and intervene as needed to reduce the potential of significant injury. Interventions included to use a Hoyer (mechanical) lift for all transfers. An emergency response report, dated [DATE] at 8:01 a.m., documented, . Female pt (patient) fell out of the sling on a hoyer (sic) lift at NH (nursing home). Pt hit her head on the lift itself while falling . Pt is wheezing with labored breathing. Pt is nonverbal, and quadriplegic secondary [MEDICAL CONDITION](cardiovascular accident) years ago . An emergency department note, dated [DATE] at 8:23 a.m., documented, . fell from hoyer (sic) lift at nursing home and has [MEDICAL CONDITION] and patient was also in low 80's (oxygen saturation) on RA ( room air) . Patient with resp (respirations) of 32 and retractions . Palpation of the skull reveals large hematoma with overlying superficial laceration/deep abrasion - secondary to undelrying (sic) swelling wound does not approximate and will need to be closed by secondary intention once swelling is resolved . Patient was initially brought in by EMS (Emergency Management Services) for chief complaint of fall and head injury. However on arrival patient is noted to be diaphoretic, in respiratory distress with significant [MEDICAL CONDITION]. On my examination of the patient, she is in respiratory distress however she does not have any wheezing noted in bilateral lung fields . Laceration evaluation demonstrates a large hematoma which prohibits primary closure on scalp, therefore this will require closure by secondary or tertiary intent . Patient admitted in stabilized but guarded condition . A hospital chest x-ray, dated [DATE] at 9:27 a.m., documented, . Interval extensive airspace and interstitial opacities involving the right upper, middle and lower lobes with moderate right pleural effusion . A hospital chest CT, dated [DATE] at 10:23 a.m., documented, . Large right effusion with compressive atelectasis underlying consolidation is not excluded . A facility progress note, dated [DATE] at 12:28 p.m., documented, . admitted to (hospital name withheld) after incident earlier reported . A hospital right shoulder x-ray, dated [DATE] at 8:56 p.m., documented, . Minimally displaced [MEDICAL CONDITION] clavicle with hematoma. Displaced right anterolateral rib fractures, suspect 2nd, cannot exclude 3rd and 4th or other fractures. Right effusion and atelectasis favored . A hospital chest x-ray, dated [DATE] at 8:58 a.m., documented, . There may also be nondisplaced scapular fracture at the level of the coracoid process . A facility initial incident report, dated [DATE] at 12:16 p.m., documented, . Nurse was called to room after a failed hoyer (sic) lift transfer resulting in a fall. Resident was observed on the floor, noted to have laceration with bleeding to posterior head . emergency transfer to hospital for evaluation due to fall and laceration . Staff member . suspended pending investigation . Resident admitted to (hospital name withheld) . Facility records documented on [DATE], the facility had 48 staff members with nursing department responsibilities. Review of facility inservice records, dated [DATE], revealed documentation an in-service was conducted on Hoyer lift transfers and the facility's resident abuse and neglect policy. It was documented 18 staff members attended the inservice. Review of additional facility records revealed documentation an additional 21 staff were inserviced individually or in small groups. It was documented nine staff members were not inserviced. Facility Hoyer lift competency checklists, dated [DATE], documented four nursing staff members were observed for competency related to using a Hoyer lift. A hospital physician's progress note, dated [DATE] at 6:53 p.m., documented, . Assessment . Scalp laceration . Right rib fracture . Chest tube in place . Right clavicle fracture . All secondary to fall from Hoyer lift at the nursing home . A hospital physician's progress note, dated [DATE] at 7:14 p.m., documented, . she appears to be imminently dying . Facility Hoyer lift competency checklists, dated [DATE], document one nursing staff member was observed for competency related to using a Hoyer lift. A hospital discharge summary, dated [DATE] at 10:36 a.m., documented, . Notified by the nurse that patient was not breathing and on her examination, patient had expired . A facility final incident report form, dated [DATE] at 12:01 p.m., documented, . Nurse was called to room after a failed hoyer (sic) lift transfer resulting in a fall. Resident was observed on the floor, noted to have laceration with bleeding to posterior head . emergency transfer to hospital for evaluation due to fall and laceration . Staff member . suspended pending investigation . Resident admitted to (hospital name withheld) . (Resident #4) is dependent upon staff for all transfers . per hoyer (sic) lift . Investigation completed by reviewing records, environmental sweep, and interviewing staff members . Staff member . was getting resident . up into the geri chair with the hoyer (sic) lift. The sling came unattached from the lift on one side, resulting in the resident sliding out of the sling and falling to the floor. The resident struck her head during the fall, resulting in a laceration to the posterior head . Staff member was suspended pending investigation. The resident was admitted to the hospital for pneumonia. All scans were negative for fractures or other injuries. Treatment was provided for the laceration to the posterior head. All nursing staff were inserviced regarding the use of hoyer (sic) lift, with competency checkoffs being completed for all staff. Staff member (name withheld) will be inserviced as well as additional training provided by Relias on resident transfers and abuse and neglect. She will also be monitored with check offs for proper use of hoyer (sic) lift and competency checklist completion. Investigation completed at this time . The incident report was signed by the director of nursing (DON). A State Of Oklahoma Death Certificate, dated [DATE], documented, . Immediate Cause of Death . Acute hypoxic [MEDICAL CONDITION] . Approximate interval onset to death . 48 hours . Congestive Health Failure . Approximate interval onset to death . 48 hours . Facility Hoyer lift competency checklists, dated [DATE], documented one nursing staff member was observed for competency related to using a Hoyer lift. On [DATE] at 11:43 a.m., certified nurse aide (CNA) #1 stated she had transferred resident #4 without assistance. She stated the nurse on duty had been in the room with the resident when she began the lift. She stated the nurse asked if she had this and then left the room. On [DATE] at 3:00 p.m., the DON stated it was the facility's policy to always have two people to assist with a mechanical lift. She stated she did not know why the staff member transferred resident #4 without assistance. The DON stated not all staff had received the inservice on using the mechanical lift, nor had competencies been completed for all nursing staff related to using the mechanical lift. She stated she did not know why the competencies had not been completed or why all nursing staff had not been inserviced. She stated she had no documentation of monitoring to ensure the inservice had been effective or that staff were using the mechanical lift correctly. On [DATE] at 3:15 p.m., the DON provided a document titled, Competency Not Completed. The names of 12 nursing staff members were listed. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance of two staff members for transfers. It was documented the resident had impairments in functional range of motion for one lower extremity. The resident's care plan, revised [DATE], documented the resident had the potential for falls related to issues including impaired mobility, poor endurance, and unawareness of safety needs. The goal was the staff would evaluate all falls and intervene as needed to reduce the potential of significant injury. Interventions included to use a mechanical/Hoyer lift with two staff for transfers. Medication administration records, dated [DATE] at 8:20 a.m., documented the resident had a pain level of 5 on a scale of 0 to 10. It was documented the resident received one Tylenol, 500 mg for pain. A significant change progress note, dated [DATE] at 9:00 a.m., documented, . focused assessment related to change in status. While CNA (certified nurse aide) on duty was performing care to resident this AM, resident began screaming in pain. She began stating that both of her legs were hurting. Upon assessment of resident, left upper thigh presented more swollen than right upper thigh. Right upper thigh was very tight and felt hard to touch. During movement or when legs or body was lightly touched, resident would begin screaming in pain. This nurse called (physician name withheld) and reported new findings . ordered for resident to be sent out to ER (emergency room ) for further evaluation . An emergency department note, dated [DATE] at 1:05 p.m., documented, . chief complaint of bilateral leg pain . nursing home states that the patient began to complain of diffuse bilateral leg pain this morning. There were no reported falls or other traumas precipitating her complaint . She states that she hurts 'everywhere' . describes her pain as severe, mainly located in the bilateral thighs, constant timing, worsened with touch and movement of the bilateral lower extremities. No medications were given prior to arrival . Abnormal range of motion and strength (severely diminished secondary to pain), Positive for diffuse bilateral thigh tenderness to palpation. Patient holds her left lower extremity in slight abduction and internal rotation. Positive for mild swelling of the bilateral distal femurs . Left and right femoral x-ray series are obtained. Findings are significant for an acute comminuted, mildly displaced distal right femoral shaft fracture. Additionally, there is an acute, displaced left femoral spiral fracture . Facility in-service reports, dated [DATE], documented all nursing staff received education related to abuse and neglect and transferring residents per their care plan instructions. A hospital operative report, dated [DATE] at 7:34 p.m., documented, . Left femoral shift comminuted displaced fracture . Closed reduction with intramedullary nailing of left femoral shift . A hospital operative report, dated [DATE] at 7:46 pm., documented, . Displaced comminuted right distal femoral shaft fracture . Open reduction, internal fixation of displaced comminuted right distal femoral shaft fracture . On [DATE] at 11:43 a.m., assistant director of nursing (ADON) #1 stated she had worked [DATE] on the day shift. She stated resident #3 complained of pain, and she had one of the other staff members to administer Tylenol to the resident. She stated it was unusual for the resident to have pain. She stated at midnight on [DATE], she was still working on the resident's unit. She stated, I heard her screaming during incontinent care. ADON #1 stated she did not document anything related to the resident's pain. The ADON stated she and the CNA had attempted to console the resident by giving her stuffed animals and adjusting her bed linens. ADON #1 stated she did not complete an assessment on [DATE] when the resident was complaining of pain. She stated she did not complete an assessment on [DATE] when she heard the resident screaming during incontinent care. She stated she would describe the resident's pain as excruciating. She stated she did not notify the physician of the pain. She stated it was difficult to reach the on-call physician as you would have to call and leave a message and wait for them to return the call. ADON #1 stated on [DATE], the resident's legs were swollen, with the left leg being really large. She stated, The right was tight and constricting looking. She stated the resident was sent to the hospital. ADON #1 stated CNA #2 reported to her that earlier in that week ([DATE] through [DATE]), she had transferred the resident without using a lift. She stated she did not document that, but she had informed the DON of the information on [DATE]. On [DATE] at 12:28 p.m., ADON #2 stated on [DATE], she was the floor nurse caring for resident #3. She stated it was the resident's shower day. She stated she and LPN #3 were going to shower the resident, but there was no lift sling in the chair under the resident. She stated they attempted a two-person transfer with the resident, but they had to set the resident on the floor. She stated LPN #3 got assistance from another nurse to get the resident off of the floor, and then they completed the shower. ADON #2 stated she did not report the fact there was no sling under the resident on [DATE]. She stated the definition of a fall was a change in elevation. She stated she did not document the fall nor did she complete an incident report. ADON #2 stated she did not know why the resident did not have a lift sling in her chair. She stated the resident was already in the chair at the beginning of her shift. ADON #2 stated she did not report the incident to the DON until [DATE], when the DON called her to ask her if she knew how the resident's injuries might have occurred. On [DATE] at 1:00 p.m., the DON stated she received a call from ADON #1 on [DATE], and ADON #1 stated the resident might have a blood clot due to COVID and pain in the resident's legs. She stated she called ADON #2 to ask her if she knew anything about resident #3 and was told she could not remember anything. The DON stated ADON #1 came to her later and told her CNA #2 may have transferred the resident by herself. The DON stated CNA #2 was sent home due to COVID-19 that morning, and she did not have a chance to interview her until the Monday before Christmas ([DATE]). The DON stated CNA #2 admitted to transferring the resident by herself, without the use of a lift. The DON stated CNA #2 was terminated due to failing to follow facility policy. The DON stated she did not gain knowledge that ADON #2 and another nurse transferred the resident without a lift on [DATE] until a report came from Adult Protective Services (APS) at the end of ,[DATE]. She stated she inserviced all staff on abuse and neglect and transferring residents on [DATE] following the incident with resident #3. The DON stated her monitoring consisted of more frequent rounds and making sure the residents' transfer status was on the Kardex. She stated the monitoring was not documented. She stated the competency of staff related to transferring residents per the plans of care had not been completed for all staff. The DON stated she had completed spot checks to ensure staff was showing competency. The DON stated the spot checks were not documented. The DON stated she did not do anything after gaining knowledge ADON #2 and LPN #3 had transferred the resident without the use of a lift because the administrator had informed her he would take care of it. The DON stated, She should have notified me.

On 02/23/21, an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to assess and monitor a resident with a significant change in condition. Resident #3 was admitted to the facility on [DATE] and was assessed to require extensive assistance of two staff members for transfers. The resident's care plan documented the resident was to be transferred with a mechanical lift. On 12/04/20 and 12/05/20, the resident exhibited signs and symptoms of excruciating pain. Staff did not assess for the cause of the pain. The staff did not monitor for ongoing pain symptoms. On 12/05/20, the resident was sent to the hospital and found to have bilateral femur fractures. At 3:59 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 4:02 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure to assess and monitor the resident. On 02/23/21 at 5:32 p.m., an acceptable plan of removal was provided. The plan of removal documented, . 1) All nursing staff will be inserviced on when to use a hoyer (sic) and proper use of a hoyer (sic) lift. Licensed nurses will be inserviced on assessment monitoring and intervening as warranted. Completed by midnight 2/23/21 2) Facility will complete competency skills check offs related to appropriate hoyer (sic) lift use with all direct care nursing staff. Completed by midnight 2/23/2021. 3) DON will be inserviced on developing, implementing and monitoring systems thorough check offs and monitoring clinical outcomes. Completed by midnight 2/23/21 4) Facility will monitor, in Q2 (part of the facility's quality assurance program), 5 times a week, related to assessing, monitoring and intervening by monitoring the 24 hour report and random audit of hoyer (sic) lift competency checklists. Completed by midnight 2/23/21. 5) All nursing staff will be inserviced on the definition of a fall and reporting criteria. Completed by midnight 2/23/21 The immediate jeopardy was removed on 02/23/21 at 10:00 p.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on interview and record review, it was determined the facility failed to assess and monitor one (#3) of four sampled residents reviewed for change in condition after the resident exhibited signs of excruciating pain. This had the potential to affect 71 of 71 residents who resided at the facility. Resident #3 was transferred without the lift during the week of 11/29/20 through 12/05/20. On 12/05/20, the resident was found to have bilateral femur fractures. Findings: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. ~ [MEDICATION NAME], a medication sometimes used for nerve pain, 300 milligrams (mgs) two daily for nerve pain; and ~ [MEDICATION NAME] (Tylenol) 500 mgs every eight hours as needed for pain. A quarterly assessment, dated 10/29/20, documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance of two staff members for transfers. It was documented the resident received a scheduled pain medication, had no as needed pain medications ordered, and had no signs or symptoms of pain. The resident's care plan, revised 11/04/20, documented the resident had the potential for acute/chronic pain. The goal was the resident would not have an interruption of normal activities due to pain. Interventions included to evaluate the effectiveness of pain interventions; monitor/record/report any signs or symptoms of non-verbal pain; and to notify the physician if interventions were unsuccessful or it current complaint was a significant change from the resident's past experiences of pain. Review of medication administration records (MARs), dated 11/2020, revealed the resident did not receive any as needed Tylenol for pain. Review of MARs, dated 12/01/20 through 12/03/20, revealed the resident did not receive any as needed Tylenol for pain. Medication administration records, dated 12/04/20 at 8:20 a.m., documented the resident had a pain level of 5 on a scale of 0 to 10. It was documented the resident received one Tylenol, 500 mg for pain. Review of the medical record revealed no documentation a pain assessment was completed. There was no documentation to show the facility attempted to determine the cause of the resident's new onset of pain. There was no documentation the resident had been assessed to see if the medication was effective. A significant change progress note, dated 12/05/20 at 9:00 a.m., documented, . focused assessment related to change in status. While CNA (certified nurse aide) on duty was performing care to resident this AM, resident began screaming in pain. She began stating that both of her legs were hurting. Upon assessment of resident, left upper thigh presented more swollen than right upper thigh. Right upper thigh was very tight and felt hard to touch. During movement or when legs or body was lightly touched, resident would begin screaming in pain. This nurse called (physician name withheld) and reported new findings . ordered for resident to be sent out to ER (emergency room ) for further evaluation . An emergency department note, dated 12/05/20 at 1:05 p.m., documented, . chief complaint of bilateral leg pain . nursing home states that the patient began to complain of diffuse bilateral leg pain this morning. There were no reported falls or other traumas precipitating her complaint . She states that she hurts 'everywhere' . describes her pain as severe, mainly located in the bilateral thighs, constant timing, worsened with touch and movement of the bilateral lower extremities. No medications were given prior to arrival . Abnormal range of motion and strength (severely diminished secondary to pain), Positive for diffuse bilateral thigh tenderness to palpation. Patient holds her left lower extremity in slight abduction and internal rotation. Positive for mild swelling of the bilateral distal femurs . Left and right femoral x-ray series are obtained. Findings are significant for an acute comminuted, mildly displaced distal right femoral shaft fracture. Additionally, there is an acute, displaced left femoral spiral fracture . A hospital operative report, dated 12/10/20 at 7:34 p.m., documented, . Left femoral shift comminuted displaced fracture . Closed reduction with intramedullary nailing of left femoral shift . A hospital operative report, dated 12/14/20 at 7:46 pm., documented, . Displaced comminuted right distal femoral shaft fracture . Open reduction, internal fixation of displaced comminuted right distal femoral shaft fracture . On 02/23/21 at 11:43 a.m., assistant director of nursing (ADON) #1 stated she had worked 12/04/20 on the day shift. She stated resident #3 complained of pain, and she had one of the other staff members administer Tylenol to the resident. She stated it was very unusual for the resident to have pain. ADON #1 stated she did not complete a pain assessment when the resident complained of pain. ADON #1 stated at midnight on 12/05/20, she was still working on the resident's unit. She stated, I heard her screaming during incontinent care. ADON #1 stated she did not document anything related to the resident's pain, and the resident was not given anything for pain. She stated she would describe the resident's pain as excruciating. She stated she did not complete a pain assessment in order to determine the cause of the resident's pain. She stated she did not notify the physician of the pain. She stated it was difficult to reach the on-call physician as you would have to call and leave a message and wait for them to return the call. ADON #1 stated on the morning of 12/05/20, the resident's legs were swollen, with the left leg being really large. She stated, The right was tight and constricting looking. She stated the resident was sent to the hospital where she was diagnosed with [REDACTED]. On 02/23/21 at 1:00 p.m., the DON stated she received a call from ADON #1 on 12/05/20, and ADON #1 stated the resident might have a blood clot due to COVID and pain in the resident's legs. The DON stated ADON #1 came to her later and told her CNA #2 may have transferred the resident by herself during the week of 11/29/20 through 12/05/20. The DON stated CNA #2 admitted to transferring the resident by herself, without the use of a lift. The DON stated CNA #2 was terminated due to failing to follow facility policy.

Based on interview and record review, it was determined the facility failed to ensure residents were free from neglect when it failed to: ~ ensure its policies and procedures related to mechanical lifts and transfers were implemented for two (#3 and #4) of four sampled residents who were reviewed for transfers; and ~ assess, monitor, and notify the physician of the new on-set of excruciating pain for one (#3) of four sampled residents who were reviewed for pain. Resident #4 was transferred by one staff member instead of two utilizing a mechanical lift. While being transferred the sling came off the lift. The resident fell to the floor and sustained a scalp laceration and fractures to the right clavicle, scapula, and ribs. Resident #3 was transferred without the lift during the week of [DATE] through [DATE]. On [DATE], the resident was found to have bilateral femur fractures. Findings: The facility's policy on abuse and neglect, revised [DATE], documented, . The facility will not tolerate . neglect . of residents . Neglect is defined as failure to provide goods and services necessary to avoid physical harm . Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas . The facility's policy on lifting and transferring residents, dated [DATE], documented, . Nurses assess and determine lifting and transfer needs and the method used for each resident . All resident(s) must be lifted or transferred according to the method determined by the nurse . The procedure should appear on the resident plan of care . The facility's policy on hydraulic (mechanical) lifts, revised [DATE], documented, . It is Grace Living Centers policy to have two staff members present during transfer to stabilize and support the resident . Remove the hooks or straps from the sling but leave the sling in place under the resident so you'll be able to transfer him back to the bed from the chair . 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident was dependent on two staff for transfers. The resident's care plan, reviewed [DATE], documented a focus related to the potential for falls. The goal was staff would evaluate all falls and intervene as needed to reduce the potential of significant injury. Interventions included to use a Hoyer (mechanical) lift for all transfers. An emergency department note, dated [DATE] at 8:23 a.m., documented, . fell from hoyer (sic) lift at nursing home and has [MEDICAL CONDITION] and patient was also in low 80's (oxygen saturation) on RA ( room air) . Patient with resp (respirations) of 32 and retractions . Palpation of the skull reveals large hematoma with overlying superficial laceration/deep abrasion - secondary to undelrying (sic) swelling wound does not approximate and will need to be closed by secondary intention once swelling is resolved . Patient was initially brought in by EMS (Emergency Management Services) for chief complaint of fall and head injury. However on arrival patient is noted to be diaphoretic, in respiratory distress with significant [MEDICAL CONDITION]. On my examination of the patient, she is in respiratory distress however she does not have any wheezing noted in bilateral lung fields . Laceration evaluation demonstrates a large hematoma which prohibits primary closure on scalp, therefore this will require closure by secondary or tertiary intent . Patient admitted in stabilized but guarded condition . A hospital chest x-ray, dated [DATE] at 9:27 a.m., documented, . Interval extensive airspace and interstitial opacities involving the right upper, middle and lower lobes with moderate right pleural effusion . A hospital chest CT, dated [DATE] at 10:23 a.m., documented, . Large right effusion with compressive atelectasis underlying consolidation is not excluded . A facility progress note, dated [DATE] at 12:28 p.m., documented, . admitted to (hospital name withheld) after incident earlier reported . A hospital right shoulder x-ray, dated [DATE] at 8:56 p.m., documented, . Minimally displaced [MEDICAL CONDITION] clavicle with hematoma. Displaced right anterolateral rib fractures, suspect 2nd, cannot exclude 3rd and 4th or other fractures. Right effusion and atelectasis favored . A hospital chest x-ray, dated [DATE] at 8:58 a.m., documented, . There may also be nondisplaced scapular fracture at the level of the coracoid process . A facility initial incident report, dated [DATE] at 12:16 p.m., documented, . Nurse was called to room after a failed hoyer (sic) lift transfer resulting in a fall. Resident was observed on the floor, noted to have laceration with bleeding to posterior head . emergency transfer to hospital for evaluation due to fall and laceration . Staff member . suspended pending investigation . Resident admitted to (hospital name withheld) . Facility records documented on [DATE], the facility had 48 staff members with nursing department responsibilities. Review of facility inservice records, dated [DATE], revealed documentation an in-service was conducted on Hoyer lift transfers and the facility's resident abuse and neglect policy. It was documented 18 staff members attended the inservice. Review of additional facility records revealed documentation an additional 21 staff were inserviced individually or in small groups. Nine staff members were not inserviced. Facility Hoyer lift competency checklists, dated [DATE], documented four nursing staff members were observed for competency related to using a Hoyer lift. A hospital physician's progress note, dated [DATE] at 6:53 p.m., documented, . Assessment . Scalp laceration . Right rib fracture . Chest tube in place . Right clavicle fracture . All secondary to fall from Hoyer lift at the nursing home . A hospital physician's progress note, dated [DATE] at 7:14 p.m., documented, . she appears to be imminently dying . Facility Hoyer lift competency checklists, dated [DATE], document one nursing staff member was observed for competency related to using a Hoyer lift. A hospital discharge summary, dated [DATE] at 10:36 a.m., documented, . Notified by the nurse that patient was not breathing and on her examination, patient had expired . A facility final incident report form, dated [DATE] at 12:01 p.m., documented, . Nurse was called to room after a failed hoyer (sic) lift transfer resulting in a fall. Resident was observed on the floor, noted to have laceration with bleeding to posterior head . emergency transfer to hospital for evaluation due to fall and laceration . Staff member . suspended pending investigation . Resident admitted to (hospital name withheld) . (Resident #4) is dependent upon staff for all transfers . per hoyer (sic) lift . Investigation completed by reviewing records, environmental sweep, and interviewing staff members . Staff member . was getting resident . up into the geri chair with the hoyer (sic) lift. The sling came unattached from the lift on one side, resulting in the resident sliding out of the sling and falling to the floor. The resident struck her head during the fall, resulting in a laceration to the posterior head . Staff member was suspended pending investigation. The resident was admitted to the hospital for pneumonia. All scans were negative for fractures or other injuries. Treatment was provided for the laceration to the posterior head. All nursing staff were inserviced regarding the use of hoyer (sic) lift, with competency check offs being completed for all staff. Staff member (name withheld) will be inserviced as well as additional training provided by Relias on resident transfers and abuse and neglect. She will also be monitored with check offs for proper use of hoyer (sic) lift and competency checklist completion. Investigation completed at this time . The incident report was signed by the director of nursing (DON). A State Of Oklahoma Death Certificate, dated [DATE], documented, . Immediate Cause of Death . Acute hypoxic [MEDICAL CONDITION] . Approximate interval onset to death . 48 hours . [MEDICAL CONDITION] . Approximate interval onset to death . 48 hours . Facility Hoyer lift competency checklists, dated [DATE], documented one nursing staff member was observed for competency related to using a Hoyer lift. On [DATE] at 11:43 a.m., certified nurse aide (CNA) #1 stated she had transferred resident #4 without assistance. She stated the nurse on duty had been in the room with the resident when she began the lift. She stated the nurse asked if she had this and then left the room. On [DATE] at 3:00 p.m., the DON stated it was the facility's policy to always have two people to assist with a mechanical lift. She stated she did not know why the staff member transferred resident #4 without assistance. The DON stated not all staff had received the inservice on using the mechanical lift, nor had competencies been completed for all nursing staff related to using the mechanical lift. She stated she did not know why the competencies had not been completed or why all nursing staff had not been inserviced. She stated she had no documentation of monitoring to ensure the inservice had been effective or that staff were using the mechanical lift correctly. On [DATE] at 3:15 p.m., the DON provided a document titled, Competency Not Completed. The names of 12 nursing staff members were listed. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance of two staff members for transfers. It was documented the resident had impairments in functional range of motion for one lower extremity. The resident's care plan, revised [DATE], documented the resident had the potential for falls related to issues including impaired mobility, poor endurance, and unawareness of safety needs. The goal was the staff would evaluate all falls and intervene as needed to reduce the potential of significant injury. Interventions included to use a mechanical/Hoyer lift with two staff for transfers. The care plan also documented the resident had the potential for acute/chronic pain. The goal was the resident would not have an interruption of normal activities due to pain. Interventions included to evaluate the effectiveness of pain interventions; monitor/record/report any signs or symptoms of non-verbal pain; and to notify the physician if interventions were unsuccessful or if current complaint was a significant change from the resident's past experiences of pain. Review of medication administration records (MARs), dated ,[DATE], revealed the resident did not receive any as needed Tylenol for pain. Review of MARs, dated [DATE] through [DATE], revealed the resident did not receive any as needed Tylenol for pain. MARs, dated [DATE] at 8:20 a.m., documented the resident had a pain level of 5 on a scale of 0 to 10. It was documented the resident received one Tylenol, 500 milligrams (mg) for pain. Review of the medical record revealed no documentation a pain assessment was completed. There was no documentation to show the facility attempted to determine the cause of the resident's new onset of pain. There was no documentation the resident had been assessed to see if the medication was effective. There was no documentation the physician was notified of the new onset of pain. A significant change progress note, dated [DATE] at 9:00 a.m., documented, . focused assessment related to change in status. While CNA on duty was performing care to resident this AM, resident began screaming in pain. She began stating that both of her legs were hurting. Upon assessment of resident, left upper thigh presented more swollen than right upper thigh. Right upper thigh was very tight and felt hard to touch. During movement or when legs or body was lightly touched, resident would begin screaming in pain. This nurse called (physician name withheld) and reported new findings . ordered for resident to be sent out to ER (emergency room ) for further evaluation . An emergency department note, dated [DATE] at 1:05 p.m., documented, . chief complaint of bilateral leg pain . nursing home states that the patient began to complain of diffuse bilateral leg pain this morning. There were no reported falls or other traumas precipitating her complaint . She states that she hurts 'everywhere' . describes her pain as severe, mainly located in the bilateral thighs, constant timing, worsened with touch and movement of the bilateral lower extremities. No medications were given prior to arrival . Abnormal range of motion and strength (severely diminished secondary to pain), Positive for diffuse bilateral thigh tenderness to palpation. Patient holds her left lower extremity in slight abduction and internal rotation. Positive for mild swelling of the bilateral distal femurs . Left and right femoral x-ray series are obtained. Findings are significant for an acute comminuted, mildly displaced distal right femoral shaft fracture. Additionally, there is an acute, displaced left femoral spiral fracture . Facility in-service reports, dated [DATE], documented all nursing staff received education related to abuse and neglect and transferring residents per their care plan instructions. A hospital operative report, dated [DATE] at 7:34 p.m., documented, . Left femoral shift comminuted displaced fracture . Closed reduction with intramedullary nailing of left femoral shift . A hospital operative report, dated [DATE] at 7:46 pm., documented, . Displaced comminuted right distal femoral shaft fracture . Open reduction, internal fixation of displaced comminuted right distal femoral shaft fracture . On [DATE] at 11:43 a.m., assistant director of nursing (ADON) #1 stated she had worked [DATE] on the day shift. She stated resident #3 complained of pain, and she had one of the other staff members to administer Tylenol to the resident. She stated it was unusual for the resident to have pain. She stated at midnight on [DATE], she was still working on the resident's unit. She stated, I heard her screaming during incontinent care. ADON #1 stated she did not document anything related to the resident's pain. The ADON stated she and the CNA had attempted to console the resident by giving her stuffed animals and adjusting her bed linens. ADON #1 stated she did not complete an assessment on [DATE] when the resident was complaining of pain. She stated she did not complete an assessment on [DATE] when she heard the resident screaming during incontinent care. She stated she would describe the resident's pain as excruciating. She stated she did not notify the physician of the pain. She stated it was difficult to reach the on-call physician as you would have to call and leave a message and wait for them to return the call. ADON #1 stated on [DATE], the resident's legs were swollen, with the left leg being really large. She stated, The right was tight and constricting looking. She stated the resident was sent to the hospital. ADON #1 stated CNA #2 reported to her that earlier in that week ([DATE] through [DATE]), she had transferred the resident without using a lift. She stated she did not document that, but she had informed the DON of the information on [DATE]. On [DATE] at 12:28 p.m., ADON #2 stated on [DATE], she was the floor nurse caring for resident #3. She stated it was the resident's shower day. She stated she and LPN #3 were going to shower the resident, but there was no lift sling in the chair under the resident. She stated they attempted a two-person transfer with the resident, but they had to set the resident on the floor. She stated LPN #3 got assistance from another nurse to get the resident off of the floor, and then they completed the shower. ADON #2 stated she did not report the fact there was no sling under the resident on [DATE]. She stated the definition of a fall was a change in elevation. She stated she did not document the fall nor did she complete an incident report. ADON #2 stated she did not know why the resident did not have a lift sling in her chair. She stated the resident was already in the chair at the beginning of her shift. ADON #2 stated she did not report the incident to the DON until [DATE], when the DON called her to ask her if she knew how the injuries with the resident may have occurred. On [DATE] at 1:00 p.m., the DON stated she received a call from ADON #1 on [DATE], and ADON #1 told her the resident might have a blood clot due to COVID and pain in the resident's legs. She stated she called ADON #2 to ask her if she knew anything about resident #3 and was told she could not remember anything. The DON stated ADON #1 came to her later and told her CNA #2 may have transferred the resident by herself. The DON stated CNA #2 was sent home due to COVID-19 that morning, and she did not have a chance to interview her until the Monday before Christmas ([DATE]). The DON stated at that time CNA #2 admitted to transferring the resident by herself, without the use of a lift. The DON stated CNA #2 was terminated due to failing to follow facility policy. The DON stated she did not gain knowledge that ADON #2 and another nurse transferred the resident without a lift on [DATE] until a report came from Adult Protective Services (APS) at the end of ,[DATE]. She stated she inserviced all staff on abuse and neglect and transferring residents on [DATE] following the incident with resident #3. The DON stated her monitoring consisted of more frequent rounds and making sure the residents' transfer status was on the Kardex. She stated the monitoring was not documented. She stated the competency of staff related to transferring residents per the plans of care had not been completed for all staff. The DON stated she had completed spot checks to ensure staff was showing competency. The DON stated the spot checks were not documented. The DON stated she did not do anything after gaining knowledge ADON #2 and LPN #3 had transferred the resident without the use of a lift because the administrator had informed her he would take care of it. The DON stated, She should have notified me. She stated she reported CNA #2 to the nurse aide registry as suspended on [DATE] after being told by ADON #1 that the CNA may have transferred the resident by herself. She stated she did not amend the report to show CNA #2 had been terminated after acknowledging she had transferred the resident by herself.

Based on record reviews, observations, and interviews, it was determined the facility failed to ensure residents were provided care and services to attain and/or maintain their highest potential by failing to assess, monitor, and intervene for six (#20, #22, #24, #25, #26, and #28) of 14 sampled residents who were identified with a rash. The residents had frequent itching that caused discomfort and interfered with their ability to sleep. This resulted in actual harm for the six residents. The facility's infection control information identified 31 residents with a rash. This had the potential to affect 74 of 74 residents who currently resided in the facility. Findings: 1. A nurse's note for resident #20, dated 04/16/12 at 12:35, documented, "Res noted to have rash to torso et extremities, fine red, occasionally itches. (Physician) [MEDICATION NAME] cream BID x @ wks. [MEDICATION NAME] 25mg 1 po Q 6 hrs prn for itching." A physician's orders [REDACTED]. A care plan update, dated 04/16/12, documented, "[MEDICATION NAME] cream topically to rash areas on torso et extremities BID x 2 weeks, then DC. [MEDICATION NAME] 25mg 1 PO Q 6 (hours) prn itching." A nurse's note, dated 04/17/12 at 12:45 p.m., documented, "...Res reports the rash all over his body has been itching. Nurse cliped (sic) Res's fingernails also..." A nurse's note, dated 04/21/12 at 3:00 a.m., documented, "...resident scratching @ rash on arms..." A nurse's note, dated 04/21/12 at 1:00 p.m., documented, "...Rash cont on body + @ x's Res wanting to scratch. Fingernails has been cliped. (sic)" A nurse's note, dated 04/22/12 at 5:40 p.m., documented, "...only discomfort is c rash..." A nurse's note, dated 04/24/12 at 1:30 p.m., documented, "...Res cont to scratch his rash. (Physician) here + seen Res. New order for [MEDICATION NAME] 250mg 1 po q day x 2 wks for skin rash..." A physician's orders [REDACTED]. A care plan update, dated 04/24/12, documented, "Problem: ...recent rash is resolving...Interventions reviewed et appropriate...Approach: [MEDICATION NAME] cream...rash areas on [MEDICATION NAME]" A nurse's note, dated 04/27/12 at 12:30, documented, "...Res reports some itching esp (especially) in groin + behind his knees..." The April 2012 MAR, documented, "[MEDICATION NAME] 25mg 1 po Q 6 hrs prn for itching 4/16/12." No [MEDICATION NAME] was documented as given. A nurse's note, dated 05/03/12 at 10:00 a.m., documented, "...Res reports some scratching to arms, torso + back behind legs..." A nurse's note, dated 05/06/12 at 4:00 a.m., documented, "...Resident c/o itching to arms, torso..." A nurse's note, dated 05/07/12 at 10:30, documented, "...Res cont to have rash on body + extremities. Rash has improved but still has rash on his back, chest, extremities, buttocks, thighs + groin area...Res has been scratching area's + reports it, the rash still itches..." A nurse's note, dated 05/08/12 at 1:25 p.m., documented, "...Res cont to have rash no body. (Physician) seen res + N.O to cont. [MEDICATION NAME] 250mg po q day x 2 wks for rash..." A physician's orders [REDACTED]. [MEDICATION NAME] 250 mg (one) po q day x 2 weeks for rash..." An untimed nurse's note, dated 05/09/12, documented, "...Rash has improved but cont to see rash on torso, + on extremities (upper) + (lower). Has scratched rash @ times. Have trimed (sic) fingernails to keep res scratching..." A nurse's note, dated 05/13/12 at 2:00 a.m., documented, "...C/O itching, scratching noted..." A nurse's note, dated 05/14/12 at 1:00 p.m., documented, "...Have noted some scratching + asked Res not to scratch his rash..." A nurse's note, dated 05/19/12 at 2:30 a.m., documented, "...Resident continues to have rash c/o itching scratching frequently..." A nurse's note, dated 05/19/12 at 1:15 p.m., documented, "...Rash noted to (upper) torso, BUE's c/o itching to torso..." A nurse's note, dated 05/20/12 at 4:30 a.m., documented, "...Rash persists c/o itching. Scratching noted..." A nurses's note, dated 05/20/12 at 10:00 a.m., documented, "...C/O itching + scratching..." An untimed nurse's note, dated 05/21/12, documented, "...Res has been scratching his rash..." A nurse's note, dated 05/22/12 at 12:30 p.m., documented, "...Res cont to scratch his rash. Torso, back, upper + lower extremities. Redness seen to groin, under knee areas, + torso + arms..." A nurse's note, dated 05/22/12 at 7:40 p.m., documented, "...Res cont to scratch his rash. Scratching his torso sides, some of his back as much as he could reach and upper & lower extremities..." A nurse's note, dated 05/23/12 at 10:00 a.m., documented, "...Res cont to have rash on torso + back of Res. Has rash on upper + lower extremities. Cont to scratch the rash..." On 05/23/12 at 12:00 p.m., the resident was transferred to the emergency room for another issue. A nurse's note, dated 05/23/12 at 6:00 p.m., documented, "...Res returned from (hospital) c N/O [MEDICATION NAME] cream apply from head to toes leave on 14 (hours) then shower off. Repeat in 2 weeks..." A physician's orders [REDACTED]. Please treat pt c [MEDICATION NAME] c/o itching - bedding needs to be washed in hot water..." A physician's orders [REDACTED]. An untimed nurse's note, dated 05/24/12, documented, "...Res cont to scratch rash which is over all of his body..." A skin assessment weekly summary, dated 05/24/12, documented, "...Rash...entire body...onset date 05/24/12...current Tx/Order: permetherine (sic) cream, apply to entire body, wash off after 14 hours, repeat in 2 weeks..." The skin assessment did not address the resident had a [DIAGNOSES REDACTED]. A nurse's note, dated 05/24/12 at 7:30 p.m., documented, "...Rash all over body et palm of hands. Up walking @ facility." The care plan, updated 05/25/12, documented, "[MEDICATION NAME] cream apply to rash areas of overall skin BID x 2 weeks...repeat permetherine (sic) cream as ordered..." A wound care note, dated 05/25/12, documented, "...Res c fine red rash over entire body et skin is dry. Was evaluated at (hospital) ER for another issue et returned c dx of scabies et tx orders. Rash area has been assessed by (physician name deleted) who does not believe rash appearance is consistent c scabies. Per (physician), ok to treat c orders from ER. Orders for permetherine (sic) cream. Apply to entire body, wash off p 14 hours et repeat in 2 wks. Also ordered [MEDICATION NAME] cream to rash areas BID x 2 wks..." A physician's orders [REDACTED]. A nurse's note, dated 05/26/12 at 4:00 a.m., documented, "...rash continuos (sic) scratching reports of itching continue." A nurse's note, dated 05/27/12 at 4:00 a.m., documented, "...Rash continues co itching, scratching..." The May 2012 MAR indicated [REDACTED]..25mg PO Q 6 hours prn itching." No [MEDICATION NAME] was documented as given. A wound care note, dated 06/01/12, documented, "...rash area is faded slightly et res reports it itches less..." A physician's orders [REDACTED]. The care plan, dated 06/06/12, documented, "[MEDICATION NAME] lotion apply to rash areas over all skin BID...permetherine (sic) cream washed off...Baby shampoo for all showers..." A wound care note, dated 06/08/12, documented, "...rash continues to fade. Second treatment of [REDACTED]. A physician's orders [REDACTED]. The care plan, dated 06/12/12, documented, "...Permetherine (sic) cream...6/20/[MEDICATION NAME] (sic) cream apply..." The care plan did not address what type of rash, the description of the rash, the location of the rash, if the resident experienced itching, and if the rash was resolving or spreading. A wound care note, dated 06/15/12, documented, "...Rash continues to fade et res reports decrease in itching. Continue c [MEDICATION NAME] lotion et baby shampoo..." On 06/27/12 at 10:20 a.m., the resident's skin was observed with a round reddened area that was approximately the size of a quarter on each side of the middle area of his back. The area was covered with small red raised bumps. There were also some red bumps that appeared in a line under the larger round areas which extended down approximately one inch away from the larger areas. He had a small, approximately one inch, reddened area on his left inner arm near his inner elbow that was also raised with bumps. There were also small reddened areas of skin in various stages of healing, some with scabs on both of his lower forearms. The resident was asked if the areas itched. He stated. " Yes, really bad on each side of my spinal column." The resident was asked how long he had been itching. He stated he was not sure it seemed like a long time. He was asked how often it itched. He stated, "It varies, but it itches like the dickens at night and I can't sleep." The June 2012 MAR indicated [REDACTED]..25mg PO Q 6 hours prn itching." No [MEDICATION NAME] was documented as given during June. On 6/28/12 at 8:10 p.m., LPN #3 was asked if a resident was given [MEDICATION NAME] where would it be documented. She stated, "[MEDICATION NAME] would be charted on the MAR." 2. A skin care plan for resident #22, dated 03/23/12, did not document the resident had a rash or experienced itching. A wound care note, dated 05/25/12, documented, "...Res has rash scattered over entire body. Fine red raised areas noted where skin is dry. Skin remedy repair cream ordered BID et prn..." The skin care plan had not been updated to address the rash the resident had acquired, what type of rash, the description of the rash, the location of the rash, if the resident experienced itching, what type of treatment, and if the rash was resolving or spreading. A wound care note, dated 06/01/12, documented, "...Rash to entire body c little change at this time. Continue c current tx at this time..." The skin care plan, updated 06/06/12, documented, "[MEDICATION NAME] lotion apply to rash areas of overall skin /bid et PRN for itching..." A wound care note, dated 06/08/12, documented, "...Rash to entire body is faded slightly. Treatment changed to [MEDICATION NAME] lotion BID et prn et baby shampoo c showers. Resident noted to be scratching less..." The skin care plan, updated 06/12/12, documented, "[MEDICATION NAME] (sic) cream apply topically from neck to sole of feet...for rash preventative..." A wound care note, dated 06/15/12, documented, "...Rash to entire body is faded et their (sic) is a decrease in scratching noted. Continue c [MEDICATION NAME] lotion BID et prn. Treated c [MEDICATION NAME] cream for rash preventative on 6/13/12..." The skin care plan, updated 06/20/12, documented, "[MEDICATION NAME](sic) cream apply topically from neck to sole of feet...rash preventative..." The skin care plan had not been updated to address the rash the resident had acquired, what type of rash, the description of the rash, the location of the rash, if the resident experienced itching, and if the rash was resolving or spreading. A wound care note, dated 06/22/12, documented, "...Rash areas drying. Less scratching noted. Cont c current tx. Retreated c [MEDICATION NAME] cream on 6/20/12 for rash preventative..." On 06/27/12 at 10:40 a.m., the resident was observed with a red, blotchy rash with raised areas and dry white patches throughout the rash. The rash was located on his abdomen and continued on his side and onto his back. The resident was observed as he scratched his rash. He was asked if he itched. He stated, "Yes." He was asked if the itching had kept him awake at night. He stated, "Yes." 3. A care plan for resident #24, dated 09/06/11, documented a problem of at risk for skin irritation and/or breakdown. An update to the care plan, dated 10/04/11, documented, "[MEDICATION NAME] 25mg 1 PO BID itching." An update to the care plan, dated 10/26/11, documented, "...(3)[MEDICATION NAME] calming cream lotion to torso et all ext BID dry skin. (4) D/C TMC cream to body. (5) [MEDICATION NAME] cream 5% to torso et all ext, shower off in 12-14...repeat in 7 days. (6) [MEDICATION NAME] to torso et all ext, TID, prn itching. Dx: Rash." An update to the care plan, dated 12/07/11, documented, "[MEDICATION NAME] 25mg PO BID itching." An update to the care plan, dated 02/02/12, documented, "Continue c [MEDICATION NAME] lotion to rash as directed." The care plan failed to address what type of rash, the description of the rash, if the resident experienced itching, and if the rash was resolving or spreading. A Medication Administration Record, [MEDICATION NAME] ([MEDICATION NAME]) 25 mg po BID for Itching 01/18/12..." A wound care note, dated 05/25/12, documented, "...Res has had rash to entire body. Rash c large patches of dry red skin c scattered red raised bumps. [MEDICATION NAME] cream is utilized BID et prn..." A Medication Administration Record, [MEDICATION NAME] ([MEDICATION NAME]) 25 mg po BID for Itching 01/18/12..." A wound care note, dated 06/01/12, documented, "...Rash to entire body red c dry skin scattered cont c [MEDICATION NAME] cream as ordered..." A skin assessment, dated 06/06/12, documented, "...Continues with rash, but is faded at this time. Continues to complain of itching...treatment changed..." A skin care plan, dated 06/06/12, documented, "...Use baby shampoo et body wash for all showers...D/C [MEDICATION NAME][MEDICATION NAME] lotion to rash areas of overall skin BID et PRN itching...D/C [MEDICATION NAME]" A wound care note, dated 06/08/12, documented, "...Rash to entire body is fading. Continues to c/o itching. Treatment changed to [MEDICATION NAME] lotion BID et prn et baby shampoo for showers..." A skin care plan, dated 06/12/12, documented, "[MEDICATION NAME] (sic) cream apply topically from neck to sole feet...rash prevention..." The care plan failed to address what type of rash, the description of the rash, the location of the rash, if the resident experienced itching, and if the rash was resolving or spreading. A wound care note, dated 06/15/12, documented, "...Rash to entire body continues to fade et skin appears less irritated. Res states itching is not as severe. Treated c [MEDICATION NAME] cream on 6/13/12..." A skin care plan, dated 06/20/12, documented, "[MEDICATION NAME] (sic) cream apply topically from neck to soles feet...rash prevention..." The care plan failed to address what type of rash, the description of the rash, the location of the rash, if the resident experienced itching, and if the rash was resolving or spreading. A wound care note, dated 06/22/12, documented, "...Rash to entire body currently red dry patchy skin s raised areas cont c [MEDICATION NAME] lotion BID et prn et baby shampoo. Retreated c [MEDICATION NAME] cream on 6/20/12 for rash preventative..." A Medication Administration Record, [MEDICATION NAME] ([MEDICATION NAME]) 25 mg po BID for Itching 01/18/12..." On 06/27/12 at 10:00 a.m., the resident was observed with a pimple like rash on the chest area and on the sides of his arms. The resident was asked how long he had the rash. He stated, "A couple of weeks." He was asked if he had reported the rash. He stated, "They know about it." The resident was asked if the rash itched. He stated, "I have had itching on my back, sides, shoulders, arms, and legs." He was asked when he itched the most. He stated, "All the time." He was asked if it kept him awake at night. He stated, "Oh yeah." 4. A physician's orders [REDACTED]. [MEDICATION NAME] Cream to rash areas on upper extremities BID x 1 wk." A physician's orders [REDACTED]. A wound care note, dated 05/25/12, documented, "...Res has fine red raised rash over entire body c frequent complaints of itching. Skin noted to be dry. Treatment initiated c [MEDICATION NAME] lotion BID et prn et baby shampoo for all showers..." A wound care note, dated 06/01/12, documented, "...Rash to entire body fading et resident reports decrease in itching Skin c less redness noted, but conts c fine raised rash..." A wound care note, dated 06/08/12, documented, "...Rash continues to fade. Resident reports itching is greatly decreased. Treatment to continue..." A wound care note, dated 06/15/12, documented, "...Rash areas continue to fade et skin appears less irritated. Res reports decrease in itching. Continue c [MEDICATION NAME] lotion BID et prn et baby shampoo for showers. [MEDICATION NAME] cream treatment for [REDACTED]. A wound care note, dated 06/22/12, documented, "Rash areas continue to fade et remaining areas are drying. Res states itching continues to improve. Retreated c [MEDICATION NAME] cream on 6/20/12 for rash preventative..." On 06/27/12 at 10:05 a.m., the resident was observed to have dry, red, raised areas approximately 3 inches in diameter behind her knees and on three fingers of her right hand. The resident was ask how long she had the rash. She stated, "A few weeks." She was asked if she had reported the rash. She stated, "I notified a nurse." She was asked if the rash itched. She stated, "Yes, it keeps me awake at night." A skin care plan, dated 06/28/12, documented, "...Problem: At risk for skin irritation/breakdown...Approach: ...Apply [MEDICATION NAME] lotion topically to rash areas of overall skin BID and PRN for itching..." 5. A skin care issue care plan, dated 04/11/12, for resident #25, did not document the resident had any skin rashes or itching. The care plan included an approach which documented, "[MEDICATION NAME] 10mg po QID prn itching." A wound care note, dated 05/25/12, documented, "...Res noted c fine red raised rash to body mainly on ankles. Skin is dry. Treatment initiated for [MEDICATION NAME] cream BID x 2 weeks. Res states area itches..." A wound care note, dated 06/01/12, documented, "...Rash continues scattered over entire body. Res reports decrease in itching at this time. Continue c current tx..." A miscellaneous care plan, updated 06/06/12, documented, "...Use baby shampoo et body wash for all [MEDICATION NAME] lotion to rash areas BID et PRN for itching..." The miscellaneous care plan failed to address what type of rash, the description of the rash, the location of the rash, if the resident experienced itching, and if the rash was resolving or spreading. A wound care note, dated 06/08/12, documented, "...Continues c scattered rash areas c greatest amount noted around the ankles. Res states it continues to itch at times. Treatment changed to [MEDICATION NAME] lotion et baby shampoo..." A miscellaneous care plan, updated 06/12/12, documented, "...Permethrien (sic) cream apply topically from neck to soles of feet...rash prevention..." The miscellaneous care plan failed to address what type of rash, the description of the rash, the location of the rash, if the resident experienced itching, and if the rash was resolving or spreading. A wound care note, dated 06/15/12, documented, "...Rash is fading et decrease in itching reported by resident. Continue c [MEDICATION NAME] lotion BID et prn..." A miscellaneous care plan, updated 06/20/12, documented, "...Permethrien (sic) cream apply topically neck to soles of feet...rash prevention..." The miscellaneous care plan failed to address what type of rash, the description of the rash, the location of the rash, if the resident experienced itching, and if the rash was resolving or spreading. A wound care note, dated 06/22/12, documented, "...Rash areas are fading et remaining is dry. Continue c [MEDICATION NAME] lotion et baby shampoo...Retreated c [MEDICATION NAME] cream on 6/20/12 for rash preventative..." A Medication Administration Record, [MEDICATION NAME] ([MEDICATION NAME]) 10 mg po QID for PRN Itching 05/19/11..." On 06/27/12 at 10:10 a.m., the resident was observed with small red bumps with scabs on his right arm. A red rash was also observed on his back, left hip and left shoulder. The resident was asked if the rash itched. He stated, "Yes, about to run me crazy." 6. A physician's orders [REDACTED]. A fax to a dermatologist, dated 01/19/12, documented, "[MEDICATION NAME] 0.1% in Velvachol 1 lb jar apply BID x 2 wks to rash then stop for 1 month then repeat..." A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A wound care note, dated 05/25/12, documented, "...Res has fine red raised rash to entire body. Res has previously been seen by dermatologist for this rash, which is a chronic intermittent issue. Majority of rash located on abdomen. Reinitiated TMC in Velvachol BID x 2 weeks, hold x 1 month then repeat..." A wound care note, dated 06/01/12, documented, "...Rash is unchanged at this time Continue c current treatment..." A physician's orders [REDACTED]. A wound care note, dated 06/08/12, documented, "...Rash continues unchanged at this time, located primarily on abdomen et arms. DC'd previous tx orders et started on [MEDICATION NAME] lotion BID et prn et baby shampoo for showers..." A physician's orders [REDACTED]. A wound care note, dated 06/15/12, documented, "...Little change noted in appearance of rash at this time. Decrease noted in scratching, however res denies decrease in itching. Continue c current tx. Treated c [MEDICATION NAME] cream on 06/13/12..." A physician's orders [REDACTED]. A wound care note, dated 06/22/12, documented, "Rash continues c little change at this time. Res states [MEDICATION NAME] lotion does help to relieve itching...Retreated c [MEDICATION NAME] cream on 6/20/12..." On 06/27/12 at 11:05 a.m., the resident was observed with a red, blotchy rash with raised areas on the resident's upper arms, abdomen, under her breasts, and on the back of her neck. She was asked how long she had the rash. She stated, "Couple to three weeks." She was asked if she had reported the rash. She stated, "Yes, I talked to the wound care coordinator." She was asked if the rash itched. She stated, "Yes, I am miserable." On 06/27/12 at 2:25 p.m., the treatment nurse was asked when the outbreak of the rashes had started. She stated, "Four to five weeks ago." The treatment nurse was asked how many residents had acquired the rash. She stated, "First, 10 to 15. Last of April, beginning of May." She was asked if staff had acquired the rash. She stated, "I think one staff member, but it didn't appear to be the same type of rash." She stated that in the month of May they started to see staff involved with rashes. She stated the corporate nurse saw some residents and staff with rashes. She stated, "We didn't know what was going on." The treatment nurse was asked what treatments they started when the rashes were identified. She stated from May 26 through June 1 there were a total of 22 rashes and an initial skin assessment was done on every resident at that time. She stated "some additional rashes" had been identified at that time. She stated, "We started [MEDICATION NAME] for two weeks, [MEDICATION NAME] and remedy creme, unless something else was ordered." The treatment nurse was asked if the rash was still prevalent in the facility among residents and staff. She stated, "Yes." She stated, "June 1 through June 8 we switched to [MEDICATION NAME] lotion and baby shampoo. It was a widespread rash so we switched." She was asked how many residents had the rash. She stated, "21 with the rash and 1 new rash area noted that week." The treatment nurse stated that someone had called and stated they had a rash and was treated for [REDACTED]. She stated they had found out about the phone call on 06/11/12 and had written orders for all the residents to be treated with [MEDICATION NAME] cream 5%. She stated an inservice was conducted on 06/13/12 and a copy of instructions had been given to the staff. She was asked if a skin assessment had been done after the treatment. She stated, "Yes. Some still have a rash and a few new people were identified with new rashes. 9 identified. We are reassessing the residents this week. Many residents still have the rashes some are drying."

Based on observation, interview and record review, it was determined the facility failed to provide supervision to prevent accidents and failed to identify and implement interventions to prevent falls for one (#3) of 12 sampled residents with falls. The facility's current roster/matrix identified 60 residents had falls. This resulted in actual harm for resident #3 when he suffered 12 falls in six months that resulted in a right wrist fracture, four sutures to the fourth finger on his left hand, a 2 cm x 1 cm abrasion to his temple/forehead requiring steri strips, six skin tears to his left elbow, a skin tear to his left wrist, and a skin tear to his left shoulder. Findings: The facility's fall awareness program documented, "Purpose: The Fall Awareness Program is designed to identify those residents who may be at risk for falls and injury...Policy: ...Falls and significant changes are reported to the Director of Nursing and the Quality Manager for review...6. Review and investigate previous falls if able. (time of day, last meal, usual or unusual activity, standing/ walking, reaching, crowd of people, bowel or bladder urgency, glare or liquid on the floor, foreign object, pattern of falls, medications given...7. Complete Fall Risk Assessment and Pain Assessment Tools...10. Evaluate need for an adjustment in resident's daily activity schedule...12. Develop care plan based on interventions used. Review quarterly and as needed...Fall Occurs: ...4. Consider factors regarding the fall. Develop care plan using appropriate interventions...14. Review and/ or revise plan of care as needed...16. Review the fall at the next Safety committee meeting and gain input for interdisciplinary team members for other possible interventions to prevent falls. Make sure to update and revise plan of care as indicated." Resident #3 had current [DIAGNOSES REDACTED]. A fall care plan, dated 12/12/11, documented, "Problem: Falls potential for injury r/t incontinency, impaired mobility, etc..Goal: No serious injury from falls for next 90 days...Approach: ...keep pathways clean & free of clutter... Utilize low bed, fall mat, geri hips, and self-releasing belt...reposition q 1-2 (hours)...resident is on our falling star program...appropriate footwear/nonskid socks..." An incontinent care plan, dated 12/12/11, documented, "Approach: Check q 2 hrs for soilage (sic) and wetness..." An incident report, dated 01/03/12 at 11:15 a.m., documented, "...Describe what happened and assessment and intervention: Res in w/c out in lobby staff could not reach res in enough time to help prevent res from falling on floor. ROM done & no pain voiced & all wnl...Summary of Investigative Actions:...1. Toileting program..." The fall care plan, updated on 01/03/12, documented, "...Approach:...social worker witnessed resi slipping out of w/c to floor...toileting program..." An incident report, dated 01/03/12 at 11:00 p.m., documented, "...resident found on floor beside bed lying on back no c/o pain no injuries noted...Summary of Investigative Actions:...1. b/p q shift x 3 days...2. neuros..." The fall care plan was updated on 01/03/12, documented, "Approach: b/p q shift for 3 d..." The fall care plan failed to address if the resident's blood pressures had been out of normal range, if the resident's blood pressure medication had been changed, and why taking the resident's blood pressure every shift for three days was an appropriate intervention. The resident's clinical record revealed the resident had blood pressures within the normal limits. An incident report, dated 01/08/12 at 6:00 a.m., documented, "...Describe what happened and assessment and intervention: resident observed on bedside mat beside bed sitting up s/t to L shoulder, wrist, et L elbow...staff educated on fall prevention..." A nurse's note, dated 01/08/12 at 6:00 a.m. and attached to the incident report, documented, "...Dr...notified new intervention...UA..." The fall care plan, updated on 01/08/12, documented, "...staff education on fall prevention - UA" The fall care plan, updated on 02/20/12, documented, "xray R wrist." The fall care plan failed to address how the resident received the wrist fracture, if the wrist fracture was the result of a fall, and the reason the wrist xray was ordered. A nurse's note, dated 02/23/12, documented, "Focused assessment r/t resident c/o R wrist hurting he was using it to eat et I noticed he had a lg bump..." An incident report dated, 02/23/12, documented, "...Event:...Unobserved event...Describe what happened and assessment and intervention: Res hand swelling of R wrist, xray reveled (sic) displaced fx of distal ulna...Summary of Investigative actions:...med review..." There was no documentation the facility investigated the right wrist fracture of unknown origin. An incident report, dated 03/05/12 at 9:30 a.m., documented, "...Initial Actions: Staff education...tippers to back of w/c...Describe what happened and assessment and intervention: Res leaning forward & to R side of w/c & fell out of chair on to buttocks & then to R side...ID Witnesses: helped back into w/c...noted tippers to back of w/c / staff education done on toileting q 2 (hours)..." The fall care plan, updated on 03/05/12, documented, "...Approach...staff education Anti tippers to w/c..." An incident report, dated 03/24/12 at 11:50 a.m., documented, "...Describe what happened and assessment and intervention: Resident heard yelling in room. Resident found lying on back by this nurse (no) alarm going off. (no) injury noted. Resident is not to be left alone in room. Staff inservice on bed alarms/chair alarms..." The fall care plan, updated on 03/24/12, documented, "...Staff education. Resident to be out of room except for ADL care c staff and when sleeping. Resi not left alone in room..." The fall care plan, updated on 04/09/12, documented, "...keep pathways clear alarm belt/, self releasing." The interventions documented on 04/09/12 on the fall care plan, had been in place since 12/21/11. An Oklahoma State Department of Health incident report, dated 04/19/12, documented, "...Description of Incident: Resident noted to be leaning forward in his wheelchair....he grabbed the doorway to his room and tipped both himself and the wheelchair over, forward...laceration to his left ring finger, skin tear to left elbow, and complained of left hip pain...sent to ER...Relevant history:...very unsteady gait, uses a wheelchair equipped with anti-tippers...He utilizes a self releasing alarm belt and geri hips. He also has a low bed with fall mat on the floor...4 sutures to left ring finger...reviewed his medications..." The fall care plan, updated on 04/19/12, documented, "...eval meds..." The fall care plan failed to document if the residents medication had been changed after the medication evaluation. An incident report, dated 04/22/12 at 1:00 p.m., documented, "CNA...was assisting Resident in w/c pushing him to hallway...res abruptly put feet down on floor bringing w/c to a quick stop. Res fell forward onto floor. Self releasing waist belt c alarm loosened at x of fall...st to L elbow & small laceration L temple and forehead 2 cm x 1 cm...Summary of investigative actions: UA..." The fall care plan, updated on 04/22/12, documented, "...UA..." An incident report, dated 04/26/12 at 5:45 a.m., documented, "...resident found lying on mat in front of bed pressure alarm not in place staff inserviced fall mat in place...Summary of investigative actions: add to restorative program..." The fall care plan, updated on 04/26/12, documented, "...restorative..." The facility's restorative book was reviewed and revealed no documentation to indicate the resident had been on a restorative program. An incident report, dated 04/26/12 at 2:10 p.m., documented, "...Res released self releasing belt slid to floor. alarm turned on, however it did not sound...Summary of investigative actions: pulse ox q shift x 3 day..." The fall care plan, updated on 04/26/12, documented, "...pulse ox q shift x 3 days." No appropriate interventions were addressed on the care plan to prevent the resident from sliding out of the wheelchair. An incident report, dated 05/04/12 at 12:45 p.m., documented, "...Resident sitting in w/c c safety belt on when he leaned forward and the belt came undone c (no) alarm sounding, causing resident to hit his head c 5 cm abrasion to R forehead (sic) will also put clip alarm on (for new intervention we cleaned equipment)... Summary of investigative actions: cleaned equipment Atb started..." The fall care plan, updated 05/04/12, documented, "...cleaned equipment...ATB started." The fall care plan failed to address what equipment was cleaned, how the equipment was related to the resident's fall, the [DIAGNOSES REDACTED]. An incident report, dated 05/14/12 at 12:30 p.m., documented, "...resident found laying on floor - self releasing belt and clip alarm in place. Found 3 skin tears to L elbow - intervention B/P q shift x 3 days et record..." The fall care plan, updated on 05/14/12, documented, "...B/P q shift x 3 days..." The fall care plan did not address the results of checking his blood pressure. The resident's clinical record revealed the resident had blood pressures within the normal limits. The resident had experienced 12 falls since January 3, 2012 and sustained a right wrist fracture, four sutures to the fourth finger on his left hand, a 2 cm x 1 cm abrasion to his temple/forehead requiring steri strips, six skin tears to his left elbow, a skin tear to his left wrist, and a skin tear to his left shoulder. An annual assessment, dated 05/22/12, documented the resident was moderately impaired in cognitive skills for daily decision making, was always incontinent of bowel and bladder, and since the last assessment had two falls without injury and two falls with a non-major injury. On 06/27/12 at 6:40 p.m., the resident was observed in the South lobby sitting up straight in his wheelchair with a personal alarm attached. On 06/28/12 at 7:24 p.m., the DON was asked when the resident had fallen the first time on 01/03/12 why was the intervention a toileting program when his fall care plan, dated 12/21/11, documented to toilet the resident every two hours. She stated, "I understand the toileting now - it is in place." She was asked on the second fall on 01/03/12, when the resident fell out of his bed, why was the intervention to check the resident's blood pressure every shift for three days. She stated, "I wanted to see if there was any change in his blood pressure to not make him feel well and we reviewed his medications." She was asked if educating staff was an appropriate intervention when the resident fell out of bed on 01/08/12. She stated, "We have some newer staff and the RN wants to educate her staff. I'm not sure what she educated them on." The DON was asked why new and relevant interventions were not documented on the fall care plan after each of the resident's 12 falls. She stated, "I felt the ones we put in place were good. He is very hard to predict. What we had in place. He is advanced Alzheimers and not aware of his safety." The DON was asked why the facility failed to put new and appropriate interventions in place after each fall. She stated, "We did to the best of our abilities. A lot of times our interventions are working with him. We are putting in interventions that we think will work at the time. I'm afraid he is a resident that is going to fall." She was asked why the right wrist fracture was not investigated as an injury of unknown source. She stated, "He is not able to tell us anything."