Every finding on record at Wilkins Health & Rehabilitation Community

Based on record review and interview, the facility failed to complete a comprehensive significant change assessment within 14 days for 2 (#3 and #23) of 2 sampled residents reviewed for a significant change in status. The administrator reported 114 residents resided in the facility. Findings: An undated significant change MDS policy showed a significant change in status assessment was triggered when there was a major change. The policy showed initiation or cessation of hospice care or a new diagnosis were examples of triggers for a significant change. The policy showed the facility must complete a significant change assessment within 14 days of identifying a significant change in a resident's condition. 1. An MDS assessment for Resident #3, dated 04/07/25, showed the resident was severely cognitively impaired with a BIMS score of 03. The assessment showed the resident had a feeding tube. The assessment showed the resident had diagnoses which included Alzheimer's disease, dementia, diabetes, chronic pain, depression, anxiety, and systemic lupus. A care plan for Resident #3, dated 04/28/25, showed the resident no longer had a desire to have the feeding tube and was requesting to eat meals by mouth. The care plan showed the resident signed a dietary waiver and received a physician's order for a regular diet. A progress note for Resident #3, dated 04/30/25, showed the resident's physician made rounds in the facility and gave an order to discontinue the resident's feeding tube. The note showed the feeding tube was removed without difficulty. Resident #3's medical record was reviewed and showed a significant change assessment, dated 05/22/25, was in progress. On 05/20/25 at 10:46 a.m., Resident #3 reported they had recently had their feeding tube removed. The resident reported eating meals by mouth without difficulty. On 05/22/25 at 4:22 p.m., the MDS coordinator reported they were just notified the previous day Resident #3's feeding tube had been removed and the significant change assessment had not been completed. The MDS coordinator reported some nurses were good to notify them when a significant change like this occurred, but some nurses failed to get the information to them. The MDS coordinator reported the significant change assessment was now in progress. 41873 2. A quarterly assessment, dated 04/25/25, showed Resident #23's cognition was moderately impaired with a BIMS score of 12. The assessment showed no hospice services. A physician's order, dated 05/02/25, showed Resident #23 received hospice every shift for sarcopenia. A hospice plan of care, dated 05/02/25, showed a start of care date of 05/02/25. A progress note, dated 05/02/25, showed newly added hospice services. On 05/22/25 at 2:32 p.m., the MDS coordinator reported a significant change assessment should be completed within 14 days from the start day of the hospice services. The MDS coordinator reported they did not get the notification the resident was started on hospice until later that week. The MDS coordinator reported the significant change assessment for Resident #23 was late.

On 03/25/25 at 5:45 p.m., the Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy situation related to the facility's failure to provide safety and interventions to prevent elopement from the facility. Resident #1 was a high risk for elopement and wandering and was let into the court yard unattended. Resident #1 exited through a gate located on the Southeast corner of the facility and staff did not identify and know the resident was missing. On 03/25/25 at 6:05 p.m., the administrator and director of nursing were notified of the immediate jeopardy and provided the immediate jeopardy template. On 03/26/25 at 11:45 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, [NAME] HEALTH & REHABILITATION COMMUNITY IMMEDIATE JEOPARDY- PLAN OF REMOVAL March 26, 2025 1. Facility Administrator was informed on 3/25/2025 at 6:05pm of Immediate Jeopardy related to Elopement. 2. The Need for Immediate Action stated: 'The facility failure to ensure residents with a risk for wandering elopement are provided interventions and safety could lead to serious injury, harm, impairment or death.' 3. THE FACILITY PLAN OF REMOVAL IS AS FOLLOWS: A. The gate in question has been secured in a different way to ensure residents do not exit through it. (3/25/25) B. Review and revision of Policy and Procedure regarding elopements was conducted (3/25/2025) C. Review of Wandering Risk scales was conducted on all residents. 3/25/25 D. Accuracy of these assessments was ensured. E. Identified all residents scoring 11 or higher on the Risk Scale in order to review the interventions already placed and to evaluate whether additional interventions are necessary. Began 3/25/25 and completed 3/26/2025 by 1200. F. 30 Minute physical checks instituted on all wander-guarded residents until new magnetic locks and Wanderguard system updated to include exits leading to the facility courtyard. Began 3/25/25 completed3/26/2025 by 1200. G. New procedure inserviced and instituted to supervise all Wander-guarded residents when outside the facility including in the facility courtyard. Began 3/25/25 completed3/26/2025 by 1200. *Any staff not yet to be inserviced, will not be allowed to work until properly inserviced and response received. H. Immediate Inservice training completed to all staff concerning Elopement. Began 3/25/25 completed3/26/2025 by 1200. I. Administrator placed call to Wanderguard companies to request immediate order and setup of system on 4 additional doors. 3/26/25 J. Gate which is newly secured will be checked twice daily to ensure that it is locked. Completed 0800 3/26/25 Plan of Removal submitted by [name withheld] Administrator On 03/26/25 at 5:41 p.m., the facility submitted an amended plan of removal. The plan of removal, read in part, Any staff not yet to be inserviced, will not be allowed to work until properly inserviced and response received. On 03/26/25 after interviews with facility staff, review of resident elopement wander risk assessments, and in-services, the immediacy was lifted, effective 03/26/25 at 5:41 p.m. The deficient practice remained at and isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to provide supervison and interventions to prevent elopement for 1 (#1) of 3 sampled residents reviewed for elopement. Resident #1 was a high risk for elopement and wandering and eloped from the facility with a wander guard in place. Resident #1 was a known exit seeker through exits not equipped with wander guard (a device to secure exit doors if some is that is at risk for elopement is attempting to exit the building) and staff were not aware of Resident #1 being gone until the facility transportation driver returned to the facilty. The driver did not know Resident #1 resided in the facility. The DON identified five residents at high risk for wandering, elopement, and had a wanderguard in place. Findings: On 03/25/25 at 12:04 p.m., all exit doors to the center court yard were observed to be unlocked and not equipped with a wander guard system. The gate on the Southeast side of the building was observed. There was a chain with a clip release on the gate. The clip could easily be removed and the gate opened. The only exits equipped with wander guards were the two main entrances in the front of the building. A policy titled Identifying and Protecting Residents at Risk for Wandering and Elopement, revised 03/01/22, read in part, The facility will strive to prevent unsafe wandering by identifying those at risk for elopement and follow-up with interventions to ensure safety for all.The resident's care plan will indicate the residents is at risk for elopement or other safety issues. Interventions try to maintain safety, such as a detailed monitoring plan will be included. Resident #1 admitted to the facility on [DATE] with diagnoses which included dementia, agitation, acute kidney failure, and heart failure. The admission Minimum Data Set assessment, with an assessment reference date of 10/10/24, showed Resident #1 had a brief interview for mental status score of 12, which showed they had moderate cognitive impairment in decision making. The assessment showed Resident #1 had no wandering and was independent with walking and ambulating. An incident report form, Oklahoma Department of Health form 283, dated 10/13/24, showed Resident #1 was presented to the facility from the police where they were approximately two blocks away from the facility. The report showed an innocent bystander notified the police due to a potential fall. The report showed the care plan was updated for risk of wandering and wander guard placement. The report showed staff conducted visual monitoring every thirty minutes. The incident report showed the resident was a recent admission, was anxious due to noise in the current room, and had a history of dementia with agitation. Resident #1's Wandering Risk Scale, dated 10/13/24, showed they were a high risk for wandering and elopement with a score of 11. A score of 11 or greater showed they were a high risk for wandering and elopement. There was no documented care plan after Resident #1 had eloped from the facility on 10/13/24. Resident #1's progress note, dated 12/25/24 at 6:27 p.m., read in part, This nurse heard the alarm for back door go off and went to investigate, resident noted exiting the back door, when asked what [they] was doing resident stated [they] was ready to go home. This nurse was able to talk resident into coming back inside building. Resident proceeded to go to front door when that alarm went off and resident realized door was locked, resident sat in chair next to door, state[sic] [they] will just sit there until [their] [family] comes to get [them]. Resident #1's progress note, dated 12/26/24 at 3:35 p.m., read in part, Resident exited out the back door causing it to alarm to sound. Aide and office nurse walked with resident around the side of the building and assisted resident back into the building. Residents became irritated when staff attempted to redirect the first of the encounter. There were no documented interventions to address Resident #1 exit seeking through doors in the facility that were not secured with the wander guard system. Resident #1's care plan, initiated 01/20/25, read in part, Focus I HAVE A WANDERGUARD AT THIS TIME R/T MY PREVIOUS ELOPEMENT FROM FACILITY ON 10/13/24. I WAS LOCATED BY POLICE SEVERAL BLOCKS FROM FACILITY. I STATE THAT I WAS CLOCKING OUT AND GOING HOME. I HAVE HAD AN INCREASE IN WANDERING AND WILL OCCASIONALLY WANDER TO EMERGENCY EXIT DOOR, IN WHICH WANDERGUARD DOES NOT WORK ON. I WAS MOVED INTO THE MEMORY CARE UNIT FOR SAFETY REASONS ON 12/6/24. ON 12/11/24 I PUNCHED ANOTHER RESIDENT IN FACE D/T [them]. WANDERING INTO MY ROOM. I WAS SENT TO [name withheld] ER AND admitted TO [name deleted]. UPON RETURN TO FACILITY, I AM RESIDING IN PATHWAY AND HAVE WANDERGUARD IN PLACE. I FREQUENTLY EXIT SEEK AND YELL AT STAFF WHEN ATTEMPTING TO ASSIST ME .Goal .I WILL HAVE A DECLINE IN BEHAVIORS OVER THE NEXT 90 DAYS .Interventions. ACTIVITY STAFF TO POST AN ACTIVITY CALENDAR IN MY ROOM MONTHLY .STAFF TO REMIND AND ENCOURAGE ME TO ATTEND ACTIVITIES .PROVIDE IN ROOM ACTIVITIES PER MY CHOICE.family] TO VISIT AS ABLE.STAFF TO ENSURE WANDERGUARD IS IN PLACE AT ALL TIMES.STAFF TO INITIATE ELOPEMENT PROCEDURES IF I AM UNABLE TO BE LOCATED, .STAFF TO OBSERVE ME AND INTERVENE IF PROBLEM BEHAVIORS ARE NOTED TO AIDE IN PREVENTION OF INJURY TO MYSELF AND OTHERS. A care plan, initiated 01/20/25, was the first care plan that addressed wandering and elopement. There continued to be no interventions in place to address the resident exit seeking through doors not equipped with the wander guard system. Resident #1's progress note, dated 03/06/25 at 4:30 a.m., read in part, Awaken at this time and ambulating without walker. Yelled at the nurse's aide when [they] took walker to res [Resident]. Exit seeking at this time trying to open front door and yelling at staff to put code in. Wander guard in place to L [left] ankle. A facility incident report, dated 03/06/25, read in part, Transportation driver [initials withheld] called this nurse [at] 1205 stated that the resident was outside the building on the north side, walking east with walker. [initials withheld] was able to get resident to come back into the building [at]1207. Resident wander guard still in place. Resident was noted at the back door of pathway [at]1150 when staff asked [them] where [they] was going. [They] stated [they] just wanted to go outside. CNA [initials withheld] showed resident that [they] could go through the dining area to the back courtyard. Which is an enclosed area. Resident was last seen at 1155 sitting in a chair outside pathway dining area. Resident states [they] just wanted to go outside. There were no documented intervention changes to address Resident #1 exit seeking through doors in the facility that was not secured with the wanderguard system. On 03/25/25 at 12:10 p.m., LPN #1 stated they were present on 03/06/25 when Resident #1 eloped from the facility. LPN #1 stated Resident #1 was sitting in the courtyard by the dining room and they did not know the resident was gone. LPN #1 stated it was determined Resident #1 left through the gate on the Southeast side. LPN #1 stated the Southeast gate chain could easily be removed and the gate would open. LPN #1 was asked how a resident with a wander guard was able to leave the building. LPN #1 stated only the front doors were equipped with the wander guard system and not the doors to the courtyard. LPN #1 stated Resident #1 had a history of exit seeking and it was documented in the progress notes. LPN #1 was asked about Resident #1 attempting to exit through doors not equipped with the wander guard system. LPN #1 stated they were not aware of any attempts to exit seek through doors not equipped with the system. On 03/25/25 at 12:26 p.m., CNA #1/facility transporter stated they were returning to the facility from the North side of the building and turned the corner to head South. CNA #1 stated they saw a person with a walker at the end of the building getting ready to cross the street to the East, heading toward second street. CNA #1 stated they notified the first nurse they saw when entering the facilty and they went out to talk with the person. CNA #1 stated the nurse notified them at that time it was a resident. CNA #1 stated they were not familiar with Resident #1 and did not even know they were a resident because they did not work with them. On 03/25/25 at 1:02 p.m., LPN #2, stated Resident #1 would walk around the facility to the dining room and sun room. LPN #2 stated Resident #1 was at risk for wandering and elopement because they wandered out of the facility and would attempt to exit seek. LPN #2 stated Resident #1 had a wander guard and would do visual checks every 30 minutes to an hour, but it was never documented. LPN #2 stated Resident #1 would attempt to exit through the back door, but while on the memory care unit they never attempted to get out. LPN #2 stated Resident #1 was sent out to the hospital and when they returned was moved off the memory care unit with a wander guard. On 03/25/25 at 1:26 p.m., CNA #2 stated Resident #1 had behaviors of pacing back and forth and would get angry. CNA #2 stated Resident #1 walked with a walker, would wander to the front and back, and sit by themselves. CNA #2 stated Resident #1 would attempt to go through the front door and it would alert them because of the wander guard. CNA #2 stated they asked Resident #1 on 03/06/25 what was wrong and showed them the door opened into the courtyard and let them out. CNA #2 stated they thought the courtyard was secure and Resident #1 got out and they did not have any idea where Resident #1 went. CNA #2 stated they asked the other staff where Resident #1 was and no one knew. CNA #2 stated the wander guard only activated the front doors and not the other exits to the facility. CNA #2 then stated the nurse found out through the transporter who came in and informed them someone was outside with a walker. CNA #2 stated they knew of no times Resident #1 attempted to exit through doors other then the main entrance. CNA #2 then stated again they thought the courtyard was secured, but it was not and Resident #1 got out. On 03/25/25 at 1:58 p.m., LPN #3/ADON stated Resident #1 was admitted to the facility the first of October and became a high risk for elopement after they eloped from the facility on 10/13/24. LPN #3 stated Resident #1 had no range of motion deficits and was able to ambulate with a walker. LPN #3 stated the interventions that were put into place were a wander guard, to check placement, redirect, and diversionary activities. LPN #3 stated the care plan addressed to check on Resident #1, but did not specify how often. LPN #3 then stated 30 minute checks should have been implemented and on the care plan. LPN #3 stated the wander guard only was effective on the front doors because it was the most traveled. LPN #3 stated all other doors could not be secured and needed to remain open. LPN #3 was asked about the intervention of Resident #1 being on the memory care unit and moved back to the non-memory care unit. LPN #3 stated it was due to the decline and Resident #1 did not exit seek and elope. LPN #3 stated they were not aware of Resident #1 exit seeking through doors not secured with a wander guard, but it was on the care plan. LPN #3 stated there must have been a history. LPN #3 was asked about the elopement that occurred on 03/06/25. LPN #3 stated Resident #1 was seen by the driver when returning from a run. LPN #3 stated Resident #1 was located at the North end of the facility getting ready to cross the road. LPN #3 stated Resident #1 was at the end of the parking lot heading East towards a busy city street. LPN #3 stated highway seven was located North of the facility approximately three blocks away. LPN #3 stated highway seven was busy with a lot of traffic all the time. LPN #3 then stated it was determined Resident #1 left through the gate located on the Southeast corner of the building. LPN #3 stated the care plan was not developed until 01/20/25 for wandering and elopement. On 03/25/25 at 2:37 p.m., the DON stated Resident #1 became a high risk for elopement and wandering on 10/13/24 when they eloped from the facilty. The DON stated Resident #1 had moderate cognitive skills for daily decision making and had a diagnosis of dementia. The DON stated Resident #1 was ambulatory and had no range of motion deficits. The DON stated a wander guard was placed on Resident #1 and visual checks were every thirty minutes. The DON stated the visual checks were not being completed until February 2025. The DON then stated the wander guard was to lock down the doors and was not allowed to be put on the exit doors other than the front door. The DON stated Resident #1 attempted to exit from doors that were not equipped with a wander guard and Resident #1 was redirected away from the doors. The DON was asked when a care plan was developed for elopement and wandering. The DON stated after the first elopement, then after reviewing the care plan, stated 01/20/25. The DON stated Resident #1 was moved to the memory care unit on 12/06/25 and then moved back to the long term care side with a wander guard when returning from the hospital on 12/23/24. The DON was asked if the care plan addressed the exit seeking from doors not equipped with the wander guard system. The DON stated Resident #1 was to be redirected away from the doors. The DON stated on 03/06/25 Resident #1 had a second elopement and the transport driver notified the nurse of a person outside the facility. The DON stated Resident #1 was going towards Second street which was a residential street. The DON stated highway seven was located about three to four blocks away and was a busy highway. The DON stated the gate was easily accessible on the Southeast side of the building and that was the way Resident #1 left the courtyard. On 03/25/25 at 3:15 p.m., the administrator stated only the front two doors were secured with the wander guard system. The administrator stated all other exit doors and the courtyard doors were emergency exits and did not have the system in place. The administrator stated they determined Resident #1 exited through the gate located on the Southeast corner of the facility.

Based on record review and interview, the facility failed to: a. provide adequate supervision and interventions to prevent falls which resulted in injury for one (#1) of three sampled residents reviewed for falls; and b. provide adequate supervision and interventions to prevent elopement for one (#4) of three sampled residents reviewed for elopement. The DON reported 109 residents resided in the facility. The DON reported two residents had eloped in the previous six months and four residents were at risk for elopement/wandering behaviors. Findings: A policy titled Identifying and Protecting Residents at Risk for Wandering and Elopement, dated 03/01/22, read in parts,The facility will strive to prevent unsafe wandering by identifying those at risk for elopement and follow-up with interventions to ensure safety for all .Complete and send state an incident report. A policy titled Falls Prevention & Management, dated 10/03/23, read in parts, As part of the initial review of preadmission medical records, the clinician reviewing as well as admission nurse will identify individuals with a history of falls and risk factors for subsequent falling .The staff will address risk factors for falling and work with care plan coordinator in developing a fall care plan individualized to resident. 1. Resident #1 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, Parkinson's disease, and chronic obstructive pulmonary disease. A fall assessment, dated 10/12/24, documented Resident #1 was a high risk for falls. An incident report, dated 10/12/24, read in parts, Resident laying next to bed in the floor on right side .Resident was wet with urine .Resident reported trying to go to the bathroom .No injuries noted at the time of the incident. A care plan addendum, dated 10/12/24, read in parts, Ask every one to two hours if I need to use the bathroom .Remind to ask for assistance .Reorient to call light if necessary .Answer call light promptly. A incident report, dated 10/14/24, read in parts, Resident found in the floor .Family member [name withheld] reported the resident was found crumpled up on the footboard .Resident attempted to tell the nurse what happened but speech was unintelligible. The incident report documented the resident was transported to the hospital by EMS for evaluation. An ODH Form 283 incident report, dated 10/14/24, read in parts, History of multiple falls .Corrective Measures: Floor mat placed on resident floor next to bed .Staff to make more frequent checks on resident .Assess resident for any needs or wants resident may have. An after visit hospital summary, dated 10/15/24, documented the reason for the visit was a fall. The summary documented diagnoses of head injury and subarachnoid hemorrhage. The summary also documented a new medication of Keppra (a medication to treat seizures), 500 mg 1 tablet by mouth in the morning and at bedtime for 13 doses, and to follow-up with primary care physician in two to three days. A comprehensive assessment, dated 10/23/24, documented Resident #1 was severly impaired with cognition and dependent on staff for most activities of daily living. Incident notes for Resident #1, dated 10/12/24 throught 12/28/24, documented the resident had 15 falls. On 01/03/25 at 9:25 a.m., the administrator reported the facility had tried multiple things to prevent the resident's falls. The administrator reported the facility had put a staff member outside the resident's room Monday through Friday from 8:00 a.m. to 5:00 p.m. and one on one supervision when staffing allowed. On 01/03/25 at 12:50 p.m., family member #1 reported walking into Resident #1's room and finding the resident had fell with their head against the footboard of the bed. The family member reported the resident told them the fall occurred while trying to get to the bathroom. The family member reported the resident was wet with urine due to staff not assisting the resident to the bathroom which they believed resulted in the fall. 2. Resident #4 had diagnoses which included cerebral infarction and chronic atrial fibrillation. A Wandering Risk Scale, dated 12/04/24, documented the resident was at low risk for wandering. The form documented the resident could not follow instructions, was ambulatory, and had no history of wandering. An incident report, dated 12/07/24, documented the charge nurse received a phone call from a CMA who was driving the facility van returning a resident to the facility. The CMA reported Resident #4 was observed walking down the street. The CMA reported they stopped and attempted to get the resident in the van, but the resident refused. The report documented the nurse drove their private vehicle to retrieve the resident. The report documented the resident told the nurse, I'll go back with you but I will plan my next escape better. The report documented a WanderGuard was applied to the resident's ankle and staff were instructed to watch the resident for any attempts to leave and to check on the resident every 30 minutes. A care plan addendum - Elopement/WanderGuard form, dated 12/07/24, documented the resident would wear a WanderGuard device to prevent elopement. An admission assessment, dated 12/09/24, documented the resident was severely impaired with cognition. The assessment documented the resident was independent with activities of daily living. A progress note, dated 12/10/24 at 9:51 a.m., documented at 9:20 a.m. the facility received a call reporting Resident #4 was observed walking down the street. The note documented the charge nurse and a CNA took the nurse's personal vehicle to the area the resident was last seen, located the resident, and was able to convince the resident to return with them. The note documented the resident was returned to the facility and immediately taken to the secured memory care unit. The note documented the WanderGuard could not be located. The note documented the resident had last been seen, prior to the elopement, at 9:10 a.m. at the nurses station talking to the nurse about needing a cell phone, then was observed to walk back toward their room. A care plan addendum - Elopement/WanderGuard form, dated 12/10/24, documented the resident would be admitted to the secured unit for the resident's safety. On 01/13/25 at 4:15 p.m., the DON reported there was no documentation of 30 minute checks related to Resident #4's elopement incident on 12/07/24. The DON reported an incident report could not be located for Resident #4's elopement on 12/10/24. The DON reported the resident had sustained no injuries during either of the elopement incidents and required no treatment.

Based on observation, record review, and interview, the facility failed to have ongoing communication and collaboration with the dialysis facility, for monitoring before and after dialysis treatments for one (#59) of one resident reviewed for dialysis. The administrator reported two residents received dialysis treatments. Findings: Res #59 had diagnoses which included chronic kidney disease and dependence on renal dialysis. A physician order, dated 08/17/23, documented the resident would receive dialysis treatments on Tuesday, Thursday, and Saturday. The order documented to remove the dressing from the left upper arm at bedtime for dialysis fistula. A quarterly MDS assessment, dated 11/10/23, documented the resident was moderately impaired with cognition. The assessment documented the resident received dialysis treatments. A care plan, dated 11/24/23, documented the resident would receive hemodialysis every Tuesday, Thursday, and Saturday related to chronic kidney disease, end stage renal disease. On 01/26/24 at 10:59 a.m., LPN #2 reported the facility did not have a dialysis communication form in use. The LPN reported if there were any changes or new orders, the dialysis nurse or physician called the facility and staff charted by exception. The LPN was asked if the facility provided any kind of report to the dialysis center when the resident went for treatments, and she stated, no, they did not have any form of communication like that in place for giving or receiving report before and after treatments. On 01/26/24 at 11:28 a.m., the resident reported he had been to dialysis the previous day. The resident reported he didn't take anything with him and the facility did not send anything with him to the dialysis center. On 01/29/24 at 9:33 a.m., the administrator reported he had talked with the dialysis center and would be implementing a communication form. The administrator stated the EMR also had an option for a dialysis communication form, which they would check into for use in the future.

Based on observation, record review, and interview, the facility failed to provide respiratory care consistent with professional standards of practice and per the facility policy for one (#22) of two residents reviewed for respiratory care. The administrator reported 15 residents received oxygen therapy. Findings: A facility policy and procedure, Respiratory Therapy Utilization and Care of Equipment, not dated, documented in part, .All O2 tubing, humidifier bottles, O2 mask, nebulizer tubing, nebulizer mask, and hand held nebulizer are to be changed on the 10-6 shift twice monthly on the 1st and the 15th and prn .All tubing are to be dated for date changed .weekend R.N. audits weekly to ensure task has been completed as per policy and procedure . Res #22 had diagnoses which included congestive heart failure. A physician order, dated 08/03/22, documented to change the oxygen tubing, mask, or nasal cannula and humidifier bottle on the 1st and 15th day of each month on the nightshift. A physician order, dated 12/05/22, documented oxygen at 2 liters via nasal cannula to keep oxygen saturations above 90%, every night for shortness of breath and/or wheezing. A quarterly MDS assessment, dated 01/12/24, documented the resident was cognitively intact and required oxygen therapy. A care plan, dated 01/17/24, documented the resident required oxygen therapy related to congestive heart failure to keep O2 saturations above 90%. Treatment administration records, for January 2024, documented the O2 tubing and humidifier bottle was changed the night of 01/01/24. There was no documentation to indicate the tubing and canister was changed on the 15th as ordered. On 01/23/24 at 10:54 a.m., the resident's O2 tubing and humidifier bottle was observed to be dated 01/02/24. The resident stated they used the O2 as needed and mainly at night. The resident reported they were unsure how often the tubing and canister was changed. On 01/26/24 at 12:44 p.m., the resident's O2 tubing was observed to still have the date of 01/02/24 on the tubing, as well as on the humidifier bottle. On 01/26/24 at 2:52 p.m., the ADON reviewed the January TAR and confirmed the tubing and humidifier bottle had not been changed on the 15th as ordered.

Based on observation, record review, and interview, the facility failed to ensure a physician response was obtained for a nutritional recommendation for one (#42) of four residents reviewed for impaired nutrition. The administrator reported a census of 101 residents and all residents received nutrition from dietary services. Findings: Res #42 was admitted with diagnoses which included dementia, diabetes mellitus, and depression. A consultant dietician nutrition form, dated 10/30/23, recommended an appetite enhancer medication for documented weight loss. A health status note, dated 11/08/23 at 1:16 p.m., documented the dietician's recommendation had been returned with no answer from the physician. The note documented a fax was sent again to the physician asking if they wanted to start the resident on Remeron (a medication used as an appetite enhancer). A quarterly MDS assessment, dated 01/02/24, documented the resident was independent with eating. A care plan, dated 01/08/24, documented the resident was able to eat independently and choose their meals, but had weight loss and their appetite had been poor. On 01/24/24 at 9:10 a.m., the resident was observed to consume 75% of the breakfast meal. A pink beverage identified as a supplement house shake had approximately 50% left in the glass. The resident reported they felt full and had no complaints related to the food served. On 01/25/24 at 9:43 a.m., RN #1 reported she reviewed weights weekly and had discussed the resident's weight loss with the physician. The RN stated the medication, Remeron, had been considered because the resident was inconsistent with meals. A physician response, dated 01/25/24, documented new physician orders for Remeron and Megace (medications used for weight gain and appetite stimulants). On 01/29/24 at 12:03 p.m., the DON reported the physician response should have been more timely but there was no specific timeframe for receiving a response. The DON stated this should have been addressed during weekly weight reviews.

Based on record review and interview, the facility failed to notify OHCA of residents with a new diagnosis of a serious mental illness, for two (#6 and #18) of two residents sampled for PASRR assessments. The administrator reported a census of 101 residents. Findings: 1. Res #6's PASRR level I assessment, dated 01/13/16, documented no evidence or diagnoses of severe mental illness. A care plan, dated 11/26/23, documented the resident was at risk for decline of psychosocial well-being related to depression and anxiety, as well as a diagnosis of schizophrenia and bipolar disorder. The care plan addressed verbal behaviors. Res #6's clinical record documented a diagnosis of bipolar disorder on 07/22/14 and schizophrenia on 01/23/16. There was no documentation OHCA was notified when the facility became aware of the new serious psychiatric diagnoses. 41873 2. Resident #18 had diagnoses which included schizophrenia, Parkinson's disease, psychosis with auditory hallucinations, anxiety, and depression. A quarterly MDS assessment, dated 10/25/23, documented the resident was cognitively intact. Res #18's care plan documented the resident was at risk for decline in mood and psychosocial well-being. The care plan documented the resident was seen by a psychiatrist outside of the facility. The resident's clinical record documented a Level I PASRR was completed on 08/22/13 and documented no Level II PASRR was required at that time. The record documented the resident had a new diagnosis of psychosis on 01/31/24, major depressive disorder 05/12/17, schizoaffective disorder 05/12/17, schizophrenia 01/02/18, hallucinations 05/02/19, and psychophysiologic insomnia 05/02/19. On 01/29/24 at 10:40 a.m., LPN #1 reported she was not aware a PASRR Level II screening was required when a resident received a new psychiatric diagnosis after admission. On 01/29/24 at 11:53 a.m., the Psych/ID analyst with OHCA reported if dementia was the primary diagnosis, then a Level II PASRR would not be required. He reported for a diagnosis of Parkinson's disease, major depressive disorder, or Alzheimer's disease with a new psych diagnosis, etc., the new diagnosis would still need to be reported so it could be documented and determined if a Level II PASRR screening was required. On 01/29/24 at 12:15 p.m., the administrator and DON reported they were under the impression a Level II PASRR screening was not required for certain diagnoses, even when a resident had a new psychiatric diagnosis.

Based on record review and interview, the facility failed to report an allegation of misappropriation within 24 hours to the OSDH for one (#2) of two sampled residents reviewed for misappropriation. The Resident Census and Conditions of Residents report, dated 02/27/23, identified 108 residents who resided in the facility. Findings: An Abuse, Neglect, and Exploitation policy & procedure, dated October 2022, read in parts, .Facility reporting- The facility will immediately report all alleged violations involving .misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law .Reporting will be completed on the following timetable .if no abuse, neglect, serious bodily injury, or psychosocial injury has occurred, report will be submitted in 24 hours .misappropriation means deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's (or responsible party's) consent .Employees will be trained regarding Misappropriation of Resident Property, how to avoid it, reporting procedures, and possible repercussions stemming from such activities .The facility will act to protect resident from Misappropriation of Property by: Reporting, Investigating, and Acting upon alleged violations of misappropriation of resident property and exploitation . Resident #2 was admitted on [DATE] with diagnoses which included CVA and Type 2 Diabetes Mellitus. An MDS Quarterly Assessment, dated 12/14/22, documented resident #2 was moderately impaired with cognition and required extensive assistance with activities of daily living. A Trust Account Withdraw, dated 02/23/23 at 4:20 p.m., read in parts, . [Resident #2] requested that Wilkins Health and Rehabilitation staff withdraw cash from my Oklahoma card in the amount of [$]60.00 . Signature [Resident #2] Received cash from [Activities Director] witnessed by [CNA #1] . On 02/27/23 at 8:55 a.m., resident #2 stated they had $81.00 missing and had reported it to LPN #1. The resident was asked if LPN #1 had asked them to fill out any type of complaint or grievance form related to the missing money. The resident stated, no, and reported the staff would just tell them they should not have left it in their room. Resident #2 stated they had an idea of who took the money, but they would not tell on people, and the resident did not catch the staff member this time. Progress Notes for resident #2 were reviewed for incidents which involved misappropriation of property. There was no documentation of the incident related to missing money. On 02/27/23 at 9:45 a.m., LPN #1 was asked what they would do if a resident reported money missing. The LPN reported they would start an investigation, interview the roommate, report to the supervisors, and they would investigate as well. LPN #1 was asked if resident #2 reported money missing over the weekend. The LPN reported no, not directly to them but it was reported to the housekeeper, who informed an aide, who then informed the LPN. LPN #1 was asked to identify the resident and she identified resident #2. LPN #1 stated resident #2 was missing $61.00. The LPN reported the resident informed them they had signed out for the money and did not know where the money was now. The LPN stated they had asked resident #2 if they wanted to wait to talk to the Administrator on Monday and the resident stated they would wait and talk to the Administrator. The LPN stated the resident did not tell her the money was stolen but the LPN made a note to inform the Administrator on Monday if the resident did not speak to the Administrator first. LPN #1 stated they did not know the name of the housekeeper who initially reported resident #2's money missing. The LPN identified CNA #1 as the aide who was informed by the housekeeper of the missing money. They were asked if they had filled out a grievance on behalf of resident #2's missing money and reported a grievance had not been completed. They stated resident #2 did not know where the money was, but did not say the money was stolen. They were asked what they would do if resident #2 reported the money was stolen. They stated they would write it down on some piece of paper and hand it over to the supervisor with written statements. On 02/27/23 at 10:05 a.m., resident #2 was asked if they had spoken with the Administrator that morning about the missing money. The resident stated he had not talked with the Administrator. On 02/27/23 at 11:04 a.m., CNA #1 was asked about resident #2's missing money. The CNA stated resident #2 had stopped them in the dining room and stated, I want my money back. The CNA replied, What money? Resident #2 stated, My money. CNA #1 reported they were aware the Activities Director signed out sixty dollars to resident #2 and they knew the resident had put the money in a black eye glasses case in their dresser drawer. The CNA was asked if LPN #1 started an investigation. The CNA stated they had worked on North Hall that day and they were not asked to submit a written statement. They reported it was Saturday [02/25/23] and they had informed LPN #1 they had not been down there on [South Hall] today. They stated everything happened on Saturday [02/25/23] and they informed LPN #1 that resident #2 suspected CNA #1 had taken the money. On 02/27/23 at 11:42 a.m., the DON was asked if they received any grievances and/or incident reports over the past weekend. The DON stated, No, I did not get any grievance reports or incident reports over the past weekend. On 02/27/23 at 12:35 p.m., LPN #2 was asked about resident #2's missing money. The LPN did not know about $61.00 missing. They were asked about the process to report missing property/money. They stated they would notify the DON/ADON, do an investigation, and report it to the State. The LPN was asked if they would start the initial investigation. The LPN stated there was an incident report form on the computer. The LPN was asked if they had done an incident report on the computer before and they stated, no. They were asked if the procedure would be the same on the weekends and they stated, To my knowledge. The LPN reported first they would contact the social services director and confirm the resident had money, then question the staff and get statements from residents and staff to begin the State report. The LPN stated resident #2 was in their right mind and was alert and oriented to person, place, and time. The LPN was asked if they would report to the ADON/DON even on the weekends, and they reported, yes, they would try to keep them informed of anything that occurred over the weekend. On 02/27/23 at 1:02 p.m., the activities director was asked if resident #2 had requested some money. They presented a trust account withdraw. They stated CNA #1 co-signed and resident #2 received $60.00 on 02/23/23. On 02/27/23 at 1:12 p.m., LPN #1 was asked to clarify the date resident #2 had missing money. The LPN stated it was on Saturday, the 25th [02/25/23]. They were asked who would start the investigation. LPN #1 stated, Me. The LPN was asked if they started an investigation, and they reported, no, because resident #2 did not say the money was stolen and wanted to wait to talk with the Administrator or the social service director. The LPN stated when they spoke with resident #2, the resident did not say the money was stolen, but that it was missing. The LPN stated resident #2 did not tell say CNA #1 took the money. The LPN was asked if the missing money was a State reportable event. The LPN stated, no, because the money wasn't reported as being stolen but only that the resident didn't know where it was. On 02/27/23 at 1:57 p.m., the Administrator was asked if the LPNs should have started the initial investigation of missing money. The Administrator stated, I think they should have notified me and I would have given them instructions. The Administrator was asked if he felt the facility policy was followed. The Administrator stated, I do see a break down. The Administrator stated the money should have been left on the medication cart. The Administrator was asked if he would report $61.00 missing within 24 hours to the State Department, and he stated he would. The Administrator stated the incident should have been reported to OSDH.

Based on record review and interview, the facility failed to ensure residents were informed, with a signed acknowledgment from the resident, of items and services for which the resident might be charged for skilled services, for two (#1 and #2) of three residents sampled for beneficiary notification review. The Administrator reported 16 residents who had discharged from skilled services in the last six months. Findings: The clinical record for Resident #1 documented the resident was admitted to skilled services on 07/22/22 and was discharged on [DATE]. The Advanced Beneficiary Notice (ABN), form CMS-10055, was not signed by the resident or their representative. The clinical record for Resident #2 documented the resident was admitted to skilled services on 08/01/22 and was discharged on [DATE]. The ABN, form CMS-10055, was not signed by the resident or their representative. On 11/02/22 at 2:11 p.m., the social services director reported she had written on the forms verbal consent, instead of having the resident or their representative sign the form to indicate they were given information related to possible charges. On 11/02/22 at 4:15 p.m., the Administrator reported the ABN forms should have been signed by the resident or their representative.

Based on observation, interview, and record review, it was determined the facility failed to ensure a dependent resident remained free from neglect for one (#2) of seven residents reviewed for abuse and/or neglect. Resident #2 was found to have wounds to the mid-back area after being left in a Geri chair for several hours without repositioning. The facility identified two allegations of abuse in the previous six months and seven residents with pressure ulcers and/or wounds. Findings: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 09/15/19, documented a Geri chair could be utilized for mobility and positioning every shift. A quarterly assessment, dated 11/25/20, documented the resident was severely impaired with cognition and required extensive assistance with all activities of daily living. A progress note, dated 12/22/20, documented three open areas to mid-back measuring, 8 x 7, 3 x 3, and 2.5 x 2.5. The note documented a new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An investigation summary, dated 12/23/20, documented it was brought to the attention of the DON and ADON on 12/22/20 that the resident had been left sitting in a Geri chair and staff had failed to put the resident to bed. The summary documented at approximately 1:30 a.m., the resident's roommate had notified the night shift aide that her roommate was not in bed yet. At that time, the aide had cleaned the resident and noted the resident's skin had made contact with the Geri chair. The investigation summary documented staff had failed to complete walking rounds and walking shift-to-shift report. The DON reviewed staffing and found ratios to be within compliance but noted staff was extremely busy due to COVID-19 precautions, PPE procedures, and quarantined residents. The DON documented the facility would continue to hire and train for extra staff to ensure staffing ratios continued to be above standards. The investigation summary documented all employees were counseled and reprimanded with some employees placed on probation. The summary documented any breech in employee code of conduct would result in immediate termination. One aide was placed on a different shift to ensure closer supervision and a nurse received a one-day suspension during the investigation, followed by a probationary period. An employee disciplinary action form, dated 12/22/20, documented CNA #2 was given a written warning for failure to do rounds and failure to place the resident in bed in a timely manner. The form documented a probation period of 30 days. An employee list, dated 12/22/20, documented staff on all three shifts were in-serviced related to resident rounds. A skin assessment report, dated 12/25/20, documented stage II wounds to the resident's right and left mid-[MEDICATION(S)] area with a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A skin assessment report, dated 01/01/21, documented wounds to the right and left [MEDICATION(S)] with measurements of, 8 x 7, 3 x 3, and 2.5 x 2.5. Treatment administration records, dated December 2020 and January 2021, documented [MEDICATION(S)] cream 1% was applied to the mid back area topically, one time daily, on 12/23/20 through 01/05/21, and discontinued on 01/06/21. A skin assessment report, dated 01/08/21, documented wounds to the right and left mid-[MEDICATION(S)] back were healed. An in-service report, dated 01/22/21, documented another staff in-service which included guidance on walking rounds and report huddle with CNA's. Skin assessments for February 2021 through April 2021 were reviewed and documented no skin issues. On 04/14/21 at 3:35 a.m., the resident was observed lying in bed and appeared to be sleeping soundly. A Geri chair was noted at the bedside. The charge nurse reported the resident was normally up for all meals and residents with Geri chairs were always in bed when the nurse arrived for her shift at 10:00 p.m. On 04/14/21 at 12:45 p.m., the resident was observed lying in bed in her room following the noon meal. LPN #1 and CNA #1 repositioned the resident, allowing the surveyor to view the resident's skin. Scarring was noted on the left mid-back area. The LPN reported the resident had previous skin breakdown in that area, was treated with cream, and the wounds healed quickly. The LPN denied knowledge of how the the breakdown had occurred. On 04/15/21 at 2:40 p.m., the DON reported as soon as she was made aware of the incident with resident #2, staff were immediately in-serviced and re-educated on shift rounds and repositioning of residents. The DON reported all nursing staff was in-serviced and one CNA was moved to another shift to ensure oversight and supervision. The DON stated all staff members were in-serviced on resident care, timely rounding, and shift change reporting.

Based on interview, record review, and observation, it was determined the facility failed to ensure: ~ a careplan intervention for a fall mat to be on the floor by a resident's bed had been put in place for one (#3) and, ~ a comprehensive care plan for falls had been developed for one (#4) of four residents whose records were reviewed for falls. This had the potential to affect 109 residents. Findings: Resident #3 had [DIAGNOSES REDACTED]. A care plan, dated 06/20/19, documented: Focus: I am at risk for fall, requiring staff assist, due to prior history of falls. Interventions: I will need staff to ensure my floor mat is at bedside in case of falls. On 08/12/19 at 3:02 p.m., resident #3 was observed in his room, sleeping on his left side, no floor mat was observed on floor beside the resident's bed. Fall mat was observed leaned up against the head of the bed. At 03:35 p.m., nurses aide (NA) #1, entered resident #3 room and closed the door followed by LPN (Licensed Practical Nurse) #1 to provide care. At 03:43 p.m., the staff were observed to have exited the resident's room and the floor mat was still leaned up against the head of the bed and not placed on floor. At 03:44 p.m., a staff member brought a Hoyer lift into resident's room and left the room. At 03:45 p.m., nurse aide #1 reported the resident is usually put to bed after lunch. He stated resident #3 had fall precautions which included: bed in lowest position, fall mat on floor beside bed, two person assist with transfers to and from wheelchair. He was in agreement the fall mat should have been down beside the resident's bed. At 04:03 p.m., the DON (director of nursing) agreed that the fall mat definitely should have been in place anytime resident was in bed, as documented in resident's care plan. Resident #4 had [DIAGNOSES REDACTED]. The clinical record documented the resident had a fall on 04/12/19, resident ambulating with a assist, using cane. On 04/12/19 a Morse Fall scale assessment documented the resident was high risk for falling. The residents assessment, dated 06/13/19, documented the resident had one fall. On 06/17/19 a Morse Fall scale assessment documented the resident was high risk for falling. A careplan, dated 06/17/19, documented: Focus: I am at risk for falls . Intervention: I will continue to utilize cane to aide me with ambulation. Staff to observe for any decline in my mobility. On 08/12/19, the director of nursing was shown this resident's careplan and she was in agreement the careplan was not comprehensive and needed more interventions to help prevent falls.

Based on record review and interview, it was determined the facility failed to ensure assessments were accurate for one (#88) of 12 records reviewed for accuracy. This had the potential to effect all 107 residents. Findings: Resident #88 was admitted with [DIAGNOSES REDACTED]. A significant change assessment, dated 03/01/19, documented the resident's active [DIAGNOSES REDACTED]. The resident's quarterly assessment, dated 06/21/19, documented the resident's active [DIAGNOSES REDACTED]. A physician's progress note, dated 06/14/19, documented the resident's medical history reviewed: dementia with behavioral disturbances and stage III [MEDICAL CONDITION]. A physician's progress note, dated 05/13/19, documented medical history updated: dementia with behavioral disturbance and stage III [MEDICAL CONDITION]. On 07/11/19 at 11:12 a.m., the assessment coordinator was shown the above findings. She agreed the [DIAGNOSES REDACTED]. At 11:30 a.m. the director of nursing was informed of the inaccurate assessment.

Based on record review and interview, it was determined the facility failed to ensure the physician was notified of a recent weight loss for one (#88) of 12 records reviewed. This had the potential to effect all 107 residents. Findings: Resident #88 was admitted with [DIAGNOSES REDACTED]. The resident's quarterly assessment, dated 06/20/19, documented the resident's cognition was mildly impaired, required supervision with eating, and received a therapeutic diet. The resident's care plan, dated 06/20/19, documented the resident was at risk for decline in nutritional status and to notify the medical doctor (MD) of any decline in appetite and report any significant weight fluctuations. A dietary progress note, dated 06/18/19, documented a significant weight loss and to alert the MD. The clinical record had not contained any documentation of the MD notification. 07/11/19 at 11:30 a.m., the director of nursing was made aware of the above findings and stated the doctor was notified today of the resident's weight loss.

Based on observation, interview and record review, it was determined the facility failed to maintain an unobstructed pathway for one (#1) of three residents' reviewed for a safe, homelike environment. This had the potential to effect 21 residents who required respiratory treatments as identified by the Resident Census and Conditions of Residents. Findings: Resident #1 quarterly assessment, dated 12/18/18, documented the resident was independent with transfers, and was self-sufficient off the unit with an electric wheelchair. Resident #2, the roommate to #1, was admitted with [DIAGNOSES REDACTED]. Resident #2 physician's orders [REDACTED]. On 03/11/19 At 11:00 a.m., the residents' room was observed to have a chair inside the door to the right with a nebulizer unit on the seat. Resident #1 was interviewed and stated she was able to come and go as she pleased unless her roommate was receiving a breathing treatment. She stated she would have to wait to enter or exit the room while a treatment was given. She stated her family members have had to wait at times when they came to visit. At 1:45 p.m., advanced certified medication aide #1 (ACMA) was observed to administer a breathing treatment for [REDACTED]. The ACMA was observed to pull the chair to the middle of the room and plug in the unit by the door, stretching the cord from the plug-in across the room, and the tubing from the chair to the resident. This was observed to have obstructed the pathway in and out of the room. At 1:54 p.m., the administrator was informed of the above findings and agreed, That is a problem.

Based on record review and interview, it was determined the facility failed to ensure the accuracy of assessments for four (#17, 97, 98, #107 ) of 15 assessments reviewed for accuracy. This had the potential to affect all 110 residents. Findings: 1. Resident #17 was admitted with [DIAGNOSES REDACTED]. A care plan, dated 04/04/18, documented the resident had a tracheotomy prosthesis and performed self tracheotomy care daily. A quarterly assessment, dated 06/18/18, documented the resident's cognition was intact and he required limited assistance with hygiene, transfers, dressing, and supervision only with eating. The assessment had not documented the use of a tracheotomy. On 09/05/18 at 01:35 p.m., the minimal data set coordinator was shown the above findings and stated she did not know the resident had a tracheotomy. She agreed the assessment was inaccurate. 2. Resident #97 had [DIAGNOSES REDACTED]. A 14-day admission assessment, dated 09/04/18, documented the resident's cognition was intact. She required supervision with eating. She required limited assistance with personal hygiene, dressing and transfers. She required extensive assistance with toilet use. She was occasionally incontinent of bowel and bladder. The clinical record had documented depression as one of her [DIAGNOSES REDACTED]. The resident's admission assessment had not documented depression as one of the resident's diagnoses. On 09/06/18 at 02:49 p.m., the assessment coordinator was shown the clinical record and the admission assessment. She was in agreement that a [DIAGNOSES REDACTED]. 3. Resident #98 was admitted with [DIAGNOSES REDACTED]. A 14-day admission assessment, dated 08/28/18, documented her cognition was moderately impaired. She required extensive assistance with all of her activities of daily living. She was frequently incontinent of bowel and always incontinent of bladder. A skin care assessment tool completed on 08/14/18, documented the resident had two stage two wounds, one to her right buttock and one to her left buttock. The admission assessment, dated 08/28/18, documented she had one stage two wound and had acquired one stage two wound after having been admitted to the facility. On 09/05/18 at 2:38 p.m., licensed practical nurse #1 was asked how many stage two wounds the resident had upon admission. She stated, She had two stage two pressure ulcers on her buttocks upon admission. At 2:45 p.m., the assessment coordinator was asked about the assessment documenting the resident only had one pressure ulcer upon admission and having acquired one since she had been admitted . She stated, the nurse had told her it was only one but she really had two. She was in agreement it was an assessment error. 4. Resident #107 was admitted on [DATE] with [DIAGNOSES REDACTED]. A social service progress note, dated 07/06/18, documented that due to the resident's wife's illness, the wife was having the resident moved to a veteran's center closer to her. A nurse's note, dated 07/09/18 at 7:30 a.m., documented that Med ride was there at the facility to transport the resident to the veteran's center. The 5-day assessment, dated 07/09/18, documented the resident had been discharged from the facility to an acute hospital. On 09/06/18 at 1:45 p.m., the assessment coordinator was asked if the resident had been discharged to an acute hospital. She stated, No. It should have documented he went to another long term care facility or other.

Based on observation, interview, and record review, it was determined the facility failed to ensure physician's orders were followed for one (#51) of 15 residents reviewed. This had the potential to affect all 110 residents. Findings: Resident #51 was admitted with [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/25/18, documented the resident had not ambulated, was severely cognitively impaired, and had an impairment of upper and lower extremities on both sides. A care plan, dated 07/20/18, documented the resident had [MEDICAL CONDITION] and was to wear a brace to his left arm to prevent contractures. A physician's order, dated Aug (YEAR), documented the resident was to have worn a brace to his left arm related to post [MEDICAL CONDITION]. On 09/04/18 at 03:30 p.m., the resident was observed to not have the brace in place. On 09/05/18 at 02:18 p.m., the resident was observed to not have the brace in place. On 09/06/18 at 02:46 p.m., the director of nursing was informed of the above findings and was in agreement the physician's orders had not been followed.

Based on observation and interview, it was determined the facility failed to ensure hands had not touched the food contact surface areas of kitchen utensils or food items. This had the potential to affect 109 residents who received food from the kitchen. Findings: On 09/06/18 at 10:09 a.m., cook #1 was observed to use a gloved hand and touched bread. Using the same gloved hand she was observed to have touched the lid of the puree machine, bread bag, spatula, and then touched the bread again. At 10:20 a.m., dietary aide #1 was observed to touch the food contact surface of a spatula, ladle, and scoop with her bare hands. The spatula was observed to have been used to pick up a biscuit on the service line. The ladle was observed to have been placed in the gravy on the line, and the scoop was observed to have been place in the chicken noodle soup on the line. At 10:44 a.m., cook #1 was asked if she should have touched other items with the same gloved hand she had touched food with. She stated she should not have. At 10:48 a.m., dietary aide #1 was asked if she should have touched the contact surface of the ladle, scoop, and spatula. She stated she should not have. At 10:50 a.m., the dietary manager was made aware of the observations. He was asked if these items should have been touched. He stated they should not have been.

Based on observation, record review and interview, it was determined the facility failed to update a resident's care plan for an indwelling catheter for one (#78) of four residents' care plans reviewed for catheters. There were no other residents with indwelling catheters according to the residents census and conditions of residents form. Findings: Resident #78 had [DIAGNOSES REDACTED]. A care plan, dated 07/20/18, documented the resident required assistance from the staff to insert a straight catheter in to his bladder three times a day. An assessment, dated 08/16/18, had documented the resident had an indwelling catheter. A physician's orders [REDACTED]. 09/04/18 at 3:14 p.m., the resident was observed in his room sitting in his wheelchair, his catheter tubing was observed to be contain red liquid. On 09/06/18 at 1:37 p.m., the care plan coordinator was asked if the care plan should have been updated to reflect the resident was no longer receiving straight catheterizations three times daily. She stated it should have been updated.

Based on record review and interview, it was determined the facility failed to ensure a significant change assessment after hospice election for one of one (#109) reviewed for hospice services. This had the potential to affect 13 residents receiving hospice services according to the resident census and conditions of residents form. Findings: Resident #109 had [DIAGNOSES REDACTED]. An admission assessment, dated 05/12/18, documented the resident was not terminally ill. A physician's orders [REDACTED]. An assessment for a death in the facility was don on 06/09/18. There was no significant change assessment within 14 days after the election of hospice, which would have been on 06/07/18. On 09/06/18 at 1:35 p.m., the assessment coordinator was asked if a significant change assessment should have been done within 14 days. She stated, Yes

Based on record review and interview, it was determined the facility failed to accurately document a resident's significant weight change for two (#37 and #58) of four residents whose records were reviewed for nutrition. This had the potential to affect 97 residents. Findings: 1. Resident #37 was admitted with [DIAGNOSES REDACTED]. The 5-day assessment, dated 06/12/17, documented the resident's weight at 142 pounds (lbs) with no significant weight loss or gain. The 30-day assessment, dated 07/01/17, documented the resident's weight at 133 lbs. with no significant weight loss or gain. This would have been a 6.3 % weight loss for the resident from the 06/12/17 weight. On 07/12/17 at 1:09 p.m., the assessment coordinator stated she had just overlooked the weight loss and had not documented it. 2. Resident #58 had [DIAGNOSES REDACTED]. The 90-day assessment, dated 02/24/17, documented the resident's weight at 106 lbs. with no significant weight gain or loss. The quarterly assessment, dated 03/03/17, documented the resident's weight at 117 lbs. with no significant weight gain or loss. The resident's weight would have been a 9.4 % gain from the 02/24/17 assessment. On 07/12/17 at 1:12 p.m. the assessment coordinator stated the 03/03/17 assessment should have documented the resident having had a weight gain.

Based on observation, record review and interview, it was determined the facility failed to: ~ provide supervision to prevent accidents for five (#7, 9, 10, 17 and #19) of nine sampled residents with falls, ~ investigate the falls to determine the reason for the falls for five (#7, 9, 10, 17 and #19) of nine sampled residents with falls, and failed to ~ monitor the effectiveness of the interventions and modify the interventions as necessary to prevent further falls for five (#7, 9, 10, 17 and #19) of nine sampled residents with falls. Resident #7, 9, 10 and #19 had falls which resulted in injuries of actual harm. 1. Resident #10 was admitted on [DATE] from home due to a fall which resulted in a hip repair surgery. The resident had twelve unwitnessed falls from the date of admission on 06/04/10 through 11/01/10. A fall risk assessment, dated 06/04/10, documented the resident's score was "10." (A score of 10 or above represents a high risk for falls.) A "Falls Management Investigation" form, dated 06/04/10, documented the resident fell at 10:45 p.m., in her room as she was going to the bathroom. The investigation form documented check marks under "no" for clues for environmental factors and healthcare factors. The questions to be answered on the form were as follows: ~ Do the clues reflect any environmental factors that could be involved in this fall? ~ Do the clues reflect any healthcare factors that could be involved in this fall? ~ If resident has had more than one fall, are there any similarities? ~ How do the clues that you have found, relate to each other? ~ What actions/plans can be made from this knowledge to reduce resident risk? ~ Is there a need to re-assess the resident? ~ Is there a need for changes to be made on the personal service (care) plan? ~ Have they been made? ~ How many previous falls are there? Where did they occur? What time did they occur? What actions were set in place after the previous fall(s)?" All questions were blank (incomplete) on the form. A care plan addendum, dated 06/05/10, documented, "1" laceration to back of head. Mobile x-ray ordered for L hip et L thigh D/T c/o pain p fall. 6/6/10 - (no) fx noted on x-ray results." The resident had an unwitnessed fall in her room on 06/09/10 at 10:30 a.m. The falls management investigation form was filled out on the front but the questions on the back were not completed. A care plan addendum, dated 06/09/10, documented, "Cont to be non-wt bearing to RLE r/t recent hip surgery. Assess resident for risk of recurrence and initiate plan to prevent additional falls." There was no plan documented to prevent additional falls. The resident had an unwitnessed fall in her room on 07/28/10 at 5:00 p.m. The falls management investigation form was filled out on the front but the questions on the back were not completed. A note was documented on her care plan, dated 07/28/10, "Fall in BR. (No) injuries noted. Intervention: Advised to call for assist. (Check) every 20 min for assist (with) ambulation." The corrective action/intervention on the incident report, dated 07/28/10, documented, "Enc to use call lt for assist. Staff to monitor q 2hr." The resident had an unwitnessed fall in her room on 08/05/10 at 10:45 a.m. The falls management investigation was not completed. The incident report, dated 08/05/10, documented, "fell , hit head on BS table, 1cm cut (above) R eye. Corrective action: Remind resident to use call system for assist." (This head injury was not reported to the OSDH.) The resident had an unwitnessed fall on 08/17/10. The incident report documented, "fell on buttocks...Corrective action - Res instructed to call for asst w/amb. Staff to monitor q 2hr." The falls management investigation, dated 08/17/10, documented the resident was ambulating without assistance to the bathroom. The back of the investigation form was incomplete. The care plan addendum was dated 08/17/10. It was a standard form with nothing checked. It had an LPN signature at the bottom and documented, "Date Resolved - 8/20/10." The resident had an unwitnessed fall on 08/31/10 at 10:15 p.m., in her room which resulted in a laceration to her head. The form sent to OSDH documented, "Resident ambulating in room et fell hitting R forehead on bedside table causing laceration & abrasion to R shoulder. Resident with short term memory impairment. Bed/chair alarm in place but resident will remove to ambulate. 1hr monitoring. Resident very confused. Mistakes closet for BR. Repeated reminders to call for assistance ignored. Fall risk (increased) from 8 to 10. (Fall risk assessment documented 10 to 12)." A fax to the resident's physician, dated 08/31/10, documented, "Res fell in room. Rec'd approx 7cm laceration to R forehead & abrasion to R shoulder. Sent to ER (The resident received sutures to her forehead)." The falls management investigation form documented the resident fell while going to the bathroom. The back of the investigation form was incomplete. The care plan addendum, dated 08/31/10, documented, "Heard calls for help - res in floor, w/blood on face & shirt - laceration R forehead, sent to ER...Intervention: Remind res to utilize call lt system for asst, instruct res to call for asst w/ambulation, staff to monitor and offer to toilet q 2hr & prn." The quarterly care plan update for falls, documented, "09/07/10 - Several falls this qtr - cont to monitor & freq checks assist w/amb, pharmacy review suggested to continue. Continue with plan of care." The resident's current comprehensive assessment, dated 09/07/10, documented her cognition was moderate independence. She had a short-term memory problem and her mental function varied over the course of the day. It documented she required extensive assistance with all her ADL's. She was on a scheduled toilet plan for the staff to assist her to the bathroom every two hours and as necessary. The care plan addendum, dated 10/06/10, documented, "8/5/10: fell while ambulating, hit head on BS table, 1cm cut above R eye...8/17/10 - was ambulating w/o assist, lost balance fell to floor landing on buttocks...8/31/10 -Heard calls for help -Res in floor, w/blood on face & shirt - laceration R forehead...sent to ER...Intervention: Remind res to utilize call light system for assist, instructed res to call for assist (with) ambulation - staff to monitor & offer to toilet q 1hr prn." The resident had an unwitnessed fall in her room on 10/08/10 at 7:30 a.m. The falls management investigation form documented she was found in her room on the floor in front of the recliner. The back of the form documented, "What actions/plans can be made from this knowledge to reduce resident risk? Encourage res to use call system for assistance...Is there a need for changes to be made on the personal (care) plan? No...What actions were set in place after the previous fall(s)? Bed/chair alarm, numerous reminders to use call system." A nurse's note, dated 10/08/10, documented, "Res discovered sitting in the floor in front of recliner (with) back resting against recliner. C/O severe back pain. When asked where, res states, "all over." Also S/T to R knee approx 2cm in length...(Physician) responded (with) order to send to ER for eval et tx. Res denies hitting her head, unable to recall what happened d/t short term memory loss." A nurse's note, dated 10/08/10, documented, "1235 (12:35 p.m.) - Res RTF from (local ER hospital) Res put back in room at 12:15 pm by driver (staff #5). Went to retrieve CNA to transfer res to bed, res attempted to get out of w/c to bed, fell down to the floor hitting her head. Res picked up et put back to bed. VS...BP 163/97. Rec 2cm skin tear to L (upper) forearm...Upon assessment, res noted (with) abrasion to R (upper) shoulder. Area not noted upon initial assessment when res sent to ER this AM. Safety alarm on et working. Will continue to monitor." A falls management investigation form, dated 10/08/10, was completed with check marks on the front of the form. The back of the form documented, "What was the resident doing? Attempt to transfer (without) assistance. What actions/plans can be made from this knowledge to reduce resident risk? Encourage the use of call system. Is there a need to re-assess the resident? No. Is there a need for changes to be made on the personal (care) plan? No. What actions were set in place after the previous fall(s)? Bed/chair alarm." An incident report, dated 10/09/10, documented, "Ambulated to toilet & fell hitting R side (with) goose egg to R forehead & ST 1 1/2" U-shaped ST to R (upper) arm...Ice applied to R side of forehead. MAE, Neuro checks started, pain on palpation to R forehead & (upper) R arm...Steps taken to prevent recurrence: Reminded her to use her call light & not to remove her bed chair alarm." The falls management investigation form, dated 10/09/10, documented the resident had an unwitnessed fall while taking herself to the bathroom. The comments at the bottom of the form, documented, "Took bed-chair alarm off & ambulated (without) assist to toilet falling in bathroom hitting R forehead & causing ST to (upper) arm. Neuro checks started." The back of the investigation form was not completed. A care plan addendum, dated 10/09/10 at 2:30 a.m., documented, "Problem - Resident has experienced (unwitnessed) fall with no apparent injury. R forehead 2 unopen STs & (upper) R arm 1 1/2" U-shaped ST...Date resolved: 10/21/10." This head injury was not reported to OSDH. An incident report, dated 10/10/10, documented, "0240 (2:40 a.m.) - Resident crying out in pain. Noted R hip out of alignment, bruised, dark purple area, hot to touch. Res unable to move R leg & leg noted (with) pitting edema. Has had several previous falls. Res sent to ER for eval. admitted (with) Fx R hip. (The steps taken to prevent recurrence was not completed)." The report sent to OSDH, dated 10/10/10, documented, "Resident in bed crying out in pain. Noted R hip out of alignment. Bruised dark purple & hot to touch. Res unable to move or support wt on R leg. Resident confused. Removes bed/chair alarm and get up (without) assist. Has had several falls in past 2 days...Final report/corrective measures implemented to prevent recurrence...Resident fell Fri nite. Did not present with any pain or deformity. Cont to ambulate. Condition changed 10/10/10. No further falls noted. admitted to hospital with pelvic fracture." The falls management investigation form, dated 10/10/10, documented the resident had an unwitnessed fall in her room. The back of the form documented, "What actions/plans can be made from this knowledge to reduce resident risk? (not completed) Is there a need to re-assess the resident? No...Is there a need for changes to be made on the personal (care) plan? No...What actions were set in place after the previous fall(s)? Bed/chair alarm." Her care plan was updated on 11/01/10. It documented, "Debility r/t R femur fx. Interventions: Staff to remind to use call light. Frequent monitoring. Placement of bed alarm...Falls - Safety bed alarm for safety and fall prevention. Interventions: Personal items within reach. Nursing to monitor side effects of medications, increased drowsiness, insomnia." "Mental status remains poor. Constant confusion r/t dementia." "Falls - Multiple falls...Remains bed rest (with) therapy for strength & endurance." A nurse's note, dated 11/02/10, documented, "0230 (2:30 a.m.) - Res on floor in room, denies hitting head. (No) apparent new injury noted d/t fall." A care plan addendum, dated 11/02/10, documented the resident had a fall. There was no other documentation regarding the fall. A nurse's note on the same day, documented, "6-2 (shift) - Res attempted to get OOB per self this shift. (No) injuries noted from previous fall." The resident was observed in bed on her back with the head of her bed elevated on 11/15/10 at 10:00 a.m., and 3:30 p.m. She was in bed on 11/16/10 at 9:00 a.m., 11:00 a.m., 1:00 p.m., and at 4:00 p.m. She was observed in bed on 11/17/10 at 9:15 a.m., 11:00 a.m., 1:35 p.m., and 2:45 p.m. On 11/16/10 at 10:05 a.m., LPN #10 was asked if the resident was able to use the bathroom or tell you if she needed to go. She stated, "She is usually incontinent." At 3:00 p.m., a family member was asked about her care at the facility. The family member stated, "When she first came in to this nursing home, I was afraid to leave her because I knew she would try to get out of bed. She fell at home and broke her hip. She was moved here to get therapy so she could walk and regain her strength. I told them (the facility) that she was very meticulous about her hygiene and wouldn't go (urinate) in her bed. I stayed with her for six or seven days and night but I wore out and couldn't stay any longer." The family member was asked if the nurses checked on her during the evening and night to assist her to the bathroom. The family member stated, "They would come in every once in a while but when they asked her if she needed to go to the bathroom, she would say no." The family member was asked if the resident knew how to use the call light system. The family member stated, "No, she doesn't even know what it is. I asked her to push it once to get help from a nurse. She had no idea what I was talking about." On 11/17/10 at 10:50 a.m., the DON and ADON were asked about the resident's repeated falls. The DON stated, "She was a very independent lady. She didn't like to sit in the chair...The most recent care plan was just finished and handed to me. Monitoring and checking on her frequently was the only way to prevent her falls. Sometimes you just can't stop her from falling." The charge nurse (#10) was asked about the resident's falls. She stated, "She was compulsive about her room being clean. She learned how to take off her alarm and roll the cord up...She had a short-term memory loss. I would explain to her how to use the call light and encourage her to use it...Her sister asked if it would help if she stayed at night. I said yes it would...We don't know which fall resulted in the fracture. I remember taking report, saying that her hip was out of alignment." 2. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's care plan, dated 04/02/10, documented, "Psychotropic Drug Use...Unsteady gait, fell in past 30 days. fell in past 31-180 days.. Problems: Past CVA left residual mild right sided hemiparesis resulting in unsteady gait and problem with her balance while sitting... Goals: Continue to stabilize condition without loss of quality of life during next 90 day period. Staff to monitor gait daily and report any changes to charge nurse immediately. Approaches: ..frequent checks for safety. Staff to observe for s/s of unsteady gait, offering assistance and encouraging periods of rest often. An incident report, dated 05/09/10, documented, "11:00 a.m., CNA amb res to DR c walker. Turned around to pull chair out from table. Res lost balance and fell on buttocks on floor. Steps taken to prevent recurrence: Did not strike head. Bears wt. Moves all ext. Denies pain. Grips firm. PERRL. will monitor." A nurse's note, dated 06/10/10, documented, "10:30 -Res ambulating to room c walker. CNA caught res as residents gait became unsteady. Res bumped L side of rib cage on footboard, bruising noted. CNA assisted to bathroom (and) to recliner. Approx. 11:15 res ambulating from room. CNA noticed blood on res hands. CNA sat res down on chair (and) called for LPN. Laceration noted to R side of scalp. Cleansed c NSS, pressure applied. Ice pack applied for 10 - 15 min. TAO then applied. Bleeding stopped..." A falls management investigation documented, "Time of fall: ? - Who witnessed fall: no one - location of fall: Rm 31 - What was the resident doing at the time : Unsure - Was the resident alone at the time of fall: yes - What was the reason for being there: Room - Was this the first fall: no - Other comments: unsure of how resident injured herself. Do the "clues" reflect any environmental factors that could be involved in this fall? No." (There was no other documentation noted.) No incident report was found. This head injury was not reported to OSDH. An incident report, dated 06/29/10, documented, "Res was in dining room sitting (at) table. She got (up) from table to get coffee (and) didn't use her walker. She fell to the floor, hitting the L side of her head. Rec'd a 2 cm knot, goose egg to L side of the head. Neuro's initiated. Steps taken to prevent recurrence: Have CNA's monitor resident more closely (and) ensure that she uses walker for ambulation." A nurse's note, dated 06/29/10, documented, "6-2 - Res in dining room sitting (at) table. Res got (up) to "get coffee." She was witnessed by (CMA) falling to the floor. Res failed to use walker. She hit her head (and) fell on her L side...Res rec'd 2 cm hematoma/knot/raised area. Res assisted to feet (and) ambulated back to room (with) slow steady gait. Ice pack applied to raised area on L side of forehead." The falls management investigation documented, "Do the "clues" reflect any environmental factors that could be involved in this fall? Yes, didn't use walker. Is there a need to re-assess the resident: Yes, possible w/c d/t res not remember to use w/c (and) recent." This head injury was not reported to OSDH. QTR (Care Plan) Review..Date 06/30/10 - "Res uses walker c ambulating. Requires frequent reminders to use walker when ambulating (without) staff assistance." An incident report, dated 07/01/10, documented, "1500 (3:00 p.m.) Res walking in hallway (with) blood on face (and) hands. ADON took res to her room (and) blood noted on floor by bedside table. Res couldn't explain what happened. BP high. PRN clonidine (anti-hypertensive) given (and) effective. Laceration (and) knot to R eyebrow area. Steps taken to prevent recurrence: Pressure applied bleeding stopped, steri strips applied abd pad wrapped (with) gauze, ice applied. Fall risk assessment (up) dated." The falls management investigation documented, "Was this her first fall: No - Other furniture involved? Swivel chair possibly." (The back of the investigations form was not completed.) This head injury was not reported to OSDH. An incident report, dated 08/24/10, documented, "0230 (2:30 a.m.) Res fell in bathroom (and) hit head on hand rail causing L-shaped skin tear (upper) R eyebrow. Steps taken to prevent recurrence: Staff instructed to monitor res q 1 (hour) (and) offer toileting q 2 (hour) res instructed to call for assist (with) ambulation (and) transfers." An incident report, dated 09/18/10, documented, "0300 (3:00 a.m.) Head hit A/C unit in room. Moving about in room, fell (with) head hitting corner of A/C, cause 1 1/2 " gash to R side of face near R eye. Lots of bleeding (with) dressing applied. Continued bleeding through dressing. Ambulance called (with) EMT's dressing soaked also. Neuro (checks) started. Sent to ER for eval. Steps taken to prevent recurrence: Frequent reminders to call for assistance." QTR (Care Plan) Review...Date 09/23/10 - "Safety alarm in use. Uses walker for ambulation, requires frequent reminders when ambulating and staff assist. Continue POC." The resident's comprehensive assessment, dated 09/26/10, documented her cognition was moderately impaired. She was able to sometimes understand others and sometimes able to be understood. She was independent with transfers and required limited assistance from staff for dressing. She required extensive assistance with hygiene and bathing. It documented she was incontinent of urine. She had fallen in the past 30 days and had fallen in the last 31 to 180 days. The care plan addendum, dated 10/04/10 documented, "Problem: 09/18/10 - Resident has experienced fall moving about room, fell (and) hit head on corner of AC unit in her room. caused 1 1/2" open area near Rt side of face near Rt eye. Sent to ER for eval. Goal: Will continue to be free from injury or complications related to fall. Approaches: Monitor for developing complications such as bruising, swelling, stiffness and pain each shift for 72 hr and document accordingly. Interventions: Frequent reminder to call for assist. Assess resident for risk of recurrence and initiate plan to prevent additional falls. Consider physical therapy evaluation and tx." The falls management investigation documented, "Was this her first fall? No - Do the "clues" reflect any environmental factors that could be involved in this fall? No." (The back of the investigation form was not completed.) A care plan addendum, dated 10/06/10, documented, "Problem: 08/24/10 Res fell and hit head on nightstand causing "L" shaped skin tear on Rt eyebrow. Resident has experienced fall injury. Goal: Will continue to be free from injury or complications related to fall. Approaches: Monitor for developing complications such as bruising, swelling, stiffness and pain each shift for 72 hr and document accordingly. Assess resident for risk of recurrence and initiate plan to prevent additional falls. Intervention: Staff instructed to monitor res q 1 hour and offer toileting q 2 (hour). Resident to utilize call light for assist (with) ambulation (and) transfers. Consider physical therapy evaluation and tx." The falls management investigation documented, "Do the "clues" reflect any environmental factors that could be involved in this fall? No - Do the "clues" reflect any healthcare factors that could be involved in this fall? Yes If resident has had more than one fall, are there any similarities? Yes - What was the resident doing? Ambulating." (The investigation form was not completed.) This head injury was not reported to OSDH. An incident report, dated 11/02/10, documented, "12:30 p.m., Resident found on floor by WNC transportation employee, notified CNA she stayed (with) resident until nurse arrive (at) 12:30 p.m. Resident sitting on floor (at) end of her bed. Was first aid administered? yes, clean c soap (and) water, gently pat dry." No comments and/or steps taken to prevent recurrence were documented. A nurse's note, dated 11/02/10, documented, "(At) approx 1230 (12:30 p.m.) - Resident found on floor sitting (at) end of bed c abrasion to R forehead R top of head 2 cm approx laceration bleeding. Wash c soap (and) water. Bleed stop applied cold compress for swelling. Res tol well, gave i/i Tylenol 325 mg for pain. Resident unable to give pain scale." This head injury was not reported to OSDH. The incident report log was not updated to include this fall. On 11/17/10 at 1:40 p.m., the DON was asked if she reported head injuries to OSDH. She stated, "No, not if they just received first aid here, I don't. I wish I could receive those memo's to keep me updated on what we are supposed to report." 3. Resident #9 was admitted to the facility's Memory Care Lane (locked unit) with [DIAGNOSES REDACTED]. The resident's care plan for falls, dated 04/30/10, documented, "Problems: Resident at increased risk for falls d/t daily use of antidepressants. fell on [DATE] while at (geriatric psych facility), hit her left hip on a trash can and x-ray was obtained which was negative. Bruise noted to left hip when readmitted to our facility. Also fell on [DATE] when slipped on wet floor. No injuries noted. At increased risk for falls d/t past history as well as taking Lexapro (antidepressant) daily for depression. Goals: Staff to monitor for s/e of antidepressants; i.e. dizziness, lethargy, HA, etc. No incidents of falls next 90 days. Approaches: Frequent checks for need for assistance to decrease falls...Attempt to redirect when observed wandering...Staff to offer routine toileting with assist...Offer to assist in toileting resident routinely every 2 hrs and PRN, observing body language signaling needing the restroom...Staff to monitor for safety. Secure Memory Care Environment." A fall risk assessment, dated 05/10/10, documented the resident's score was "15" (A score of 10 or above represents the resident is at high risk for falls). An incident/accident report, dated 05/10/10 at 5:00 a.m., documented, "Resident was getting up to go to the bathroom, became dizzy (and) fell to floor on buttocks. Reddened area to buttocks (without) open areas. Steps taken to prevent recurrence: Q 2 hr toileting schedule. Observe (gait)." A falls management investigation, dated 05/10/10, documented the resident was "getting out of bed", was alone at the time of the fall, and "states she became dizzy (and) sat on her bottom.'" The following areas were checked "Yes" on the investigation: Recent return from hospital? Changes in mental status? and Changes in behaviors? The investigation form questions regarding "clues" about the fall, action plan, changes and assessments were blank and did not include the signature of the person completing the investigation. A fall risk assessment, dated 05/12/10, documented the resident's score was "19." A nurse's note, dated 05/12/10, documented, "Res found on bathroom floor by CNA @ 1215A (12:15 a.m.). (No) apparent injuries noted. Balance very unsteady upon standing. Assisted back to bed X 2. Denies any pain. Bed alarm placed on resident to assure safety. (No) adverse reactions noted to new medications. (No) behaviors this shift. Will cont. to monitor." A falls management investigation form, dated 05/12/10, documented, "Location of fall: bathroom... Was resident alone at the time of fall? Yes. Recent return from hospital? Yes. Changes in behaviors? Yes. Changes in mobility status? Yes." The investigation form questions regarding "clues" about the fall, action plan, changes and assessments were blank and did not include the signature of the person completing the investigation. A physician's telephone order, dated 05/12/10, documented, "Clarification: Bed alarm for safety. Attach bed alarm for safety (and) fall precaution Q HS (and) PRN. Check battery for efficacy on 6-2 shift." The resident's individual incident report log documented the resident had a fall in her room on 05/21/10 at 9:00 a.m. There was no documentation in the residents' nurses' notes. No incident report could be located in the incident report book regarding a fall on 05/21/10. A Medicare 30-day assessment, dated 05/22/10, documented the resident's cognition was moderately impaired (poor decisions; cues/supervision required). She had short and long term memory problems. She sometimes understood others and was sometimes understood. Her vision was highly impaired. She made negative statements, repetitive questions, repetitive verbalizations, had persistent anger, unpleasant mood in the morning, crying/tearfulness and repetitive physical movements. She wandered throughout the secured unit, was verbally and physically abusive, displayed socially inappropriate behaviors and resisted care. She required limited assistance from the staff for transfers, but ambulated independently. A nurse's note, dated 06/27/10, documented, "0900 (9:00 a.m.)... Res found sitting on floor beside bed. Alert. Normal LOC. (No) evidence of head or other injury. Bears wt. Moves all ext. Grips firm bilat. Denies pain. PERRL. Safety alarm was unclipped - did not go off..." An incident/accident report, dated 06/27/10, documented, "9:00 a.m. - Resident found sitting on floor beside bed. Safety alarm was unclipped (and) did not go off. (No) evidence of head or other injury. Denies pain. Steps taken to prevent recurrence: Bears wt. Moves all ext. (No) c/o pain. Will have CNA get res (up) earlier (with) other residents." A falls management investigation, dated 06/27/10, documented, "...Who witnessed the fall? N/A... What was the resident doing at the time? Resting in bed. Was the resident alone at the time of the fall? Yes. What was the reason for being there? Still sleeping. Was this the first fall? No. Resident using incontinent supplies at the time of fall? Yes. Comment: Feet were tangled in bedding. Safety alarm was undone. CNAs had left res in bed till 9AM because she was still asleep. Comment: Res has safety alarm which was unclipped (and) did not go off. Will have CNA get res (up) earlier for breakfast (with) other residents. May want to consider low bed." The investigation form questions regarding "clues" about the fall, action plan, changes and assessments were blank and did not include the signature of the person completing the investigation. The care plan update for falls, dated 07/26/10, documented, "Res fell coming out of bathroom on 05/12/10. (No) injuries noted. Physician (and) family notified. Cont (with) current plan of care. Admin meds as ordered." An incident/accident report, dated 08/08/10, documented, "10:00 a.m. - Sat down @ nurses desk on rolling office chair. Attempted to get (up) (and) lost balance landing on back on floor. (No) injury apparent. Steps taken to prevent recurrence: Bears wt. Moves all ext. PERRL. Grips firm. (No) injury apparent. Will monitor neuro (checks) per protocol." A falls management investigation, dated 08/08/10, documented, "Who witnessed the fall? (Name deleted LPN and name deleted RN). Location of fall? In front of nurses desk. What was the resident doing at the time? Sitting in chair. Was the resident alone at the time of fall? No. What was the reason for being there? Waiting to get TB test. Resident in a hurry? Yes. Why? Always restless. Resident using incontinent supplies at the time of fall? Yes. Comment: Sat down in rolling office chair @ nurses dest to wait for TB test. attempted to stand (and) lost balance. "Neuro (check) done per protocol. (No) injury apparent." A fax to the resident's physician, dated 09/02/10, documented, "0010 (12:10 a.m.) - Found on floor face down next to bed (with) chair/bed alarm on not sounding. (L) eye (and) side of face of face swollen (with) some discoloration. (L) wrist bruising. Both knees (with) redness. Neuro (checks) started. (L) eye swollen shut (with) hard swollen area to (L) side near eye. Sent to ER for evaluation @ 0100." The physician response documented, "Agree." A nurse's note, dated 09/02/10, documented, "0010 (12:10 a.m.) Found on floor next to bed on face (and) abdomen sleeping. (L) eye swollen (with) eye turning black. Swollen area to (L) eye swollen (and) discolored. Bilateral knees red but (no) open areas. Neuro (checks) started... Grips strong (and) equal. Her usual to keep both eyes closed (with) (L) eye swollen (and) side of face swollen. Call to husband to inform him of the roll out of bed. Chair/bed alarm still attached (and) not sounding off as it was still together attached to gown (and) bed. Ambulance called for non-emergency transport..." Physician's reports for the CT scans performed on the resident at the hospital documented, "Small right parietal hematoma... Left facial soft tissue swelling..." The emergency room discharge report, dated 09/02/10, documented, ED (Emergency Department) Diagnosis: [REDACTED]. The fall was not recorded on the individual incident report log. There was not an incident report in the incident report book. There was not a falls management investigation form for the fall. The fall was not addressed in the facility's safety minutes. A fax to the resident's physician, dated 09/09/10, documented, "Res leaning to (R) side. (Decreased) LOC. (Decreased) responsiveness to all stimuli. Bilat. hand grips weak, R > L...(blood pressure) 189/90... BP taken again: 165/100. Res BP does not run that high... Sent to ER per husband request..." The resident was observed in the emergency room and sent back to the facility with no new orders. A fax to the resident's physician, dated 09/19/10, documented, "Res leaning to (R) or (L) when sitting or walking. Husband here visiting. Thinks its because she having back pain d/t previous surgeries. Takes no routine pain meds. Has PRN order for Lortab 7.5 mg, but it's only given occasionally. She won't c/o pain or ask for pain med d/t advanced dementia. Is high fall risk. Could we try routine Ultram or something? We're concerned that routine Lortab might increase falls." The physician ordered Tramadol (pain reliever) 50 mg - one tablet by mouth every 12 hours. A falls care plan update, (no date), documented,