Every finding on record at Woodlands Skilled Nursing and Therapy

Based on record review and interview, the facility failed to ensure residents were provided the opportunity to vote and provide activities for 3 (#2, 6, and #7) of 3 sampled residents reviewed for resident rights. The administrator identified 54 residents resided in the facility. Findings: A facility document titled RESIDENT'S RIGHTS AND CONFIDEMTIALITY, revised 08/01/17, read in part, At the facility, we recognize the importance of protecting and promoting the rights of all its residents. The right to civil and religious liberties. The right to participate in social, religious and group activities of choice. An activities calendar posted in a resident common area showed activities for 05/2026. A facility form titled Grievances, dated 06/2026, showed on 06/09/26 a specific concern regarding voting. 1. An undated admission record showed Resident #2 had diagnoses which included acute and chronic respiratory failure with hypoxia, chronic pain, and diabetes mellitus. A quarterly assessment for Resident #2, dated 02/25/26, showed the resident had a BIMS score of 15 and was not cognitively impaired. On 06/18/26 at 3:55 p.m. Resident #2 stated the facility did not provide activities for the residents. Resident #2 stated if an activity was scheduled it was usually cancelled. Resident #2 stated they did not get to vote last week on the 15th because the activities staff failed to complete the required documentation. 2. An undated admission record showed Resident #6 had diagnoses which included major depressive disorder and history of falls. An annual assessment for Resident #6, dated 04/21/26, showed the resident had a BIMS score of 15 and was not cognitively impaired. On 06/19/26 at 3:47 p.m. Resident #6 stated the facility did not have scheduled activities. Resident #6 stated they were unable to vote last week because the activities staff failed to complete the required paperwork. 3. An undated admission record showed Resident #7 had diagnoses which included chronic obstructive pulmonary disease, parkinsonism, and diabetes mellitus. An annual assessment for Resident #7, dated 05/16/26, showed the resident had a BIMS score of 15 and was not cognitively impaired. On 06/18/26 at 9:57 a.m., Resident #7 stated they were upset because they did not get to vote in the election last week. Resident #7 stated the activities staff did not complete the paperwork to allow the resident to obtain an absentee ballet to vote. On 06/18/26 at 11:14 a.m., the administrator stated the activities staff had not competed the required paperwork in time to allow the residents to vote in the election last week. The administrator stated the activities staff was off on vacation until next week and there was no one providing activities in their absence.

Based on record review and interview, the facility failed to complete a thorough investigation for an allegation of neglect for 1 (#4) of 1 sampled resident reviewed for neglect. The administrator identified one allegation of neglect in the last six months. Findings: A facility policy titled Administrative Policies and Procedures Resident Abuse, Neglect and Misappropriation of Property, revised 11/01/22, read in part, A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH [Oklahoma State Department of Health]-283.Thorough investigations may include interviewing relevant staff, residents, families and/or other witnesses, reviewing chart information and contacting the physician. An undated admission record showed Resident #4 had diagnoses which included acute respiratory failure with hypoxia and a pressure ulcer of the sacral region stage 2. An admission assessment for Resident #4, dated 03/30/26, showed the resident had a BIMS score of 15 and was not cognitively impaired. The assessment showed Resident #4 was incontinent and dependent on staff for toileting. An Oklahoma State Department of Health incident report form, dated 04/15/26, showed an allegation of neglect for Resident #4. The report showed Resident #4's family had reported the resident had been left in a soiled brief on two separate occasions. The report showed an undated and unsigned handwritten document with residents being asked if they had any concerns at that time. The report showed an investigation was completed. There were no documented staff, family, or physician interviews. On 06/22/26 at 12:30 p.m., the administrator reviewed the investigative documentation regarding the allegation of neglect for Resident #4. They identified the initials on the undated and unsigned handwritten document as resident initials. The administrator stated the residents were asked the question Do you have any concerns at this time? The administrator did not provide documented staff, family, or physician interviews.

Based on record review and interview, the facility failed to ensure a resident was treated in a dignified manner during ADL care for 1 (#35) of 1 sampled resident reviewed for dignity. The administrator identified 45 resident resided in the facility. Findings: An undated transfer/discharge report showed Resident #35 had diagnoses which included mononeuropathy, anxiety disorder, and major depressive disorder. An annual assessment, dated 04/23/25, showed Resident #35 was cognitively intact and had a brief interview for mental status score of 15. The assessment showed the resident was independent with ADLs including showers. The care plan, revised 04/24/25, showed Resident #35 had an ADL self care performance deficit related to musculoskeletal impairment. The care plan showed the resident was able to bathe self, feed self independently, ambulate independently, and toilet self. The resident council minutes for the meeting held 05/19/25 was reviewed. The minutes showed on a resident response form a concern from resident council regarding the nursing department. The form showed the aides were coming into the shower room when someone was showering without knocking. On 05/21/25 at 8:54 a.m., Resident #35 stated Monday they were taking a shower and CNA #2 opened the door when they were undressed. Resident #35 stated it had happened about three times before. Resident #35 stated the in use sign was displayed and the CNA did not even knock. Resident #35 stated CNA #2 said they had to get the shower chair from the room to give another resident a shower. Resident #35 stated they told CNA #1 who was also working on the hall about the incident. On 05/21/25 at 11:27 a.m., CNA #1 stated they were aware of the incident regarding CNA #2 opening the door while the resident was showering. CNA #1 stated this was not the first time CNA #2 had opened the door to the shower room while Resident #35 was showering. CNA #1 stated they did not tell the nurse and should have reported the incident to the nurse. On 05/22/25 at 9:13 a.m., the administrator stated there was no facility policy regarding dignity. The administrator stated they followed resident rights. On 05/22/25 at 9:43 a.m., CNA #2 was interviewed regarding opening the door when Resident #35 was showering. CNA #2 stated there was an incident Monday regarding Resident #35. CNA #2 stated they walked in on Resident #35 while they were taking a shower. CNA #2 stated they did not notice the sign on the door the shower room was in use and they did not knock. CNA #2 stated it had happen once before and the resident was not upset. CNA #2 stated the resident was upset about the incident occurring on Monday.

Based on record review and interview, the facility failed to ensure the care plan was revised for 1 (#32) of 12 residents reviewed for care plans. The administrator reported 45 residents resided in the facility. Findings: Resident #32's undated medical diagnoses list showed diagnosis of Parkinsonism. A facility incident report, dated 05/08/25, showed Resident #32 had a fall on 05/08/25. A fall risk assessment, dated 05/08/25, showed Resident #32 was high risk for falls. There was no documentation in Resident #32's care plan to reflect the fall on 05/08/25. On 05/22/25 at 11:46 a.m., registered nurse #1 stated the fall on 05/08/25 should have been care planned with an intervention put in place.

Based on observation and interview, the facility failed to maintain a homelike environment for two (#3 and #4) of three sampled residents reviewed for home like environment. The administrator identified 54 residents resided in the facility. Findings: On 05/07/24 at 3:10 p.m., two children were observed running through the dining area and common area. On 05/07/24 at 3:12 p.m., food wrappers and chewed gum was observed on the floor of the activity room. On 05/07/24 at 3:15 p.m., two children were observed running down the 200 hall. On 05/08/24 at 10:12 a.m., Resident #4 stated the staff bring their children to work with them and it keeps them from getting their rest because they run up and down the hallways and are loud. On 05/08/24 at 11:00 a.m., Resident #3 stated having children running up and down the hallway bothers them. They have caught children in their room and observed them coming out of other residents' rooms. It upsets them because the children tear up the yard ornaments in the courtyard, especially the bird feeders. They have reported this to the DON but the children still run up and down the halls. On 05/08/24 at 12:48 p.m., the houskeeping supervisor stated it is the responsibility of the parent to clean up after their children, but they don't and it makes their job harder. They have brought this to the attention of the administrator but it has not been addressed. 05/08/24 at 3:12 p.m., the DON stated it is the parent's job to supervise and clean up after their children. They stated they need to have people come to work so they bring their children. 05/08/24 at 3:15 p.m., the administrator stated they do not have a policy regarding employees bringing their children to work.

Based on observation and interview the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. The administrator identified 55 resident residing in the facility. Findings: 1. On 02/12/24 at 9:02 a.m., an initial tour of the kitchen was conducted. The following observations were made. The large round trash can by the deep fryer was not covered. The stand up freezer which held the house shakes was observed to have ice build up. On 02/12/24 at 9:04 a.m., the refrigerator was observed to have a large mixing bowl with what looked like chocolate pudding in the bowl the plastic wrap was not covering the bowel and was in the pudding. There were 13 individual cups of pudding not labeled in the refrigerator. A bowl of what looked like tomato soup was cover with plastic wrap but not labeled or dated. A donut on a plate cover with plastic wrap not labeled or dated. A plate with cake and a dessert cup on the plate covered with plastic wrap that was coming unsecured from the plate was observed in the refrigerator not labeled or dated. Cook #1 stated the pudding was made for today's lunch. The bowl had tomato soup in it and the cake was an employees. Cook #1 stated the items should have been labeled and dated. On 02/12/24 at 9:08 a.m., the storage room was observed to have large areas of missing tile. On 2/12/24 at 9:10 a.m., DA #1 was observed entering he kitchen and did not wash their hands. On 2/12/24 at 9:18 a.m., DA #1 returned to the kitchen, hand washing was not performed by the staff member. On 02/12/24 at 9:24 a.m., debris was observed on the shelving under the prep table where the steam table lids were contained. The prep area was observed to have bread crumbs and multiple items on the counter with debris around them. On 02/12/24 at 11:28 a.m., during dining observation the DM was observed going in and out of the kitchen not washing her hands when entering the kitchen. On 02/14/24 at 10:44 a.m., The DM stated the trash should be covered. The DM stated the prep tables and shelving should be cleaned. The DM stated when staff enter the kitchen they should put on a hair net and wash their hands. The DM stated they try and defrost the freezer once a month but the one with the shakes in it was the oldest and it frosts over quicker than the other freezers. On 02/14/24 at 10:56 a.m., the DM was observed to touch the trash can lid and them move the cooked meat to puree to the prep table and then washed their hands. On 02/14/24 at 10:56 a.m., a housekeeping staff member entered the kitchen to replace the soap in the dispenser. The housekeeper did not have on a hair net. On 02/14/24 at 11:23 a.m. the DM was observed to go into the kitchen and did not wash their hands. On 02/14/24 at 11:33 a.m., DA #2 was observed to deliver a meal on a tray to a resident . DA #2 sat the tray on the table gave the meal to the resident and returned to the steam table, placed the tray back on the top of the steam table and another meal was place on the tray to deliver to another resident. On 02/14/24 at 12:02 p.m., the DM stated the staff should not be sitting the trays on the tables and then reusing them they should just hold the tray to serve the meal.

Based on observation, record review, and interview, the facility failed to ensure menus were followed for one of one meal service observed. The administrator identified 55 resident who resided in the facility. Findings: On 2/14/24 at 10:39 p.m., the menu for lunch this day documented beef tacos, refried beans, Mexican rice, and desert of the day. On 02/14/24 at 12:15 p.m., the lunch service was observed and the resident were served white rice for the noon meal. On 02/14/24 at 12:27 p.m., a test tray was sampled and the white rice was very sticky and bland to the taste. On 02/15/24 at 1:23 p.m., the DM stated they did not make the Mexican rice because they did not have all the ingredients to make it.

Based on observation, and interview, the facility failed to ensure food was served at an appetizing temperature. The administrator identified 55 residents who resided in the facility. Findings: On 02/14/24 at 11:11 a.m., the yogurt was taken out of the refrigerator and sat on the counter. At 11:17 a.m., it was place on some of the trays for the hall meals. On 02/17/24 at 12: 20 p.m., the DM was plating meals for hall 300. The yogurt remained on the hall trays. At 12:22 p.m., the cooperate dietary manager obtained the temperature of the yogurt and it was 59.2 degrees Fahrenheit. On 02/15/24 at 1:23 p.m., the DM stated the temperature on cold food should be no higher than 41 degrees when serving.

Based on observation, record review and interview, the facility failed to act upon grievances presented during resident council meetings or provide rationale as to why concerns could not be met. The administrator identified 55 residents resided in the facility. Findings: The resident council reports dated 08/24/23 documented several concerns related to laundry, employees on cell phones too much, and different food request made by the residents. The resident council reports, dated 09/13/23, documented the residents were getting tired of jello and pudding for snacks and nothing else offered. There was also concerns about items missing from laundry. The resident council reports, dated 01/17/24, documented items being missed from laundry. On 02/12/24 at 9:00 a.m., an observation was made of four children being on hallway 200 with staff member. The children were observed to be standing in the doorways of the resident rooms while aides were assisting residents and passing medications. On 02/12/24 at 10:46 a.m., Res #19 stated items were always missing from laundry, the only foods food alternative meals were soups, snack consist of oatmeal pies and fudge rounds. They also stated the facility never offers fresh fruit or ice cream. Res #19 stated all the foods are locked up in the evening and there will only be peanut butter and jelly sandwiches available in the evenings. They also stated there were several residents that would like to have ham and cheese or turkey with cheese sandwiches but we only get peanut butter and jelly and we never get chips of any kind, only Fritos are offered. On 02/12/24 at 2:55 p.m., LPN #2 stated there was many times staff members would bring their children up to the facility related to staff members not having a babysitter and at times the children were in the facility for long periods of time. The children would sit in the common area watching the residents' television and laying on the couch preventing residents from sitting there to watch television. LPN #2 stated the children would be disruptive to staff members and the resident by running up and down the hallways of the facility. On 02/14/24 at 1:05 p.m., a council meeting was conducted with 12 residents. The residents voiced complaints related to their grievances about the kitchen and food were never addressed. They voiced complaints they always had the same food and whenever they asked for something different they were ignored. They stated they have asked for cottage cheese and fruit, roast with carrots and potatoes, Indian tacos with fry bread, peanut butter and snickerdoodle cookies, fried fish, tater tots, and porkloin. They complained about the sauce for chili, tacos, and spaghetti was the same every time and watered down. The council also complained about never getting extra food and the staff telling the residents there was not enough food for extra. They want different kind of beans and want the cornbread cooked thoroughly related to the cornbread always being rare in the middle. The council did complain about children being in the facility running up and down the hallways and going in and out of resident rooms without permission. They stated the children play with puzzles and games in room [ROOM NUMBER] and leave it in a mess for housekeeping to clean up. They also complained about no RN coverage on weekends. The council wanted to have bible study again and some different activities to participate in. They stated they rarely turned in any grievance anymore related to the facility not addressing the problems. On 02/14/24 at 3:00 p.m., observation was made of an activity station for toddlers to play on in room [ROOM NUMBER]. There was also observation of toddler toys stacked up on a shelf in room [ROOM NUMBER]. On 02/15/24 at 9:47 a.m., the laundry supervisor stated they did not know Res #26 was missing a certain blanket. On 02/15/24 at 9:52 a.m., Res #26 stated there was a grievance filed shortly after being admitted into the facility but their blanket was never found. On 02/15/24 at 1:00 p.m., the social service director stated they did not do anything with the council meeting complaints because they did not know they were supposed to take the complaints to administration. On 02/15/24 at 2:34 p.m., the administrator stated they have not seen the council meeting minutes and the complaints as social services always kept those meetings. They also stated they did not know they were suppose to address each complaint that the council members brought up in the meetings. The administrator then stated they would begin addressing the problems the council brought to the meetings. On 02/15/24 at 3:43 p.m., Res #19 stated they did order a chef salad for lunch but did not receive a chef salad.

Based on observation and interview, the facility failed to document required daily staffing information. The administrator identified 55 residents resided in the facility. Findings: On 02/12/24 at 9:30 a.m., and throughout the survey the staffing board was observed to have no documentation of the facility name, date, census, staff names, hours of nursing staff, or titles. On 02/15/24 at 3:36 p.m., the administrator and the DON stated they were not aware of the requirements regarding posted staff information.

Based on record review and interview the facility failed to ensure the services of an RN was available in the facility eight hours daily seven days a week. The administrator identified 55 residents resided in the facility. Findings: A document titled Time & Attendance Detail, date range: 11/01/23 through 01/31/23, documented an RN was not in the facility for eight hours on 12/16/23. On 02/15/24 at 3:07 p.m., the corporate nurse stated on 12/16/23 there was only 6.50 hours for RN coverage.

Based on observation and interview, the facility failed to honor resident's choice of entertainment for one (#11) of two sampled residents who was reviewed for choices. The DON identified 58 residents resided in the facility. Finding: Res #11 had diagnoses which included recurrent depressive disorders and diabetes mellitus with diabetic polyneuropathy. A significant change assessment, dated 12/27/23, documented the resident was moderately impaired with cognition and required assistance with most ADLs. On 02/12/24 at 10:37 a.m., an observation was made of Res #11 having a television mounted on the wall approximately four foot from another television mounted on the wall for the other resident which resided in the same room. The resident stated the remote control operates both televisions in the room. They stated every time the other resident utilizes their remote control for their television it operates both televisions. Res #11 stated they could not watch what they wanted related to their television being controlled by the other resident's remote. On 02/14/24 at 3:42 p.m., an interview was conducted with the maintenance man and they stated the televisions were too close together and the remote operated both televisions in the room. On 02/14/24 at 3:45 p.m., an interview was conducted with the DON and they stated there was a problem with a remote controlling the sound on two televisions but they bought some headphones for the one resident which fixed the problem. They also stated they did not know about any other problems with the televisions in other rooms.

Based on record review and interview, the facility failed to ensure nursing staff completed required competency demonstrations annually for one (CMA #2) of five staff reviewed for annual competency. The administrator identified 55 residents resided in the facility. Findings: On 02/15/24 at 11:42 a.m., competency documentation was requested. On 02/15/24 at 1:43 p.m., HR stated they did not have an annual competency for CMA #2. On 02/15/24 at 2:54 p.m., the DON stated CMAs competencies were to be completed annually.

Based on observation, record review, and interview, it was determined the facility failed to ensure the code status was identified and correct for one (#44) of 24 residents whose code status was reviewed. The administer identified 55 residents who resided in the facility. Findings: Res #44 had diagnoses which included diabetes mellitus, dependence on renal dialysis, chronic kidney disease, and congestive heart failure. An advanced directive acknowledgment form, dated [DATE], documented the resident did not have a DNR. An admission assessment, dated [DATE], documented the resident was intact with cognition and required substantial to maximal assistance with most ADLs. A care plan, dated [DATE], documented the resident had full code status. On [DATE] at 11:29 a.m., a red name tag was observed on the outside of the resident room. A review of the EHR, documented the resident's code status was full code. A DNR was not found in the resident's hard chart. On [DATE] at 3:29 p.m., LPN # 3 stated when a resident had a red name tag on the door they are a DNR code status. On [DATE] at 3:29 p.m., LPN #4 stated red on the door is for DNR. LPN #4 stated we would not have performed CPR if it had been needed because the resident had a red name plate.

Based on record review and interview, the facility failed to ensure a resident received the necessary services to maintain their scheduled baths for one (#42) of one sampled resident for assistance with bathing. The administrator identified 55 residents who resided in the facility. Findings: Res #42 had diagnoses which included history of falling, reduced mobility, and osteoarthritis. A quarterly assessment, dated 12/21/23, documented the resident was intact with cognition and required partial to moderate assistance with bathing. A care plan, revised 12/28/23, documented the resident has a self care deficit related to impaired balance and pain. The care plan documented the resident required limited physical help from staff participation with bathing. The residents bathing schedule was bath on Monday and Thursday on the 7 to 3 shift. The resident should have received baths on 01/15, 01/18, 01/22, 01/25, 01/29, 02/01, 02/05, 02/08, and 02/12. A review of the bathing sheet for 30 days documented the resident had a bath on 01/23, refused on 01/24, refused on 01/29, was bathed on 02/01, 02/05, 02/08, and 02/12. The resident missed a baths on 01/15 and 01/18/24. On 02/13/24 at 10:22 a.m., Res #42 stated most times it takes the staff an hour or so for them to get down here to get them up in the morning and some times it was 9 or 10 at night before they will assist them to bed. Res #42 stated they knew the staff are busy. Res #42 stated they were supposed to get a two showers a week on Monday and Thursday. The resident stated some weeks they did not get bathed. Res #42 stated they did not get a bath yesterday. Res #42 stated most the time the students who come into the facilty help with their bath, if they did not, they would not get bathed. On 02/14/24 at 4:00 p.m., CNA #1 stated when they give a shower they document the bath in PCC, under the tasks. CNA #1 stated most of the residents are scheduled for two showers a week and if a a resident refused they document refused. On 02/14/24 at 4:10 p.m., CNA #2 stated they believed the residents are scheduled for three baths a week. CNA #2 stated they felt at this time they were able to get showers completed but they had missed giving residents their baths in the past due to staffing issues. On 02/15/24 at 10:14 a.m., the DON stated the baths are only documented in the EHR. The DON stated the missed baths may have not been documented, could have been a documentation error.

Based on record review, and interview, the facility failed to ensure wound care treatments were completed as ordered for one (#17) of three sampled resident reviewed for pressure ulcers. The DON identified 55 residents resided in the facility. Res #17 had diagnoses which included dementia without behavioral disturbances, atrial fibrillation, arthropathy, chronic pain, and stage II pressure ulcer. Weekly skin assessment, dated 10/27/23, documented there was no skin problems with res #17. Weekly skin assessment, dated 11/10/23, documented there was no skin problems with res #17. A physician order, dated 11/16/23, documented apply skin prep to spine every day and evening shift for wound management/prevention. A skin assessment summary documented on 11/22/23, the resident had a pressure ulcer. There was also documentation of a wound consultant visit on this day. A physician order, dated 11/22/23 documented cleanse mid back with normal saline, pat dry, apply medihoney, cover with calcium alginate, and secure with bordered foam every day shift, Monday, Wednesday, Friday, related to pressure ulcer, unstageable and as needed for soiled or dislodgment. This order was not implemented until 11/27/23 according to treatment record. A physician order, dated 01/04/24, documented cleanse mid back with NS, pat dry, apply Dakin's soaked gauze and secure with bordered foam every day shift related to pressure ulcer, unstageable and as needed for soiled or dislodgment. A care plan, dated 01/23/24, documented to cleanse mid back with normal saline, pat dry, apply Santyl, cover with calcium alginate and secure with bordered foam as per orders related to pressure ulcer, unstageable. On 02/15/24 at 11:51 a.m., the wound care nurse stated they did not know anything about the wound on the resident's back until the pressure ulcer was unstageable.

Based on observation and interview, the facility failed to ensure staff did not stand while feeding residents for two (#14 and #206) of 24 sampled residents. The Resident Census and Conditions of Residents report documented 50 residents who resided in the facility. Findings: On 01/04/23 at 8:26 a.m., LPN #1 was observed standing at the bedside while feeding Res #206. On 01/04/23 at 8:30 a.m., CNA #1 was observed standing at bedside while feeding Res #14. On 01/04/23 at 5:12 p.m., a staff member was observed standing at bedside while feeding Res #14. On 01/09/23 at 10:16 a.m., the DON stated that the staff should be eye level with the resident or seated while assisting them to eat.

Based on record review and interview, the facility failed to act upon grievances presented during resident council meetings or provide rationale as to why concerns could not be met. The Resident Census and Conditions of Residents report documented 50 residents resided in the facility. Findings: The resident council minutes were reviewed for 02/11/22, 03/23/22, 04/27/22, 05/23/22 and 09/30/22, which were all of the meeting minutes provided for review for the last 12 months. There was no documentation the residents' grievances had been acted upon. On 01/05/23 at 1:33 p.m., a resident group meeting was conducted with nine residents attending. During the meeting, residents stated that they were not sure who the grievance official was, but they thought it was the administrator. They stated none of the staff, including the administrator, ever responded to their concerns or gave a reason as to why the concerns were not addressed. On 01/05/23 at 3:40 p.m., the president of the council was asked if he was allowed to have council meetings without a staff member present. He stated several meetings had been cancelled by social services because there there was no staff member available to attend the meeting. He stated he did not know the council could meet without a staff member present. He stated he would have been having council meetings if he had known there did not have to be staff members present. On 01/05/23 at 4:03 p.m., the social service director was asked why the council had not been having meetings on a regular basis and why their concerns had not been addressed. She stated she would schedule a council meeting but if she was not available, then she would cancel the meeting. She also said she would speak to the department head about any concerns that the council had but did not have any documentation related to the responses.

Based on observation and interviews, the facility failed to provide mail delivery to residents on Saturdays. The Resident Census and Conditions of Residents identified 56 residents who resided in the facility. Findings: On 01/05/23 at 1:33 p.m., a group meeting was held with nine alert and oriented residents. They all agreed the mail came to the facility but did not get distributed every day and especially not on Saturdays. They stated the mail is distributed by social services. On 01/05/23 at 2:48 p.m., social services was observed delivering the mail to residents. On 01/05/23 at 4:03 p.m., the social services director stated the mail usually came to the facility and they would put it in her mail slot. She stated she then would separate the mail by resident and deliver the mail to the residents on the days she is schedule to work, when she had time.

Based on record review and interview, the facility failed to ensure MDS assessments accurately reflected the residents' status for 2 (#12 and #33) of 18 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: 1. Res #33 had diagnoses which included dementia and delusional disorder. A significant change assessment, dated 11/09/22, documented the resident was severely impaired with cognition and required extensive to total assist with activities of daily living. The assessment documented the resident had no behaviors and received an antipsychotic medication. The assessment documented the resident had a physician documented contraindicated GDR on 10/26/22. The resident's medical record did not document a contraindication for a reduction of the antipsychotic medication on 10/26/22. On 01/06/23 at 1:37 p.m., MDS coordinator #1 stated she got the date in October from a mental health progress note which documented to continue current medication. 46909 2. Res #12 had a physician order, dated 06/21/22, for clopidogrel bisulfate (an antiplatelet medication) 75 mg daily related to atherosclerosis of arteries of left leg with ulceration of calf. A quarterly MDS assessment, dated 10/14/22, documented the resident received an anticoagulant medication. On 01/07/23 at 10:28 a.m., the MDS coordinator #1 stated she thought that Plavix (clopidogrel bisulfate) and was on the list to code as anticoagulants.