Based on record review and interview, the facility failed to perform an assessment and notify the physician of a dislodged PEG tube for one (#5) of three sampled residents reviewed for feeding tubes. The DON identified three residents in the facility with feeding tubes. Findings: Resident #5 had diagnoses which included dysphagia and dementia. A care plan intervention, initiated 01/09/24, documented to monitor document and report any signs or symptoms of the tube becoming dislodged, infection, or malfunction of the feeding tube. A nurse's note, dated 01/12/24 at 7:55 p.m., documented Resident #5 pulled the PEG tube out approximately 2 inches and the nurse was unable to replace the PEG tube. It was documented they passed the information to the night nurse to report it to the day nurse. There was no documentation Resident #5 five was assessed or the physician notified. A nurse's note, dated 01/13/24 at 7:29 a.m., documented the nurse assessed Resident #5 and sent them to the hospital for evaluation and treatment. On 09/19/24 at 7:54 a.m., agency nurse #2 stated if a resident dislodged their PEG tube they should be assessed, and the physician should be notified. On 09/19/24 at 8:02 a.m., LPN #1 stated if a resident pulled out their PEG tube the physician should be notified, and the resident should be assessed. On 09/19/24 at 8:44 a.m., LPN #2 stated the physician should be notified and the resident should be assessed immediately. They stated it was not appropriate to just pass it on to the next shift to take care of. On 09/19/24 at 9:27 a.m., the DON stated if a PEG tube was pulled out the expectation was the physician would be notified immediately, and the resident assessed.

Based on record review and interview, the facility failed to ensure a care plan was revised after a resident with a history of elopement attempts was observed by staff opening the facility's locked lobby door for one (#25) of twelve residents reviewed for care plan accuracy. A facility Midnight Census Report, dated 08/10/24, documented 39 residents resided at the facility. Findings: An undated facility policy Monroe Manor Care Plan Policy, read in part, A comprehensive care plan must be developed within 7 days after the completion the comprehensive assessment and is periodically reviewed and revised by a team of qualified persons after each assessment. Resident #25 had diagnoses which included dementia. A care plan focus located in Resident #25's care plan, dated 05/20/24, read in part, I am an elopement/wanderer (SPECIFY) risk r/t History of attempts to leave facility unattended. The goal connected to the elopement focus was for the resident to remain safe through the next review date and was dated 05/20/24 with a revision date of 08/08/24. There were two interventions attached to the focus. One intervention to assess the resident for falls and a second intervention to attempt to identify the reason the resident attempted to elope. Each intervention was dated 05/20/24. A progress note, dated 06/29/24, documented the resident had been observed by staff attempting to depart the facility through the locked front door. On 08/12/24 at 10:10 a.m., MDS Coordinator #1 stated they did not see how the elopement intervention to assess the resident for falls had any usefulness regarding elopement. They stated the care plan focus for elopement had not been revised following the resident opening the locked door on 06/29/24. On 08/12/24 at 1:19 p.m., CNA #3 stated they had been sitting outside the facility on the date Resident #25 opened the front lobby door. They stated they had heard the alarm for the front lobby door go off and the door open. They stated they could see Resident #25 open the door and then a staff member inside the facility pull their wheelchair back into the lobby. They stated the resident did not exit the building and staff were nearby the resident and responded to the alarm. On 08/14/24 at 10:02 a.m., the DON stated the facility had done interventions following the attempted elopement but had not documented them. They stated they need to do a better job of care planning.

Based on record review and interview, the facility failed to ensure influenza vaccinations were offered for two (#32 and #34) of five residents reviewed for immunizations. The administrator reported the census was 39. Findings: An undated Influenza and Pneumonia Immunization Policy read in part, .All residents, staff and volunteers will be offered the influenza vaccine annually .For resident immunizations, documentation of the administration of the vaccine, including education, type of vaccine, lot number and injection site will be documented in the residents' clinical record . 1. Resident #32 had diagnoses which included diabetes mellitus and hypertension. A review of Res #32's immunization record did not document the resident had received or been offered a flu vaccination. 2. Resident #34 had diagnosis which included cerebral palsy and hypertension. A review of Res #34's immunization record did not document the resident had received or been offered a flu vaccination. On 08/14/24 at 9:56 am, the infection preventionist stated no documentation regarding Res #32 or Res #34's vaccination status had been located.

Based on record review and interview, the facility failed to: a) Ensure side effect monitoring was in place for one (#20) of five residents reviewed for unnecessary medications. b) Ensure PRN psychotropic medication orders are limited to 14 days for one (#26) of five residents reviewed for unnecessary medications. c) Ensure a gradual dose reduction recommendation was addressed by the physician for one (#9) of five residents reviewed for unnecessary medications. The DON identified 29 residents in the facility receiving psychotropic medications. Findings: 1. Resident #20 had diagnoses which included major depressive disorder and insomnia. A care plan intervention, implemented 04/08/22, documented Res #20 was to be given psychotropic medications as ordered and monitored for side effects every shift. A care plan intervention, implemented 11/28/23, documented Res #20 was to be given antidepressant medications as ordered and monitored for side effects every shift. An annual assessment, dated 05/25/24, documented the resident routinely received antipsychotic medication and an antidepressant medication. A review of Res #20's medical records did not document they were being monitored every shift for side effects. On 08/13/24 at 11:32 am, LPN #1 stated side effect monitoring should be documented in the TAR. On 08/13/24 at 12:27 pm, the DON stated they would update Res #20's medical record to include the appropriate side effect monitoring every shift. On 08/14/24 at 8:00 am, LPN #2 stated side effect monitoring for antidepressants and psychotropics should be documented in the TAR. 2. Resident #26 had diagnoses which included anxiety disorder and depression. A quarterly assessment, dated 06/27/24, indicated Res #26 received an antianxiety medication. A physician's order, dated 05/17/23, documented the resident was to receive diazepam (an antianxiety medication) 5mg by mouth PRN every 24 hours. The order did not have a stop date. On 08/13/24 at 11:32 am, the DON stated they were unsure why the order was PRN or why it was ordered for more than 14 days. 3. Resident #9 had diagnoses which included major depressive disorder. An active medication order, dated 11/08/24, documented Resident #9 was to be administered Latuda [an antipsychotic medication] 60 mg once each day at bedtime. A document from the facility's contracted pharmacy, titled Consultant Pharmacist's Medication Regimen Review Active Recommendations Lacking a Final Response, dated 01/29/24, documented Resident #9 had been taking Latuda 60 mg at bedtime since May of 2023. It further documented a pharmacist recommended the resident's physician evaluate the current dose and consider a dose reduction to 40 mg at bedtime. The document further stated there had been no response from the physician. On 08/13/24 at 2:39 p.m., the administrator stated they had called the pharmacy and reviewed their documentation at the facility in regards to the pharmacist's dose reduction recommendation of 01/29/24. They stated they had found no documentation the physician had responded. On 08/14/24 at 10:00 a.m., the DON stated the physician had not followed policy regarding responding to pharmacy recommendations. They stated if a resident did not get a proper dose it could effect them negatively.

Based on observation and interview, the facility failed to ensure an unlocked container of ice was not utilized by residents and visitors. A facility Midnight Census Report, dated 08/10/24, documented 39 residents resided at the facility. Findings: An undated facility Ice Machine / Ice Chest Safety policy, read in part, All employees will use sanitary methods to obtain ice for themselves and for elders and visitors from any ice machine or ice chest. the policy further read in part, Only employees may obtain ice if the use of an ice scoop is needed. On 08/11/24 at 9:51 a.m. a ice chest was observed in the hallway across from the nurses station. The container was full of ice, had an ice scoop located next to it, and there was no lock on the container. On 08/13/24 at 7:33 a.m. a ice chest was observed in the hallway across from the nurses station. The container was full of ice, had an ice scoop located next to it, and there was no lock on the container. On 08/13/24 at 7:35 a.m., CNA #1 stated the ice in the chest was for anyone who needed it. They stated the residents can get their own ice it they want it. On 08/13/24 at 7:42 a.m. CNA #4 stated the ice chest was for staff to give to residents but there was nothing stopping residents or visitors from getting the ice themselves. On 08/13/24 at 7:45 a.m., CNA #3 stated the ice chest was for residents. They stated they had seen family members and resident get ice out of the container. On 08/13/24 at 7:48 a.m., a resident was observed getting ice from the ice chest and putting it into a cup. They stated they always get ice from the container. The resident used the ice scoop but their hand did touch the ice repeatedly. On 08/13/24 at 10:14 a.m., the dietary manager stated they place the ice in the container for the staff to pass out to resident. They stated the residents should not be getting their own ice from the container. On 08/13/24 at 10:14 a.m., the DON stated it was an infection control issue for residents and visitors to get ice from the cooler. On 08/14/24 at 9:41 a.m., the DON stated the staff allowing resident and visitors to get ice from the ice chest were not following infection control standards or facility policy.

Based on observation, interview and record review, the facility failed to: a) Have a system of surveillance and monitoring designed to identify and prevent Legionnaire's disease. b) Implement a policy and procedure related to enhanced barrier precautions. C) Ensure that infection control practices were followed during wound care for two (#32 and #15) of two residents reviewed for wound care. The administrator reported the census was 39. Findings: 1. On 08/13/24 at 11:40 am, the maintenance supervisor stated they were not aware of any monitoring of the water system related to Legionnaire's disease. On 08/14/24 at 9:56 am, the infection preventionist stated they did not have a program in place to prevent Legionnaire's disease. On 08/14/24 at 10:07 am, the DON stated they needed to implement a water management program at the facility. 2. Resident #32 had diagnoses which included pressure ulcer of the sacral region and diabetes mellitus. On 08/13/24 at 1:20 pm, CNA #1 was observed providing catheter care for Res #32, CNA #1 was not wearing a gown. On 08/13/24 at 2:40 pm, the DON was observed providing wound care for Res #32, the DON was not wearing a gown. On 08/13/24 at 2:40 pm, the DON was observed providing wound care for Res #32. During the procedure, the DON was observed to remove soiled gloves and don clean gloves seven times. On all seven occasions, the DON failed to perform hand hygiene before donning the clean gloves. On 08/14/24 at 7:30 am, RN #1 stated the facility did not use enhanced barrier precautions, and hygiene should be performed before putting on gloves and after removing gloves. On 08/14/24 at 8:00 am, LPN #2 stated they were not familiar with enhanced barrier precautions. On 08/14/24 at 10:07 am, the DON stated they were not using enhanced barrier precautions. On 08/14/24 at 8:00 am, CNA #2 stated hand hygiene should be performed when changing gloves. On 08/14/24 at 10:07 am the DON stated hand hygiene should be performed when changing gloves. 3. Resident #15 had diagnoses which included a stage four pressure ulcer of the sacral region [area of the lower back at the bottom of the spine]. A facility Skin Observation Tool, dated 07/27/24, documented Resident #15 had a stage four pressure ulcer located at the sacral region of their back. On 08/11/24 at 1:09 p.m., Resident #15 stated they did not think the staff changed the bandages on their pressure ulcers as ordered. On 08/12/24 at 2:58 p.m., LPN #1 was observed as they provided wound care to Resident #15. LPN #2 assisted LPN #1 by providing support to the resident during the care. During the wound care Resident #15 required a break and was resting on their back. After the break LPN #1 was observed to grasp the bed pad, that was under the resident's back and buttock, with their gloved hands to assist the resident back onto their side. After the resident was positioned LPN #1 obtained the packing materiel to be used in the sacral pressure wound without first cleaning their hands and changing their gloves. LPN #1 then proceed to pack the material into the wound. On 08/13/24 at 11:37 a.m., LPN #1 stated they had not been 100% confident about the wound care on 08/12/. They stated they believed they should have changed gloves more often. She stated she should have change gloves after touching the bed pad. On 08/14/24 at 10:05 a.m., the DON stated LPN #1 should have change their gloves between making contact with the bed pad and then handling the packing material. They stated LPN #1 had not been following standards of care and facility policy.

Based on record review and interview, the facility failed to ensure a resident experiencing pain received treatment for pain for one (# 1) of four residents reviewed for pain. The administrator reported the census was 38. Findings: Resident #1 had diagnoses which included aftercare following joint replacement surgery and osteoarthritis. A baseline care plan, dated 06/27/24 at 12:34 pm, documented the residents pain level was an eight. A nurse note, dated 06/27/24 at 1:08 pm, documented Resident #1's left knee was swollen, and the resident rated their pain at an eight out of ten. A physician's order, dated 06/27/24 at 1:45 pm, documented Resident #1 could have oxycodone-acetaminophen (a pain medication) 7.5/325mg every six hours as needed for pain. The treatment administration record for June documented the resident received pain medication on 06/28/24 at 3:30 am. A review of the clinical record did not document the physician was contacted regarding the resident's pain level, or that any non-pharmacological interventions had been attempted. On 07/23/24 at 1:00 pm, RN #1 stated the physician should have been contacted or the pharmacy should have been contacted to expedite the medications. On 07/23/24 at 1:05 pm MDS Coordinator #1 stated that the physician should have been contacted or nursing interventions like positioning or ice packs should have been attempted. On 07/23/24 at 1:25 pm, the Administrator stated they were unable to locate a policy related to pharmacy services or pain management. They also stated the medication was not available until the pharmacy company delivered it around 3:00 am.

Based on record review and interview, the facility failed to report an allegation of abuse to the Oklahoma State Department of Health within the mandated time frame for one (#1) of three sampled resident reviewed for abuse. The DON reported the facility had a census of 39 residents. Findings: A facility policy titled, Prevention and Reporting of Abuse, Neglect, and Misappropriation of Resident Property, read in part, When possible the facility shall notify the State Department of Health within 12 hours of the incident. An incident report fax cover sheet documented a combined initial and final incident report regarding an allegation of verbal abuse by Resident #1 was faxed to OSDH on 05/20/24. The incident report documented the incident had occurred on 05/09/24. On 05/28/24 at 11:59 a.m., the DON stated they had witnessed a verbal interaction between Resident #1 and CMA #1 on 05/09/24. They stated the resident did not report feeling abused at that time and they did not believe what they had seen was abuse. They stated on 05/10/24 they received a phone call from the BOM who informed them that Resident #1 had reported they had been verbally abused. The DON stated they were on leave and informed the BOM the administrator would need to be informed and something needed to be done about the situation. They stated they reported back to work on 05/13/24. On 05/28/24 at 1:30 p.m. the Administrator stated that on 05/10/24, Resident #1 had informed them that they had been verbally abused by staff on 05/09/24. They stated they did not report the allegation to OSDH at that time as they believed the DON would do so when they returned from leave on 05/13/24. They stated they did not meet the 24-hour time limit for reporting. On 05/28/24 at 1:33 p.m. DON stated they sent an incident report to OSDH about the incident of 05/09/24 on 05/20/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to investigate an allegation of abuse and suspend an alleged perpetrator during the time of an investigation into the alleged abuse, for one (#1) of three sampled resident reviewed for abuse. The DON reported the facility had a census of 39 residents. Findings: A facility policy titled, Prevention and Reporting of Abuse, Neglect, and Misappropriation of Resident Property, read in part, It is the policy of [NAME] Manor to thoroughly investigate all allegations concerning resident abuse, neglect, and misappropriation of resident property, and to prevent further potential abuse, neglect, and misappropriation pending an investigation. An incident report, dated 05/20/24, documented an allegation of abuse by Resident #1 that allegedly occurred on 05/09/24. On 05/28/24 at 11:59 a.m., the DON stated they had witnessed a verbal interaction between Resident #1 and CMA #1 on 05/09/24. They stated the resident did not report feeling abused at that time and they did not believe what they had seen was abuse. They stated they did instruct CMA #1 and the nurse on duty that CMA #1 was not to work with Resident #1 after that day. They stated CMA #1 continued to work with other residents as usual and had not been suspended at any point since the incident. They stated on 05/10/24 they received a phone call from the BOM who informed them that Resident #1 had reported they had been verbally abused. The DON stated they were on leave and informed the BOM the administrator would need to be informed and something needed to be done about the situation. They stated they reported back to work on 05/13/24. They stated they believed an investigation had never been done. On 05/28/24 at 1:30 p.m., the Administrator stated that on 05/10/24 they and the BOM had visited with Resident #1 and the resident stated they had been verbally abused by staff. They stated they did perform an investigation at that time because they believed DON would do so when they returned from leave. They stated CMA #1 had not been suspended because the DON had previously instructed CMA #1 not to work with Resident #1 and after speaking with staff believed the CMA had followed those instructions. On 05/28/24 Aa 1:33 p.m. DON stated they sent an incident report to OSDH about the incident of 05/09/24 on 05/20/24. They stated they had not interviewed other residents about their interactions with CMA #1 or knowledge of the reported incident of 05/09/24. They stated an investigation should be conducted and the CMA should have been suspended during an investigation.

Based on observation, record review, and interview, the facility failed to notify a resident's physician after a significant loss of weight for one (#2) of three sampled residents reviewed for weight loss. A Resident Listing Report documented 39 residents resided in the facility. Findings: A facility weight policy, undated, documented a resident's weights were to be taken according to the physicians' orders. Resident #2 had diagnoses with included Alzheimer's dementia, nutritional anemia, acquired absence of parts of the digestive tract. A care plan focus, dated 08/22/23, documented the resident had unplanned weight loss related to poor food intake. The care plan had related interventions, dated 08/22/23, that if weight loss continued staff were to contact the physician and dietitian immediately, and if poor consumption over a 48-hour period, the nutritionist would be alerted. A Weights and Vitals Summary document for Resident #2 documented the resident weights 120 lbs. on 12/28/23, 114 lbs. on 01/16/24, 104 lbs. on 01/23/24, and 107 lbs. on 01/25/24. On 01/30/24 at 1:31 p.m., Resident #2 stated they were not aware of weight loss but would appreciate help eating. At 2:59 p.m., the DON stated the physician had not been made aware of the resident's significant weight loss in January 2024. They stated the physician should have been notified.

Based on observation and interview, the facility failed to ensure the dignity of a resident was protected for one (#1) of three residents sampled for dignity. The administrator reported the census was 38. Findings: An undated policy titled Resident Rights Policy read in part, .Each resident has a right to a dignified existence, self-determination and exercise of his/her rights .The right to reside in and receive services of the facility with reasonable accommodation of individual needs, maintain quality of life, enhance dignity . Resident #1 had diagnoses which included cirrhosis of the liver and frequent falls. On 01/17/24 at 8:30 a.m., the resident was observed laying on the floor in his room, naked on a fall mat. The door to his room was open and Resident #1 was clearly visible from the hallway. Staff and other residents were observed walking up and down the hallway. On 01/17/24 at 12:32 p.m., Resident #1 was observed laying on the floor in his room, naked on a fall mat. The door to his room was open and Resident #1 was clearly visible from the hallway. Staff and other residents were observed walking up and down the hallway. On 01/17/24 at 2:22 p.m., the resident was observed laying on the floor in his room, naked on a fall mat. The door to his room was open and Resident #1 was clearly visible from the hallway. Staff and other residents were observed walking up and down the hallway. On 1/18/24 at 1:30 p.m., CNA #6 stated the resident should not have been exposed like that. On 1/18/24 at 1:35 p.m., CNA #3 stated the resident was noncompliant, but they should do better protecting the resident's dignity. On 1/23/24 at 4:15 p.m., the DON stated steps should have been taken to protect the resident's dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement interventions to prevent falls/ minimize injuries for one resident (#1) of three sampled residents reviewed for falls. Resident #1 had 15 falls over 50 days. The last fall resulted in Resident #1 sustaining a facial laceration, hematoma, and their second subdural hematoma related to falls. The administrator reported the facility census was 38. Findings: An undated Fall Prevention Policy read in part, .The care plan will state the goals, interventions and approaches for every resident who is identified as being at risk for falls .The falls prevention approaches will be evaluated by the QA committee to determine the effectiveness of the approaches. With the recommendations of the committee, changes will be implemented to reduce fall risk in the facility. Resident #1 had diagnoses which included history of falls and depression. A Morse Fall Scale, dated 11/25/23, documented a score of 80 which indicates a high risk for falling. An admission MDS, dated [DATE], documented the resident had a history of falls prior to admission. A fall note, dated 11/29/23 at 7:33 p.m., documented the resident was found on the floor near the bed. The note also documented that the resident was reminded to use his call light and that an assessment was conducted, and the resident was without injuries. A fall note, dated 11/30/23 at 9:33 a.m., documented the resident was found on the floor and the resident reported weakness in his legs. No interventions we documented. A fall note, dated 11/30/23 at 2:44 p.m., documented Resident #1 one was found in the floor, it further documented they were trying to go to the bathroom and that Resident #1 was reminded to use the call light. A fall note, dated 12/03/23 at 10:30 p.m., documented the resident was found on floor in bathroom and found to have a large hematoma to top of head, neuro checks were started. The note further documented the resident was educated to wear non-slip socks and use the call light. A fall note, dated 12/07/23 at 11:00 p.m., documented the resident was found on the floor, an assessment was conducted, and the resident was instructed to use the call light for assistance. A fall note, dated 12/11/23 at 12:46 p.m., documented the resident was found on the floor by the bed. The note also documented redness to left side and mid back was noted and the resident was reminded to use the call light for assistance. An unwitnessed fall report, dated 12/13/23, documented the resident was found on the floor in his room. The fall report document read in part .resident was lying on floor acting like he was trying to get up by grabbing his left leg and then he would start dropping his head back and hitting the back of his head on the floor. This nurse tried several times to get his attention and get him to focus, which he could not. Checked head to toe even when he was throwing his arms and legs. Resident does have knot on the back of his head .resident did not respond to neuro checks .by the time the ambulance arrived resident was in bed snoring like breathing but still not waking and responding to commands and physical or verbal stimuli . No new interventions were documented. A physician order, dated 01/06/24, documented Resident #1's bed was to be in the lowest position. A fall note, dated 01/06/24 at 10:47 a.m., documented the resident was found on the floor and the resident was encouraged to use call light. The note also documented staff were to visit often, no documentation of frequent visits was provided. A fall note, dated 01/07/24 at 9:27 p.m., documented the resident was found on the floor in the bathroom with a large knot noted to back of the resident's head. The note also documented that the resident was reminded to use the call light. A fall note, dated 01/09/24 at 9:24 p.m., documented the resident was found on the floor and was in extreme pain. The note further documents the resident was sent to the emergency room for treatment. No interventions were documented. A nurse note, dated 01/09/24 at 9:35 p.m., documented the resident's family had called and stated the resident had been sent to the hospital with a brain bleed. A nurse note, dated 01/12/24 at 5:50 p.m., documented the resident was readmitted to the facility with a diagnosis of a subdural hematoma. The note further documented the resident was intermittently confused and reminded to use the call light. A fall note, dated 01/14/24 at 00:00 a.m., documented the resident was lying in front of the bathroom door, with scattered bruising to both arms and legs and a new abrasion on the left side. The note further documents that Resident #1 refused to go the ER and that the resident was reminded to use the call light. A fall note, dated 01/15/24 at 9:40 a.m., documented the resident had fallen and was lying on the floor. The note also documented the resident was reminded to use the call light and wear nonslip footwear. A fall note, dated 01/15/24 at 3:30 p.m., documented the resident was found on the floor with no injury. The note further documented the resident would receive frequent visits from staff. Documentation of frequent visits was requested but not received. A fall note, dated 01/15/24 at 11:15 p.m., documented the resident fell with no injuries. No interventions were documented. A care plan updated 01/17/24, documented to refer to the at-risk plan for interventions. On 01/17/24 at 10:00 a.m., the DON stated the resident was too noncompliant for an at-risk plan. On 01/17/24 at 10:30 a.m., The MDS coordinator stated that Resident #1 does not have an at-risk plan and the facility no longer uses them. They also stated they should stop putting them in the care plan. On 01/17/24 at 1:21 p.m., the DON stated none of the interventions they have put in place for Resident #1 were effective. They also stated that the resident is declining rapidly and does not understand how to use a call light. A fall note, dated 01/18/24 at 5:57 a.m., documented the resident was found on the floor with a hematoma and a cut above the right eyebrow. The note further documented EMS was notified to transfer resident to the ER. A nurse note, dated 01/18/24 at 10:33 a.m., documented the resident was being sent from the ER to another hospital due to a second brain bleed.

Based on record review and interview, the facility failed to ensure a dependent resident received baths for one (#37) of three sampled residents for bathing. The Resident Census and Conditions of Residents, dated 07/11/23, documented 39 residents required assistance with showers/baths. Findings: Res #37 was admitted with diagnoses which included Parkinson's disease and dementia. A care plan, dated 05/24/23, documented Res #37 required the assistance of one for bathing. An MDS assessment, dated 06/05/23, documented Res #37 had impaired cognition and required assistance with bathing. A TAR, dated 05/24/23 through 07/13/23, documented 12 missed opportunities for baths. On 07/13/23 at 1:39 p.m., CNA #3 was asked how often Res #37 should have received baths. They stated, every other day. CNA #3 was asked if there was documentation of the resident refusing baths or a reason Res #37 did not receive baths as scheduled. They stated, Not that I'm aware of. On 07/13/23 at 1:48 p.m., the DON was asked about the schedule for bathing Res #37. The DON stated Res #37 was scheduled for baths on Mondays, Thursdays, Saturdays, and PRN. The DON was asked how many baths Res #37 had received from 05/24/23 through 07/13/23. The DON stated baths were documented on 5/24/23, 05/29/23, 06/07/23, 06/29/23, 07/03/23, 07/06/23, and 07/13/23. The DON was asked if Res #37 had received baths as scheduled and stated, by the documentation, no. The DON was asked how many missed opportunities there were for baths since 05/24/23. The DON stated there were 12 missed baths and no refusals were documented. The DON was asked if the bathing schedule for Res #37 had been followed. The DON stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent: a. burns from hot coffee for two (#13 and #17) and b. falls for one (#37) of four residents reviewed for accidents. The Matrix for Providers documented 14 residents had fallen in the past 12 months and DON identified two residents had been burned from hot coffee within the past 12 months. Findings: 1. Res #13 was admitted with diagnoses which included chronic pain and obesity. A quarterly assessment, dated 05/17/23, documented Res #13 was cognitively intact and able to eat independently. An Incident Report Form, dated 06/02/23, documented Res #13 had a hot coffee burn to the right anterior and posterior thigh. The form documented redness was noted at the the time of the incident and later in the day blisters had formed. A blister on the posterior thigh measured 14 cm x 1.5 cm and a blister on the anterior thigh measured 15 cm x 2 cm. The form documented Res #13 was instructed to ask for assistance when obtaining coffee. On 07/11/23 at 1:58 p.m., Res #13 reported they had spilled coffee on their lap on 06/02/23. The resident reported later in the day, a blister had formed on the back of their thigh. Res #13 also reported the burn was painful and staff continued wound care. The resident reported another resident was burned with coffee several months prior. Res #13 reported they no longer drank coffee due to the burn. Res #13 also reported they were not aware of any changes made by the staff to prevent burns from hot coffee. 2. Res #17 was admitted with diagnoses which included dementia. A quarterly assessment, dated 04/04/23, documented Res #17 was severely impaired with cognition and required setup assistance with feeding. A progress note, dated 04/04/23, documented Res #17 burnt self with hot coffee. The note documented ice was applied to the resident's hands which the resident tolerated for a small time, then refused. The progress note documented the resident was taken back to the dining room for coffee at the resident's request. On 07/12/23 at 7:25 am, the CDM was asked about the policy for serving hot coffee to dependent residents. The CDM stated, Usually if it's a dependent residence we cool it and serve it with a lid. All other residents get it however they ask. The CDM stated they were not sure about the policy. On 07/12/23 at 8:30 a.m., Res #17 was observed drinking coffee from a cup without a lid in the dining room. On 07/12/23 at 10:00 a.m., the DM reported the vendor had adjusted the temperature of the coffee after Res #17 was burned. The DM also reported there was no documentation to show the coffee temperature had been adjusted. On 07/12/23 at 1:30 p.m., the DON reported the progress note, dated 04/04/23, was the only documentation available for Res #17's incident with coffee. The DON reported they were not aware of interventions implemented to prevent coffee burns. On 07/12/23 at 2:00 p.m., the administrator reported they were not aware of interventions implemented to prevent burns from hot coffee. The administrator also reported the facility did not have a policy for hot liquids and did not conduct hot liquid safety assessments. 3. A facility fall prevention policy, undated, read in part, .It is the policy of [NAME] Manor to identify residents at risk for falls, and to implement a fall prevention approach to reduce the risk of falls and possible injury .Staff will be trained to be alert to risk and hazards for fall in the environment . Res #37 was admitted with impaired cognition and diagnoses which included Parkinson's and dementia. A care plan, dated 05/24/23, read in part, .I am a high risk for falls r/t Gait/balance problems. Unaware of safety needs .Be sure my call light is within reach and encourage me to use it .Educate me/my family about safety reminders . A resident assessment, dated 06/05/23, documented Res #37 had a history of falling, required one person physical assistance with transfers and ambulated with a walker or a wheel chair. A review of records documented Res #37 had fallen nine times without injury, from 05/26/23 to 07/13/23, (06/01/23, 06/10/23, 06/16/23, 06/17/23, 06/21/23, 07/06/23, and 07/13/23) and once with injury on 06/23/23. A review of the care plan and physician's orders did not document new fall prevention interventions since 05/24/23. On 07/12/23 at 2:35 p.m., LPN #2 was asked about Res #37's falls. LPN #2 stated Res #37 fell because they transferred without asking for assistance. The LPN stated, We can't redirect and remind or re-educate because of memory issues because they won't remember. On 07/13/23 at 7:13 a.m., LPN #1 was asked why Res #37 had frequent falls. LPN #1 stated Res #37 was very independent. They also stated Res #37 would try to sit up, scooted too far, and slid onto the floor. LPN #1 was asked what interventions were in place to prevent falls for Res #37. The LPN stated they would remind the resident to use the call light and wait for assistance. On 07/13/23 at 2:11 p.m., the DON was asked how many times Res #37 had fallen since 05/24/23. The DON stated Res #37 had fallen ten times. The DON was asked to review the care plan for documentation of new fall prevention interventions since 05/24/23. The DON stated there were no new fall prevention interventions documented in the care plan. The DON was asked what interventions had been implemented to prevent falls. The DON stated Res #37 should have had a fall mat. The DON was asked to review the care plan for a fall mat. The DON stated there was not a care plan intervention for a fall mat. The DON was asked how staff would know to use a fall mat if it wasn't care planned. The DON stated, They would not know. The DON was asked about the root cause of Res #37's frequent falls. The [NAME] stated Res #37 would forget to use their special walker and wheel chair, and try to walk. The DON was asked if redirecting and re-educating the resident about call lights were effective interventions. The DON stated, they wouldn't remember. On 07/13/23 at 2:29 p.m., the DON walked to Resident #37's room with the surveyor. The bed was observed in the highest position and no fall mat was present. The DON stated a fall mat should have been in place and the bed should have been in the lowest position. The DON stated there was no documentation in the EHR, therefore staff would not know to lower the bed or use the fall mat.

2. Resident #34 had diagnoses which included Parkinson's disease and muscle weakness. A physician order, dated 07/18/20, documented the resident was to have restorative nursing for splint placement on his right hand daily, range of motion 3-5 times a week, and ambulation 3-5 times a week with the walk to dine program. A physician progress note, dated 10/23/20, documented the resident needed range of motion of bilateral arms and shoulders and restorative services. Review of the ADL sheets and progress notes in the electronic record for February 2021 did not reveal documentation for restorative services. A quarterly assessment, dated 03/20/21, documented the resident was severely impaired in cognition, had not received restorative nursing services or utilized a splint/device during the look back period. A care plan, updated 03/22/21, documented the resident had Parkinson's disease. An intervention documented, .Encourage/provide gentle range of motion as tolerated with daily care . Review of the ADL sheets and progress notes in the electronic record for March 2021 did not reveal documentation for restorative services/range of motion. On 04/06/21 at 10:04 a.m., the resident was observed in his room sitting in his chair. His right hand was observed to not have full range of motion. A splint or device was not observed to be in use. On 04/07/21 at 8:46 a.m., the resident was observed in the TV room. A splint or device was not observed to be in use for his right hand. On 04/08/21 at 11:14 a.m., the DON was asked for documentation the resident had received restorative nursing services as ordered by the physician. She stated the order was placed in the electronic medical record but there was not documentation to support restorative services had been completed as ordered. She stated they had just updated the care plan. She stated the resident refused the splint at times. She was asked where refusal of the splint was documented. She stated she would look for documentation. On 04/08/21 at 1:34 p.m., the restorative aide was asked what restorative services were provided for resident #34. She stated the resident had a splint for his right hand, but he would not use it much and at times refused it. She was asked where she had documented the resident had refused the splint. She stated she had not documented the refusal of the splint because she had worked the floor as a CNA several times recently. A care plan, updated 04/09/21, documented the resident required restorative therapy. An intervention documented, .Restorative nursing for splint placement on right hand daily, ROM 3-5x weekly . On 04/09/21 at 9:05 a.m., the DON stated the restorative aid kept restorative notes in a notebook. She stated she would review the restorative sheets. On 04/09/21 at 11:02 a.m., the MDS coordinator stated an order for restorative was in the electronic medical record but had not been implemented with a schedule for documentation. She stated they had no documentation restorative services had been provided. By the end of the survey, documentation had not been provided regarding completion of restorative services for the resident. Based on observation, interview, and record review, it was determined the facility failed to ensure restorative therapy was performed for two (#27 and #34) of two sampled residents whose records were reviewed for restorative therapy. 1. Resident #27 had a diagnosis of quadriplegia. The March 2021 order summary report was reviewed. A physician's order designated as active, dated 08/13/18, documented the resident was to have restorative nursing perform range of motion therapy for both upper and both lower extremities 3 (to) 5 times each week. A review of the March 2021 MAR and TAR found no documentation that restorative therapy had occurred that month. A review of a documentation survey report for March 2021 found no documentation that restorative therapy had occurred that month. It did document the initials NA for the term non applicable had been entered on four dates that month. An annual assessment, dated 03/06/21, documented the resident's cognition was intact, required total assistance for activities of daily living, had impairment to all extremities, and had received restorative therapy on one day of the seven day look back period. The April 2021 order summary report was reviewed. A physician's order designated as active, dated 08/13/18, documented the resident was to have restorative nursing perform range of motion therapy for bilateral upper and lower extremities 3 - 5 times each week. A review of the April 2021 MAR and TAR from the date of 04/01/21 to 04/09/21 found no documentation that restorative therapy had occurred during that time period. A review of a documentation survey report for April 2021 from the date of 04/01/21 to 04/09/21 found documentation that restorative therapy had been offered on two of those nine dates. It also documented the initials NA for the term non applicable had been entered on one date during that time period. On 04/07/21 at 10:11 a.m. the resident was observed in a resident common area in the company of family and staff. The resident's arms were visible and had appeared to have possible contractures at the elbows, wrists, and hands. On 04/08/21 at 9:23 a.m., the resident was observed in his assigned room in bed. Observations of the resident's extremities found them bent at the joints but able to be easily extended by the staff. No skin issues were observed. At 9:27 a.m. RN #1 was asked if the resident had been receiving any therapy related to his condition. He stated the resident had received passive ROM. He was asked who performed that task. He stated it was a task the nurse aides did when they provided the resident care. He further stated that the facility did have a designated restorative aide but that person had been working mostly on other duties related to general care. At 10:30 a.m. CNA #2 was asked what care the resident received. She stated he received passive ROM. She was asked who performed that task. She stated it was the nurse aids and that she had done so earlier in the day. She was asked where that was documented. She stated the nurses document that as the aides did not have a place to do so in the EMR. She was asked to show this surveyor the nurse aide screen in the EMR. She did so and a place to document ROM was on the screen. She appeared surprised and then acknowledged that it was possible for the aides to chart ROM but she had not done so. At 10:53 a.m. RN #1 was asked who documented the ROM when it had been done. He stated it was the person who did it and that would have been a CNA. He was informed of the lack of documentation and then stated he had been unaware it was not being done. He was asked who was responsible for ensure the CNA's work was done and documented. He stated the nurses who supervise them. At 11:23 a.m. the DON was shown the lack of documentation in the the resident's EMR related to ROM. She acknowledged documentation of ROM having been performed was not present it the chart but should have been.