Every finding on record at Ada Care Center

Based on observation, record review, interview, and facility policy review, the facility failed to ensure:- staff performed hand hygiene between handling soiled and clean items during wound care/dressing changes for 2 (Resident #20 and Resident #44) of 2 residents observed for dressing changes/wound care;- staff performed hand hygiene between providing direct care to 2 (Resident #28 and Resident #24) of 5 sampled residents observed for hand hygiene during care;- staff donned appropriate personal protective equipment (PPE) during care of residents who required enhanced barrier precautions (EBP) for 2 (Resident #34 and Resident #28) of 5 sampled residents reviewed for EBP.- staff performed hand hygiene between residents during food and beverage services for residents who resided on 1 (East Hall) of 3 halls; and,- the laundry area was clean and free of excessive dust and dryer lint, dirty laundry containers were covered, and clean and dirty laundry was separated in 1 of 1 laundry room. This failure had the potential to affect all 40 residents who resided in the facility. Findings included: A facility policy titled, Hand Hygiene, revised 04/10/2025, indicated, All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. The policy further indicated, 7. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. A facility policy titled, Infection Prevention and Control Program, revised 04/02/2025, indicated, 4b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. C. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. A facility policy titled, Enhanced Barrier Precautions, revised 04/10/2025, indicated, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: 'Enhanced barrier precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The policy also specified, 4. High-contact resident care activities include: a. Dressing. b. Bathing. c. Transferring. d. Providing hygiene. e. Changing linens. f. Changing briefs or assisting with toileting. g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC [peripherally inserted central catheter] lines, midline catheters. h. Wound care: any skin opening requiring a dressing. 1. An admission Record revealed the facility admitted Resident #20 on 07/25/2025. According to the admission Record, the resident had a medical history that included diagnoses of basal cell carcinoma of the skin and restless leg syndrome. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2026, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had five venous and/or arterial ulcers and required the application of nonsurgical dressings and ointments/medications to areas other than the feet. Resident #20's Care Plan included a focus area revised on 06/01/2026 that indicated the resident had impairment to skin integrity related to basal cell carcinoma, cellulitis, and fungal infections. Interventions directed staff to refer to on-site wound care for evaluation and treatment as indicated (initiated 07/29/2025) and referral to vascular doctor related to slow healing vascular wounds (initiated on 07/25/2025). Resident #20's Treatment Administration Record for June 2026 indicated the resident was to receive scheduled and as-needed (PRN) skin/wound care as follows:- Dakins (a sodium hypochlorite-based topical antiseptic) 1/4-strength external solution 0.125% - apply to right/left (RT/LT) lower leg and right and left (R&L) foot topically every day shift every Monday, Wednesday and Friday for wound care. Refer to Silvadene order.- MediHoney wound/burn dressing external gel - apply to left lateral lower leg topically as needed for wound care. Start date: 06/01/2026.- Silvadene external cream 1% - apply to right lower leg (RLL), left anterior lower leg ([NAME]), left foot (LF), right foot (RF) topically as needed for wound care. Start date: 06/01/2026. During an observation on 06/02/2026 at 10:18 AM, Licensed Vocational Nurse (LVN) #9 gathered supplies to perform Resident #20's wound care and donned a gown and gloves without first performing hand hygiene. LVN #9 cleaned the resident's bilateral legs with gauze pads moistened with H-Chlor (a sodium hypochlorite-based topical antiseptic) 0.125%, then removed her gloves and donned clean gloves without performing hand hygiene. The LVN used betadine swab sticks then applied Medihoney gel and Silvadene cream to the resident's bilateral legs, then removed her gloves and applied clean gloves without first performing hand hygiene. During an interview on 06/02/2026 at 3:40 PM, LVN #9 stated that she changed gloves between cleaning and applying the different creams. She stated that she was not aware of a need to perform hand hygiene between glove changes and indicated she was not supposed to leave the room during wound care and that no chemicals were allowed in the resident's room. LVN #9 stated she had not been trained and/or expected to do hand hygiene between glove changes. During an interview on 06/04/2026 at 11:47 AM, the Director of Nursing (DON) stated that infection prevention was reviewed at every facility in-service twice a month. She stated that she observed staff to ensure they were doing the right thing. During a follow-up interview at 1:43 PM, the DON stated that she had conducted in-services on handwashing by watching the staff to catch them in real time and re-educate them. During an interview on 06/04/2026 at 3:19 PM, the Administrator stated that staff had been trained and were expected to perform hand hygiene before putting on or taking off gloves and during medication pass. During a follow-up interview at 3:30 PM, the Administrator stated that she monitored the staff for infection control but had nothing written down. She stated there was a performance improvement plan (PIP) related to hand hygiene that started in April for the facility. Review of a document titled, Proper Hand washing Procedures with Return Demonstration, dated 9/25 (it was unclear whether this represented September 25th of an unknown year or September 2025), indicated LVN #9 was observed performing a return demonstration of hand hygiene. LVN #9's signature on the document was also dated 9/25. The document indicated, 2. Appropriate ten second hand washing must be performed under the following conditions: The list of conditions included the following:- e. Before handling clean or soiled dressings, gauze pads, etc. [et cetera].- f. After handling used dressings, contaminated equipment, etc.- j. After removing gloves.The document also indicated, 3. The use of gloves does not replace hand washing. 2. An admission Record revealed the facility admitted Resident #34 on 03/31/2026. According to the admission Record, the resident had a medical history that included diagnoses of chronic kidney disease and benign prostatic hyperplasia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/14/2026, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident had an indwelling catheter Resident #34's Care Plan included a focus area initiated 03/27/2024 that indicated the resident had an indwelling urinary catheter and required assistance with toileting hygiene. Interventions directed staff to use enhanced barrier precautions (EBP) as indicated and to wear at least gloves/gowns when performing high contact resident care activities such as providing hygiene, changing briefs, or performing device care including urinary catheter care (revised 04/07/2026). During an observation on 06/04/2026 at 10:21 AM, Certified Nursing Assistant (CNA) #10 donned a pair of clean gloves and entered Resident #34's room without donning a gown. CNA #10 provided urinary catheter care and applied a clean brief and pants to the resident while wearing gloves and no gown. CNA #10 exited the room and did not perform hand hygiene. At the time of this observation, there was a sign on the door to the room to alert staff of the need for enhanced barrier precautions. The sign indicated everyone must clean their hands, including before entering the room and when leaving the room and that providers and staff must also wear gloves and a gown when providing hygiene, changing briefs or assisting with toileting, and during urinary catheter care. During an interview on 06/04/2026 at 10:31 AM, CNA #10 stated that she had received training upon hire and was expected to perform the tasks outlined on any signage on a resident's door. She stated that she had not seen the EBP signage on the door to Resident #34's room prior to entering the room to perform care. She stated the signage meant that she was expected to put on a gown and gloves when care was performed and to perform hand hygiene when using gloves. During an interview on 06/04/2026 at 1:43 PM, the DON stated that training on EBP was performed recently. She stated that she had spoken to the nurses to have them assist with monitoring to ensure EBP was performed correctly. During an interview on 06/04/2026 at 3:19 PM, the Administrator stated that clinical nursing staff were responsible for the training on EBP, and her expectation was that staff followed the guidelines when caring for residents. 3. An admission Record revealed the facility admitted Resident #44 on 05/28/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure, bipolar disorder, autistic disorder, and ileus. Resident #44's Tide Admission/Re-Admission/Quarterly/Significant Change Assessment - TIDE V2, indicated the facility newly admitted the resident on 05/28/2026. The assessment indicated the resident was alert but was unable to make decisions. The assessment indicated enhanced barrier precautions should be applied due to the presence of wounds or indwelling medical devices. Resident #44's Order Summary Report included a physician's order dated 05/28/2026 for enhanced barrier precautions every shift due to the resident's percutaneous endoscopic gastrostomy (PEG) tube. Resident #44's Care Plan included a focus area initiated 06/01/2026 that indicated the resident required bolus tube feedings four times a day with flushes before and after medications and feedings. During an observation on 06/03/2026 at 9:30 AM, Licensed Vocational Nurse (LVN) #9 wore gown and gloves while cleaning around the resident's PEG tube and applying a clean split-gauze dressing. She then removed her gloves and gown and exited the room without performing hand hygiene. LVN #9 then donned a clean gown and a pair of clean gloves and reentered the room, then left the room again to obtain a stethoscope and returned to the room to auscultate the resident's heart. 4. A facility policy titled, Infection Prevention and Control Program, revised 04/02/2025, indicated, 12 b. Clean linen shall be separated from soiled linen at all times. A facility policy titled, Laundry, revised 04/10/2025, indicated, 3. Soiled laundry shall be kept separate from clean laundry at all times. During observations of the laundry room on 06/04/2026 at 8:16 AM, there were two yellow barrels of soiled laundry on wheels positioned in the entrance door into the laundry room, as well as a blue cart used for sorting dirty linen that had no lid or cover, located near a shelf where clean linen was stored and covered by a mesh-type net. A clean laundry folding area was located opposite the dirty linen. Heavy accumulation of dust was noted behind the two washing machines and two dryers, and four to five inches of lint accumulation was observed in the bottoms of the dryers and on the lint filters of both dryers. The floor was observed to have areas of cracked, exposed cement. During an interview on 06/04/2026 at 8:16 AM, the Housekeeping/Laundry Supervisor stated that she was supposed to clean the lint filters on the dryers every two hours when in the laundry room. She stated she had no formal training on how to do the laundry and/or how to do the housekeeping services. She indicated that soiled laundry was brought into the laundry room and sorted into the cart in the area near the entry door by the clean linen shelf. During a follow-up interview on 06/05/2026 at 9:05 AM, the Housekeeping/Laundry Supervisor stated that she had no assistance from anyone with cleaning the dryers of lint. During an interview on 06/05/2026 at 8:40 AM, the Maintenance Director stated that he cleaned the outside dryer filters every two weeks and behind the inside dryers every two weeks. During an interview on 06/04/2026 at 1:43 PM, the DON stated that she knew the dirty and clean laundry should not be mixed and she had noticed the amount of dust in the laundry area. The DON stated that she was not monitoring the area for infection control. During an interview on 06/04/2026 at 2:47 PM, the Administrator stated that the dirty linen was in the barrels and a top had been ordered for the blue cart. She stated the facility had trained the Housekeeping/Laundry Supervisor as best they could from what the Administrator had learned from prior surveys and that the Housekeeping/Laundry Supervisor had received some training from the previous housekeeper. She stated the Housekeeping/Laundry Supervisor had some training by word of mouth from the facility's chemical/equipment supplier, but there was no formal documentation of the training. The Administrator did not respond when shown the cracked and exposed cement on the laundry room floor. 5. A facility policy titled, Hand Hygiene, revised 04/11/2025, indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. An attached, Hand Hygiene Table, indicated that either soap and water or alcohol-based hand rub should be used between resident contacts; after handling contaminated objects; before applying and after removing personal protective equipment (PPE), including gloves; and before performing resident care procedures. a. Resident #28's admission Record revealed the facility admitted the resident on 05/05/2026. According to the admission Record, the resident had a medical history that included diagnoses of severe sepsis without septic shock and cellulitis of the left lower limb. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/12/2026, indicated Resident #28 scored 15 on a Brief Interview for Mental Status (BIMS), which indicated the resident had intact cognition. The MDS indicated that upon admission, the resident required partial/moderate assistance to roll to the left and right in bed. Resident #28's Care Plan Report included a focus area initiated on 05/06/2026 that indicated the resident needed dialysis, was admitted with a fistula to the left upper extremity, and received dialysis three days per week. Interventions directed staff to use enhanced barrier precautions (EBP) and to wear at least gown and gloves when performing high-contact resident care activities. Resident #28's Order Summary Report with active orders as of 06/02/2026 contained a physician's order for EBP related to a fistula. The order directed staff to ensure every shift that signage was posted on the door to the resident's room and indicated that staff must use gown and gloves when performing care. During an observation on 06/01/2026 at 12:32 PM, Certified Nursing Assistant (CNA) #5 and CNA #6 provided a linen change for Resident #28 without donning personal protective equipment (PPE) other than gloves. There was a sign on the door to the room indicating enhanced barrier precautions were required for high-contact care. After completing the linen change, CNA #5 and CNA #6 exited the room and removed their gloves. Neither CNA performed hand hygiene before entering Resident #24's room at 12:38 PM with a bedpan. b. Resident #24's admission Record revealed the facility admitted the resident on 03/25/2026. According to the admission Record, the resident had a medical history that included diagnoses of cellulitis of the left lower limb and a non-pressure chronic ulcer of an unspecified foot. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/01/2026 revealed Resident #24 scored 13 on a Brief Interview for Mental Status (BIMS), which indicated the resident had intact cognition. The MDS indicated at admission, the resident was dependent for toileting hygiene and toilet transfer. Resident #24's Care Plan Report included a focus area initiated on 03/25/2026 that indicated the resident had the potential for impaired skin integrity, was admitted with an indwelling catheter, was frequently incontinent of bowel, and required assistance with toileting hygiene and repositioning. Interventions directed staff to use enhanced barrier precautions and to wear at least gloves and gowns when performing high-contact care activities such as providing hygiene, changing briefs, or assisting with toileting. During an observation on 06/01/2026 at 12:38 PM, Certified Nursing Assistant (CNA) #5 and CNA #6 entered Resident #24's room with a bedpan after having left Resident #28's room without performing hand hygiene. Both CNAs donned gloves. After providing care to Resident #24, both CNAs exited the room. CNA #5 carried the bedpan with a glove on one hand and no glove on the other hand. CNA #6 doffed her gloves, then both CNAs entered the soiled linen room and exited without performing hand hygiene. During an interview on 06/02/2026 at 2:45 PM, CNA #6 denied having received training on PPE use but acknowledged she had received classroom education on EBP. She stated she was not really sure of the difference between EBP and transmission-based precautions. During an interview on 06/02/2026 at 3:09 PM, CNA #5 acknowledged that she did not use proper PPE during care of Resident #28 on 06/01/2026 and stated, I should have, honestly. She stated she received training on PPE about a year ago and received hand hygiene training recently, during which she was required to perform a return demonstration. 6. A facility policy titled, Food Safety Requirements, revised 06/30/2025, indicated, Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety. The policy specified, 5. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. Strategies include, but are not limited to: c. Washing hands properly before distributing trays. d. Washing hands between contact with residents and after collecting soiled plates and food waste. e. Use gloves when touching and assisting ready-to-eat foods. The policy further indicated, 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. a. Staff shall wash hands according to facility procedures. During observations on 06/01/2026 at 1:00 PM, Certified Nursing Assistant (CNA) #5 and CNA #6 were passing meal trays on the East Hall. Both CNAs entered and exited multiple rooms on the hall to deliver meal trays, open containers, and pour liquids for the residents who received meals in their rooms. Neither CNA performed hand hygiene between entering and exiting different residents' rooms. During an interview on 06/02/2026 at 2:45 PM, CNA #6 stated if her hands were probably dirty, she would clean them before assisting a resident. She stated this was her second day on the job. She stated she had received hand hygiene training but denied being educated on hand hygiene during meal pass. During an interview on 06/02/2026 3:09 PM, CNA #5 stated she had been working in the facility for going on three years. She stated she received hand hygiene training recently and had to perform a return demonstration at that time. During observations on 06/02/2026 at 1:25 PM, CNA #8 was serving meal trays and ice to residents on the East Hall. CNA #8 touched and moved a wheelchair that was parked in the corridor and continued serving ice in cups to residents without performing hand hygiene. CNA #8 then pushed a meal cart down the hall and without washing her hands, retrieved a tray from the cart and entered a resident's room. During observations on 06/02/2026 at 1:25 PM, Certified Medication Assistant (CMA) #7 delivered cups of milk to numerous resident rooms without performing hand hygiene before or after entering each room. During an interview on 06/02/2026 at 2:38 PM, CMA #7 stated she had been working in the facility since 2020. She stated she had been a CNA for 22 years. She acknowledged that she had delivered cups of milk to the residents and that she had not performed hand hygiene before and after serving each resident but that she should have done so. She stated she was aware that she should wash her hands before and after serving each resident. CMA #7 stated she did not like the hand sanitizer gel that was provided by the facility. She stated she had hand hygiene training about a month ago and that hand hygiene was important because, you can carry germs from one person to the other. During an interview on 06/02/2026 at 3:00 PM, CNA #8 stated she should have used hand sanitizer after coming out of a resident's room before entering the next room. She stated that she had been working at the facility for over a year and that she had received in-service training on hand hygiene a little while ago, during which she was required to perform a return demonstration. She stated that after using hand sanitizer three times, she should be washing her hands with soap and water. CNA #8 stated she did not remember receiving education on when to perform hand hygiene during meal pass. She stated that she was just in a rush and forgot to perform hand hygiene because this was her first time performing meal service. During an interview on 06/04/2026 at 11:35 AM, the Minimum Data Set/ Licensed Vocational Nurse (MDS/LVN) stated that she, along with the Director of Nursing (DON), provided in-services at every staff meeting and as issues arose regarding infection control and hand hygiene. She stated that every payday they took the opportunity to conduct in-services. During an interview on 06/04/2026 at 11:47 AM, the DON stated the facility went over infection control information at every in-service twice per month. She stated that during some months, they went more in-depth. The DON stated the facility held people accountable and would [NAME] on staff about infection control but could not babysit them. She stated that she also observed staff without their knowledge to ensure they were doing the right thing. The DON stated there was no official training on meal pass but that the staff received on-the-job training with the person they were shadowing. During a follow-up interview on 06/04/2026 at 3:22 PM, the DON stated that it was her expectation that staff use hand sanitizer and then wash with soap and water after every third use of hand sanitizer. She stated for some tasks, staff may need to wash their hands more often. She indicated hand hygiene was, one of our biggest training topics that we hit the most. During an interview on 06/04/2026 at 3:51 PM, the Administrator stated it was her expectation that staff use hand sanitizer before they picked up meal trays, between trays, and after meal pass. She stated the facility had a hand hygiene skills check-off during their most recent in-service.

Based on observation, interview, and facility policy review, the facility failed to ensure 1) food was labeled with the open date and the expiration date for 1 of 2 kitchen observations and 2) expired foods were discarded for 1 of 2 refrigerators. The failure had the likelihood to affect the 38 residents in the facility. Findings included: A facility policy titled, Food Safety Requirements, revised on 06/30/2025, indicated, Food safety practices shall be followed throughout the facility's entire food handling process. Practices to maintain safe refrigerated storage include labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or discarded. A facility policy titled, Date Marking for Food Safety, revised on 06/30/2025, indicated, The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. 1. During an initial kitchen observation on 06/01/2026 at 9:15 AM, five large plastic containers of cereal with closed lids were on the serving line to be used in pouring up individual servings into bowls during the meal service. The five plastic cereal containers were labeled raisin bran, fruit loops, rice krispies, corn flakes, and bran. The cereal containers were three-fourths full, except for the container labeled bran, which was one-fourth full. The five plastic cereal containers were not dated as to when the cereal was opened or with an expiration date. During an interview on 06/01/2026 at 9:20 AM, the Dietary Supervisor (DS) stated the original cereal packages were opened and the contents were placed in the plastic containers to make it easier for the cereals to be poured on the service line by the Cook. The Dietary Supervisor confirmed the plastic cereal containers lacked the date each cereal was opened and the date each cereal expired. The DS stated she expected the kitchen staff to label all foods with open and expired dates. During an interview on 06/04/2026 at 3:44 PM, the Administrator stated she expected all food items to be labeled correctly with the date the item was opened and when it expired. 2. During the initial kitchen observation on 06/01/2026 at 9:30 AM, Refrigerator #1 had four 5-pound containers of low-fat cottage cheese that were beyond their expiration dates. One container had expired on 01/06/2026, and three containers had expired on 05/13/2026. During an interview on 06/01/2026 at 9:35 AM, the Dietary Supervisor (DS) confirmed the four containers of low-fat cottage cheese in the refrigerator had expired and should have been used prior to the expiration date or discarded on the expiration date. The DS stated the cooks were supposed to review food containers for expiration dates. The DS stated the containers should have been thrown away. The DS stated the food could have been spoiled and had bacterial growth that could make residents sick if served to them. The DS stated she expected the kitchen staff to monitor all foods for use-by or expired dates and to remove items from the kitchen that were expired. During an interview on 06/04/2026 at 3:44 PM, the Administrator stated she expected the kitchen staff to use a food product before it expired or throw it away when it expired. She stated if the kitchen used an expired food item, it could make a resident sick.

Citation Form for QAFacility: Ada Care CenterSurveyor: [NAME] 51215Tag: F655S/S: EList other surveyors citing this tag: [NAME] and [NAME] AgarwalWho is writing the deficient practice statement? [NAME] Based on interview, record review, and facility policy review, the facility failed to initiate baseline care plans within 48 hours for 4 of 7 residents (Residents #4, #25, #28, and #44). Findings included: The facility's policy titled, Baseline Care Plan, revised on 06/30/2025, indicated, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. A supervising nurse shall verify withing 48 hours that a baseline care plan has been developed. 1. Resident #25's admission Record indicated the facility admitted the resident on 04/30/2026. According to the admission Record, the resident had a medical history that included diagnoses (DX) of chronic obstructive pulmonary disease, schizophrenia, major depressive disorder, anxiety disorder, nuclear cataract, bilateral primary open-angle glaucoma, and convulsions. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2026, revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A review of Resident #25's medical record revealed no baseline care plan, and the resident's comprehensive care plan was initiated on 05/06/2026, seven days after their admission to the facility on [DATE]. During an interview on 06/02/2026 at 1:36 PM, the MDS/Licensed Vocational Nurse (LVN) revealed that the facility did not have separate baseline care plans for residents, and that a resident's comprehensive care plan was initiated on admission and updated throughout their stay and when changes occurred. During a follow up interview on 06/04/2026 at 11:02 AM, the MDS/LVN stated she made sure care plans were opened and submitted in a timely manner. 2. Resident #28's admission Record indicated the facility admitted the resident on 04/29/2026. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with diabetic neuropathy, parkinsonism, multiple sclerosis, paroxysmal atrial fibrillation, acute diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and end stage renal disease. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/12/2026, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15. Review of Resident #28's medical record revealed no baseline care plan, and the resident's comprehensive care plan was initiated on 05/05/2026, six days after their admission to the facility on [DATE]. During an interview on 06/02/2026 at 1:36 PM, the MDS/Licensed Vocational Nurse (LVN) revealed that the facility did not have separate baseline care plans for residents, and that a resident's comprehensive care plan was initiated on admission and updated throughout their stay and when changes occurred. During a follow up interview on 06/04/2026 at 11:02 AM, the MDS/LVN stated she made sure care plans were opened and submitted in a timely manner. 3. An admission Record revealed the facility admitted Resident #4 on 05/01/2026. According to the admission Record, the resident had a medical history that included nondisplaced comminuted fracture of the right fibula. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2026, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of Resident #4's medical record revealed no baseline care plan, and the resident's comprehensive care plan was initiated on 05/06/2026, seven days after their admission to the facility on [DATE]. During an interview on 06/02/2026 at 1:36 PM, the MDS/Licensed Vocational Nurse (LVN) revealed that the facility did not have separate baseline care plans for residents, and that a resident's comprehensive care plan was initiated on admission and updated throughout their stay and when changes occurred. During a follow up interview on 06/04/2026 at 11:02 AM, the MDS/LVN stated she made sure care plans were opened and submitted in a timely manner. MDS/LVN stated that she was not sure of the time frame to create the baseline care plan but that she tries to get them in as soon as possible. 4. An admission Record revealed the facility admitted Resident #44 on 05/28/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure, bipolar disorder, autistic disorder, and ileus. A Minimum Data Set (MDS), dated [DATE], was completed for the resident, with no Brief Interview for Mental Status (BIMS) completed.Review of Resident #44's medical record revealed no baseline care plan, and the resident's comprehensive care plan was initiated on 06/01/2026, three days after their admission to the facility on [DATE]. During an interview on 06/02/2026 at 1:36 PM, the MDS/Licensed Vocational Nurse (LVN) revealed that the facility did not have separate baseline care plans for residents, and that a resident's comprehensive care plan was initiated on admission and updated throughout their stay and when changes occurred. During a follow up interview on 06/04/2026 at 11:02 AM, the MDS/LVN stated she made sure care plans were opened and submitted in a timely manner. MDS/LVN stated that she was not sure of the time frame to create the baseline care plan but that she tries to get them in as soon as possible. During an interview on 06/04/2026 at 3:27 PM, the Director of Nursing (DON) stated that it was her expectation that the care plan be completed in a timely manner. The DON stated she thought the timeframe for the baseline care plan to be initiated was 24 hours but was not sure. During an interview on 06/04/2026 at 3:51 PM, the Administrator stated that she was not clinical and therefore would defer to her nursing team for MDS and care plans, but it was her expectation that baseline care plans be completed in a timely manner.

Based on observation, interview, record review, facility policy review, and review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure the most recent resident assessment accurately reflected a resident's smoking status, which affected 1 (Resident #28) of 3 residents reviewed for accident hazards related to smoking. Findings included: The Centers for Medicare & Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2025, revealed, J1300: Current Tobacco Use included Steps for Assessment, which included 1. Ask the resident if they used tobacco in any form during the 7-day look-back period; 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes; and 3. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the lookback period, review the medical record and interview staff for any indication of tobacco use by the resident during the lookback period. The manual revealed, Coding Instructions, which revealed, Code 0, no: if there are no indications that the resident used any form of tobacco; and Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period. An admission Record indicated the facility admitted Resident #28 on 04/29/2026. According to the admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD). An admission Admission/Re-admission/Quarterly/Significant Change Assessment, dated 04/29/2026 and completed by Licensed Vocational Nurse (LVN) #3, indicated that the resident smoked, used electronic cigarettes, or used tobacco products at the time of the assessment. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/12/2026, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed that J1300 was coded to indicate that the resident did not use tobacco at the time of the assessment. Resident #28's Care Plan Report included a focus area initiated 05/05/2026, that indicated that the resident had an activity of daily living self-care performance deficit. The Care Plan Report did not include any information related to the resident smoking. During an observation on 06/01/2026 at 11:35 AM, Resident #28 was observed outside smoking during a scheduled smoking time. During an interview on 06/02/2026 at 11:58 AM, Resident #28 revealed that they usually kept smoking material on their person or in the nightstand drawer. Resident #28 stated that a smoking assessment was completed upon admission and that staff were aware of their smoking habits. During an interview on 06/03/2026 at 3:36 PM, LVN #3 stated that Resident #28 told him that they were an unsupervised smoker at the time of admission. He stated that the Director of Nursing (DON), the Assistant Director of Nursing (ADON)/MDS/LVN, and all the other nurses could see what was documented in the admission records that he completed. During an interview on 06/03/2026 at 9:15 AM, the DON revealed that she and the ADON/MDS/LVN completed the MDS assessments and adjusted the care plans as things came up or if there was a need to update them. During an interview on 06/04/2026 at 11:02 AM, the ADON/MDS/LVN stated that she was aware that Resident #28 smoked and confirmed that she did not reflect that on the resident's MDS. She stated that she was responsible for completing the MDS assessments, but they were signed off by the DON before they were closed and submitted. ADON/MDS/LVN stated that she looked at a lot of information, like the nursing documentation, medication administration records (MARs), treatment administration records (TARs), behavior notes, and certified nursing assistant (CNA) documentation, to complete the MDS. She stated that depending on which section of the MDS she is looking at determined which documents she looks at. The ADON/MDS/LVN stated that at the beginning of the assessment, she completed a resident interview where she reviewed documentation and asked the resident if they would like to continue smoking. MDS/LVN stated that she was responsible for completing the MDS, creating the care plans, adding diagnoses and medications, and based on conversation with the resident, anything else necessary. During an interview on 06/04/2026 at 3:27 PM, the DON revealed that she tried to assist with admissions along with the ADON/MDS/LVN. The DON stated that it was her expectation that the MDS assessments be accurate. She stated that smoking should have been indicated on Resident #28's MDS. During an interview on 06/04/2026 at 3:51 PM, the Administrator revealed that she was not clinical staff and therefore deferred to her nursing team for MDS related questions.

Based on facility policy review, record review, observation, and interview, the facility failed to ensure a resident's comprehensive person-centered care plan accurately reflected the resident's status for 1 of (Resident #10) of 2 residents reviewed for respiratory care and 2 (Resident #25 and Resident #28) of 3 residents reviewed for accident hazards related to smoking. Findings included: A facility policy titled, Comprehensive Care Plans, revised 06/30/2025, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. 1. A facility policy titled, Oxygen Administration, revised 05/16/2025, indicated, 1. Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and resident's goals and preferences. The policy revealed, 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to, which included a, The type of oxygen delivery system; b. When to administer, such as continuous or intermittent and/or when to discontinued; and c. Equipment setting for prescribed flow rates. An admission Record revealed the facility admitted Resident #10 on 02/19/2026. According to the admission Record, the resident had a medical history that included a diagnosis of obstructive sleep apnea. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2026, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #10 had an active diagnosis of obstructive sleep apnea. The MDS indicated that the resident received respiratory treatments via a non-invasive mechanical ventilator. Resident #10's Order Summary Report, with active orders as of 06/02/2026, contained an order, dated 02/27/2026, to ensure that a CPAP was on at bedtime related to obstructive sleep apnea, and to remove the CPAP every morning. The report did not include specific orders for the settings of the CPAP machine. Resident #10's Care Plan Report included a focus area initiated 02/20/2026, that indicated the resident was at risk for altered respiratory status related to obstructive sleep apnea. The Care Plan Report did not include any information about Resident #10's use of a CPAP machine. During a concurrent observation and interview on 06/01/2026 at 11:31 AM, a CPAP mask was on top of Resident #10's bed. Resident #10 stated that they (Resident #10) did everything needed for the CPAP, including cleaning the mask, and they knew the CPAP order. During an observation on 06/01/2026 at 2:00 PM, a CPAP machine was observed next to the resident's bed in an open dresser drawer. During a concurrent observation and interview on 06/02/2026 at 3:06 PM, Resident #10 was lying on their bed and holding the CPAP mask to their face. Resident #10 stated that they were preparing to take a nap. The resident also stated that they managed the CPAP machine themselves by turning the CPAP machine on and off. An observation on 06/04/2026 at 9:37 AM revealed Resident #10 was lying in bed sleeping with their CPAP mask on. During an interview on 06/03/2026 at 11:05 AM, Licensed Vocational Nurse (LVN) #2 stated that if a resident used a CPAP, it should have been documented on the resident's care plan. During an interview on 06/04/2026 at 11:47 AM, the Assistant Director of Nursing (ADON)/MDS/LVN stated that she was aware that Resident #10 had a CPAP machine. She stated that a care plan should be in place for the CPAP for Resident #10, but there had been no MDS triggers for it to put it in the resident's care plan. 2. A facility policy titled, Resident Smoking, revised 06/10/2025, indicated It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. The Policy Explanation and Compliance Guidelines revealed 5. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS [Minimum Data Set] assessment process. The policy revealed 10. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan.An admission Record indicated the facility admitted Resident #25 on 04/30/2026. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD); schizophrenia unspecified; major depressive disorder recurrent, moderate; anxiety disorder, unspecified; age-related nuclear cataract of the left eye; ocular hypertension, bilateral (higher than normal pressure inside both eyes); primary open-angle glaucoma, bilateral, stage unspecified; and unspecified convulsions. An admission MDS, with an Assessment Reference Date (ARD) of 05/07/2026, revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that Resident #25 was a current tobacco user at the time of the assessment. Resident #25's Care Plan Report included a focus area initiated 05/06/2026, that indicated the resident had an activity of daily living (ADL) self-care performance deficit. Interventions directed staff to provide assistance with one to two staff members with all ADLs. The Care Plan Report did not include a focus area, goals, or interventions related to smoking. During an observation and interview on 06/02/2026 at 3:25 PM, Resident #25 was lying on their bed in their room. A lighter was on top of the nightstand. Resident #25 stated it was usually kept there or in their pants pocket for smoke break. Resident #25 stated they attended the smoke break that morning and had been doing so since admission when staff assisted. Resident #25 stated they had received the facility rules about smoking at the time of admission and kept their cigarettes on them. Resident #25 opened their nightstand drawer, revealing a carton of cigarettes. Resident #25 stated that staff were always present during the smoke break. During an interview on 06/04/2026 at 11:02 AM, the Assistant Director of Nursing (ADON)/MDS/Licensed Vocational Nurse (LVN) stated that she was aware that Resident #25 was a smoker and admitted to not completing a care plan reflecting it. She stated that she would be adding it. An admission Record indicated the facility admitted Resident #28 on 04/29/2026. According to the admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD). An admission Admission/Re-admission/Quarterly/Significant Change Assessment, dated 04/29/2026 and completed by LVN #3, indicated that the resident smoked, used electronic cigarettes, or used tobacco products at the time of the assessment. An admission MDS, with an ARD of 05/12/2026, revealed Resident #28 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #28's Care Plan Report included a focus area initiated 05/05/2026, that indicated that the resident had an activity of daily living self-care performance deficit. The Care Plan Report did not include any information related to the resident smoking. During an observation on 06/01/2026 at 11:35 AM, Resident #28 was observed outside smoking during a scheduled smoking time. During an interview on 06/02/2026 at 11:58 AM, Resident #28 revealed that they usually kept smoking material on their person or in the nightstand drawer. Resident #28 stated that a smoking assessment was completed upon admission and that staff were aware of their smoking habits. During an interview on 06/03/2026 at 3:36 PM, LVN #3 stated that Resident #28 told him that they were an unsupervised smoker at the time of admission. He stated that the Director of Nursing (DON), the ADON/MDS/LVN, and all the other nurses could see what was documented in the admission records that he completed. During an interview on 06/03/2026 at 9:15 AM, the DON revealed that she and the ADON/MDS/LVN completed the MDS assessments and adjusted the care plans as things came up or if there was a need to update them. During an interview on 06/04/2026 at 3:27 PM, the DON stated that smoking should be reflected on a resident's care plan.

Based on facility policy review, record review, observation, and interview, the facility failed to accurately complete a smoking safety assessment to determine the potential hazards or risks for 1 (Resident #25) of 3 residents reviewed for accident hazards related to smoking. Findings included: A facility policy titled, Resident Smoking, revised 06/10/2025, indicated It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. The Policy Explanation and Compliance Guidelines revealed 5. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS [Minimum Data Set] assessment process. The policy revealed 6. Residents who smoke will be further assessed to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. The policy revealed 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. The policy revealed 10. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. The policy revealed 15. Documentation to support decision making will be included in the medical record, may include but not limited to, which included a. Resident's wishes, or those of the resident's representative; b. Assessment of relevant functional and cognitive factors affecting ability to smoke safely; c. Response to smoking cessation interventions; and Compliance with smoking policy.An admission Record indicated the facility admitted Resident #25 on 04/30/2026. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD); schizophrenia unspecified; major depressive disorder recurrent, moderate; anxiety disorder, unspecified; age-related nuclear cataract of the left eye; ocular hypertension, bilateral (higher than normal pressure inside both eyes); primary open-angle glaucoma, bilateral, stage unspecified; and unspecified convulsions. An admission MDS, with an Assessment Reference Date (ARD) of 05/07/2026, revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed that Resident #25 required supervision or touch assistance with all activities of daily living (ADLs). The MDS indicated that Resident #25 was a current tobacco user at the time of the assessment. Resident #25's Care Plan Report included a focus area initiated 05/06/2026, that indicated the resident had an ADL self-care performance deficit. Interventions directed staff to provide assistance with one to two staff members with all ADLs. The Care Plan Report did not include a focus area, goals, or interventions related to smoking. Resident #25 admission Progress Notes, dated 04/30/2026, written at 5:01 PM, revealed no documentation of his smoking preferences, nor any smoking discussion or assessment. An Admission/Re-Admission/Quarterly/Significant Change Assessment, dated 04/30/2026, included a Safe Smoking Evaluation that indicated that Resident #25 did not currently smoke. The assessment did not include the name of the person who completed it. During an observation and interview on 06/02/2026 at 3:25 PM, Resident #25 was lying on their bed in their room. A lighter was on top of the nightstand. Resident #25 stated it was usually kept there or in their pants pocket for smoke break. Resident #25 stated they attended the smoke break that morning and had been doing so since admission when staff assisted. Resident #25 stated they had received the facility rules about smoking at the time of admission and kept their cigarettes on them. Resident #25 opened their nightstand drawer, revealing a carton of cigarettes. Resident #25 stated that staff were always present during the smoke break. An observation on 06/03/2026 at 8:46 AM revealed Resident #25 outside, in the smoking area. Resident #25 was smoking alongside five other residents, and Certified Nursing Assistant (CNA) #1. During an interview on 06/03/2026 at 9:00 AM CNA #1 stated that education was provided on orientation about smoke breaks and taking residents out. CNA #1 stated that staff were aware of which residents should be supervised; their cigarettes were kept in the locked box labeled with their names. During an interview on 06/04/2026 at 8:41 AM Licensed Vocational Nurse (LVN) #2 stated that the facility had an admission packet that was completed when an admission arrived at the facility. LVN #2 stated that they also received a report from the hospital, and they discussed preferences like if the resident was a smoker and how often they smoked during the head-to-toe assessment. She stated that then all retrieved information was typed in a nurse note, then added to the admission form in the packet. LVN #2 stated that the assessment sheet in the admission packet then went to the Director of Nursing (DON) for further addition and completion. LVN #2 stated that Resident #25 revealed being a smoker but did not have any supplies at the time of admission. LVN #2 stated that it was in error that the assessment documentation reflected that the resident was not a smoker. LVN #2 stated that she did not realize that an error was made. During an interview on 06/03/2026 at 9:15 AM the DON stated that there was no one person responsible for the smoking task. The DON stated that the nurses were responsible for completing the smoking assessment and scheduling someone to accompany the residents on the smoke breaks. The DON further stated that ultimately, the responsibility lay with herself and the Assistant Director of Nursing (ADON)/MDS/LVN, to complete the MDS and assessments, adjust the care plans as needed, or update them when necessary. During an interview on 06/04/2026 at 11:39 AM the ADON/MDS/LVN revealed that there was an admission assessment completed that covered all the assessment areas so staff did not miss anything, however, Resident #25's admission assessment was only checked to ensure completion, not for errors. During an interview on 06/04/2026 at 3:27 PM the DON stated that both herself and the ADON/MDS/LVN tried to assist with admissions, but the charge nurse was supposed to do it for the most part. The DON stated that the expectation was for the admission assessment to be completed in a timely manner. During an interview on 06/04/2026 at 3:51 PM the Administrator stated that the expectation was for assessments, including MDS assessments, and care plans to be completed in a timely manner but noted that nursing questions would be referred to the clinical team. The Administrator stated that they reviewed the new admissions charts the following morning for additional information on residents' needs and preferences.

Based on facility policy review, record review, observation, and interview, the facility failed to ensure physician orders for the use and care of a continuous positive airway pressure (CPAP) machine included ordered settings, which affected 1 (Resident #10) of 2 residents reviewed for respiratory care. Findings included: A facility policy titled, Oxygen Administration, revised 05/16/2025, indicated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and resident's goals and preferences. The Policy Explanation and Compliance Guidelines revealed, 1. Oxygen is administered under orders of a physician, except in the case of an emergency. The policy revealed, Types of delivery systems include which included d. CPAP Mask-this mask is part of a system that allows a resident to receive continuous positive airway pressure (CPAP), with or without an artificial airway. The system is comprised of a mask, tubing, and a machine that generates a constant flow of air pressure. Machines have different settings. The policy revealed, 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to, which included a, The type of oxygen delivery system; b. When to administer, such as continuous or intermittent and/or when to discontinued; and c. Equipment setting for prescribed flow rates. An admission Record revealed the facility admitted Resident #10 on 02/19/2026. According to the admission Record, the resident had a medical history that included a diagnosis of obstructive sleep apnea. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2026, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #10 had an active diagnosis of obstructive sleep apnea. The MDS indicated that the resident received respiratory treatments via a non-invasive mechanical ventilator. Resident #10's Care Plan Report included a focus area initiated 02/20/2026, that indicated the resident was at risk for altered respiratory status related to obstructive sleep apnea. The Care Plan Report did not include any information about Resident #10's use of a CPAP machine. Resident #10's Order Summary Report, with active orders as of 06/02/2026, contained an order, dated 02/27/2026, to ensure that a CPAP was on at bedtime related to obstructive sleep apnea, and to remove the CPAP every morning. The report did not include specific orders for the settings of the CPAP machine. During a concurrent observation and interview on 06/01/2026 at 11:31 AM, a CPAP mask was on top of Resident #10's bed. Resident #10 stated that they (Resident #10) did everything needed for the CPAP, including cleaning the mask, and they knew the CPAP order. During an observation on 06/01/2026 at 2:00 PM, a CPAP machine was observed next to the resident's bed in an open dresser drawer. During a concurrent observation and interview on 06/02/2026 at 3:06 PM, Resident #10 was lying on their bed and holding the CPAP mask to their face. Resident #10 stated that they were preparing to take a nap. The resident also stated that they managed the CPAP machine themselves by turning the CPAP machine on and off. An observation on 06/04/2026 at 9:37 AM revealed Resident #10 was lying in bed sleeping with their CPAP mask on. During an interview on 06/03/2026 at 11:05 AM, Licensed Vocational Nurse (LVN) #2 stated that residents who used a CPAP machine should have two physician orders, one that specified the CPAP schedule and one that directed the treatment nurse to monitor its use. LVN #2 reviewed Resident #10's physician orders and confirmed that the medical record did not contain a physician order for the CPAP settings. During an interview on 06/03/2026 at 4:12 PM, LVN #3 stated that when a resident had a CPAP machine, the LVN ensured the machine had distilled water, confirmed the machine was clean, and verified the physician orders. LVN #3 stated that to his knowledge, he had not ever seen orders specifically for the CPAP settings. During an interview on 06/05/2026 at 10:16 AM, the Administrator stated she expected medical staff to have all appropriate orders in place for resident care.

Based on observation, record review, and interview, the facility failed to ensure adequate safety for smokers for two (#2 and #43) of two residents sampled for smoking safety. The administrator identified 20 residents who smoked. Findings: An undated Smoking Policy, read in parts, Purpose: to provide maximum safety to all residents at all times .Smoking will be allowed in smoking areas ONLY .Any restrictions will be noted in the resident's record .Smoking privileges will be addressed in the Care Plan .Smoking materials will be kept in a designated area accessible only by staff .Residents assessed as likely to drop ashes on their clothing or self will wear a smoking apron provided by the Center. 1. Resident #43 had diagnoses which included diabetes, seasonal allergies, anxiety, and chronic pain. A Smoking Assessment, dated 11/22/24, documented Resident #43 could smoke independently and the facility did not need to store their lighter and cigarettes. An MDS assessment for Resident #43, dated 11/23/24, documented the resident was cognitively intact. A Care Plan for Resident #43, dated 12/03/24, documented the resident was a smoker. The care plan did not address smoking safety. The care plan documented the resident had a self-care performance deficit related to impaired mobility. On 02/02/25 at 2:55 p.m., Resident #43 reported they smoked independently. They stated they kept their cigarettes and lighter in their room and could go out to smoke anytime they wished. On 02/03/25 at 2:40 p.m., Resident #43 was observed smoking on the back porch, approximately four to five feet from the back door, which was not the designated smoking area. On 02/04/25 at 9:02 a.m., Resident #43 was observed outside on the back porch sitting on their scooter and smoking. An unidentified resident was observed to join them and sat down to smoke also. A sign was observed on the back door which reminded residents this area was not a designated smoking area and to go to the covered awning to smoke. On 02/04/25 at 9:08 a.m., maintenance staff reported there was not a receptacle on the back porch for smokers to dispose of their cigarettes because they were not supposed to be smoking there. They stated there was adequate receptacles under the awning in the designated smoking area and residents had been told numerous times not to smoke on the back porch. On 02/04/25 at 3:16 p.m., the DON reported all smokers should be going to the designated smoking area, but it had been an ongoing problem with them smoking on the back porch. The DON reported residents were assessed individually and then determined whether they could keep their smoking materials or if they would need to be kept at the nurse's desk. 41873 2. Resident #2 had diagnoses which included cerebrovascular accident. A smoking assessment, dated 11/18/24, documented Resident #2 required supervision and a smoking apron while smoking for safety. A care plan, dated 01/15/25, documented Resident #2 required assistance from staff with smoking materials. An MDS assessment, dated 01/30/25, documented Resident #2's range of motion was impaired on one side of the upper and lower extremities. The assessment documented the resident's cognition was severly impaired. On 02/03/25 at 9:47 a.m., Resident #2 was followed by an unknown staff member outside the facility to the smoking area to smoke. The unknown staff member had the resident's cigarettes and lighter and lit the resident's cigarette. The staff member was observed helping the resident put ashes in the ashtray. The resident was observed not wearing a smoking apron for safety. On 02/04/25 at 3:45 p.m., CNA #5 was observed outside with Resident #2 while the resident smoked. The resident was observed not wearing a smoking apron. On 02/04/25 3:54 p.m., CNA #5 reported not being aware of any current resident in the facility that required a smoking apron. On 02/04/25 3:56 p.m., the DON reported Resident #2 was required to wear a smoking apron for safety.

Based on observation, record review, and interview, the facility failed to ensure food was completely covered while being served. The administrator reported 57 residents received meals from the kitchen. Findings: A Preventing Foodborne Illness-Food Handling policy, dated July 2014, read in part, Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. On 02/02/25 at 11:40 a.m., residents were observed during the noon meal. Dessert was observed to be served on a saucer with a plastic lid sitting on top of the dessert. The plastic lid did not completely cover the cake being served for dessert. On 02/03/25 at 8:17 a.m., cook #2 was asked about serving the desserts on an uncovered saucer the previous day. The cook stated they were out of bowls and the plastic wrap was not the proper size. On 02/03/25 at 8:19 a.m., the dietary manager was asked about the cake that was served uncovered the previous day. They stated the administrator had ordered some dessert dishes and they were waiting on them to come in.

Based on observation, record review, and interview, the facility failed to: a. ensure proper disposal of the lancet and blood contaminated glucometer strip for one (#105) of two sampled residents reviewed for blood glucose monitoring; b. to properly dispose of soiled PPE supplies for two (#2 and #204); and c. failed to use proper PPE for enhanced barrier precautions for one (#2) of five sampled residents reviewed for infection control. The administrator reported 59 residents resided in the facility. The DON reported 12 residents with blood glucose monitoring. Findings: A Obtaining a Fingerstick Glucose level policy, dated October 2011, read in part, Dispose of lancet in the sharps disposal container, Discard disposable supplies in the designated containers. A Enhanced Barrier Precautions policy, dated 04/01/24, read in part, EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room. 1. A physician's order for Resident #105, dated 01/29/25, documented the resident would receive Novolog insulin per sliding scale instructions related to diabetes. A care plan for Resident #105, dated 01/30/25, documented the resident had diabetes mellitus. On 02/03/25 at 10:45 a.m., LPN #1 was observed to prepare supplies for Resident #105's finger stick blood sugar test. After the finger stick blood sugar was obtained, the LPN removed their gloves and rolled the strip and the lancet up in the glove and disposed of it in the trash in the resident's room. On 02/03/25 at 11:17 a.m., LPN #1 reported they usually disposed of biohazard materials in the sharps container. The LPN was asked about the facility policy for proper disposal and they stated the lancet/strip should have been put in the biohazard. On 02/03/25 at 11:24 a.m., the administrator reported the facility policy was to dispose of biohazard in the sharps container. On 02/03/25 at 11:29 a.m., the ADON reported staff should dispose of all biohazard in the sharps container. 41873 2. Resident #204 had diagnoses which included neuromuscular dysfunction of the bladder. A physician's order, dated 04/22/22, read in part, Cleanse suprapubic catheter site with normal saline solution, pat dry, apply a split dressing, and secure with tape daily. A care plan intervention, dated 04/20/24, read in parts, Use enhanced barrier precautions (EBP) .Wear at least gloves/gown .EBP is employed when performing high-contact device care or use: urinary catheter and any skin opening requiring a dressing or other devices/conditions recommended by the CDC. On 02/04/25 at 2:00 p.m., Resident #204's door to their room was observed with enhanced barrier signage. On 02/04/25 at 2:00 p.m., LPN #3 was observed donning a gown and gloves before entering Resident #204's room to provide catheter care. The LPN exited the resident's room with used catheter care supplies and wearing a used gown. The LPN was observed to discard used supplies and PPE used for catheter care in the trash can on the treatment cart in the hallway. 3. Resident #2 had diagnoses which included peripheral vascular disease. A care plan, dated 04/01/24, read in parts, Use enhanced barrier precautions (EBP). Wear at least gloves/gown .EBP is employed when performing high-contact device care or use: wound care - any skin opening requiring a dressing or other devices/conditions recommended by the CDC. Physician orders, dated 02/03/25, read in part, Clean with normal saline, apply collagen, cover with bordered gauze 3 times weekly and as needed. The orders also read, Clean with normal saline, apply Medihoney to right lateral ankle topically, cover with bordered foam 3 times weekly and as needed. On 02/04/25 at 2:45 p.m., LPN #3 was observed to provide wound care to resident #2's right shin, right heel, and right ankle. The wounds on the right ankle and shin were observed to be open wounds that required dressings. The LPN was observed performing wound care with gloves, but failed to don a gown for enhanced barrier precautions. The LPN was observed to discard used wound care supplies and used gloves in the trash can on the side of the nurses treatment cart in the hallway outside the resident's room. On 02/04/25 at 2:50 p.m., LPN #3 reported they had not seen the EBP sign on Resident #2's door and should have worn a gown to perform the wound care. The LPN reported using the trash can on the treatment cart to discard their used supplies after exiting a resident's room was normal routine. The LPN reported they made sure the trash can was emptied two to three times a shift. On 02/04/25 at 2:59 p.m., the DON reported staff should follow enhanced barrier precautions (using a gown and gloves) when providing care for all residents with wounds and catheters. The DON reported used PPE and used treatment supplies should be discarded in a trash can in the resident's room before exiting.

Based on observation, record review, and interview, the facility failed to revise care plans related to smoking interventions for two (#2 and #43) of two residents sampled for smoking safety. The administrator identified 20 residents who smoked. Findings: An undated Smoking Policy, read in parts, Purpose: to provide maximum safety to all residents at all times .Smoking will be allowed in smoking areas ONLY .Any restrictions will be noted in the resident's record .Smoking privileges will be addressed in the Care Plan .Smoking materials will be kept in a designated area accessible only by staff .Residents assessed as likely to drop ashes on their clothing or self will wear a smoking apron provided by the Center. A Care Plans, Comprehensive Person-Centered policy, dated March 2022, read in parts, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. Resident #43 had diagnoses which included diabetes, seasonal allergies, anxiety, and chronic pain. A Smoking Assessment, dated 11/22/24, documented Resident #43 could smoke independently and the facility did not need to store the resident's lighter and cigarettes. An MDS assessment for Resident #43, dated 11/23/24, documented the resident was cognitively intact. A Care Plan for Resident #43, dated 12/03/24, documented the resident was a smoker. The care plan did not address smoking safety or interventions. The care plan documented the resident had a self-care performance deficit related to impaired mobility. On 02/02/25 at 2:55 p.m., Resident #43 reported they smoked independently. They stated they kept their cigarettes and lighter in their room and could go out to smoke anytime they wished. On 02/03/25 at 2:40 p.m., Resident #43 was observed smoking on the back porch, approximately four to five feet from the back door, which was not the designated smoking area. The resident was observed sitting on their scooter smoking and visiting with another resident. On 02/04/25 at 9:02 a.m., Resident #43 was observed outside on the back porch sitting on their scooter and smoking. An unidentified resident was observed to join them and sat down to smoke also. A sign was observed on the back door which reminded residents this area was not a designated smoking area and to go to the covered awning to smoke. On 02/04/25 at 9:08 a.m., maintenance staff reported there was not a receptacle on the back porch for smokers to dispose of their cigarettes because they were not supposed to be smoking there. They stated there was adequate receptacles under the awning in the designated smoking area and residents had been told numerous times not to smoke on the back porch. On 02/04/25 at 3:16 p.m., the DON reported all smokers should be going to the designated smoking area, but it had been an ongoing problem with them smoking on the back porch. The DON reported residents were assessed individually and then determined whether they could keep their smoking materials or if they would need to be kept at the nurse's desk. The DON stated the resident's care plan should include interventions and safety measures related to smoking. 41873 2. Resident #2 had diagnoses which included cerebrovascular accident. A smoking assessment, dated 11/18/24, documented Resident #2 required supervision and a smoking apron while smoking for safety. A care plan, dated 01/15/25, documented no intervention related to Resident #2 requiring a smoking apron while smoking. An MDS assessment, dated 01/30/25, documented Resident #2's range of motion was impaired on one side of the upper and lower extremities. The assessment documented the resident's cognition was severly impaired. On 02/04/25 at 3:45 p.m., Resident #2 was observed smoking without a smoking apron. On 02/04/25 3:54 p.m., CNA #5 reported they were not aware of any current resident in the facility who required a smoking apron. On 02/05/25 at 12:45 p.m., the MDS coordinator reported smoking and smoking interventions should be included on the resident's care plan.

Based on record review and interview, the facility failed to ensure an as needed (PRN) medication for anxiety had a documented rational for continued use beyond 14 days for one (#11) of five residents sampled for unnecessary medications. The DON reported 14 residents received anti-anxiety medications. Findings: A Psychotropic Medication Use policy, dated July 2022, read in part, Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotic's: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, [they] will document the rational for extending the use and include the duration for the PRN order. Resident #11 had diagnoses which included heart failure, hypertension, and anxiety/depression. A care plan, dated 03/18/22, documented the resident received anti-anxiety medications r/t anxiety. A Physician Order, dated 11/15/24, documented Ativan (benzodiazepine) 0.5 mg tablet by mouth in the morning for anxiety and give 0.5 mg tablet by mouth every eight hours as needed for anxiety. A pharmacy report, dated 12/06/24, read in parts, CMS requires that orders for non-antipsychotic psychotropic medications that are given on a PRN basis be limited to 14 days unless otherwise indicated .If extended use is required, the clinical rationale for continued need and duration of therapy must be provided to be in compliance with regulatory requirements .May we attempt to D/C or change this order to routine? The report documented the physician disagreed with the recommendation and documented, adds to routine dose. An MDS assessment, dated 12/13/24, documented the resident had moderate cognitive impairment. On 02/04/25 at 10:40 a.m., the ADON reported the PRN order for Ativan was part of the routine Ativan order. On 02/04/25 at 10:45 a.m., the DON reported the PRN order for Ativan was part of the routine order. The DON reported they knew if the Ativan was ordered PRN it had to be evaluated every two weeks.

Based on observation, record review, and interview, the facility failed to ensure proper storage of dry goods. The administrator reported 55 residents received services from the kitchen. Findings: On 11/16/23 at 11:00 a.m., a kitchen tour was conducted. On 11/16/23 at 12:21 p.m., a 50 lb. bag of oats was observed sitting on the floor in dry storage room. Dietary Aide #1 reported the oats had been delivered to the facility last Thursday. They reported the oats were stored on the floor because all of our storage buckets were full. On 11/28/23 at 11:03 a.m., the dietary supervisor reported it was the facilities policy to not store food on the floor. They could not locate the food storage policy, but stated they would store it on a rack off of the floor, if the buckets were not available.

Based on record review and interview, the facility failed to have a registered nurse on duty eight hours a day and/or seven days a week. The administrator reported 55 residents resided in the facility. Findings: A Oklahoma Health Care Authority Report documented three days on the weekends in August 2023, five days on the weekends in September 2023, and two days on the weekends in October 2023 had less than the required staff per resident ratio. The nursing schedules from August 2023 through October 2023 were reviewed and revealed the facility failed to have consistent RN coverage for the weekends. The facility failed to have RN Coverage: Five of eight opportunities in August 2023 Eight of nine opportunities in September 2023 Four out of seven opportunities in October 2023. On 11/16/23 at 10:49 a.m., the administrator and DON both reported the facility had one RN who worked one weekend a month. On 11/27/23 at 2:43 p.m., the DON reviewed the schedules and stated there had not been an RN who had worked on all the weekend shifts.

Based on record review and interview, the facility failed to ensure accurate coding of MDS assessments for one (#22) related to falls and for one (#23) related to CPAP machine usage of 19 sampled residents whose MDS assessments were reviewed. The administrator reported 55 residents resided in the facility. Findings: Comprehensive Assessments policy, dated March 2022, read in part, .A significant error is an error in an assessment where .the resident's overall clinical status is not accurately represented (i.e., miscoded) .A significant error differs from a significant change because it reflects incorrect coding of the MDS and not an actual significant change in the resident's health status . 1. Res #22's physician order, dated 10/23/23, documented PT/OT/ST to evaluate and treat for Part A services. The care plan, dated 11/04/23, documented the resident had a fall next to their bed and their right elbow was red with no bruising or edema noted. A quarterly assessment, dated 11/10/23, documented diagnosis which included cardiovascular accident and hemiplegia/hemiparesis. The assessment documented no falls. On 11/27/23 at 11:50 a.m., MDS coordinator reported they made a correction to the quarterly MDS dated [DATE] to show one fall with injury (bruise to right elbow) on 11/04/23 and one fall without injury on 11/05/23. They reported they missed it on the MDS assessment. 2. Res #23's physician order, dated 04/01/22, documented CPAP at 10 cm H20 with humidification and supplies, apply at HS, remove upon waking related to obstructive sleep apnea. An annual MDS assessment, dated 08/25/23, documented diagnosis which included, HTN, asthma, and obstructive sleep apnea. The assessment documented the resident had an invasive mechanical ventilator and was marked no related to a non-invasive mechanical ventilator (BiPap/CPAP). A care plan, dated 09/14/23, documented the resident had sleep apnea, wore a CPAP at 10 cm H20 with humidification, apply at HS, and remove upon waking. On 11/22/23 at 8:53 a.m., Res #23 reported they used a CPAP machine at night. On 11/22/23 at 10:28 a.m., the MDS coordinator was asked about the CPAP documented on the MDS as an invasive mechanical ventilator. They reported that was an error and it should be reversed.

Based on record review and interview, the facility failed to ensure a quarterly assessment was completed within the required timeframe for one (#46) of 19 sampled residents' assessments reviewed. The administrator reported 55 residents resided in the facility. Findings: Res #46's medical record documented the last quarterly assessment was dated 07/13/23, and a quarterly assessment was due in October 2023. The resident's record did not contain a quarterly assessment, dated for October 2023. On 11/21/23 at 4:18 p.m., the corporate MDS coordinator reviewed and reported the system did not identify the missed quarterly assessment or a discharge assessment. They reported the MDS would be corrected and did not know why it did not show up in the system.

On 09/28/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement their abuse policy by ensuring a thorough investigation was conducted, to include timely reporting, of an allegation of sexual abuse of a cognitively impaired resident. A progress note, dated 08/12/22, documented resident #7 reported to LPN #1 that she had been sexually abused by LPN #3. LPN #1 reported the allegation of sexual abuse to Administration and the DON at that time. LPN #1 was told the allegation would be investigated. Administration stated they did not report the sexual abuse allegation to state agencies, or conduct an investigation with other residents and staff, because LPN #3 was no longer working in the facility at the time the allegation was reported. Administration made a decision to move the resident from the current room to a private room on a hall without male staff and male residents. LPN #3 no longer worked in the facility but had continued to work for a sister facility. The facility failed to ensure the safety of resident #7, and all other residents, by not following their abuse policy for an allegation of sexual abuse. On 09/28/22 at 5:41 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 09/28/22 at 6:05 p.m., the Administrator and the corporate RN were notified of the IJ situation. On 09/29/22 at 11:55 a.m., an acceptable Plan of Removal was provided by the Administrator and the corporate RN. It documented the following: Plan of removal 09/28/22 1. The Administrator and Director of Nursing have been in-serviced on the abuse policy and investigation an allegation of sexual abuse as of 09/28/22 at 9:00 a.m. 2. All staff will be in-serviced on abuse policy. 3. All staff on duty and available have been in-serviced as of 09/28/22 at 5:00 p.m. 4. All other staff not on duty will be in-serviced prior to returning to work. 5. An investigation was initiated on 09/27/22 when incident was reported to corporate staff. 6. An initial state report was completed and submitted as well as notification to APS and local law enforcement, board of nursing, OSDH, family and physician on 09/27/22 at 6:40 p.m. 7. A PIP plan has been developed to audit all progress notes during stand up meeting to ensure that any and all incidents or unusual occurrence are immediately reported and investigated. 8. The nurse the allegation was made against had resigned on 07/24/22 and has not worked at this facility since. Said employee is currently working for a sister facility and has been placed on suspension once the corporate staff were made aware of the allegation and will remain suspended until investigation is complete. 9. The facility will interview all staff and alert and oriented residents by 11:00 a.m. on 09/29/22, and has interviewed a total of 6 staff members and 6 residents on 09/28/22 to determine if any forms of abuse are occurring in the facility. All staff and residents interviewed have denied any abuse or neglect at this time occurring in the facility. 10. Investigation is currently ongoing and will be completed within the timeline per state and federal regulation included in our policy. On 09/29/22, interviews were conducted with facility staff regarding education and in-service training pertaining to the immediate jeopardy plan of removal. Staff reported they had been in-serviced and were able to verbalize understanding of the information and training provided. The IJ was lifted, effective 09/29/22 at 2:57 p.m., when all elements of the plan of removal had been implemented. The deficient practice remained at a isolated level of no actual harm with a potential for more than minimal harm. Based on observations, record review, and interviews, it was determined the facility failed to ensure the abuse policy was implemented for one (#7) of six residents reviewed for abuse. The facility failed to implement their abuse policy by ensuring a thorough investigation was conducted, to include timely reporting, of an allegation of sexual abuse of a cognitively impaired resident. The administrative assistant reported nine allegations of abuse were reported in the last year. The Administrator reported 42 residents resided in the facility. Findings: The facility's Abuse and Neglect policy, dated 08/12/22, read in parts, .It is the policy of this facility to maintain an abuse free environment .The facility has developed and implements policies and procedures regarding abuse that include seven components including screening, training, prevention, identification, investigation, protection and reporting/response .Investigation: Any allegation of abuse will be investigated by the Administrator and the DON. The Administrator and the DON will, as a minimum: Review the resident medical record looking for events leading up to the incident .Interview the person(s) reporting the incident .Interview any witnesses to the incident .Interview the resident (if cognitive ability permits) .Interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident if necessary .Interview the resident's roommate, family members, and visitors as able and necessary .Interview other residents to whom the accursed employee provides care or services .Review all events leading up to the incident .Residents who have been alleged to have been abused will be protected from harm during the investigation .Employees of this facility who have been accused of resident abuse will be suspended from duty until the investigation has been completed .Protection: Residents who have been alleged to have been abused will be protected from harm during the investigation. Employees of this facility who have been accused of resident abuse will be suspended from duty. This action will remain in effect until the investigation has been completed .Reporting: All incidents and allegations involving abuse is required to be reported within 2 hours .The Administrator will notify the Oklahoma State Department of Health and AP'S by faxing the Incident Report Form. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, dated 04/28/22, read in parts .The resident has a behavior problem .On 04/28/22 resident extremely upset, using foul language, making derogatory remarks about the nurse, stating she was raped in the past and that is why she can not sleep at night, and declining her medications .Administer medications as ordered .Intervene as necessary to protect the rights and safety of others .Minimize potential for the resident's disruptive behaviors, by offering tasks which divert attention .Monitor behavior episodes and attempt to determine underlying cause. A Quarterly Assessment, dated 06/29/22, documented the resident's cognition was impaired and required extensive assistance with most ADLs. A Nurse Note, dated 08/12/22 at 9:44 a.m., documented, Reported by patient that nurse assaulted her rectally and now she is pregnant. She is requesting to see a specialist to prove that it happened. She continues to say male worker assaulted her. Resident then reported same information to CNA. At this time above information reported to administration and DON. Decision was made to move resident from her current room to private room on hall without male staff and patients. On 09/27/22 at 4:00 p.m., the corporate RN reported no incident report had been completed for resident #7 related to sexual abuse. On 09/28/22 at 11:30 a.m., the Administrator reported an incident report had not been initiated related to the sexual abuse allegation for resident #7 on 08/12/22. The Administrator stated the incident was not reported or investigated due to the alleged employee no longer working at the facility when the allegation was made. The Administrator reported the resident had been sick with a [CONDITION(S)] and had been displaying many verbal and physical behaviors at the time the allegation was made. On 09/28/22 at 2:38 p.m., LPN #1 was interviewed and reported on 08/12/22, resident #7 had told her that LPN #3 had raped her. LPN #1 reported this was the first time sexual abuse had been reported to her from any resident. LPN #1 reported the resident did not tell her when the incident occurred but she knew the named employee, LPN #3, had not worked in the facility since the end of July 2022. The LPN stated she reported the allegation to the Administrator and the administrative assistant and they told her they would investigate it. The LPN reported an incident report should have been done when the allegation was made to her by the resident. On 09/28/22 at 2:45 p.m., the administrative assistant was interviewed and reported the sexual abuse allegation, reported by the resident on 08/12/22, was discussed with the Administrator and a decision was made not to investigate the allegation. The administrative assistant stated they were under the impression the incident had happened the previous night, the alleged nurse was no longer employed at the facility, and had not worked since July 2022. The administrative assistant reported the decision was made to move the resident to another hall with no male residents or male staff. The administrative assistant reported they received verbal report from LPN #1 of the sexual abuse allegation, and no other residents or staff were interviewed at the time of the allegation.

On 09/28/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a thorough investigation was conducted for an allegation of sexual abuse to a cognitively impaired resident. A progress note, dated 08/12/22, documented resident #7 reported to LPN #1 that she had been sexually abused by LPN #3. LPN #1 reported the allegation of sexual abuse to Administration and the DON at that time. LPN #1 was told the allegation would be investigated. Administration stated they did not report the sexual abuse allegation to state agencies, or conduct an investigation with other residents and staff, because LPN #3 was no longer working in the facility at the time the allegation was reported. Administration made a decision to move the resident from the current room to a private room on a hall without male staff and male residents. LPN #3 no longer worked in the facility but had continued to work for a sister facility. The facility failed to ensure the safety of resident #7, and all other residents, by not conducting a thorough investigation for an allegation of sexual abuse. The facility failed to ensure the risk of sexual abuse to resident #7, and other residents, did not remain. On 09/28/22 at 5:41 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 09/28/22 at 6:05 p.m., the Administrator and the corporate RN were notified of the IJ situation. On 09/29/22 at 11:55 a.m., an acceptable Plan of Removal was provided by the Administrator and the corporate RN. It documented the following: Plan of removal 09/28/22 1. The Administrator and Director of Nursing have been in-serviced on the abuse policy and investigation an allegation of sexual abuse as of 09/28/22 at 9:00 a.m. 2. All staff will be in-serviced on abuse policy. 3. All staff on duty and available have been in-serviced as of 09/28/22 at 5:00 p.m. 4. All other staff not on duty will be in-serviced prior to returning to work. 5. An investigation was initiated on 09/27/22 when incident was reported to corporate staff. 6. An initial state report was completed and submitted as well as notification to APS and local law enforcement, board of nursing, OSDH, family and physician on 09/27/22 at 6:40 p.m. 7. A PIP plan has been developed to audit all progress notes during stand up meeting to ensure that any and all incidents or unusual occurrence are immediately reported and investigated. 8. The nurse the allegation was made against had resigned on 07/24/22 and has not worked at this facility since. Said employee is currently working for a sister facility and has been placed on suspension once the corporate staff were made aware of the allegation and will remain suspended until investigation is complete. 9. The facility will interview all staff and alert and oriented residents by 11:00 a.m. on 09/29/22, and has interviewed a total of 6 staff members and 6 residents on 09/28/22 to determine if any forms of abuse are occurring in the facility. All staff and residents interviewed have denied any abuse or neglect at this time occurring in the facility. 10. Investigation is currently ongoing and will be completed within the timeline per state and federal regulation included in our policy. On 09/29/22, interviews were conducted with facility staff regarding education and in-service training pertaining to the immediate jeopardy plan of removal. Staff reported they had been in-serviced and were able to verbalize understanding of the information and training provided. The IJ was lifted, effective 09/29/22 at 2:57 p.m., when all elements of the plan of removal had been implemented. The deficient practice remained at a isolated level of no actual harm with a potential for more than minimal harm. Based on observations, record review, and interviews, it was determined the facility failed to ensure an allegation of sexual abuse was thoroughly investigated for one (#7) of six residents reviewed for abuse. The facility failed to ensure the safety of all residents in the facility. The administrative assistant reported nine allegations of abuse were reported in the last year. The Administrator reported 42 residents resided in the facility. Findings: The facility's Abuse and Neglect policy, dated 08/12/22, read in parts, .It is the policy of this facility to maintain an abuse free environment .The facility has developed and implements policies and procedures regarding abuse that include seven components including screening, training, prevention, identification, investigation, protection and reporting/response .Investigation: Any allegation of abuse will be investigated by the Administrator and the DON. The Administrator and the DON will, as a minimum: Review the resident medical record looking for events leading up to the incident .Interview the person(s) reporting the incident .Interview any witnesses to the incident .Interview the resident (if cognitive ability permits) .Interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident if necessary .Interview the resident's roommate, family members, and visitors as able and necessary .Interview other residents to whom the accursed employee provides care or services .Review all events leading up to the incident .Residents who have been alleged to have been abused will be protected from harm during the investigation .Employees of this facility who have been accused of resident abuse will be suspended from duty until the investigation has been completed .Protection: Residents who have been alleged to have been abused will be protected from harm during the investigation. Employees of this facility who have been accused of resident abuse will be suspended from duty. This action will remain in effect until the investigation has been completed .Reporting: All incidents and allegations involving abuse is required to be reported within 2 hours .The Administrator will notify the Oklahoma State Department of Health and AP'S by faxing the Incident Report Form. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, dated 04/28/22, read in parts .The resident has a behavior problem .On 04/28/22 resident extremely upset, using foul language, making derogatory remarks about the nurse, stating she was raped in the past and that is why she can not sleep at night, and declining her medications .Administer medications as ordered .Intervene as necessary to protect the rights and safety of others .Minimize potential for the resident's disruptive behaviors, by offering tasks which divert attention .Monitor behavior episodes and attempt to determine underlying cause. A Quarterly Assessment, dated 06/29/22, documented the resident's cognition was impaired and required extensive assistance with most ADLs. A Nurse Note, dated 08/12/22 at 9:44 a.m., documented, Reported by patient that nurse assaulted her rectally and now she is pregnant. She is requesting to see a specialist to prove that it happened. She continues to say male worker assaulted her. Resident then reported same information to CNA. At this time above information reported to administration and DON. Decision was made to move resident from her current room to private room on hall without male staff and patients. On 09/27/22 at 4:00 p.m., the corporate RN reported no incident report had been completed for resident #7 related to sexual abuse. On 09/28/22 at 11:30 a.m., the Administrator reported an incident report had not been initiated related to the sexual abuse allegation for resident #7 on 08/12/22. The Administrator stated the incident was not reported or investigated due to the alleged employee no longer working at the facility when the allegation was made. The Administrator reported the resident had been sick with a [CONDITION(S)] and had been displaying many verbal and physical behaviors at the time the allegation was made. On 09/28/22 at 2:38 p.m., LPN #1 was interviewed and reported on 08/12/22, resident #7 had told her that LPN #3 had raped her. LPN #1 reported this was the first time sexual abuse had been reported to her from any resident. LPN #1 reported the resident did not tell her when the incident occurred but she knew the named employee, LPN #3, had not worked in the facility since the end of July 2022. The LPN stated she reported the allegation to the Administrator and the administrative assistant and they told her they would investigate it. The LPN reported an incident report should have been done when the allegation was made to her by the resident. On 09/28/22 at 2:45 p.m., the administrative assistant was interviewed and reported the sexual abuse allegation, reported by the resident on 08/12/22, was discussed with the Administrator and a decision was made not to investigate the allegation. The administrative assistant stated they were under the impression the incident had happened the previous night, the alleged nurse was no longer employed at the facility, and had not worked since July 2022. The administrative assistant reported the decision was made to move the resident to another hall with no male residents or male staff. The administrative assistant reported they received verbal report from LPN #1 of the sexual abuse allegation, and no other residents or staff were interviewed at the time of the allegation.

On 09/28/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure an allegation of sexual abuse was reported immediately after the allegation was reported to the Administrator. A progress note, dated 08/12/22, documented resident #7 reported to LPN #1 that she had been sexually abused by LPN #3. LPN #1 reported the allegation of sexual abuse to Administration and the DON at that time. LPN #1 was told the allegation would be investigated. Administration stated they did not report the sexual abuse allegation to state agencies, or conduct an investigation with other residents and staff, because LPN #3 was no longer working in the facility at the time the allegation was reported. Administration made a decision to move the resident from the current room to a private room on a hall without male staff and male residents. LPN #3 no longer worked in the facility but had continued to work for a sister facility. The facility failed to ensure timely reporting of an abuse allegation to maintain the safety of resident #7 and all other residents in the facility. On 09/28/22 at 5:41 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 09/28/22 at 6:05 p.m., the Administrator and the corporate RN were notified of the IJ situation. On 09/29/22 at 11:55 a.m., an acceptable Plan of Removal was provided by the Administrator and the corporate RN. It documented the following: Plan of removal 09/28/22 1. The Administrator and Director of Nursing have been in-serviced on the abuse policy and investigation an allegation of sexual abuse as of 09/28/22 at 9:00 a.m. 2. All staff will be in-serviced on abuse policy. 3. All staff on duty and available have been in-serviced as of 09/28/22 at 5:00 p.m. 4. All other staff not on duty will be in-serviced prior to returning to work. 5. An investigation was initiated on 09/27/22 when incident was reported to corporate staff. 6. An initial state report was completed and submitted as well as notification to APS and local law enforcement, board of nursing, OSDH, family and physician on 09/27/22 at 6:40 p.m. 7. A PIP plan has been developed to audit all progress notes during stand up meeting to ensure that any and all incidents or unusual occurrence are immediately reported and investigated. 8. The nurse the allegation was made against had resigned on 07/24/22 and has not worked at this facility since. Said employee is currently working for a sister facility and has been placed on suspension once the corporate staff were made aware of the allegation and will remain suspended until investigation is complete. 9. The facility will interview all staff and alert and oriented residents by 11:00 a.m. on 09/29/22, and has interviewed a total of 6 staff members and 6 residents on 09/28/22 to determine if any forms of abuse are occurring in the facility. All staff and residents interviewed have denied any abuse or neglect at this time occurring in the facility. 10. Investigation is currently ongoing and will be completed within the timeline per state and federal regulation included in our policy. On 09/29/22, interviews were conducted with facility staff regarding education and in-service training pertaining to the immediate jeopardy plan of removal. Staff reported they had been in-serviced and were able to verbalize understanding of the information and training provided. The IJ was lifted, effective 09/29/22 at 2:57 p.m., when all elements of the plan of removal had been implemented. The deficient practice remained at a isolated level of no actual harm with a potential for more than minimal harm. Based on observations, record review, and interviews, it was determined the facility failed to ensure an allegation of sexual abuse was reported immediately to the state agency for one (#7) of six residents reviewed for abuse. The facility failed to ensure the safety of all residents in the facility by not reporting an abuse allegation in a timely manner. The administrative assistant reported nine allegations of abuse were reported in the last year. The Administrator reported 42 residents resided in the facility. Findings: The facility Abuse and Neglect policy, dated 08/12/22, read in parts, .It is the policy of this facility to maintain an abuse free environment .The facility has developed and implements policies and procedures regarding abuse that include seven components including screening, training, prevention, identification, investigation, protection and reporting/response .Reporting: All incidents and allegations involving abuse is required to be reported within 2 hours .The Administrator will notify the Oklahoma State Department of Health and AP'S by faxing the Incident Report Form. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, dated 04/28/22, read in parts .The resident has a behavior problem .On 04/28/22 resident extremely upset, using foul language, making derogatory remarks about the nurse, stating she was raped in the past and that is why she can not sleep at night, and declining her medications .Administer medications as ordered .Intervene as necessary to protect the rights and safety of others .Minimize potential for the resident's disruptive behaviors, by offering tasks which divert attention .Monitor behavior episodes and attempt to determine underlying cause. A Quarterly Assessment, dated 06/29/22, documented the resident's cognition was impaired and required extensive assistance with most ADLs. A Nurse Note, dated 08/12/22 at 9:44 a.m., documented, Reported by patient that nurse assaulted her rectally and now she is pregnant. She is requesting to see a specialist to prove that it happened. She continues to say male worker assaulted her. Resident then reported same information to CNA. At this time above information reported to administration and DON. Decision was made to move resident from her current room to private room on hall without male staff and patients. On 09/27/22 at 4:00 p.m., the corporate RN reported no incident report had been completed for resident #7 related to sexual abuse. On 09/28/22 at 11:30 a.m., the Administrator reported an incident report had not been initiated related to the sexual abuse allegation for resident #7 on 08/12/22. The Administrator stated the incident was not reported or investigated due to the alleged employee no longer working at the facility when the allegation was made. The Administrator reported the resident had been sick with a [CONDITION(S)] and had been displaying many verbal and physical behaviors at the time the allegation was made. On 09/28/22 at 2:38 p.m., LPN #1 was interviewed and reported on 08/12/22, resident #7 had told her that LPN #3 had raped her. LPN #1 reported this was the first time sexual abuse had been reported to her from any resident. LPN #1 reported the resident did not tell her when the incident occurred but she knew the named employee, LPN #3, had not worked in the facility since the end of July 2022. The LPN stated she reported the allegation to the Administrator and the administrative assistant and they told her they would investigate it. The LPN reported an incident report should have been done when the allegation was made to her by the resident. On 09/28/22 at 2:45 p.m., the administrative assistant was interviewed and reported the sexual abuse allegation, reported by the resident on 08/12/22, was discussed with the Administrator and a decision was made not to investigate the allegation. The administrative assistant stated they were under the impression the incident had happened the previous night, the alleged nurse was no longer employed at the facility, and had not worked since July 2022. The administrative assistant reported the decision was made to move the resident to another hall with no male residents or male staff. The administrative assistant reported they received verbal report from LPN #1 of the sexual abuse allegation, and no other residents or staff were interviewed at the time of the allegation.

Based on record review and interview, the facility failed to ensure finger stick blood sugar checks and insulin administration was performed per the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Census and Conditions of Residents documented 42 residents resided in the facility. Findings: A facility policy and procedure for glucose monitoring and insulin administration read in part .documentation: 1) the resident's blood glucose result .2) the dose and concentration of the insulin injection . 1. Resident (Res) #4 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's Quarterly Assessment, dated 6/28/22, documented the resident was moderately impaired with cognition and received injections for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's Care Plan, dated 06/28/22, documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A Physician Order, dated Sept. 2022, documented: [MEDICATION(S)] solution 100 unit/ml inject 15 unit subcutaneously at bedtime. [MEDICATION(S)] solution 100 unit/ml inject 60 unit subcutaneously in the morning. [MEDICATION(S)] solution 100 unit/ml inject as per sliding scale . The Insulin Administration Record for Res #4 was left blank for a total of 23 opportunities for FSBS and insulin injections for the months of August and September 2022. 2. Resident #20 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's Admission Assessment, dated 07/26/22, documented the resident was severely impaired of cognition and received four injections in the past seven day look back period. The resident's Care Plan, dated 08/11/22, documented to give insulin [MEDICATION(S)] 100 unit/ml, 10uts SQ BID for diabetes mellitus. A Physician Order, dated [DATE], documented to give [MEDICATION(S)] flextouch Sol Pen-injector 100 unit/ml give 10 units SQ BID for DM. An Insulin Flowsheet/Finger-stick form, for 08/01/22 - 08/31/22, and 09/01/22 - 09/29/22, documented several blanks where there was no documentation to indicate if the resident refused the [MEDICATION(S)] or if a blood sugar was not obtained. 3. Resident #40 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's Annual Assessment, dated 08/29/22, documented the resident's cognition was intact and received seven injections in the 7 day look back period. The resident's Care Plan, dated 08/29/22, documented the resident received insulin medication routinely .had declined insulin .refused sliding scale .indicated to document refusals. A Physician Order, dated [DATE], documented to give: [MEDICATION(S)] [MEDICATION(S)] pen-injector 100 unit/ml inject 15 ml at bedtime [MEDICATION(S)] [MEDICATION(S)] pen-injector 15 units in the morning [MEDICATION(S)] solution 100 unit/ml inject per SS A review for August and September insulin flowsheet/blood sugar record, documented a total of 20 blanks with no refusals noted or blood sugar or insulin injections given. On 09/29/22 at 9:01 a.m. LPN #2 reported the process for administering insulin and obtaining finger stick blood sugar levels. She stated if the record was left blank it would mean the nurse before her did not do it or she forgot to write it down. On 09/29/22 at 9:40 a.m. RN #1 reviewed the clinical records for August and September and reported the blanks should have been reported to her. The RN stated the blanks would indicate the blood sugar check and insulin administration had not been done per the physician orders.

Based on observation, record review, and interview, it was determined the facility failed to provide monitoring and interventions to prevent pressure ulcers and/or promote healing of pressure ulcers for two (#14 and #59) of four residents reviewed for pressure ulcers. A wound care specialist evaluation for resident #59, dated 01/25/18, documented a stage III pressure ulcer with a duration of greater than 11 days that measured 0.8 x 0.4 x 0.2 cm with moderate serous exudate. The evaluation documented a site 2 on the resident's distal left hand as a stage III pressure ulcer with a duration of greater than four days. The evaluation documented the site 2 wound measured 0.6 x 0.2 x 0.1 cm with moderate exudate. The resident census and condition form documented eight of 62 residents had pressure ulcers. Findings: 1. Resident #59 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A bath sheet/form, dated 12/18/17, documented the resident's nails had been trimmed. An annual assessment, dated 12/23/17, documented the resident was at risk for developing pressure ulcers and had no unhealed pressure ulcers. A care plan, dated 12/27/17, documented the resident was at risk for skin breakdown related to incontinence of bowel and bladder. A care plan intervention was for the staff to perform weekly skin assessments. The care plan documented the resident needed one person assistance with ADL care. An intervention documented for staff to provide total assistance for the resident's personal hygiene. The resident's care plan did not contain any entry which addressed the resident's closed left hand. A bath sheet/form, dated 01/03/18, documented the resident's nails were trimmed. A Braden scale for predicting pressure sore risk form, dated 01/06/18 at 9:22 a.m., documented the resident was a high risk for the development of pressure ulcers. A nurse's note, dated 01/11/18 at 6:44 p.m., documented the resident had a weekly skin assessment performed. The nurse's note documented the resident had no open areas/redness/irritation noted. A nurse's note, dated 01/16/18 at 2:30 p.m., documented a nurse had gotten the resident to open his left hand, noted foul odor, and had an open area where his fingernails had embedded into the palm of his hand. The nurse's note documented the physician was notified and a treatment order was obtained. The nurse's note documented the family was notified and the resident's fingernails were trimmed. A nurse's note, dated 01/16/18 at 2:45 p.m., documented the resident was having problems with the fingernails of his left hand digging into the palm of his hand. The nurse's note documented the resident received Tylenol for discomfort. A skin/wound entry in a nurses' note, dated 01/18/18 at 7:21 p.m., documented the wound specialist physician followed up on the resident's left hand and noted a stage III pressure ulcer which measured 2.8 cm x 1.8 cm x 0.3 cm with moderate serous exudate with 20% granulation tissue. The note documented a new order was received to apply silver alginate and cover with a dry protective dressing three times per week and PRN. The note documented for the staff to apply a hand roll to keep nails away from his palm and may apply [MEDICATION NAME] as needed to dessicate and prevent [MEDICAL CONDITION] in contracted skin folds. The note documented the staff would continue to monitor and report changes to the physician. A wound care specialist evaluation, dated 01/18/18, documented the stage III pressure wound of the resident's left hand was at least of four days duration. The evaluation documented the resident appeared to have associated pain evidenced by grimacing and being restless. The additional information of the evaluation documented the wound was from a contracted third digit and the physician recommended to keep a carrot or cylinder of packing gauze in the resident's hand at all times to keep nails away from his palm. A care plan, dated 01/23/18, documented the resident had actual impairment to skin integrity related to pressure area to his left hand. Care plan interventions listed were for the staff to keep his hands from excessive moisture; to keep his fingernails short; to identify/document potential causative factors and eliminate/resolve when possible; and to monitor/document location, size, and treatment of [REDACTED]. A wound care specialist evaluation, dated 01/25/18, documented site 1 as a stage III pressure ulcer with a duration of greater than 11 days measured 0.8 x 0.4 x 0.2 cm with moderate serous exudate and 100% granulation tissue. The evaluation now documented a site 2 on the resident's distal left hand as a stage III pressure ulcer with a duration of greater than four days. The site 2 wound measured 0.6 x 0.2 x 0.1 cm with moderate exudate and 100% granulation tissue. The physician's treatment orders for both sites was the same as previously. The evaluation documented site 2 was probably not a new wound since the resident had allowed a better examination on this date. The evaluation documented, .PAIN ADDRESSED: recommend hospice supervision and evaluation of wound care to revise PRN options . A skin/wound entry in a nurse's note, dated 02/01/18 at 1:47 p.m., documented a weekly skin assessment was conducted with the wound physician at the resident's bedside. The note documented the stage III pressure ulcer to the resident's left hand measured 0.7 cm x 0.3 cm x 0.2 cm with moderate serous exudate and 100% granulation tissue. The note also documented the resident had a left distal hand stage III wound with moderate serous exudate. The nurse's note documented the physician orders [REDACTED]. A wound care specialist evaluation, dated 02/01/18, documented site 1 with the measurements in the above nurse's note. The evaluation documented the resident appeared to have associated pain evidenced by withdrawal. The evaluation documented site 2 of the left distal hand measured 0.4 cm x 0.2 cm x 0.1 cm with moderate serous exudate and 100% granulation tissue. A wound care specialist evaluation, dated 02/08/18, documented the resident's left hand site 1 measured 0.5 x 0.3 x 0.1 cm with moderate serous drainage with 100 % granulation and hypergranulation tissue within the wound margins. The evaluation documented site 2 measured 0.4 x 0.2 x 0.1 cm with light serous drainage with 100% granulation tissue. Both sites had hypergranulation tissue in the wound margins and had chemical cauterization of the hypergranulation tissue. A wound care specialist evaluation, dated 02/15/18, documented the resident's left hand site 1 measured 0.4 x 0.2 x 0.1 cm with moderate serous drainage with 100% granulation. The evaluation documented the resident's left distal hand site 2 measured 1.0 x 0.4 x 0.2 cm with moderate serous drainage with 100% granulation tissue. The evaluation documented the site 2 wound progress was deteriorated due to new trauma from nails. The evaluation documented a recommendation to trim, buff, and smooth nails and to keep carrot or roll in hand at all times to prevent pressure from nails. The wound physician made no changes in treatment orders. A wound care specialist evaluation, dated 03/01/18, documented the site 1 on the resident's left hand (palm) had resolved. The evaluation of site 2 (left distal hand) documented the wound measured 0.9 x 0.2 x 0.1 cm with moderate serous drainage with 100% granulation tissue. A nurse's note, dated 03/08/18 at 8:26 p.m., documented a weekly skin assessment was conducted. The note documented the measurements to the resident's left distal hand was 0.9 x 0.2 x 0.1 cm with 100% granulation tissue. The note documented for the staff to trim, buff, and smooth nails frequently to keep them from the resident's palm of his hand due to contraction and to apply a hand roll to keep nails away from his palm. A nurse's note, dated 03/15/18 at 5:53 p.m., documented a weekly skin assessment was conducted. The note documented the left distal hand stage III pressure ulcer measured 0.7 x 0.2 x 0.1 cm with 100% granulation. The note documented again about nail care to keep nails away from the palm of his hand due to contraction. A wound physician progress notes [REDACTED]. The note documented the nursing staff reported the wound was better than the previous week. A quarterly assessment, dated 03/25/18, documented the resident was severely impaired in cognition with no exhibited depression. The assessment documented the resident exhibited physical and verbal behaviors towards others for one to three days of the look back period. The assessment documented the resident required extensive assistance to total assistance for ADLs except for eating for which the resident was independent with set up. The assessment documented the resident was at risk for developing pressure ulcers. The assessment documented the resident had one stage III (full thickness loss) pressure ulcer. A care plan, dated 03/26/18, documented the resident needed one person assistance with ADL care. The care plan documented one intervention was for the staff to provide total assistance with personal hygiene. The care plan documented the resident had actual impairment to skin integrity related to a pressure area to his left hand. The goal was documented for the area to heal without signs/symptoms of infection for 30 days. Interventions listed were for the staff to provide treatments as ordered, to perform weekly skin assessments, to monitor for s/s infection, and to keep the resident's fingernails short. A wound care specialist evaluation, dated 03/29/18, documented site 2 with a duration greater than 65 days measured 0.6 x 0.2 x 0.1 cm with moderate serous drainage with 100% granulation tissue. A skin/wound entry in a nurse's note, dated 04/05/18 at 5:19 p.m., documented a weekly skin assessment of the resident's pressure ulcer to his left distal hand was provided. The note documented the stage III pressure ulcer measured 0.6 x 0.2 x 0.1 cm with moderate serous exudate and 100% granulation tissue. The note documented the wound treatment remained the same and to continue with nail care frequently to keep nails away from the resident's palm due to contraction and apply a hand roll. On 04/11/18 at 9:05 a.m., LPN #1 was observed to provide wound care for the resident. The LPN reported the wound physician was seeing the resident for care. The resident's left hand was observed to have a hand roll in place (with a silver alginate strip to the wound). The LPN asked the resident if the treatment could be done and explained to him what would be done. The resident agreed to treatment after three requested attempts. The LPN gloved and removed the old dressing with the hand roll. The LPN gloved and cleansed the hand wound with NS and dried the area. The LPN applied new gloves and applied the hand roll with silver alginate to the wound. The LPN reported the treatment to the wound was scheduled on Mondays,Wednesdays, and Fridays. The LPN reported she would trim his fingernails again this afternoon. The resident did not open his hand completely for the treatment, and his fingers remained curled. On 04/11/18 at 5:00 p.m., the DON was asked if the resident had a hand roll in his left hand prior to him developing the pressure ulcer. The DON reported the resident probably would not have allowed the staff to place one. The DON was asked about his nail care being provided. The DON reported the resident was selective about who he allowed to do anything for him, if at all, and was usually non compliant with care. On 04/12/18 at 9:20 a.m., CMA #1 was asked how long the resident's hand had been closed as a fist. The CMA reported she had been employed since (MONTH) (YEAR) and his hand had been that way when she had came to work. The CMA reported the resident's hand was slowly getting worse for closing. On 04/12/18 at 9:23 a.m., LPN #1 was asked how long the resident had held his left hand as a fist. The LPN reported for years and his left hand was closed more now. The LPN was asked if the resident had ever had a hand roll and the LPN reported the resident would not allow staff to place a hand roll or to cut his nails. On 04/12/18 at 9:25 a.m., the DON reported the resident's hospice service had carrot rolls for his hand ordered. On 04/12/18 at 9:37 a.m., CNA #6 was asked if the resident had a hand roll in his left hand before the open area occurred. The CNA reported the resident was supposed to but the resident would remove it or say get it out of his hand. At the same time, CNA #7 was asked about a hand roll for the resident prior to the occurrence of the open area. The CNA reported attempts had been made to place a hand roll and the resident would remove it. The CNA reported a hospice service would trim his fingernails, but the CNA reported the resident would fight them with attempts for care. On 04/12/18 at 9:40 a.m., the DON reported attempts to place hand rolls for the resident's left hand had been made. The resident's clinical record contained no documentation of attempts of the hand roll placement prior to the wound occurrence. On 04/12/18 at 11:30 a.m., the MDS coordinator reviewed the resident's last MDS assessment which documented the resident had no impairment in range of motion to his extremities. The MDS coordinator was asked if the resident should have been identified to have problems with opening his left hand and how he holds his hand closed. The MDS coordinator reported yes and then she could have care planned the issue. A wound care specialist evaluation, dated 04/12/18, documented the site 2 wound was in duration of greater than 79 days and measured 0.9 x 0.4 x 0.1 cm with moderate serous drainage with 100% granulation tissue. The evaluation documented under the additional information section a single wound on volar hand surface, deep impression of fifth nail. The evaluation documented the resident's nails were clipped and [MEDICATION NAME] as allowed. The recommendation section of the evaluation documented to off-load wound, bolster/carrot in hand to prevent pressure from nail on palm. On 04/12/18 at 3:30 p.m., the wound specialist physician reported the resident opened his hand for him today. He reported the hand was improving with no depth and the wound exhibited hypergranulation. On five days of the five day survey, a treatment gauze hand roll was observed in the resident's left hand. During the five day survey, the resident was observed in bed, in his wheelchair in hallway, lobby, dining room, and eating meals. When observed, the resident did not attempt to remove the rolled gauze. On 04/12/18 at 3:45 p.m., the ADM and DON were informed of the findings which concerned the development of the resident's stage III pressure ulcers in his left hand. The ADM and DON made no comment. 2. Resident #14 was admitted on [DATE] and had [DIAGNOSES REDACTED]. An annual comprehensive assessment, dated 01/12/18, documented the resident was severely impaired in cognition, exhibited no depression symptoms, and exhibited no behaviors. The assessment documented the resident required extensive to total assistance with all ADLS, was incontinent of bowel and bladder functions, and was at risk for pressure ulcer. A care plan, dated 01/16/18, documented the resident had very fragile skin and was at risk for skin tears. The care plan goal documented the resident would be free from skin tears through the review date. The interventions included a new order which was received for protective sleeves to be placed on the resident's forearms and to be worn at all times to protect skin due to the resident's fragile skin, frequent bruising, and skin tears; to provide treatment as ordered; and weekly skin assessments. A care plan, dated 01/16/18, documented a pressure area was noted to an area between the resident's right thumb and index finger. The goal was for the area to be healed x 30 days. The interventions documented for the staff to monitor for signs and symptoms of infection, increase in size, odor; drainage; notify the physician as warranted; treatment as ordered; and weekly skin assessments. The resident's care plan documented the resident needed extensive to total assistance with all ADL care, and the resident was on hospice services which provided bathing for the resident two times a week and prn. A nurse's note, dated 02/21/18 at 1:29 p.m., documented, CNA informed nurse and hospice nurse that resident nails were long and cutting into her right. hospice nurse trimmed her nails and cleaned her hand small cut to hand no s/s (signs and symptoms) infection. A (MONTH) (YEAR) hospice nurse's note documented the resident had hand pain noted with assessment and kept her hand clenched. A hospice nurse's note, dated 04/03/18, contained no documentation of the resident's hand. On 04/09/18 at 10:00 a.m., the resident was observed in bed and lying on her right side. The resident had her eyes closed and appeared to be in no distress. On 04/09/18 at 12:39 p.m., the resident was observed to be partially on her back, with the head of her bed up for meal assistance. The resident had her eyes closed and no distress noted. On 04/10/18 at 11:00 a.m., a hospice staff member was observed in the resident's room. On 04/10/18 at 2:27 p.m., the resident was observed to be lying in bed facing the right side of the bed. The resident's (MONTH) (YEAR) weekly skin check by a licensed nurse on the day shift, documented the resident's skin was intact on 04/10/18. On 04/10/18 at 4:09 p.m., the resident was observed during incontinent care provided by CNA #3 and CNA #4. After the incontinent care was completed, the resident was observed to have a purplish item in her right hand. The CNAs were asked what was the resident holding. CNA #3 opened the resident's hand. The resident winced when her hand was opened. The resident's thumb was observed to be lying across the resident's palm and was a purplish color. The thumb's discoloration began to subside once the hand was opened. The resident's right palm was observed to be red with white particles lying over the redness. An indention was observed at the base of the the resident's little finger where the nail of her thumb was lying. At that time, the CNAs were asked if a hand roll was used by the resident. CNA #3 reported hand rolls had been tried and the resident cried when her hand was opened. On 04/11/18 at 8:30 a.m., CNA #2 was asked about the resident keeping her hand in a fist. The CNA reported the resident would fuss when the staff would try to open her hand. On 04/11/18 at 8:35 a.m., the DON was informed of the resident having hospice care and a skin assessment on the day before (04/10/18). The DON was informed of the observation of the resident's thumb discoloration, the thumbnail indented into the base of the resident's little finger, and the resident's palm being red and possibly having yeast. The DON reported the hospice aides and facility staff should have caught the problem. The DON was asked if the skin assessment by the facility staff should have identified the resident's palm redness and interventions be put in place. The DON reported yes. On 04/11/18 at 9:40 a.m., a hospice nurse was asked if she was familiar with the resident. The hospice nurse reported she was. The hospice nurse was informed of the observations of the resident's thumb positioning and the resident's palm redness and white matter, which resembled yeast. The hospice nurse reported the resident's fingernails on her right hand were moist and flimsy. The hospice nurse reported the hospice aide should have informed the facility or her supervisor of any issues with the resident's hand. On 04/11/18 at 9:50 a.m., the MDS coordinator was asked if the resident's hand positioning and potential for skin integrity impairment should have been addressed on the care plan. The MDS coordinator reported she had not been informed by nursing the resident had an problem with her right hand.

Based on record review, observation and interviews, it was determined the facility failed to: a) Assess and monitor the status of a non-pressure wound resulting in harm for one (#2) of one sampled resident with a non pressure wound resulting in a decline in the wound. This had the potential to affect six residents, identified by the DON, who had non-pressure wounds. b) Assess and monitor signs and symptoms of upper respiratory infections for one (#2) of two sampled residents who had experienced upper respiratory infections. This had the potential to affect 30 residents, identified by the DON, who had experienced infections in the last three months. c) Failed to provide catheter care consistently for one (#2) of one sampled resident who required the use of an indwelling urinary catheter. This had the potential to affect five residents, identified by the Resident Census And Conditions Of Residents form, who required the use of indwelling urinary catheters. d) Failed to assess, monitor and identify two toe [MEDICAL CONDITION] for one (#11) of eight sampled residents whose toes were observed. This resulted in harm for resident #11. This had the potential to affect eighteen residents, identified by the DON who required podiatry services. e) Assess and monitor an elevated temperature for one (#1) of one sampled resident who had experienced an elevated temperature. This had the potential to affect all 55 residents who resided in the facility. Findings: A facility Policy and Procedure for Skin and Wound Management, documented the following: "...The purpose of this procedure is to guide the prevention and treatment of [REDACTED]. Preparation 1. Obtain a physician's orders [REDACTED]. 2. Review the resident's care plan, current orders, and [DIAGNOSES REDACTED]. 3. Check the treatment record. 4. Assemble the equipment and supplies as needed. ...Documentation Record the following information in the resident's medical record: 1. The site and description of the abrasion or wound. 2. The date and time the abrasion was discovered. 3. The date and time the injury occurred, if known. 4. The date and time the wound care was given. ...6. All assessment data (i.e., bleeding, size of wound, tissue loss, etc.) obtained when inspecting the wound. ...11. Interventions implemented or modified to prevent additional abrasions..." 1. a) Resident #2 had been admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. A nurse's note, dated 06/22/14 at 12:20 p.m., documented, "Another nurse reported to this nurse that there was a notable odor to Left AKA site. Order for wound culture and sensitivity obtained. Culture obtained..." On 06/25/14, the culture report to the wound was positive for Proteus Mirabilis and Escherchia Coli ESBL. The resident had been and continued to receive wound care at an acute hospital close to the facility. On 06/27/14 at 1317 (1:17 p.m.), a nursing progress note documented the facility had spoke with the wound care nurse. The wound care nurse advised the facility she believed the best course of action was to have the resident admitted to a long term acute care facility. On 06/30/14 at 12:15 p.m., the resident was transferred to a long term acute care hospital. The resident returned to the facility on [DATE] at 11:15 a.m. A Nurses' Admission Assessment, dated 09/11/14, documented, on the lower thigh of the left leg, an area with healing scabs with multiple sizes above the amputation site. The assessment documented an indwelling urinary catheter in place upon readmission to the facility. A nurse's note, dated 09/13/14 at 10:57 a.m., documented, "Left AKA with scabbing on the lateral side of the leg-scabs are dry and intact with no drainage noted..." A nurse's note, dated 09/13/14 at 5:21 p.m., documented, "Left AKA with scabbing on the lateral side of the leg-resident states it is from adhesive from the dressing after revision surgery..." There was no documentation of the size or number of scabs at the site. The nurses' notes, dated 09/13/14, documented, "11:36 a.m., Left AKA with scabbing on the lateral side of the leg-scabs are dry and intact with no drainage noted... 17:21 (5:21 p.m.) Left AKA with scabbing on the lateral side of the leg-resident states it is from adhesive from the dressing after revision surgery." A nurse's note dated, 09/15/14 at 10:57 a.m., documented, "Left AKA with scabbing on the lateral side of the leg conts" A quarterly assessment, dated 09/16/14, documented the resident was cognitively intact, required limited assistance for transfers, dressing and hygiene, did not walk, required extensive assistance with bathing, required an indwelling urinary catheter, was occasionally incontinent of bowel, had a history of [REDACTED]. The nurses' notes documented the following: 09/16/14 at 3:09 a.m., "Left AKA with scabbing on the lateral side." 09/16/14 at 4:16 p.m., "Left AKA with scabbing on the lateral side of the leg conts." 09/17/14 at 7:46 p.m., "Left AKA with scabbing on the lateral side." 09/18/14 at 4:46 p.m., "Left AKA with scabbing on the lateral side conts this shift." 09/19/14 at 7:53 p.m., "Left AKA with scabbing on the lateral side conts." 09/21/14 at 12:18 p.m., "I noticed the Res picking at the scabs on her L thigh, I reminded the Res not to do that..." 09/21/14 at 8:27 p.m., "noted Res has been picking at her Lt thigh scabs and they are bleeding at this time, n/o for TAO (triple antibiotic ointment), [MEDICATION NAME], and secure with tape, will cont to monitor..." A physician's orders [REDACTED]." There was no description of any open wounds in the medical record. The wounds had not been assessed. No skin assessments had been completed since the resident had been admitted back to the facility on [DATE]. The nurses' notes documented the following: 09/22/14 at 10:07 a.m., "Left AKA with scabbing on the lateral side conts." 09/23/14 at 1:33 p.m., "Left AKA with scabbing on the lateral side conts." 09/24/14 at 2:43 a.m., "Left AKA with scabbing on the lateral side conts." 09/25/14 at 5:58 a.m., "Left AKA with scabbing on the lateral side conts." There was no further documentation of the scabbed areas until 10/12/14, seventeen days later. No skin assessments had been completed for the resident. The nurses' notes documented the following: 10/12/14 at 9:02 p.m., "scab intact to Res top Lt thigh healing well with no s/s of infection to site." 10/16/14 at 9:18 a.m., "Resident was noted this pm to be "picking" at stump area talked with resident about possible getting infection in area resident states ok." There was no documentation of how many scabs had been removed, how many remained or a description of the areas under the removed scabs. No skin assessment had been completed for the resident. A physician's orders [REDACTED]." The nurses' notes documented the following: 10/29/14 at 11:13 a.m., "Resident noted this pm to be picking at her scabbed areas to lt (left) stump area talked with resident about not doing this due to causing infection resident states I know but conts to pull scabs off daughter here at this time and also talked to resident encouraged not to pull off scabs." A nurse's note, dated 11/01/14 at 4:14 a.m., documented, "noted the Res has been picking at scabs to Lt above knee amp." There was no documentation of how many scabs had been removed, how many remained or description of the areas under the removed scabs. No skin assessment had been completed for the resident. A care plan, dated 11/13/14, documented a problem of a wound to L AKA. Interventions included: Arginade for wound healing, to document and monitor measurements weekly, keep dressing dry and intact, monitor for s/sx of infection and weekly skin evaluations. There was no further documentation of the scabbed areas until 11/22/14, twenty-one days later. A nurse's note dated, 11/22/14 at 11:52 a.m., documented, "While performing wound care, the wound was noted to be malodorous. New order received for wound culture. Culture obtained and delivered to (hospital name deleted) lab by this nurse." There was no description of the wound in the medical record. The wound was not sized or staged. A nurse's note, dated 11/28/14 at 12:36 p.m., documented, "Wound culture results received from (lab name deleted) (physician's name deleted) notified of results and sensitivities, New order received for [MEDICATION NAME]. Family notified." A nurse's note, dated 11/29/14 at 2:14 p.m., documented, "Res. received initial dose of [MEDICATION NAME] this evening..." The antibiotic was initiated seven days after the culture was obtained. On 11/30/14, the resident was seen by a wound care physician. A Wound Care Specialist Initial Evaluation record documented the following: "History of Present Illness Chief Complaint: [AGE] year old female patient has a wound of the left, distal, dorsal thigh of at least 10 days duration. There is heavy serous exudate associated with the wound... Wound of the Left Distal Dorsal Thigh Focused Wound Exam (Site) Duration 10 days Objective: Healing Wound Size (LXWXD): 3.6 x 4.5 x Not Measurable cm Surface Area: 16.20 cm Exudate: Heavy Serous Thick Adherent Devitalized Necrotic Tissue: 95% Skin: 5% Additional Information 2014 [DATE] first assessment by me. Clinically infected site separate from surgical incision but concerning... Procedure: Surgical Excisional Detriment of Muscle Indication Remove Necrotic Tissue and Establish the Margins of Viable Tissue Remove Thick Adherent Eschar and Devitalized Tissue... Residual Necrosis: Present and Scored... Description Wound debrided via surgical excision and muscle removed along with necrotic tissue..." On 12/09/14 at 2:30 p.m., wound care was observed for the resident. The wound was observed open with muscle tissue visible in the bottom of the wound bed. The wound was draining serous fluid. At that time, the resident reported the area had started out as a blistered area when the dressing was removed, while she was still in the hospital. She reported the blister had dried up and left scabbed areas. LPN #2, who was providing the wound care, reported the wound care physician had debrided the wound last week. She reported the wound physician would be in the facility tomorrow and measure the wound. On 12/10/14, the resident was seen by a wound care physician. A Wound Care Specialist Initial Evaluation record documented the following: "History of Present Illness Chief Complaint: [AGE] year old female patient has a wound of the left, distal, dorsal thigh of at least 19 days duration. There is heavy serous exudate associated with the wound the patient verbalizes pain with score of 5 out of 10. Wound of the Left Distal Dorsal Thigh Focused Wound Exam (Site) Duration 19 days Objective: Healing Wound Size (LXWXD): 2.5 x 5.0 x Not Measurable cm Surface Area: 12.50 cm Periwound radius: [DIAGNOSES REDACTED], margins ragged. Exudate: Heavy Serous Thick Adherent Devitalized Necrotic Tissue: 80% Granulation Tissue: 20% Wound Progress: Improved Findings that indicate improvement: Decreased Surface Area Procedure: Surgical Excisional Detriment of Muscle Indication Remove Necrotic Tissue and Establish the Margins of Viable Tissue Remove Residual Necrosis: Present and Scored... Description: Wound debrided via surgical excision and muscle removed along with necrotic tissue..." On 12/10/14 at 4:15 p.m., the DON was asked for any other documentation for the wound. She reported she would try and find the information. She was asked if she knew when the wound opened up. She reported she had not seen the wound. On 12/11/14 at 8:20 a.m., the DON reported the only documentation of the wound would be in the wound care physician's notes. She reported no skin assessments had been completed. The facility failed to assess and monitor the wound in a consistent manner. No skin assessments with size and measurements were completed for the wound, which required debridement of muscle and tissue. b) Resident #2 had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. [MEDICATION NAME] Z-Pak 250 MG Tablet By mouth-AM MEDICATION PASS Everyday." A nurse's note, dated 10/09/14, documented, "...Resident also continues to be on Z-PACK AND [MEDICATION NAME] DOSE PACK for cough and congestion without any noted s/e. Continues to have occasional non productive cough." There was no documentation of the resident's condition or what prompted the need for the above medications. There was no assessment in the medical record of the resident's respiratory status before the medications were initiated. A physician's orders [REDACTED]. [MEDICATION NAME] Z-Pak 250 MG Tablet By mouth-AM MEDICATION PASS Everyday." A nurse's note, dated Late Entry 10/31/14, documented, "received order for z-pak and [MEDICATION NAME] dose pak. order written, family notified. will cont to monitor." There was no documentation of the resident's condition or what prompted the need for the above medications. There was no assessment in the medical record of the resident's respiratory status before the medications were ordered. On 12/10/14 at 4:40 p.m., the DON was notified of the lack of assessment of the resident's respiratory status. She reported she would check to see if there was any more information about the resident's status. On 12/11/14 at 8:20 a.m., the DON reported she could not find anything else on the resident's respiratory status prior to the need for the respiratory medications. c) Resident #2 had been admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. On 06/30/14 at 12:15 p.m., the resident was transferred to a long term acute care hospital. The resident returned to the facility on [DATE] at 11:15 a.m. A Nurses' Admission Assessment, dated 09/11/14, documented, on the lower thigh of the left leg, an area with healing scabs with multiple sizes above the amputation site. The assessment documented an indwelling urinary catheter in place upon readmission to the facility. A physician's treatment order, dated 11/11/14, documented, "Foley Cath Care Q Shift. Order Date: 11/11/2014 Q SHIFT EVERY SHIFT Everyday." A care plan, dated 11/13/14, documented a problem of the resident requiring an indwelling urinary catheter related to a [DIAGNOSES REDACTED]. On 12/09/14 at 4:10 p.m., the resident was asked if she would allow the surveyor to observe catheter care when the care was scheduled. The resident reported no one did catheter care for her. The resident reported she did the catheter care herself. The treatment sheet for December 2014 was reviewed. Catheter care was documented for all three shifts from December 1st to December 10th. On 12/10/14 at 1:30 p.m., LPN #2 was observed providing catheter care for the resident. At that time, the resident was asked if the catheter care was always provided in the way it was currently being done. She stated, "Are you kidding? No." After the catheter care was completed, and LPN #2 had left the resident's room, LPN #2 was asked about the resident not receiving the catheter care as documented on the treatment sheet. LPN #2 reported she did not do the catheter care. She reported the CNAs did the catheter care when doing perineal care. She reported she would then chart the catheter care as being done. She was asked about the charting every shift. She reported the catheter care was not completed every shift as documented. On 12/11/14 at 8:20 a.m., the DON was notified of the lack of catheter care for the resident. She reported she would check on it and see what was going on. 2. Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/02/14, documented the resident was moderately impaired with cognition, exhibited occasional depression and exhibited no behaviors toward others. The resident required extensive assistance of one person for hygiene and total assistance for bathing of one person. The resident was always incontinent of bowel and bladder. A nursing care plan, dated 10/15/14, identified a problem for weight loss. Interventions listed was for the resident to have diabetic nail and foot care weekly by the LPN. The resident was to have her feet inspected daily for open areas, sores, pressure areas, blister, [MEDICAL CONDITION] or redness and to have weekly skin checks. On 12/11/14 at 11:20 a.m., the DON was asked to accompany the surveyor to look at the resident's feet. The DON removed the resident's socks. Band-Aids were observed on both of the resident's great toes. The DON was asked why the resident had Band-Aids on her toes. She reported she did not know why there were Band-aides on the resident's toes. The DON reported the facility did not have Band-Aids on the premises. If a Band-Aid type of dressing was required, the staff used a cotton ball and a piece of tape. The DON was asked how or when the Band-Aids had been applied. She reported maybe when the podiatrist did toenail procedures on 11/14/14. When the surveyor requested to read the procedure notes, the DON reported the notes were not in the facility. She reported the facility had contacted the podiatry service multiple times to obtain the notes. At 1:40 p.m., the DON was asked to remove the Band-Aid from the resident's great toes. As the DON removed the right great toe Band-Aid, the resident complained of discomfort. The Band-Aid was well adhered to the right toe. The left great toe's Band-Aid was removed with more difficulty. The resident reported it hurt. There was a 0.3 cm. scabbed area on the tip of the resident's left great toe. There was an abrasion on the medial side of the left great toe. The DON reported she was not aware the resident had these areas. The left great toe's nail bed was moist with no odors or drainage observed. The resident's feet were extremely dry. The resident's right toes and bottom of her right foot were coated with thick dry skin. The DON provided skin care with lotion to the resident's feet. The resident reported her feet felt much better. The DON was asked if she thought the head to toe weekly skin assessments were being conducted. She stated, "Obviously not." The DON was asked if the daily feet inspections were accurate. She shook her head no. The DON reported the issue would be addressed. At 4:40 p.m., LPN #2 was asked about the Band-Aids to the resident's great toes. She reported she knew nothing about the resident having Band-Aids on her toes. The LPN was asked about the scabbed area to the tip of the resident's toe. She reported she didn't know the resident had a scabbed area on her toe. The LPN was asked, when she did the resident's head to toe assessments, did she remove the resident's socks. The treatment nurse reported she guessed she over looked removing the resident's socks. The LPN reported she would make sure she was looking at all of the residents' feet when doing head to toe skin assessments. 3. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. On 08/14/14, the clinical record documented the resident's temperature was 101.3 degrees F., respirations were congested and wheezing heard. Tylenol was administered as directed by the physician's routine order. The clinical record contained no documentation the effectiveness of the Tylenol medication was monitored or the resident was reassessed. The clinical record documented the staff notified the physician of the resident's temperature and respiratory congestion. New orders were obtained from the physician for a mobile chest ray. The radiology report indicated the resident had atelectasis. Additional orders were given for the facility to administer breathing treatments to the resident for five days. A quarterly assessment, dated 10/16/14, documented the resident was severely impaired with cognition and demonstrated minimal depression. The resident required total assistance of the staff for all ADLs. A nursing care plan, dated 11/24/14, documented a goal was for the resident to remain free of side effects or complications related to tube feeding through the review date. Interventions listed "... monitor/document/report to MD PRN: Aspiration-fever, SOB, Tube dislodged, infection at the tube site, self-extubation, abnormal breath/lung sound..." On 12/10/14 at 9:50 a.m., the DON was asked if she expected the staff to monitor the effectiveness of medication or treatments. She stated,"Yes." She reported she would conduct education with the staff.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to notify the physician when a resident (#14) experienced a change in condition. At 3:45 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified at 4:00 p.m. At 4:10 p.m., the ADM and the DON were notified of the IJ situation. At 5:10 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "Ada Care Center Plan of removal for IJ related to Assessment monitoring and Physician notification. 100% of Staff will be inserviced on observing for any change of condition and notifying charge nurse immediately. 100% of Nurses will be inserviced on when notified of any change of condition what follow up is required, including assessment and monitoring applicable to change of condition with Physician notification. Will be completed by [DATE] at 12:00 Noon. Any staff that is not inserviced at that time will be inserviced prior to working their scheduled shift." A copy of the Plan of Removal was provided on [DATE] with the notation, "All staff was completed at 3:00 PM on [DATE]." On [DATE] at 10:00 a.m., the staff were interviewed and were knowledgeable in regard to the reporting of resident condition changes. All licensed staff were knowledgeable concerning notifying the physician of changes in condition and proper documentation. The Immediate Jeopardy was removed after all staff had been inserviced on [DATE], at 3:00 p.m. The deficient practice remained at actual harm at a pattern. Based on record reviews, observations, and interviews, it was determined the facility failed to: a) Ensure the physician was notified when one (#14) of one sampled resident, had experienced an episode of eating difficulties and a decrease in oxygen saturation. This had the potential to affect 57 residents, identified by the DON, who received meals from the dining room. Three residents, identified by the DON, received nourishment via gastrostomy tubes. b) Ensure the physician was notified when one (#7) of one sampled resident, had significant weight loss. This had the potential to affect all 61 residents who resided in the facility. c) Ensure the physician was notified when one (#12) of one sampled resident, continued to have pain with restorative services. This resulted in actual harm. This had the potential to affect eight residents, identified by the DON, who received restorative services. d) Ensure the physician was notified when one (#3) of one sampled resident, had dietary recommendations which concerned the resident's weight loss and when the resident had experienced frequent loose stools. This had the potential to affect 18 residents, identified by the DON, who had dietary recommendations in the past three months. e) Ensure the physician was notified when one (#8) of one sampled resident, refused to wear TED hose. This had the potential to affect one resident, identified by the DON, who had an order for [REDACTED]. Findings: 1. Resident #14 had [DIAGNOSES REDACTED]. A speech therapy report, dated [DATE], documented the resident had a modified [MEDICATION NAME] swallow study completed. The speech therapist recommended a mechanical soft diet with nectar consistency liquids. No documentation was provided by the facility in regard to the recommendation being acted upon. The resident's care plan, initiated [DATE], documented, "Focus (Resident's name deleted) has a potential nutritional problem unplanned weight changes, aspiration, noncompliance r/t receives a Regular NAS diet with Nectar Thick Liquids... Interventions ...Monitor/document/report to MD PRN for s/sx of dysphagia: Pocketing, choking, coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals... Focus (Resident's name deleted) has had a significant decline noted in his cognitive function... Interventions ...Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status..." The [DATE] physician's orders [REDACTED]. "Diet: Type: NAS (No Added Salt) Texture: Regular Fluid Consistency: Nectar Special Instructions: Magic cup and Health Shake with each meal... Supplement: Protein Powder Special Instructions: 4 scoops of protein powder in hot cereal with breakfast daily..." Continuous O2 @ 3 LPM DX of [MEDICAL CONDITION] - EVERY SHIFT Everyday." A physician's progress note, dated [DATE] documented, "Mouth sore. apneic spells /c sleep (word undecipherable) arousable mouth tongue dry & red. blood dried on lower lip. lungs coarse bs (breath sounds) heart reg abd soft nontender...." On [DATE], at 1:35 p.m., the nurses' notes documented, "during lunch resident noted to hold food in mouth, contents manually removed by this nurse, o2 cont at 3 l/m per o2 tank, per n/c, color ashen does refuse to eat pushing our hand back saying no no, did get resident to drink few drinks of health shakes, resident cont up in w/c with portable o2 on, resident to rm per cna. hospice nurse paged." At 1:45 p.m., the nurses' notes documented, "resident resting in bed with eyes closed, o2 on per n/c at 3 Lpm, respirations shallow. at present resident not following command to breath through nose. v/s ,[DATE]-[DATE].4 o2 sats ,[DATE]% on his o2. skin cool/dry." There was no documentation of notification of the physician in regard to the resident's pocketing food episode or the resident's oxygen saturations. There was documentation of assessing the resident's lung sounds or respiratory status. At 5:54 p.m., the nurses' notes documented, "resident noted with vitl (sic) functions ceased. no obtainable b/p or pulse. hospice and family notified. also dr. (name deleted) notified." There was no documentation of assessing the resident, monitoring the resident, or contacting the physician between 1:45 p.m. and 5:54 p.m. On [DATE], at 1:15 p.m., the DON was asked about the resident's condition prior to the pocketing episode. She reported the resident had declined for weeks. At 1:20 p.m., LPN #3 was asked about the resident's condition. She reported the resident had not been eating well and had declined over time. The resident was fed by CNA #2 at lunch and she (LPN #3) had to remove food from the resident's mouth during the meal due to pocketing and not swallowing. At 1:45 p.m., CNA #2 was interviewed. He reported the resident had problems breathing if his oxygen was off. He reported the resident always made panting noises when breathing, even with oxygen. He reported at the noon meal on that day, the resident pocketed his food and had trouble trying to eat, and was not attempting to swallow. He reported the resident had not appeared to be in distress or trouble. He reported the resident appeared more red in the face. He reported he did not think the resident choked on the food. CNA #2 further reported he had only given the resident a couple of bites of food when a family/staff member, who was the administrative assistant, observed the resident with food in his mouth. The family member/ administrative assistant then notified the charge nurse to assist the resident. LPN #3, the charge nurse, removed the food from the resident's mouth. CNA #2 reported the resident's family member/administrative assistant tried to get the resident to eat more and the resident refused. CNA #2 reported he assisted the resident back to bed between 1:30 p.m. and 1:40 p.m. He reported he removed the oxygen tubing from the resident for the transfer from the wheelchair to the bed and forgot to apply the oxygen back on the resident. CNA #2 reported he was making change of shift rounds at 1:45 p.m., when CNA #7 informed him she had reapplied the oxygen to the resident. CNA #2 reported he believed the resident's oxygen was not off for more than ,[DATE] minutes. He reported the resident always had difficulty breathing but he did not notice the resident breathing any differently. At 2:10 p.m. the family member/administrative assistant was interviewed. She reported she was the only management person in the building on that day since it was a holiday. The family member/administrative assistant reported, at approximately 1:15 p.m., she noticed CNA #2 trying to feed the resident. She reported there was "a hunk of wiener" sticking out of the side of the resident's mouth. She reported she noticed the resident was not breathing. She told the CNA the resident was not breathing and for him to get the food out of the resident's mouth. She reported the CNA stated, "Come on buddy, spit it out." She reported she notified the charge nurse, LPN #3, of the problem, at that time. She reported the LPN stated, "He's packing," and took a spoon and scooped the food from the resident's mouth. The family member/administrative assistant reported there was about a "bowlful" of food removed. The family member/administrative assistant reported the resident looked strange and his breathing was not audible. She reported he started to get purple around the lips. She reported the resident was staring and had his mouth open. The family member/administrative assistant reported the LPN #3 told CNA #2 to assist the resident to bed in "a little bit." The family member/administrative assistant reported the resident was less responsive and "was in a daze." She reported the resident did not shake or nod his head to respond to questions. The family member/administrative assistant reported the hospice nurse arrived after that, but was unsure of the time, but reported it was before 2:15 p.m. She reported the hospice nurse reported the hospice staff would increase their visits to five times a week. She reported she did not know if the hospice nurse saw the resident. The family member/administrative assistant reported she did not see the resident again before she left work. She reported she got the phone call about the resident expiring about 6:00 p.m., while she was on her way home. At 2:50 p.m., LPN #3 was interviewed. She reported she was called to the dining room during the lunch meal. She reported CNA #2 told her the resident was pocketing food. She reported she took a spoon and scooped out "not more than a couple of bites." She reported the resident took a few sips of the Health Shake after the food was removed. LPN #3 reported the resident did not cough or choke and the resident did not stop breathing. LPN #3 reported she called hospice, but she did not notify the physician. LPN #3 reported before she had left the resident's room to give shift report, the resident's oxygen saturation was 90%. There was no documentation of this oxygen saturation in the clinical record. On [DATE], at 4:00 p.m., LPN #2 was interviewed. She reported she was told by LPN #3 during the shift change report, that she (LPN #3) had removed a lot of food out of the resident's mouth at lunch time. LPN #2 reported she had seen the resident that afternoon after shift change. She reported she should have documented her observations. She reported she had not taken another set of vital signs or obtained oxygen saturations. She reported she did not call the physician until the resident had expired. 2. Resident #12 was readmitted on [DATE], with [DIAGNOSES REDACTED]. The care plan dated [DATE], documented, "Focus (resident name deleted) has a Dx: Arthritis and generalized pain. Goals (resident name deleted) will maintain acceptable level of comfort (as expressed by her)... (name deleted) will remain free of further complications related to arthritis: contractures, joint stiffness, swelling, or further decline in mobility through review date. Interventions Daily range of motion exercises both active and passive as tolerated during routine care. ...Give [MEDICATION NAME] as ordered by the physician. Monitor and document for side effects and effectiveness.... Monitor/document/report to MD PRN s/sx or complications related to arthritis: Joint pain, Joint stiffness, usually worse on wakening, Swelling, Decline in mobility, Decline in self care ability, Contracture formation/joint shape changes, Crepitus (creaking or clicking with joint movement), pain after exercise or weight bearing." A significant assessment, dated [DATE], documented the resident's cognition was moderately impaired with short and long term memory problems, required extensive assistance of two persons with transfers and required total dependence of one person for bathing. The resident was dependent in a wheelchair for mobility. The assessment, for functional limitation in range of motion, documented impairment on one side for upper extremity (shoulder, elbow, wrist, and hand) and impairment on both sides for lower extremity (hip, knee, ankle, and foot). The [DATE] physician's orders [REDACTED]." A progress note, dated [DATE], documented, "RA progress: Resident tolerating hand splint to right hand during RA sessions. Tolerates lower extremity PROM well. Does not tolerate upper extremity PROM as well." The RA progress notes for [DATE], documented the resident cried when ROM was performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The RA progress notes for [DATE], documented the resident cried when ROM was performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The RA progress notes for [DATE], documented the resident cried when ROM was performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No documentation was found in the progress notes of the physician being notified concerning the resident's pain when restorative exercises were performed. On [DATE] at 8:30 a.m., the RA was interviewed in regard to how restorative care was performed on resident #12. She reported she assisted the resident with upper and lower exercises. The RA was asked if the the resident complained of pain when she performed restorative care. She reported the resident would complain of pain and cry at times. The RA was asked what she would do when the resident would complain of pain and start to cry. She reported she would try different ways to move her arms and loosen them up. The RA reported some days the resident would try really hard to work through the pain. The RA was asked if she had reported the resident's pain to the charge nurse. She stated, "Yes." The RA also reported she would meet with the DON once a week and report how the residents on restorative services were doing. The RA was asked if she had received her restorative certification. She stated, "No." The RA reported she was enrolled for the August class for restorative certification, but the class was canceled. The RA was asked if she had been trained by the physical therapy personnel. She stated, "Nobody from PT came and showed me what to do. All I know is what I got from CNA class." LPN #3 and LPN #1 were both asked if the RA had notified either of them about the resident experiencing pain with restorative exercises. Both LPNs reported they did not think the RA reported the pain. Both LPNs reported they would have given medication for pain relief. At the same time, the DON was asked how she monitored the restorative care provided for the residents. The DON reported she would ask the restorative aide once a month how everyone was doing. The DON was asked if she kept a record on how the residents were progressing or declining on their restorative program. She stated, "No." At 1:20 p.m., the resident was asked by the surveyor if her arm hurt when the staff moved her. The resident just looked down and no comment was made. The resident's extremities were observed. The right arm was flexed at the elbow and the wrist was contracted backward. The right hand and fingers were flexed downward. The right hand was flexed at 90 degrees inward toward the resident's body. The RA was observed to provide restorative exercises for the resident. The right hand was lifted by the RA to straighten her fingers. The resident expressed a facial grimace at that time. At the same time, CNA #8 was asked if the resident grimaced during care. The CNA reported the resident grimaced and made noise when she was dressed. The CNA stated, "We try to be easy with her, but it does hurt her." The CNA reported the resident had not cried with the ADL care provided. On [DATE] at 4:00 p.m., the DON was notified of the resident experiencing pain with the restorative exercises and was asked if the physician had been notified of the resident's pain. She reported she was unaware of the resident's pain with restorative exercises and she would address the matter. 3. Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. The [DATE] physician's orders [REDACTED]. Hold and notify charge nurse if residual greater than 100 cc. Flush Peg Tube with 150 cc H2O each shift. Enteral Tube - EVERY SHIFT Everyday FLUSH TUBE AFTER EACH MED WITH 30 CC WATER. Enteral Tube Everyday.. [MEDICATION NAME] 10 mg/ml liquid enteral tube - twice daily Everyday..." An admission assessment, dated [DATE], documented the resident had severe cognitive impairment, required extensive assistance of two persons with transfers, extensive assistance of one person with bed mobility, dressing, hygiene and toileting, required total assistance with bathing and eating of one person and was incontinent of bowel and bladder function. The admission assessment documented his weight as 117 pounds. The resident's care plan, updated [DATE]., documented: "Focus (Resident's name deleted) has a potential nutritional problem of unplanned weight loss, aspiration r/t receives all nutrition via PEG tube. NPO status. Goals (Resident's name deleted) will maintain adequate nutritional status as evidenced by maintaining weight within 5% of baseline... Interventions ...Monitor/record/report to MD PRN s/sx of [MEDICAL CONDITION]: Emaciation (Cachexia), muscle wasting, significant weight loss... ...Provide, administer Fibersource HN1 can q 4 hours...Monitor intake and record q meal. RD to evaluate and make diet change recommendations PRN... RD to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed... Monitor/document/report to MD PRN...Diarrhea..." The May and [DATE] ADL forms documented the resident had experienced loose stools. On [DATE], the Registered Dietician documented, "No wt change last month - this month wt decreased to 110# Would consider changing formula to more calorically dense: [MEDICATION NAME] 1.5 6 can/day would provide additional 360 Kcal/day or [MEDICATION NAME] HN - reduce feedings to 5 cans/day would still provide additional 600 kcal/day (tolerance can be more difficult - has less fiber)." The resident's weight summary documented: [DATE]...116.5 [DATE]...116.4 [DATE]...109.6 [DATE]...109.0 [DATE]...109.4 [DATE]...109.8 [DATE]...108.8 [DATE]...109.0. During a review of the resident's MAR and TAR, there was missing documentation for the administration of the feeding. In April, 2012, there were 11 missed opportunities to document the FiberSource HN in the MAR. In June, 2012, there were eight missed opportunities to document the FiberSource HN in the MAR. In July, 2012, there were two missed opportunities to document the FiberSource HN in the MAR. There was no documentation in the clinical record of the amount/volume of feeding and fluids the resident had received since admission to determine accurate daily calorie intake. On [DATE] at 3:00 p.m., CNA #1 was interviewed in regard to the resident's care. The CNA reported the resident always had loose stools. At 3:15 p.m., the DON was asked about the recording of intake and output for the resident. The DON raised her hands and stated, "I don't know. Usually in POC, but wasn't there. I'm taking care of it now." On [DATE] at 8:05 a.m., the DON and ADM were notified of concerns with the resident's weight. The DON reported she thought the change in weight from 116 to 109 pounds was due to the change of how the resident was weighed. The DON reported the weights were consistent now. The DON reported any recommendations made by the dietician were sent to the physician. A copy of the dietician's recommendation, with the physician's response, was requested. At the same time, the DON was interviewed concerning the resident's loose stools. She reported she would address the situation. At 4:30 p.m., (Physician's name deleted) was interviewed at the facility. He reported he knew the resident's weight and would wait on the recommendation from the dietician before he changed the feeding order. He reported it was his protocol on changing tube feeding orders to go by the recommendation of the dietician. The physician reported he was not aware of the resident having loose stools. He reported the [MEDICATION NAME] should be held when a resident had loose stools. On [DATE], at 2:15 p.m., the Registered Dietician reported she made recommendations and printed an explanation to make the recommendation clearer. She reported the facility was to send the recommendation to the physician. When informed the physician was not aware of her recommendations, she made no comment. At 4:00 p.m., the DON reported she had notified the physician of the RD's recommendations. She reported she obtained a new order to hold the [MEDICATION NAME] when the resident had loose stools. 4. Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission assessment and the comprehensive care plan were still in progress for completion. An interim/temporary care plan had been formulated on [DATE]. A physician's orders [REDACTED]." On [DATE], [DATE], and [DATE], the resident was observed without the TED hose. On [DATE] at 4:00 p.m., the resident was asked about the use of the TED hose. The resident reported when she had a shower on [DATE], the TED hose were sent to the laundry and she had not received them back. At 4:50 p.m., LPN #2 was asked why the resident did not have her TED hose on as ordered. The LPN reported she had not realized the TED hose were not on the resident. At 4:55 p.m., the DON was asked about the resident not wearing her TED hose as ordered. The DON reported the resident had been refusing to wear the TED hose. The DON further reported the resident had told the nurses since she already had a blood clot in her lung, she did not think the TED hose would make a difference. At 5:00 p.m., the resident was asked if she had refused to wear the TED hose before. The resident reported she had refused before since they were uncomfortable and were difficult to get on and off. The resident reported she would rather not wear them, but then added would do so if told. There was no documentation in her clinical record that the resident had refused to wear the TED hose. The physician had not been notified the resident was not wearing the TED hose as ordered. On [DATE] at 1:20 p.m., LPN #2 reported the physician was notified today. 5. Resident #7 was admitted on [DATE], with numerous [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented, "Focus resident (name deleted) has a potential nutritional problem unplanned weight changes r/t s/sx of depression, [MEDICAL CONDITION], Nausea/Vomiting. Goals resident (name deleted will maintain adequate nutritional status as evidenced by maintaining weight within 5% of her admission weight, no s/sx of [MEDICAL CONDITION], consuming at least 25% of meals daily through review date. Interventions monitor/record/report to MD PRN s/sx of [MEDICAL CONDITION]: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs in 1 week, greater than 5% in one month, greater than 7.5% in 3 months, greater than 10% in 6 months." At the time of admission, the resident was on a regular diet. The following were the monthly weights for the resident: [DATE] 149.8 pounds [DATE] 148.4 pounds February 2012 142.2 pounds [DATE] 138.2 pounds [DATE] 136.0 pounds. No documentation was in the clinical record to indicate the physician was notified of the resident's weight loss from [DATE] to [DATE]. On [DATE], the resident had a physician's orders [REDACTED]. Snacks were ordered to be given at 2 p.m. and 8 p.m. This change was made to the resident's diet after losing 13.8 lbs from [DATE] to [DATE]. A significant change assessment, dated [DATE], documented the resident was cognitively intact and required supervision and setup only with eating. The significant change assessment did not document the resident's weight loss, which was greater than 7.5% in three months. The resident's May weight was documented at 131 pounds. The resident had a weight loss of an additional five lbs. in one month. There was no change made to the resident's diet. No documentation was in the clinical record to indicate the physician was notified of the resident's additional five pound weight loss in May. The monthly weights indicated the resident experienced a significant weight loss. On [DATE] at 11:00 a.m., the DM was interviewed. She reported she would talk to the dietician about the resident's weight loss. At 1:45 p.m., the DON was asked why the resident was not on the weight loss list. She reported the resident should have been on the weight loss list to provide weekly weights and maybe she was taken off the list too soon. When the DON was asked if the physician had been notified in regard to the additional weight loss, she stated, "I don't see anything." At 2:15 p.m., the RD was interviewed. The RD reported she would make the dietary recommendations and then the facility would notify the physician.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to assess, monitor and intervene when a resident (#14) experienced a change in condition. At 3:45 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified at 4:00 p.m. At 4:10 p.m., the ADM and the DON were notified of the IJ situation. At 5:10 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "Ada Care Center Plan of removal for IJ related to Assessment monitoring and Physician notification. 100% of Staff will be inserviced on observing for any change of condition and notifying charge nurse immediately. 100% of Nurses will be inserviced on when notified of any change of condition what follow up is required, including assessment and monitoring applicable to change of condition with Physician notification. Will be completed by [DATE] at 12:00 Noon. Any staff that is not inserviced at that time will be inserviced prior to working their scheduled shift." A copy of the Plan of Removal was provided on [DATE] with the notation, "All staff was completed at 3:00 PM on [DATE]." On [DATE] at 10:00 a.m., the staff were interviewed and were knowledgeable in regard to the reporting of resident condition changes. All licensed staff were knowledgeable concerning notifying the physician of changes in condition and proper documentation. The Immediate Jeopardy was removed after all staff had been inserviced on [DATE], at 3:00 p.m. The deficient practice remained at actual harm at a pattern. Based on record reviews, observations, and interviews, it was determined the facility failed to: a) Ensure assessment and monitoring was conducted for one (#14) of one sampled resident, after a change in condition. This had the potential to affect all 61 residents who resided in the facility. b) Ensure intervention was provided for one (#12) of one sampled resident who experienced pain with restorative services. This resulted in actual harm. This had the potential to affect eight residents, identified by the DON, who received restorative services. c) Ensure assessment and monitoring was conducted on a consistent basis for one (#1) of one sampled resident who experienced a stasis ulcer. This had the potential to affect five residents, identified by the DON, with non-pressure ulcers. d) Ensure nursing and pain assessments were completed for one (#6) of nine sampled residents. This had the potential to affect all 61 residents who resided in the facility, e) Ensure assessment and monitoring was conducted for the skin condition of one (#10) of three sampled residents who had history of skin conditions. This had the potential to affect 55 residents, identified by the DON, who received preventative skin treatments. f) Ensure proper placement of the urinary catheter tubing was provided for one (#5) of one sampled resident who had an indwelling urinary catheter. This had the potential to affect four residents, identified by the DON, with indwelling urinary catheters. Findings: 1. Resident #14 had [DIAGNOSES REDACTED]. A speech therapy report, dated [DATE], documented the resident had a modified [MEDICATION NAME] swallow study completed. The speech therapist recommended a mechanical soft diet with nectar consistency liquids. No documentation was provided by the facility in regard to the recommendation being acted upon. The resident's care plan, initiated [DATE], documented, "Focus (Resident's name deleted) has a potential nutritional problem unplanned weight changes, aspiration, noncompliance r/t receives a Regular NAS diet with Nectar Thick Liquids... Interventions ...Monitor/document/report to MD PRN for s/sx of dysphagia: Pocketing, choking, coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals... Focus (Resident's name deleted) has had a significant decline noted in his cognitive function... Interventions ...Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status..." The [DATE] physician's orders [REDACTED]. "Diet: Type: NAS (No Added Salt) Texture: Regular Fluid Consistency: Nectar Special Instructions: Magic cup and Health Shake with each meal... Supplement: Protein Powder Special Instructions: 4 scoops of protein powder in hot cereal with breakfast daily..." Continuous O2 @ 3 LPM DX of [MEDICAL CONDITION] - EVERY SHIFT Everyday." A physician's progress note, dated [DATE] documented, "Mouth sore. apneic spells /c sleep (word undecipherable) arousable mouth tongue dry & red. blood dried on lower lip. lungs coarse bs (breath sounds) heart reg abd soft nontender...." On [DATE], at 1:35 p.m., the nurses' notes documented, "during lunch resident noted to hold food in mouth, contents manually removed by this nurse, o2 cont at 3 l/m per o2 tank, per n/c, color ashen does refuse to eat pushing our hand back saying no no, did get resident to drink few drinks of health shakes, resident cont up in w/c with portable o2 on, resident to rm per cna. hospice nurse paged." At 1:45 p.m., the nurses' notes documented, "resident resting in bed with eyes closed, o2 on per n/c at 3 Lpm, respirations shallow. at present resident not following command to breath through nose. v/s ,[DATE]-[DATE].4 o2 sats ,[DATE]% on his o2. skin cool/dry." There was no documentation of notification of the physician in regard to the resident's pocketing food episode or the resident's oxygen saturations. There was documentation of assessing the resident's lung sounds or respiratory status. At 5:54 p.m., the nurses' notes documented, "resident noted with vitl (sic) functions ceased. no obtainable b/p or pulse. hospice and family notified. also dr. (name deleted) notified." There was no documentation of assessing the resident, monitoring the resident, or contacting the physician between 1:45 p.m. and 5:54 p.m. On [DATE], at 1:15 p.m., the DON was asked about the resident's condition prior to the pocketing episode. She reported the resident had declined for weeks. At 1:20 p.m., LPN #3 was asked about the resident's condition. She reported the resident had not been eating well and had declined over time. The resident was fed by CNA #2 at lunch and she (LPN #3) had to remove food from the resident's mouth during the meal due to pocketing and not swallowing. At 1:45 p.m., CNA #2 was interviewed. He reported the resident had problems breathing if his oxygen was off. He reported the resident always made panting noises when breathing, even with oxygen. He reported at the noon meal on that day, the resident pocketed his food and had trouble trying to eat, and was not attempting to swallow. He reported the resident had not appeared to be in distress or trouble. He reported the resident appeared more red in the face. He reported he did not think the resident choked on the food. CNA #2 further reported he had only given the resident a couple of bites of food when a family/staff member, who was the administrative assistant, observed the resident with food in his mouth. The family member/ administrative assistant then notified the charge nurse to assist the resident. LPN #3, the charge nurse, removed the food from the resident's mouth. CNA #2 reported the resident's family member/administrative assistant tried to get the resident to eat more and the resident refused. CNA #2 reported he assisted the resident back to bed between 1:30 p.m. and 1:40 p.m. He reported he removed the oxygen tubing from the resident for the transfer from the wheelchair to the bed and forgot to apply the oxygen back on the resident. CNA #2 reported he was making change of shift rounds at 1:45 p.m., when CNA #7 informed him she had reapplied the oxygen to the resident. CNA #2 reported he believed the resident's oxygen was not off for more than ,[DATE] minutes. He reported the resident always had difficulty breathing but he did not notice the resident breathing any differently. At 2:10 p.m. the family member/administrative assistant was interviewed. She reported she was the only management person in the building on that day since it was a holiday. The family member/administrative assistant reported, at approximately 1:15 p.m., she noticed CNA #2 trying to feed the resident. She reported there was "a hunk of wiener" sticking out of the side of the resident's mouth. She reported she noticed the resident was not breathing. She told the CNA the resident was not breathing and for him to get the food out of the resident's mouth. She reported the CNA stated, "Come on buddy, spit it out." She reported she notified the charge nurse, LPN #3, of the problem, at that time. She reported the LPN stated, "He's packing," and took a spoon and scooped the food from the resident's mouth. The family member/administrative assistant reported there was about a "bowlful" of food removed. The family member/administrative assistant reported the resident looked strange and his breathing was not audible. She reported he started to get purple around the lips. She reported the resident was staring and had his mouth open. The family member/administrative assistant reported the LPN #3 told CNA #2 to assist the resident to bed in "a little bit." The family member/administrative assistant reported the resident was less responsive and "was in a daze." She reported the resident did not shake or nod his head to respond to questions. The family member/administrative assistant reported the hospice nurse arrived after that, but was unsure of the time, but reported it was before 2:15 p.m. She reported the hospice nurse reported the hospice staff would increase their visits to five times a week. She reported she did not know if the hospice nurse saw the resident. The family member/administrative assistant reported she did not see the resident again before she left work. She reported she got the phone call about the resident expiring about 6:00 p.m., while she was on her way home. At 2:50 p.m., LPN #3 was interviewed. She reported she was called to the dining room during the lunch meal. She reported CNA #2 told her the resident was pocketing food. She reported she took a spoon and scooped out "not more than a couple of bites." She reported the resident took a few sips of the Health Shake after the food was removed. LPN #3 reported the resident did not cough or choke and the resident did not stop breathing. LPN #3 reported she called hospice, but she did not notify the physician. There was no hospice assessment documented. LPN #3 reported before she had left the resident's room to give shift report, the resident's oxygen saturation was 90%. There was no documentation of this oxygen saturation in the clinical record. On [DATE], at 4:00 p.m., LPN #2 was interviewed. She reported she was told by LPN #3 during the shift change report, that she (LPN #3) had removed a lot of food out of the resident's mouth at lunch time. LPN #2 reported she had seen the resident that afternoon after shift change. She reported she should have documented her observations. She reported she had not taken another set of vital signs or obtained oxygen saturations. She reported she did not call the physician until the resident had expired. 2. A policy titled, "Pain--Clinical Protocol" documented, "...4. The nursing will identify any situations or interventions where an increase in resident's pain may be anticipated; for example, wound care, ambulation, or repositioning..." Resident #12 was readmitted on [DATE], with [DIAGNOSES REDACTED]. The care plan dated [DATE], documented, "Focus (resident name deleted) has a Dx: Arthritis and generalized pain. Goals (resident name deleted) will maintain acceptable level of comfort (as expressed by her)... (name deleted) will remain free of further complications related to arthritis: contractures, joint stiffness, swelling, or further decline in mobility through review date. Interventions Daily range of motion exercises both active and passive as tolerated during routine care. ...Give [MEDICATION NAME] as ordered by the physician. Monitor and document for side effects and effectiveness.... Monitor/document/report to MD PRN s/sx or complications related to arthritis: Joint pain, Joint stiffness, usually worse on wakening, Swelling, Decline in mobility, Decline in self care ability, Contracture formation/joint shape changes, Crepitus (creaking or clicking with joint movement), pain after exercise or weight bearing." A significant assessment, dated [DATE], documented the resident's cognition was moderately impaired with short and long term memory problems, required extensive assistance of two persons with transfers and required total dependence of one person for bathing. The resident was dependent in a wheelchair for mobility. The assessment, for functional limitation in range of motion, documented impairment on one side for upper extremity (shoulder, elbow, wrist, and hand) and impairment on both sides for lower extremity (hip, knee, ankle, and foot). The [DATE] physician's orders [REDACTED]." A progress note, dated [DATE], documented, "RA progress: Resident tolerating hand splint to right hand during RA sessions. Tolerates lower extremity PROM well. Does not tolerate upper extremity PROM as well." The RA progress notes for [DATE], documented the resident cried when ROM was performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The RA progress notes for [DATE], documented the resident cried when ROM was performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The [DATE] MAR indicated [REDACTED]. The [DATE] TAR documented no prn Muscle Rub or Icy Hot was administered for generalized pain. The RA progress notes for [DATE], documented the resident cried when ROM was performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The [DATE] MAR indicated [REDACTED]. The July TAR documented no prn Muscle Rub or Icy Hot was administered for generalized pain. No documentation was found of the physician being notified concerning the resident's pain when restorative exercises were performed. The June and July nurses' notes documented several episodes of crying with pain. There were no nursing assessments documented and no documentation of prn pain medication administered by the nurses in the clinical record. On [DATE] at 8:30 a.m., the RA was interviewed in regard to how restorative care was performed on resident #12. She reported she assisted the resident with upper and lower exercises. The RA was asked if the the resident complained of pain when she performed restorative care. She reported the resident would complain of pain and cry at times. The RA was asked what she would do when the resident would complain of pain and start to cry. She reported she would try different ways to move her arms and loosen them up. The RA reported some days the resident would try really hard to work through the pain. The RA was asked if she had reported the resident's pain to the charge nurse. She stated, "Yes." The RA also reported she would meet with the DON once a week and report how the residents on restorative services were doing. The RA was asked if she had received her restorative certification. She stated, "No." The RA reported she was enrolled for the August class for restorative certification, but the class was canceled. The RA was asked if she had been trained by the physical therapy personnel. She stated, "Nobody from PT came and showed me what to do. All I know is what I got from CNA class." LPN #3 and LPN #1 were both asked if the RA had notified either of them about the resident experiencing pain with restorative exercises. Both LPNs reported they did not think the RA reported the pain. Both LPNs reported they would have given medication for pain relief. At the same time, the DON was asked how she monitored the restorative care provided for the residents. The DON reported she would ask the restorative aide once a month how everyone was doing. The DON was asked if she kept a record on how the residents were progressing or declining on their restorative program. She stated, "No." At 1:20 p.m., the resident was asked by the surveyor if her arm hurt when the staff moved her. The resident just looked down and no comment was made. The resident's extremities were observed. The right arm was flexed at the elbow and the wrist was contracted backward. The right hand and fingers were flexed downward. The right hand was flexed at 90 degrees inward toward the resident's body. The RA was observed to provide restorative exercises for the resident. The right hand was lifted by the RA to straighten her fingers. The resident expressed a facial grimace at that time. At the same time, CNA #8 was asked if the resident grimaced during care. The CNA reported the resident grimaced and made noise when she was dressed. The CNA stated, "We try to be easy with her, but it does hurt her." The CNA reported the resident had not cried with the ADL care provided. On [DATE] at 4:00 p.m., the DON was notified of the resident experiencing pain with the restorative exercises and was asked if the physician had been notified of the resident's pain. She reported she was unaware of the resident's pain. 3. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment, dated [DATE], documented the resident had no cognitive impairment, required extensive assistance of two persons with transfers and dressing required extensive assistance of one person with hygiene and bathing, The resident had ROM impairment on one side, upper and lower extremities, and was occasionally incontinent of bowel function. The resident's care plan, dated [DATE], documented, "Goals (Resident's name deleted) will show no s/sx of Urinary Infection through review date. Interventions ...The resident has an indwelling catheter. Position catheter bag and tubing below the level of the bladder. Keep tubing coiled..." On [DATE] at 8:00 a.m., the morning meal was observed. Resident #5 was sitting at the dining room table. Her catheter tubing was noted to be touching the floor under her wheelchair. At 12:20 p.m., the resident was observed in the dining room. Her urinary catheter tubing was touching the floor under her wheelchair. On [DATE] at 4:45 p.m., the resident was observed in the hallway with a staff member taking the resident in a wheelchair to the dining room. The resident's urinary catheter tubing was observed to be dragging on the floor. On [DATE] at 9:10 a.m., the DON was notified of observations made of the resident's catheter tubing touching the floor on three separate occasions. The DON reported she would educate her staff on proper catheter tubing placement. 4. Resident #1 was admitted on [DATE] with numerous [DIAGNOSES REDACTED]. A care plan update, dated [DATE], documented the resident had a high potential for pressure ulcer development related to a history of ulcers, as a problem. The goal was for the resident to have intact skin through the next review date. An intervention listed was for staff to follow facility policies and procedures for the prevention of skin breakdown. A nurse's note, dated [DATE] at 11:00 a.m., documented, "RESIDENT NOTED TO HAVE DRAINAGE CLEAR YELLOW IN COLOR...-DR. (Name Deleted) NOTIFIED AND N/O REC'D (1) CLEANSE LEFT LOWER EXTREMITY WITH NSS-PAT DRY-APPLY ABD PAD AND WRAP WITH KLING QD TIL RESOLVED..." There was no documentation describing the area or measurements of the area which was draining. A nurse's note, dated [DATE], documented,"NOTED RESIDENT'S LLE ( left lower extremity) WITH LARGE AMOUNT OF DRAINAGE-DR. (Name Deleted) NOTIFIED AND N/O REC'D (received) (1) CLEANSE LLE WITH NSS-PAT DRY-APPLY [MEDICATION NAME] THEN COVER WITH ABD PAD AND WRAP WITH KLING QD TIL RESOLVED...." There was no documentation describing the area or measurements of the area which was draining. The treatment administration record, dated ,[DATE], had 11 opportunities to document the resident's treatment to the left lower leg. Of the 11 opportunities four were blank. A quarterly assessment, dated [DATE], documented the resident was cognitively intact and exhibited no moods or behaviors. The resident required extensive assistance of two persons to dress and total assistance of one person to bathe. The resident did not transfer or ambulate in the past seven day look back period. The resident had ROM limitations on both sides of her upper and lower extremities. The resident was continent of bowel and always incontinent of bladder. A nurse's note, dated [DATE] at 11:00 a.m., documented, "RESIDENT'S TX TO LLE CONT AND HEALING WELL WITHOUT S/S OF INFECTION NOTED SOME DRAINAGE NOTED CLEAR YELLOW IN COLOR-LLE WITH +2 [MEDICAL CONDITION] AND PITTING..." There was no documentation describing the area or measurements of the area which was draining. A nurse's note, dated [DATE] at 9:00 a.m., documented, "WOUND EDUCATOR HERE FOR HOME VISIT THIS DAY -ASSESSED AREA TO LEFT LOWER EXTREMITY AND SUGGESTED TX TO BE CHANGED -DR. (Name Deleted) NOTIFIED...." An American Medical Technologies patient wound care order sheet, dated [DATE], documented the resident had a wound to the left lower leg. The size of the wound was 5.00 cm. by 8.00 cm. with an undetermined depth. The etiology was documented as lesion of unspecified disorder of skin. A physician's telephone order, dated [DATE], documented to change the treatment to the area. The treatment included to cleanse the area with normal saline, pat dry and apply a thin layer of [MEDICATION NAME] to the wound bed. The order documented then to apply calcium alginate to fit the wound bed and wrap the area with kling and repeat daily until the wound was resolved. The treatment administration record, dated ,[DATE], had 30 opportunities to document the resident's treatment to the left lower leg. Of the 30 opportunities six were blank. The next nurse's note regarding the wound, dated [DATE], documented, "AMT WOUND SPECIALIST HERE FOR HOME VISIT-AREA TO LEFT LOWER EXTREMITY HEALING WELL WITH S/S OF INFECTION AND MINIMAL DRAINAGE NOTED, CLEAR YELLOW IN COLOR PERI WOUND PINK AND BLANCHABLE AREA 3.5 CM X 3.0 CM X <0.1CM..." A telephone physician's orders [REDACTED]. The treatment included to cleanse the area with normal saline, pat dry and apply a thin layer of [MEDICATION NAME] to the wound bed. The order documented then to apply collagen to fit the wound bed and wrap the area with kling and repeat daily. There was no documentation from [DATE] to [DATE] regarding the wound status in the resident's medical record. The treatment administration record, dated ,[DATE], had 18 opportunities to document the resident's treatment to the left lower leg. Of the 18 opportunities five were blank. On [DATE] at 8:30 a.m., LPN #1 and the DON were interviewed regarding the lack of documentation concerning the resident's wound. LPN #1 reported she had found the wound on [DATE] and had thought she had measured the wound but could not find her notes. The LPN reported she had called the physician and received treatment orders. At that time, the surveyor then asked them why there was no documentation describing the resident's wound from [DATE] to [DATE]. The LPN reported she did not know why there were no notes describing the wound but she had been checking the wound during the treatments. The surveyor then asked the LPN about the missing documentation for the treatments to the wound. The LPN reported the treatments had been done daily and she must have forgotten to document them. The DON reported the wound should have been described, measured and documented in the nurse's notes at least weekly and all of the treatments performed should have been documented. On [DATE] at 2:30 p.m., the resident's physician was interviewed regarding the resident's wound. The physician reported the wound was a stasis ulcer due to the resident's [MEDICAL CONDITION]. The physician reported the resident's wound was unavoidable. 5. Resident #10 had [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident was admitted with two stage II pressure ulcers. A quarterly assessment, dated [DATE], documented the resident had severely impaired cognition, required extensive assist of one person with transfers, limited assistance of one person for ambulation and extensive assistance of two persons for bed mobility. The assessment documented the resident was frequently incontinent of bowel and bladder. The resident's care plan, dated [DATE], documented, "Focus resident (name deleted)has potential for pressure ulcer development r/t immobility, skin irritation on buttocks, moisture, fragile skin. Goals resident (name deleted) will have intact skin, free of redness, blisters or discoloration by review date. Interventions Monitor/document/report..." The monthly skin assessments were as follows: [DATE] One out of four weekly skin assessments by the licensed nurse were blank. [DATE] Four out of five weekly skin assessment by the licensed nurse were blank. [DATE] Two out of two weekly skin assessments by the licensed nurse were blank. A weekly skin condition worksheet, dated [DATE] through [DATE], documented the resident acquired a stage II pressure ulcer to the sacrum on [DATE]. The pressure ulcer resolved [DATE]. On [DATE] at 11:30 a.m., the DON was notified of the lack of skin assessments and monitoring for the pressure ulcer. The DON reported she was aware of the problem and would take care of it. 6. Resident #6 was admitted on [DATE], with numerous [DIAGNOSES REDACTED]. On [DATE], a record review was completed of the resident's medical record. No admission/initial pain assessment or admission/initial nursing assessment was found in the resident's medical record. The DON was asked if she could located the admission/initial pain assessment and admission/initial nursing assessment in the computer. The DON reported an admission pain assessment was not found in the computer. The DON was then asked if the assessment had been completed. She reported the pain assessment had not been completed

Based on record review, observation and staff interviews, it was determined the facility failed to: a) Identify and ensure interventions were put in place to prevent the development of pressure sores and the decline in the condition of pressure sores for one (#2) of five sampled residents with pressure sores. This caused actual harm to the resident. b) Assess, monitor and treat a pressure sore for one (#12) of five sampled residents with pressure sores. This had the potential to affect five residents, identified by the facility with pressure sores. 1. The facility's Prevention of Pressure Ulcers policy, documented, "...Interventions and Preventive Measures: General...Change position at least every two hours or more frequently if needed; Determine if resident needs a special mattress...Risk Factor-Immobility...When in bed, every attempt should be made to "float heels" (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician...Risk Factor-Poor Nutrition...Administer vitamins, mineral and protein supplements in accordance with physician orders [REDACTED]. Resident #2 had been admitted to the facility on [DATE]. A Braden scale, dated 02/11/11, for predicting pressure sore risk documented the resident's total score was 18, indicating the resident was at risk for pressure ulcers. An initial assessment dated [DATE], identified the resident as alert and oriented, required moderate assistance with limited assistance with bed mobility, extensive assistance with transfers, dressing, hygiene/bathing, was non-ambulatory and had no pressure ulcers. A care plan, dated 02/23/11, documented the following: "Focus The resident has potential for pressure ulcer development r/t Disease process, Immobility Goals The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Inform the resident/family/caregivers of any new area of skin breakdown. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. The resident needs assistance to turn/reposition with routine rounds and more often as needed or requested. The resident needs moisturizer applied after showers and with daily care to skin. Do not massage over bony prominences and use mild cleansers for peri-area/washing. The resident requires Pressure reducing device on bed. The resident requires the bed as flat as possible to reduce shear. He requires 2 person assist with repositioning by staff..." A nurse's note, dated 03/14/11, documented, "1730 (5:30 p.m.) late entry CNA getting resident ^ for pm meal et noted sm amt (small amount) blood on sock-Lpn notified et upon assessment noted (L) heel c open area approx 8.0 cm x 8.7 cm < 0.1cm-N/O rec'd (1) cleanse (L) heel c NSS-pat dry-apply TAO then collagen cover c 4/X 4 gauge pad et wrap c gauze wrap QD til resolved-Tx sheet ^ dated et wound consultant notified." A weekly skin condition worksheet, dated 03/18/11, documented, "(Resident's name deleted) Date first observed 3/14/11, facility (acquired) L heel stage II 4.8 x 4.0 Depth UTD (unable to determine) minimal drainage, santyl-collagen foam dressing Clinical basis Pressure, Dietary interventions Protein Added, super cereal,[MEDICATION NAME] Care planned Yes, Preventive Equipment, Friction Reducing Mattress, Heel Protectors, Other Progress yellow/infected, black/necrotic/worsening, Pain Yes or No N (no)." A weekly skin condition worksheet, dated 03/18/11, documented, "(Resident's name deleted) Date first observed 3/16/11, facility (acquired) R heel stage II 2.0 x 1.9 Depth UTD (unable to determine) no drainage, TAO-collagen Clinical basis Pressure, Dietary interventions Protein Added, Care planned Yes, Preventive Equipment, Friction Reducing Mattress, Positioning Wedge, Heel Protectors or Cubes, Progress Red/Healing/Granulation, Pain Yes or No N (no)." There was no documentation of the pressure sore, on the right heel, in the clinical record, before the above weekly skin condition worksheet. A weekly skin condition worksheet, dated 03/25/11, documented, "(Resident's name deleted) Date first observed 3/14/11, facility (acquired) L heel stage II 3.7 x 3.9 Depth UTD (unable to determine) minimal drainage, santyl-collagen foam dressing Clinical basis Pressure, Dietary interventions Protein Added, calories added, [MEDICATION NAME] Care planned Yes, Preventive Equipment, Friction Reducing Mattress, Heel Protectors, Other Progress yellow/infected, black/necrotic/worsening, Pain Yes or No N (no)." A weekly skin condition worksheet, dated 03/25/11, documented, "(Resident's name deleted) Date first observed 3/16/11, facility (acquired) R heel stage II 1.7 x 1.7 Depth 0.1 no drainage, santyl-collagen, Clinical basis Pressure, Dietary interventions Protein Added, Other Care planned Yes, Preventive Equipment, Other, Progress Red/Healing/Granulation, Pain Yes or No N (no)." The ADL Report for March 2011, documented a section titled, "No shift" in which the 3/11 CNAs were the only shift documenting "Float heels when in bed Freq: daily." A Nutrition Risk Assessment, dated 03/27/11, documented, "...Goal: PO & supplements to heal wound..." A weekly skin condition worksheet, dated 04/01/11, documented, "(Resident's name deleted) Date first observed 3/14/11, facility (acquired) L heel stage II 4.5 x 3.8 Depth UTD (unable to determine) minimal drainage, santyl-collagen foam dressing Clinical basis Pressure, Dietary interventions Protein Added, calories added, [MEDICATION NAME] Care planned Yes, Preventive Equipment, Friction Reducing Mattress, Heel Protectors, Other Progress yellow/infected, black/necrotic/worsening, Pain Yes or No N (Y)." A weekly skin condition worksheet, dated 04/01/11, documented, "(Resident's name deleted) Date first observed 3/16/11, facility (acquired) R heel stage II 1.0 x 1.5 Depth 0.1 minimal drainage, santyl-collagen, clinical basis Pressure, Dietary interventions Protein Added, Other Care planned Yes, Preventive Equipment, Other, Progress Black/Necrotic/Worsening, Pain Yes or No N (no)." A weekly skin condition worksheet, dated 04/04/11 thru 04/08/11, documented, "(Resident's name deleted) Date first observed 3/14/11, facility (acquired) L heel stage II 4.5 x 3.8 Depth <0.1 No drainage, santyl-collagen foam dressing Clinical basis Pressure, Dietary interventions Protein Added, Vitamin Therapy Pre-Album Check, [MEDICATION NAME] Care planned Yes, Preventive Equipment, Friction Reducing Mattress, Positioning wedge, Heel Protectors or Cubes, Other Progress yellow/infected, black/necrotic/worsening, Pain Yes or No N (Y)." A weekly skin condition worksheet, dated 04/04/11 thru 04/08/11, documented, "(Resident's name deleted) Date first observed 3/16/11, facility (acquired) R heel stage II 1.4 x 1.5 Depth < 0.1 No drainage, santyl-collagen, Clinical basis Pressure, Dietary interventions Protein Added, Vitamin Therapy Pre-Album Check Care planned Yes, Preventive Equipment, Other, Progress Red Healing/Granulation, Pain Yes or No N (Y)." A weekly skin condition worksheet, dated 04/15/11, documented, "(Resident's name deleted) Date first observed 3/14/11, facility (acquired) L heel stage II 4.8 x 5.0 Depth UTD Minimal drainage, santyl-collagen foam dressing Clinical basis Pressure, Dietary interventions Protein Added, Calories added, [MEDICATION NAME] Care planned Yes, Preventive Equipment, Friction Reducing Mattress, Positioning wedge, Heel Protectors or Cubes, Other Progress yellow/infected, black/necrotic/worsening, Pain Yes or No N (Y)." A weekly skin condition worksheet, dated 04/15/11, documented, "(Resident's name deleted) Date first observed 3/16/11, facility (acquired) R heel stage II 1.5 x 1.5 Depth 0.2 Minimal drainage, santyl-collagen, Clinical basis Pressure, Dietary interventions Protein Added, Other Care planned Yes, Preventive Equipment, Other, Progress Eschar Present, Pain Yes or No N (N)." A weekly skin condition worksheet, dated 04/18/11 thru 04/22/11, documented, "(Resident's name deleted) Date first observed 3/14/11, facility (acquired) L heel stage III 4.8 x 4.0 Depth UTD Minimal drainage, [MEDICATION NAME]-Foam Pad-gauze wrap Clinical basis Pressure, Dietary interventions Protein Added, Vitamin Therapy, Care planned Yes, Preventive Equipment, Friction Reducing Mattress, Positioning wedge, Heel Protectors or Cubes, Progress yellow/infected, black/necrotic/worsening, Pain Yes or No N (Y)." A weekly skin condition worksheet, dated 04/18/11 thru 04/22/11, documented, "(Resident's name deleted) Date first observed 3/16/11, facility (acquired) R heel stage II 1.3 x 1.1 Depth < 0.1 Minimal drainage, santyl-hydrafera blue foam dressing, Clinical basis Pressure, Dietary interventions Protein Added, Vitamin Therapy, Pre-Album Check Care planned Yes, Preventive Equipment, Friction Reducing Mattress, Positioning wedge, Heel Protectors or Cubes, Progress Yellow/Infected Present, Pain Yes or No N (N)." A nurse's note, dated 04/18/11 at 3:40 p.m., "Resident (L) heel s (triangle sign) (change) c current tx- DON notified of unsuccessful tx et the need for sharps debridement-Dr (Name deleted) notified- N/O recvd Send out to Wound Care Specialists for eval et tx to (L) heel pressure ulcer." An addition to the care plan, dated 04/18/11, documented, "Resident referred to wound care specialist. DON/Hospice notified." Un-dated new interventions to the care plan documented, "Float Heels when in bed, Heel Protectors @ all times when in bed, Avoid tight fitting shoes, Wear skid sole socks til area resolved." A nurse's note, dated 04/20/11 at 1:30 p.m., documented, "Resident out of facility to appt c Wound Care Specialists in Sulphur." A nurse's note, dated 04/20/11 at 5:05 p.m., documented, "Van Driver called et informed resident admitted to (Hospital name deleted) for debridement of (L) heel pressure ulcer...1710 (5:10 p.m.) notified (Family members name deleted) of resident's admit." A care plan update on 04/20/11, documented, "Tx (changed) to santyl-hydrafera blue-border foam drsg to (R) heel c [MEDICATION NAME]-foam pad et [MEDICATION NAME] Meds to include for wound healing-Multi Vit Daily-Vit C 500mg BID Double Protein shots." A nurse's note, dated 04/26/11 at 9:00 a.m., documented, "Wound Care Specialists called from Sulphur to confirm appt-informed them to d/c resident from services D/T family request..." A weekly skin condition worksheet, dated 04/24/11 thru 04/29/11, documented, "(Resident's name deleted) Date first observed 3/14/11, facility (acquired) L heel stage III 7.0 x 4.5 Depth UTD Minimal drainage, [MEDICATION NAME]-Foam dressing Clinical basis Pressure, Dietary interventions Protein Added, Vitamin Therapy, Pre-Album Check Care planned Yes, Preventive Equipment, Friction Reducing Mattress, Positioning wedge, Heel Protectors or Cubes, Progress yellow/infected, black/necrotic/worsening, Pain Yes or No N (Y)." A weekly skin condition worksheet, dated 04/24/11 thru 04/29/11, documented, "(Resident's name deleted) Date first observed 3/16/11, facility (acquired) R heel stage II 0.9 x 1.0 Depth 0.1 Minimal drainage, santyl-hydrafera blue foam dressing, Clinical basis Pressure, Dietary interventions Protein Added, Vitamin Therapy, Pre-Album Check Care planned Yes, Preventive Equipment, Friction Reducing Mattress, Positioning wedge, Heel Protectors or Cubes, Progress Eschar Present, Pain Yes or No N (Y)." A weekly skin condition worksheet, dated 05/02/11 thru 05/06/11, documented, "(Resident's name deleted) Date first observed 3/14/11, facility (acquired) L heel stage III 7.0 x 4.8 Depth UTD No drainage, [MEDICATION NAME]-Foam drsg Clinical basis Pressure, Dietary interventions Protein Added, Vitamin Therapy, Pre-Album Check Care planned Yes, Preventive Equipment, Friction Reducing Mattress, Positioning wedge, Heel Protectors or Cubes, Progress yellow/infected, black/necrotic/worsening, Pain Yes or No N (Y)." A weekly skin condition worksheet, dated 05/02/11 thru 05/06/11, documented, "(Resident's name deleted) Date first observed 3/16/11, facility (acquired) R heel stage III 1.2 x 1.2 Depth 0.1 Minimal drainage, santyl-hydrafera blue foam drsg, Clinical basis Pressure, Dietary interventions Protein Added, Vitamin Therapy, Pre-Album Check Care planned Yes, Preventive Equipment, Friction Reducing Mattress, Positioning wedge, Heel Protectors or Cubes, Progress Eschar Present, Pain Yes or No N (Y)." The ADL Report for May 2011, documented a section of "No shift" in which the 3/11 CNAs were the only shift documenting "Float heels when in bed Freq: daily." On 05/09/11 at 4:15 p.m., the DON was asked for the ADL documentation for February and April. She reported the records could not be found. She reported when she started there were a lot of missing records. The DON was then notified there was no documentation the resident's heels were being floated, before the pressure sores were identified. She was notified of the new interventions to the care plan which documented to float heels when in bed and use heel protectors at all times when in bed. She was also notified of the interventions not being on the original care plan, but were added after the pressure ulcers had developed. She reported she was not the DON then and could only tell what had happened since she had been the DON. She reported the heels were getting worse and she had sent the resident to the hospital in Sulphur for wound treatment and evaluation. She was notified of the wound healing multivitamin and the vitamin C not being ordered until 04/21/11, more than a month after the pressure sores had developed. She reported a new system for pressure sores had been put in place since she had started working in the facility. 2. Resident #12 had been admitted to the facility on [DATE]. An initial assessment, dated 03/15/11, identified the resident had long and short term memory loss, was moderately impaired for daily decision making, required extensive assistance with transfers, ambulation, dressing hygiene and bathing, was always incontinent of bowel and bladder and was at high risk for pressure sores. A care plan, dated 03/18/11, documented the following: "Focus (Resident's name deleted) is at risk for pressure ulcer development related to incontinence and decreased mobility. Goals The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Inform the resident/family/caregivers of any new area of skin breakdown. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. The resident needs assistance to turn/reposition with routine rounds and more often as needed or requested. The resident needs moisturizer applied after showers and with daily care to skin. Do not massage over bony prominences and use mild cleansers for peri-area/washing. The resident requires Pressure reducing device on bed. The resident requires the bed as flat as possible to reduce shear. He requires 2 person assist with repositioning by staff... Focus (Resident's name deleted) is resistive to care r/t Dx: [MEDICAL CONDITION], dementia with behavioral disturbances, senility. Goals (Resident's name deleted) will exhibit increased cooperation with care through next review date. Interventions Allow the resident to make decisions about treatment regime, to provide sense of control. Encourage as much participation/interaction by the resident as possible during care activities. Give clear explanation of all care activities prior to and as they occur during each contact. If possible, negotiate a time for ADLs, reassure resident, leave and return 5-10 minutes later and try again. Praise the resident when behavior is appropriate. Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, care givers and routine, as much as possible. Provide resident with opportunities for choice during care provision. Focus (Resident's name deleted) has mood problem r/t Dx: dementia with behavioral disturbances and new admission to facility. Goals (Resident's name deleted) will have improved mood state: happier, calmer appearance, decreased s/sx of depression, anxiety and sadness through the review dated. Interventions: Allow the resident ample time to talk PRN. Encourage him to express his feelings. Administer medications as ordered. Monitor/document for side effects and effectiveness... Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis..." An admission nurse's note, dated 03/03/11 at 8:00 p.m., documented, "Overall assessment finished. Noted on L hip (bony prominence) area x 2 1. 0.5 x 0.5 2. 0.1 x 0.1 each c dry scab. Redness around areas 2 x 1. On R hip (bony prominence) area x 1 0.5 x 0.5 c dry scab at present. Redness around area 2 x 2. Noted on R ischial area rough healed area. Also noted on R inner buttocks (crack) Raised area approx 1 1/2 cm Long. No redness noted..." A physician's orders [REDACTED]. "Skin assessment weekly 2-10 evening shift every thu (Thursday)" The March 2011, treatment orders were reviewed. The assessments on 03/10/11 and 03/18/11, had been circled as not being done. The physician had not been notified of the resident refusing the above skin assessments. A physician's orders [REDACTED]. The treatment had been circled, as not done, 39 times and 16 times the treatment areas were left blank for the month of March 2011. The April treatment sheets could not be found by the facility during the four day survey. The treatment had been circled six times, as not done, and seven times the treatment areas were left blank from May 1st through May 10th 2011. The physician had not been notified of the resident refusing the above [MEDICATION NAME] treatments. A Would/Skin Record, dated 05/10/11, documented, "Date of onset 5/10/11 (R) hip Stage II 0.6 x 0.3 <0.1 wound bed pink..." On 05/11/11 at 2:40 p.m., the resident was observed in bed. His right hip was covered with a dressing. The CNA removed the covering. A stage II pressure sore was observed. On 05/12/11 at 11:30 a.m., LPN #1 was shown the treatment sheets for the resident. She was asked if the physician had been notified the resident was refusing the treatments and skin assessments. She reported it didn't look like the physician had been notified of the resident refusing care. At that time, she was notified of the stage II pressure sore on the resident's right hip. She reported she had been notified of the area.