Every finding on record at Antlers Manor

Based on record review and interview, the facility failed to ensure elopement prevention interventions were implemented on the care plan for 1 (#1) of 3 sampled residents reviewed for elopement.A wandering and elopement risk assessment for Resident #1, dated 05/28/25, showed the resident was at risk for wandering and elopement.An incident report form, dated 11/06/25, showed Resident #1's family member informed the facility the resident had walked to their home. The report showed the resident had a small abrasion to their forehead.Resident #1's care plan did not show wandering and elopement incidents/interventions prior to 11/06/25.The administrator identified 21 residents in the facility at risk for elopement.On 05/13/26, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident at risk for wandering and elopement had care plan interventions to address and prevent elopement. This resulted in the elopement of Resident #1 from the facility.On 05/13/26 at 5:11 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 05/13/26 at 5:16 p.m., the administrator was notified of the IJ situation and the IJ template was provided.On 05/14/26 at 4:23 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal read in part,Amended Plan of Removal F656 Elopement Care PlansCompletion Date 5-14-26 3:00 p.m.Clinical Staff EducationClinical managers will be educated on how to care plan accurate interventions for residents at risk for wandering/elopement. This education will be provided by [name withheld], Regional Nurse.A sign in sheet will be utilized for staff that are currently in the facility. Any remaining staff will be called to the facility for education; or educated over the telephone. Employee names and the time of the telephone call will be documented. This education will be completed by 9:00 p.m. on 5-13-26.Currently in progress:All care plans will be audited and updated accordingly for residents that are at risk for wandering/elopement.Resident #1's elopement risk assessment and care plan will be updated.The resident elopement book will be updated to include any residents at risk for elopement.On 05/18/26, the IJ was lifted, effective 05/14/26, when all components of the plan of removal had been verified as completed. Clinical staff were interviewed regarding care plan interventions for elopement and wandering. All staff interviewed were knowledgeable on the education and training provided. The plan of removal records including staff education, care plan audits, elopement risk assessments, and elopement book were reviewed.The deficiency remained at a pattern level with the potential for more than minimal harm that is not immediate jeopardy. A facility policy titled Care Plans-Comprehensive, revised 10/2010, read in part, Each Resident's comprehensive care plan is design to .Incorporate identified problem areas .Incorporate risk factors associated with identified problems.A wandering and elopement risk assessment for Resident #1, dated 05/28/25, showed the resident was at risk for wandering and elopement.A nursing note, dated 06/01/25 at 4:18 a.m., showed Resident #1 wandered frequently in the facility.A nursing note, dated 08/29/25 at 12:27 a.m., showed Resident #1 frequently ambulated aimlessly in the facility.A quarterly assessment for Resident #1, dated 09/01/25, showed the resident had a diagnosis of dementia and their cognition was severely impaired with a BIMS score of 5. The assessment did not show the resident wandered.An incident report form, dated 11/06/25, showed Resident #1's family member informed the facility the resident had walked to their home. The report showed the resident had a small abrasion to their forehead.Resident #1's care plan did not show wandering and elopement incidents/interventions prior to 11/06/25.On 05/12/26 at 2:27 p.m., a family member of Resident #1 stated the resident arrived at their home in the middle of the night. They stated the resident was wearing dark clothes and had to cross the main road to get to the house. The family member stated they were grateful it was in the middle of the night because the resident could have been hit by a truck. They stated Resident #1 had a skin tear on their forehead and the resident told them they had fell. The family member for Resident #1 stated it was a chilly night and the resident was cold.On 05/13/26 at 11:26 a.m., CMA #1 stated the resident occasionally wandered and liked to walk around hall three.On 05/13/26 at 11:47 a.m., the MDS coordinator stated Resident #1 had wandering behaviors since admission to the facility. They stated the resident wandered around the dining room and hall three.On 05/13/26 at 12:08 p.m., the MDS coordinator stated Resident #1's care plan did not address wandering and elopement prior to 11/06/25. They stated the care plan should have included interventions for wandering and elopement.On 05/13/26 at 12:10 p.m., the MDS coordinator stated they reviewed nurse's notes, nursing assessments, talked with residents, and talked with staff for care plan development and revision.On 05/13/26 at 12:49 p.m., the administrator stated the facility investigation showed Resident #1 left the facility because the laundry room was left unlocked and the back gate by the laundry room was unlocked and slightly opened. The administrator stated it would take about 13 minutes to walk from the facility to Resident #1's home. They stated the resident was missing for about two hours and 30 minutes based on the facility's investigation.

Based on observation, record review, and interview, the facility failed to provide adequate supervision and maintain a secure environment to prevent elopement of a resident with a known history of wandering and elopement risk for 1 (#1) of 3 sampled residents reviewed for elopement.A wandering and elopement risk assessment for Resident #1, dated 05/28/25, showed the resident was at risk for wandering and elopement. A quarterly assessment for Resident #1, dated 09/01/25, showed the resident had a diagnosis of dementia and their cognition was severely impaired with a BIMS of 5.An incident report form, dated 11/06/25, showed Resident #1's family member informed the facility the resident showed up at their home. The report showed the resident had a small abrasion to their forehead.On 05/12/26 at 2:27 p.m., Resident #1's family member stated the resident showed up at their home in the middle of the night. They stated the resident was wearing dark clothes and had to cross the main road to get to the house. Resident #1's family member stated they were grateful it was in the middle of the night because the resident could have been hit by a truck. They stated Resident #1 had a skin tear on their forehead and the resident told them they had fell. Resident #1's family member stated it was a chilly night and the resident was cold.On 05/13/26 at 12:49 p.m., the administrator stated the facility investigation showed the resident left the facility because the laundry room was left unlocked and the back gate by the laundry room was unlocked and slightly opened.The administrator identified 21 residents in the facility at risk for elopement.On 05/13/26, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide adequate supervision and a secure environment to prevent elopement for a resident with known wandering and elopement risk. This resulted in the elopement of Resident #1.On 05/13/26 at 5:11 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 05/13/26 at 5:16 p.m., the administrator was notified of the IJ situation and the IJ template was provided.On 05/14/26 at 4:23 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal read in part,Amended Plan of Removal F689 Elopement PreventionCompletion Date 5-14-26 3:00 p.m.All Staff EducationElopement Policy and ProceduresAll staff will be educated on the facility elopement policy and procedures to include interventions and prevention of elopement by [name withheld], Administrator.Interventions/prevention can include observing and redirecting wandering /eloping residents by the staff in all departments. Optimizing environmental conditions such as securing exit doors, not propping doors open, and checking the door locks for proper locking. Educating staff members on each resident's habits as well as any physical, mental, or behavioral issues they may have. Social engagement and increasing participation in activities. Clinical Staff EducationAll RNs and LPNs will be educated on the proper completion of the Elopement Risk Assessment upon admission and quarterly by [name withheld], Regional Nurse.A sign in sheet will be utilized for staff that are currently in the facility. Any remaining staff will be called to the facility for education; or educated over the telephone. Employee names and time of the telephone call will be documented. This education will be completed by 9:00 p.m. on 5-13-26.Currently in progress:All residents will be assessed for wandering/elopement with the completion of an Elopement Risk AssessmentResident #1's elopement risk assessment will be updated.The resident elopement book will be updated to include any residents at risk for elopement. Enhanced supervision rounds initiated for identified high risk residents.All exterior exit doors and locking mechanisms are being checked for proper function by maintenance. Any malfunctioning equipment will be repaired immediately or taken out of service until repaired. The door keypad codes have been changed. The facility implemented routine checks of exterior exit doors each shift. The Administrator will conduct environmental rounds to identify additional safety concerns related to wandering/elopement. On 05/18/26, the IJ was lifted, effective 05/14/26, when all components of the plan of removal had been verified as completed. Staff in various departments and shifts were interviewed regarding elopement policy and procedures, securing and checking exit doors, supervision rounds, and completion of wandering and elopement risk assessments. All staff interviewed were knowledgeable on the education and training provided. The plan of removal records including facility's elopement policy and procedure, observation of the elopement book, elopement risk resident audits, exit doors check off sheets, and staff in-services were reviewed. Doors were checked for security. The deficiency remained at an isolated level with the potential for more than minimal harm that is not immediate jeopardy. Findings: On 05/12/26 at 12:17 p.m., Highway 3, the road Resident #1 crossed to walk home, was observed as a busy two-lane road in which vehicles passed through. The highway was the main street adjacent the facility.On 05/14/26 at 3:45 a.m., Highway 3 was observed as dimly lit with some streetlights. There was no continuous dedicated sidewalk which led from the facility to Resident #1's home. Three cars were observed driving on the highway during the drive to Resident #1's neighborhood.An undated facility policy titled Elopement, read in part, To identify residents at risk for unsafe wandering and exit seeking behavior and prevent elopements .Upon admission, quarterly and with significant change in status, the nurse will complete an Elopement Screen.A wandering and elopement risk assessment for Resident #1, dated 05/28/25, showed the resident was at risk for wandering and elopement. There was no additional wandering and elopement assessments.A nursing note, dated 06/01/25 at 4:18 a.m., showed Resident #1 wandered frequently in the facility.A nursing note, dated 08/29/25 at 12:27 a.m., showed Resident #1 frequently ambulated aimlessly in the facility.A quarterly assessment for Resident #1, dated 09/01/25, showed the resident had a diagnosis of dementia and their cognition was severely impaired with a BIMS score of 5. The assessment did not show the resident wandered.An incident report form, dated 11/06/25, showed the Resident #1's family member informed the facility the resident showed up at their home. The report showed the resident had a small abrasion to their forehead.On 05/12/26 at 2:27 p.m., Resident #1's family member stated the resident showed up at their home in the middle of the night. They stated the resident was wearing dark clothes and had to cross the main road to get to the house. Resident #1's family member stated they were grateful it was in the middle of the night because the resident could have been hit by a truck. They stated Resident #1 had a skin tear on their forehead and the resident told them they fell. Resident #1's family member stated it was a chilly night and the resident was cold.On 05/13/26 at 11:26 a.m., CMA #1 stated the resident occasionally wandered and liked to walk around hall three.The facility laundry room was observed on hall three.On 05/13/26 at 11:28 a.m., CMA #1 stated the last time they laid eyes on the resident was around the 2:00 a.m. rounds. They stated they were in the middle of the 4:00 a.m. round when the administrator called to inform them the resident had eloped from the facility.On 05/13/26 at 11:47 a.m., the MDS coordinator stated Resident #1 had wandering behaviors since admission to the facility. They stated the resident wandered around the dining room and hall three.On 05/13/26 at 12:32 p.m., the DON stated Resident #1 had one wandering and elopement assessment completed since admit on 05/28/25. They stated the assessments were to be completed quarterly.On 05/13/26 at 12:39 p.m., the DON stated the facility did not complete an elopement and wandering assessment after the resident eloped on 11/06/25.On 05/13/26 at 12:49 p.m., the administrator stated the facility investigation showed Resident #1 left the facility because the laundry room was left unlocked and the back gate by the laundry room was unlocked and slightly opened. The administrator stated it would take about 13 minutes to walk from the facility to Resident #1's home. They stated the resident was missing for about two hours and 30 minutes based on the facility's investigation.On 05/13/26 at 1:50 p.m., LPN #1 stated they were not sure how Resident #1 eloped. They stated the staff had checked on the resident during the 2:00 a.m. round. LPN #1 stated Resident #1 had some confusion, and their gait was not steady.

Based on observation, record review, and interview, the facility failed to ensure the low temperature dish machine had the appropriate amount of chemical to sanitize dishes for the facility. The administrator identified 32 residents who ate meals prepared by the kitchen. Findings: On [DATE] at 11:38 a.m., the DM obtained a bottle of test strips for testing the sanitizer level for the dish machine. The test strip did not register a result. The container of tests strips documented the strips had expired on ,d+[DATE]. On [DATE] at 1:25 p.m., the DM used new test strips obtained by the facility to check the sanitizer level. The test strip showed 10 parts per million. A undated manufacturers operations guide for the dish machine, read in part, Verify Sanitizer levels regularly. Use test strip to ensure sanitizer level is at least 50 ppm and no more than 200 ppm. A dish machine temperature log for [DATE] did not document the sanitizer level results for the dish machine. On [DATE] at 12:24 p.m., the DM stated they had been using the expired test strips for at least two weeks. The DM stated they had not been documenting the sanitizer level. On [DATE] at 1:59 p.m., the regional director stated there was no facility policy/instructions for testing the chemical used in the dish machine.

Based on record review and interview, the facility failed to ensure: a. a PRN psychotropic medication had a 14 day stop date for 1 (#11], and b. an antipsychotic medication had an appropriate diagnosis for 1 (#5) of 5 residents sampled for unnecessary medications. The administrator reported 32 residents resided in the facility. Findings: 1. Res #5 admitted to the facility with diagnoses of other Alzheimer's disorder, other depressive episodes, and bipolar disorder. A physician order, dated 02/19/24, showed risperidone (antipsychotic medication) tablet 0.5 mg, one tablet by mouth twice a day for a diagnosis of Alzheimer's disease. On 03/06/25 at 8:39 a.m., the DON stated Alzheimer's was not an appropriate diagnosis for an antipsychotic medication. 2. Res #11 admitted to the facility with diagnoses of Alzheimer's and anxiety disorder. A physician order, dated 11/22/24, showed Ativan (benzodiazepine) 0.5 mg by mouth every 12 hours PRN. There order did not contain a 14 day stop date. On 03/06/25 at 8:35 a.m., the DON reported the Ativan should have had a 14 day stop date.

Based on record review and interview the facility failed to ensure a resident was assessed related to smoking and accident hazards for 1 (#22) of 1 sampled resident reviewed for smoking. The administrator identified three residents were smokers. Findings: A policy titled SMOKING SAFETY, dated 08/03/15, read in part Initiate and complete the Smoking Safety evaluation if the resident requests smoking privileges as follows: 1. On Admission 2. Quarterly .Staff will monitor distribution of smoking material during smoking sessions .Document interventions on the resident's care plan. Resident #22 had diagnoses which included acute upper respiratory infection, chronic atrial fibrillation, shortness of breath, congestive heart failure, and chronic obstructive pulmonary disease. An annual minimum data set assessment, dated 12/21/24, documented the resident was cognitively intact and currently used tobacco. The resident's plan of care, revised 12/23/24, did not document the resident's use of tobacco. The facility could not provide documentation regarding smoking safety assessments completed on admission or quarterly per the policy. On 03/03/25 at 3:26 p.m., the resident stated they smoked independently with no staff present when smoking. On 03/06/25 at 12:15 p.m., the DON stated a smoking assessment should have been completed on admission and reassessed quarterly. The DON stated the smoking assessments must have been missed. The DON reviewed the resident's plan of care and stated there was no plan of care for smoking.

Based on observation and interview, the facility failed to prepare pureed food in a sanitary manner. DA #1 identified four residents who received a pureed diet. Findings: A facility policy, titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised December 2008, read in part, .4. Employees must wash their hands .g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks .10. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing . On 11/13/23 at 10:45 a.m., DA #1 was observed to wash their hands, put on disposable gloves, and take chili and corn chips from the steam table to the blender bowl. DA #1 was observed to leave the blender bowl to get American cheese slices out of the refrigerator. With their same gloved hands, DA #1 was observed to touch the refrigerator and the cheese slice package and return to the blender bowl. Without removing their contaminated gloves, DA #1 was observed to separate the cheese slices and place them in the blender bowl one-by one for a total of six times. DA #1 was observed to drop one cheese slice onto the prep table and then pick it up and place it into the blender bowl. DA #1 was observed to have worn the same pair of gloves, which became contaminated, during the entire preparation of the puree meals. On 11/13/23 at 11:00 a.m., DA #1 stated they should have removed their gloves once they were contaminated, washed their hands, and put on new gloves. DA #1 reported the prep table was clean so they thought the cheese which fell on to the prep table could be used. On 11/13/23 at 11:10 a.m., the DM reported DA #1 should have removed their contaminated gloves, washed their hands, and put on new gloves, before putting the cheese into the blender bowl. The DM reported DA #1 should have thrown away the cheese that fell on to the prep table.

Based on observation, record review, and interview, the facility failed to attempt to use alternatives, assess for risks, obtain informed consent, prior to installing side rails on resident beds for four (#2, 12, 19, and #27) of five residents reviewed for accident hazards related to side rails. The facility administrator identified 10 resident who had side rails installed on their beds. Findings: 1. Res #2 had diagnoses which included dementia, schizophrenia, psychotic disorder and seizures. A physician order, dated 09/14/14, documented the resident had quarter side rails to enhance independent bed mobility. A side rail consent form, dated 04/23/18, did not document what interventions the facility attempted prior to installing side rails, or how the facility was going to mitigate the risk from the use of side rails specific to the resident. A side rail assessment, dated 05/30/18, was provided for review by the facility. The assessment did not document all the required components. No other assessments were provided by the facility. A quarterly MDS assessment, dated 09/28/23, documented Res #2 was severely impaired in cognition and required total assistance with bed mobility and transfers. A care plan, last reviewed on 09/26/23, documented the resident's use of side rails. The care plan documented the resident used side rails to assist when turning and the facility was to assess the use of side rails quarterly to determine if they were still needed and to eliminate the use of side rails if possible. On 11/08/23 at 12:32 p.m., the resident was observed lying in their bed with 1/2 side rails up on the head of the bed on both sides. 2. Res #12 had diagnoses which included functional quadriplegia, corrosion of unspecified degree of trunk, fracture of neck, and pressure ulcers. A side rail consent form, dated 06/30/16, did not document interventions which were attempted prior to installation of the side rails and how the facility was going to mitigate risks from the use of side rails specific to the resident. The last side rail assessment completed by the facility, dated 04/18/18, did not document the required components. A quarterly MDS assessment, dated 10/22/23, documented Res #12 was intact in cognition and required substantial/maximal assistance with rolling right to left. On 11/08/23 at 12:22 p.m., Res #12 was observed lying in their bed on an low air loss mattress. The resident's bed was observed to have grab bars in the up position on both sides of the head of the bed. At that time the resident stated they were paralyzed from the neck down. The stated they had minimal movement in their arms and their hands were contracted before they entered the facility and were not able to turn without assistance. A care plan, last reviewed on 11/09/23, documented the resident was paralyzed and used bed rails for independent positioning. The care plan documented the facility was to reassess the resident quarterly to determine if side rails were still required and to eliminate them if possible. 3. Res #19 had diagnoses which included Huntington's disease, difficulty in walking, lack of coordination, and muscle weakness. A combined side rail assessment and consent form, dated 12/26/19, did not document the required components for the assessment portion, the interventions attempted prior to installation of side rails, the risks associated with the use of side rails, the mitigation the facility would use related to the risks, or a resident/representative signature. An annual MDS assessment, dated 01/20/23, documented the resident was moderately impaired in cognition and required extensive assistance with bed mobility and transfers. A nurse note, dated 09/05/23, documented the resident had a cut to their right eyebrow. The note documented the resident was asked if they had struck their head on their side rail the resident stated, Yes. A care plan, last reviewed/revised on 09/05/23, documented the resident had an abrasion with bruising to the right eyebrow and the facility was to have therapy assess for appropriate protective devices such a pads and arm rolls and to make recommendations as warranted. The care plan did not document a plan of care related to the use of side rails. A quarterly MDS assessment, dated 10/23/23, documented the resident was moderately impaired in cognition, was independent with rolling left and right and was dependent with lying to sitting on the side of the bed. The assessment documented the resident was dependent with chair/bed-to-chair transferring. On 11/08/23 at 11:30 a.m., the resident was observed lying in bed with side rails up on both sides at the head of the bed. On 11/14/23 at 10:49 a.m., the resident was observed lying in bed on their side with the blankets over their head and side rails were in the up position on both sides of their bed. 4. Res #27 had diagnoses which included open wound of the left hip, anxiety disorder, and chronic pain syndrome. A side rail assessment, education tool, and consent form, dated the day of admission, did not document all of the required components. The EHR did not document an order for the use of side rails. An admission MDS assessment, dated 04/11/23, documented the resident was moderately impaired in cognition and required extensive assistance with bed mobility and transfer. A quarterly MDS assessment, dated 10/12/23, documented the resident was moderately impaired in cognition and required substantial/maximal assistance with rolling right to left and was dependent with chair/bed-to-chair transfer. On 11/08/23 at 12:03 p.m., the resident was observed lying in bed with side rails up on both sides of the head of the bed. 5. On 11/14/23 at 12:31 p.m., MDS coordinator #1 stated side rail assessments were to have been done on all residents using side rails on admission and quarterly thereafter. On 11/14/23 at 12:54 p.m., Corporate Nurse Consultant #1 reviewed the assessment and consent forms and confirmed they did not document all the required components. The corporate nurse stated Res #19's assessment and consent form had been completed on the date the resident had been admitted and therefore it was unlikely the facility had attempted alternatives to side rail use for the resident. On 11/14/23 at 2:41 p.m., the DON stated Res #27's family wanted the side rails to prevent falls and confirmed side rails was not an appropriate intervention for falls. The DON stated alternatives to the use of side rails were not tried prior to side rails being used. The DON stated the side rail assessments should have been completed quarterly.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for three (#7, 31 and #38) of three sampled residents whose care plans were reviewed. The Long-Term Care Application for Medicare and Medicaid form documented 34 residents resided in the facility. Findings: The Care Planning - Interdisciplinary Team policy, revised December 2008, read in part, .A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment . 1. Res #7 was admitted on [DATE] with diagnoses which included diabetes, hypertension, Alzheimer's, aphasia and depression. There was no comprehensive care plan for Res #7 in their clinical record. 2. Res #31 was admitted on [DATE] with diagnoses which included intellectual disability, seizures, cellulitis, anxiety and depression. There was no comprehensive care plan for Res #31 in their clinical record. 3. Res #38 was admitted on [DATE] with diagnoses which included cerebral infarction, dysphagia, hypertension, diabetes and anxiety. There was no comprehensive care plan for Res #38 in their clinical record. On 11/14/23 at 1:05 p.m. the DON reported a comprehensive care plan should have been developed for Res #7, 31 and #38 within the required timeframe. On 11/14/23 at 1:15 p.m., the MDS Coordinator reported a baseline care plan should have been developed for Res #7, 31 and #38 within the required timeframe.

Based on record review and interview, the facility failed to ensure an admission MDS resident assessment was completed within 14 days from admission for three (#31, 38 and #39) of 12 residents whose assessments were reviewed. The Long-Term Care Application for Medicare and Medicaid form documented 34 residents resided in the facility. Findings: A facility policy titled, Resident Assessment Instrument, revised October 2010, read in part, The Assessment Coordinator is responsible for ensuring .timely resident assessments .in accordance with the following schedule: a. Within fourteen (14) days of the resident's admission to the facility . 1. Res #31 was admitted on [DATE] with diagnoses which included intellectual disability, seizures, cellulitis, anxiety and depression. A review of Res #31's assessments showed the admission assessment, dated 09/18/23, was still in progress and not completed. 2. Res #38 was admitted on [DATE] with diagnoses which included cerebral infarction, dysphagia, hypertension, diabetes and anxiety. A review of Res #38's assessments showed the admission assessment, dated 09/05/23, was still in progress and not completed. 3. Res #39 was admitted on [DATE] with diagnoses which included COPD, diabetes, atherosclerotic heart disease, dysphasia, aphasia and hypertension. A review of Res #39's assessments showed no admission assessment had been started. 4. On 11/14/23 at 1:05 p.m. the DON reported the admission assessments should have been completed within the required timeframe for Res #31, 38, and #39. On 11/14/23 at 1:15 p.m., the MDS coordinator reported the admission assessment should have been completed within the required timeframe for Res #31, 38 and #39.

Based on record review and interview the facility failed to ensure a baseline care plan was developed for two (#7 and #38) of 12 residents whose care plans were reviewed. The Long-Term Care Application for Medicare and Medicaid form documented 34 residents resided in the facility. Findings: A facility policy titled, Care Plans - Preliminary, revised August 2006, read in part, .To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission. 1. Res #7 was admitted on [DATE] with diagnoses which included diabetes, hypertension, Alzheimer's, aphasia and depression. A baseline care plan for Res #7 was not documented in their clinical record. 2. Res #38 was admitted on [DATE] with diagnoses which included cerebral infarction, dysphagia, hypertension, diabetes and anxiety. A baseline care plan for Res #7 was not documented in their clinical record. On 11/14/23 at 1:05 p.m. the DON reported a baseline care plan should have been developed for Res #7 and #38 upon admission. On 11/14/23 at 1:15 p.m., MDS Coordinator #1 reported a baseline care plan should have been developed for Res #7 and #38 upon admission.

Based on observation, record review, and interview, the facility failed to treat each resident with respect and dignity and care for each resident in a manner which promoted their quality of life by standing above the residents while assisting them to eat for two (#2 and #27) of two residents sampled for dignity. The facility administrator documented 11 residents required assistance with eating. Findings: 1. Res #2 had diagnoses which included dementia, schizophrenia, seizures, and malnutrition. A care plan, dated 11/13/18, documented the staff were to maintain adequate nutrition for the resident by adhering to the diet and feeding him. On 11/08/23 at 12:37 p.m., the resident was observed being fed by an unidentified staff member who was standing at the residents bedside. 2. Res #27 was admitted with diagnoses which included generalized anxiety disorder, chronic pain syndrome, and anemia. A quarterly assessment, dated 10/12/23, documented the resident was dependent with eating. On 11/08/23 at 12:03 p.m., an unidentified staff member was observed standing at the resident's bedside assisting them to eat. On 11/14/23 at 1:54 p.m., the DON stated staff should have been seated at the residents' level when assisting residents to eat.

Based on observation, record review, and interview, the facility failed to ensure MDS assessments accurately reflected the residents' status for three (#1, 19, and 32) of 12 residents whose assessments were reviewed. The facility failed to accurately assess for: a. gradual dose reductions for Res #1. b. oral health and condition of teeth for Res #19. c. antiplatelet medications for Res # 32. The Long-Term Care Facility Application for Medicare and Medicaid form documented 34 residents resided in the facility. Findings: 1. Res #1 had diagnoses which included intellectual disability, Alzheimer's disease, epilepsy, and personality and behavioral disorder. A consultant pharmacist review, dated 03/16/23, documented a request for reduction of Rexulti from 0.5 mg to .25 mg at bedtime. A physician response, dated 04/18/23, documented they disagreed with the request documenting the nursing staff stated the resident was still yelling out and a reduction was appropriate at that time. A physician order, dated 04/26/23, documented the facility was to administer Rexulti (an antipsychotic medication) 0.5 mg daily at bed time for a diagnosis of dementia with behavioral disturbances. An annual MDS assessment, dated 06/08/23, documented Res #1 was severely impaired in cognition, received antipsychotic medication for seven days of the seven day assessment period, and a gradual dose reduction was not attempted. The assessment documented the physician had not provided a contraindication for a dose reduction. A quarterly MDS assessment, dated 09/08/23, documented Res #1 was severely impaired in cognition, received antipsychotic medication for seven days of the seven day assessment period, and a gradual dose reduction was not attempted. The assessment documented the physician had not provided a contraindication for a dose reduction. On 11/13/23 at 12:59 p.m., MDS coordinator #1 confirmed the resident's dose of Rexulti was reduced in March of 2022 and should have been captured on the MDS. 2. Res #19 had diagnoses which included Huntington's disease, dysphagia, and chronic apical periodontitis. An annual MDS assessment, dated 01/20/23, documented Res #19 was moderately impaired in cognition, required total assistance with personal hygiene, and no issues were documented with dental conditions. A quarterly MDS assessment, dated 10/23/23, documented Res #19 was moderately impaired in cognition and was dependent on staff with oral hygiene. On 11/08/23 at 11:30 a.m., Res #19 was observed lying in their bed. The resident's teeth were observed to have been brown and broken. On 11/14/23 at 10:14 a.m., CNA #1 stated the residents oral care was done when they received a shower. The CNA stated they have to be careful as the resident became physically aggressive when staff tried to perform physical cares such as oral care. On 11/14/23 at 10:49 a.m., corporate nurse consultant #1 observed resident's teeth and stated they had obvious missing and broken teeth and cavities. The corporate nurse stated the annual MDS was not correct. On 11/14/23 at 12:17 p.m., MDS coordinator #1 stated when coding an annual assessment they would check the residents' teeth. The MDS coordinator stated they were aware the resident had missing teeth and other issues with their dental health and it was possible they did not perform a visualization of the resident's teeth for the last annual MDS. 3. Res #32 had diagnoses which included cerebrovascular disease and cerebral infarction. A physician order, dated 09/27/23, documented the facility was to administer adult low dose aspirin (an antiplatelet medication) 81 mg daily. An admission MDS assessment, dated 10/08/23, documented the resident was severely impaired in cognition and did not receive antiplatelet medications during the assessment period. On 11/13/23 at 3:24 p.m., MDS coordinator #1 confirmed aspirin was to have been coded as an antiplatelet on the MDS assessments. The stated they missed the order and coded the MDS incorrectly for Res #32.

Based on record review, observation, and interview, the facility failed to develope and implement fall interventions for two (#15 and #25) of two residents reviewed for falls. The administrator identified 12 residents who had fallen in the last four months. Findings: 1. Res #15 had diagnoses which included dementia, anxiety, [CONDITION(S)], and [CONDITION(S)]. The care plan, dated 07/02/17, documented the resident had a history of falling. The eight interventions documented under this problem were dated 07/02/17. No additional interventions were documented past this date. An annual assessment, dated 02/03/22, documented the resident was totally dependent with bed mobility, transfers, locomotion and had no history of falls since the last assessment. An incident report, dated 04/07/22, read in part, . the resident fell forward out of chair, hitting her head causing a large bump on forehead and laceration on corner of left eye, scraped [sic] on knee, call 911, transferred to [hospital name deleted] ER . The quarterly assessment, dated 05/06/22, documented the resident had one fall with injury since the prior assessment. On 07/14/22 at 11:55 a.m., DON and ADON stated they were not sure how this resident fell but that she does lean forward in geri-chair sometimes. On 07/14/22 at 11:56 a.m., the DON stated that new fall interventions were not developed or implemented after the resident fell but that they should have been. 2. Res #25 had diagnoses which included [CONDITION(S)], chronic pain, and congested heart failure. An incident report, dated 12/21/21, documented the resident was found in her on her left side on the floor with no injuries noted. Res #25's care plan, dated 12/21/21, documented to keep the bed in low position when care is not being provided and keep the call light in reach at all times. An incident report, dated 05/06/22, documented the resident had a fall resulting in a major injury. The report documented the resident slipped out of her wheelchair while in the hallway causing the resident to be admitted into the hospital for several days. A nurse note, dated 05/10/22, documented the resident returned to the facility. The quarterly assessment, dated 06/13/22, documented the resident had one fall with major injury. The care plan was not updated with new interventions to prevent the resident from falling again. On 07/13/22 at 10:48 AM, the resident was observed in lying in her bed. The bed had bolsters on both sides of the head of the bed. The resident's wheelchair was next to the resident's bed. On 07/14/22 at 10:20 a.m., the corporate nurse confirmed that the care plan should have been updated after the fall on 05/06/22 and that interventions should have been initiated to prevent the resident from falling again.

Based on record review and interview, the facility failed to ensure the physician responded to the MRR in a timely manner for two (#9 and #28) of five residents who were sampled for medication review. The Resident Census and Conditions of Residents report documented 31 residents resided at the facility. Findings: A facility policy, dated November 2018, read in part .If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. 1. Res #9 had diagnoses which included anxiety and depression. A MRR, dated 12/16/21, documented the pharmacist requested a reduction for [MEDICATION(S)] (an antidepressant medication). The review was not signed and received from the physician until 03/09/22. 2. Res #28 had diagnoses of dementia with behavioral disturbance, depression, and [CONDITION(S)]. A MRR, dated 11/24/21, documented the pharmacist requested a reduction for [MEDICATION(S)] (an antipsychotic medication). The review was not signed and received from the physician until 03/09/22. On 07/13/22 at 4:36 p.m., the corporate nurse reported the physician had 30 days to respond and return the MRR. The corporate nurse reported the MRR should have been addressed before March.

Based on record review and interview, the facility failed to revise care plan related to falls for two (#15 and #25) of two residents who were reviewed for falls. The administrator identified 12 residents who had fallen in the last four months. Findings: 1. Res #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 07/02/17, documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional interventions were documented past this date. An incident report, dated 04/07/22, read in part, . the resident fell forward out of chair, hitting her head causing a large bump on forehead and laceration on corner of left eye, scraped [sic] on knee, call 911, transferred to [hospital name deleted] ER . The quarterly assessment, dated 05/06/22, documented the resident had one fall with injury since the prior assessment. On 07/14/22 at 11:56 a.m., the DON stated new fall interventions were not developed or implemented and the care plan was not revised after the resident fell but that it should have been. 2. Res #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An incident report, dated 12/21/21, documented the resident was found in her on her left side on the floor with no injuries noted. Res #25's care plan, dated 12/21/21, documented to keep the bed in low position when care is not being provided and keep the call light in reach at all times. An incident report, dated 05/06/22, documented the resident had a fall resulting in a major injury. The report documented the resident slipped out of her wheelchair while in the hallway causing the resident to be admitted into the hospital for several days. A nurse note, dated 05/10/22, documented the resident returned to the facility. The quarterly assessment, dated 06/13/22, documented the resident had one fall with major injury. The care plan was not updated with new interventions to prevent the resident from falling again. On 07/14/22 at 10:20 a.m., the corporate nurse confirmed that the care plan should have been updated after the fall on 05/06/22 and that interventions should have been initiated to prevent the resident from falling again.

Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for two (#9 and #231) of 15 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 31 residents resided in the facility. Findings: 1. Res #231 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Res #231's care plan, dated 10/08/20, documented the resident was admitted with a pressure area to the left buttock and to the left ankle. Res #231's annual MDS assessment, dated 10/22/21, documented the resident had one stage III and one stage IV pressure ulcer upon admission. The care plan, dated 01/14/22, documented alteration in skin integrity related to the left lateral foot. The quarterly MDS assessments, dated, 01/22/22, 04/24/22, and 07/03/22, documented the resident had one stage III and two stage IV pressure ulcers which were present upon admission. On 07/13/22 at 3:53 p.m., the MDS coordinator stated the quarterly MDSs were documented incorrectly and the additional pressure ulcer was not present upon admission and must have occurred while the resident was under care of the facility. 2. Resident #9 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS assessment, dated 04/20/22, documented the resident had no behaviors such as rejection of care. A review of the resident's TAR revealed the resident had refused wound care frequently. On 07/13/22 at 4:36 p.m., the MDS cordinator reported she only looked at the weekly wound report to determine if the resident refused care. She reported the resident did refuse care with certain staff members. On 07/13/22 at 5:32 p.m., the administrative assistant confimed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interview, the facility failed to refer a resident with a new serious mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator identified seven residents with PASRR II evaluations. Findings: Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR level I, dated 03/10/07, contained no documentation of revision after the resident was diagnosed with [CONDITION(S)]. Record review documented the resident was diagnosed with [CONDITION(S)] on 03/21/18. On 07/13/22 at 3:40 p.m., the corporate nurse reported the DON was responsible for the PASRRs. The corporate nurse was shown the PASRR level I for the resident dated 2007 and then shown a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The corporate nurse stated she was not sure why the PASRR was not reviewed or revised after the resident was given the [CONDITION(S)] diagnosis. On 07/13/22 at 4:34 p.m., the corporate nurse reported that she could not find any documentation that OHCA was notified of the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, observation, and interview, the facility failed to ensure all staff were screened for being found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law prior to hire. The Resident Census and Conditions of Residents form documented 31 residents resided in the facility. Findings: A facility policy, titled Abuse - Reportable Events dated 08/2019, read in parts, .1. Screening: a. Pre-employment screening will be completed on all employees, to include: * Criminal History Check * Background Check * Reference check from previous employers . * Misconduct Registry * OIG . On 07/14/22, the employee files for staff members hired during the last six months were reviewed. Housekeeper #1 did not have a screening or letter of final clearance in their file. On 07/14/22 at 4:28 p.m., the corporate administrator stated the business office personnel was new and did not complete a screening on the housekeeper as they were a re-hire. She stated the business office manager did not know they were required to complete a screening on re-hires.

Based on observation, interview, and record review, the facility failed to: a. institute their infection control program to help prevent the development and transmission of COVID for 31 of 31 residents who resided in the facility. The facility failed to: -residents donned face masks if tolerated. -symptomatic residents who refused testing were quarantined. -reusable activity equipment was cleaned and disinfected between use. The resident census sheet documented 31 residents were living at the facility. Findings: A policy titled COVID-19 Novel coronovirus, last revised on 03/22/21, read in part, . .Residents will wear facemasks/cloth face coverings as tolerated when out of rooms and during close contact with staff . Limit the number of people .participating in an activity . to a number that will ensure social distance is maintained at all times . Clean and sanitize common areas and all items used before and after each activity . Instructional signage throughout the facility .on COVID-19 .infection control precautions (e.g., use of face covering or mask, .) . Implement appropriate infection prevention practices for symptomatic residents including transmission based precautions. 1. On 10/04/21 at 09:10 a.m., it was observed that no COVID-19 prevention signage was posted on the entry door or throughout the facility. During the initial tour, conducted on entry, unmasked residents were observed ambulating in the halls, sitting in the common areas, and visiting each other without appropriate social distancing. On 10/04/21 at 9:30 a.m., resident (Res) #2 was observed sitting in a wheelchair near the desk on the skilled nursing unit. Res #2 reported feeling ill with flu-like symptoms. Res #2 reported RN #1 had been notified of not feeling good and stated the RN had not done anything and had not been instructed to wear a mask. On 10/04/21 at 09:45 a.m., RN #1 stated Res #2 had reported symptoms but did not have a temperature. The RN #1stated Res #2 was coughing, but this was normal for them, and had refused COVID-19 testing. The RN #1 stated it was Res #2's right to refuse testing, to not quarantine, to not socially distance from other residents, or wear a mask. On 10/05/21 at 10:30 a.m., the DON stated when a resident was symptomatic and refused testing they should have been quarantined. The DON stated residents should wear a mask if tolerated. 2. On 10/04/21 at 10:16 a.m., a group of four residents were observed sitting together at a card table in the activity area playing dominos. On 10/04/21 at 3:45 p.m., the AD stated the dominos were not sanitized before, during, or after the game ended. On 10/05/21 at 12:02 p.m., the CIPN stated all activity equipment should have been clean and disinfected between use by residents. The CIPN reported the facility should have signage related to infection control measures such as hand washing, mask wearing, and maintaining social distancing, at the entry door, and throughout the facility.

Based on observation and interview it was determined the facility failed to ensure potentially hazardous food was not stored with other foods in the refrigerator. The facility identified 33 residents who received meals from the kitchen. Findings: On 01/26/20 at 4:51 PM, a cardboard box of raw hamburger meat was observed thawing on the bottom rack of the refrigerator and next to a cardboard box of butter. On 01/26/20 at 5:25 PM, the temporary dietary manager (DM) was observed removing the butter from the refrigerator and reported the raw hamburger meat should have been in a drip pan and should not have been next to the butter.

On [DATE] a past-noncompliance immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to provide the correct therapeutic diet as ordered by the physician. The facility failed to follow a menu for a resident on a ground meat diet. The wrong texture of diet was provided which resulted in a choking incident for the resident. Resident #1's clinical record documented the resident expired the same day of the incident. On [DATE] at 2:45 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the past-noncompliance IJ situation in regard to the failure of the facility to provide the correct therapeutic diet. The deficient practice was determined to be past-noncompliance since the facility identified the IJ situation and implemented interventions to prevent the recurrence of the situation. On [DATE] at 4:50 p.m., the regional administrator was notified of the past-noncompliance IJ situation. On [DATE], the corporate nurse and the dietary manager (DM) in-serviced staff one on one and in groups of three or less in regards to dietary monitoring of each meal for the correct diet; swallowing problems and diet textures; and how dietary orders are updated and communicated to the dietary department. The in-service also included cardiopulmonary resuscitation (CPR), a conscious choking resident, and the [MEDICATION NAME] maneuver and abdominal trust. The facility documented systems were put into place on [DATE] related to the plan of correction were as follows: 1. Wrote plan of correction. 2. Diet cards reviewed with orders in charts and electronic health record for accuracy. 3. In-service with all staff on [DATE]. 4. Telephone order copy to director of nurses (DON) basket and minimum data set (MDS) basket for stand up meeting and accuracy on not missing a diet as ordered. 5. Communication forms in place between nursing and dietary being signed off on. 6. Color coded dot diet identification chart put in place. 7. Diet trays leaving dietary kitchen being monitored by DON or designee and charge nurse when DON is out of the facility with diet orders, diet card, and meal trays. 8. DON to do random audit on electronic health record data entry and diet cards. 9. Large dining room is changed to be delivered first in meal pass. 10. Dietary monitoring sheet in dining room for breakfast, lunch, and dinner in place. On [DATE] an in-service was provided by the dietician. The topics for the in-service were diet textures, infection control, and food handler certification. A quality assessment and performance improvement (QAPI) meeting report, dated [DATE], documented current improvement identified with therapeutic diets, meal time assistance, supervision, and emergency care. On [DATE] an in-service was provided by the speech therapist. The staff members were in-serviced regarding the identification and management of swallowing problems. The assistant administrator reported the first in-service training began on [DATE] at 9:00 a.m. and the last staff member was in-serviced on [DATE] at 5:00 p.m. Based on interview and record review, it was determined the facility failed to prepare and serve food in a form designed to meet the resident's needs for one (#1) of three sampled residents reviewed for mechanically altered diets. The facility failed to serve the resident a ground meat diet as ordered by the physician. The facility identified 18 residents who currently received a mechanically altered diet. Findings: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A dietary waiver, dated [DATE], documented the resident's diet had been explained to him and the possible negative outcomes by not following the physician order [REDACTED]. A care plan meeting record, dated [DATE], documented the resident was to have a ground meat diet with nectar thick liquids for all meals. The record documented the staff members were to remind the resident to eat slowly. A physician order, dated [DATE], documented a speech evaluation had been completed for the resident. The order documented the resident was to have a mechanical soft with chopped meats diet with no bread. The order documented the resident was to have nectar thick liquids and direct supervision with meals. The care plan, dated [DATE], documented the resident did not like his diet and had signed a diet waiver. The care plan documented the dietician was to re-evaluate the resident every month. The care plan documented the resident was screened by speech therapy due to the resident coughing at meals or when taking medication. The care plan documented the liquids had been changed to nectar thick. The care plan did not document the resident's chopped meat diet or the need for direct supervision with meals. A physician order, dated [DATE], documented the resident was to receive a ground meat diet with no breads with staff supervision. The care plan was reviewed and did not document the ground meat diet as ordered by the physician. The quarterly assessment, dated [DATE], documented the resident was moderately impaired for daily decision making. The assessment documented the resident required supervision with eating. The assessment documented the resident held food and coughed with eating. An order report, dated [DATE], documented the resident's diet order. The words ground meats were circled and the words ''fix it'' was written on the report. An incident report, dated [DATE], documented the resident was eating lunch in the dining room, began to have [MEDICAL CONDITION] activity and choke. The report documented the [MEDICATION NAME] maneuver and abdominal thrusts were performed on the resident. The report documented the resident became unconscious, without a pulse, and CPR was initiated. The report documented emergency medical services (EMS) was called and transported the resident to the hospital were he was pronounced dead. A nurse note, dated [DATE], documented the resident was in the dining room eating a soft diet. The note documented the roast on the resident's plate was soft, cut in pieces, and had no bones. The note documented the resident was feeding himself and the staff were close. The note documented the resident's head was shaking, coughed forcefully, and appeared choked. The note documented [MEDICATION NAME] maneuver and abdominal thrusts were performed. The note documented EMS was called, the resident appeared unconscious, and CPR was initiated. The note documented the resident was transported by EMS. An EMS report, dated [DATE], documented they were called to the facility for a choking victim. The report documented upon arrival CPR was in progress, the resident was without a pulse, pupils fixed, and had no breath sounds. The report documented during an intubation attempt the resident's airway was observed to have a large chunk of chicken which was removed. An emergency room /hospital record, dated [DATE], documented the resident arrived with CPR in progress. The record documented EMS removed a bolus of food approximately two inches from the resident's throat using forceps. The report documented the resident was suctioned in the emergency room , removed small pea size to pinto bean size particles with lots of undigested masticated bolus from the resident's throat. The record documented the resident was dead on arrival (DOA). The record documented the immediate cause of death was cardiopulmonary arrest secondary to choking. On [DATE] the dietary manager provided the resident's dietary card. The card documented the resident was on a reduced concentrated sugar mechanical soft diet with ground meat and honey thick liquids. On [DATE] at 1:45 p.m., the DM was interviewed regarding the meal served to the resident for the incident occurring on [DATE]. The DM stated the resident's diet card documented a ground meat diet. The DM stated the resident was not served a ground meat diet the day of the incident. The DM said the resident has always received a chopped diet to her knowledge. The DM stated the meal should have been sent back to the kitchen and corrected. On [DATE] at 2:15 p.m., registered nurse (RN) #1 was interviewed regarding the incident occurring [DATE] for the resident. The RN stated the resident was on a ground meat diet. The RN stated she felt the meat served for the noon meal was not in small enough pieces, so she used a fork to cut the meat in smaller pieces. The RN stated she should have sent the plate back to the kitchen to correct the meat size. The RN stated the resident was feeding himself when his head started shaking and he began to cough. The RN stated she was approximately five feet away at another table assisting another resident with their meal when the incident occurred. The RN stated she approached the resident and did the [MEDICATION NAME] maneuver and abdominal thrusts. On [DATE] and [DATE], interviews and record reviews were conducted to verify the completion of staff in-services. Documentation was provided to indicate all staff had been in-serviced regarding therapeutic diets. Staff members reported knowledge and were observed monitoring for therapeutic diets. On [DATE], the DM provided a spring/summer (YEAR) menu for day 14. The menu documented, under the soft diet column, ground pot roast, two ounces of gravy, seasoned carrots, and plain chocolate cake. The DM stated this was the meal prepared for [DATE] lunch meal. On [DATE] at 8:25 a.m., the emergency medical service (EMS) parametric was interviewed regarding the incident occurring on [DATE] involving the resident. The parametric stated a piece of meat, later identified as roast, was removed from the resident's throat. The parametric stated the meat was one solid piece, two to three inches long and one inch wide. The parametric stated the meat was removed with forceps and did not separate when removed. On [DATE] at 3:02 p.m., the physician was interviewed regarding the incident for the resident which occurred on [DATE]. The physician confirmed the incident when the resident choked/aspirated. The physician was asked about possible [MEDICAL CONDITION] activity. The physician stated he was not aware of any [MEDICAL CONDITION] activity during incident.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who entered the facility without limited range of motion (ROM) did not experience a reduction in range of motion for one (#37) of five residents sampled for contractures. The facility failed to ensure interventions to prevent contractures were put into place for a resident who was assessed as being at risk for contractures. The resident was observed to have contractures of his fingers on both hands and one knee. The assistant administrator (adm)/registered nurse (RN) identified four residents with contractures and three residents with contractures on admission. Findings: The facility's range of motion policy documented, .When the resident's activity level or joint function is at risk of or decreases, range of motion should be started as soon as possible. Joints begin to stiffen within 24 hours of disuse .POSSIBLE RELATED MINIMUM DATA SET TRIGGERS 1. Cognitive loss and dementia. 2. ADL (activities of daily living) function/rehabilitation potential. 3. Psychosocial well being. 4. Falls. 5. Nutritional status. 6. Dehydration and fluid balance. 7. [MEDICAL CONDITION] drug use. 8. Physical restraints . Resident #37 was re-admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The care plan, dated 10/17/15, documented the resident needed one person assistance due to his weakness. The care plan documented the resident would maintain his body in functional alignment when at rest. The care plan documented the resident was unable to walk and was in a geri chair due to being unable to sit up straight. The care plan documented staff were to provide assistance with repositioning. The care plan documented the resident had a tendency to slide down and turn side ways in the bed. The care plan did not identify or document the resident's risk for contractures/limitation in range of motion. An admission assessment, dated 10/30/15, documented the resident was moderately cognitively impaired and had no rejection of care behaviors. The assessment documented the resident needed extensive to total assistance with activities of daily living (ADLs) and did not walk. The assessment documented the resident had functional impairment on both sides of his lower extremities and no impairment of his upper extremities. The assessment did not document the resident had received physical therapy or restorative therapy during the assessment period. The care area assessment (CAA) summary, dated 10/30/15, documented the following care areas which triggered for care planning: ~ cognitive loss, ~ visual function, ~ communication, ~ ADL function/rehabilitation potential, ~ urinary incontinence and indwelling catheter, ~ psychosocial well-being, ~ mood state, ~ activities, ~ falls, ~ nutritional status, ~ feeding tube, ~ dehydration/fluid maintenance, ~ pressure ulcer, and ~ [MEDICAL CONDITION] drug use. The CAA worksheet for ADLs functional status/rehabilitation potential, dated 10/30/15, documented the following problems which could have affected the resident's function: ~ [MEDICAL CONDITION], ~ fall, ~ recent hospitalization , ~ nutritional problems, ~ pain, ~ communication problems, and ~ vision problems. The CAA worksheet for ADLs functional status/rehabilitation potential, dated 10/30/15, documented the resident received psychoactive medications which could have contributed to functional decline. The CAA worksheet for ADLs functional status/rehabilitation potential, dated 10/30/15, documented the resident had the following limiting factors which resulted in the need for assistance with ADLs: ~ physical limitations such as weakness, ~ poor coordination, ~ poor balance, ~ visual impairment, and ~ pain. The CAA worksheet for ADLs functional status/rehabilitation potential, dated 10/30/15, documented the following problems the resident was at risk for because of functional decline: ~ unidentified pain, ~ depression, ~ contractures, and ~ incontinence. A quarterly assessment, dated 08/01/16, documented the resident was moderately cognitively impaired and had no rejection of care behaviors. The assessment documented the resident needed extensive to total assistance with ADLs and did not walk. The assessment documented the resident had functional impairment on both sides of his lower extremities and no impairment of his upper extremities. The assessment did not document the resident had received physical therapy or restorative therapy during the assessment period. On 10/24/16 at 2:54 p.m., during the staff interview, the director of nursing (DON) was asked if the resident had contractures. The DON said the resident did not have contractures but did have a hand roll for his left hand. On 10/25/16 at 10:08 a.m., the resident was observed lying on his back in bed. He had his feet drawn up towards his buttocks, legs crossed, and his knees bent in the up position. The resident's hands were observed resting on his stomach. The resident's hands were holding hand rolls. The certified nurse aide (CNA) #2 said the hand rolls were there to keep the resident's finger nails from cutting his skin. The resident was asked to open his hands. The resident shook his head no. CNA #2 said the resident did not like to open his hands. The CNA was observed to attempt to gently open the resident's hands and was unable to do so. The CNA asked the resident to lay his legs down straight on the bed. The resident's left leg did not straighten all the way. The left knee was observed raised off the bed two to three inches. The CNA said the resident liked to keep his knees bent most of the time. On 10/25/16 at 1:43 p.m., the minimum data set (MDS) nurse was asked how long had the resident had contractures. The MDS nurse reported she did not know the resident had contractures. She said she had a misconception of what a contracture was. She said she had recently noticed the resident's left leg would not straighten out and did not know the resident's fingers were contracted. On 10/26/16 at 9:58 a.m., the MDS nurse presented the surveyor with the January 2016 care plan meeting notes. The care plan meeting note documented the resident had been observed to sit with his legs crossed while in a geri chair. The note documented staff would encourage the resident to straighten his legs out instead of keeping his legs bent. The MDS nurse was asked if the resident was put on restorative services since his last admission. She stated, They had missed the ball on getting him on restorative. On 10/26/16 at 3:15 p.m., the assistant adm/RN and the DON were asked if they knew the resident had contractures. The assistant adm/RN and DON said they did not know the resident had contractures. On 10/26/16 at 3:45 p.m., the assistant adm/RN and the DON reported they had just assessed the resident and found the resident had contracted fingers on both hands and a mild contracture of the left knee. On 10/26/16 at 5:16 p.m., certified medication aide (CMA) #1 was asked how long the resident had contractures. She stated approximately one month. She said she had noticed hand rolls in his hands about a month ago. The CMA was asked about the resident's pain. She stated the resident would ask for pain medication every evening. The CMA stated the resident, in the past, would hold the syringe while she administered his medications through the peg (percutaneous endoscopic gastrostomy) tube. She said about two months ago she noticed he was unable to hold the syringe. On 10/26/16 at 5:22 p.m., CNA #1 was asked how long had the resident had contractures. The CNA said she noticed his hands were contracted about a week ago. On 10 /26/16 at 5:26 p.m., RN #1 was asked how long had the resident had contractures. The RN stated the resident's hands had been contracted for about six months. She was asked if she had told anyone about the contractures. She said she could not remember if she had told anyone about the contractures. She said the CNAs were putting hand rolls in the resident's hands. On 10/26/16 at 5:30 p.m., CMA #2 was asked how long had the resident had contractures. The CMA said about 6 months. On 10/26/16 at 5:32 p.m., CMA #3 was asked how long had the resident had contractures. The CMA stated the resident's hands had been contracted for approximately two months. The CMA said she was the one who usually cut his finger nails and had noticed he could no longer extend his fingers. On 10/26/16 at 5:43 p.m., the assistant director of nursing (ADON) was asked how long the resident's hands and knee had been contracted. She said she did not know the resident had contractures. An occupational therapy evaluation, dated 10/26/16, documented the resident had bilateral upper extremity impairment. The evaluation documented the resident had limited ROM at all joints in all planes/directions. The evaluation documented the resident's hands were in a C shape with the resident tolerating little movement. The evaluation documented the resident's elbows were at approximately 90 degrees. The evaluation documented the resident tolerated approximately 10 degrees of shoulder flexion. On 10/27/16 at 8:18 a.m., the resident's physician assistant (PA) was asked if he had noticed the resident's contractures of his hands and left knee. He said he first noticed the resident's hands were stiff in early September. He said he told the staff to watch the resident. On 10/27/16 at 8:34 a.m., the physical therapist aide (PTA) and the certified occupational therapist aide (COTA) were interviewed. The COTA said the resident was discharged from therapy when he went to the hospital on [DATE] and was not put back on therapy after he returned on 10/17/15. The PTA and COTA said the resident did not have contractures at the time of discharge on 10/08/15. On 10/27/16 at 8:45 a.m., CNA #2 was asked how long the resident's hands and knee had been contracted. The CNA stated she had noticed the contractures since August 2016. On 10/27/16 at 9:02 a.m., the MDS nurse was asked if the resident had any contractures during the time she completed the admission assessment in October 2015 and the quarterly assessment in August 2016. The MDS nurse stated she did not notice any contractures during these two assessment times. She said she coded the resident as having impairment in his lower extremities because the resident was very slow at moving his legs in bed and the resident did not walk. On 10/27/16 at 11:05 a.m., the MDS nurse was asked why the resident's risk for contractures was not care planned. The MDS nurse said it was overlooked. On 10/27/16 at 11:39 a.m., the assistant adm/RN was asked if interventions or services should have been put into place to prevent the resident from developing contractures. The assistant adm/RN stated the facility should have had interventions in place to prevent contractures.

Based on record review, observation and staff interview, it was determined the facility failed to ensure a gradual dose reduction of Ambien had been attempted for one (#1) of two residents sampled who were prescribed Ambien. This had the potential to affect two residents identified by the MDS coordinator as being prescribed hypnotic medications. Findings: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 10/22/12, Ambien 10mg had been started at bedtime for the resident's insomnia and since then there had never been an attempt at reducing the medication. An I.R., dated 10/05/13 at 8:30 p.m., documented "...Res. changing her socks and slid out of W/C into floor. Denies injury..." On 10/23/13, a 'Drug Regime Review', documented, "...could Ambien be changed to Trazodone or Melatonin..." The physician circled 'Disagree' and stamped in the comments, "Patient is controlled on present dosage with no side effects." An I.R., dated 12/07/13 at 9:00 p.m., documented "...I'm ok guess I sat in floor, was lying on back with head up. I'm not hurt, I'm ok. Refused to go to ER, no injuries..." On 01/30/14, a 'Medication Regime Review', documented, "...could Ambien be changed to Trazodone or Melatonin..." The physician again circled 'Disagree' and again stamped in the comments, "Patient is controlled on present dosage with no side effects." An I.R., dated 01/30/14 at 8:30 p.m., documented "...Res. in floor. I just layed down in floor. Scrape to R knee 2 cm, superficial area...to bed a few minutes before with call light in reach. Meds given at 8 p.m..." On 04/24/14, a 'Medication Regime Review', documented "...could Ambien be changed to Trazodone or Melatonin..." The physician circled 'Disagree' and documented, "Resident does well with current med-Stable states she sleeps well at night." This was the third time the pharmacist had recommended a change to the Ambien prescription after three falls had occurred at night. The physician would not agree to a dose reduction or a change in the medication. A nurse's note, dated 05/12/14 at 8:20 p.m., documented "...Res. in room sitting on buttocks upright said 'I was in W/C, got up grabbed table, it moved and I fell .' 4 cm area to Lt. arm, moves BLE...Res. was put to bed earlier..." The incident report, dated 05/12/14, documented the fall occurred at 8:20 p.m., neuro checks were begun and the resident's left arm was injured with a 4 cm. skin tear. Report documented the resident refused to go to the hospital. An annual assessment, dated 07/13/14, documented the resident was cognitively intact, required limited assistance with bed mobility, transfers, dressing, toileting and personal hygiene. A nurse's note, dated 07/16/14 at 9:15 p.m., documented "...Res sitting in floor, states she was trying to get into W/C and slid off of bed. No injury noted..." On 07/29/14, a 'Medication Regime Review', three months after the last recommendation for Ambien to be changed, documented, "...could Ambien be changed to Trazodone or Melatonin..." The physician circled "Disagree" and documented, "...wants to keep Ambien for sleep. Very stable on this med..." The resident had experienced five falls at night after being put to bed. The pharmacy consultant had recommended to the physician four different times from January 2014 through July 2014, for a change in the hypnotic medication. The physician had continually disagreed to change the medication due to the resident being stable on the medication. The resident had experienced a fall with injury on 05/12/14, to her arm. A 'Medication Flowsheet' for the month of July 2014, documented the resident received Ambien every night at 8:00 p.m. The falls had all occurred after the 8:00 p.m., Ambien had been administered. On 08/04/14 at 5:20 p.m., the resident was observed eating dinner in the DR, feeding herself and visiting with her daughter. The resident appeared cheerful and talkative. On 08/05/14 at 12:20 p.m., the pharmacy consultant was interviewed. He said the Ambien should be reduced. He said he had asked for a reduction several times but the physician disagreed. On 08/06/14 at 2:00 p.m., the DON was interviewed regarding the resident's Ambien being reduced. She reported maybe it could be reduced and stated, "I will talk to the doctor."

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure preventive skin care interventions had been developed and instituted for a resident (#8) who had footdrop and developed a pressure sore on their toe. The deficient practice constituted harm to the resident, due to the lack of prevention; and assessment and treatment when the pressure sore had first been observed as a, "reddened" area. b) Ensure pressure sores were assessed per the facility's policy for two (#1 and #8) of two sampled residents with pressure sores. This had the potential to affect two residents identified with pressure sores (one identified during the survey) per the DON. Findings: The facility's policy and procedure documented: "Skin Integrity Management Pressure Sore: Definitions: Pressure Sore- any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure sores usually occur over any bony prominence and are staged to classify the degree of tissue damage observed... Guideline: The following information provided guidelines for the prevention, early intervention, monitoring and treatment of [REDACTED]. This evaluation will be documented using the 'Skin Assessment Flowsheet- Pressure Sores'...Skin assessment must be completed on any resident with a pressure sore (including Stage I) on a weekly basis...All notifications to physician and interested party of the resident are to be completed and documented..." 1. A care plan for resident #8 (born on 10/11/1973), dated 04/05/13, documented, "Problem: Resident has contractures R/T spinal injuries...Approach...Report signs of venous [MEDICAL CONDITION] (tenderness, redness, warmth, taunt/shiny skin, increased size compared to non-affected extremity, increased skin temperature." A quarterly assessment, dated 07/09/13, documented the resident had severely impaired cognition, was totally dependent on staff for bed mobility, transferring between surfaces, all ADL care, had a gastrostomy tube, was not ambulatory, had an indwelling urinary catheter, was always incontinent of bowel and was at risk for pressure sores. The September 2013, physician's orders [REDACTED].once a day...F/C care c soap & water q shift..." The September 2013, treatment sheet documented, "Clean Lt great toe c N/S pat dry apply TAO to S/T nonstick dsg q day..." The treatment had been initiated on 09/23/13. The nurse's notes were reviewed for documentation of a skin assessment for the left great toe. The last documentation in the nurses' notes was on 09/18/13. The nurses' notes did not contain documentation related to the left great toe. On 09/26/13 at 10:00 a.m., LPN #1 was observed providing G/T treatment and indwelling urinary catheter care. The resident was observed lying in her bed. The LPN untucked the sheet from under the mattress at the foot of the resident's bed. The resident was observed to have foot drop of both feet. The resident's toes were in a fixed arch, curving downward. The resident's left great toe, on the inner edge of the toe near the base of the toenail at the first distal joint had an open area, draining a yellow substance. After the LPN had completed the treatments, she was asked what had happened to the resident's toe. The LPN reported she did not know, that it looked like it was draining puss and was infected. The LPN returned to the treatment book and reported the resident had a treatment for [REDACTED]. At 11:00 a.m., the DON was asked if the open area had been assessed and/or documented in the nurses' notes. The DON reported she was unable to find any assessment or documentation in regard to the open area on the resident's toe. At 2:00 p.m., a family member was interviewed. During the interview, the family was ask if they were informed of changes in their family members condition or new treatments. The family member reported they had been contacted on 09/23/13, related to an area on the resident's right great toe. The toe had been, "angry, inflamed and had a blister," which had become infected. The family member reported they had asked the facility staff repeatedly not to tuck in the resident's sheets at the foot of her bed, due to it putting pressure on the resident's toes. At 2:35 p.m., CNA #3 and CNA #4 were interviewed. The CNAs reported they had provided care for the resident last week and this week. CNA #3 reported the area on the resident's left great toe had been a blister last week and it had opened up on Monday (09/23/13). The CNAs stated on 09/23/13, they had reported the resident's toe to the charge nurse and she had obtained a treatment order. The CNAs were asked what the area had looked like last week. They reported it had been a blister. The CNAs were asked if last week was the first time they had noticed the toe having a blister. They reported the toe had been red for a long time. The CNA further reported they felt the toe 'irritation' may have been from her feet rubbing together or from the sheet rubbing her toes. On 09/26/13 at 3:00 p.m., RN #1 who had obtained the treatment order was interviewed. The RN was asked if she had assessed the resident's toe. She reported she had looked at it, but had not measured it. The RN reported she had called the physician and obtained a treatment order. No assessment of the toe had been documented in the record, including when the toe was red, had blistered and/or broken down. The resident's care plan did not address the care of the resident's feet and/or foot drop or any measures to prevent skin breakdown. 2. Resident #1's [DIAGNOSES REDACTED]. A care plan, dated 08/21/13, documented the resident had impaired skin integrity. A "Skin Assessment Flowsheet- Pressure Sore", dated 08/21/13, documented: "Left Heel: Stage II, dimensions (cm) 1.6 x 2.4 x .01 Right buttock: Stage II, dimensions (cm) 4.8 x 1.2 x .01" The next pressure sore assessment was 23 days later. A "Skin Assessment Flowsheet - Pressure Sore", dated 09/12/13, documented: "Left heel: Stage (blank), dimensions (cm) 1.4 x 1.7 Right buttock: Stage II, dimensions (cm) 4 x 2" A quarterly assessment, dated 09/16/13, documented the resident had moderately impaired cognition, was occasionally incontinent of bowel and bladder, was at risk of developing a pressures sore, had one Stage I pressure sore that had granulation tissue. The next pressure sore assessment was 10 days later. A "Skin Assessment Flowsheet- Pressure Sore", dated 09/22/13, documented: "Left heel: Stage (blank), dimensions (cm) 1.2 x 1.4 Right buttock: Stage II, dimensions (cm) 4 x 2" On 09/25/13 at 3:20 p.m., RN #1 was observed providing pressure sore treatments for the resident. The RN was observed to measure the pressure sores prior to applying the treatments. The resident was observed to have four Stage II pressure sores; two more than was documented. The RN assessed the pressure sore on the resident's left heel and reported it as a Stage II, measured 1.5 cm x 1 cm. The RN assessed the two pressure sores on the resident's right inner buttock. The RN reported both pressure sores as Stage II, one (A) measured 3.5 cm x 1.5 cm and the 2nd pressure sore (B) measured 1 cm x 5 cm (new). The RN assessed the second new pressure sore on the resident's left buttock and reported it as a Stage II. The RN did not measure the area at the time of the observation. She reported she would have to contact the physician for a treatment order for the new pressure sore. On 09/24/13 at 3:00 p.m., the DON was interviewed regarding the resident's pressure sores not being assessed weekly as the facility's policy and procedure documented. The DON reported the facility had a problem with the nurse that had been doing the pressure sore assessments. She further reported the ADON was now responsible for the pressure sore assessments.

Based on record review, observation and staff interview, it was determined the facility failed to ensure the necessary care was provided for residents to maintain their highest practicable well-being by failing to: a) Ensure a topical medication patch was removed before applying an additional patch for one (#13) of four sampled residents with topical medication patches. This resulted in harm to the resident, who had to be hospitalized as a result of having two patches on at the same time. This also had the potential to affect six residents identified by the DON as receiving a topical medication patch. b) Ensure a laxative was administered in a timely manner, after a resident had gone five days without a bowel movement for one (#2) of nine sampled residents with [DIAGNOSES REDACTED]. 1. The medical record for resident #13 documented the resident had been admitted to the facility on [DATE]. The resident had a readmission date of [DATE]. The resident's [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Nurses' notes on 04/26/11, documented the following: "1:35 p.m., Alert & oriented to self c confusion noted...5:45 p.m., Called to resi rm by family d/t 'resi not acting like herself '. Resi alert & vocal c confusion noted. Resi is semi lethargic & drowsy but does c/o nausea & reports vomiting X 1 earlier today. 0 emesis noted @ this X. PRN [MEDICATION NAME] offered for nausea- family refused & stated she can't take that it makes her crazy & they req to go to ER." A physician's telephone order, dated 04/26/11, documented, "Send to...ER for eval R/T drowsiness." A history and physical report dated 04/26/11, from the hospital documented, "Chief Complaint: Decreased responsiveness. History of present illness: This is a [AGE] year old lady who has been on hospice. She was brought in from the nursing home because her daughter discovered two [MEDICATION NAME]es attached associated with decreased responsiveness. One was on the front and the other on the back, possibly obscuring the location. She had recently been in the (Name deleted) psychiatric hospital to try to help with her [MEDICAL CONDITION], where they placed her on [MEDICATION NAME] and [MEDICATION NAME]. I agreed that she was possibly over sedated and thought it best that she be admitted to the hospital for further observation..." A "medication / documentation error report", dated 04/26/11, documented, "Date of error 4/26/11. Time of error 8 am. Reason for making error. CMA put a patch on s ensuring the old one was removed." A "patient transfer form", dated 05/06/11, documented the resident was transferred to the hospital for decreased responsiveness. A five day assessment, dated 05/10/11, documented the resident had inadequate short and long term memory, had moderately impaired cognition, had signs and symptoms of [MEDICAL CONDITION] that fluctuated. Nurses' notes, dated 05/10/11, documented, "5:45 p.m., Return to facility...c orders to DC to home. 7:55 p.m., Dtr here to get resi. Left c all personal belongings & meds." On 09/01/11 at 2:05 p.m., the DON was interviewed regarding the residents hospitalization . The DON was shown the hospital records of the resident being admitted for decreased level of responsiveness and having two [MEDICATION NAME]es. The DON reported the CMA had placed a second patch on the resident that morning, without removing the patch from the day before. The DON then reported the resident may had been having a side effect to receiving too much [MEDICATION NAME]. Prior to the incident the facility did not have a system for monitoring the [MEDICATION NAME]es. The DON reported they were monitoring patches more closely now. The DON also reported, the resident had returned to the facility on [DATE]. The [MEDICATION NAME] had been discontinued at the hospital. The DON reported when the resident returned a nurse placed an [MEDICATION NAME] on the resident, without an order. 2. Resident #2 had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. An annual assessment dated [DATE], documented the resident had inadequate short and long term memory, had severely impaired cognition, was always incontinent of bowel and utilized an indwelling urinary catheter. The care plan, dated 06/23/11, documented: "Problem: ADL deficit:... requires extensive to total care in ADL's due to physical limitations... Interventions: Incontinent of bowels. Indwelling Foley catheter intact and patent. Provide incontinent care following each episode..." A nurse's note, dated 08/31/11 at 3:00 p.m., documented, "Fecal impaction DT hospice nurse said it has been a few days. Abd soft non-tender ABSX4 BM soft & firm c sm amt on pad." The August 2011, medication administration sheet was reviewed. The sheet did not contain documentation of the resident receiving a laxative during the month of August. The resident had 2 different PRN laxatives ordered. The August 2011, ADL flow-sheet was reviewed. The sheet documented the resident had a small bowel movement on 08/26/11. No bowel movements were documented for 27th through the 31st, a five day period. The August 2011, physician's orders [REDACTED]. On 08/30/11 at 12:15 p.m., the resident was observed sitting up in a G/C in the dining room. The resident was observed being spoon-fed by the staff. On 09/01/11 at 11:00 a.m., the DON was interviewed. The DON was shown the resident's ADL sheet dated August 2011. She was shown the lack of bowel movements for the five day period and the resident not being treated with a laxative for the constipation, but instead checked for an impaction. The DON reported that when the CNAs documented the ADLs for the day they should have informed the LPN of the lack of BM's after 3 days. She then reported the LPN would have administered a laxative.