Every finding on record at Arbor Village

Based on record review and interview, the facility failed to ensure medications were administered as ordered for 1 (#5) of 3 sampled residents reviewed for medications.The DON identified 65 residents resided in the facility.Findings:An admission record, dated 03/05/26, showed Res #5 had diagnoses which included epilepsy and heart failure.A physician's order, dated 03/05/26, showed Res #5 was to receive 750 mg of levetiracetam (an anticonvulsant medication) twice a day by mouth for epilepsy. The order was discontinued on 03/07/26.A nurse note, dated 03/07/26 at 2:04 p.m., showed Res #5 had seizure activity at 9:50 a.m., 11:55 a.m., and 12:21 p.m. The note showed hospice arrived at 2:00 p.m. to assess the resident.A physician's order, dated 03/07/26, showed Res #5 was to receive 1000 mg of levetiracetam twice a day by mouth for epilepsy.A nurse note, dated 03/08/26 at 4:44 p.m., showed Res #5 was had seizure activity throughout the day. The note showed hospice had been notified earlier in the morning the increased dose of levetiracetam was not available in the facility. The note showed the pharmacy had reported the medication would not be delivered until the following day.A nurse note, dated 03/08/26 at 5:00 p.m., showed the medication would be delivered later that night.A MAR, dated 03/2026, showed Res #5 received 750 mg of levetiracetam on 03/07/26 at 8:00 a.m. The MAR showed Res #5 was given 1000 mg of levetiracetam on 03/09/26 at 8:00 a.m. The MAR did not show Res #5 was given levetiracetam on 03/07/26 at 8:00 p.m., 03/08/26 at 8:00 a.m., or 03/08/26 at 8:00 p.m.On 06/05/26 at 12:00 p.m., the DON stated the facility did not have documentation the levetiracetam was administered to Res #5 on the evening of 05/07/26 or the two doses on 05/08/26.

The 2567 had been amended based on a determination resulting from an Informal Dispute Resolution (IDR). Existence of Immediate Jeopardy (IJ) has been removed. Based on observation, record review, and interview, the facility failed to:a. ensure supervision for residents who smoke and to secure smoking materials to prevent accident hazards for 1 (#5) of 3 sampled residents reviewed for smoking; andb. prevent elopement for 1 (#7) of 3 sampled residents reviewed for elopement.The DON identified 15 residents at risk for elopement resided in the facility.Findings:1. On 06/08/26 at 8:45 a.m., Res #5 was observed to have three packs of cigarettes and a lighter on their overbed table. On 06/09/26 at 9:54 a.m., Res #5 was observed to have cigarettes and a lighter on their overbed table.An undated Resident Smoking policy showed residents would be assessed to determine if they were safe to smoke either supervised or unsupervised. The policy showed smoking materials of residents requiring supervision would be secured by staff.A baseline care plan, dated 03/05/26, showed Res #5 received oxygen therapy and was a supervised smoker. A behavior note, dated 03/16/26 at 7:00 p.m., showed Res #5 was observed smoking in their room while receiving oxygen therapy. The note showed Res #5 was placed on supervised smoking and their smoking materials were secured by the nurse; the resident was not injured.A smoking assessment, dated 03/16/26, showed Res #5 was placed on supervised smoking for safety.An admission assessment, dated 03/18/26, showed Res #5 had a BIMS score of 15 which indicated intact cognition for daily decision making.On 06/08/26 at 8:50 a.m., CMA #1 stated residents on supervised smoking could only smoke during designated smoke breaks and their smoking materials were kept in the med room.On 06/08/26 at 9:30 a.m., CNA #3 stated supervised smokers should not have cigarettes and lighters in their room.On 06/08/26 at 10:00 a.m., the DON stated residents on supervised smoking should not have smoking materials in their room. They stated Res #5's family visited this weekend and probably left the smoking materials with the resident.On 06/09/26 at 10:05 a.m., housekeeper #1 stated Res #5 was a supervised smoker, and their smoking materials should be kept in the medication room. Housekeeper #1 stated they had observed smoking materials in Res #5's room in the past.On 06/09/26 at 10:10 a.m., CNA #2 stated Res #5 was a supervised smoker and should not have smoking materials in their room. CNA #2 stated they had observed smoking materials in Res #5's room in the past.On 06/09/26 at 10:15 a.m., the ADON stated Res #5 was allowed to keep their cigarettes in their room, but they should not have a lighter in their room.2. An admission record, dated 01/30/26, showed Res #9 had diagnoses which included dementia and asthma.A significant change assessment, dated 05/15/26, showed Res #9 had a BIMS score of 0, which indicated the resident was severely impaired in cognition for daily decision making, and could walk independently. An incident report form, dated 06/06/26 at 2:30 a.m., showed the facility received a call from the police stating Res #9 was next door in the grocery store parking lot. The report showed all exit doors were secured, and the resident was assessed for injuries and placed on one-to-one supervision with staff.On 06/09/26 at 2:50 p.m., the ADON stated they were on duty when Res #9 eloped. They stated they made rounds every two hours, and they were making rounds at 2:30 a.m. when the police called and reported Res #9 was next door in the parking lot. The ADON stated they had eight staff members on duty at the time Res #9 eloped and they had checked the resident's window and all the doors in the facility were secure.On 06/10/26 at 3:10 p.m., the DON stated all the doors and windows had been inspected, and they were not sure how Res #9 got out of the building.

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained for residents with indwelling urinary catheters for 1 (#8) of 3 sampled residents reviewed for infection control.The DON identified 5 residents with indwelling urinary catheters.Findings:On 06/04/26 at 2:25 p.m., Res #8 was observed in the lobby area of the facility seated in their wheelchair with their catheter drainage bag attached to the back of their wheelchair. The bottom of Res #8's catheter drainage bag and part of the drainage tubing was observed to be resting on the floor.On 06/04/26 at 2:57 p.m., Res #8 was observed in the outside smoking area. The bottom of the catheter drainage bag and part of the drainage tubing was observed to be resting on the floor.An undated facility policy titled Indwelling Catheter Use and Removal, read in part, If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance to current professional standards that include . Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures.An admission record, dated 01/24/25, showed Res #8 had diagnoses which included urine retention and diabetes mellitus.A quarterly assessment, dated 05/05/26, showed Res #8 had a BIMS score of 14, which indicated the resident was intact in cognition for daily decision making. The assessment showed Res #8 had an indwelling urinary catheter.On 06/04/26 at 2:45 p.m., CNA #1 stated catheter bags and drainage tubing should be kept off the floor.On 06/04/26 at 3:00 p.m., LPN #1 stated catheter bags and drainage tubing should be kept off the floor.On 06/04/26 at 3:45 p.m., the DON stated to maintain infection control, catheter bags and drainage tubing should not be in contact with the floor.

Based on record review and interview, the facility failed to assess, monitor, and intervene to prevent worsening pressure ulcers for 1 (#2) of 3 sampled residents reviewed for pressure ulcers.The DON identified 7 residents with pressure ulcers resided in the facility. Findings:An undated Pressure Injury Prevention and Management policy, read in part, Licensed nurses will conduct a full body assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Findings should include type of wound, wound measurements (measured upon discovery and at least weekly thereafter), other wound characteristics (color, exudate, odor, pain, tissue type in wound bed), and treatment and interventions implemented.An admission note, dated 01/19/26, showed Res #2 had multiple wounds upon admission including a wound to the right buttock, wound to the left gluteal fold, a wound to the left great toe, deep tissue injury to right heel, scab on the right earlobe, wound to upper lip, and a small pea-sized wound to the top of the left foot.An admission record, dated 01/19/26, showed Res #2 had diagnoses which included a stage II pressure ulcer of the left buttock, dependence on renal dialysis, and diabetes mellitus.A physician's order, dated 01/21/26, showed to clean buttocks wound with normal saline, pat dry, apply Medi-honey (sterilized honey used in wound care), apply calcium alginate (antimicrobial wound gel), cover with abdominal pad, and secure with tape daily.An admission assessment, dated 01/26/26, showed Res #2 had a stage II pressure ulcer upon admission.A weekly skin screen, dated 01/26/26, read in part, Eschar and slough to wound to buttocks Stage 2 to [left] gluteal fold scab to [right] ear Scabbing to upper lip open callous like area to [left] great toe Open area to top of [left] foot [deep tissue injury] to [right] heel A skilled nurse note, dated 01/27/26 at 6:08 p.m., showed wound care was completed as ordered and the wounds seemed to be improving. A skilled nurse note, dated 01/28/26 at 5:17 p.m., showed the wounds were improving. A skilled nurse note, dated 01/29/26 at 2:28 p.m., showed the wounds were improving. A skilled nurse note, dated 01/30/26 at 6:04 p.m., showed wound care was provided and the wounds seemed to be improving. A skilled nurse note, dated 01/31/26 at 9:15 a.m., showed wound care was provided and the wounds seemed to be improving. A skilled note, dated 02/01/26 at 5:34 p.m., read in part, Wound to right buttock noted with 95% slough, wound edges noted to be granulated tissue. During wound cleansing resident skin noted to roll back from the edges. Evidence of deterioration. Large amount of brown odoris drainage noted to previous bandage. Small open area noted to right ear lobe, skin in bed beside resident head. Doctor notified, new order for betadine to right ear lobe daily. A skilled nurse note, dated 02/02/26 at 6:22 p.m., showed wound care was provided. A weekly skin screen, dated 02/03/26, read in part, Unstageable wound to sacral region diabetic wound to [left] great toe Open area to [right] ear lobe scabbing to upper lip A skilled note, dated 02/03/26 at 4:33 p.m., showed wound care was performed with large amounts of purulent drainage (pus). The note showed the physician was notified and orders were received to obtain a wound culture and for the wound care provider to assess the wound. A nurse note, dated 02/04/26 at 4:49 p.m., showed Res #2's family wanted the resident sent to the hospital for an evaluation and treatment. The note showed the physician was notified and an ambulance was called. An Emergency Department to Hospital admission form, dated 02/04/26, showed upon admission to the emergency department, Res #2 had a large unstageable decubitus ulcer with cellulitis and severe sepsis. An operative report, dated 02/05/26, showed Res #2 underwent an excisional debridement of skin, subcutaneous tissue, and muscle. The report showed the postoperative diagnosis was a stage IV sacral wound measuring 25 cm x 18 cm x 4 cm. A review of Res #2's medical record did not show an initial assessment of Res #2's wounds had been completed, or that the wounds had been reassessed during their stay. On 06/04/26 at 7:45 a.m., the ADON stated they had written the skilled note for Res #2, dated 02/01/26 at 5:34 p.m. They stated they could not recall if they notified the physician about the drainage from Res #2's wound. On 06/08/26 at 9:50 a.m., LPN #2 stated wounds should be thoroughly assessed to determine if they were improving or declining. On 06/08/26 at 10:00 a.m., the DON stated Res #2's wounds were not adequately monitored and assessed.

Based on record review and interview, the facility failed to develop a comprehensive care plan for 1 (#5) of 3 sampled residents reviewed for care plans.The DON identified 65 residents resided in the facility.Findings:An undated Comprehensive Care Plans policy, read in part, 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.An admission record, dated 03/05/26, showed Res #5 had diagnoses which included depression and atrial fibrillation.An admission assessment, dated 03/18/26, showed Res #5 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making. The assessment showed Res #5 was always incontinent, was at risk for developing pressure ulcers, and received an opioid pain medication.Res #5's care plan, revised on 05/22/26, did not show focus areas or interventions related to incontinence, skin integrity, or pain management.On 06/04/26 at 1:55 p.m., the MDS coordinator stated a care plan should address care areas and preferences of the resident. They stated Res #5's care plan was not complete and did not address incontinent care, skin integrity, or pain management.On 06/04/26 at 3:45 p.m., the DON stated Res #5's care plan was incomplete.

Based on record review and interview, the facility failed to provide an environment free of accident hazards for 1 (# 69) of 20 sampled residents reviewed for accident hazards. The administrator identified 84 residents resided in the facility. Findings:A quarterly assessment, dated 02/24/25 ,showed Resident #69 had diagnoses which included anxiety and vascular dementia, and a BIMs score of 5 which indicated the resident was severely cognitively impaired for daily decision making. An elopement evaluation, dated, 03/04/25, showed a score of 9 which put Resident #2 at risk for elopement. The evaluation showed Resident #2 had a history of walking around the facility but did not exhibit exit seeking behaviors. A progress note, dated 04/24/25 at 7:00 p.m., showed dietary staff notified nursing staff Resident #2 had fallen outdoors. The progress note showed Resident #2 was transported to a hospital for evaluation. A facility incident report to the Oklahoma Stated Department of Health, dated 04/24/25, showed Resident #2 exited the facility through a propped open door and fell on the uneven ground. The report showed the resident was assessed and treated for injuries at a local hospital.On 08/07/25 at 2:20 p.m., the administrator in training #1 reported the investigation was completed by the previous administrator. They stated the investigation showed a kitchen staff member propped a side door open to take out the trash. Resident #2 walked out the propped open door, stumbled and fell resulting in cuts and abrasions. The administrator in training #1 stated the kitchen staff who propped open the door was educated on resident safety, facility policies and protocols, and allowed to return to work. On 08/07/25 at 2:20 p.m., the admissions coordinator reported the staff member should not have left the door propped open. They stated there was a reason the door was locked in the first place. They (cook #1) broke facility protocols for protecting the safety of the resident. On 08/10/25 at 1:37 p.m., [NAME] #1 stated they propped open the door to take the trash out of the kitchen, and Resident #69 walked out of the open door and fell on the ground. [NAME] #1 stated it was the first time they had propped open the door to take out the trash. They stated the door was propped open for less than a minute. [NAME] #1 stated they regretted propping open the door and would not do it again.

Based on record review and interview, the facility failed to:a. review infection prevention control policies and procedures at least annually,b. assess locations Legionella and other opportunistic waterborne pathogens can grow and spread,c. implement measures to prevent the growth of waterborne pathogens, andd. have monitoring in place to evaluate effectiveness of water pathogen program.The administrator reported 64 residents resided in the facility. FindingsA facility policy titled Legionella Surveillance, implemented on 08/22/22, did not include a plan for assessing, evaluating and monitoring the measures to prevent the growth of waterborne pathogens.On 08/07/25 at 2:20 p.m., the infection prevention coordinator was asked about annual review of policies. They stated they were not current and had not been reviewed in a few years.On 08/10/25 at 10:05 a.m., the administrator was asked about the annual review of infection control policies. They stated they could not find any documentation of any reviews.On 08/07/25 at 2:20 p.m., the infection prevention coordinator was asked about the facility assessment and evaluation for Legionella or waterborne pathogens. They stated there was not a facility assessment or evaluation in place.On 08/10/25 at 10:05 a.m., the administrator was asked if there was any documentation a facility assessment or evaluation related to Legionella or waterborne pathogens had been completed. They stated there was not any documentation they were aware of showing this had been done.

Based on record review and interview, the facility failed to ensure the arbitration agreement provided the selection of a neutral arbitrator for 3 (#2, 11, and #71) of 3 sampled residents whose arbitration agreements were reviewed.The administrator identified 63 residents had signed binding arbitration agreements. Findings:An undated Policy and Procedure for Arbitration, read in part, Arbitration: A binding process where a neutral third party [arbitrator] hears and resolves disputes outside of court.Arbitrator Selection: Arbitration will be conducted by a neutral, qualified arbitrator agreed upon by both parties.1. An Arbitration Agreement, signed by Resident #2's representative, on 05/09/24, did not show a neutral arbitrator would be utilized.An admission assessment, dated 05/17/25, showed Resident #2 had BIMS score of 15, which indicated the resident was cognitively intact for daily decision making.2. An Arbitration Agreement, signed by Resident #11 on 07/29/24, did not show a neutral arbitrator would be utilized.A quarterly assessment, dated 04/10/25, showed Resident #11 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making.3. An admission assessment, dated 06/28/25, showed Resident #71 had a BIMS score of seven, which indicated the resident was severely impaired in cognition for daily decision making.An Arbitration Agreement, signed by Resident #71's representative, on 07/21/25, did not show a neutral arbitrator would be utilized.On 08/07/25 at 2:23 p.m., the administrator stated they had reviewed the facility's arbitration agreement and stated they did not know why it did not contain verbiage a neutral arbitrator would be utilized.

Based on record review and interview, the facility failed to ensure assessments were accurate for 1 (#2) of 20 sampled residents whose assessments were reviewed. The administrator identified 64 residents resided in the facility. Findings: An admission assessment, dated 05/17/25, showed Resident #2 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, had a diagnosis of hemiplegia, and was taking an anticoagulant during the seven-day look back period. A medication administration record, dated 05/01/25 through 05/31/25, did not show Resident #2 had received an anticoagulant medication during the look back period. On 08/10/25 at 10:05 a.m., the MDS coordinator reviewed the admission assessment, physician orders, and the medication administration record and stated the assessment had been coded in error regarding the anticoagulant medication. They stated Resident #2 had not been ordered or received an anticoagulant medication during the look back period for the assessment.

Based on record review and interview, the facility failed to ensure assessments were submitted/transmitted within 14 days of completion for 2 (#27 and #28) of 20 sampled residents whose assessments were reviewed.The administrator identified 64 residents resided in the facility.Findings: 1. A quarterly/discharge return not anticipated assessment, dated 07/01/25, showed Resident #27 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and the assessment had been completed late on 07/20/25. An MDS 3.0 NH Final Validation Report, dated 08/05/25, showed the quarterly/discharge return not anticipated assessment for Resident #27, dated 07/01/25, had been submitted late. On 08/10/25 at 10:15 a.m., the MDS coordinator stated the quarterly/discharge return not anticipated had been submitted/transmitted on 08/05/25. The MDS coordinator stated they had not known how to transmit/submit assessments so the regional office had been transmitting them. 2. A quarterly assessment, dated 06/29/25, showed Resident #28 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and the assessment had been completed late on 07/20/25. An MDS 3.0 NH Final Validation Report, dated 08/05/25, showed the quarterly assessment for Resident #28, dated 06/29/25, had been submitted late. On 08/10/25 at 10:19 a.m., the MDS coordinator stated the quarterly assessment for Resident #28 had been submitted/transmitted late on 08/05/25. They stated the regional office had been submitting/transmitted assessments until they had learned the program for submission/transmission.

Based on record review and interview, the facility failed to ensure quarterly assessments were completed within 14 days of the assessment reference date for 3 (#6, 27, and #28) of 20 sampled residents whose assessments were reviewed. The administrator identified 64 residents resided in the facility. Findings: 1. A quarterly assessment, dated 06/17/25, showed a BIMS assessment had not been conducted for Resident #6 and the assessment had been completed on 07/12/25. On 08/10/25 at 10:12 a.m., the MDS coordinator stated they were unable to complete the BIMS assessment because they had completed the quarterly assessment late and they were outside of the timeframe to obtain a BIMS score. They stated the quartely MDS was completed late for Resident #6 because the previous MDS coordinator had resigned, they did not have access to complete MDS assessments for a while, and they had gotten behind. 2. A quarterly/discharge return not anticipated assessment, dated 07/01/25, showed Resident #27 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and the assessment had been completed late on 07/20/25. On 08/10/25 at 10:15 a.m., the MDS coordinator stated the previous MDS coordinator had resigned and they had not had access to complete MDS assessments. 3. A quarterly assessment, dated 06/29/25, showed Resident #28 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and the assessment had been completed late on 07/20/25. On 08/10/25 at 10:19 a.m., the MDS coordinator stated the quarterly assessment for Resident #28 was completed late because they had not had access to complete MDS assessments after the previous MDS coordinator had resigned.

Based on record review and interview, the facility failed to ensure care plans were updated for 1 (#2) of 20 sampled residents reviewed for care plans. The administrator identified 64 residents resided in the facility. A care plan, dated 05/09/25, did not include restorative care for Resident #2.An admission assessment, dated 05/17/25, showed the Resident #2 had diagnoses which included hemiplegia and hemiparesis and a BIMS score of 15 which indicated the resident was cognitively intact. A restorative care order dated, 07/07/25, showed a resting hand splint was to be applied daily to the right hand and removed after 6-8 hours. A progress note, dated 07/07/25, documented restorative care treatment with the application of a splint to Resident #2's right hand. On 08/10/25 at 10:01 a.m. the admissions coordinator stated Resident #2 was on restorative care and the restorative aide provided the care. The admissions coordinator was asked who completed the restorative care on days the aide was not in the facility. The admission coordinator stated they would need to train someone. On 08/10/25 at 11:03 a.m., MDS coordinator #1 stated when restorative care adds a resident to their care list, they update the care plan to include the restorative care. The MDS coordinator stated Resident #2's care plan had not been updated to include restorative care.

Based on record review and interview, the facility failed to complete a performance review of nurse aides, hired over one year ago, at least once every 12 months for 1 (CNA #1) of 2 reviewed for performance reviews. Human resources identified 13 CNAs have been employed over one year. Findings:Review of employee training records showed one of two employee files did not have an annual performance review or skills assessment completed in past year.On 08/10/25 at 9:40 a.m., CNA #1 was asked if they had an annual performance review or skills checklist completed in past year. CNA #1 stated they only worked on the weekends and had not done anything like that, that they were aware of.On 08/10/25 at 10:05 a.m., the administrator stated they had not been doing annual evaluations until recently. On 08/10/25 at 2:36 p.m., the administrator in training stated performance and skills assessments had not been consistently done before their arrival a few months ago. The administrator in training stated they have been trying to get them all completed, but they were not sure if they had all been updated.

Based on observation, record review, and interview the facility failed to store, prepare, and serve food under sanitary conditions for 77 residents who ate meals prepared by the kitchen. The administrator identified 77 residents who resided in the facility and ate meals prepared by the kitchen. Findings: A policy titled Food Service/Distribution documented .Dietary staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food . A policy titled Sanitization documented .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks,corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . On 03/11/24 at 10:12 a.m., a scoop was observed in the sugar bin. On 03/11/24 at 10:13 a.m., the dietary cook #1 stated the scoop should not be left in the sugar bin. On 03/11/24 at 10:15 a.m., a staff member entered the kitchen and identified their job title as a host for the residents. The staff had a beard and was not wearing a beard guard. On 03/11/24 at 10:16 a.m., the host stated they should have been wearing a beard guard. On 03/11/24 at 10:30 a.m., the dish machine had dust and dirt debre on top of the machine. On 03/11/24 at 10:31 a.m., the dish washing staff stated the dish machine had not been cleaned since they had been hired two months. On 03/11/24 at 10:32 a.m., a can of soda was observed in the freezer that had frozen and had burst open. The stove had a black substance layer on the bottom and the door had a large amount of brown substance on the inside. On 03/11/24 at 10:36 a.m., cook #1 stated they did not know the can of soda was in the freezer and shouldn't have been there. The cook stated there was no current cleaning schedule. The cook provided the last documented cleaning schedule dated for November. The cook stated that was most likely the last time the oven was cleaned. On 03/13/24 at 11:56 a.m., during a meal service observation it was noted there were two cases of unpasteurized eggs, but no pasteurized eggs available. The dietary supervisor stated the facility does offer eggs prepared over easy. On 03/13/24 at 12:46 p.m., the dietary supervisor stated per review of the food delivery receipt for this week only unpasteurized eggs had been received. The dietary supervisor stated they were unsure when the last time pasteurized eggs had been received.

Based on observation, record review, and interview the facility failed to maintain an infection prevention and control program for one (#10) of one resident reviewed for pressure ulcers. The director of nursing identified 12 residents who received wound care. Findings: A policy titled Hand Hygiene documented .All staff will perform proper had hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene is indicated and will be performed under conditions listed in, but not limited to, the attached hand hygiene table .After handling contaminated objects .Before applying and after removing personal protective equipment (PPE), including gloves .When, during resident care, moving from a contaminated body site to a clean body site . Resident #10 had diagnoses which included hemiplegia and hemiparesis, type 2 diabetes mellitus, and pain. The care plan, dated 01/18/24, documented the resident had actual impairment to skin integrity of the right ankle on the lateral side. A discharge return anticipated assessment, dated 02/04/24, documented the resident was modified independent with daily decision making. The assessment documented the resident had a stage 2 pressure ulcer. On 03/13/24 at 8:00 a.m., a wound care observation was conducted. LPN #1 gathered supplies, entered the resident's room, placed the supplies on the bedside table, and washed their hands. The LPN did not clean the bedside table before placing their supplies. The LPN donned a pair of gloves, removed the bedding from the resident's lower extremities, removed the resident's heel protectors, and repositioned the resident. The LPN placed the Triamcinolone Acetonide External Lotion 0.025 % (Triamcinolone Acetonide (Topical) to the left top of the foot. The LPN did not change their gloves or wash their hands. The LPN continued the treatment with the same gloved hands opening and obtained a new skin prep pad for both heels, the right ankle, and upper left side of foot without changing their gloves or washing their hands between areas or opening new packages. The LPN removed their gloves, exited the room, and used the alcohol hand gel dispenser in the hall by the medication cart. On 03/13/24 at 8:24 a.m., LPN #1 stated they did not change their gloves or wash their hands between tasks or from clean to dirty areas and should have. On 03/13/24 at 9:37 a.m., the DON stated the LPN should have provided a clean surface for placing supplies and changed their gloves and washed their hands between tasks.

Based on record review and interview the facility failed to ensure the physician responded to the pharmacist medication reviews related to the GDR request with a clinical rational for three (#1, 25, and #34) of five sampled residents reviewed for unnecessary medications. The Administrator reported 77 residents resided in the facility. Findings: 1. Res #1 admitted to the facility with diagnoses of Hypertension, Dementia, and depression. A pharmacy recommendation, dated 06/24/23, documented to evaluate the use of Glimeperide 4mg QD. The physician marked- report reviewed- no changes, no rational was documented by the physician. A pharmacy recommendation, dated 10/21/23, documented to evaluate the use of an opioid with a Gabapentinoid, Morphine ER, Norco, and Gabapentin. The physician did not document a rational. 2. Res #25 admitted to the facility with diagnoses of heart failure, DM, HTN, dementia, PTSD, and obstructive sleep apnea. A pharmacy recommendation, dated 10/21/23, documented: Please evaluate the routine use of an Opioid with a Gabapentoid, Tylenol with Codeine and Gabapentin. This combination has been deemed by CMS as an inappropriate due to potential adverse drug reaction. The physician did not document a rational. 3. Res #34 admitted to the facility on [DATE] with diagnoses of depression, COPD, DM, Parkinson's, anxiety, and HTN. A pharmacy request, dated 10/21/23, to evaluate the routine use of an Opioid with a Gabapentinoid, Tramadol and Gabapentin. The physician did not document a rational. On 03/14/24 at 11:14 a.m., the DON reported the GDRs should have had a rational from the physician.

Based on record review and interview, the facility failed to ensure the PASRR for a resident with a serious mental health diagnosis was filled out correctly and referred to the OHCA for two (#14 and #25) of three sampled residents reviewed for PASRR evaluations. The Administrator identified 77 residents resided in the facility. Findings: 1. Res #14 admitted to the facility with diagnoses of PTSD, COPD, A-Fib, Depression, and alcohol abuse. A PASRR Level I, dated 06/13/23, documented the resident did not have a mental health diagnosis. A quarterly assessment dated , 01/09/24, documented the resident had a mental health diagnosis. 2. Res #25 was admitted to the facility on [DATE] with diagnoses of PTSD, heart failure, HTN, dementia, obstructive sleep apnea, DM, and GERD. A PASRR level I, dated 10/12/23, documented the resident did not have a mental health diagnosis. A quarterly assessment, dated 1/11/24, documented the resident had a mental health diagnosis. On 03/14/24 at 11:20 a.m., the Administrator and ADON reported that OHCA should have been notified of the mental health diagnosis of PTSD.

Based on record review and interview, the facility failed to ensure a baseline care plan included fall risk and interventions for one (#1) of three sampled residents reviewed for falls. The DON identified 70 residents resided in the facility. Findings: A facility Fall Risk Assessment/Falls policy, dated 01/08/21, read in part, .Each resident's plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident .Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice . Res #1 admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, syncope and collapse, COPD, and COVID-19. A fall risk assessment, dated 01/19/24, documented the resident was high risk for falls. A baseline care plan, initiated 01/19/24, did not document the resident was at risk for falls or include fall interventions. A progress note, dated 01/20/24 at 9:39 p.m., documented a nurse entered Res #1's room to check on them and noted the resident was on their back in the floor. The note documented there were no injuries. The resident stated they were unsure how the fall occurred. The nurse documented it appeared the resident had rolled from their bed onto the floor. The note documented a concave mattress was applied to the bed as a fall intervention. A facility incident report, dated 01/20/24, documented Res #1 had a fall without injury and an intervention to place a concave mattress. A fall care plan, initiated 01/24/24, included the following interventions: - Anticipate and meet needs - Assist with transfers - Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance. - Check on resident frequently - Offer activities that promote exercise, physical activity for strengthening and improved mobility, - Physical therapy to evaluate and treat as needed An admission MDS, dated [DATE], documented Res #1 was cognitively intact, utilized a walker, required partial assistance with transfer from sitting to standing, and required partial assistance with walking 10 feet. On 02/13/24 at 7:52 a.m., the MDS coordinator stated the fall risk and interventions were not included in the resident's baseline care plan. They stated fall risk and precautions should have been included in the baseline care plan.

Based on record review, observation, and interview, the facility failed to develop a comprehensive person-centered care plan for one (#42) of six residents reviewed for care plans. The Resident Census and Conditions of Residents, dated 01/23/23, documented a census of 78. Findings: A policy titled Comprehensive Care Plans, dated 08/01/21, read in parts, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .to meet the resident's medical, nursing . needs that are identified in the resident's comprehensive assessment . Res #42 was admitted with diagnoses which included encounter for cystostomy, kidney failure, Parkinson's disease, and neuromuscular dysfunction of bladder. An admission assessment, dated 10/26/22, documented Res #42 was cognitively intact, required minimum assistance with activities of daily living, and had a suprapubic urinary catheter (a drainage tube from the abdominal wall to the bladder). A care plan, dated 01/11/23, read in part, Neuromuscular dysfunction of bladder .document and notify physician of s/sx of UTI . A Plan of Care Note, dated 01/23/23, read in part, .has a suprapubic cath .prefers to do her care herself . On 01/24/23 at 1:00 p.m., Res #42 was observed in their room with urinary catheter bag draining yellow urine. Res #42 reported they cared for their own urinary catheter. On 01/24/23 at 1:23 p.m., the MDS coordinator reported the urinary catheter self-care was not included in the care plan and should have been. On 01/24/23 at 1:30 p.m., the administrator reported the care plan should have been revised to include the self-care of the urinary catheter.

Based on record review and interview, the facility failed to develop a discharge summary for one (#77) of one resident reviewed for discharge summary. The Entrance Conference Worksheet, completed on 01/23/23, documented 10 residents had been discharged in the last six months. Findings: A Discharge Summary and Plan of Care policy, dated 10/01/19, read in part, .a discharge summary will be provided . Res #77 was admitted with diagnoses which included acute cholecystitis, diabetes mellitus, and congestive heart failure. A review of the record for Res #77 failed to show a discharge summary. An admission assessment, dated 01/08/23, documented Res #77 was cognitively intact and required minimum assistance with activities of daily living. A physician's order, dated 01/12/23, read in parts, Discharge to home on 01/16/23 with .home health . On 01/25/23 at 10:26 a.m., the MDS coordinator reported a discharge summary for Res #77 was not completed. On 01/25/23 at 10:28 a.m., the administrator reported a discharge summary should have been completed.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent accidents for one (#1) of one resident who eloped seven times and had one injury. The facility identified one resident as having eloped and suffered an injury. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission fall risk assessment documented a score of 13, which indicated the resident was a moderate risk for falls. The admission wanderer risk assessment documented a score of 12, which indicated the resident was a high risk for wandering. admission orders [REDACTED] Namenda, an anti-dementia medication, 5 mg twice daily; Neurontin, 300 mg three times daily for pain; Effexor, an anti-depressant medication, 75 mg daily; Aricept, an anti-dementia medication, 10 mg daily; Haldol, an antipsychotic medication, 5 mg twice daily as needed; and Ativan, an anti-anxiety medication, 0.5 mg every six hours as needed. An admission care plan, dated 07/09/12, documented a problem, "... I have impaired cognitive function/dementia or impaired thought processes..." Interventions included, "... I need supervision...Engage me in simple, structured activities that avoid overly demanding task...provide me with a homelike environment...administer my medications... and report to MD any changes..." Another problem identified was "... I am moderate risk for falls r/t wandering and medication..." Interventions included, "...anticipate and meet my needs...encourage me to participate in activities...ensure that I am wearing appropriate footwear... I need activities that minimize the potential for falls while providing diversion and distraction...PT to evaluate..." Another problem identified was, "...I am high risk for elopement dementia (sic)..." Interventions included, "...Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Document wandering behavior and attempted diversional interventions in behavior monitoring log. Identify pattern of my wandering. Is my wandering purposeful, aimless, or escapist? Am I looking for something? Does it indicate I need more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Provide me with structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes..." A physician's progress note, dated 07/10/2012, documented the resident was confused, occasionally aggressive, and non-cooperative. An admission assessment, dated 07/17/2012, documented the resident was cognitively impaired, needed limited assistance with all activities of daily living, and was independent in ambulation. A nurse's note, dated 07/22/12 at 8:49 a.m., documented the resident refused his medication and was hitting and cursing. It was documented the staff could not get the resident to take his Haldol. A physician's orders [REDACTED]. A nurse's note, dated 07/26/12 at 3:00 a.m., documented, "...Wandering to other resident's rooms...Cursing..." A wander assessment, dated 07/26/12, documented the resident scored a 16. This indicated the resident was high risk for wandering. A physician's orders [REDACTED]. It was documented the resident's Ativan was changed to routine, three times daily. A physician's progress note, dated 07/28/12, documented, "...(resident) got easily upset, ambulates, recent urinary infection was better, gets overly stimulated..." A nurse's note, dated 07/31/12 at 1:30 a.m., documented the resident was wandering into other residents' rooms; continued to get up every few minutes; was cursing, angry, confused; and unable to rest. It was documented the staff tried diversion without success. An incident report, dated 07/31/12 at 12:40 p.m., documented the resident was in the lobby during a church music activity. It was documented, "...Lobby, church music...yelling out, was being (wheeled) out - hit visitor (sic)..." A physician's orders [REDACTED]. A nurse's note, dated 08/11/12 at 7:15 p.m., documented, "...Received a call from Reasors , (resident #1) at store...went to bring resident back to facility..." An incident report, dated 08/11/12 at 7:15 p.m., documented the resident was found at Reasor's grocery store, next door. The resident had no injuries. It was documented the nursing staff notified the Director of Nurses, the physician, and the family member. A physician's orders [REDACTED]. Review of the care plan revealed no documentation to show the care plan was updated to show the medication adjustment or the resident's elopement from the facility. A nurse's note, dated 08/12/12 at 2:00 p.m., documented, "..Out the door, off of dining room area, climbing fence in courtyard - redirected..." A physician's orders [REDACTED]. Review of the care plan revealed no documentation to show the care plan was updated to show the medication adjustment or the resident's attempt to elope from the facility. A nurse's note, dated 08/20/12 at 1:20 p.m., documented, "...Agitated-yelling-curse staff- in DR..." An incident report, dated 08/22/12 at 7:30 p.m., documented, "...Outside - fell in the road outback - neighbor notified nursing home, - (sent resident) to (hospital name withheld)..." A nurse's note, dated 08/22/12 at 7:59 p.m., documented, "Resident was able to get outside at 1920p.m. (7:20 p.m.), neighbor came in res. walking outside fell in the road back of the building neighbor observed, alerted facility staff, res. has a skin tear to right hand, multiply (sic) bruises of the rt arm purple in color of varies (sic) sizes and shapes, res. has a gash/hematoma to the rt temporal/forehead...called Dr. (name deleted) gave order to send to (hospital name deleted) ER..." A hospital nursing assessment, dated 08/22/12 at 8:55 p.m., documented, "...Musculoskeletal Symptoms: Other: pain from fall...Skin Integrity: Not intact...Incision Wound Type 1: Abrasion...Location...right forehead, large deep abrasion Incision Wound Type 2: Other; bruising...location from right hand to right shoulder..." The hospital History & Physical, dated 08/23/12 at 10:53 a.m., documented, "...He does have a large hematoma on the right frontal part of his forehead...There is also a large superficial abrasion in this area...There is some tenderness and ecchymoses on the dorsolateral aspect of his right arm..." A physician's orders [REDACTED]. Review of the care plan revealed no documentation to show the care plan was updated to show the medication adjustment or the resident's elopement from the facility. A nurse's note, dated 08/25/12 at 11:00 a.m., documented, "...(Resident) attempted to go outside today, walked out of the dining room, staff redirected him..." A nurse's note, dated 08/25/12 at 12:00 p.m., documented, "...(Resident) tried to get outside by pushing visitor, front door lobby, screaming derogatory names..." A nurse's note, dated 08/25/12 at 1:00 p.m., documented, "...At 11:00 (a.m.), (resident) got out of dining room door - Redirected..." A nurse's note, dated 08/25/12 at 10:34 p.m., documented, "...Resident has been agitated most of shift. Pacing halls, rattling door handles, swinging at staff..." A nurse's note, dated 08/27/12 at 6:43 p.m., documented, "...Resident agitated and exit seeking this shift. Resident grabbed a hold of staff finger and started bending it to the side and slapped staffs hand X 2..." A physician's orders [REDACTED]. A nurse's note, dated 08/29/12 at 6:17 p.m., documented, "...Res. was able to get outside. Res. hard to redirect... No injuries noted. Res. combative with staff..." Review of the care plan revealed no documentation to show the care plan was updated to reflect the resident's elopement from the facility, increasing behaviors, or medication adjustments. There were no new interventions identified or implemented. Nursing monthly summary notes, dated 08/30/12, documented, "...Combative..." A nurse's note, dated 08/30/12 at 2:53 p.m., documented, "Resident transferred to (Geriatric psychiatric hospital unit name deleted)..." On 09/14/12 at approximately 3:00 p.m., Employee #1 was asked what happened with the resident on 08/22/12 when he eloped from the facility and fell . The surveyor was taken outside the facility to the southwest side of the building. South Diane Street was observed to run parallel to the west side of the facility. The employee stated the resident had fallen on the pavement of South Diane Street and rolled into the grass. The employee pointed west, in the direction of South Hickory Street, which was approximately one block away from the facility and stated the resident's house was a few blocks south of the facility on South Hickory Street. The employee stated the resident tried to go home on three other occasions and was found in back of the facility in the vacant, grassy empty lot, located next to the southwest corner of the facility property each time. On 09/14/12 at 3:45 p.m., the DON was asked what she knew of the resident's elopements and fall. She stated she had been informed of the wandering and behaviors by word of mouth from the nursing staff. She stated the computerized charting did not notify the administration of incidents of any type. She stated the nursing staff did input incident reports into residents' computerized charting; however, there was no accurate process to track and trend the incidents. She stated she was not aware of the elopements, only the behaviors and attempts to leave. She stated the facility put preventive measures in place after the resident attempted to leave. The DON was asked if she was aware of the five elopements the resident made and she stated, "No." At approximately 4:00 p.m., the administrator and DON were asked what interventions had been implemented to prevent the resident from eloping from the facility. She stated the resident had been agitated and wandering from door to door on 08/18/12 and 08/19/12 so he had a one to one sitter for safety on those two days. The administrator stated a stop sign had been placed on the dining room door and the resident had not gone out that door again. On 09/27/12 at approximately 3:45 p.m., the DON and administrator stated they had been informed the resident was outside but not that he had been off the nursing home property. The DON stated she did not send a state incident report for elopement. The administrator stated the new plan of care for the resident was to deter him from large groups and noises. She stated staff and church groups had been inserviced on dementia management. On 10/22/12 at 4:20 p.m., the administrator and DON were asked if there had been any other interventions put into place to prevent the resident from eloping. The administrator stated on 08/11/12 a paddle lock was put on the gate in the court yard that was located off of the dining room. The administrator stated after the fall she had discussed with the family about moving the resident to a secure facility. She stated the family declined to move the resident. The administrator stated the wander guard system had been ordered and was installed on 08/30/12. Other interventions included the decision to camouflage the exit door next to the laundry/kitchen area and transfer the resident to an in-patient psychiatric hospital for evaluation and medication adjustment.

Based on observation, interview, and record review, it was determined the facility failed to provide wound care for existing pressure ulcers, identify new pressure ulcers and wounds, and/or identify a worsening of existing pressure ulcers for 2 (#1 and #3) of 4 sampled residents with pressure sores. The facility's failure to assess the resident's pressure ulcers, provide treatments for the pressure ulcers, and failure to obtain medications for the pressure ulcers constituted an Immediate Jeopardy situation for resident #3, who had three stage III pressure ulcers that did not receive treatment. The pressure ulcers were first identified on 03/16/11. Findings: An undated quality of care policy documented, "Pressure ulcers. The facility will...ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless pressure ulcers are unavoidable...Residents having pressure ulcers receive necessary treatment and services to promote healing,...and prevent new pressure ulcers from developing..." 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The wound care specialist documentation for January, February, and March 2011 revealed no physician's orders for the resident to be seen by the wound care specialist. A Braden pressure ulcer risk assessment, dated 03/01/11, documented the resident scored 13. The form documented, "...12 or less = high risk..." The care plan, last reviewed on 03/07/11, documented, "...Focus...I am at risk for aleteration (sic) in my skin intergity (sic) dt incontinence...Goals...I will maintain my skin intergity (sic)...Interventions...weekly skin assessments by RN/LPN...report to my nurse if you see any red or open areas...Focus...I am on a therapeutic and mechanically altered diet dt my dm...Interventions...special monitoring of my skin for redness..." No pressure ulcers, blisters, or blackish areas were documented on the care plan. A weekly head to toe skin review, dated 03/16/11, documented, there were no existing pressure ulcers. The findings area documented, "...3 X 5 open areas to secrum (sic)...mark areas and submit to DON..." The form did not contain a description of the pressure ulcers or the stages. Review of the clinical record revealed no documentation to show the physician was notified of the open areas and there were no orders for treatments. A reentry assessment, dated, 03/21/11, documented the resident was totally dependent for bed mobility, transfers, eating, toileting, and hygiene. No pressure ulcers, stage 1 or higher, were documented. A hospital discharge record, dated 03/25/11, documented, "...Pressure ulcer (unreadable) bottox (sic)... stage 2, stage I coccyx." A dietary progress note, dated 03/26/11 and signed by the RD, documented, "...Skin Review:...Had 2 wds to buttocks, per DON." A weekly head to toe skin review, dated 03/28/11, documented the resident had a 4 cm pressure ulcer on the coccyx, a 3 cm pressure ulcer on the left gluteal fold and a 2 cm X 2 cm pressure ulcer on the lower coccyx. The form documented, "...cleanse c NS, apply Santyl cover and tape...Mark area and submit to DON..."The form did not contain a description of the pressure ulcers or the stages. Review of the clinical record revealed no documentation to show the physician was notified of the pressure ulcers. The documentation showed the facility first became aware of the pressure ulcers on 03/16/11. There was no physician's order for the Santyl documented in the clinical record from 03/28/11 until 04/01/11. A physician's order, dated 04/01/11, documented, "...cleanse wounds to buttocks c NS. Apply Santyl & cover c drsgs 4 X 4s. Cover with [MEDICATION NAME] & qd & prn..." A weekly head to toe skin review, dated 04/04/11, documented the resident had existing pressure ulcers. The pressure ulcers were not staged. The skin review documented "...findings: no change in wound or tx..." There were no measurements, descriptions, or staging of the pressure ulcers. A Medication Administration Record, [REDACTED]'s & cover c [MEDICATION NAME] qd & prn soilage..." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A physician's order, dated 04/06/11, documented, "...order clarification: cleanse 3 sites L gluteal fold & 2 in coccyx region c NS, Apply Santyl, cover c 4 X 4's & secure c [MEDICATION NAME] qd & prn soilage..." The Medication Administration Record, [REDACTED]. On 04/07/11 at 10:23 a.m., two surveyors and CNAs #4 and #5 completed a skin check for the resident. The resident was observed to have a stage III pressure ulcer, measuring approximately 5 cm X 5 cm, on his right gluteal fold; a stage III pressure ulcer, measuring approximately 4 cm X 4 cm, on his left gluteal fold; a stage III pressure ulcer, measuring approximately 2 cm X 3 cm, on his sacral area; a fluid filled blister, measuring approximately 1.5 cm X 2 cm, on the medial aspect of his upper right thigh; and 3-4 pea sized blackish areas on the bottom of his left heel. No dressings were observed on the resident's pressure ulcers, blister, or left heel. CNA #4 was asked when she had first seen resident #3 today (04/07/11). She stated, "At 7:30 a.m." She was asked if he had dressings on his pressure ulcers at that time. She stated, "No." CNA #5 stated, "Yesterday was the first day he had dressings on his pressure ulcers." CNA #5 was asked if the resident had shoes on when up in a chair. She stated, "Sometimes when his feet aren't too swollen." At 10:45 a.m., LPN #1 was asked for the resident's treatment sheets. She stated the resident was due for a skin check today (04/07/11). The treatment sheets were reviewed and it was noted only one treatment had been documented as being completed for the month of 04/2011. LPN #1 was asked if she had completed the resident's dressing changes for 04/07/11. She stated, "No." She stated she would be completing the dressing changes later. At approximately 11:00 a.m., no Santyl for the resident was observed on the treatment cart. At 11:15 a.m., the facility's pharmacy was called. The pharmacy was asked when Santyl had been ordered for the resident. The pharmacy representative checked the facility's orders and stated, "No Santyl has been ordered for that resident." At 12:25 p.m., CMA #1 was asked if there was only one medication room. She stated, "Yes." The medication room was checked for Santyl for the resident. None was found. At 12:30 p.m., LPN #1 was asked to describe the process for ordering treatment medications. She stated, "It (the order) is faxed to the pharmacy, then write it on the MAR/TAR, put order in the MDS box and then that person puts it in the computer. Then I think it goes to the DON. She does something with it, then the doctor signs it and it goes back on the chart." LPN #1 was asked if medications were logged in when received from the pharmacy. She stated, "Yes, in the medication receipt log. A sticker on the medication is placed on receipt ledger, and the date, quantity, and the person logging it in signs their initials. If it is a narcotic, a narcotic sheet is filled out as well." LPN #1 was asked if the facility had a way to confirm a fax was sent to the pharmacy. She stated, "Yes, the nurse stands at the fax machine, makes sure the fax goes through, and puts confirmation sheet on pile next to fax machine." She provided the fax confirmations sheets. No fax confirmation sheets were found for resident #3. At 1:10 p.m., the resident was observed in the main dining room, seated in his wheelchair, eating the noon meal. No padding was observed in his wheelchair. At 1:28 p.m., the DON was asked about resident #3's pressure ulcers. She stated, "He has 2 of them, stage II, they are being treated but I don't know with what." The DON was asked if she was aware the resident did not have any dressings on his pressure ulcers this morning. She stated, "Yes, I told the CNAs to tell the charge nurse." The DON was asked how many pressure ulcers the resident had. She stated, "Two to my knowledge." She was told the resident had three pressure ulcers. She stated, "I'm aware of two." The DON was asked what the treatment was for the pressure ulcers. She stated, "Not off the top of my head." She was asked how long he has had treatment orders. She stated, "1 - 1 1/2 weeks." She was asked if she had been aware of a blister on the resident's right inner thigh. She stated, "I only know of two." The DON was asked when was the last time she had seen the resident's pressure ulcers. She stated, "One week ago today." She was asked what her process was for observing pressure ulcers. She stated, "I usually observe pressure ulcers every Wednesday, unless it is new or when the staff has had questions. I'm not going to tell you every Wednesday, but usually Wednesdays." The DON was shown the dietary progress note, dated 03/26/11 that documented the DON had informed the RD that resident #3 had two wounds on his buttocks prior to his hospitalization . She stated, "I don't remember that." The DON was asked what the process was for ordering medications for the resident. She stated, "The nurse is to write on the pharmacy start up sheet, fax it, receive a return fax, and the medication comes to the facility." The DON looked at the medication order and was asked what medication was ordered for treatment of [REDACTED].? Yes." She was asked what date the medication was ordered. She stated, "On 4/1. On 4/6, cleanse with something to gluteal fold and coccyx, secure with something." She was asked what medication was ordered. She stated, "Santyl." The DON was asked how many times it was documented the dressing changes were completed. She stated, "One." She was asked what date was documented. She stated, "The 6th, the only day." The DON was informed there was no Santyl in the facility for the resident. She was asked how a treatment was completed if the resident did not have any Santyl. She stated, "Good question. I couldn't do the treatment without the Santyl." Immediate Jeopardy Identified On 04/07/11, an Immediate Jeopardy (IJ) situation was identified regarding the facility's failure to assess and monitor pressure ulcers, provide treatments for pressure ulcers, ensure necessary medications were available for the treatment of [REDACTED]. At 1:57 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ related to pressure ulcers. At 2:05 p.m., the administrator and DON were informed of the IJ related to pressure ulcers and that this placed the facility in an extended survey. On 04/07/11 at 3:02 p.m., a medication receipt ledger documented Santyl for resident #3 was received at the facility. At 3:30 p.m., the assessment/care plan coordinator and CNA #8 were observed as they treated the resident's pressure ulcers with Santyl. Facility plan of removal for immediate jeopardy At 6:22 p.m., the facility submitted an acceptable plan of removal. The plan of removal documented: "Steps taken to remove Immediate Jeopardy condition relating to the required treatment medication not being available for administration to a resident and for the proper procedure for identification and reporting of pressure ulcers. 4/7/11 We have performed the following actions: Once the medication was received, we performed the wound treatment. We inserviced all nurses and CMAs on the proper procedures for ordering medications and for the proper procedure to follow if a needed medication is not available. We will perform a skin screening on all residents to verify that there are no other residents with unidentified wounds or treatments that have not been completed. We will inservice all nurses, CNAs and CMAs regarding the proper procedures for identifying, documenting, and reporting wounds. Then getting treatment orders and ordering medications. All nurse's (sic) and CMAs will perform the medication administration. If a medication is not available, they will immediately alert the charge nurse. She will immediately phone the pharmacy and alert them of the omitted mediation (sic) and request that the medication be delivered immediately. Each morning our medical records person will check orders written against the medications received report (or the medications ordered fax confirmation, if not yet received) and the treatment administration record. She will report those findings at stand-up each morning. Timeline 2:10 PM - We were informed of the immediate jeopardy 2:30 PM - Treatment medication was ordered 3:00 PM - Medication arrived and treatment started 4:03 PM - The treatment was completed 5:10 PM - Inservice on procedures for ordering medications completed 8:00 PM - Skin screening on all residents will be completed 4/8/2011 - 10:00 Inservice will be completed for all shifts regarding wound care, identification and reporting. Inservice for all nursing personnel regarding the proper procedures for identifying, documenting, and reporting wounds. When a CNA notices a blister, a reddened area, a scab, or other abnormal skin condition for a particular resident, she should finish completing her current task and leave the resident in a safe condition. She should then go to the nurse on duty to report the condition. The nurse should go into the resident's room to examine and measure the area of concern. She should then document the condition on a weekly skin sheet. Then she should call the doctor for treatment orders, document the order on a telephone order and the Treatment Administration Record. The order should be faxed to the pharmacy, if applicable. She should perform the treatment immediately or once the medication is available. The information contained in the in-services on 4/7/2011 and 4/8/2011 relating to the identification and reporting of pressure ulcers will be present to all nursing department new hires during orientation. The information contained in the in-service on 4/7/2011 relating to the ordering of medications and the steps to follow if the medication is not available will be presented to all new licensed nurses and new CMAs during orientation." Immediacy Removed On 04/08/11 at 10:00 a.m., the DON provided the skin assessments for all residents in the facility. The skin assessments revealed 3 additional residents were found to have unidentified pressure ulcers. The DON provided documentation ensuring all staff had been in-serviced on skin assessments, reporting of compromises to skin integrity, and ordering medications. The IJ was removed on 04/08/11 at 10:00 a.m. after the facility provided documentation that all components of the plan of removal had been completed. Staff were interviewed in regard to their knowledge of the in-service; to ensure their understanding of skin assessments, reporting of any compromises to skin integrity, and the ordering of medications. The deficient practice remained at a pattern level of actual harm. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital discharge orders, dated 01/12/11, documented, "...skin condition pressure ulcer (checked) pressure ulcer size 2 in...location (left) heel...heel protector..." The wound care specialist documentation for January, February, and March 2011 revealed no physician's orders for the resident to be seen by the wound care specialist. A nurse's note, dated 01/12/11 at 5:00 p.m., documented, "...Res has a black 2 in. in diameter to (left) heel. Res uses boot protectors to heal (sic)..." A nurse's note, dated 01/12/11 at 7:30 p.m., documented, "...Pressure area noted to Lt heel..." Review of the clinical record revealed no documentation to show the facility obtained physician orders to treat the left heel wound that was identified on admission. A resident data collection form, dated 01/12/11, documented the resident had a 2 inch diameter black pressure area on her left heel. It was documented heel protectors were used and the resident was able to bear full weight. A monthly summary, dated 01/13/11, documented, "...Pr. ulcer on (L) heel, soft area to R heel, Heel protectors @ all times..." A weekly head to toe skin review, dated 01/13/11, documented the resident had a left heel wound and a soft right heel. It was documented heel boots were to be used at all times. The form did not contain any measurements for the left heel wound. Review of the clinical record showed no other skin assessments for the month of 01/2011. A Braden pressure ulcer risk assessment form, dated 01/13/11, documented the resident scored a 14. The form documented, "...13 or 14 = moderate risk..." The care plan, dated 01/25/11, documented a problem, "...I was admitted with a wound and poor skin integrity caused by prolonged pressure related to: nutritional deficit and cognitive impairment...and have additional areas poor healing..." The goal was, "...My wound will be healed by 20% by next review..." Interventions included, "... Foam boots on at all times as ordered...Weekly skin assessments by RN/LPN doucment (sic) size color depth drainage...Treatment as ordered report to physician if no improvement in two weeks..." The care plan did not document what the other areas with poor healing were. A physician's order, dated 01/26/11, documented, "...Paint L) heel c [MEDICATION NAME] BID..." A medication sheet, dated 01/2011, documented the [MEDICATION NAME] treatment did not begin until 01/28/11 and only one treatment (instead of two) was given on 01/28/11 and 01/31/11. Monthly physician orders, dated 02/2011, documented, "...bilateral heel protectors at all times lt heel wound...paint lt heel with [MEDICATION NAME] bid...weekly skin assessments q week Wed ..." A monthly summary, dated 02/02/11, documented, "... Pressure sore to to the (L) heal (sic) being Treated c betidine (sic) BiD (sic)..." A 5 day medicare assessment, dated 02/08/11, documented the resident was totally dependent on two people for bed mobility, transfers and toileting. It also documented the resident was at risk for developing pressure ulcers and had one unstageable pressure ulcer. The unstageable pressure ulcer was documented to be 4 cm x 4 cm with necrotic tissue. The care plan, dated 02/09/11, documented a problem, "...I have diabetes mellitus..." The goal was "... I will be free from any s/sx of [MEDICAL CONDITION] through the review date..." Interventions included, "...Inspect feet daily for open areas, sores, pressure areas, blisters, [MEDICAL CONDITION] or redness..." Treatment records for the month of 02/2011 documented skin assessments were completed on 02/02, 02/09, 02/16, and 02/23; however, the skin assessments could not be found in the clinical record. Treatment records for the month of 02/2011 documented the resident's left heel was to be painted with [MEDICATION NAME] twice daily. The form documented out of 28 days, the treatment was completed only one time a day on 11 days. Treatment records for the month of 02/2011 documented the resident was to have heel protectors on at all times. The form documented out of 28 days, the heel protectors were not in use at all times on 19 days. An undated physician's order, but located between orders dated 02/26/11 and 02/28/11, documented, "...Santyl to L) heel MWF- apply Santyl (and) damp gauze, wrap c Kerlix or cover c foam border gauze..." Treatment sheets, dated 02/2011, did not document the new treatment order. There was no documentation to show the treatment was completed on 02/27/11 or 02/28/11. Monthly physician's orders, dated 03/2011, documented, "...apply Santyl and damp gauze wrap with Kerlix cover with foam bordered gauze Mon Wed Fri...bilateral heel protectors at all times lt heel wound...weekly skin assessments q week..." A weekly head to toe skin review, dated 03/04/11, documented a wound to the right heel. There were no measurements or wound descriptions. There was no documentation of a left heel wound. A monthly summary, dated 03/06/11, documented, "...has wound to (L) heal (sic) c Tx daily..." A weekly head to toe skin review, dated 03/10/11, documented a wound to the right heel. There were no measurements or wound descriptions. There was no documentation of a left heel wound. A nurse's note, dated 03/22/11 on the day shift, documented, "...also performed drsgs to bilateral heels..." Review of the clinical record revealed no documentation to show the physician had been notified of a right heel wound or that orders had been obtained to perform wound care to the right heel. A 60 day medicare assessment, dated 03/23/11, documented the resident was totally dependent on two persons for bed mobility and toilet use. The summary score of the MDS Brief Interview for Mental Status (BIMS) documented the resident was cognitively intact. It also documented the resident had three unstageable pressure ulcers, one of which was present on admission. It documented one was unstageable due to coverage of the wound bed by slough and/or eschar. The largest unstaged pressure ulcer was documented to be necrotic tissue and was 3.5 cm x 3.5 cm. A nurse's note, dated 03/23/11, on the evening shift, documented, "...worried about her feet. anxious. ..." A weekly head to toe skin review, dated 03/24/11, documented a wound to the right heel. There were no measurements or wound descriptions. There was no documentation of a left heel wound. A nurse's note, dated 03/24/11, on the day shift, documented, "...wound care to bilateral heels completed..." Review of the clinical record revealed no documentation to show the physician had been notified of a right heel wound or that orders had been obtained to perform wound care to the right heel. A nurse's note, dated 03/25/11, on the evening shift, documented, "...Floating heels off bed c loose sheets on toes..." A nurse's note, dated 03/26/11, on the day shift, documented, "...Drsg Rt heel intact. ..." A nurse's note, dated 03/27/11, on the day shift, documented, "...Drsg on L. ft (heel) D/I..." A nurse's note, dated 03/28/11, on the evening shift, documented, "...cont. to c/o of pain in feet... on the night shift... Res. has c/o pain to toes/feet all shift has been medicated effective for short time..." A physical therapy discharge summary, dated 03/30/11, documented, "...Progress & Response to Tx: Patient has reached maximum potential with skilled services at this time due to wounds on (B) feet..." Monthly physician's orders, dated 04/2011, documented, "...apply Santyl and damp gauze wrap with Kerlix cover with foam bordered gauze Mon Wed Fri...bilateral heel protectors at all times lt heel wound...weekly skin assessments q week...elevate feet while in bed..." On 04/05/11 at 3:30 p.m., the resident was observed lying in bed with her eyes closed. A sign above the resident's bed documented, "Please float heels off bed." The resident's lower legs and heels were lying on a pillow. A dressing was noted on the resident's left heel. On 04/06/11 at 9:20 a.m., the resident's heel protectors were observed in a chair in the resident's room. The resident was asked if the staff put the heel protectors on her. The resident stated, "They do at night." The resident was asked if the staff put the heel protectors on her whenever she was in bed. The resident stated, "No, just at night." At 10:40 a.m., RN #2 was observed performing a dressing change to the resident's pressure ulcer on her left heel. The resident was sitting in a wheelchair with her feet resting on a sheet on the floor. RN #2 obtained the needed supplies, washed her hands and donned gloves. RN #2 applied Santyl to the left heel pressure ulcer, placed a dry gauze pad over the pressure ulcer, wrapped the foot with Kerlix, and taped it in place. When asked to describe the pressure ulcer, RN #2 replied, "About 3.5 cm, black with necrotic tissue, unstageable." RN #2 removed her gloves, washed her hands and donned new gloves. RN #2 then applied Santyl to the right heel, covered the pressure ulcer with a dry gauze pad, wrapped the foot with Kerlix and taped it in place. When asked to describe the right heel pressure ulcer, RN #2 replied, "Necrotic, only about 1 cm in diameter." At 3:10 p.m., RN #2 was asked how often wound assessments were performed. RN #2 stated, "Weekly." When asked where the skin assessments were charted she stated, "On the sheets." When asked if she knew when the right heel pressure ulcer appeared on the resident, RN #2 stated, "She was admitted with them." RN #2 was informed there was no record of the right heel pressure ulcer on admission. RN #2 stated, "Oh, I guess she got it here." At 3:18 p.m., the resident was observed lying in her bed with her eyes closed, both lower legs were elevated on a pillow and her heels were resting on the mattress. The foam heel protectors were in the chair. At 4:30 p.m., the DON was asked what type of wound was on the resident's right heel. She replied, "I am unaware of a wound on her right heel." When asked if the physician was notified of the pressure ulcer on the right heel, the DON replied, "I don't see anything in the chart about the right heel." The DON was asked what the facility's policy was on the completion of skin and pressure ulcer assessments. The DON stated, "Everyone gets one every week." When asked if staff were supposed to measure pressure ulcers, the DON replied, "Yes, weekly." The DON was shown the weekly skin review sheets and was asked if those were the forms for documenting pressure ulcer assessments. She stated the weekly skin review sheet was a form "floating" around the facility but it was not the form the staff was supposed to use. The DON was asked to provide the correct forms that contained the pressure ulcer assessments. The DON left the room, returned, and stated the other documentation regarding pressure ulcers was on the quality assurance log. The DON asked the surveyors to review the log. Review of the forms revealed no wound assessments or descriptions. Skin logs dated 01/21, 01/26, 02/14, 02/17, 02/28, 03/07, 03/09, 03/10, 03/11, 03/14, 03/17, 03/18, 03/22, 03/25, and 03/31 did not contain a skin assessment for resident #1. No other documentation was provided before the end of the survey. On 04/07/11 at 9:20 a.m., LPN #1 was asked to measure the resident's pressure ulcers. LPN # 1 stated the right heel was .75 cm x 1.5 cm and covered with eschar and that the left heel was 3.75 cm x 3.0 and covered with eschar. A large area of unblanching white skin, approximately 3.0 cm x 4.0 cm, on the achilles tendon area of the left leg, was not noted or measured by LPN #1. At 9:55 a.m., the DON was asked if she had looked at the wound on the resident's right heel. The DON stated, "Yes, I finally did." When asked what she thought the wound was, she replied, "I would say pressure." At 10:00 a.m., the DON was asked to assess the resident's pressure ulcers. The DON did not assess the large area on achilles tendon area of the left leg until it was brought to her attention. The DON measured the area and stated it was 2 cm x 3 cm. The DON was asked what she thought that wound was, she stated, "Blister."