Every finding on record at Ardmore Center for Rehabilitation and Healthcare

Based on observation, record review, and interview, the facility failed to ensure food was served at a safe temperature to prevent a burn for 1 (#10) of 1 resident sampled for food related burns. The DON reported 51 residents received food from the facility kitchen. Findings: On [DATE] at 12:09 p.m., Resident #10 was observed sitting in the dining room eating lunch. The resident was observed to eat independently with set-up supervision. An Assistance with Meals policy, dated [DATE], read in part, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. A Hospitality Aide Qualifications and Training Requirements policy, dated [DATE], read in part, Hospitality aides must undergo a state-approved training program .Applicants who meet the qualifications for a hospitality aide and are in training will have a minimum of 16 hours of training in the following areas prior to direct contact with residents .Assisting with eating and hydration .Proper feeding techniques. Resident #10 had diagnoses which included encephalopathy, chronic obstructive pulmonary disease, atrial fibrillation, protein-calorie malnutrition, dysphagia, and adult failure to thrive. An minimum data set admission assessment, dated [DATE], showed the resident was moderately cognitively impaired. The assessment showed the resident required supervision with eating. An incident progress note, dated [DATE] at 10:00 a.m., showed CNA #1 reported to LPN #1 they entered Resident #10's room to assist with feeding the resident. CNA #1 reported they observed another unidentified aide feeding the resident oatmeal with a spoon and steam was observed coming off the oatmeal. CNA #1 reported they attempted to stop the aide from feeding the resident the hot oatmeal but it was too late and the resident already had it in their mouth. CNA #1 reported the resident made a crying noise and was visibly in pain. The note documented LPN #1 went in and observed the resident sitting in bed with blankets up to their mouth. The resident was hesitant for the nurse to look in their mouth but after a few moments opened their mouth and the nurse noted two white blisters on the top of the resident's mouth. The note showed LPN #1 reported the incident to the resident's nurse, LPN #2, and the DON. The note showed LPN #1 provided education to the unidentified aide on proper feeding techniques and safety protocol. A progress note, dated [DATE] at 10:24 a.m., showed Resident #10's physician was notified of the incident which caused two white blisters in the back, soft portion of the resident's oral cavity. The note showed the resident's family member was notified concerning the incident during which the resident had a bite of oatmeal that was too hot, causing blisters in the back of their oral cavity. An incident report to the Oklahoma State Department of Health, dated [DATE], showed an incident in which an unidentified aide was feeding Resident #10 hot oatmeal and caused two blisters in the resident's mouth. The report showed CNA #1 saw the other aide starting to put a steaming spoon of oatmeal in the resident's mouth and could not stop them before it was in the resident's mouth. The report showed the nurse assessed the resident and found two white blisters in the resident's mouth. An All Nursing Staff in-service training, dated [DATE], showed the DON gave an in-service over hot foods and liquids. The in-service sign-in sheets included kitchen staff. A care plan for Resident #10, dated [DATE], showed the resident had a potential for nutritional problems related to adult failure to thrive and protein calorie malnutrition. The care plan showed the resident required a mechanical soft diet. On [DATE] at 4:22 p.m., CNA #1 was interviewed regarding the incident with Resident #10. CNA #1 reported they heard the resident holler and when they walked into the room to see what was wrong, they could see steam coming off the oatmeal another aide was feeding the resident. CNA #1 reported they did not know the other aide's name. CNA #1 stated they did not know how the oatmeal stayed so hot from the kitchen to the resident's room and did not know if the oatmeal had been reheated. On [DATE] at 4:30 p.m., CNA #1 reported they could not remember who the aide was that was observed feeding Resident #10. CNA #1 reported the DON immediately gave a detailed in-service following the incident. On [DATE] at 11:06 a.m., the DON provided the employee file for aide #1, and reported this was the aide who was feeding Resident #10 when they got burned. The DON reported the aide no longer worked in the facility. A copy of the aide's Long Term Aide certification showed the certification had expired [DATE]. On [DATE] at 11:13 a.m., the BOM reported aide #1 had worked in the facility about a week and a half. The BOM reported the aide came from a sister facility where they had been in the hospitality aide program, and they had planned to have the aide continue the training at this facility. The BOM stated the aide worked for a short period of time and then did not show up one day. On [DATE] at 1:14 p.m., CNA #2 reported any aide that was not certified was used as a hospitality aide while waiting to go through CNA training. CNA #2 reported aides in training do not provide direct resident care. On [DATE] at 2:15 p.m., CNA #4 reported hospitality aides provide only non-direct care and do not feed residents. On [DATE] at 2:23 p.m., CNA #3 reported they had worked at the facility a little over 2 weeks. The CNA reported they had not been in-serviced on hot liquids/hot foods. CNA #3 was asked if they went through an orientation period and stated, no, they went straight to the floor. On [DATE] at 2:36 p.m., Resident #10's physician reported they saw the resident a few days after the incident when the resident was burned. The incident happened on [DATE] and the physician saw the resident on [DATE]. The physician reported they saw no blisters or redness in the resident's mouth at that time. On [DATE] at 3:06 p.m., the DM reported they were not aware of an incident with Resident #10 in which the resident was burned from hot oatmeal. The DM reported if they send something out of the kitchen they temp it beforehand. On [DATE] at 4:43 p.m., the BOM reported it was their understanding, after talking to OSDH, that nurse aides in training were the same as a hospitality aide in what they can and cannot do. The BOM stated basically they should be shadowing a CNA and not providing direct care to residents. On [DATE] at 9:58 a.m., LPN #1 was interviewed by phone. LPN #1 reported they had worked at the facility as needed and was no longer working at the facility. LPN #1 reported they did not think they were working Resident #10's hall at the time of the incident, but responded when the aide asked for help. LPN #1 reported it took them a few minutes to calm the resident, but was eventually able to coax the resident to open their mouth. LPN #1 reported the blisters were easily seen when the resident opened their mouth. LPN #1 stated they reported the information to LPN #2 since they were the charge nurse for that hall. On [DATE] at 10:38 a.m., LPN #2 was interviewed by phone and reported they were the charge nurse the day of the incident with Resident #10. The LPN reported they returned from lunch and was told the resident's mouth was burned and the physician had been notified. LPN #2 reported LPN #1 told them there were two blisters in the resident's mouth and it might be hard for the resident to eat for awhile, and reported they had left the resident with cool liquids to drink. On [DATE] at 11:23 a.m., the DON reported the incident happened on a Saturday and they came to the facility to in-service all staff that same day. The DON was asked if they interviewed the aide who was feeding the resident and they stated, yes, but was not sure if they had any documentation of the interview.

Based on record review and interview, the facility failed to ensure a resident's representative was issued a written discharge form for 1 (#152) of 1 sampled resident reviewed for involuntary discharge. The DON reported 52 residents resided in the facility. Findings: The facility's Transfer or Discharge Notice policy, dated 12/01/16, read in part, A resident, and/or [their] representative, will be given a thirty day advance written notice of an impending transfer or discharge from our facility .Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: The safety of individual in the facility endangered .The resident and/or resident representative will be notified in writing. Resident #152 had diagnoses which included chronic obstructive pulmonary disease, diabetes, Alzheimer's dementia, and cognitive communication deficit. Progress notes for Resident #152, dated October through November 2024, showed multiple behaviors in which the resident was aggressive and abusive toward staff members, as well as being disruptive around other residents. A progress note, dated 11/08/24 at 10:08 a.m., showed facility staff spoke with the resident's family to discuss the resident's behaviors and possible plans moving forward. The note showed there was discussion regarding long term facilities which specialized in geri psych services. The note documented a referral was made to another facility at the family's request. A progress note, dated 11/08/24 at 3:20 p.m., showed Resident #152 was found in another resident's room tearing up belongings and yelling. The note showed multiple episodes of outbursts and combativeness. The note showed staff attempted to deescalate the situation and calm the resident without success. The note showed the resident was sent to the hospital for medical clearance and the resident had already been accepted to a behavioral unit once medically cleared. The note showed there had been multiple conversations with the resident's family regarding not being able to keep the resident at this facility and the need to find appropriate placement for the resident. The note showed family would be picking up the resident's belongings and the resident would be going to a geri psych facility better equipped to meet the resident's needs. A progress note, dated 11/20/24 at 11:23 a.m., showed staff members from the hospital/behavior health phoned the facility stating the resident was now ready for discharge and they had been unsuccessful in finding a facility that would accept the resident. The note showed they were informed the family had picked up the resident's belongings and the resident was discharged after belongings had been picked up. It was explained that the facility's last communication with family was that the resident would be transported to [name withheld] when discharged from the hospital. On 02/26/25 at 5:00 p.m., the administrator reported it was an emergency discharge and they believed it was in agreement with the resident's family member that they were taking the resident to another facility after the resident was checked out in the emergency room. The administrator reported the resident was aggressive, even with emergency medical services staff, while on the gurney being transferred. The administrator reported 9-1-1 was called because the resident was ripping down items in a resident's room and being aggressive towards other residents and staff. On 02/27/25 at 1:15 p.m., the ombudsman reported although the discharge was an emergency situation, the administrator should have had the family sign a discharge form when they picked up the resident's belongings.

Based on record review and interview, the facility failed to: a. ensure an allegation of abuse was fully investigated for one (#1); and b. prevent the potential for further abuse while an investigation was in progress for one (#1) of three sampled residents reviewed for abuse. The DON identified 47 resided in the facility. Findings: An Abuse Policy, dated 10/01/2020, read in part, Begin taking written statements from the person reporting the allegation or suspicion and any witnessess including staff, family, and/or residents/patients. The policy also read, Assess all residents/patients who may have been affected by the allegation or suspicion of abuse. An Abuse Prevention Program policy, revised 12/2016, read in part, Protect residents during abuse investigations. Resident #1 had diagnoses which included Adult failure to thrive, dementia, heart failure. A care plan dated 6/2024 documented Resident #1 had dementia and required extensive assistance with ADL's. A nurse note dated 07/30/24 at 8:12 a.m. documented CNA #2 stated Resident #1 bit their arm when getting them dressed for breakfast and again at lunch. CNA #2 was moved to a different hall and the physician was called. An Initial Incident Report Form sent to OSDH, for incident date of 7/30/24 documented, CNA (#1) reported that CNA (#2) was being rough with resident while trying to get (them) up and dressed for breakfast. Minutes later CNA (#1) reported (they) were at the nurses station and heard CNA (#2) screaming, (they) went to (Resident #1) room and CNA (#2) stated the resident bit (them) and that (they) was done with her. Resident #1 was found to be scared and appeared to be crying and stated (they) did not want CNA (#2) assisting (them). CNA (#2) was suspended immediately upon Owner/admin hearing of allegations. There were no interviews or statements included from residents or staff in the investigation. On 08/28/24 at 2:30 p.m., Resident # 1 was observed in their room in bed, unable to answer orientation questions and had nonsensical responses to questions. On 08/29/24 at 3:34 p.m., the DON stated they were unable to locate the safe surveys or any statements for the incident on 07/30/24. On 08/29/24 at 4:12 p.m., the DON stated the abuse policy was not followed on the 07/30/24 investigation because no safe surveys were completed. On 08/30/24 at 8:17 a.m., CNA #1 stated that they were aware of an abuse incident that the police were called on not too long ago. They stated it occurred on hall 200 with Resident #1. They stated they heard CNA #2 screaming, saw the resident was crying and upset and telling CNA #2 to stop pulling them. They stated CNA #2 was forcing Resident #1 to get out of bed. CNA #1 stated they stepped in as both the CNA #2 and Resident #1 were upset and CNA #1 tried to relieve CNA #2; who stated, No. CNA #1 stated they went to get the charge nurse then heard a scream and CNA #2 yelled their name. CNA #1 and the charge nurse got there and CNA #2 started cussing, saying the resident bit them, and that they were done with the resident and stormed out of he room. CNA # 1 stated they calmed Resident #1 down as they were shaking and crying. They took over the residents care. The police were called and CNA #2 no longer worked there anymore. On 08/30/24 at 9:37 a.m., the DON stated again they did not have any statements and they should have done safe surveys and stated it was cut and dry that it took 20 minutes as they admitted and were terminated. There were no safe surveys to ensure no other residents were at risk or harmed and there were no interviews conducted to provide a thorough investigation.

Based on record review and interview, the facility failed to ensure the physician and/or the resident's representative were notified after a change in the resident's condition for one (#1) of three sampled residents reviewed for notification. The DON identified 42 residents resided in the facility. Findings: An Assessing Falls and Their Causes policy, dated 11/23/20, documented to notify the resident's attending physician and family in an appropriate time frame after a fall. Res #1 had diagnoses which included Alzheimer's disease and psychosis. A witnessed fall report, dated 06/25/24, documented the resident was walking and grabbed onto the nurses' station, slid down the wall, and went to the ground. It was documented the resident was assessed and there were no injuries. There was no documentation the resident's representative was notified. An incident note, dated 07/02/24 at 5:28 a.m., documented the aide was going to get Res #1's roommate up. It was documented Res #1 appeared to have fallen going to the restroom. It was documented the resident had a small laceration to their upper left brow area. It was documented the fall was not witnessed by staff. An incident note, dated 07/02/24 at 5:37 a.m., documented the laceration was over the resident's right brow area and not the left. A health status note, dated 07/02/24 at 7:36 a.m., documented the nurse received report the resident had fallen and had a laceration to their eyebrow. It was documented when the nurse entered the room the resident had significant bleeding from the laceration. It was documented blood was present on the resident's forehead where they had been wiping the blood. It was documented vitals were obtained, the resident's forehead was cleaned, gauze applied over the laceration, wrapped, and taped. It was documented the physician and resident's representative was notified. There was no documentation the physician and the resident's representative were notified of the incident until report had been provided to the oncoming nurse. On 07/17/24 at 1:09 p.m., Corporate Nurse Consultant #1 was asked to locate documentation the resident's representative was notified of their fall on 06/25/24. They were asked when was the physician and resident's representative notified of their fall on 07/02/24. They stated they should have been notified at the time of the fall. On 07/17/24 at 1:35 p.m., Corporate Nurse Consultant #1 stated there was no documentation the resident's representative was notified regarding the incident on 06/25/24.

Based on record review and interview, the facility failed to assess and monitor a resident after an unwitnessed fall for one (#1) of three sampled residents reviewed for accident hazards. The DON identified 42 residents resided in the facility. Findings: Res #1 had diagnoses which included Alzheimer's disease and psychosis. An annual assessment, dated 05/17/24, documented the resident's cognition was severely impaired. It was documented the resident required supervision or touching assistance with transfers and was independent with walking. An incident note, dated 07/02/24 at 5:28 a.m., documented the aide was going to get Res #1's roommate up. It was documented Res #1 appeared to have fallen going to the restroom. It was documented the resident had a small laceration to their upper left brow area. It was documented the fall was not witnessed by staff. It was documented neurological checks were to be started. There was no documentation neurological checks began at the time of the resident's fall. An incident note, dated 07/02/24 at 5:37 a.m., documented the laceration was over the resident's right brow area and not the left. A health status note, dated 07/02/24 at 7:36 a.m., documented the nurse received report the resident had fallen and had a laceration to their eyebrow. It was documented when the nurse entered the room the resident had significant bleeding from the laceration. It was documented blood was present on the resident's forehead where they had been wiping the blood. It was documented vitals were obtained, the resident's forehead was cleaned, gauze applied over the laceration, wrapped, and taped. There was no documentation the resident was assessed after they had fallen until report had been provided to the oncoming nurse. A neurological flow sheet, initiated 07/02/24, documented neurological checks began at 7:36 a.m. On 07/17/24 at 11:14 a.m., the COO was asked to provide documentation the resident was assessed after they had fallen. On 07/17/24 at 12:51 p.m., Corporate Nurse Consultant #1 stated neurological checks were not started until 7:36 a.m. They stated neurological checks should have been started at the time of the resident's fall. They stated neurological checks were to be conducted every 15 minutes X one hour, every 30 minutes X one hour, every one hour X four hours, then every four hours X 24 hours. On 07/17/24 at 1:09 p.m., Corporate Nurse Consultant #1 stated there was no documentation the resident was assessed by the nurse until 7:36 a.m.

Based on observation, record review, and interview, the facility failed to store and serve food to ensure food service safety. The Resident Census and Condition of Residents documented a census of 39 residents. Findings: On 09/12/22 at 9:56 a.m., a tour of the kitchen facility was conducted with the dietary manager (DM). Personal staff items, including an employee's purse and drink, were observed on the preparation counter. The DM reported staff were allowed to store personal items in her office if needed. The DM reported a designated area would be established for storage of personal items. The microwave and toaster were observed to have food debris build-up. The DM reported she did not currently have a cleaning schedule and equipment was cleaned as needed. The food storage area was observed and a bowl, being used as a scoop, remained in the flour bulk container. The DM reported staff had just used the flour that morning and scoops should not be left in the bulk food items. A refrigerator was observed to have a watery liquid in the bottom of the cooler. Eggs in a cardboard carton were observed to be approximately one inch from the watery liquid. A folded towel was observed behind the cardboard carton of eggs and noted to be saturated with liquid. The DM removed the eggs and placed them in a large bowl. The DM reported Administration was aware and a plan in place to repair the refrigerator. On 09/12/22 at 10:30 a.m., the DM unlocked the employee lounge where the ice machine was stored. The ice machine was observed to have white build-up on the lid with water dripping in the ice tray when opened. The ice guard dispenser was observed to have a thick brown, black, and gray slimy residue build-up. The DM reported she thought dietary staff was responsible for cleaning the ice machine but stated she did not know when it was last cleaned. On 09/12/22 at 10:40 a.m., a three-compartment sink was observed with thawing meats submerged in water. Staff reported the meat products were for the evening meal and the following day. No water was observed to be running over the thawing meats. The DM instructed the staff that the water was to be left running while thawing meats. The DM reported the meats had been in the sink full of water approximately an hour before she noticed the water was not running. The meats had not fully thawed and were observed to still be partially frozen. On 09/13/22 9:33 a.m., dietary staff #1 was interviewed regarding handling beverages by touching and gripping the tops of glasses when serving residents. She stated she understood she was improperly handling the glasses and would serve them by holding the bottom of the glass instead of the surface of the drinking rim. On 09/13/22 at 11:01 a.m., the vice president of Clinical Services reported there was no cleaning schedule for the maintenance of the ice machine and a new policy and procedure would be implemented.

Based on observation, record review, and interview, the facility failed to maintain their infection control program. The facility failed to label and date a solution used to sanitize a glucometer for one (#25) of one sampled resident for finger stick blood sugar (FSBS) monitoring. The DON identified eight residents who required FSBS monitoring. Findings: A policy titled, Finger Stick Blood Sampling, not dated, read in parts, .It is the policy of this facility to use lancets to obtain finger stick blood samples in a safe manner for residents and staff .Procedure .Clean the Glucometer with germicidal wipes/or bleach/h2o solution diluted with a 1 to 10 ratio before initial use, after final use and between each resident following manufacturer recommendations . A Physician Order, for resident (Res) #25, dated 08/20/22, read in parts, .check finger stick AC & HS before meals and at bedtime for DM (Diabetes Mellitus) . On 09/14/22 at 11:30 a.m., LPN #1 was observed to perform a FSBS for Res #25. LPN #1 was asked if the glucometer was shared between residents and she stated, yes. After the FSBS was performed, and before cleaning the glucometer, the LPN removed a bottle from the treatment cart, labeled shampoo and body wash apple strawberry. The LPN was observed to smell the contents of the bottle and stated she was checking to see if it was bleach. She reported the solution should be 10% bleach water. The LPN was asked if she mixed the solution and she stated, yes, we do. She was asked how the solution was mixed and the LPN stated, I always have to ask. On 09/14/22 at 1:30 p.m., the DON was asked about the facility's policy for sanitizing the glucometer. The DON reported they used a 1:10 bleach solution or germicidal wipes. The DON confirmed the same glucometer was shared between residents. On 09/14/22 at 1:30 p.m., the DON was asked if she was aware the cleaning solution was mixed in a shampoo and bodywash bottle on the treatment cart. She reported the facility previously used a spray bottle with an appropriate label and date to indicate when the solution was mixed. The DON removed the shampoo and bodywash bottle from the treatment cart and stated, it needs a label. The DON reported staff were expected to mix the solution daily, label the bottle, and date it appropriately.

Based on observation, record review, and interviewed, the facility failed to ensure assessments accurately reflected the resident's use of oxygen for one (#4) of five residents reviewed for therapy. The Resident Census and Conditions of Residents, dated 09-12-22, documented 7 residents received respiratory treatment. Findings: Resident #4 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician Telephone Order, dated 07/03/21, documented O2 at 2-3 LPM via NC, may remove for ADLs. The resident's MDS Assessment, dated 05/26/22, documented no oxygen therapy. On 09/14/22 at 2:51 p.m., the DON reported .resident #4 had received oxygen since July 2021 but she had failed to transfer the telephone order to the resident's monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, observation, and interview, the facility failed to develop a comprehensive person-centered care plan for one (#4) of 13 residents whose care plans were reviewed. The Resident Census and Conditions of Residents, dated 09-12-22, documented 39 residents resided in the facility. Findings: Resident #4 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician Telephone Order, dated 07/03/21, documented O2 at 2-3 LPM via NC, may remove for ADLs. The resident's MDS Assessment, dated 05/26/22, documented the resident's cognition to be intact. The resident's Comprehensive Care Plan was reviewed and contained no documentation related to [CONDITION(S)] or oxygen therapy. On 09/12/22 at 2:18 p.m., the resident was observed in her room, up in recliner, and wearing oxygen tubing via NC. On 09/14/22 at 2:51 p.m., the DON reported .resident #4 had received oxygen since July 2021 but she had failed to transfer the telephone order to the resident's monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, observation, and interview, the facility failed to ensure: a. oxygen therapy was provided per professional standards of care for one (#4), and b. oxygen tubing and humidifier bottles were labeled and dated per professional standards of care for two (#4 and #34) of five residents reviewed for respiratory services. The Resident Census and Conditions of Residents, dated 09/12/22, documented, 7 residents received respiratory treatment. Findings: The facility's oxygen administration policy, dated 10/2010, read in parts, .After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record .The date and time that the procedure was performed .The name and title of the individual who performed the procedure .The rate of oxygen flow, route and rationale .The frequency and duration of the treatment . Resident #4 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician Telephone Order, dated 07/03/21, documented, O2 at 2-3 LPM via NC, may remove for ADLs. The resident's MDS Assessment, dated 05/26/22, documented, cognition intact, moderate assistance with most ADL's, and no oxygen therapy. The resident's Comprehensive Care Plan, documented, no [CONDITION(S)] or oxygen therapy. The resident's Treatment Administration Record, reviewed for July 2022, August 2022, and September 2022, contained no documentation related to oxygen therapy. The resident's Monthly Physician Orders, were reviewed for August 2021 through September 2022, documented no orders for oxygen. On 09/12/22 at 2:18 p.m., the resident was observed in her room, up in recliner, and wearing oxygen via NC at 2 LPM. On 09/13/22 at 3:37 p.m., the DON reported the resident #4 had a order written in the hard chart for oxygen, dated 07/03/21, but they had recently switched to electronic medical records on 08/01/22 and the oxygen order did not get added. The DON reported since the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported oxygen tubing and humidifier bottles are changed by the night shift nurse one time a month, usually on the 7th day of the month. The DON reported the oxygen tubing and humidifier bottle should be labeled with the date it was changed on piece of tape and also documented on the treatment administration record. On 09/13/22 at 3:40 p.m., the DON checked the resident's with this surveyor and verified the tubing and no label present with the date it had been changed and the date written on the humidifier bottle was warn off and not readable. She reported the nurse working the night shift had reported to her that all oxygen tubing and humidifier bottles had been changed this month, but it was not documented on this resident. She reported the nurses knew this resident well and what her order for oxygen was but failed to document it had been monitored. On 09/14/22 at 2:51 p.m., the DON reported .resident #4 had received oxygen since July 2021 but she had failed to transfer the telephone order to the resident's monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .An in-service training was conducted last night for all nursing staff related to documenting in the electronic medical record related to oxygen therapy and labeling oxygen tubing and humidifier bottles when changed with a piece of tape. The DON reported labeling the tubing and humidifier with tape with be made part of the facility's oxygen policy. Resident #34 was readmitted to the facility on [DATE] with COVID-19 , [CONDITION(S)] and [CONDITION(S)]. The resident's Monthly Physician Orders', dated 09/01/22, documented .Change O2 tubing monthly on the 7th .O2 @ 3 LPM per NC continuously maybe off for ADLS. A MDS Assessment,, dated 09/06/22, documented, moderately impaired cognition, totally dependant of staff with most ADLs, and oxygen therapy. On 09/12/22 at 4:00 p.m., the resident was in bed with O2 at 3 LPM via NC. No label with a date was present on the resident's O2 tubing or on the humidifier bottle. On 09/13/22 at 03:40 p.m., the DON checked resident #34's oxygen tubing and humidifier bottle with surveyor and verified it was not labeled with the date it was last changed. The DON reported the residents tubing and the humidifier bottle was last changed when the resident had recovered from COVID-19 and came out of isolation on 09/09/22. The DON reported the oxygen tubing and humidifier bottle should have been labeled with the date it was changed on a piece of tape and also documented on the treatment administration

Based on observation, record review, and interview, it was determined the facility failed to ensure dignity was maintained in providing clean clothing and face/hands for one (#16) of 12 residents reviewed. The ADM reported 34 residents lived in the facility. Findings: Resident #16 was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 03/06/18, documented the resident was severely impaired in cognition and exhibited no depression or behaviors. The assessment documented the resident required one person extensive assistance for bed mobility, transfers, toileting, personal hygiene, bathing, and dressing. The assessment documented the resident required supervision with set up for locomotion and eating. The assessment documented the resident was occasionally incontinent of bowel and frequently incontinent of urine. A care plan, dated 03/14/18, documented the resident required extensive assistance with ADLs. The goal was for the resident to be clean, dry, odor free, appear well groomed daily, and to have assistance with ADLs as needed, which included personal hygiene. One intervention listed was for the staff to check to assure the ADLs had been performed to usual standards. The care plan documented the resident required assistance with toileting and was incontinent of bowel and bladder at times. The care plan documented the resident did not summon the staff for assistance. The goal was for the resident to have assistance with toileting. An intervention listed was for the resident to receive the medication Nullo for urine odor. Another intervention was for the staff to assist the resident to be toileted at least every two hours, as needed, and to check for incontinence. On 05/22/18 at 10:35 a.m., the resident was observed to be seated in his wheelchair in the dining room, drinking coffee, and watching other residents play bingo. The resident was dressed in flannel pajama pants and a long sleeve knit top, shoes, and had a cap on his head. The resident was observed to have a short beard growth. A urine odor was detected when the surveyor sat next to the resident. When the surveyor spoke to the resident, his conversation could not always be followed when asked questions about his care. The resident's shirt was observed to have food debris and stains on it. Two flies were observed on his shirt and one fly was observed on his pajama pants. On 05/22/18 at 11:32 a.m., the resident was observed to be seated in his wheelchair at the dining table. The resident's head was hanging downward with his eyes closed. One fly was observed on the dining table in front of the resident and two flies were observed on the resident's shirt. The resident was seated with two other table mates and directly behind another resident. A urine odor continued to be detected coming from the resident. On 05/22/18 at 11:48 a.m., the resident received his pureed meal and was observed to feed himself. At that time, one fly was observed to continue to fly around the dining table, landed on a wash cloth, and landed on the resident's clothing. After eating, the resident was observed to have a brownish red food stain on the right side of his face extending downward. The resident had eaten pureed chili and chocolate ice cream at his lunch meal. On 05/22/18 at 12:13 p.m., the resident was observed in the hallway near the dining room using the handrail to help propel himself. Food stains were observed on his mouth and clothing. One fly was observed to land on his clothing. A staff member wheeled the resident to his room. On 05/22/18 at 12:25 p.m., the resident was observed in his room seated in his wheelchair in front of a blue screen on the TV/DVD player. The resident continued with food stains on his face and clothing, and with a urine odor detected. On 05/22/18 at 2:38 p.m., the resident was observed to be wheeling himself with the use of the hand rail in the hallways and the resident had a brownish food stains on his mouth and hands. The resident was observed to remain in the same clothing and with a urine odor detected. Two flies were observed to swarm around him and land on his clothing. On 05/22/18 at 3:06 p.m., CNA #1 was asked when she had last checked and changed the resident for incontinence. The CNA reported she had changed the resident before lunch. The CNA reported the resident would at times take his brief off and urinate anywhere. On 05/22/18 at 3:07 p.m., CNA #1 and #2 were asked to check the resident for incontinence. CNA #2 explained to the resident they would change him. CNA #2 told the resident they would wash his face and his hands since they were a mess. CNA #2 explained to the resident his clothes would be changed since his top and pants were both dirty with food. Both aides transferred the resident to bed, removed his pants, and a strong urine odor was detected. CNA #2 reported the resident's flannel pants were wet. The resident was observed not to have on a disposable brief. CNA #2 reported the pad in the wheelchair would be changed since it was wet. A fly was observed in the room and landed on the wheelchair seat. The CNAs changed the resident and dressed the resident with clean clothing. On 05/24/18 at 12:00 p.m., the DON was informed the resident had prolonged urine odor, untimely incontinent care, and was unkept with personal hygiene to his face, hands, and clothing. The DON reported the resident should have been cleaned, dressed, and changed in a timely manner. On 05/24/18 at 12:30 p.m., CNA #1 reported she had changed the resident before lunch and the resident was not changed again until the surveyor requested an incontinent check to be performed for the resident at 3:07 p.m. on 05/22/18. The CNA reported at mid morning the resident was dry and she reported, when she had changed the resident before lunch, he had on a disposable brief. The CNA reported she had not seen the resident remove the brief. The CNA reported around 1:00 p.m. on 05/22/18, the resident had a fudge ice cream bar as an afternoon snack, which he carried around with him to eat. (The resident was observed with brown stains on his face and hands when he was changed at 3:07 p.m.)

Based on observation, record review, and interview, it was determined the facility failed to provide ADL assistance in regard to personal hygiene and toileting/incontinent care in a timely manner for one (#16) of 12 residents reviewed. The ADM reported 34 residents lived in the facility. Findings: Resident#16 was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 03/06/18, documented the resident was severely impaired in cognition and exhibited no depression or behaviors. The assessment documented the resident required one person extensive assistance for bed mobility, transfers, toileting, personal hygiene, bathing, and dressing. The assessment documented the resident required supervision with set up for locomotion and eating. The assessment documented the resident was occasionally incontinent of bowel and frequently incontinent of urine. A care plan, dated 03/14/18, documented the resident required extensive assistance with ADLs. The goal was for the resident to be clean, dry, odor free, appear well groomed daily, and have assistance with ADLs as needed, which included personal hygiene. One intervention listed was for the staff to check to assure the ADLs had been performed to usual standards. The care plan documented the resident required assistance with toileting and was incontinent of bowel and bladder at times. The care plan documented the resident did not summon the staff for assistance. The goal was for the resident to have assistance with toileting. An intervention listed was for the resident to receive the medication Nullo for urine odor. Another intervention was for the staff to assist the resident to the toilet at least every two hours, as needed, and to check for incontinence. On 05/22/18 at 10:35 a.m., the resident was observed to be seated in his wheelchair in the dining room, drinking coffee, and watching other residents play bingo. The resident was dressed in flannel pajama pants and a long sleeve knit top, shoes, and had a cap on his head. The resident was observed to have a short beard growth. A urine odor was detected when the surveyor sat next to the resident. When the surveyor spoke to the resident, his conversation could not always be followed when asked questions about his care. The resident's shirt was observed to have food debris and stains on it. Two flies were observed on his shirt and one fly was observed on his pajama pants. On 05/22/18 at 11:32 a.m., the resident was observed to be seated in his wheelchair at the dining table. The resident's head was hanging downward with his eyes closed. One fly was observed on the dining table in front of the resident and two flies were observed on the resident's shirt. The resident was seated with two other table mates and directly behind another resident. A urine odor continued to be detected coming from the resident. On 05/22/18 at 11:48 a.m., the resident received his pureed meal and was observed to feed himself. At that time, one fly was observed to continue to fly around the dining table, landed on a wash cloth, and on the resident. After eating, the resident was observed to have a brownish red food stain on the right side of his face extending downward. The resident had eaten pureed chili and chocolate ice cream at his lunch meal. On 05/22/18 at 12:13 p.m., the resident was observed in the hallway near the dining room using the handrail to help propel himself. Food stains were observed on his mouth. One fly was observed to land on his clothing. A staff member wheeled the resident to his room. On 05/22/18 at 12:25 p.m., the resident was observed in his room seated in his wheelchair in front of a blue screen on the TV/DVD player. The resident continued with food stains on his face and with a urine odor detected. On 05/22/18 at 2:38 p.m., the resident was observed to be wheeling himself with the use of the hand rail in the hallways with a brownish food stain to his mouth and hands. The resident was observed to remain in the same clothing and with a urine odor detected. Two flies were observed to swarm around him and land on his clothing. On 05/22/18 at 3:06 p.m., CNA #1 was asked when she had last checked and changed the resident for incontinence. The CNA reported she had changed the resident before lunch. The CNA reported the resident would at times take his brief off and urinate anywhere. On 05/22/18 at 3:07 p.m., CNA #1 and #2 were asked to check the resident for incontinence. CNA #2 explained to the resident they would change him. CNA #2 told the resident they would wash his face and his hands since they were a mess. CNA #2 explained to the resident his clothes would be changed since his top and pants were both dirty with food. Both aides transferred the resident to bed, removed his pants, and a strong urine odor was detected CNA #2 reported the resident's flannel pants were wet. The resident was observed not to have on a disposable brief. CNA #2 reported the pad in the chair would be changed since it was wet. The wheelchair seat was observed to be moist and had cracks in the seat with the underneath fabric exposed. The CNAs dressed the resident with clean clothing and transferred him to the wheelchair. On 05/24/18 at 12:00 p.m., the DON was informed the resident had prolonged urine odor, untimely incontinent care, and was unkept with personal hygiene to his face, hands, and clothing. The DON reported the resident should have been cleaned, dressed, and changed in a timely manner. On 05/24/18 at 12:30 p.m., CNA #1 reported she had changed the resident before lunch and he had not been changed again until the surveyor requested an incontinent check to be performed for the resident at 3:07 p.m. on 05/22/18. The CNA reported at mid morning the resident was dry. The CNA reported when she had changed the resident before lunch he had on a brief. The CNA reported she had not seen the resident remove the brief. The CNA reported at around 1:00 p.m. on 05/22/18, the resident had a fudge ice cream bar as an afternoon snack, which he carried around with him to eat. (The resident was observed with brown stains on his face and hands when he was changed at 3:07 p.m.) At the time of the above interview, the DON explained to CNA #1 to check the resident every two hours for incontinence assistance.

Based on observation, record review, and interview it was determined the facility failed to assess, monitor, and complete a comprehensive care plan with interventions and measurable objectives for one (#10) of one resident reviewed for [MEDICAL TREATMENT] care. The ADM reported two residents received [MEDICAL TREATMENT] services. Findings: Resident #10 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/07/18, documented the resident was moderately impaired in cognition, exhibited minimal depression symptoms, and exhibited no behaviors. The assessment documented the resident required extensive assistance with personal hygiene and dressing. The assessment documented the resident required [MEDICAL TREATMENT]. The resident's care plan, last revised 05/11/18, did not address the resident received [MEDICAL TREATMENT] with measurable goals or interventions directed toward the goals. On 05/22/18 at 10:50 a.m., the resident was observed to be clean and well groomed. The resident reported she received [MEDICAL TREATMENT] three times per week at an outside [MEDICAL TREATMENT] unit. On 05/23/18 at 2:29 p.m., the staff reported the resident was out to [MEDICAL TREATMENT]. The clinical record contained no documentation the resident had been assessed or monitored after she returned from [MEDICAL TREATMENT]. On 05/24/18 at 12:57 p.m., the DON reported the facility staff did not assess or monitor the resident upon return from [MEDICAL TREATMENT] unless the [MEDICAL TREATMENT] unit notified them of a problem. The DON also reported vital signs were not obtained on return from [MEDICAL TREATMENT]. The DON was asked if the care plan should have had goals and interventions specific to [MEDICAL TREATMENT]. The DON stated, In hindsight, yes.

Based on observation, record review, and interview, it was determined the facility failed to ensure clean items did not come in contact with a contaminated surface for one (#16) of 12 residents reviewed. The ADM reported 34 residents lived in the facility. Findings: Resident #16 was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 03/06/18, documented the resident was severely impaired in cognition and exhibited no depression or behaviors. The assessment documented the resident required one person extensive assistance for bed mobility, transfers, toileting, personal hygiene, bathing, and dressing. The assessment documented the resident required supervision with set up for locomotion and eating. The assessment documented the resident was occasionally incontinent of bowel and frequently incontinent of urine. A care plan, dated 03/14/18, documented the resident required extensive assistance with ADLs. The goal was for the resident to be clean, dry, odor free, appear well groomed daily, and have assistance with ADLs as needed, which included personal hygiene. One intervention listed was for the staff to check to assure the ADLs had been performed to usual standards. The care plan documented the resident required assistance with toileting and was incontinent of bowel and bladder at times. The care plan documented the resident did not summon the staff for assistance. The goal was for the resident to have assistance with toileting. Another intervention was for the staff to assist the resident with toileting at least every two hours, as needed, and to check for incontinence. On 05/22/18 at 3:06 p.m., CNA #1 was asked when she had last checked and changed the resident for incontinence. The CNA reported she had changed the resident before lunch. On 05/22/18 at 3:07 p.m., CNA #1 and #2 were asked to check the resident for incontinence. CNA #2 explained to the resident they would change him since his flannel pants were wet. Both aides transferred the resident to bed, removed his pants, and a strong urine odor was detected. The resident was observed to not have on a disposable brief. CNA #2 reported the pad in the chair would be changed since it was wet. The wheelchair seat was observed to be moist and had cracks in the seat with the underneath fabric exposed. The CNA was observed to place the clean disposable brief on the wheelchair seat without cleaning the seat. A fly was observed in the room and landed on the wheelchair seat. The CNAs placed a clean protective pad in the wheelchair seat without cleaning the seat. The CNAs dressed the resident with clean clothing and transferred him to the wheelchair. On 05/24/18 at 12:00 p.m., the DON was asked if clean items should have been placed on the contaminated wheelchair seat. The DON reported no.

Based on observation and interview, it was determined the facility failed to ensure the patient care equipment of wheelchairs and Geri-chairs were maintained in safe and good condition to promote comfort and skin integrity for five (#12, 13, 14, 15, and #16) of 34 residents who utilized either wheelchairs or Geri-chairs for mobility. Findings: On 03/14/17, during the noon meal in the dining room, the following observations were made. The right wheelchair armrest was observed to be missing for resident #12. The right wheelchair armrest was observed to be torn and the top of the wheelchair backrest was observed to be torn with exposed interfabric for resident #13. The right wheelchair armrest was observed to be torn for resident #14. On 03/16/17 at 8:30 a.m., the Geri-chairs' armrests were observed to be both torn exposing the underneath fabric for resident #15 and #16. On 03/16/17 at 11:05 a.m., the ADM was informed of the above observations of the resident equipment. The ADM reported the issue would be addressed.

Based on observation and interview, it was determined the facility failed to ensure the resident environment remained free from accident hazards for 44 of 44 residents. The facility failed to ensure oxygen cylinders were secured and not free-standing. Findings: On 03/16/17 at 9:37 a.m., the oxygen closet, which was located directly across from the nurses' station and adjacent to the lobby, was observed with the DON in attendance. Four larger and two smaller oxygen cylinders were observed to be free-standing, setting directly on the floor, and not secured in the floor rack available in the closet. The non-secured cylinders were identified as empty cylinders. On 03/16/17 at 10:05 a.m., the DON reported she would place the oxygen cylinders in the rack to secure. On 03/16/17 at 10:10 a.m., the DON reported the oxygen cylinders were secured.

Based on observation, record review, and interview, it was determined the facility failed to ensure a resident's clinical record was accurately documented in regard to oxygen levels for one (#9) of three residents reviewed with oxygen use. The ADM reported 44 residents resided in the facility. Findings: Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. An initial care plan, dated 02/23/17, documented the resident was to receive oxygen at four liters per minute. The skilled nurses' notes, dated 02/23-27/17, documented the resident had received oxygen at three liters per minute. A skilled nurse's note, dated 02/28/17, documented on the systems checklist the resident had received oxygen at three liter per minute. The same form documented at 3:00 p.m., the resident was receiving oxygen at two liters per minute via nasal cannula. The March 2017 physician's orders [REDACTED]. The physician's orders [REDACTED]. The skilled nurses' notes, dated 03/01-16/17, documented the resident had received oxygen at three liters per minute on the review of systems checklist. An admission assessment, dated 03/02/17, documented the resident had severe impairment with cognition with minimal depression. The assessment documented the resident required one to two person extensive assistance with ADLs except eating. The assessment documented the resident was continent of bowel and bladder. The assessment documented the resident utilized oxygen therapy. Skilled nurses' notes, dated 03/04/17 and 03/07/17, documented the resident was receiving oxygen at 2-3 liters per minute. A March 2017 treatment administration record documented the as needed treatment of [REDACTED]. The treatment record was blank for the use of the oxygen therapy. On 03/14/17 at 10:00 a.m., an initial tour of the facility was conducted with LPN #1. The LPN reported the resident was alert, oriented, and at times a little forgetful. The LPN reported she believed the resident would be interviewable for accurate information. On 03/15/17 at 5:00 p.m., the resident was seated in a chair in her room with oxygen on at 4 liters per minute per nasal cannula. The resident was clean and well groomed. On 03/16/17 at 9:25 a.m., the resident was observed seated in her chair in her room with oxygen on at 4 liters per minute per nasal cannula. The resident was asked if she knew what setting should her oxygen level be set at on the oxygen concentrator. The resident reported she checked the level herself and it was to be on 4 liters per minute. The resident stated, I know what my air is to be. Important to me. The resident was asked if the staff would come in and look at the setting on the oxygen concentrator. The resident shook her head no. On 03/16/17 at 9:46 a.m., the ADM and DON were informed about the documentation concern in regard to the resident's oxygen level. The DON reported the staff may have followed the setting which was previously charted. The DON reported the staff would be educated. On 03/16/17 at 10:40 a.m., the DON was shown the March 2017 treatment administration record which was blank concerning the oxygen use. The DON reported the staff should initial on the form when the oxygen was utilized.

Based on observation and interview, it was determined the facility failed to have a system in place to maintain sanitary conditions in the dietary department for the preparation of meals for 45 of 45 residents who received meals from the dietary department. The facility failed to maintain cleanliness of equipment, store items dry, and maintain equipment in good working order. The dietary manager identified one resident received total nourishment through a PEG tube. Findings: On 01/19/16 at 10:00 a.m., on the initial tour of the dietary department, the following observations were made. The can opener blade had dark dried debris. Two large pots had dried food debris on the inner surfaces. A cake sheet pan had white dust-like debris on the inner surface. A strainer and a colander both had dried food debris. Serving bins and meal trays were stacked wet. A ladle was stored wet in the utensil drawer. A rubber spatula had edges which were chipped and flaking. A turning spatula had melted plastic edges which were chipped and flaking. At 10:30 a.m., the DM reported the items would be washed and stacked dry. The DM reported the chipped spatulas would be discarded. The DM reported the staff would be in-serviced. On 01/21/16 at 9:45 a.m., the ADM was informed of the findings in the dietary department. The ADM reported the issues would be addressed.

Based on record review, observation, and interviews, it was determined the facility failed to provide care in an environment which provided dignity by not waiting for permission to enter the residents' rooms for two (#1 and #4) of seven sampled residents who were observed during care. Forty six residents resided in the facility. Findings: 1. Resident #4 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/24/15, documented the resident was cognitively impaired, required total assistance with ADLs, required feeding via a PEG tube, and required a [MEDICAL CONDITION]. On 01/20/16 at 9:45 a.m., LPN #1 was observed providing [MEDICAL CONDITION] care. The door to the resident's room was closed. During the [MEDICAL CONDITION] care, CNA #1 knocked on the resident's door. The LPN responded by telling the CNA a treatment was in progress. Without waiting for permission to enter, CNA #1 opened the resident's door and entered the resident's room. The CNA then retrieved a pair of socks out of the cabinet and left the room. At that time, LPN #1 was asked if the CNA should have waited for permission before entering the resident's room. She stated, Yes. On 01/21/16 at 9:30 a.m., the DON was notified of the CNA not waiting for permission to enter the resident's room. She reported the CNA should have waited to enter. 2. Resident #1 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/12/15, documented the resident was moderately impaired in cognition and required assistance with all ADLs. On 01/20/16 at 9:00 a.m., the resident was observed during provision of treatments by LPN #1. After the treatments completion, a staff member knocked on the resident's door and opened the door at the same time. The staff member reported she could not hear through the doors. On 01/21/16 at 9:30 a.m., the DON was asked if the staff should wait for permission before entering the resident's room. The DON reported the staff should wait for permission to enter.

Based on observation, record review, and interview, it was determined the facility failed to have a system in place to ensure the facility was maintained in a sanitary and orderly manner for 46 of 46 residents who lived at the facility. The facility resident condition and census form documented 46 residents resided in the facility. Findings: On 01/19/16 and 01/20/16, environmental tours of the facility were conducted. The window blind in resident #1's room was broken with a piece of a slat missing. Rooms #114, #125, and #130 had bent window blinds. In the front lobby, six chairs and two couches had dark, soiled arms on all arms of the furniture. In the North shower room, the faucet was covered with grimy build-up. The wall outside of the nurses' station had missing, peeling, and loose texture. The laminate of the backsplash in the break room was loose, exposing moist wood behind the laminate. The break room was accessible to residents. On 01/21/16 at 10:35 a.m., during a confidential family interview, the family member reported the arms of the furniture in the lobby was filthy. At 11:30 a.m., the ADM and the maintenance supervisor were notified of the findings. The ADM reported the areas would be addressed.