Every finding on record at Artesian Home

Based on observation, record review, and interview, the facility failed to ensure food was prepared and served in a sanitary manner to minimize the risk of infection/cross contamination during 3 of 3 meal preparation and service observations. The dietary manager identified 50 residents received nutrition from the kitchen. Findings: On 05/05/26 11:45 a.m., the dietary manager was observed with visible facial hair performing tasks without wearing a beard guard. The dietary manager was observed to place grocery items in the refrigerator, then began to help with preparing lunch meals. A Food Distribution and Service policy, revised 10/2017, read in part, Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. On 05/05/26 at 11:45 a.m., the dietary manager stated, they believe the policy said if a person could pull and tug on their facial hair a beard guard must be worn. On 05/06/26 at 11:50 a.m., the regional registered nurse stated if staff have facial hair and are preparing or serving food, they must wear a beard guard. They stated, The staff knows the policy.

Based on record review and interview, the facility failed to ensure a resident's family member was notified of a medication change and a urinary tract infection for 1 (#1) of 1 sampled resident reviewed for notification of change.The DON identified 17 residents had urinary tract infections in the past three months.Findings:A facility document titled Change in a Resident's Condition or Status, dated February 2021, read in part, Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical /mental and or status (e.g. [for example], change in level of care, billing/payments, resident rights, etc.).A progress note for Resident #1, dated 04/21/26, showed new physician orders of an antibiotic medication were received with the diagnosis of an UTI and prescribed Augmentin. The progress note did not show Residents #1's family member was notified.On 05/06/26 at 10:09 a.m., family member #1 stated they were not notified when Resident #1 had a UTI and was prescribed a new medication.On 05/07/2026 at 11:21 a.m., LPN#1 stated Resident #1's family member should have been notified of the UTI and new medication. LPN #1 stated the notification should be documented in the medical record.On 05/07/2026 at 11:24 a.m., the ADON stated Resident #1's family member should have been notified of the UTI and new medication. The ADON stated the change in condition should be documented in the medical record.

Based on observation, record review, and interview, the facility failed to ensure EBP were followed during urinary catheter care for 1 (#36) of 1 sampled resident reviewed for urinary catheters.The DON identified one resident with a urinary catheter resided in the facility.Findings:On 05/06/26 at 2:50 p.m., LPN #1 was observed to perform urinary catheter care for Resident #36. LPN #1 washed their hands, used hand gel, and applied gloves to perform urinary catheter care. LPN #1 was not observed to wear a gown.An Enhanced Barrier Precautions policy, dated 12/01/24, read in part, Enhanced barrier precautions apply when a resident is not known to be infected or colonized with any multi drug resistant organisms, has a wound, or has indwelling medical devices.indwelling medical devices include urinary catheters.Enhanced barrier precautions employ targeted gown and glove use in addition to standard precautions during high-contact resident care activities. A physician's order for Resident #36, dated 05/09/25, showed urinary catheter care every shift.An annual assessment for Resident #36, dated 02/17/26, showed the resident's cognition was intact with a brief interview for mental status score of 15. The assessment showed Resident #36 was dependent on staff for activities of daily living. The assessment showed Resident #36 had an indwelling urinary catheter and a diagnosis of neurogenic bladder.A care plan for Resident #36, dated 02/16/26, read in part, The resident requires EBP due to the presence of urogenital implants and a suprapubic catheter.Utilize gown and gloves/PPE [personal protective equipment] during care as indicated.On 05/06/26 at 2:55 p.m., LPN #1 stated enhanced barrier precautions for urinary catheter care should include wearing gloves and a gown. LPN #1 stated a gown should have been worn for Resident #36's urinary catheter care. LPN #1 stated they forgot to put a gown on because enhanced barrier precautions were not hanging on Resident #36's door.On 05/08/26 at 11:50 a.m., the ADON/infection preventionist stated staff should have worn a gown and gloves to perform Resident #36's urinary catheter care as part of enhanced barrier precautions.

Based on observation, record review, and interview, the facility failed to maintain an effective pest control program to limit the number of flies in the facility. The Resident Census and Conditions of Residents form, dated 06/28/23, documented 48 residents resided in the facility. Findings: A facility Pest Control policy, not dated, read in part, .Our facility shall maintain an effective pest control program. On 06/25/23 at 2:45 p.m., a tour of the facility was conducted upon entrance. Multiple flies were observed in the halls, resident rooms, in the dining room, and in the kitchen. Flies were observed on resident's arms, clothing, dining room tables, and bedside tables. Dead flies were observed on the window seals and window ledges in the dining room. On 6/26/23 at 11:30 a.m., kitchen cook #1 was asked if the facility had been having a problem with flies. The cook stated the fly situation had been horrible. On 06/26/23 at 1:56 p.m., an anonymous resident was interviewed in their room. Three or four flies were observed flying around the resident's bed, two were observed to land on the resident's legs. The resident was asked about the flies, if they were bothered by them, and they stated the fly problem had been pretty bad recently. The resident stated they thought it might have been worse related to weather and rain. The resident reported they kept a fly swatter nearby in their nightstand. On 06/26/23 at 4:15 p.m., the double glass doors in the dining room, which lead to the back patio, were observed to have a gap between the two doors. The gap between the doors was measured with a measuring tape, by the surveyor, and found to be a 5/8 inch gap. Six dead flies were observed on the windowsill by the doors leading outside, several dead flies were observed on the floor, and three lives flies were observed in the dining room at that time. On 6/26/23 at 4:50 p.m., the Regional Director of Operations reported pest control had been contacted and they would be implementing measures to decrease the flies in the dining room, such as blue lights to pull the flies away from the doors. They reported maintenance would be replacing the weather stripping between the doors to help with the fly problem. On 06/27/23 at 10:00 a.m., a housekeeper reported they had been working at the facility approximately three months and the flies had been a problem for that period of time.

Based on interview and record review it was determined the facility failed to ensure a resident was free from abuse for one (#39) of three residents reviewed for abuse. The director of nursing (DON) identified 34 residents who resided in the facility. Findings: Resident #39 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An admission assessment, dated 9/15/20, documented the resident was severely impaired with cognition, exhibited no behaviors, and required extensive assistance with activities of daily living. An initial incident report form, with an incident date of 12/31/20, documented an employee reported certified nurse aide (CNA) #2 smacked the resident on the leg twice. The report documented the CNA was immediately suspended pending an investigation. A facsimile transmission report documented the report was faxed to the Oklahoma State Department of Health on 12/31/20 at 11:49 p.m. A final incident report, with an incident date of 12/31/20, documented statements were obtained from all parties involved and the facility's cameras were reviewed by the administrator. The report documented the allegation of abuse was substantiated. A final incident report documented the CNA was terminated on 01/06/21. On 08/05/21 at 8:30 a.m., corporate nurse #1 reported CNA #2 had been in-serviced related to the facility abuse policy.

Based on interview and record review, it was determined the facility failed to complete a thorough investigation of an allegation of abuse for one (#39) of three residents reviewed for abuse. The director of nursing (DON) identified 34 residents who resided in the facility. Findings: Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An admission assessment, dated 9/15/20, documented the resident was severely impaired with cognition, exhibited no behaviors, and required extensive assistance with activities of daily living. An initial incident report form, with an incident date of 12/31/20, documented an employee reported certified nurse aide (CNA) #2 smacked the resident on the leg twice. The report documented the CNA was immediately suspended pending an investigation. A facsimile transmission report documented the report was faxed to the Oklahoma State Department of Health on 12/31/20 at 11:49 p.m. A final incident report, with an incident date of 12/31/20, documented statements were obtained from all parties involved and the facility's cameras were reviewed by the administrator. The report documented the allegation of abuse was substantiated. A final incident report documented the CNA was terminated on 01/06/21. On 08/05/21 at 8:30 a.m., corporate nurse #1 reported no in-service related to abuse had been conducted but should have. Corporate nurse #1 and #2 reported no other residents had been interviewed during the investigation but should have according to the facility abuse policy.

Based on interview and record review, it was determined the facility failed to ensure a resident received adequate supervision and assistance to prevent falls for one (#39) of five sampled residents who were reviewed for falls. The facility failed to modify and evaluate interventions for effectiveness for a resident who had frequent falls. The director of nursing (DON) identified 34 residents resided in the facility. Findings: Resident #39 was admitted to the facility on [DATE] and with diagnoses which included type 2 diabetes mellitus without complications, other specified depressive disorders, pain, dementia with behavioral disturbance, transient cerebral ischemic attack, and [CONDITION(S)]. An admission assessment, dated 03/15/20, documented the resident had severely impaired cognition. The assessment documented the resident required extensive two person assistance with transfers. The assessment documented the resident was dependent on two person staff for walking in his room. The assessment documented the resident was not stable, only able to stabilize with staff assist when moving from seated to standing position, when walking and during surface to surface transfer. The assessment documented the resident had two or more non-injury falls since admission, and one fall with minor injuries. The assessment documented bed and chair alarms were used daily. A care area assessment (CAA) detail worksheet for falls, dated 03/15/20, documented the resident was non-compliant with using call light and waiting for assistance. The CAA documented the resident had multiple falls since admission. The CAA documented the resident was at risk for falls/injury. A nurses note dated 07/09/20, documented resident had one fall since 03/12/20. The note documented new order received from physician to discontinue bed alarm, chair alarm, and mattress gripper. The clinical record documented the resident had falls on 07/24/20, 08/28/20, 11/04/20, and 12/15/20. A care plan, dated 12/15/20, documented the resident was at risk for falls due to impaired balance. The care plan documented for the staff to ensure call light was within reach, encourage the resident to request assistance, and bed to be in low position at all times if needed. A quarterly assessment, dated 12/17/20, documented the resident was severely impaired with cognition. The assessment documented the resident required extensive two person assistance with transfers, and limited one person assistance with ambulation. The assessment documented the resident was not steady, only able to stabilize with staff assist when moving from seated to standing position, walking, and with surface to surface transfer. The assessment documented the resident was at risk for falls. The assessment documented the resident had more than two falls with no injures since the previous assessment. The assessment documented bed and chair alarms were used daily. The clinical record indicated the resident had a fall on 12/20/20. A new care plan approach, dated 12/21/20, documented the resident was reminded to keep gripper socks on and to use call light. The resident had a fall on 12/24/20. A new care plan approach, dated 12/24/20, documented for the staff to educate resident to use call light and make frequent checks on resident. The clinical record documented the resident fell on [DATE]. A care plan approach, dated 12/30/20, documented nursing restorative range of motion. The clinical record documented the resident fell on [DATE]. A care plan approach, created on 01/04/21, documented a call light was attached to the residents chair and put in his lap and restorative exercises to help with strength. The clinical record documented the resident fell on [DATE]. A care plan approach, created on 01/11/21, documented for staff to encourage resident to get close to items reaching for to prevent sliding from wheelchair. The clinical record documented the resident had a fall on 01/13/21. A care plan approach, created on 01/14/21, documented the resident was instructed on bathroom call light use for transfers onto and off of commode. The clinical record documented the resident fell on [DATE] and 01/25/21. A care plan approach, created on 01/26/21, documented the resident was reminded to use call light and wear non-slip shoes for transfers, and an order was pending for bed alarm. The clinical record documented the resident fell on [DATE]. A care plan approach, created on 01/29/21, documented to re-educate staff to provide for toileting needs every 2 hours. The clinical record documented the resident fell on [DATE]. The care plan contained no new approaches. On 02/11/21 a five day assessment documented the resident remains with severe cognitive cognition. On 08/05/21 the ADON reported the approaches put into place for resident reminders and re-education were inappropriate due to severe cognitive deficit.

Based on observation and interview, it was determined the facility failed to ensure the removal of expired medications from the medication storage room and accurate medication labeling. This had the potential to affect all 34 residents who resided in the facility. Findings: On 08/03/21 at 10:58 a.m., the medication room was observed. Expired medications were found in the facility's medication room for the following: 1. [MEDICATION(S)] nasal spray with an expiration date of 06/09/21. 2. Saline nasal spray with a use by date of 04/15/21. 3. One bottle of house stock Ibuprofen 200 mg with a use by date of 04/16/21. 4. A zip-lock bag containing two [MEDICATION(S)] inhalers with no label or names on the inhalers. A copy of the pharmacy invoice that received date of 05/24/19 and a start date of 02/02/20. On 08/03/21 at 10:58 a.m., certified medication aide #1 reported the expired medications should have been removed from the medication room.

Based on observation and interview, it was determined the facility failed to ensure food had been prepared in a sanitary manner for pureed residents. The facility reported four residents received a pureed diet. Findings: On 08/03/21 at 11:30 a.m., the dietary manager (DM) was observed to place corn bread with milk into a blender. The blender had an opening in the top where a plastic cover had been broken off. The DM picked up a dirty rag off of the counter top and covered the opening while the food had been pureed. After the blender was cleaned, the DM placed beans with ham in the blender, wiped the counter off with the same dirty rag and placed it over the opening of the blender to puree the food. The DM then cleaned the blender and placed turnip greens into the blender. The staff member again wiped off the counter and then placed the same dirty rag over the top of the blender a third time. On 08/03/21 at 11:45 a.m., the DM reported the plastic cover had broken off. The DM stated, I usually use a napkin to cover it, I just wasn't thinking. On 08/03/21 at 12:00 p.m., the administrator was informed of the above findings. The administrator reported, it would be taken care of.

Based on observation, interview, and record review, it was determined the facility failed to ensure infection control was maintained during wound care for two (#23 and #20) of three sampled residents who were reviewed for wound care. The facility identified four residents who had wounds. Findings: A facility dressing change guideline, documented for the staff to don gloves utilizing aseptic technique, cleanse wound, remove gloves and wash hands and don clean gloves prior to dressing the wound. The guideline documented when more than one wound gloves should be removed, hands washed, and fresh gloves applied for each wound. 1. Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 05/28/21, documented the resident was moderately impaired with cognition, exhibited mild depression, rejected care one to three days of the look back period. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident required an indwelling catheter. The assessment documented the resident was always incontinent of bowel. The assessment documented the resident had two unstageable deep tissue injuries. A care plan, dated 06/01/21, documented the resident had multiple pressure areas to the left lower extremity and left buttock. The care plan documented for the staff provide wound care as ordered by the physician. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order documented for the staff to apply a [MEDICATION(S)] Extra Dressing with special instructions to apply triple antibiotic ointment to the portion of leg wound that had granulation tissue. The order documented do not apply to eschar. The order documented for the staff to apply Mesalt to the debrided portion of the wound that had slough, cover with calcium alginate and a gauze dressing. The order documented for the staff to apply [MEDICATION(S)] Extra Dressing with special instructions to apply [MEDICATION(S)] to the buttock wound, cover with calcium alginate and a gauze dressing. On 08/02/21 11:03 AM, the resident was observed lying on pressure relieving mattress. On 08/03/21 10:50 AM, registered nurse (RN) #1 was observed to provide wound care to the resident's three wounds. The RN applied [MEDICATION(S)] to the eschar on the left heel. The RN then cleaned around the eschar with 4 X 4 gauze soaked in normal saline solution (NSS). The RN then applied triple antibiotic ointment with soiled gloves. The RN reported she normally changed gloves between cleaning the wound and applying the treatment. The RN then cleansed the wound to the left outer leg with NSS. The nurse applied triple antibiotic ointment with a Qtip applicator to the wound on the outer left leg. The RN then applied Mesalt gauze, calcium alginate, 4 X 4 gauze, and wrapped the left lower leg wound with kerlix. The RN did not change her soiled gloves prior to applying the clean dressing. The RN then removed the soiled gloves used hand gel and applied clean gloves prior to cleansing the coccyx area with NSS. The RN then applied skin prep with soiled gloves. The RN then applied an antiseptic gel with a Qtip applicator. The RN applied calcium alginate with the same soiled gloves. The RN applied border gauze with the same soiled gloves. The RN was asked once cleaned the wound were the gloves considered dirty. The RN stated, Yes they are dirty. The RN reported she should have hand gelled and changed gloves between cleaning the wounds and applying the medication and dressing. 08/03/21 04:18 PM, the corporate nurse reported the RN should have changed her soiled gloves throughout the wound care. 2. Resident #20 was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/04/21 at 3:52 P.M., wound care was observed for resident #20. The wound care doctor was observed entering the resident's room already wearing gloves. The wound care doctor cleaned off a corner of a table using an alcohol prep pad. The doctor wearing the soiled gloves then set clean supplies on the table. The wound care doctor was observed to move the resident's trash can to the end of the resident's bed wearing the same soiled gloves. The wound care doctor was observed to measure the resident's wound and then sprayed it with normal saline solution wearing the same soiled gloves. The wound care doctor was observed to debride the wound using a sterile scalpel and sterile gauze pads but continued to wear the same soiled gloves. On 08/05/21 at 8:30 a.m., the corporate nurse #1 reported the wound care doctor should have changed gloves several times throughout the procedure.

Based on observation, interview, and record review, it was determined the facility failed to complete a discharge summary for one (#37) of nine closed records reviewed. The facility identified 34 residents lived in the facility. Findings: Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 02/09/21, documented the resident was intact with cognition. The assessment documented the resident did not want to speak to anyone about leaving the facility. The assessment documented no community referral was needed. A nurse's progress note, dated 05/12/21, documented the nurse going off shift reported the resident had discharged to another facility. A social services note, dated 05/13/21, documented the resident discharged to another facility the previous day. The clinical record did not contain a discharge summary. On 08/04/21 01:09 PM, the corporate registered nurse reported a discharge summary should have been completed.

Based on observation, interview, and record review, it was determined the facility failed to provide assistance with meals in a timely manner for one (#23) of two residents reviewed for meal assistance. The facility reported five residents required meal assistance. Findings: Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 05/28/21, documented the resident was moderately impaired with cognition, exhibited mild depression, rejected care one to three days of the look back period. The assessment documented the resident required extensive assistance with eating. A care plan, dated 06/01/21, documented the resident was at risk for altered nutritional status. The care plan documented for the staff to encourage and assist the resident with oral intake of food and fluids. On 08/02/21 12:34 PM, the resident's lunch tray was observed sitting on her bedside table still covered. The resident was observed lying in bed with her eyes closed. On 08/02/21 12:43 PM, the resident's lunch tray was observed sitting on her bedside table still covered. The resident was observed lying in bed with her eyes closed. On 08/02/21 12:51 PM, the resident's lunch tray was observed sitting on her bedside table still covered. The resident was observed lying in bed with her eyes closed. On 08/02/21 12:58 PM, the assistant director of nurses (ADON) was observed standing outside of the resident's room. On 08/02/21 01:01 PM, certified nurse aide (CNA) #1 reported she had passed the resident's plate and then assisted with others in the dining room. The CNA reported she should have stayed with the resident and fed her when she delivered the lunch plate. On 08/04/21 04:02 PM, the ADON reported the CNA should have began to feed the resident after delivering the plate of food.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (#20) of five residents reviewed for unnecessary medications was free from unnecessary [CONDITION(S)] medication. The facility reported 34 residents lived in the facility. Findings: Resident #20 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, [CONDITION(S)], essential hypertension, other specified depressive episodes, generalized anxiety disorder, mood disorder due to known physiological condition, unspecified, adjustment disorder with anxiety, and major depressive disorder, recurrent. A medication regimen review, dated 05/24/21, documented the resident's [MEDICATION(S)] had been decreased to 5 mg on 04/01/21. The review documented [MEDICATION(S)] 100 mg daily was added on 05/20/21. The review documented both medications were for dementia. The review documented a recommendation to decrease [MEDICATION(S)] to 2.5 mg every evening. A physician's order, dated 06/11/21, documented [MEDICATION(S)] 2.5 mg once a day for mood disorder due to known physiological condition. A quarterly assessment, dated 06/12/21, documented the resident had severe cognitive impairment. The assessment documented the resident had no behaviors. The assessment documented the resident required extensive assistance with activities of daily living (ADLs). The assessment documented the resident received an antipsychotic medication for seven days of the seven day look-back period. The assessment documented the date of last gradual dose reduction was 04/01/21. A physician's progress note, dated 06/15/21, documented no depression, anxiety or confusion worse than baseline. The progress note documented to continue treatments as directed, for dementia, to include [MEDICATION(S)]. A care plan, initiated on 06/16/21, documented the resident was a risk for developing signs and symptoms of side effects/adverse reactions for use of an antipsychotic medication as prescribed related to other specified depressive episodes, generalized anxiety disorder, and mood disorder due to known physiological condition. A medication regimen review, dated 06/29/21, documented [MEDICATION(S)] was reduced to 2.5 mg daily on 06/11/21, [MEDICATION(S)] 100 mg daily continues, will follow up. Behavior flow sheets for May 2021, June 2021, and July 2021, had no documented behaviors. On 08/04/21 09:59 AM, assistant director of nursing (ADON) reported mood disorder, dementia, depressive episodes, nor anxiety disorder were appropriate clinical indications for the use of the antipsychotic medication.

On 02/19/20 an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent falls and to consistently identify and implement interventions to prevent falls. The facility failed to provide supervision to prevent multiple falls for resident #41. Resident #41 sustained a [CONDITION(S)] and a fractured humerus. On 02/19/20 at 1:42 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ situation in regard to the failure of the facility to provide supervision to prevent falls. On 02/19/20 at 1:56 p.m., the chief operations manager and interim administrator were notified of the IJ situation. On 02/19/20 at 4:55 p.m., a plan of removal was accepted. The plan of removal documented; 1. All licensed Rn's and Lpn's will be in-serviced on completing an incident report anytime a resident falls. 2. Licensed nurses will be in-serviced on completing an incident investigation to determine the root cause of the fall. 3. Licensed nurse will ensure an appropriate intervention is implemented to prevent reoccurrence 4. All fall incident reports will be reviewed the following business day in morning meeting by the IDT team to ensure appropriate interventions are implemented. 5. All licensed nursing staff on duty has been in-serviced as of 2-19-2020 at 240pm. 6. All residents will be re-assessed for fall risk and those at risk will be identified through this process 7. Those with fall risk will have a root cause analyse [sic], with interventions and care plans updated. 8. Director of Nursing will ensure supervision to prevent accidents/falls. 9. All other licensed nursing staff not on duty will be in-serviced. 10. All will be completed by 2-19-2020 at 1159 pm. On 02/19/20 an in-service was provided by registered nurse (RN) #2. The topics for the in-service were ensuring falls had a root cause analysis, interventions, an incident report, and investigations. On 02/20/20 at 10:15 a.m., the immediate jeopardy was removed when all components of the plan of removal had been completed. The deficient practice remained at an actual harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to: A. Provide supervision to prevent falls and to consistently identify and implement interventions to prevent falls for three (#41, #28 and #34) of three residents reviewed for falls. The facility failed to provide a root cause analysis for falls, update care plans, and implement interventions to prevent further falls. Resident #41 experienced multiple falls and sustained a [CONDITION(S)] and a fractured humerus. The facility identified 25 residents who were at high risk for falls. B. Provide supervision to ensure foods were safely prepared and served for 43 of 43 residents who lived at the facility. Findings 1. Resident #41 was admitted to facility on 01/09/18 with diagnosis which included Alzheimer's disease and a history of repeated falls. An admission assessment, dated 01/22/18, documented the resident was cognitively impaired. The assessment documented the resident was independent with all activities of daily living except bathing. The assessment documented the resident had no physical impairment. A care plan, initiated on 08/23/19, documented the resident was at risk for falls due to side effects of [CONDITION(S)] medication and impaired safety awareness. A quarterly assessment, dated 11/12/19, documented the resident was severely impaired with cognition. The assessment documented the resident required assistance with dressing, toileting, hygiene and bathing. The assessment documented the resident had no falls during the look back period. A fall risk assessment, dated 11/12/19, documented the resident was a high risk for falls. A nurse's note, dated 12/27/19 at 12:49 p.m., documented, Was called to resident room, resident setting on the floor next to bed on buttocks, blood noted to resident face, 2 laceration noted above and below chin. Trying to clean resident up and the resident fighting with staff. Resident c/o [complains of] left jaw pain. Received VO [verbal order] from PCP [primary care physician] and resident was transported to [name-deleted hospital] for eval [evaluation]. Family notified. A facility incident report, dated 12/27/19, documented the resident had fallen and had been sent to the emergency room for further evaluation. The report contained no interventions to prevent recurrence. The report documented the resident was not on a fall program. A nurse's note, dated 12/27/19 at 4:05 p.m., documented the resident's computed tomography (CT) results were negative. The note documented a laceration to the resident's chin was cleaned and steri-strips were applied. A nurse's note, dated 12/30/19 at 4:14 a.m., documented the resident was ambulating in the hallway and common areas that shift. A nurse's note, dated 01/08/20 at 10:38 p.m., documented, Resident has increase in restlessness and agitation. Has been following employees in to other residents room. Trying to push residents in wheelchairs around even when they tell her not too . A handwritten nurse's note, dated 02/10/20 and clarified by the director of nurses (DON) as 01/10/20, documented, 5:25pm Resident fell out in main lobby, med aide observed fall & Reported that resident did not hit her head, but landed on her left side. Resident received small skin tear to L [left] Elbow area cleaned with NSS [normal saline solution], patted dry with 4 x 4's, then steri strips applied x 3. Size 2cm [centimeters] x 1cm. Resident c/o [complained of] pain to left leg, unable to move left leg without severe pain, left leg is rotated outward & slightly shortened. Assisted resident up in w/c [wheelchair] with assist of other staff. Dr. [name deleted] notified of such, and [name deleted] resident friend who is down for primary contact. 5:42 pm, 400mg [milligrams] of [MEDICATION(S)] given @ this time for pain. VS [vital signs] bp [blood pressure] 89/44 - hr [heart rate] 72 - resp [respiration] 20 - T [temperature] 98.2. Mobile x-ray was called but then was canceled & at 5:50 pm Resident was transferred by EMS [emergency medical system] to [name deleted] hospital. 6:55pm, [name deleted] DON [director of nursing] here & called [name deleted] hospital for update. Resident does have fx [fracture] to L hip. Dr. [name deleted] & DON notified of such. A facility incident report, dated 01/10/20, documented the resident fell in the main lobby. The report documented the resident was sent to the emergency room via ambulance. A state reportable incident report for the incident documented, .resident admit to hospital for left hip surgery. Upon return will assess, evaluate resident's needs and implement further interventions as deemed necessary . A nurse's note, dated 01/17/20 at 2:14 p.m., documented, Resident arrived via ambulance, on gurney . Requires assist of two person for transfers, also requires assist with eating. A nurse's note, dated 01/17/20 at 10:30 p.m., documented, Resident requiring one on one care d/t [due to] trying to get out of bed on her own and not leaving wedge between legs . A care plan, implemented on 01/17/20, documented the resident was post op left hip fracture and was at risk for pain and immobility. The care plan documented a goal for the resident was to prevent immobility and decrease pain. The care plan documented for the staff to assist with activities of daily living (ADLs) as needed, give pain meds as ordered, maintain the adduction of the affected extremity, monitor for an increase in pain or discomfort, observe for signs or symptoms (s/s) of thrombophlebitis, report to physician immediately, provide appropriate skin care to prevent pressure sores, provide routine postop care, and therapy if ordered. The care plan contained no interventions to prevent further falls. A nurse's note, dated 01/18/20 at 12:15 a.m., documented, Resident sitting on side of bed. Tried to talk to resident to have her lay back down but resident trying to get up our [sic] of bed. A nurse's note, dated 01/19/20 at 5:33 a.m., documented, Resident trying to stand up from couch and wheelchair during beginning of shift . A nurse's note, dated 01/19/20 at 7:03 p.m., documented, Resident has been in day room for most of shift, resident just now began trying to stand and walk, resident redirected to couch. A nurse's note, dated 01/20/20 at 1:31 a.m., documented, resident resting on couch at this time, several attempts to attempt to ambulate w/o [without] assistance, redirected as needed. A fall risk assessment, dated 01/27/20, documented the resident was a high risk for falls. A significant change assessment, dated 01/29/20, documented the resident was severely impaired with cognition. The assessment documented the resident required extensive assistance with bed mobility, transfers, and locomotion on and off the unit. The assessment documented the resident had not ambulated in room or corridor. The assessment documented an active diagnosis of hip fracture. The assessment documented the resident had a fall in the last month prior to the assessment, a fall in the last 2-6 months prior to the assessment, and a fracture related to a fall in the last six months prior to assessment. A care plan, edited on 01/29/20, documented the resident was at risk for falls due to side effects of [CONDITION(S)] medications, impaired safety awareness, and limited mobility post hip fracture. The care plan documented the resident would be free of falls. The care plan interventions included assessment and treatment for postural/[CONDITION(S)], implement exercise program which targets strength, gait and balance, increased staff supervision with intensity based on resident need, order comprehensive medication review by pharmacist, assess for polypharmacy and medications that increase the fall risk, and provide individualized toileting interventions based on needs/patterns. A facility incident report, dated 01/29/20 at 1:40 p.m., documented the resident was found in the floor in the common room. The incident report documented no acute findings. A nurse's note, dated 01/30/20 at 3:59 p.m., documented, Resident found in room on floor. Fall was not witnessed by staff. Resident laying under wheelchair. Resident laying on R [right] side, c/o [complains of] pain to R hip and elbow. Mobile xray notified and will perform xray of R hip and elbow. Resident is resting in bed with bed in lowest position and call light within reach. A nurse's note, dated 01/31/20 at 4:02 a.m., documented, resident resting on couch at beginning of shift. Frequently trying to stand up. Resident fell during previous shift . A nurse's note, dated 02/01/20 at 10:00 a.m., documented, Resident noted falling in hall way, witnessed by med aide, resident was able to assist with getting out of floor no new injuries noted, will monitor resident for 72 hours, doctor notified and [name deleted] mobile called. A nurse's note, dated 02/02/20 at 4:06 p.m., documented, Resident in day room at this time, has been sleep most of shift, refused breakfast and dinner, resident continues to attempt to get up out of chair and bed with no assistance, resident unable to understand usage of call light for assistance. A nurse's note, dated 02/08/20 at 10:10 p.m. (recorded as Late Entry on 02/09/2020 05:34), documented, Resident found lying on stomach in floor outside of her room in the hallway. Assisted up and into wheelchair. Laceration noted to left eyebrow with moderate bleeding from site. Bruising starting to left cheek. Pain voiced when left arm moved. Care provided to laceration and bleeding controlled. Resident grimacing and moaning d/t [due to] pain. Dr. [name deleted] and DON notified of fall. The note documented the resident was sent to the emergency room via ambulance. A facility incident report, dated 02/08/20, documented the resident fell in hallway. The report documented the resident was sent to the emergency room . The report contained no interventions to prevent further falls. A state reportable incident report, dated 02/08/20, documented the resident fell and was sent to the emergency room via ambulance. The report documented the resident returned from the hospital on 02/09/20 with a closed, non-displaced surgical neck fracture of the left humerus. The report documented the resident had an immobilizer to the left arm. The report documented the resident was to follow up with an orthopedist. The report contained no interventions to prevent further falls. A nurse's note, dated 02/09/20 at 4:25 a.m., documented, Resident brought back to home via facility van. Assisted into bed by staff. Dermabond applied to left eyebrow while in the ER [emergency room ]. Resident has closed, non-displaced surgical neck fracture of the left humerus. Immobilizer placed to left arm in ER. Resident to follow up within two days with orthopedist. A care plan, implemented on 02/10/20, documented the resident had a closed, non-displaced surgical neck fracture of the left humerus due to a fall. The care plan documented a goal for the resident was to prevent immobility and decrease pain. The care plan documented approaches for the staff to assist with activities of daily living (ADLs) as needed, give pain meds as ordered, monitor for an increase in pain or discomfort, provide appropriate skin care to prevent pressure sores, and provide immobilizer care. The care plan contained no new interventions to prevent further falls. On 02/11/20 at 8:27 a.m., the resident was observed lying in bed with her eyes closed. The resident was observed to have a bandage to her right wrist and a transparent patch to her left shoulder. A fall mat was observed on the floor beside the bed. The resident was observed to have a reddened area above her left eye brow. On 02/12/20 at 08:44 a.m., the licensed practical nurse (LPN) #1 reported the resident was out of facility for a follow up appointment. On 02/18/20 at 11:04 a.m., the resident was observed lying in bed with her eyes closed. The resident's head of bed and knees were slightly elevated. On 02/18/20 at 11:06 a.m., LPN #1 reported the resident fell multiple times within four to six weeks. The LPN reported the resident had a fall with a hip fracture and a fall with a shoulder fracture. The LPN reported after the first fall, the resident was readmitted to the facility with orders for hospice. The LPN reported the resident was independent prior to the hip fracture. The LPN reported a fall mat had been put into place and staff members were to keep their eyes on the resident. On 02/19/20 at 8:18 a.m., the resident was observed lying in bed on her back with her eyes closed and the head of the bed and knees were slightly elevated. A visitor was in the resident's room. The visitor identified himself as the resident's significant other (SO). The SO reported prior to the falls, the resident was mobile, active, and very busy. He reported he had difficulty keeping up with the resident. The SO reported it was very difficult to see the resident just lying in the bed. 2. Resident #28 was admitted to the facility on [DATE] with diagnoses which included fracture of left clavical, depressive episodes, and unspecified fall, sequela. An admission assessment, dated 11/19/19, documented the resident was moderately impaired with cognition, required limited assistance with activities of daily living, and utilized a walker or wheelchair for ambulation. The assessment documented the resident was not steady and was only able to stabilize with staff assistance. The assessment documented the resident was always continent of bowel and bladder. The assessment documented the resident was at risk for falls and had a fall with a fracture in the past six months. The assessment documented the resident had a fall since admission. The assessment documented the resident had received occupational and physical therapy for two days. The assessment documented the resident was to receive restorative therapy for transfer and dressing. A nurse's note, dated 11/19/19 at 2:17 p.m., documented the resident was found outside under the gazebo on the ground. The note documented the resident reported she hit the right side of her head. The note documented neuro checks were initiated and no other were injuries noted. A nurse's note, dated 11/24/19 at 10:01 p.m., documented the resident was ambulating with a rolling walker, lost balance, and fell to the floor. The note documented no injuries were noted. A nurse's note, dated 12/02/19 at 3:12 p.m., documented the resident was found lying on her back in the courtyard. The note documented the resident complained of neck and left shoulder pain. The note documented the resident was sent to the emergency room via ambulance. The note later documented the resident had no fractures or injuries. A fall risk assessment, dated 01/01/20, documented the resident was a high fall risk. A significant change assessment, dated 01/01/20, documented the resident was moderately impaired with cognition and required limited assistance with activities of daily living. The assessment documented the resident had impairment to one side of upper extremity. The assessment documented the resident utilized a wheelchair for mobility. The assessment documented the resident was continent of bowel and bladder. The assessment documented the resident had two or more falls with injuries. The assessment documented the resident required hospice care. The assessment documented the resident required restorative therapy for transfers and dressing. A care plan, updated 01/03/20, documented the resident was at risk for falls related to weakness, unsteady balance, and gait. The care plan documented a goal for the resident was to be protected from falls. The care plan documented for the staff to assist with ambulation and transfers if needed. The care plan documented approaches for the staff to assure safety and take whatever measures necessary to ensure safety, for the resident's bed to be in low position at all times, encourage the resident to ask for assistance, keep the call light within reach, promote proper use of hand rolls, and hand grips in the bathroom. The care plan documented the resident required assist to go outside and to smoke due to history of falling in the courtyard. A nurse's note, dated 01/26/20 at 8:32 a.m., documented the resident was found sitting on the floor in her room between the bed and her wheelchair. The note documented the resident denied injuries and had no complaints. A nurse's note, dated 02/14/20 at 1:00 p.m., documented the resident was found sitting on the floor in front of her wheelchair. The note documented no injuries were noted. The clinical record contained no root cause analysis for the resident's falls or any new interventions to prevent further falls. On 02/19/20 at 5:07 p.m., the minimum data set (MDS) coordinator reported all care plans should have been updated and interventions implemented with each fall. 3. Resident #34 was admitted on [DATE] with diagnoses which included dementia, open wound to right ankle and right great toe, and below the knee amputation of left leg. An initial assessment, dated 04/17/19, documented the resident was cognitively intact and required extensive assistance with two-person assist with transfers. The assessment documented the resident was non-ambulatory and required a wheelchair for locomotion. The assessment documented the resident required one person assistance with dressing, toilet use, and personal hygiene. The assessment documented the resident required total assistance with bathing. The assessment documented the resident was incontinent of bowel and bladder. A care plan, dated 07/18/19, documented the resident was at risk for falls related to a left below knee amputation. The care plan documented for the staff to assist with ADLs. An assessment, dated 10/17/19, documented the resident was cognitively intact and required extensive assistance with one-person assist with both toileting and bathing. An incident report, dated 12/21/19 at 5:45 a.m., documented the resident had an unwitnessed fall while trying to get into her wheelchair. The report documented no major injuries. A progress note, dated 12/21/19, documented the resident was found lying on the floor. The note documented the resident reported she was transferring herself to the wheelchair and the wheels were not locked. An incident report, dated 01/01/20 at 5:13 a.m., documented the resident had an unwitnessed fall. The report documented the resident was found on the floor between her bed and her wheelchair. The report documented the resident had an abrasion to the back, below her left scapula, and an abrasion to her right lateral ankle. A progress note, dated 01/01/20, documented the resident was found on the floor between her bed and her wheelchair. The note documented the resident verbalized she fell during self transfer from her wheelchair to her bed. The note documented first aid was administered to the abrasions. A care plan, dated 01/14/20, documented the resident was at risk for falls due to a left below the knee amputation and needed assistance with ADLs. The care plan documented a goal for the resident was to be free of falls. The care plan documented approaches for the staff to assess and treat for postural/[CONDITION(S)], encourage to use call light with transfers, increase supervision, and provide toileting interventions based on needs. A physician's order, dated 01/19/20, documented the resident may have a slide board for transfer and a wheelchair for locomotion. An incident report, dated 01/22/20 at 7:35 p.m., documented the resident was found sitting on the floor between her bed and her wheelchair. The report documented the resident denied hitting her head and no injuries were noted. The report documented the resident complained of left hip pain but reported her hip had been hurting prior to the fall. The report documented the resident had surgery to her left hip in the past. The report documented the staff would monitor for increased pain or bruising. A care plan, revised 01/23/20, documented the resident was at risk for falls due to a left below the knee amputation and needed assistance with ADLs. The care plan documented the resident utilized a slide board for transfers. The care plan documented a goal for the resident was to be free of falls. The care plan documented no new interventions to prevent falls. The care plan did not document new interventions. On 02/19/20 at 8:34 a.m., the resident reported the facility was short-staffed and she performed transfers herself. The resident reported she did not have a slide board to be used for transfers. On 02/19/20 5:02 p.m., RN #1 reported the resident should have resident-specific interventions implemented after a fall as well as updated interventions in the care plans specifically for the resident. On 02/20/20 at 2:40 p.m., the DON reported the resident should have received assistance with transfers to prevent falls. 4. On 02/10/20 at 10:00 a.m., the facility staff reported the facility was without an administrator since 01/31/20. On 02/10/20 during the noon meal, residents were observed to have fried pies. The fried pies were wrapped in plastic and slid down into paper wrappers. The plastic was stuck to the fried pies and the paper wrappers were white in color with brown burned spots. Residents were observed to try to open the fried pies and could not because the plastic wrap was stuck to the fried pie. On 02/10/20 at 11:43 a.m., a staff member removed a fried pie from an unidentified resident's plate and replaced it with a fruit cup. On 02/10/20 at 12:01 p.m., licensed practical nurse (LPN) #1 was observed picking up the remaining fried pies. The LPN told the residents they would get a different desert. The LPN reported the fried pies were unsafe due to the plastic wrap stuck to the pies. On 02/11/20 at 9:25 a.m., the dietary manager (DM) reported she was not certified and was not scheduled to attend class to obtain her certification for dietary manager. On 02/11/20 at 9:30 a.m., cook #1 reported she had cooked the fried pies the previous day. The cook reported she had cooked them on one other occasion. The cook reported the fried pies were wrapped in plastic wrap, then put in the paper wrappers, and then had been cooked in the convection oven on both occasions. The cook reported she thought the paper wrappers were parchment paper. On 02/11/20 at 9:35 a.m., the DM reported the fried pies should have been unwrapped and place on the cookie sheet to heat. On 02/11/20 at 9:53 a.m., an interview was conducted with the dietary aid (DA), the DM, and the registered dietitian (RD). The DA reported on 02/10/20, she had warmed the fried pies in the oven at 140F. The DA reported she had heated fried pies one time previously. The DA reported she heated 36 pies on 02/10/20. The DA reported the fried pies were placed on flat pans and placed in the oven. The DA reported the plastic did not melt the last time she had heated them. The DA reported she did not check the fried pies prior to serving them on 02/10/20. The DA reported the fried pies should have been unwrapped and heated. The DA reported the fried pies should not have been heated in cellophane and paper. The DM was asked why the fried pies had stopped being served on 02/10/20. She reported the nursing staff alerted her the residents nor staff could remove the melted plastic from the fried pies. The DM reported she did not get approval from the RD for the food substitutions. On 02/11/20 at 10:23 a.m., the dietician reported the fried pies should have been taken out of the packaging before being placed in the oven. The dietician reported the paper wrappers did not look like parchment paper and could have started a fire in the oven. The dietician reported the cook would probably have cooked in the same manner if the situation had not been brought to her attention.

On 02/18/20 an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to provide the correct therapeutic diet as ordered by the physician. The facility failed to follow a menu for a resident on a mechanical soft diet. The wrong texture of diet was provided which resulted in a choking incident for the resident. A hospital transfer form for resident #94 documented the resident was to be transferred to another facility to be admitted to the intensive care unit for aspiration pneumonia and acute hypoxic respiratory failure. The facility continued to provide and serve incorrect diets to residents. On 02/18/20 at 6:10 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ situation in regard to the failure of the facility to provide the correct therapeutic diet. On 02/18/20 at 6:25 p.m., the chief operations manager was notified of the IJ situation. On 02/19/20 at 9:00 a.m., a plan of removal was accepted. The plan of removal documented: 1. All licensed Rn's and Lpn's will be in-serviced on verifying tray card to diet consistency before serving to a resident. 2. All dietary staff will be in-serviced on following diet orders and preparing tray as per tray card. 3. All Cna's, Cma's, and all other staff will be in-serviced on ensuring that the nurse has verified proper diet consistency as per tray card and that they understand diet consistency. 4. The dietician has been in-serviced to ensure dietary staff understand the diets and ensuring that all trays are verified by a licensed nurse prior to serving a resident. 5. All tray cards have been updated to prescribed diet order. 6. Tray cards will be audited weekly by the dietary manager and monthly by the dietician. 7. All staff will be in-serviced prior to the start of their shift and continuing until all staff have been in-serviced. Completed by 02/19/2020 at 0700. On 02/18/20 an in-service was provided by registered nurse (RN) #1. The topics for the in-service were ensuring proper diet consistency and verifying food tray with diet card, a licensed nurse must verify tray card with food tray prior to serving to the resident, all tray cards will be audited weekly by the dietary manager and monthly by the dietician. On 02/20/20 at 10:15 a.m., the immediate jeopardy was removed when all components of the plan or removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on observation, interview, and record review, it was determined the facility failed to prepare and serve food in a form designed to meet resident needs for three (#94, 36 and #31) of three residents reviewed for mechanically altered diets. The facility failed to serve the residents a mechanical soft diet as ordered by the physician. Resident #94 choked on partially cooked scalloped potatoes that were served to him. A hospital transfer form for resident #94 documented the resident was to be transferred to another facility to be admitted to the intensive care unit for aspiration pneumonia and acute hypoxic respiratory failure. The facility identified six residents who currently received a mechanically altered diet. Findings: 1. Resident #94 was admitted to the facility on [DATE] with diagnoses which included Down's syndrome, dementia, mood disorder, and congestive heart failure. A physician order, dated 01/31/20, documented for the resident to receive a mechanical soft diet with chopped meats. An admission assessment, dated 02/12/20, documented the resident was severely impaired with cognition and required set up with meals. The assessment documented the resident required a mechanically altered diet. The assessment documented the resident was edentulous. A care plan, dated 02/13/20, documented the resident required a mechanical soft diet with chopped meats and was at risk for choking/aspiration. The care plan documented for the staff to allow the resident extra time to eat and to provide the diet as ordered by the physician. The care plan documented the resident was edentulous and did not wear dentures. A facility menu for Mondays documented meatloaf, scalloped potatoes, buttered corn, roll, and marbled sour cream pound cake for the noon meal. A nurse's note, dated 02/17/20 at 2:10 p.m., documented, Was called to dining room, Resident appeared to be choking on food, 2 staff member stood resident up, while this nurse started [MEDICATION(S)] Maneuver, 5 abdominal thrusts completed, crash cart brought to dining room was able to suction parts of potatoes from resident mouth. Resident able to breath but some portions of food still lodge, EMS arrived during suctioning and transported resident to EMS. A hospital transfer form, dated 02/17/20, documented the resident was to be transferred to another facility to be admitted to the intensive care unit for aspiration pneumonia and acute hypoxic respiratory failure. On 02/18/20 at 2:45 p.m., resident #10 reported the scalloped potatoes served the previous day were raw and not done. On 02/18/20 at 2:50 p.m., resident #30 reported the scalloped potatoes served the previous day were not cooked. The resident reported the potatoes were hard. The resident reported they chopped up a raw potato and put it on our plates. On 02/18/20 at 2:54 p.m., resident #43 reported lunch the previous day consisted of meatloaf and slices of potatoes that were raw and had cheese on them. On 02/18/20 at 2:54 p.m., an unidentified resident at table spoke up and stated, Them potatoes were raw. On 02/18/20 at 3:00 p.m., the dietary manager (DM) reported she had received complaints from some of the residents the previous day. The DM reported the residents complained the scalloped potatoes had not been cooked long enough. The DM reported the potatoes were not tender. The DM reported for a mechanical soft diet the potatoes should have been cooked until tender and then chopped. The DM reported the residents with mechanical soft diet orders did not receive their diet as ordered when served the scalloped potatoes. 2. Resident #36 was admitted to the facility on [DATE]. A physician's order, dated 10/23/19, documented the resident was to receive a regular diet with ground meat. On 02/18/20 at 6:04 p.m., resident #36 received a hall tray. The resident's plate consisted of a regular hamburger patty, tater tots, and fixings. Registered nurse #1 was shown the plate. RN #1 read the diet card on the tray and stated, I need to take that, that's the wrong tray. The RN took the tray from the resident's room. 3. Resident #31 was admitted to the facility on [DATE]. A physician's order, dated 02/14/20, documented the resident was to receive a mechanical soft diet with chopped meats. On 02/18/20 at 4:42 p.m., resident #31 was observed in the dining room. The resident's plate of food consisted of ground hamburger meat, tater tots, and lettuce 1/2 inch wide by 1-2 inches in length. An extended menu for Tuesday evening meals, documented, Finely chopped lettuce. On 02/18/20 at 4:43 p.m., the DM was asked if the lettuce was considered finely chopped. The DM stated, No. The DM reported the lettuce should have been finely chopped. The DM was shown the lettuce on resident #31's plate and asked if she would consider the lettuce finely chopped. The DM reported no ma'am.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean, comfortable, and homelike on two (East and South Hall) of three halls and two (Dining Room and the Lobby) of two common areas. The facility identified 43 residents who lived at the facility. Findings: On 02/10/20 at 10:00 a.m., residents were observed sitting in the lobby. Furniture was observed in the lobby. A strong urine odor was noted in the lobby area and on the South Hall. On 02/10/20 at 2:00 p.m., the furniture had been removed from the lobby and there was no where for the residents to sit in the lobby. On 02/10/20 at 4:44 p.m., the East Hall shower room had broken floor tiles in the shower, the shower had no cover over the drain, and there was no handle to turn the shower off/on. On 02/10/20 at 5:18 p.m., water soaked blankets were laying on the floor in the southeast corner of the dining room. The maintenance supervisor reported the southeast corner of the dining room had been leaking on and off for the past year. The maintenance supervisor reported the facility was in the process of getting a loan to repair the roof. On 02/10/20 at 5:28 p.m., certified medication aide #1 stated, Every time it rains it just pours in all the way across to other side. The CMA was referring to the dining room. On 02/11/20 at 8:05 a.m., furniture was not in the lobby and was observed beside a dumpster outside of the facility. No furniture was present in the lobby for the residents to sit on. On 02/12/20 at 8:13 a.m., a trash can was located in the South and East Hall doorways to catch the water leaking from the ceiling. On 02/12/20 at 8:21 a.m., a trash can was located in front of nurse's desk to catch the water leaking from the ceiling. On 02/19/20 at 9:35 a.m., two broken and discolored ceiling tiles were observed in the dining room. On 02/20/20 at 8:00 a.m., the operation manager reported he had sat down on the furniture on Monday 02/10/20 and noted a strong odor of urine. The operation manager reported he had the furniture removed from the facility and brought new furniture to the facility on Monday 02/17/20.

Based on observation, interview, and record review, it was determined the facility failed to employ sufficient staff with appropriate competencies to ensure dietary services met the needs and nourishment for 43 residents who received meals from the dietary department. The facility reported 43 residents received meals from the dietary department. Findings: On 02/10/20 at 10:10 a.m., a brief tour of the dietary department was conducted. Throughout the tour dietary staff were observed to contaminate plates, utensils, and food by not washing hands. On 02/11/20 at 8:45 a.m., dietary aide (DA) #1 was asked to test the chemical dishwasher. The DA reported he had not been trained to test the chemicals for the dishwasher. The DA reported he had been employed for one month. The dietary manager (DM) was asked if the DA had been trained to test the chemicals in the dishwasher. The DM reported the DA had not been trained. On 02/11/20 at 9:25 a.m., the dietary manager reported she did not have a certification. The dietary manager reported she had not been scheduled for training to become a certified dietary manager. At 11:50 a.m., the DM was observed retrieving a bag of bread, opened the bread, and placed four slices of bread on a stainless steel tray. The DM made two peanut butter sandwiches, moved a plastic basket from the prep table to another location, then retrieved plates and lids for the plates to continue hall tray preparation. The DM placed the sandwiches on the plates, covered them and placed them on the hall tray cart. No handwashing or glove change was observed. At 11:57 a.m., the DM returned to the kitchen and told the DA to stop serving the fried pies. She went into the pantry, retrieved a large can of fruit cocktail, opened the can using a manual crank can opener, retrieved a large bowl and a strainer, placed the strainer inside the large bowl, and poured the contents of the can into the strainer. She retrieved serving bowls from the clean dish shelf with fingers inside the bowls, and placed them on the prep table. She began scooping fruit cocktail into the serving bowls. Serving bowls were covered with cling wrap. No handwashing or glove change was observed. At 12:00 p.m., the DA was observed retrieving seven pieces of silverware by the eating surface, wrapped them in a paper napkin, and placed them on the hall tray cart. No handwashing or glove change was observed prior to touching the silverware. The menu for 02/10/20 was reviewed for the lunch meal. The menu documented BBQ chicken, potato salad, zucchini/tomatoes, roll, brownie, beverage, and 2% milk. The DM was interviewed regarding food items that were substituted and the omission of the roll. The DM reported the substitution sheet was in her office. The DM reported the omission of the roll was an oversight. The DM reported the fried pies were donated from the community and were served to the residents as a treat. The DM produced a blank meal substitution sheet. She had not documented food item substitutions. Three freezers in the DM office were observed to contain seven boxes of fried pies in various flavors. The frozen, individual serving sized pies were observed to be wrapped in cellophane in a thin, white, bakery-style paper sack with the pie company logo printed on the paper sack. The evening meal menu for 02/10/20 documented baked potato soup, ham salad sandwich, lettuce, tomato slices, fresh fruit cup, beverage, and 2% milk. At 4:45 p.m., three special request plates were observed on the prep table uncovered. The evening meal consisted of a bowl of baked potato soup, a ham salad sandwich and a bowl of canned fruit cocktail. The lettuce and tomato slices were omitted. The DM was observed preparing plates and passing them to dietary aid (#2) at the door to be served to residents. All plates were observed to be prepared with the same food items. The DM was observed retrieving ketchup packets from a plastic bin, then continued to place sandwiches on plates. No handwashing or glove change was observed. The DM was observed to retrieve serving bowls for fruit cocktail, three at a time, by reaching into the mouth of the bowls with fingers. The DM was observed retrieving packages of crackers from the stainless steel bowl from the shelf above a rat trap. The DM continued to handle sandwiches and serve the meal without washing hands or changing gloves. On 02/11/20 at 9:53 a.m., an interview was conducted with the dietary aid (DA), the DM, and the registered dietitian (RD). The DA reported on 02/10/20, she had warmed the fried pies in the oven at 140F. The DA reported she had heated fried pies one time previously. The DA reported she heated 36 pies on 02/10/20. The DA reported the fried pies were placed on flat pans and placed in the oven. The DA reported the plastic did not melt the last time she had heated them. The DA reported she did not check the fried pies prior to serving them on 02/10/20. The DA reported the fried pies should have been unwrapped and heated. The DA reported the fried pies should not have been heated in cellophane and paper. The DM was asked why the fried pies had stopped being served on 02/10/20. She reported the nursing staff alerted her the residents nor staff could remove the melted plastic from the fried pies. The DM reported she did not get approval from the RD for the food substitutions.

Based on observation, interview, and record review, it was determined the facility failed to ensure the dietary department stored, prepared, and distributed food under sanitary conditions. The facility reported 43 residents received meals from the dietary department. Findings: On 02/10/20 at 9:15 a.m., an initial tour of the kitchen was conducted. Contents of the refrigerator were observed to be opened and undated included a carton of Easy Eggs, a pint carton of chicken salad, a pint of deviled egg potato salad, a bag of unsealed bacon, and a zip-locked bag of lettuce. A toaster on a rolling utility cart was noted to have grease and crumbs along the top. A toaster on the countertop was noted to have crumbs along the top. An electric fryer was observed to be coated with grease and was full of dark colored oil and food particles. The microwave was splattered with debris inside the door and on the inside walls. Shelves that contained clean dishes were observed to be splattered with debris. The fire extinguishers were covered in dust and grease. A wire shelving unit by the entry door was observed to be coated with dust and debris. A crumpled dried wash cloth was observed on a rack next to various containers of spices. A stainless steel bowl containing packages of crackers was observed on the bottom shelf. A rat trap was observed on the floor under the bowl of crackers. The dry goods pantry was observed to have three dirty blankets on the floor under the wire shelving units. The DM reported there had been a leak in the laundry room and water had gotten into the dry goods pantry. Crushed cereal, napkins, sugar packets, and a fly swatter were observed scattered on the floor. Dirt, debris, and spider webs were observed under and behind the wire shelving units. A rat trap was observed under a wire shelving unit. A box of Cream of Wheat cereal, a 5 pound box of cornbread mix, and a carton of whipped potatoes were observed opened and undated. A cereal tote was opened. A second cereal tote was observed without a lid. A cake batter bin was observed to be covered with thick dust/debris. Multiple canned goods were observed with thick dust on the top. The flour and sugar totes were observed to have thick dust/debris and were not latched. Six plastic cereal containers were observed to have debris and were sticky. A stiff dusty bag of an unidentified substance was observed on the shelf beside a box of coffee packets. The DM removed the bag and stated, I don't know what this is, but it's growing. The wire shelving units were observed to be coated with dust. The stove was observed to be caked with dark grease. A pool of grease was observed to the right of the grill and contained food particles. The vent hood above the stove was observed to be caked with grease with multiple dried dark grease drips over the cooking surface. A wadded up greasy towel was observed in the floor, partially under and behind the stove. The fire safety apparatus along the front of the vent hood was observed to be caked with grease and dust. The mat in front of the stove was observed to have black debris caked inside the ventilation holes. The floor was observed to be dirty along the walls, the cabinets, under the prep table, under the wire shelving units, behind the stove, and along the refrigerators. On 02/11/20 at 10:23 a.m., the dietician reported she had been to the facility on [DATE]. The dietician reported she had concerns regarding the cleanliness in the dietary department on multiple occasions. The dietician reported for the past six or seven months the sanitation of the dietary department had not been up to standards. The dietician reported she had called the previous administrator about her findings in the dietary department.

Based on observation, interview, and record review, it was determined the facility failed to ensure the facility was effectively managed in a manner to: ~ prevent Immediate Jeopardy Situations and substandard quality of care deficiencies; ~ ensure there was sufficient nursing staff to provide supervision and care to residents to promote their highest practicable well being; ~ ensure there was competent dietary staff to safely prepare and serve food and ensure sanitary conditions were maintained in the kitchen; and ~ ensure the resident environment was clean and well maintained for 43 of 43 residents who lived at the facility. Findings:. On 02/10/20 at 10:00 a.m., a corporate nurse reported the facility had been without an administrator since 01/31/20. On 02/10/20 at 5:18 p.m., water soaked blankets were laying on the floor in the southeast corner of the dining room. The maintenance supervisor reported the southeast corner of the dining room had been leaking on and off for the past year. The maintenance supervisor reported the facility was in the process of getting a loan to repair the roof. On 02/11/20 at 9:25 a.m., the dietary manager reported she did not have a certification. The dietary manager reported she had not been scheduled for training to become a certified dietary manager. On 02/11/20 at 10:23 a.m., the dietician reported she had been to the facility on [DATE]. The dietician reported she had concerns regarding the cleanliness in the dietary department on multiple occasions. The dietician reported for the past six or seven months the sanitation of the dietary department had not been up to standards. The dietician reported she had called the previous administrator about her findings in the dietary department. An Oklahoma State Department of Health Notice of Change form documented the facility's prior administrator's effective date of departure was 01/31/20 and a new administrator's date of hire was 02/11/20. 1. On 02/19/20 an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent falls. The facility failed to provide supervision to prevent multiple falls for resident #41. Resident #41 sustained a [CONDITION(S)] and a fractured humerus. The facility failed to: A. Provide supervision to prevent falls for three (#41, #28 and #34) of three residents reviewed for falls. The facility failed to provide a root cause analysis for falls, update care plans, and implement interventions to prevent further falls. Resident #41 experienced multiple falls and sustained a [CONDITION(S)] and a fractured humerus. The facility identified 25 residents who were at high risk for falls. B. Provide supervision to ensure foods were safely prepared and served for 43 of 43 residents who lived at the facility. The findings at F689 are incorporated here by reference. 2. On 02/18/20 an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to provide the correct therapeutic diet as ordered by the physician. The facility failed to follow a menu for a resident on a mechanical soft diet. The wrong texture of diet was provided which resulted in a choking incident for the resident. A hospital transfer form for resident #94 documented the resident was to be transferred to another facility to be admitted to the intensive care unit for aspiration pneumonia and acute hypoxic respiratory failure. The facility failed to prepare and serve food in a form designed to meet resident needs for three (#94, 36 and #31) of three residents reviewed for mechanically altered diets. The facility failed to serve the residents a mechanical soft diet as ordered by the physician. Resident #94 choked on partially cooked scalloped potatoes that were served to him. A hospital transfer form for resident #94 documented the resident was to be transferred to another facility to be admitted to the intensive care unit for aspiration pneumonia and acute hypoxic respiratory failure. The facility identified six residents who currently received a mechanically altered diet. The findings at F805 are incorporated here by reference. 3. The facility failed to employ sufficient staff with appropriate competencies to ensure dietary services met the needs and nourishment for 43 residents who received meals from the dietary department. The facility reported 43 residents received meals from the dietary department. The findings at F801 are incorporated here by reference. 4. The facility failed to provide sufficient nursing staff to provide supervision to prevent falls, restorative care, assistance with showers and/or personal care for 8 (#2, #10, #12, #21, #25, #34, #37, and #43) of 32 sampled residents. The facility reported 43 residents lived at the facility. The findings at F725 are incorporated here by reference. 5. The facility failed to ensure the environment was clean, comfortable, and homelike on two (East and South Hall) of three halls and two (Dining Room and the Lobby) of two common areas. The facility identified 43 residents who lived at the facility. The findings at F584 are incorporated here by reference. 6. The facility failed to ensure the dietary department stored, prepared, and distributed food under sanitary conditions. The facility reported 43 residents received meals from the dietary department. The findings at F812 are incorporated here by reference.

Based on observation, interview, and record review, it was determined the governing body failed to oversee the facility and failed to appoint an administrator who was responsible to ensure the facility was effectively managed in a manner to: ~ prevent Immediate Jeopardy Situations and substandard quality of care deficiencies; ~ ensure there was sufficient nursing staff to provide supervision and care to residents to promote their highest practicable well being; ~ ensure there was competent dietary staff to safely prepare and serve food and ensure sanitary conditions were maintained in the kitchen; and ~ ensure the resident environment was clean and well maintained for 43 of 43 residents who lived at the facility. Findings:. On 02/10/20 at 10:00 a.m., a corporate nurse reported the facility had been without an administrator since 01/31/20. On 02/10/20 at 5:18 p.m., water soaked blankets were laying on the floor in the southeast corner of the dining room. The maintenance supervisor reported the southeast corner of the dining room had been leaking on and off for the past year. The maintenance supervisor reported the facility was in the process of getting a loan to repair the roof. On 02/11/20 at 9:25 a.m., the dietary manager reported she did not have a certification. The dietary manager reported she had not been scheduled for training to become a certified dietary manager. On 02/11/20 at 10:23 a.m., the dietician reported she had been to the facility on [DATE]. The dietician reported she had concerns regarding the cleanliness in the dietary department on multiple occasions. The dietician reported for the past six or seven months the sanitation of the dietary department had not been up to standards. The dietician reported she had called the previous administrator about her findings in the dietary department. An Oklahoma State Department of Health Notice of Change form documented the facility's prior administrator's effective date of departure was 01/31/20, and a new administrator's date of hire was 02/11/20. 1. On 02/19/20 an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent falls. The facility failed to provide supervision to prevent multiple falls for resident #41. Resident #41 sustained a [CONDITION(S)] and a fractured humerus. The facility failed to: A. Provide supervision to prevent falls for three (#41, #28 and #34) of three residents reviewed for falls. The facility failed to provide a root cause analysis for falls, update care plans, and implement interventions to prevent further falls. Resident #41 experienced multiple falls and sustained a [CONDITION(S)] and a fractured humerus. The facility identified 25 residents who were at high risk for falls. B. Provide supervision to ensure foods were safely prepared and served for 43 of 43 residents who lived at the facility. The findings at F689 are incorporated here by reference. 2. On 02/18/20 an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to provide the correct therapeutic diet as ordered by the physician. The facility failed to follow a menu for a resident on a mechanical soft diet. The wrong texture of diet was provided which resulted in a choking incident for the resident. A hospital transfer form for resident #94 documented the resident was to be transferred to another facility to be admitted to the intensive care unit for aspiration pneumonia and acute hypoxic respiratory failure. The facility failed to prepare and serve food in a form designed to meet resident needs for three (#94, 36 and #31) of three residents reviewed for mechanically altered diets. The facility failed to serve the residents a mechanical soft diet as ordered by the physician. Resident #94 choked on partially cooked scalloped potatoes that were served to him. A hospital transfer form for resident #94 documented the resident was to be transferred to another facility to be admitted to the intensive care unit for aspiration pneumonia and acute hypoxic respiratory failure. The facility identified six residents who currently received a mechanically altered diet. The findings at F805 are incorporated here by reference. 3. The facility failed to employ sufficient staff with appropriate competencies to ensure dietary services met the needs and nourishment for 43 residents who received meals from the dietary department. The facility reported 43 residents received meals from the dietary department. The findings at F801 are incorporated here by reference. 4. The facility failed to provide sufficient nursing staff to provide supervision to prevent falls, restorative care, assistance with showers and/or personal care for 8 (#2, #10, #12, #21, #25, #34, #37, and #43) of 32 sampled residents. The facility reported 43 residents lived at the facility. The findings at F725 are incorporated here by reference. 5. The facility failed to ensure the environment was clean, comfortable, and homelike on two (East and South Hall) of three halls and two (Dining Room and the Lobby) of two common areas. The facility identified 43 residents who lived at the facility. The findings at F584 are incorporated here by reference. 6. The facility failed to ensure the dietary department stored, prepared, and distributed food under sanitary conditions. The facility reported 43 residents received meals from the dietary department. The findings at F812 are incorporated here by reference.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent [MEDICAL CONDITION] two (#2 and #4) of four residents reviewed for accidents. The facility reported two residents had [MEDICAL CONDITION] to hot packs. The facility reported 39 residents lived in the facility. Resident #4 had received burns/blisters to his buttocks when a hot pack was applied. Resident #2 had received burns/blisters to her abdomen when a hot pack was applied. Findings: The facility reported there was no policy for preparation of hot packs for residents. 1. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/29/19, documented the resident was cognitively intact. The assessment documented the resident required extensive to total assistance with activities of daily living (ADLs). The assessment documented no presence [MEDICAL CONDITION] blisters. A care plan, dated 06/30/19, documented the resident was treated for [REDACTED]. The care plan documented the resident required restorative care with range of motion. The care plan documented the resident required extensive assistance with most ADLs. An event report, dated 06/30/19 at 3:57 p.m., documented a fluid-filled blister to the abdomen which measured 10 centimeters (cm) x 11.5 cm. A progress note, dated 06/30/19 at 5:05 p.m., documented the resident had yellow, fluid-filled blisters to the abdomen. The progress note documented the physician was notified and orders were received to apply skin prep to the blistered area twice a day (BID). A progress note, dated 07/12/19 at 3:31 p.m., documented a physician order [REDACTED]. A wound evaluation and management summary, dated 07/17/19, documented a burn/blister to the abdomen occurred from a hot compress. The form documented the wound measured 14.5 cm x 12.5 cm x 0.1 cm and the treatment plan would be to apply [MEDICATION NAME] three times a day for 30 days. The form documented surgical excisional debridement was performed to remove necrotic tissue and establish the margins of viable tissue. On 07/22/19 at 9:20 a.m., resident #2 reported she had received a burn to her abdomen related to a hot pack. The resident reported a hot, wet towel had been placed in a plastic bag and heated in the microwave and then placed inside a pillowcase. The resident reported certified nurse aide (CNA) #1 applied the hot pack to her left shoulder at the resident's request due to shoulder pain. The resident reported the hot pack must have slipped down to her abdomen after she fell asleep and caused the burn/blister. On 07/22/19 at 10:40 a.m., the administrator (ADM) reported the burn incident occurred on 06/30/19. She stated she reviewed the event report on 07/01/19, but was not made aware of how the incident happened until 07/05/19. The ADM reported an in-service had been completed for all staff. The ADM reported staff were instructed to no longer use hot packs. The ADM reported it had been common practice to use hot packs at the resident's request without a physician's orders [REDACTED].>On 07/22/19 at 11:34 a.m., the ADM reported the CNA who had applied the hot pack should have been counseled but this had not been done. On 07/22/19 at 2:35 p.m., CNA #2 reported she did not attend the in-service on 07/05/19. The CNA reported another aide informed her they would no longer use hot packs but she had not been formally in-serviced. On 07/22/19 at 3:08 p.m., CNA #3 reported he did not attend the in-service on 07/05/19. The CNA reported he had returned to work on 07/08/19 but had not been in-serviced regarding hot packs until that day, 07/22/19. On 07/22/19 at 3:41 p.m., CNA #4 reported she had worked at the facility less than one month. The CNA reported she had not received instruction regarding the use of hot packs. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A progress note, dated 05/25/19 at 6:16 p.m., documented the resident was noted to have two reddened blistered areas on the right buttocks. The note documented the physician was notified. An event report, dated 05/25/19 at 6:39 p.m., documented a blistered area to the inferior right buttocks of 3.5 centimeters (cm) x 3.7 cm. The report documented a blistered area to the superior right buttocks of 3.5 cm x 3.7 cm as well. A progress note, dated 05/25/19 at 7:31 p.m., documented a physician order [REDACTED]. A physician order, dated 05/25/19, documented for the staff to monitor the right superior and inferior buttocks for signs or symptoms of infection related to blisters every shift. A progress note, dated 05/26/19 at 12:38 p.m., documented the resident was to be seen by VOHRA wound care for sores to buttocks. A progress note, dated 05/28/19 at 1:52 p.m., documented, Blisters to right buttocks from previous heating pad. Awaiting rx [MEDICATION NAME] to be delivered, applied hydraguard this shift. A wound evaluation and management summary, dated 05/29/19, documented the resident was treated for [REDACTED]. The summary documented the wound measured 5 cm x 6 cm. An annual assessment, dated 06/24/19, documented the resident was cognitively intact. The assessment documented the resident was independent with most ADLs. The assessment documented the resident had experienced a 2nd or 3rd degree burn. A care plan, dated 06/25/19, documented the resident required assistance of trapeze with bed mobility and transfers. The care plan documented the resident required assistance with ADLs related to [MEDICAL CONDITION]. The care plan documented the resident was at risk for skin breakdown due to limited mobility. The care plan did not address the use of hot packs or [MEDICAL CONDITION]/or blisters. Progress notes, as well as wound evaluation and management summaries, were reviewed and documented treatment to the right buttock, related to burns, continued through (MONTH) and (MONTH) 2019. A progress note, dated 07/10/19 at 5:49 p.m., documented new orders were received from the physician to change the treatment to the resident's right buttocks to skin prep. On 07/22/19 at 3:00 p.m., CNA #5 reported she knew of two residents who would occasionally request hot packs, residents #2 and #4. The CNA reported resident #2 would instruct the CNA regarding how long to leave the wet towel in the microwave. The CNA reported resident #4 had sustained blisters from a hot pack about a month ago. The CNA reported an in-service had been conducted and staff would no longer be allowed to give hot packs to residents because it had been determined to be unsafe. On 07/22/19 at 3:45 p.m., resident #4 reported he had [MEDICAL CONDITION] his lower back and buttocks a couple of months previous. The resident reported an aide, who no longer worked at the facility, had placed a hot pack to his back when he complained of pain to his lower back. The resident reported he thought the hot pack was made with a moistened towel which had been microwaved in a plastic bag. The resident reported the bag was initially wrapped in a towel but had slipped out of the towel and caused blisters to his buttocks. The resident reported he didn't know he had blisters until the same evening when staff assisted him with a shower. The resident reported the charge nurse looked at his back/buttocks that evening and the director of nursing (DON) saw the blisters the following day. The resident reported he thought the aide was careless when she applied the hot pack and didn't notice the bag had slipped out of the towel. The resident reported staff continued to use hot packs for a couple of weeks after he was blistered but did not make them as hot. On 07/22/19 at 4:45 p.m., the DON was interviewed regarding the incident in (MONTH) in which the resident was burned. The DON reported she couldn't remember if it was her or another staff member that witnessed the resident's burns/blisters. The DON was asked if the facility had a policy or procedure for the use of hot packs. The DON reported she was not aware of a policy.

Based on observation, record review, and interview, it was determined the facility failed to ensure two (#28 and #91) of four residents reviewed received treatment and services necessary to promote healing and prevent infection of pressure ulcers and/or prevent new pressure ulcers. The facility failed to: a) Notify the resident physician of wound changes and/or development of a new pressure ulcer for resident #28 and resident #91. b) Obtain treatment orders for a new pressure ulcer from the physician for resident #28. c) Implement measures to prevent and/or promote healing of pressure ulcers for resident #28 and resident #91. Resident #28 experienced worsening of existing pressure ulcers, development of new pressure ulcers, and pressure ulcer infections. A hospital discharge summary for resident #91, dated 03/16/18, documented the resident's admitting [DIAGNOSES REDACTED]. The discharge summary documented active problems which included an unstageable pressure ulcer of sacral region and osteo[DIAGNOSES REDACTED] of sacrum. The hospital course section of the discharge summary documented the resident was admitted to the hospital after being seen in wound care with an unstageable, large, deep wound on her sacrum. The discharge summary documented she was taken directly to surgery for [REDACTED]. The summary documented a rectal tube was inserted, she had a Foley (urinary) catheter to protect the wound, and a wound vac was in place. The summary documented Proteus mirabilis, E. Coli, and [MEDICATION NAME] were growing from her wound and were found in her urine. The resident census and conditions of residents form documented four residents had pressure ulcers. Findings: A facility policy titled pressure sores, dated (MONTH) 2005, documented, .GUIDELINES: All residents will be evaluated utilizing the Preventive Guidelines for Residents at Risk for Pressure Sores, Skin Integrity Monitoring Guidelines, Skin Integrity Management of Pressure Sores, and the Treatment Guidelines for Pressure Sores .A care plan will be developed that specifies the interventions that will be taken for all pressure sores. The pressure sore will be evaluated according to the Skin System guidelines .GUIDELINES: .Pressure reducing mattresses may be used .Turn the resident at least every two hours .TREATMENT: treatment of [REDACTED]. The nurse is responsible for implementing measures to prevent pressure sores .D[NAME]UMENTATION .Date, time. Preventive measures used. Condition of the residents skin. Physician notification, if appropriate. Preventive equipment used. If pressure sore is present, the licensed nurse is responsible to record condition of the skin, including stage, size, site, depth, color, drainage and odor as well as the treatment provided. Notification of the physician is required when a new pressure sore is identified as well as when treatment is not effective. 1. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 08/18/17, documented the resident was severely impaired with cognition, required total assistance of one staff member for hygiene and bathing. The assessment documented the resident required extensive assistance of one staff member for bed mobility, transfer, dressing, and eating. The assessment documented the resident was always incontinent of bowel and bladder. The assessment documented the resident was at risk for developing a pressure ulcer. The assessment documented the resident required a pressure reducing device for her bed. A nurse's note, dated 01/12/18 at 1:25 p.m., documented, Shear to right buttock resolved, Upon assessment Stage II pressure ulcer noted to coccyx, measures 1.5 cm x 0.4 x < 0.2, physician and family notified, new order received, TAR updated. A physician's orders [REDACTED].Special Instructions: Apply to Stage II pressure ulcer on coccyx q shift until resolved. A quarterly assessment, dated 02/13/18, documented the resident was severely impaired with cognition, required total assistance of one staff member for hygiene and bathing. The assessment documented the resident required extensive assistance of one staff member for bed mobility, transfer, dressing, and eating. The assessment documented the resident was always incontinent of bowel and bladder. The assessment documented the resident was at risk for developing a pressure ulcer. The assessment documented the resident had one stage two pressure ulcer. The assessment documented the resident required a pressure reducing device for her bed. A care plan, dated 02/14/18, documented the resident had potential for altered skin integrity from pressure, incontinence and/or skin tears; needed assist with bed mobility to make significant changes in position; experienced multiple incontinent episodes daily; required staff assist with toileting and personal hygiene; and had fragile skin that tore and bruised easily. The care plan, dated 02/14/18, documented a goal for the resident was to have no altered skin integrity from pressure, incontinence, or skin tears through next target date. The care plan, dated 02/14/18, documented the following approaches: Encourage 75-100% of diet; encourage fluid intake; exercise caution during transfers and handling; keep clean and dry at all times; monitor for discoloration, bruises, swelling, skin tears, and redness, and report red areas promptly; and turn and reposition every two hours or more often if necessary to maintain adequate circulation to all pressure points. A wound management form, dated 02/22/18 at 11:05 a.m., documented a coccyx pressure ulcer size of 0.4 x 0.3 x 0.1 cm. A nurse's note, dated 02/23/18 at 6:05 a.m., documented, Additional pressure sore developed on right buttock, stage II, cleansed with nss (normal saline solution), applied venelex. Resident tolerated well. The clinical record contained no additional information pertaining to the newly developed pressure ulcer. The clinical record contained no documentation the physician was notified of the second pressure ulcer or to obtain new wound treatment orders. A nurse's note, dated 02/28/18 at 2:17 p.m., documented, .Stage II pressure ulcer to right buttock resolved . A wound management form, dated 02/28/18 at 2:17 p.m., documented the coccyx pressure ulcer size was 0.8 x 0.3 x 0.2 cm. The clinical record contained no documentation the physician had been notified of the pressure ulcer change. The clinical record contained no documentation of a change in intervention. A wound management form, dated 03/02/18 at 4:22 a.m., documented the pressure ulcer to the right mid upper buttock measured 2 x 1.25 cm. A nurse's note, dated 03/02/18 at 4:27 a.m., documented, Additional pressure sore noted to R mid upper buttock. n/o (new order) apply venelex bid. A physician's orders [REDACTED]. A wound management form, dated 03/02/18 at 2:25 p.m., documented the coccyx pressure ulcer size was 1.2 x 0.8 x 0.2 cm. The clinical record contained no documentation the physician had been notified of the pressure ulcer change. An updated care plan, dated 03/05/18, documented the resident had an unstageable pressure ulcer to the sacrum, coccyx, and upper right upper buttock. A goal was for the resident's pressure ulcer to heal without complications. The care plan, dated 03/05/18, documented the following approaches: administer antibiotics if ordered, place an air mattress on her bed to reduce pressure, provide nutritional supplements as ordered to promote pressure ulcer healing, keep clean and dry as possible, keep resident off affected area, provide incontinence care after each incontinent episode, and report signs of [MEDICAL CONDITION] (localized pain, redness, swelling, tenderness, drainage, fever);[MEDICAL CONDITION] (fever, malaise, change in mental status, [MEDICAL CONDITIONS], N/V). A wound management form, dated 03/09/18 at 12:24 p.m., documented the coccyx pressure ulcer measured 1.5 x 1.5 x 0.2 cm. The clinical record contained no documentation the physician had been notified of the pressure ulcer change. A wound management form, dated 03/11/18 at 4:12 a.m., documented the coccyx pressure ulcer measured 2 x 1.5 x 0.3 cm. The clinical record contained no documentation the physician had been notified of the pressure ulcer change. A nurse's note, dated 03/15/18 at 4:28 p.m., documented, Pressure ulcers remain to right buttock and coccyx, decline noted to wound to coccyx, primary care provider (name deleted) notified, new treatment orders received and new order for air mattress, TAR updated, see wound management. A wound management form, dated 03/15/18 at 4:29 p.m., documented the pressure ulcer to right upper buttock measured 2 x 1.5 x 0.1 cm. A wound management form, dated 03/15/18 at 4:30 p.m., documented the coccyx pressure ulcer measured 2 x 1.5 cm x unstageable. A physician's orders [REDACTED].Santyl ([MEDICATION NAME] ,[MEDICAL CONDITION]. isto.) ointment; 250 unit/gram .Special instructions: Cleanse pressure ulcer to right buttock with NS (normal saline), pat dry, apply Santyl, cover with foam pad, and secure with tape daily until resolved. A physician's orders [REDACTED].Santyl ([MEDICATION NAME] ,[MEDICAL CONDITION]. isto.) ointment; 250 unit/gram .Special instructions: Cleanse unstageable pressure ulcer to coccyx with NS (normal saline), pat dry, apply Santyl, cover with foam pad, and secure with tape daily until resolved. A physician's orders [REDACTED]. A nurse's note, dated 03/16/18 at 4:54 a.m., documented, Resident has reddened buttock that is beginning to excoriate. There is small stg (stage) II above her coccyx that has yellow drainage coming from it. Will notify day shift to call for new orders for treatment as there is no eschar or slough present at this time. The clinical record contained no documentation the physician had been notified of the yellow drainage in the pressure ulcer to the coccyx. A nurse's note, dated 03/18/18 at 5:21 a.m., documented, Significant Change to wound to buttock. Wound to coccyx is now 2.5 x 2.0 x 0.3 with raised edges and induration noted at 10 O'clock to 12 O'clock position. Wound is wet with brown/yellow exudate and some biofilm. Wound to R buttock is now 2.0 x 1.5 x 0.2 with raised edges, wound is also wet with brown/yellow exudate and some biofilm and there is [DIAGNOSES REDACTED] surrounding the wound > 4cm. There is also a rectangular lesion on right hip measuring 2.5 x 4.5. There is also a stage 1 to lumbar back on left side measuring 1.8 x 0.8. Awaiting call back from health care management company (name deleted) for new orders. Resident expresses minimal pain when touched around area of induration. The clinical record contained no documentation of a follow up to the above nurse's note. The clinical record contained no new orders. A nurse's note, dated 03/23/18 at 4:50 a.m., documented, Dressing change due to soiled and dislodged. Pressure Ulcer to coccyx is declining with eschar and slough over the entire wound. There is SDTI (suspected deep tissue injury) at the deepest part of the wound bed. Ulcer to R buttock continues to decline as well with continued eschar and slough. Tx provided per orders. Resident is now having moderate pain with dressing changes. A wound management form, dated 03/23/18 at 11:28 a.m., documented the coccyx pressure ulcer measured 6.5 x 3.5 cm x unstageable. A nurse's note, dated 03/23/18 at 11:35 a.m., documented, Pressure ulcer to coccyx remains, pressure ulcer to right buttock has merged with pressure ulcer to coccyx, foul odor noted to wound, see wound management. PCP from (name deleted) health care management company notified of odor and wound decline, new order received for [MEDICATION NAME] 100 mg BID for 7 days, MAR updated, faxed to pharmacy. Stage I to lower back lumbar resolved. A physician's orders [REDACTED].ointment; 250 unit/gram .Special Instructions: Cleanse unstageable pressure ulcer to coccyx/right buttock with NS, pat dry, apply Santyl, cover with foam pad, secure with tape daily until resolved .[MEDICATION NAME] ([MEDICATION NAME]) 100 mg .(DX: Local infection of the skin and subcutaneous tissue, unspecified) . On 03/26/18 at 9:10 a.m., the resident was observed lying in bed on her back. The resident would open her eyes when spoken to and stared into space with no verbal response. On 03/26/18 at 10:20 a.m., the resident was observed lying in bed on her back. On 03/26/18 at 11:35 a.m., the resident was observed lying in bed on her back. On 03/26/18 at 5:14 p.m., the resident was observed sitting up in her Broda chair in the dining room being assisted with the evening meal. On 03/27/18 at 7:45 a.m., the resident was observed sitting up in her Broda chair in the dining room being assisted with her breakfast. On 03/27/18 at 8:55 a.m., the resident was not in her room. The staff reported the resident was being assisted with her shower. On 03/27/18 at 10:17 a.m., wound care was observed to be provided to the resident by RN #1. The coccyx wound bed was observed to have eschar and slough. The nurse was observed to clean the wound with NS, pat dry, apply Santyl and triple helix collagen powder mixture to the wound as ordered. On 03/27/18 at 3:13 p.m., the resident was observed lying in her bed on her right side. There was no air mattress observed. The resident was observed to be lying on a concave mattress. On 03/27/18 at 4:55 p.m., the resident was observed lying in her bed on her right side. On 03/27/18 at 5:20 p.m., the resident was observed lying in her bed on her right side, same as above. On 03/27/18 at 5:30 p.m., the resident was observed lying in her bed on her right side, same as above. At that time, RN #3 was told the resident had been in the same position for over two hours. The RN was asked how often the resident's position should have been changed. The RN reported usually every two hours or more as needed. The RN was asked if she expected the resident to have had a position change. She stated, Yes. On 03/27/18 at 5:32 p.m., an unidentified CNA was asked how many CNAs were working. The CNA reported two. The CNA was asked if there was enough staff to take care of the residents. The CNA reported not really. The CNA was asked if they were able to give bath/showers as scheduled. The CNA reported not always. The CNA was asked if they were able to reposition residents in a timely manner. The CNA reported not always. On 03/28/18 at 10:46 a.m., the resident was observed in bed lying on her right side. No air mattress was observed on the resident's bed. On 03/28/18 at 11:43 a.m., the resident was observed sitting up in her Broda chair in the dining room. On 03/28/18 at 11:45 a.m., an unidentified CNA was asked if he/she cared for the resident. The CNA stated, Yes. The CNA was asked if the resident could turn herself in bed. The CNA stated, No. The CNA was asked how often the resident was supposed to be turned. The CNA reported every two hours. The CNA was asked if there was enough staff to take care of the residents. The CNA reported some days there wasn't enough staff. The CNA reported the resident was sick back in (MONTH) and (MONTH) and she stayed in bed a lot. The CNA reported they were short staffed about that time and they may not have had enough staff to get to everyone like they should have. On 03/28/18 at 1:12 p.m., the resident was observed lying in bed on her left side. No air mattress was observed on her bed as ordered on [DATE]. On 03/28/18 at 1:55 p.m., RN #1 reported the resident had been sick at the beginning of (MONTH) with nausea, vomiting and diarrhea. The RN reported after the resident quit having the symptoms she stayed in the bed and had not eaten very well for a couple of weeks. The RN was asked if the resident required assistance with bed mobility. The RN stated, Yes. The RN was asked how often the staff were supposed to reposition the resident while she was in bed. The RN stated, At least every two hours. The RN was asked if she was aware the resident had not been repositioned for over two hours the day before. The RN reported she had been told. The RN was asked if the staff should have repositioned the resident more timely. The RN stated, Yes. The RN was asked why the resident had not received the air mattress as ordered on [DATE]. The RN reported they were waiting on approval from the health care management company. The RN reported the company that was supposed to send the air mattress had not received the order. The RN was asked if someone should have followed up when the resident had not received the air mattress in a timely manner. The RN stated, Yes. The RN was shown the nurses' notes and asked if the physician should have been notified when there were changes in the resident's pressure ulcers. The RN stated, Yes. On 03/28/18 at 3:00 p.m., an interview with an unidentified healthcare provider was conducted. The healthcare provider was asked why a culture of the resident's wound had been ordered on [DATE]. The healthcare provider reported for preventative measures because of other infections and wounds in the facility. The healthcare provider was asked if he/she expected to be notified when the resident's wound had yellow drainage or had increased in size. The healthcare provider stated, I would think so. I'm seeing some really bad things like skin breakdown and infections. The healthcare provider stated, I'm trying to stay on top of it to prevent another bad wound. The healthcare provider was asked if he/she had been made aware of the yellow drainage, would he/she have ordered a different treatment. The healthcare provider reported he/she would have started the resident on an antibiotic knowing what he/she was dealing with. The healthcare provider was asked if he/she thought the residents were being repositioned enough. The healthcare provider stated, No. The healthcare provider reported he/she had changed one of the other resident's soiled brief three times and one time there was fecal matter in the resident's wound. The healthcare provider reported he/she did not know if there was enough staff. The healthcare provider reported he/she had offered to provide an in-service to the staff. On 03/28/18 at 3:57 p.m., RN #1 was shown the nurse's note, dated 03/16/18, and asked if the physician should have been notified regarding the yellow drainage from the pressure ulcer. The RN stated, Yes. The RN was then shown the nurse's note, dated 03/18/18, and asked if someone should have followed up with the physician regarding the change in condition of the pressure ulcer. The RN stated, Yes. 2. Resident #91 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 09/18/17, documented the resident had a recurring 1 cm semicircle stage II wound to coccyx with no drainage or odor. A nurse's note, dated 09/30/17, documented the resident's coccyx wound had resolved. A nurse's note, dated 10/20/17, documented a right upper buttock wound which measured 1x1cm x unable to determine depth. A facility wound management assessment, dated 10/21/17, documented a stage III wound measured 0.9 x 0.6 x 0.3 cm with white rolled edges and surrounding pink normal tissue. The wound management assessments documented the wound continued, would improve, remain stable, and decline over time. A physician's orders [REDACTED]. A wound care evaluation from the wound nurse consultant, dated 12/05/17, documented the resident had an unstageable full thickness coccyx pressure ulcer which measured 3.30 cm x 1.5 cm X unable to determine the depth with minimal exudate. The evaluation documented the wound had undermining of 2.5 cm from 12 o'clock. A facility wound management assessment, dated 01/12/18, documented the resident's stage III pressure ulcer wound measured 1.3 cm (length) x 1 cm (width) x 2 cm (depth) with light serosanguineous exudate with sinus tract tunneling of 3 cm at six o'clock. The observation documented the resident had a reddened wound edge and documented the wound healing status was stable. A facility action plan, dated 01/15/18, was brought to the surveyors for review by RN #1. The action plan documented the facility identified areas of concern: notification of primary care provider, completion of skin assessments, and proper documentation. The action taken area documented the facility would re-educate staff/train and/or replace with new staff, educate the new staff on documentation of notification of the primary care provider, and provide continuous education on wound care. The action plan documented in (MONTH) (YEAR) all licensed nurses had been replaced and the new nurses were educated. The plan documented the facility would continue educating staff on primary care provider notification and documentation. A wound care evaluation from the wound nurse consultant, dated 01/17/18, documented the resident had a full thickness stage IV pressure ulcer which measured 4.0 cm x 2.5 cm x 2 .0 cm with undermining of 2.5 cm at 12 o'clock with serosanguineous drainage. The evaluation documented, Wound Bed: 90% Pink/Red; Healthy Granulation; Other (eg. tendon/muscle/bone) 10%; Additional Wound Bed Comments: BONE .Infection/Critical Colonization: Localized s/s: Debris, Smell/Odor, Systemic s/s: Size Increase, [DIAGNOSES REDACTED]/[MEDICAL CONDITION] .Clinical Rationale/Wound Comments: PHYSICIAN PLAN FOR OIL [MEDICATION NAME] GAUZE AS CONTACT LATER FOR EXPOSED BONE. [MEDICATION NAME] DAILY. [MEDICATION NAME] GAUZE WILL FILL UNDERMINING AND WOUND CAVITY AND DECREASE BIOBURDEN. CALCIUM ALGINATE WILL MANAGE EXUDATE. DAILY F[NAME]FOR DRESSING INTEGRITY AFTER QD APPLICATION OF [MEDICATION NAME]. Treatment Intervention: 1. CLEANSE C[NAME]CYX WOUND PER FACILITY PROT[NAME]OL. 2. APPLY OIL [MEDICATION NAME] GAUZE TO EXPOSED BONE. 3. LOOSELY FILL WOUND CAVITY AND UNDERMINING WITH [MEDICATION NAME] GAUZE, LEAVING TAG OUTSIDE. 4. APPLY CALCIUM ALGINATE FOLDING TO A 2X2. 5. COVER WITH ABSORBATIVE DRESSING (Super Absorpbative OR non bordered foam). 6. SECURE WITH TAPE. 5. REPEAT DAILY .Evaluation Comments C[NAME]CYX WOUND POSITIVE [MEDICAL CONDITION] WITH ANTIBIOTIC ACTIVE. The clinical record had no documentation the physician was aware of the above pressure ulcer evaluation. A nurse's note, dated 01/17/18 at 3:40 p.m., documented the resident returned to the facility from the hospital after having PEG tube placement. A facility's staff wound management assessment, dated 01/19/18, documented the resident's stage III pressure ulcer measured 1.7 cm x 0.8 cm x 1.8 cm with heavy exudate of serosanguineous drainage with 3.2 tunneling at six o'clock. The medical record contained no documentation the physician was notified of the change/increase of the pressure ulcer drainage. The clinical record documented a visit from the nurse practitioner on 01/20/18. A facility wound management note, dated 01/23/18, documented the stage III pressure ulcer measured 1.4 cm x 0.6 cm with moderate [MEDICAL CONDITION] (yellow or tan, cloudy and thick) exudate and 3.4 tunneling at six o'clock. The assessment documented the skin surrounding the pressure ulcer as dark purple or rusty discoloration and white or gray pallor. The medical record contained no documentation the physician was notified of the change in the consistency of the pressure ulcer drainage. A nurse's note, dated 01/30/18 at 6:42 a.m., documented the resident had two loose stools and the coccyx dressing was soiled and had to be changed. A nurse's note, dated 01/30/18 at 12:15 p.m., documented a new order had been received for the treatment to the pressure ulcer to the resident's left buttock/iliac crest. A nurse's note, dated 01/31/18 at 6:08 a.m., documented the Dakin's solution did not come and the staff would continue with previous treatment order until it arrives. The nurse's note documented the resident continued to have loose stool and PRN [MEDICATION NAME] was administered. A facility wound management note, dated 01/31/18, documented the stage III pressure ulcer measured 2.1 cm x 1.5 cm x 2.2 cm with 2.2 cm tunneling and had moderate amount [MEDICAL CONDITION] exudate. The medical record contained no documentation the physician was notified of the increase in the pressure ulcer size. A nurse's note, dated 02/02/18 at 3:04 a.m., documented the resident continued to have loose stools. A facility wound management assessment, dated 02/02/18, documented the stage III pressure ulcer measured 3.5 cm x 5.5 cm x 2 cm with moderate [MEDICAL CONDITION] exudate and 3.4 cm tunneling at six o'clock with redness surrounding the wound. The assessment documented the pressure ulcer healing status as declining. A nurse's note, dated 02/03/18 at 10:27 a.m., documented the resident continued with pressure ulcer to coccyx and the facility was waiting for 0.25% Dakin's solution from the pharmacy to soak gauze to fill the pressure ulcer base. The note documented the [MEDICATION NAME] was continued at that time. A nurse's note, dated 02/04/18 at 2:48 p.m., documented the resident had one loose stool that morning. A significant change assessment, dated 02/04/18, documented the resident was severely impaired in cognition with no exhibited depression or behaviors. The assessment documented the resident required total assistance for all ADLs, had an indwelling urinary catheter, and was always incontinent of bowel. The assessment documented the resident had a feeding tube and received 51% or more for intake/nourishment through the feeding tube. The assessment documented the resident had one stage III pressure ulcer with granulation tissue. A care plan, dated 02/05/18, documented a problem of pressure ulcer with the potential of altered skin integrity. The goal documented was for the resident to have no altered skin integrity from pressure, incontinence, skin tears through the next target date. Interventions listed was for an air flow mattress, for the staff to keep the resident clean and dry at all times, to turn and reposition every two hours or more often if necessary to maintain adequate circulation to all pressure points. The care plan documented the resident had a history of [REDACTED]. A nurse's note, dated 02/05/18 at 6:23 a.m., documented the resident had two episodes of diarrhea during the shift. The nurse's note documented the resident's pressure ulcer dressing was soiled and was replaced. A nurse's note, dated 02/05/18 at 11:22 a.m., documented the resident had one episode of loose stool that morning. A nurse's note, dated 02/06/18 at 6:44 a.m., documented the resident had two episodes of diarrhea with the pressure ulcer dressing being soiled and changed. The clinical record contained no documentation the physician was aware of the loose stools with soiling to the pressure ulcer dressings. A nurse's note, dated 02/07/18 at 6:21 a.m., documented the resident had two loose stools with soiling of the coccyx pressure ulcer dressing and the dressing was reapplied. A nurse's note, dated 02/07/18 at 2:42 p.m., documented the resident had one episode of loose stool that morning. The note documented the nurse practitioner from the healthcare management company had visited and had given no new orders. A facility wound management assessment, dated 02/09/18, documented the stage III pressure ulcer measured 5 cm x 5 cm x 2 cm with moderate [MEDICAL CONDITION] exudate, with macerated/soft wound edges, with no tunneling or undermining, and with redness to the skin surrounding the pressure ulcer. The assessment documented the pressure ulcer healing status was stable. (The previous wound management assessment, dated 02/02/18, documented the stage III pressure ulcer measured 3.5 cm x 5.5 cm x 2 cm with moderate [MEDICAL CONDITION] exudate and 3.4 cm tunneling at six o'clock with redness surrounding the pressure ulcer.) The resident's medical record contained no documentation the physician was notified of the changes in the pressure ulcer. A facility wound management assessment, dated 02/10/18, documented the stage III pressure ulcer measured 5.5 cm x 5.9 cm x 1.5 cm with moderate [MEDICAL CONDITION] exudate, with 2 cm tunneling at six o'clock, and with redness of the skin surrounding the pressure ulcer bed. The assessment documented the pressure ulcer status was stable. The resident's medical record contained no documentation the physician had been notified of the change in the pressure ulcer. A nurse's note, dated 02/13/18 at 9:33 a.m., documented the health care management company was notified of the resident's increased [MEDICAL CONDITION] in her right upper extremity and the left side of her face. The note documented at 11:05 a.m., an order was received to administer [MEDICATION NAME] daily for three days. A facility wound management assessment, dated 02/13/18 at 11:46 a.m., documented the stage III pressure ulcer measured 7.0 cm x 6.0 x UTD with moderate [MEDICAL CONDITION] exudate with 3.5 cm tunneling with 50% of the pressure ulcer covered by granulation and 50% covered by slough. The assessment documented the pressure ulcer healing status as declining. The clinical record had no documentation the physician had been notified of the changes in the pressure ulcer. A nurse's note, dated 02/14/18 at 6:13 a.m., documented the resident had been incontinent of stool and the dressing to the pressure ulcer had been soiled and replaced. The note documented the pressure ulcer was not healing. A wound evaluation by the wound nurse consultant, dated 02/14/18, documented the resident had a stage IV pressure ulcer which measured 7.0 cm x 6.0 cm x UTD (unable to determine) depth with serosanguineous drainage and with 3.0 cm undermining from 12 o'clock. The assessment documented, Wound Bed: Red 70%/ Pink/Red; Healthy Granulation; Yellow 30%, Adherent [MEDICATION NAME] Slough .Infection/Critical Colonization: Localized s/s: Debris, Smell/Odor, Systemic s/s: Size Increase, [DIAGNOSES REDACTED]/[MEDICAL CONDITION] .Treatment Intervention: 1. CLEANSE C[NAME]CYX WOUND PER FACILITY PROT[NAME]OL. 2. APPLY DAKINS SOAKED ROLL GAUZE LOOSELY TO WOUND CAVITY AND UNDERMINING. 3. APPLY SILVER HYDOGEL AND COLLAGEN TO WOUND BED. 4. COVER WITH NON ADHERENTDRESSING. 5. SECURE [NAME]CLUSIVELY WITH TAPE. 6. REPEAT DAILY. A progress note written by the nurse practitioner from the healthcare management company, dated 02/15/18, documented the wound care nurse was seeing the resident. The progress note documented the resident had a CT scan of the pelvis ordered for the area of the coccyx pressure ulcer which had tunneling and was being packed. The assessment documented the resident had a stage III sacral pressure ulcer covered with a dressing. A nurse's note, dated 02/20/18 at 10:56 a.m., documented the resident was out of the facility for CT of the sacral region. A radiology report of the resident's CT scan with contrast of the pelvis, dated 02/20/18, documented the reason for the scan was for osteo[DIAGNOSES REDACTED] of the vertebra and the sacral region. The rep (TRUNCATED)

Based on record review and staff interview, it was determined the facility failed to notify the physician when one (#1) of 13 sampled residents experienced a change in condition. The resident was admitted to the hospital and the hospital discharge summary documented final [DIAGNOSES REDACTED]. This had the potential to affect six residents, identified by the interim DON, who experienced changes in condition and required physician notification in the past three months. Findings: Resident #1 had [DIAGNOSES REDACTED]. A memo form from the office of Dr. (name deleted), dated 06/17/14, documented, "Dr. (name deleted) wished to inform all Nursing Homes that he should only be contacted about patient care by office phone ONLY....The office has an Answering Service who will relay any message or report to him after hours. Dr. (name deleted) specially requests NO Text messages regarding patients care. Please DO NOT send faxes or contact Dr. (name deleted) through the Urgent Care as this is a separate Entity..." The memo form had initials and signatures of the staff who had read the memo. A care plan, dated 08/18/14, documented ADL function as a problem. Interventions listed were to encourage adequate fluid intake, to provide diet as ordered, and to monitor and record intake. The care plan also addressed a potential for elevated blood pressure as a problem. An intervention listed was for the staff to notify the physician if elevated blood pressures occurred. A care plan, dated 08/27/14, identified the resident's nutritional status as a problem with an intervention listed for the staff to encourage fluids. A significant change assessment, dated 08/28/14, documented the resident was severely impaired in cognition and exhibited mild depression. The resident required one person extensive assistance in bed mobility, transfers, dressing, eating, personal hygiene and bathing. The resident was always incontinent of bowel and bladder. A nurse's progress note, dated 08/30/14 at 4:22 p.m., documented the resident had been refusing food and medications. A care plan, dated 08/30/14, documented the resident had urinary incontinence with a UTI as a problem. A fax sheet sent to the resident's physician, dated 08/31/14 at 5:08 p.m., documented, "(Resident's name deleted)- continues to refuse to eat. not drinking much of anything either. Have been successful to get meds down with great difficulty.-Having some nausea. Bowels are moving well. Vital are OK except for low O2 sats - 78-85 on room air. Won't keep O2 on. Just an update. (nurse's initials deleted)." A nurse's progress note, dated 08/31/14 at 5:26 p.m., documented, "...Sent fax message to Dr. regarding fact res continues to not eat...Res. was given [MEDICATION NAME] gel for nausea...." At 5:27 p.m., a nurse's progress note documented the resident had not voided all shift. There was no physician notification which concerned the resident's decreased output. At 9:40 p.m., a nurse's progress note, documented, "...difficult to get to eat or drink fluids..." A nurse's progress note, dated 09/01/14 at 1:02 p.m., documented, "...Did not eat but a few bites for breakfast, noon meal she fed herself 1/2 of her dessert then became nauseated and vomited. Adm. (administered) [MEDICATION NAME] gel...Res took about 10 bites of broth only would not eat noodles. Drank approx. 50 cc of fluids/water before refusing any more...Res skin is tenting showing signs of dehydration. I sent a fax message to Dr. office yesterday (method of choice per Dr.) so he would see it first thing on Tuesday since its a holiday weekend. Will pass info on to day nurse tomorrow to communicate with Dr." On 09/01/14, there was no physician notification follow-up to the fax sent on 08/31/14. The "Vitals Report" computerized form, dated 09/01/14, did not contain an entry for the amount of meals or fluids taken for the entire day. The Vitals Report, dated 09/02/14, documented the resident had "Not Taken: Refused" her breakfast, including fluids and supplements. There was no entry for the dinner meal, fluids and supplements taken. On 09/02/14, there was no physician notification of the resident's continued decreased intake. A care plan intervention, dated 09/02/14, documented for the staff to encourage fluids, offer extra fluids with medication pass, encourage 100% fluid consumption during meals. Another approach listed was for the staff to monitor findings and document in the nurse's notes. The staff was to provide the physician with updates. A nurse's progress note, dated 09/03/14 at 5:18 p.m., documented, "...Continues to refuse to eat and refused boost drink today." The Vitals Report, dated 09/03/14, documented the resident had "Not Taken: Refused" her breakfast, her lunch and fluids for the respective meals. On 09/03/14, there was no physician notification of the resident's continued decreased intake. A nurse's progress note, dated 09/04/14 at 6:47 p.m., documented, "...Continues to not eat or take meds, will put food in mouth and then just let it run out..." The Vitals Report, dated 09/04/14, documented no entries for breakfast, lunch and dinner meal intakes. The report documented the resident had taken 120 cc of fluid and no supplements in the evening. On 09/04/14, there was no physician notification of the resident's continued decreased intake. A nurse's progress note, dated 09/05/14 at 1:20 p.m., documented, "...had decreased urine output d/t not eating or drinking much." At 1:30 p.m., a nurse's progress note documented, "Spoke with DON regarding res. throwing up when she eats or drinks anything. adm (administered) [MEDICATION NAME] gel at 1215 (12:15 p.m.) for vomiting. DON placed call in to Dr. (name deleted) to discuss possible IV fluids." At 8:07 p.m., a nurse's progress note documented, "1600 (4:00 p.m.), res given [MEDICATION NAME] for nausea topically before meal to see if res could tolerate a meal. Res given clear liquid diet. Res only drank about 50 cc water and about 5 bites of broth for me....Did not hear back from Dr. (name deleted)..." At that time, there was no physician notification of the resident's continued decreased intake. The Vitals Report, dated 09/05/14, documented no entries for the amount of breakfast, fluids or supplements taken. There were no entries for fluids or supplements taken at lunch. A nurse's progress note, dated 09/06/14 at 12:14 p.m., documented, "...0830 (8:30 a.m.) res was fed a few bites of am meal. res threw up. no return call from Dr. (name deleted) as of yet." The Vitals Report, dated 09/06/14, documented no entries for the amount of breakfast fluids or supplements taken. At 2:02 p.m., a nurse's progress note documented, "...1245 (12:45 p.m.) called Dr. (name deleted) d/t res not eating and vomiting. Dr. states to draw a CBC and CMP start IV fluids if possible. I told Dr. that res is very dehydrated. Will try to get IV access. If unable Dr. states to send to ER." At 2:13 p.m., a nurse's progress note documented, "...1315 (1:15 p.m.) ...was unable to start IV. Res is too dehydrated. Will send to ER..." A hospital (name deleted) Emergency Physician Record, dated 09/06/14, documented, "chief complaint: ...concern for dehydration...associated symptoms: vomiting...PHYSICAL EXAM...Skin...poor turgor... LABS...Na (sodium) 150...BUN 109 Creat (creatinine) 3.85...UA ...bacteria heavy...dip: [MEDICATION NAME]/leu esterase...PROGRESS: ...Pt noted to have elevated Creatinine & bacteria in urine c (with) esterase & [MEDICATION NAME]. Pt started on 60 ml /hr normal saline...CLINICAL IMPRESSION: Vomiting ... Dehydration... Acute on [MEDICAL CONDITION] Urinary Tract Infection..." The resident returned to the facility on [DATE] after her hospital stay. A hospital (name deleted) discharge summary, dated 09/12/14, documented discharge [DIAGNOSES REDACTED]. The Vitals Record, dated 10/08/14 at 8:15 a.m., documented the resident's blood pressure reading was 127/100. There was no physician notification of the resident's elevated blood pressure. On 10/15/14 at 10:25 a.m., the interim DON was shown the nurses' progress notes in regard to the resident not eating and drinking. The interim DON was asked if the physician should have been notified further and follow-ups to the fax and telephone calls should have been conducted. She stated, "Yes." She was asked if the physician should have been notified of the above elevated blood pressure and the she stated, "Yes." At 2:15 p.m., the interim DON was asked if there was any documentation to show the physician had further notification or follow-up. The interim DON with the surveyor reviewed the 24 hour shift reports and no further physician notification was located. At 2:30 p.m., RN #1 (who faxed the physician on 08/31/14) was interviewed in regard to physician notification for the resident. The RN reported there was a problem with notification to the resident's attending physician. She reported the physician only wanted to be contacted by FAX. She reported she had not documented her numerous attempts to contact the physician, but she felt she "tried my hardest to do my best for her." RN #1 reported she had tried to text him and tried repeatedly to call the physician with no success. She reported that was why she had the DON text the physician since he would answer her possibly and still had no response. She reported when she would call the physician's office the office staff would "pick and choose" who got through to speak with the physician. There was no documentation in the clinical record of any other attempts by the staff to notify the physician in regard to the resident's changes in condition.

Based on observation, record review and staff interviews, it was determined the facility failed to provide necessary care and services to ensure residents maintained their highest levels of well-being for four (#1, #2, #3, and #6) of 13 sampled residents sampled for levels of functioning. Resident #1 admitted to the hospital and the hospital discharge summary documented final [DIAGNOSES REDACTED]. The facility failed to: a) notify the physician when one (#1) of 13 sampled residents experienced a change in condition and failed to ensure low pulse oximeter readings were monitored for one (#1) of three sampled residents who required pulse oximeter readings. The interim DON identified six residents who experienced changes in condition and required physician notification in the past three months. b) Ensure the skin condition was monitored for one (#6) of two sampled residents who had experienced a decline in skin condition. This had the potential to affect 43 residents, identified by the facility's Resident Census And Conditions Of Residents form, who received preventive skin care. c) Ensure a reddened excoriated area was assessed and monitored for one (#2) of two sampled residents who had experienced a decline in skin condition. This had the potential to affect 43 residents, identified by the facility's Resident Census And Conditions Of Residents form, who received preventive skin care. d) Ensure dietary supplements were given as ordered by the physician for two (#1 and #3) of two sampled residents with physician's orders [REDACTED]. This had the potential to affect seven residents, identified by the facility Dietary Report, who required dietary supplements. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. a) A memo form from the office of Dr. (name deleted), dated 06/17/14, documented, "Dr. (name deleted) wished to inform all Nursing Homes that he should only be contacted about patient care by office phone ONLY....The office has an Answering Service who will relay any message or report to him after hours. Dr. (name deleted) specially requests NO Text messages regarding patients care. Please DO NOT send faxes or contact Dr. (name deleted) through the Urgent Care as this is a separate Entity..." The memo form had initials and signatures of the staff who had read the memo. A care plan, dated 08/18/14, documented ADL function as a problem. Interventions listed were to encourage adequate fluid intake, to provide diet as ordered, and to monitor and record intake. The care plan also addressed a potential for elevated blood pressure as a problem. An intervention listed was for the staff to notify the physician if elevated blood pressures occurred. A care plan, dated 08/27/14, identified the resident's nutritional status as a problem with an intervention listed for the staff to encourage fluids. A significant change assessment, dated 08/28/14, documented the resident was severely impaired in cognition and exhibited mild depression. The resident required one person extensive assistance in bed mobility, transfers, dressing, eating, personal hygiene and bathing. The resident was always incontinent of bowel and bladder. A nurse's progress note, dated 08/30/14 at 4:22 p.m., documented the resident had been refusing food and medications. A care plan, dated 08/30/14, documented the resident had urinary incontinence with a UTI as a problem. A fax sheet sent to the resident's physician, dated 08/31/14 at 5:08 p.m., documented, "(Resident's name deleted)- continues to refuse to eat. not drinking much of anything either. Have been successful to get meds down with great difficulty.-Having some nausea. Bowels are moving well. Vital are OK except for low O2 sats - 78-85 on room air. Won't keep O2 on. Just an update. (nurse's initials deleted)." A nurse's progress note, dated 08/31/14 at 5:26 p.m., documented, "...Sent fax message to Dr. regarding fact res continues to not eat...Res. was given [MEDICATION NAME] gel for nausea...." At 5:27 p.m., a nurse's progress note documented the resident had not voided all shift. There was no physician notification which concerned the resident's decreased output. At 9:40 p.m., a nurse's progress note, documented, "...difficult to get to eat or drink fluids..." A nurse's progress note, dated 09/01/14 at 1:02 p.m., documented, "...Did not eat but a few bites for breakfast, noon meal she fed herself 1/2 of her dessert then became nauseated and vomited. Adm. (administered) [MEDICATION NAME] gel...Res took about 10 bites of broth only would not eat noodles. Drank approx. 50 cc of fluids/water before refusing any more...Res skin is tenting showing signs of dehydration. I sent a fax message to Dr. office yesterday (method of choice per Dr.) so he would see it first thing on Tuesday since its a holiday weekend. Will pass info on to day nurse tomorrow to communicate with Dr." On 09/01/14, there was no physician notification follow-up to the fax sent on 08/31/14. The "Vitals Report" computerized form, dated 09/01/14, did not contain an entry for the amount of meals or fluids taken for the entire day. The Vitals Report, dated 09/02/14, documented the resident had "Not Taken: Refused" her breakfast, including fluids and supplements. There was no entry for the dinner meal, fluids and supplements taken. On 09/02/14, there was no physician notification of the resident's continued decreased intake. A care plan intervention, dated 09/02/14, documented for the staff to encourage fluids, offer extra fluids with medication pass, encourage 100% fluid consumption during meals. Another approach listed was for the staff to monitor findings and document in the nurse's notes. The staff was to provide the physician with updates. A nurse's progress note, dated 09/03/14 at 5:18 p.m., documented, "...Continues to refuse to eat and refused boost drink today." The Vitals Report, dated 09/03/14, documented the resident had "Not Taken: Refused" her breakfast, her lunch and fluids for the respective meals. On 09/03/14, there was no physician notification of the resident's continued decreased intake. A nurse's progress note, dated 09/04/14 at 6:47 p.m., documented, "...Continues to not eat or take meds, will put food in mouth and then just let it run out..." The Vitals Report, dated 09/04/14, documented no entries for breakfast, lunch and dinner meal intakes. The report documented the resident had taken 120 cc of fluid and no supplements in the evening. On 09/04/14, there was no physician notification of the resident's continued decreased intake. A nurse's progress note, dated 09/05/14 at 1:20 p.m., documented, "...had decreased urine output d/t not eating or drinking much." At 1:30 p.m., a nurse's progress note documented, "Spoke with DON regarding res. throwing up when she eats or drinks anything. adm (administered) [MEDICATION NAME] gel at 1215 (12:15 p.m.) for vomiting. DON placed call in to Dr. (name deleted) to discuss possible IV fluids." At 8:07 p.m., a nurse's progress note documented, "1600 (4:00 p.m.), res given [MEDICATION NAME] for nausea topically before meal to see if res could tolerate a meal. Res given clear liquid diet. Res only drank about 50 cc water and about 5 bites of broth for me....Did not hear back from Dr. (name deleted)..." At that time, there was no physician notification of the resident's continued decreased intake. The Vitals Report, dated 09/05/14, documented no entries for the amount of breakfast, fluids or supplements taken. There were no entries for fluids or supplements taken at lunch. A nurse's progress note, dated 09/06/14 at 12:14 p.m., documented, "...0830 (8:30 a.m.) res was fed a few bites of am meal. res threw up. no return call from Dr. (name deleted) as of yet." The Vitals Report, dated 09/06/14, documented no entries for the amount of breakfast fluids or supplements taken. At 2:02 p.m., a nurse's progress note documented, "...1245 (12:45 p.m.) called Dr. (name deleted) d/t res not eating and vomiting. Dr. states to draw a CBC and CMP start IV fluids if possible. I told Dr. that res is very dehydrated. Will try to get IV access. If unable Dr. states to send to ER." At 2:13 p.m., a nurse's progress note documented, "...1315 (1:15 p.m.) ...was unable to start IV. Res is too dehydrated. Will send to ER..." A hospital (name deleted) Emergency Physician Record, dated 09/06/14, documented, "chief complaint: ...concern for dehydration...associated symptoms: vomiting...PHYSICAL EXAM...Skin...poor turgor... LABS...Na (sodium) 150...BUN 109 Creat (creatinine) 3.85...UA ...bacteria heavy...dip: [MEDICATION NAME]/leu esterase...PROGRESS: ...Pt noted to have elevated Creatinine & bacteria in urine c (with) esterase & [MEDICATION NAME]. Pt started on 60 ml /hr normal saline...CLINICAL IMPRESSION: Vomiting ... Dehydration... Acute on [MEDICAL CONDITION] Urinary Tract Infection..." The resident returned to the facility on [DATE] after her hospital stay. A hospital (name deleted) discharge summary, dated 09/12/14, documented discharge [DIAGNOSES REDACTED]. The Vitals Record, dated 10/08/14 at 8:15 a.m., documented the resident's blood pressure reading was 127/100. There was no physician notification of the resident's elevated blood pressure. On 10/15/14 at 10:25 a.m., the interim DON was shown the nurses' progress notes in regard to the resident not eating and drinking. The interim DON was asked if the physician should have been notified further and follow-ups to the fax and telephone calls should have been conducted. She stated, "Yes." She was asked if the physician should have been notified of the above elevated blood pressure and the she stated, "Yes." At 2:15 p.m., the interim DON was asked if there was any documentation to show the physician had further notification or follow-up. The interim DON with the surveyor reviewed the 24 hour shift reports and no further physician notification was located. At 2:30 p.m., RN #1 (who faxed the physician on 08/31/14) was interviewed in regard to physician notification for the resident. The RN reported there was a problem with notification to the resident's attending physician. She reported the physician only wanted to be contacted by FAX. She reported she had not documented her numerous attempts to contact the physician, but she felt she "tried my hardest to do my best for her." RN #1 reported she had tried to text him and tried repeatedly to call the physician with no success. She reported that was why she had the DON text the physician since he would answer her possibly and still had no response. She reported when she would call the physician's office the office staff would "pick and choose" who got through to speak with the physician. There was no documentation in the clinical record of any other attempts by the staff to notify the physician in regard to the resident's changes in condition. b) A physician's orders [REDACTED]. On 10/13/14 at 12:23 p.m., a noon meal observation was conducted. The resident was not served a house supplement with her meal. At 5:40 p.m., during an observation of the evening meal, the resident was not served a house supplement. There was no house supplement documented on the resident's meal card. There was a list of residents' names, who were to receive house supplements with meals, posted next to the tea dispensers in the dining room. The resident's name was not listed. On 10/14/14 at 9:50 a.m., the interim DON was asked who was responsible to give the residents their ordered house supplements. The interim DON reported the dietary department was responsible. She reported she was uncertain how the dietary department would be informed of changes in diet. On 10/15/14 at 10:50 a.m., the DM was asked how the dietary department received information from nursing service when dietary orders were changed. The DM reported the facility had a communication form to relay the information to the dietary department. The DM reported she had not received anything on a house supplement for the resident. The DM reported she would look into the situation. c) A care plan, dated 08/18/14, documented an intervention for staff to have oxygen available as ordered and as needed. Other interventions listed were for the staff to monitor for episodes of dyspnea, implement interventions as ordered and notify MD if persistent dyspnea. A physician order, dated 10/04/13, documented the resident was to receive oxygen at 2-4 l/m via NC every shift prn. The orders documented the resident was to have oxygen saturations taken every shift. A nurse's progress note, dated 08/30/14 at 6:15 p.m., documented the resident's oxygen saturation was 70% and O2 was applied. There was no reassessment of the resident's oxygen saturation. A nurse's progress note, dated 09/20/14, documented the resident's color was dusky with an oxygen saturation of 79% and oxygen was applied. There was no reassessment of the resident's oxygen saturation. On 10/15/14 at 10:25 a.m., the interim DON was asked if the lowered oxygen saturations should have had further assessments conducted. She stated, "Yes." 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 09/21/14, documented the resident was severely impaired with cognition and required extensive assistance of one staff member for transfers, bed mobility, ambulation, dressing, eating, hygiene and bathing. An updated care plan, dated 09/23/14, documented the resident had a potential for weight loss as a problem. A goal was for the resident to consume adequate amounts of essential nutrients and fluids to maintain weight and adequate hydration. One intervention listed was for the staff to offer a house supplement or nourishment and document the amount taken. A computerized physician's orders [REDACTED]. On 10/13/14 at 12:35 p.m., during the noon meal observation. The resident did not receive a house supplement with her meal. At 5:05 p.m., during the evening meal observation. The resident did not receive a house supplement with her meal. The resident's diet card was reviewed and contained no documentation the resident was to receive a house supplement. On 10/14/14 at 9:45 a.m., the Interim DON was interviewed in regard to the resident not receiving the house supplement with her meals. The Interim DON was asked who was responsible for delivering the house supplement during the meals. The Interim DON reported dietary services was responsible. The Interim DON was made aware of the resident not receiving a house supplement on both observations and asked if the resident should have received a house supplement. The Interim DON stated, "Yes, she should have." 3. Resident #2 had been admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. A care plan, dated 05/02/2014, documented a problem for a potential for altered skin integrity from pressure, incontinence or skin tears related to the resident's skin being fragile and tears and bruises easily. The goal was for the resident to have no altered skin integrity from pressure or incontinence. Approaches included for the staff to keep the resident clean and dry at all times, monitor for discoloration, bruises, swelling, skin tears, report red areas promptly and to complete a weekly skin audit. A quarterly assessment, dated 07/29/14, documented the resident was cognitively impaired with poor decision making skills, required extensive assistance with transfers,dressing, eating and hygiene and total assistance with bathing. The resident did not ambulate and was incontinent of bowel and bladder. The resident was high risk for pressure ulcers. An additional care plan approach, dated 08/18/2014, documented to apply "buttpaste" to the perineal area for redness until resolved. A nurse's progress note, dated 08/20/14 at 5:35 p.m., documented, "08/20/14 1300 (1:00 p.m.) CNA report res. peri area and buttocks are reddened. new order for butt paste q shift ordered from Dr. (named deleted) office. may use till resolved then keep PRN." There was no assessment documentation regarding the reddened areas until 09/11/14. A nurse's progress note, dated 09/11/14, documented, "butt paste changed to routine treatment q shift d/t buttocks reddened." A nurse's progress note, dated 09/15/14, documented, "buttocks have worsened, buttpaste order made q shift." There was no assessment documentation describing the areas on the buttocks as to size, condition or staging if needed. There was no assessment documentation regarding the reddened areas until 09/23/14. A nurse's note, dated 09/23/14, documented, "Wound charting 09/23/14. Resident's bottom dressing changed per orders. Resident tolerated well and c/o no pain or discomfort. Wound to residents bottom seem to be declining. Open areas to both sides of the coccyx are increasing in size. The opening to the R (right) measures 3.6cm x2.1cm with redness and peeling skin located directly around. The open area to the L (left) measures 6.4cm x 2.7cm there is an area of dark colored discoloration located inside this wound near the coccyx, the dark discolored area measures 2.3cm x 0.9cm. Area appears not to be healing well..." The progress notes, dating from 07/25/14 through 10/10/14, documented the resident had a decline in condition related to difficulty eating and drinking, with changes in diet and liquid consumption i.e., thickened liquids. Multiple interventions had been made related to dietary supplements which had not solved the resident's refusal to eat or drink. On 10/11/14, the resident had been placed on Hospice services for palliative care only. The resident was a DNR and did not want any measures taken to extend her life. On 10/14/14 at 10:30 a.m., the corporate RN was asked for any skin assessments completed for the resident. She reported there were no skin assessments for the resident. She was notified of the lack of monitoring and assessments of the resident's skin condition. She reported the facility had identified the problems with skin monitoring and were having an inservice the next day to address the issues. 4. Resident #6 was admitted on [DATE] with numerous [DIAGNOSES REDACTED]. A care plan, dated 02/17/14, documented the resident had a potential for altered skin integrity related to occasional incontinence, as a problem. The goal was for the resident's excoriated area on his buttocks to heal. An intervention listed was for staff to treat the area on the resident's buttocks as ordered. A nurse's note, dated 06/24/14 at 11:38 a.m., documented, "skin observation. res. has 12 cm x 10 cm reddened rash area on coccyx and down buttocks. also noted a 3 cm x 2 cm li (sic) very light purple bruise on Left buttock likely from where resident said rash itched but now it hurts. New order initiated for butt paste q shift till resolved." There was no further documentation in the resident's medical record the above area had been assessed and monitored. A quarterly assessment, dated 07/30/14, documented the resident was moderately impaired with cognition and demonstrated no moods. The resident had experienced skin tears. On 10/13/14 at 3:00 p.m., the corporate nurse was shown the above documentation. The corporate nurse reported the facility had identified the problem and would be having an in-service on documentation and performance of weekly skin assessments soon.

Based on observation, record review and staff interview, it was determined the facility failed to ensure: a) Staff followed set interventions to prevent falls for one (#5) of three sampled residents who had experienced three falls. Two of the falls caused injury to the resident resulting in harm. This had the potential to affect 38 residents, identified by the DON, as having experienced a fall in the past three months. b) Licensed nursing staff did not attempt to give oral foods and fluids to an unresponsive hypoglycemic resident for one (#2) of five sampled residents who had the [DIAGNOSES REDACTED]. This had the potential to affect 16 residents, identified by the DON, as having the [DIAGNOSES REDACTED]. 1. Resident #5 had [DIAGNOSES REDACTED]. An incident report dated 03/06/11, documented, "Resident sitting in w/c in Room - Lap buddy in place. Body Alarm sounded - found resident on floor - leaning toward Rt side - appeared to have slid from w/c. No apparent injuries found..." The steps to prevent reccurrence included not to leave the resident unattended in his room while he was in his wheel chair. The resident was to be taken to the lobby and watched. A significant change assessment, dated 05/18/11, documented the resident had difficulty hearing, some difficulty understanding, had severely impaired cognition, inattention, was totally dependent on staff for bed mobility, transfers and locomotion, could not stand without physical support, had falls and had range of motion limitations in lower extremities. An incident report, dated 05/27/11, documented the resident fell again while unattended in his room. The report documented, "Observed resident lying on R side in floor of room beside W/C with lap buddy in floor. Abrasion to R side of forehead. Staff will not allow resident to be in room, unattended in his W/C., res. will be placed in his bed or recliner with feet elevated..." A care plan, dated 05/27/11, documented the following: "Problem: High Risk for Falls Related to Alzheimer's, mobility deficits As exhibited by: Resident requires extensive assist with transfers and toileting, can not stand without physical support, fatigues quickly, forgets safety measures such as locking w/c and using hand rails, lap buddy is used to remind him not to lean over in chair, personal alarm on at all times. Goal: Will prevent/manage future likelihood of falls... Interventions: ...Assess cause, pattern of previous falls & act upon resolvable factors...Do not leave resident in room unattended when up in w/c, take to lobby where he can be monitored." An incident report, dated 07/05/11, documented the resident fell again while unattended in his room. The report documented, "Res. apparently fell out of W/C into floor. Sustained abrasion to Left forehead and bruise to L arm-reddened area on L knee. Staff will not leave res. in W/C in room-will assist into recliner or bed when in room." On 07/26/11 at 4:30 p.m., the resident was observed sleeping in the lobby sitting in a wheelchair with a lap buddy in place. On 07/28/11 at 1:30 p.m., the resident was observed in his room sleeping in his bed. At 3:15 p.m., the DON was asked about the falls dated 03/06/11, 05/27/11 and 07/04/11. She was asked why the staff continued to leave the resident unattended in his room. She reported she did not know who had left the resident unattended in his room for two of the falls. She did report the fall on 05/27/11, was a result of the housekeeper trying to help out. The housekeeper pushed the resident to his room to make room for EMS staff who were coming down the hall. The housekeeper did not know the resident was not to be left unattended in his room while he was in his wheelchair. The DON reported she was trying to ensure all staff were aware that the resident should not be left unattended in his room while he was in his wheelchair. 2. A facility policy on nursing care of residents with a [DIAGNOSES REDACTED]. The physician was also to be notified if the resident had a sudden change in level of consciousness. A facility policy on change of condition documented the physician was to be notified if the resident experienced a significant change in physical or mental status and with any clinical complications. Resident #2 was admitted on [DATE], with numerous [DIAGNOSES REDACTED]. A swallow study, dated 01/21/09, documented the resident had mild to moderate dysphasia and swallow precautions were recommended. A significant change assessment, dated 06/09/11, documented the resident had long and short term memory problems and was severely impaired in cognitive skills. The resident exhibited moderate depression and was tired 12 out of 14 days. The resident required total assistance of two persons for transfers, dressing and bathing. The resident had one Stage II pressure ulcer and was always incontinent of bowel and bladder. The resident required a mechanically altered therapeutic diet. A care plan, dated 06/17/11, documented the resident was at risk for hyperglycemia or [DIAGNOSES REDACTED]. The goal was for the resident's blood sugars to be within acceptable limits through the next review date. An intervention listed was to monitor and record the resident's FSBSs as ordered. A computerized physician's orders [REDACTED]. On 07/25/11 at 12:10 p.m., the resident was observed in the dining area. The resident did not respond to her name. At 12:40 p.m., the resident's daughter came to the dining room to visit the resident. The daughter reported the resident was diaphoretic, not responding and asked for the resident to be returned to her room. At 12:50 p.m., the resident was observed in bed. LPN #1 replaced the resident's oxygen and performed a FSBS. The FSBS was 42. The LPN left the room and went to the dietary department to obtain the resident's lunch meal. The resident did not respond to the daughter's touch or name call. At 1:00 p.m., the LPN #1 raised the residents head of bed and began to attempt to feed the resident. The LPN placed a spoon full of food on the resident's tongue and with her other hand moved the resident's mouth up and down, in a chewing motion. The LPN was speaking loudly to the resident encouraging her to awaken and swallow. The food fell from the sides of the resident's mouth. At that time, the surveyor asked if the LPN would like the charge nurse to come to the resident's bedside. The LPN reported she would. The surveyor left and returned with the LPN #2 and the DON. LPN #2 reported the resident's FSBS was low and to continue to attempt to have the resident swallow some fluids and foods. LPN #2 then attempted to give the resident food and fluids. The resident continued to be non-responsive and the foods and fluids were falling from the sides of the residents mouth. The resident did not cough or choke. At 1:07 p.m., LPN #2 reported she could not awaken the resident to swallow and was going to notify the physician. The DON left the resident's room with the LPN. At 1:10 p.m., LPN #1 rechecked the resident's FSBS. The FSBS result was 52. The resident continued to be unresponsive. At 1:13 p.m., LPN #2 returned with orange juice with sugar added. The mixture was thick. The LPN reported the physician had instructed her to give orange juice with sugar. The LPN reported the physician had also given a low FSBS parameter of 80 to be contacted. LPN #2 attempted to spoon the mixture into the resident's mouth. The mixture either fell from the resident's mouth or remained on the resident's tongue. The DON returned to the resident's room and also attempted to use the spoon to place the mixture of orange juice and sugar on the resident's tongue with the same result. The DON removed the mixture she had placed from the resident's tongue when the resident did not respond. LPN #2 reported she was going to call the physician for further orders. Both the DON and charge nurse left the resident's room. LPN #1 proceeded to attempt to give the resident the orange juice and sugar mixture. The resident remained unresponsive and the mixture fell from the sides of the resident's mouth. The resident continued to remain unresponsive. At 1:20 p.m., the MDS coordinator returned to the resident's room and reported EMS had been called and the resident was to be transported to the hospital. At 1:30 p.m., the resident was transported to the hospital by the EMS. At 3:25 p.m., the corporate nurse and DON were interviewed regarding the attempt to feed the resident. The DON reported the physician should have been notified of the initial low blood sugar and been made aware of the resident's mental status and inability to respond. The DON reported the resident should have been transferred to the hospital at that time and no attempt should have been made to give the resident food or fluids.