Every finding on record at Aspen Health and Rehab

Based on record review and interview, the facility failed to develop a resident's care plan for dementia for 1 (#14) of 23 sampled residents reviewed for dementia. Findings: An undated care plan policy, read in part, Facility will develop and review the care plan of each resident .the IDT team will develop and review the care plan .The care plan will specify the opportunities, goal and interventions. A medical diagnoses list for Resident #14, dated 12/20/24, showed the resident had a diagnosis of dementia. A care plan for Resident #14, dated 04/09/26, showed the resident had dementia as a diagnosis which had not been cared planned. On 05/18/26 at 3:13 p.m., RN #1 stated Resident #14 had a diagnosis of dementia which had not been care planned. On 05/18/26 at 4:38 p.m., the administrator stated it was their expectation for an RN to care plan a resident's diagnosis of dementia.

Based on record review and interview, the facility failed to ensure grievances were filed without fear of reprisal for 1 (#3) of 3 sampled residents who were reviewed for grievances. The administrator identified 93 residents resided at the facility. Findings: A grievance form, dated 04/03/25, showed a concern for Resident #3 regarding a resident they did not like. The intervention showed the administrator, AD, and SSD spoke to the resident. A quarterly assessment, dated 04/21/25, showed Resident #3 had a BIMS of 15, which indicate their cognition was intact, and diagnoses which included hypertension, renal insufficiency, and diabetes. A grievance form, dated 06/30/25, showed a concern for Resident #3 as resident to resident. No intervention was provided on the grievance form. A social services/activities note, dated 06/30/25, showed the SSD and AD met with Resident #3 to address their complaints. The note showed the conversation included a question to Resident #3 about if the resident was happy living at the facility and if not, should they consider whether the facility was the right place or not. The note showed Resident #3 became very angry and gestured twisting their mouth and stated, So I'll just shut my mouth and not say a word ever again. The note showed Resident #3 asked the SSD to leave. On 07/03/25 at 2:32 p.m., Resident #3 stated they were told by social services if they kept complaining, there were other homes they could go to. Resident #3 stated they turned in complaints about the multiple staff's children being unsupervised at the facility. Resident #3 stated a couple of days ago, the SSD sort of threatened them when the SSD told them if they kept complaining, they would find them other placement. On 07/07/25 at 9:33 a.m., the representative for Resident #3 stated the SSD and AD had the conversation with Resident #3 on 06/30/25 on video with audio. The representative stated they would bring the video to the facility when they visited Resident #3. On 07/07/25 at 12:06 p.m., the representative informed the surveyor they were in the room of Resident #3 and had brought the recorded video segment in question. The video was observed. The video segment was dated 06/30/25 and showed the activities director in view but the social services director was not. A conversation was taking place. At 3:54 p.m. in the video, the AD was observed to stand and inform they had a call and left the room. The conversation continued with an unseen visitor. The visitor stated they Were working on the child thing. The visitor continued to say, You gotta be careful how much you complain about things that are not in your control. Resident #3 questioned Not in my control? The visitor responded, Yeah, like the children are not in your control, and that's okay, we are working on that. The puzzles are not in your control, [Resident #2] is not in your control and you complain constantly. After watching the video, Resident #3 was asked how that conversation made them feel. They stated It doesn't matter what I think. You really don't have a lot of rights here. The activities person says it is my home and to come to them with any issues, but when I do, this happens. Resident #3 began to cry. Resident #3 stated it has taken their joy of being around people. On 07/08/25 at 9:49 a.m., the AD stated a resident could not make too many grievances. The AD stated they would turn in anyone who told a resident to stop complaining. The AD stated on 06/30/25, they had to leave the conversation with Resident #3 to take a phone call, but had asked the SSD how the remainder of the discussion went and the SSD informed them it ended ok. The AD stated Resident #3 requested to speak to them several days later and when they followed up the surveyor was in the room. On 07/08/25 at 10:15 a.m., the SSD stated they were involved with resident concerns by providing comfort, education, listening, re-direction, and getting representative involvement when needed. The SSD stated if the concern was something problematic they became involved. They gave an example of what would be problematic, such as interfering with the care of a resident to the point of causing harm. The SSD stated the only reason a resident would be transferred would be if the resident was unhappy at the facility either with peers or conditions. They stated, Otherwise it's people who were unhappy with having rules. The social services director stated, There is a common thread, people start acting like a prisoner when they are consistently unhappy. The SSD was asked to react to the statement, You need to be careful how much you complain. The SSD stated they would not like that and it should not be said. The SSD stated if they had said that they would correct and clarify it. On 07/08/25 at 10:52 a.m., the administrator stated their policy for grievances was a resident could submit a grievance to any administrative staff member in person or in writing, and all grievances came to the administrator. The administrator stated a resident could submit as many grievances as they wished. The administrator stated they usually determined the root cause and either assigned it to the corresponding department or involved social services and activities. They stated they had reviewed cameras to verify if something happened or not in the past. The administrator was asked why a resident would be told to be careful how much you complain about things you have no control over. They stated they had not heard that and did not know what context that would be in.

Based on observation and interview, the facility failed to maintain comfortable sound levels in halls, by resident rooms, and resident common areas of the facility. The facility alphabetical room roster showed there were 100 residents. On 06/04/25 at 4:30 p.m., several children were observed in the second floor billiard room, playing with the billiard balls on the billiard table by slamming the billiard balls against one another. The children's voices were loud. On 06/04/25 at 6:00 p.m., two children were observed entering the elevator. The children appeared to be under the age of 10 and each wore the walkie-talkie style headset the staff wore for inter-facility communication. On 06/04/25 at 6:15 p.m., a group of children stood in the first floor hallway, near an open office door. Another group of children were observed to access resident snacks off of the snack cart by the first floor nurses' station. On 06/06/25 at 1:00 p.m., Resident #A stated the administrator's child would come through and pass out activity calendars or other things. The resident stated this week, the administrator's child brought another child into the resident's and asked the resident if they wanted ice. On 06/06/25 at 1:17 p.m., Resident #B stated there were kids in the hallways and in the therapy department. The resident stated the children jumped on the trampoline and played on the therapy equipment. On 06/06/25 at 1:25 p.m., Resident #C stated there were kids everywhere. The resident stated the children would come into the billiard room, slap the billiard cues together like they were [NAME] fighting, throw the billiard balls around, and/or slam the billiard balls together on and off the billiard table. Resident #C stated they had to repeatedly tell the children to quiet down and/or stop and felt it was not their duty to supervise someone else's children. The resident stated a child followed the nurse into the resident's room and laid on the resident's bed. Resident #C stated the child did not belong to the nurse, was not known to the resident, and did not ask permission to enter the room or be on the bed. The resident stated the nurse told the child to get up and that they should not be in the resident's bed/room. Resident #C stated they understood the administrator brought their child to work as well. The resident stated they understood child care was expensive but felt the children should not be left for the residents to supervise. Resident #C stated they did not feel they could bring their concern to the administrator since the administrator also brought their child to work. The resident stated, It's disturbing. On 06/06/25 at 1:35 p.m., Staff #D stated there were kids in the building that were unsupervised. The staff member stated the children did not stay in one room or office, but would wander the halls, enter residents' rooms, enter common areas, slap billiard cues together, slam billiard balls together, and make a lot of noise. Staff #D stated the children had parents that worked in the building, but the parents did not supervise the children. On 06/06/25 at 2:00 p.m., the administrator stated the children were informed of their expected behavior prior to the children being allowed to go about the facility. The administrator stated there were lots of people around providing supervision for the children. The administrator stated they would accept the deficiency every time because the children's presence was therapeutic to the residents.

Based on record review and interview, facility staff failed to follow the plan of care for 1 (#4) of 6 residents whose clinical records were reviewed. The facility alphabetical room roster showed there were 100 residents. Findings: An undated Closet Care Plan, for resident #4 showed the resident was confused at times, had left side weakness, and transferred with a mechanical lift/sling and two person assistance. The history and physical, dated 05/02/25, showed the resident was recently hospitalized for a stroke as well as a history of stroke with subsequent left side weakness and numbness. The history and physical showed the resident also had a history of dementia and chronic right should pain. The Care Plan, dated 05/02/25, showed the resident had activities of daily living performance deficit related to impaired mobility secondary to a stroke. The interventions showed the resident required partial moderate assistance with upper body dressing and personal hygiene. The interventions showed the resident required substantial to maximal assistance with toileting, showering, lower body dressing, and rolling side to side in bed. The interventions showed the resident was dependent with all other care related to activities of daily living. The comprehensive assessment, dated 05/07/25, showed resident #4 usually could make themselves understood and usually understood others, was moderately impaired in daily decision making with a BIMS score of 10, had functional range of motion in both upper and lower extremities, and was able to wheel themselves 150 feet in a manual wheelchair. The comprehensive assessment documented the resident was 5'9 tall and 201 pounds. A progress note, dated 05/14/25, read in part, Resident family member states that resident [sic] knee was injured during a transfer on Saturday night. Family states that resident was transferred without [the use of a mechanical lift] and leg got caught in wheelchair. Family member refused to let this nurse ask resident or spouse due to dementia diagnosis. The progress note showed the resident's physician was aware of the allegation and an x-ray was ordered. A facility reported incident, dated 05/14/25, showed the facility initiated an allegation of abuse/mistreatment involving CNA #1, LPN #1, and Resident #4. The report showed the CNA and LPN came into the resident's room to transfer the resident from their wheelchair to their bed. The report showed CNA #1 held the back of the wheelchair and LPN #1 stood in front of the wheelchair. The LPN advised the resident to place their hands around the nurse's neck and LPN #1 proceeded to lift the resident from the wheelchair. The note showed the LPN could not lift the resident high enough to clear the arm of the wheelchair and attempted to do so a few times before lifting them over the armrest and onto the bed. The note read in part, In the interim, [family member] stated that (the resident's) feet were caught in the foot pedals and this was also preventing [the resident] from clearing the wheelchair. The note showed that once the resident was on the bed, the (family member) felt LPN #1 was too quick in straightening the resident in bed. The report showed the resident was to transfer with the assistance of two staff members and a mechanical lift. The report showed LPN #1 admitted to transferring the resident without the use of a mechanical lift, but stated there were no complaints of pain and that family was not in the room at the time of the transfer. The report showed CNA #1 denied being in the room at the time of the transfer. The report showed the administrator reviewed camera footage and determined the family, LPN #1, and CNA #1 were all present at the time of the transfer. The report read in part, [CNA #1] had retrieved the nurse for assistance and both went in the room and shut the door. The Hoyer lift was clearly visible, right outside the resident room. Both staff members walked past the Hoyer lift. The report showed both staff members were terminated and the remaining staff were in-serviced on following the closet care plan. A physician's progress note, dated 05/15/25, showed the x-ray to left knee was performed and the physician's impression of the x-ray was no acute fracture or dislocation present but there was moderate osteoarthritic changes notes. The note showed the resident had a left knee brace in place during the examination. On 06/04/25 at 5:00 p.m., family member #1 stated the resident was to be transferred by mechanical lift per the resident's closet care plan. The family member on a weekend afternoon, a CNA and nurse entered the room to transfer the resident from their wheelchair to their bed. The family member stated the two did not use a mechanical lift and instead transferred the resident by violently jerking the resident up out of the wheelchair. The family member stated the CNA was behind the wheelchair and the nurse was in front of the wheelchair. The family member stated the nurse jerked the resident upward and toward the bed but was unable to clear the left arm rest of the wheelchair. The family member stated the nurse attempted the transfer again and again, each time hitting the resident's hip into the hard arm rest. The family member stated the resident's feet were caught up in the foot pedals and front wheels of the wheelchair and did not have their feet planted for the transfer nor have the space to assist with the transfer. The family member stated the nurse sat the resident back down and then quickly jerked the resident up off their feet and with feet dangling, twisted and let go of the resident over the bed. The family member stated the resident was left with their head dangling off one side of the bed and their legs/feet off the other side of the bed. The family member stated the nurse then grabbed the resident by the arm and quickly reoriented the resident so their head was at the head of the bed. The family member stated this action was done too quickly for the resident. The family member stated this incident left the resident and family distraught. The family member stated after the incident, the resident complained of left knee pain and was unable to participate in physical therapy to the same level as before the transfer. On 06/05/25 at 2:00 p.m., Therapist #1 stated Resident #4 did complain of left knee pain and was not able to participate in therapy to the same level for a few days after the incident but was back to the same level as before the incident within the week. The therapist stated the resident would participate in therapy until the resident complained the left knee would dislocate and they could no longer bear weight on the joint. The therapist stated the resident would move the knee around to get the joint back in place. The therapist stated sometimes the knee joint would go back in place and the resident would resume therapy but most often it did not and any weight bearing therapy was halted for the day. The therapist stated the knee brace helped to some extent and so did the administration of pain medication an hour before therapy. The therapist stated the knee did limit the resident's ability to bear weight but felt it only delayed the resident's plateau in their level of function by a few days. The therapist stated they felt the transfer incident had little overall effect of the resident's course of therapy. On 06/06/25 at 11:20 a.m., the administrator stated when they were notified of the incident regarding the CNA and nurse not following the plan of care, they immediately reported the incident to the State and licensing agencies. The administrator stated they started their investigation of the incident but could only substantiate that the staff did not follow the plan of care. The administrator stated the closet care plan was one of their primary ways to communicate a resident's personalized care needs and Resident #4's closet care plan showed they were to transfer with a mechanical lift.

On 04/01/25 at 9:18 a.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from abuse and neglect. A nurse's statement, dated 03/27/25 at 11:15 p.m., showed Resident #1 reported to RN #1, CNA #1 on the evening shift was mean and hurt them. Resident #1 reported CNA #1 threw them on the bed hard enough to make the bed move and hurt them every time CNA #1 was their aide. Resident #1 reported CNA #1 had been hurting them for a while and they were afraid to report it because they were afraid CNA #1 would get meaner. RN #1 documented Resident #1 broke down into tears crying and asked to keep CNA #1 out of their room. On 03/31/25 at 11:39 a.m., Resident #1 stated the incident on 03/27/25 made them feel abused in a way. Resident #1 then stated to the surveyor, on 03/30/25 on the night shift, when they called for assistance to the restroom, CNA #2 told them to just go in your brief because they could not lift them to take them to the restroom due to having a bad back. Resident #1 stated CNA #2 changed their brief once, then did not check on them the rest of the night. Resident #1 stated they did not use their call light again because they knew CNA #1 would not assist them to the restroom. Resident #1 stated by the morning they were soaked through their brief, gown, and linens on the bed. On 04/01/25 at 4:44 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 04/01/25 at 4:49 p.m., the administrator was notified of the IJ situation and provided the IJ template. On 04/02/25 at 1:27 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Plan of Removal: 1. ALL STAFF will be inserviced in-person on the Abuse and Neglect policy PRIOR to their next shift by the ADMINISTRATOR, DON [director of nursing], OR ADON. ALL STAFF will be given a written competency exam on the Abuse and Neglect Policy. Anyone who is on leave for FMLA [The Family and Medical Leave Act] leave, vacation, or otherwise cannot physically come to the facility will be inserviced by phone. ALL STAFF will be inserviced by Wednesday 4/2/25. Any PRN[as needed] or Part-time staff who do not have a scheduled shift, and who do not respond to repeated phone calls, will be inserviced prior to their next scheduled shift. On 4/1/25 at 4pm, Department Head Staff was brought to conference room, inserviced on the Abuse and Neglect Policy by the Administrator and issued a competency exam on the Abuse and Neglect policy. Once they were inserviced and passed the exam, they were given a phone list to make immediate calls to inform ALL STAFF of the required IN PERSON inservice that they are required to attend prior to their next shift. All dates and times that phone calls were made was documented. Calls to ALL STAFF were completed by 5pm. Any staff who did not answer their phone were left a voicemail with instruction. After the Department Head Staff was inserviced on 4/1/25 at 4pm, ALL STAFF present in the building was relieved from their post one at a time, brought to the conference room, inserviced, and given a written competency exam. ADON will be at the facility at 9:30pm on 4/1/25 to inservice and give competency tests to all 10pm-6am staff. ADON will be at the facility at 5:30am on 4/2/25 to inservice and give competency tests to all 6am-2pm staff. ADMINISTRATOR will give all 2pm-10pm staff inservice and competency tests on 4/2/25. All remaining staff will be contacted by a member of the Department Team by phone to be inserviced and given the exam orally on 4/2/25. 2. ALL STAFF will take a written (oral if by phone) competency exam on the Abuse and Neglect Policy immediately following the inservice. The inservice will be conducted in small groups or one-on-one to ensure understanding. 3. ALL alert and oriented residents will be interviewed for potential abuse allegations by end of business day 4/2/25. 4. IJ will be resolved by 4pm on 4/2/25. The IJ was lifted, effective 04/02/25 at 4:34 p.m., when all components of the plan of removal had been verified as completed, with interviews and review of in-service documentation. The deficient practice remained at pattern level with the potential for more than minimal harm. Based on record review and interview, the facility failed to protect the resident's right to be free from physical abuse and neglect by staff for 3 (#1, 2 and #3) of 3 sampled residents who were reviewed for abuse and neglect. The administrator identified 103 residents who resided at the facility. Findings: 1. An Abuse, Neglect, Misappropriation and Exploitation Investigation & Reporting policy, revised 10/18/22, read in part, The Facility will endeavor to protect residents from abuse neglect and exploitation.It recognizes resident rights to be free from physical, verbal or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints.Neglect. The failure to provide protection for a vulnerable adult who is unable to protect his or her own interest; the failure to provide a vulnerable adult with adequate shelter, nutrition, health care, .or negligent acts or omissions that result in harm or the unreasonable risk of harm to a vulnerable adult through the action, inaction, or lack of supervision by a caretaker providing direct services.Abuse. A caregiver causing or permitting: 1. the infliction of physical pain, injury, sexual abuse, sexual exploitation, unreasonable restraint or confinement, or mental anguish, or 2. the deprivation of nutrition, clothing, shelter, healthcare, or other care or services without which serious physical or mental injury is likely to occur to a vulnerable adult by a caretaker or other person providing services to a vulnerable adult. Resident #1 had diagnoses which included polyneuropathy, right knee osteoarthritis, constipation, hypertension, age related physical debility, and a history of transient ischemic attack (mini-stroke). Review of the January grievance log showed on 01/23/25, a resident had a concern with wait times and etiquette. The intervention was shown to be an inservice of floor staff on 01/23/25. No named staff were provided on the form. Review of the March grievance log showed on 03/17/25, a resident had a concern for not being changed when asked. The intervention was shown to be discipline by the ADON. No named staff were provided on the form. An admission assessment, dated 03/23/25, showed Resident #1 had a BIMS of 15, which indicated they were cognitive for daily decision making. Resident #1 required substantial/maximal assistance for toileting hygiene, lower body dressing, putting on/taking off footwear, and toilet transfers. The assessment showed Resident #1 required partial/moderate assistance with upper body dressing, lying to sitting on side of bed, sitting to standing and chair/bed-to-chair transfers. The assessment showed Resident #1 was frequently incontinent of bowel and bladder. A written nurse's statement, dated 03/28/25, showed RN #1 documented Resident #1 broke down into tears crying and asked to keep CNA #1 out of their room. Resident #1 stated it made them feel abused in a way. A care plan, initiated 03/31/25, showed Resident #1 had an ADL (activity of daily living) self-care deficit related to decreased mobility. The care plan showed interventions which included assist of one staff member with bed mobility, dressing, and to encourage the resident to participate to the fullest extent possible with each interaction. On 03/31/25 at 11:39 a.m., Resident #1 recounted the incident which occurred on 03/27/25 at 11:15 p.m. Resident #1 stated they reported to RN #1, CNA #1 on the evening shift, was mean and hurt them. Resident #1 stated CNA #1 threw them in the bed hard enough to make the bed move and hurts them every time CNA #1 was their aide. Resident #1 stated CNA #1 had been hurting them for a while and they were afraid to report it because they were afraid CNA #1 would get meaner. Resident #1 then stated to the surveyor on 03/30/25 on the night shift, when they called for assistance to the restroom, CNA #2 told them to just go in your brief because they could not lift on them to take them to the restroom due to having a bad back. Resident #1 stated CNA #2 changed their brief once, then did not check on them the rest of the night. Resident #1 stated they did not use their call light again because they knew CNA #1 would not assist them to the restroom. Resident #1 stated by the morning they were soaked through their brief, gown, and linens on the bed. The incident on 03/30/25 on the night shift was reported to the administrator by the surveyor on 03/31/25 at 11:54 a.m. On 03/31/25 at 3:05 p.m., the administrator stated they had suspended CNA #1. The administrator stated they had never received a complaint against CNA #1 before. The administrator stated CNA #1 had admitted to rushing Resident #1. The administrator stated CNA #1 had given them a two page statement. The administrator stated CNA #1 will not come back until 04/02/25. The administrator stated they had a conversation about bones, fragility of the elderly with CNA #1. The administrator stated to this point in their investigation they had not found any other residents who were affected by the care of CNA #1. The administrator stated CNA #1 would be shadowed for several weeks before working independently. The administrator stated they did not believe CNA #1 intentionally hurt Resident #1. On 03/31/25 at 3:40 p.m., CNA #1 was interviewed via phone. CNA #1 stated they had been employed by the facility twice for a total of two or three years and had been back approximately six months. CNA #1 stated for the past month they had worked D hall where Resident #1 lived. CNA #1 stated sometimes they felt rushed if they spent a lot of time with a resident and had a lot of call lights on. CNA #1 was asked about types of abuse and they stated forcing residents to do something they do not want to, screaming at residents and touching residents hard would be abuse. CNA #1 stated not providing care and services would be neglect. CNA #1 stated they had told Resident #1 they were too busy to help them and to just go in their brief because they did not have time. They stated it was neglect. On 03/31/25 at 4:10 p.m., staff #1 stated they worked the night shift. Staff #1 stated they had written a statement about CNA #1 being mean and hurting Resident #1 because Resident #1 had reported the incident to them. Staff #1 stated they had spoken to CNA #1 about the incident and CNA #1 admitted to them they were being mean because they were busy and stressed. Staff #1 stated they had reported it to the charge nurse. Staff #1 stated what was reported to them by Resident #1 would be an abuse allegation. On 04/01/25 at 9:30 a.m., the administrator was asked what measure had been implemented to ensure the safety of all residents. The administrator stated CNA #1 would return to work on 04/02/25 and would work with a shadow. The administrator stated they would review abuse/neglect with CNA #1 and reiterate what had been previously discussed before CNA #1 provided any care to the residents. 2. A quarterly assessment for Resident #2, dated 03/11/25, showed the resident's cognition was intact with a BIMS score of 15. On 03/31/25 at 12:05 p.m., Resident #2 stated CNA #1 would usually come in to turn off the call light, say they would return, but never would. 3. A quarterly assessment for Resident #3, dated 02/02/25, showed the resident's cognition was intact with a BIMS score of 15. On 03/31/25 at 12:42 p.m., Resident #3 stated they could not remember staff names, but a couple of the CNAs were just awful. Resident #3 stated one of them jerked them around in the bed. Resident #3 stated another aide would throw the call light at them when they were finished providing care. Resident #3 stated sometimes the aides would get anxious and turn them really quickly, and it made them feel like they were going to fall off the bed. Resident #3 stated they had been told to just pee in my brief once or twice because the staff did not have time. Resident #3 stated they had not reported the incidents because they did not want to cause problems.

Based on record review and interview, the facility failed to ensure labs were completed as ordered by the physician for 2 (#2 and #6) of 3 sampled residents whose labs were reviewed. The ADON identified 113 residents who resided in the facility. Findings: 1. Resident #2 had diagnoses which included chronic obstructive pulmonary disease. The progress note by the physician, dated 02/20/25 at 2:01 p.m., read in part, Please obtain readmit labs. Review of the clinical record did not show the readmission labs had been completed. On 02/27/25 at 4:19 p.m., the DON stated the charge nurses were responsible to ensure physician orders from the progress notes were implemented. They stated medical records staff reviewed the clinical record to ensure orders were implemented. On 02/27/25 at 4:22 p.m., medical records #1 stated they completed daily audits to ensure labs ordered by the physician had been implemented and ordered from the lab company. They stated they would look for the labs for Resident #2. On 02/27/25 at 4:48 p.m., medical records #2 stated they did not have any readmission labs for Resident #2. On 03/03/25 at 1:53 p.m., the DON stated they did not know why the readmission labs were not completed for Resident #2. 2. Resident #6 had diagnoses which included congestive heart failure. A progress note by the physician, dated 01/16/25 at 9:34 a.m., read in part, CBC [complete blood count], CHEM 8 [basic metabolic panel], A1c [glycated hemoglobin]. Review of the clinical record did not show the labs had been completed as ordered by the physician. On 03/03/25 at 1:50 p.m., the DON stated the labs the physician ordered on 01/16/25 had not been completed. They stated they did not know why the lab orders had not been implemented. They stated the medical records department monitored physician progress notes to ensure orders were implemented.

Based on record review and interview, the facility failed to ensure medication orders from the physician were implemented for 2 (#2 and #4) and failed to ensure daily weights were obtained as ordered by the physician for 1 (#4) of 3 sampled residents who were reviewed for quality of care. The ADON identified 113 residents who received medications and 20 residents who were ordered daily weights. Findings: 1. Resident #2 had diagnoses which included low back pain and chronic pain. A physician order, dated 02/23/24, showed Resident #2 had been ordered cyclobenzaprine (a muscle relaxer) 10 mg every 12 hours as needed. The progress note by the physician, dated 02/20/25 at 2:01 p.m., read in part, Discontinue cyclobenzaprine. Review of the February 2025 medication administration record showed Resident #2 had been administered cyclobenzaprine 10 mg on 02/20/25 at 7:01 p.m. and on 02/23/25 at 12:36 a.m. The February 2025 medication administration record did not show the cyclobenzaprine had been discontinued per the physician's order. On 02/27/25 at 4:19 p.m., the DON stated the nurses implemented the physician orders and the medical records staff reviewed the physician orders and progress notes every day to ensure orders had been implemented. On 02/27/25 at 4:22 p.m., medical records #1 stated they ran a report of the physician progress notes daily and ensured the physician orders were implemented. They stated they would need to check on the cyclobenzaprine order for Resident #2. On 02/27/25 at 4:48 p.m., medical records #1 stated the order to discontinue the cyclobenzaprine had been missed. On 03/03/25 at 1:53 p.m., the DON stated they did not know why the cyclobenzaprine had not been discontinued or how it was missed during the daily audits. 2. Resident #4 had diagnoses which included hypertension and generalized edema. The progress note by the physician, dated 02/18/25 at 10:16 a.m., read in part, Daily weights. Review of the February 2025 treatment administration record showed a daily weight for fluid retention had not been obtained on 02/24/25 or 02/25/25. The progress note by the physician, dated 02/26/25 at 1:43 p.m., read in part, DC [discontinue] losartan [a medication used for high blood pressure] due to low BP [blood pressure]. Review of the February 2025 medication administration record showed Resident #4 continued to have losartan 25 mg ordered and the medication had been held, due to vital signs outside of parameters, on 02/26/25 and 02/27/25. The Nsg [nursing] Discharge Instructions v5 form, dated 02/27/25, showed Resident #4 had been discharged home from the facility and medications had been given to the family or the resident. The form was signed by LPN #1. The Medications Released on Leave of Absence/Discharge form, dated 02/27/25, showed Resident #4 was discharged with five losartan 25 mg tablets. On 03/03/25 at 1:13 p.m., the DON stated the charge nurses were responsible to obtain daily weights. They stated they had recently had a staffing change and the daily weights for Resident #4 had not been obtained. The DON stated they monitored weights weekly, on Thursdays, to ensure daily weights were obtained per the physician orders. They stated Resident #4 had discharged , from the facility, before the weekly meeting so they had not identified weights were not obtained on 02/24/25 or 02/25/25. The DON stated they sent the medication administration record with residents upon discharge. They stated LPN #1 had discharged Resident #4 so they would need to ask them what medications were sent with the resident upon discharge to home. On 03/03/25 at 1:54 p.m., LPN #1 stated they provided residents who were discharging their medications, discharge instructions, and a list of medications they sent with them. LPN #1 reviewed the Medications Released on Leave of Absence/Discharge form for Resident #4 and stated they had sent the listed medications, including losartan 25 mg, with Resident #4 upon discharge from the facility. On 03/03/25 at 2:19 p.m., the DON stated they reviewed the clinical record for Resident #4. They stated the daily weights had not been obtained on 02/24/25 or 02/25/25 and the losartan had not been discontinued as ordered by the physician. The DON stated the nurses on the second floor of the facility were not aware they needed to review the physician progress notes for orders.

Based on observation, record review, and interview, the facility failed to ensure assessments were accurate for 1 (#3) of 7 sampled residents whose assessments were reviewed. The administrator identified 113 residents who resided in the facility. Findings: On 02/27/25 at 1:50 p.m., a BiPap was observed on Resident #3's nightstand. Resident #3 had diagnoses which included sleep apnea. A physician's order, dated 09/02/22, showed the resident was to wear a BiPap at bedtime. The quarterly assessment, dated 01/11/25, showed the resident did not utilize a non-invasive mechanical ventilator. On 03/03/25 at 8:51 a.m., Resident #3 stated they utilized their BiPap every night. On 03/03/25 at 1:34 p.m., MDS (minimum data set) coordinator #1 reviewed the quarterly assessment and stated the assessment was inaccurate for Resident #3. They stated the assessment should have shown the resident utilized a non-invasive mechanical ventilator.

Based on record review and interview, the facility failed to ensure allegations of abuse were reported to the Oklahoma State Department of Health within 2 hours for 1 (#1) of 3 sampled residents who were reviewed for abuse. The administrator identified 113 residents who resided in the facility. Findings: Resident #1 had diagnoses which included unspecified dementia. The Abuse, Neglect, Misappropriation and Exploitation Investigation and Reporting policy, dated 10/18/22, read in part, All alleged violations will be reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do no involve abuse and do not result in serious bodily injury. The following persons or entities will be notified, as required by state law, by Facility personnel (Administrator or Administrator Designee): a. Administrator b. State Survey Agency. The ODH form 283 showed an initial report for allegation of abuse/mistreatment, for Resident #1, dated 02/16/25. The ODH form 283 showed on 02/17/25 at approximately 4:00 p.m., Resident #1 reported to the ADON, that sometime during the evening shift on 02/16/25, an unidentified person put their finger in Resident #1's vagina. The fax cover sheet showed the ODH form 283 initial report for the sexual abuse allegation for Resident #1 was not sent to the State Agency within 2 hours. The fax cover sheet showed the ODH form 283 was not sent until the next day, on 02/18/25 at 1:24 p.m. On 03/03/25 at 3:40 p.m., the ADON stated on 02/17/25 Resident #1 had reported an allegation of sexual abuse from 02/16/25 and they immediately notified the administrator and DON. On 03/03/25 at 3:42 p.m., the administrator stated the ADON reported the allegation of sexual abuse, for Resident #1, to them on 02/17/25. The administrator stated they were the abuse coordinator for the facility. The administrator stated they did not know they were to report allegations of abuse to the State Agency within 2 hours. They stated they thought they had 24 hours to report allegations of abuse to the State Agency.

Based on observation and interview, the facility failed to secure protected health information for six (Resident #206, #310, #315, #316, and Resident #318) of six residents whose protected health information was observed in a bin secured to the wall outside of a social service office. The administrator identified 113 residents in the facility. Findings: On 06/30/24, during the initial tour, the protected health information for six (Resident #206, #310, #315, #316, and Resident #318) of six residents was observed hand written on six sheets of paper observed in a a wall bin just outside of an office for social services. Each sheet of paper listed a resident's name, room number, sex, diagnoses, insurance, number of skilled nursing days available, hospital admitted , therapy ordered, prior living environment, and the resident's goal for their discharge living environment. On 07/03/24 at 3:50 p.m., the administrator reviewed the documents and stated the records were not secured.

Based on observation, record review, and interview, the facility failed to ensure interventions were developed to treat limited range of motion for one (#27) of one sampled residents who were reviewed for limited range of motion. The DON identified 34 residents who had limited range of motion. Findings: Resident #27 had diagnoses which included paralytic syndrome affecting right dominant side. The Care Plan, revised 05/16/24, documented the resident had hemiplegia/hemiparesis of the right side and would remain free of complications through the review date. The quarterly assessment, dated 05/29/24, documented the resident was cognitively intact for daily decision making and had impairment on one side of the upper extremity. The Nsg Admit/Readmit/Quarterly Assessment, dated 06/24/24, documented the resident had limited range of motion to one hand. On 06/30/24 at 9:12 a.m., Resident #27 was observed in their room. Their right hand was observed to be closed with no splints or devices in place. Resident #27 stated they could not fully open their hand. On 07/02/24 at 3:42 p.m., the DON stated the Resident #27 had a contracture to their right hand since admission to the facility. The DON was asked what interventions were in place related to the contracture/limited range of motion for Resident #27. They stated they would need to review the care plan. On 07/02/24 at 3:49 p.m., the DON and MDS coordinator #1 stated Resident #27 had participated in the restorative program, in September 2023, for transfers. On 07/03/24 at 10:54 a.m., the DON stated they had not implemented/developed interventions for the limited range of motion/contracture for Resident #27. The DON stated the charge nurses performed weekly skin assessments and they would expect them to report any contractures or a change in a resident's range of motion.

Based on record review and interview, the facility failed to ensure residents were monitored for side effects from psychotropic medications for five (#5, 27, 39, 52, and #86) of five sampled residents who were reviewed for unnecessary medications and failed to implement pharmacy recommendations as ordered by the physician for one (#5) of five sampled residents who were reviewed for unnecessary medications. The DON identified 50 residents who received psychotropic medications. Findings: 1. Resident #5 had diagnoses which included depression. The Ace 51 Anti-Depressant-Evaluation of Continued Need v2 form, from the pharmacist, dated 06/28/23, documented to evaluate the use of antidepressants and the resident was ordered Doxepin 50 mg at bedtime. The form read in part, .New Orders Decrease doxepin to 25mg 1 PO q HS . The form documented the physician had provided new orders and the resident's record had not been updated with the current physician orders. The Ace 50 Nurse See Previous Report form from the pharmacist, dated 07/30/23, read in parts, .June UDA indicated a new order to decrease to doxepin 25mg, 1 tab QHS. Nursing section on UDA acknowledges new order was given but indicates resident record was not updated with current physician orders-could not find any doc why reduction not done . The Medication Administration Record, dated August 2023, documented the resident was ordered Doxepin 50 mg at bedtime on 06/14/23 and it had not been discontinued until 08/05/23. The Side Effects Monthly Flow Sheet, dated April 2024, documented side effects for antidepressant medication use was documented six times out of 90 opportunities. The Side Effects Monthly Flow Sheet, dated May 2024, documented side effects for antidepressant medication use was documented two times out of 93 opportunities. The annual assessment, dated 05/23/24, documented an antidepressant medication was received during the look back period. The Side Effects Monthly Flow Sheet, dated June 2024, documented side effects for antidepressant medication use was documented 47 times out of 90 opportunities. The Care Plan, revised 06/05/24, documented the resident received antidepressant medication and staff were to monitor and document side effects/effectiveness every shift. The Progress Note from the nurse practitioner, dated 06/11/24, read in part, .Decrease Lexapro to 5mg PO q day x 14 days then DC . The Medication Administration Record, dated June 2024, documented Resident #5 had received Lexapro 10 mg one tablet daily from 06/01/24 through 06/24/24 and Lexapro 5 mg one tablet daily from 06/12/24 through 06/24/24. On 07/03/24 at 12:16 p.m., the DON reviewed the clinical record and stated the order to decrease the Doxepin for Resident #5 should have been implemented within five days of receiving the physician approved pharmacy recommendation. They stated they did not know why the medication order had not been changed until 08/05/23. The DON stated they did not know why the Lexapro 10 mg tablet had not been discontinued when the physician had ordered Lexapro 5 mg daily for 14 days then discontinue. On 07/03/24 at 3:11 p.m., the DON stated charge nurses were to monitor and document side effects of psychotropic medications every shift on the side effect monitoring flow sheets. They stated they did not know why side effects had not been documented as monitored each shift for Resident #5. 2. Resident #27 had diagnoses which included major depressive disorder and schizoaffective disorder. The Side Effects Monthly Flow Sheet, dated April 2024, documented side effects for antidepressant and antipsychotic medication use was documented six times each out of 90 opportunities. The Side Effects Monthly Flow Sheet, dated May 2024, documented side effects for antidepressant and antipsychotic medication use was documented one time each out of 90 opportunities. The Care Plan, revised 05/16/24, documented to monitor for side effects and effectiveness of psychotropic medications and document every shift. The quarterly assessment, dated 05/29/24, documented the resident had received an antidepressant medication and antipsychotic medication during the look back period. The Side Effects Monthly Flow Sheet, dated June 2024, documented side effects for antidepressant and antipsychotic medication use was documented 48 times each out of 90 opportunities. Review of the clinical record revealed Resident #27 had received an antidepressant and an antipsychotic medication in April, May, and June 2024. On 07/03/24 at 3:11 p.m., the DON stated charge nurses were to monitor and document side effects of psychotropic medications every shift on the side effect monitoring flow sheets. They stated they did not know why side effects had not been documented as monitored each shift for Resident #27. 46703 3. Resident #86 had diagnoses which included bipolar disorder, schizoaffective disorder, depression, and anxiety. A Care Plan, dated 05/17/24, documented to administer medication as directed and monitor/document for side effects and effectiveness. The Side Effects Monthly Flow Sheet, dated June 2024, documented side effect monitoring for antianxiety medication use was documented seven times out of 90 opportunities. The Side Effects Monthly Flow Sheet, dated June 2024, documented side effect monitoring for antipsychotic medication was documented six times out of 90 opportunities. The Side Effects Monthly Flow Sheet, dated June 2024, documented side effect monitoring for antidepressant medication was documented six times out of 90 opportunities. 42171 4. Resident #39 had diagnoses which included anxiety disorder and depressive disorder. The Care Plan, dated 05/28/24, documented to administer antidepressant medications as ordered and to document side effects every shift. The five-day Medicare assessment documented the resident received antidepressant and antianxiety medications during the look back period. The Side Effects Monthly Flow Sheet, dated April 2024, documented side effects for antidepressant medication use was documented six times out of 90 opportunities. The Side Effects Monthly Flow Sheet, dated May 2024, documented side effects for antidepressant medication use was documented one time out of 93 opportunities. The Side Effects Monthly Flow Sheet, dated June 2024, documented side effects for antidepressant medication use were documented 51 times out of 90 opportunities. The Side Effects Monthly Flow Sheet, dated April 2024, documented side effects for antianxiety medication use was documented six times out of 90 opportunities. The Side Effects Monthly Flow Sheet, dated May 2024, documented side effects for antianxiety medication use was documented one time out of 93 opportunities. The Side Effects Monthly Flow Sheet, dated June 2024, documented side effects for antianxiety medication use was documented 51 times out of 90 opportunities. 30267 5. Resident #52 had diagnoses which included recurrent depressive disorder, bipolar disorder, anxiety, dementia, and inappropriate sexual behaviors. The care plan, revised 02/24/23, documented the resident had diagnoses of bipolar disorder and anxiety and to administer medications as ordered and monitor/document side effects and effectiveness. The care plan, revised 08/25/23, documented the resident was to receive a psychotropic medication as ordered by the physician and to monitor for side effects and effectiveness every shift. The Side Effects Monthly Flow Sheet, dated April 2024, documented side effects for antidepressant and antipsychotic medication use was documented 22 of 90 opportunities for the antidepressant and 23 of 90 opportunities for the antipsychotic. The Side Effects Monthly Flow Sheet, dated May 2024, documented side effects for antidepressant and antipsychotic medication use was documented 21 of 93 opportunities for the antidepressant and 21 of 93 opportunities for the antipsychotic. The care plan, revised 05/31/24, documented the resident was to receive antidepressant medications as ordered by the physician and to monitor and document side effects and effectiveness every shift. On 07/03/24 at 3:11 p.m., the DON stated charge nurses were to monitor and document side effects of psychotropic medications every shift on the side effect monitoring flow sheets. The DON stated they did not know why side effect monitoring was not documented for resident #52.

Based on observation and interview, the facility failed to ensure garbage containers in the food preparation area were covered with lids. The DM identified 112 residents who received services from the kitchen. Findings: On 06/30/24 at 8:04 a.m., a tour of the kitchen was conducted. A large garbage can without a lid was observed next to the metal food preparation table. The garbage can was filled with refuse including food waste from the breakfast meal. Three other large garbage containers without lids were observed beside a refrigerator. On 06/30/24 at 8:10 a.m., [NAME] #1 stated the garbage cans should be covered with lids. On 07/01/24 at 9:30 a.m., the DM stated they did not have a policy regarding refuse containers but, the garbage cans should always be covered with lids.

Based on observation, record review, and interview, the facility failed to assess a resident for continued need of an indwelling urinary catheter for one (#312) of four residents who were reviewed for catheters. The Administrator identified 12 residents with indwelling urinary catheters. Findings: Resident #312 was admitted to the facility on [DATE] with an indwelling urinary catheter and diagnoses which included a displaced intertrochanteric fracture of the left femur. On 06/30/24 at 2:00 p.m., Resident #312 was observed with an indwelling urinary catheter bag draining at bedside. On 06/30/24 at 2:10 p.m., Resident #312 stated they had a urinary catheter since being in the hospital because they couldn't walk to the bathroom. The resident stated they can use a urinal if they had to. On 07/02/24 at 1:56 p.m., LPN # 1 reviewed the resident's medical record and stated they could not find a diagnosis for the indwelling urinary catheter and the Resident #312 should not have one. On 07/02/24 at 2:40 p.m., the DON stated there was not a diagnosis requiring the Resident #312 to have an indwelling urinary catheter.

Based on observation, interview and record review, the facility failed to ensure: a. The temperature of the second-floor medication room was documented. b. The temperature of the second-floor medication refrigerator was documented. C. Treatment/medication carts were locked when unattended. The administrator reported the census was 120. Findings: A facility policy titled Medication Storage in the Facility dated 01/01/15, read in part, .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Medications and biologicals are stored at their appropriate temperatures and humidity .Room temperatures: 59 F - 77 F .Refrigeration 36 F - 46 F .the facility should maintain a temperature log in the storage area to record temperatures at least once a day . a. The upstairs medication room temperature log for June 2024 was reviewed, the temperature of the medication room was documented five times out of 30 opportunities. b. The upstairs refrigeration temperature log for June 2024 was reviewed, the temperature of the refrigerator was recorded six times out of 60 opportunities. c. On 07/03/24 at 8:24 am, an unlocked treatment cart was observed outside of room [ROOM NUMBER]. 07/03/24 at 8:43 am, CMA #3 stated medication and treatment carts should be locked when unattended. 07/03/24 at 9:15 am, LPN #1 stated they were unsure who was responsible for documenting the temperature of the medication room, they also stated medication carts and treatment carts should always be locked. 07/03/24 at 9:20 am, LPN #2 stated the lead CMA is responsible for temperature monitoring, they also stated it did not appear the temperature of the upstairs medication room or the temperature of the upstairs refrigerator had been documented since the first week of June. LPN #2 also stated medication and treatment carts should be locked when not in use. 07/03/24 at 10:25 am, the DON stated the lead CMA was responsible for documenting temperatures and that carts should be locked while staff is away.

Based on record review and interview, the facility failed to follow physician's orders when administering a medication for one (#1) of three sampled residents whose medication administration records were reviewed. The Detailed Census Report, dated 09/06/23, documented a census of 104 residents. Findings: Res #1 was admitted with diagnoses which included hypertension and atrial flutter. A physician's order, dated 03/17/23, read in part, Metoprolol (A drug for hypertension) 25mg, Give 1 tablet by mouth two times a day . Hold if SBP <120. The medication administration record for 03/17/23 through 03/31/23 documented Res #1's Metoprolol was administered four times when it should have been held: 03/17/23 at 7:00 a.m. - blood pressure was 110/70 03/18/23 at 7:00 a.m. - blood pressure was 118/63 03/20/23 at 7:00 a.m. - blood pressure was 110/79 03/22/23 at 7:00 p.m. - blood pressure was 112/57 The medication administration record for 04/01/23 through 04/30/23 documented Res #1's Metoprolol was administered 16 times when it should have been held: 04/04/23 at 7:00 p.m. - blood pressure was 114/65 04/12/23 at 7:00 p.m. - blood pressure was 117/71 04/13/23 at 7:00 p.m. - blood pressure was 113/71 04/15/23 at 7:00 p.m. - blood pressure was 115/66 04/16/23 at 7:00 p.m. - blood pressure was 117/75 04/18/23 at 7:00 p.m. - blood pressure was 111/58 04/19/23 at 7:00 p.m. - blood pressure was 104/65 04/22/23 at 7:00 p.m. - blood pressure was 108/70 04/23/23 at 7:00 a.m. - blood pressure was 109/77 04/23/23 at 7:00 p.m. - blood pressure was 93/65 04/26/23 at 7:00 p.m. - blood pressure was 110/59 04/27/23 at 7:00 p.m. - blood pressure was 117/61 04/28/23 at 7:00 p.m. - blood pressure was 113/58 04/29/23 at 7:00 p.m. - blood pressure was 119/77 04/30/23 at 7:00 a.m. - blood pressure was 102/57 04/30/23 at 7:00 p.m. - blood pressure was 115/78 The medication adminstration record for 05/01/23 through 05/26/23 documented Res #1's Metoprolol was administered five times when it should have been held: 05/06/23 at 7:00 p.m. - blood pressure was 100/65 05/07/23 at 7:00 p.m. - blood pressure was 114/75 05/13/23 at 7:00 p.m. - blood pressure was 102/72 05/14/23 at 7:00 p.m. - blood pressure was 107/63 05/22/23 at 7:00 p.m. - blood pressure was 116/68 On 09/07/23 at 11:15 a.m., LPN #1 reported Res #1's Metoprolol should have been held when their systolic blood pressure was below 120. On 09/07/23 at 1:30 p.m., the DON reported Res #1's Metoprolol should have been held per physician's orders.

Based on interview and record review, the facility failed to ensure residents and/or resident representatives were invited to and participated in their plan of care conference for one (#13) of one sampled resident reviewed for participation in care plan conferences. The Resident Census and Conditions of Residents report, dated 05/22/23, documented 88 residents resided in the facility. Findings: An undated, Care Plan Meetings policy, read in parts, .Social Services/designee will invite Resident and/or Family to attend the care plan meeting .The IDT will meet with the Resident and/or Family regarding resident's care .Documentation of the care plan meeting invitation will be placed in the Resident Medical Record .Documentation of the care plan meeting will be placed in the Resident Medical Record. Resident #13 had diagnoses which included neuropathy. An ICP Multidisciplinary Care Conference form, dated 02/22/23, documented the social worker and nursing administration were present for the care conference. The form did not document the resident's representative or the resident had attended the care conference. The clinical record did not reveal an attempt to invite either the resident or resident representative to the care conference. A quarterly assessment, dated 03/05/23, documented the resident was moderately impaired in cognition for daily decision making. On 05/22/23 at 1:33 p.m., Resident #13 stated they did not remember participating in a care plan meeting. On 05/24/23 at 4:32 p.m., the Care Plan Coordinator was asked who was responsible for conducting a care conference. They stated they were responsible and scheduled the care conference with themselves and social services. The Care Plan Coordinator was asked who was invited to the care conference. They stated if the resident was their own responsible person no other representatives were invited, unless requested by the resident. They stated if the resident had a responsible party, other than themselves, they were invited via letter. The Care Plan Coordinator was asked where the invitation was documented that the responsible party for Resident #13 had been invited to a care conference in February. They stated it was not documented. They stated the resident representative had previously requested to not be invited to the care conferences. The Care Plan Coordinator was asked where that had been documented. They stated it was not documented. The Care Plan Coordinator was asked where it was documented Resident #13 had attended their February care conference. They stated it was documented in the ICP Multidisciplinary Care Conference form. The Care Plan Coordinator was asked to review the 02/22/23 ICP Multidisciplinary Care Conference form. They stated it was not documented the resident had attended the care conference.

Based on observation, record review, and interview, the facility failed to ensure medications were administered as ordered for three (#16, 33, and #42) of 13 residents observed during medication administration. This resulted in a medication error rate of 12%. The administrator identified 88 residents who received medications in the facility. Findings: A Medications, Pharmacy Errors policy, dated 11/22/16, read in part, .Medications will be ordered from the local back up pharmacy as necessary in order to administer them as ordered and in a timely manner . 1. Resident #42 had diagnoses which included glaucoma. A Physician's Order, dated 05/09/22, documented to administer one drop of Brimonidine Tartrate (a medicated eye drop) 0.15% in each eye. On 05/23/23 at 3:06 p.m., CMA #2 was observed to administer Brimonidine Tartrate 0.15% eye drops to Resident #42. CMA #2 was observed to administer two drops to the right eye and one drop to the left eye. 2. Resident #16 had diagnoses which included dry eye syndrome. A Physician's Order, dated 07/26/22, documented to administer one drop of Olopatadine HCl Solution (a medicated eye drop) 0.2 % in the right eye. On 05/24/23 at 8:17 a.m., CMA #3 was observed to administer Olopatadine HCL Solution 0.2% to Resident #16. CMA #3 was observed to administer one drop in both eyes. 3. Resident #33 had diagnoses which included radiculopathy (a nerve disease) of the lumbosacral (lower back) region. A Physician's Order, dated 03/31/23, documented to administer 100mg of gabapentin (a nerve pain medication) once a day. On 05/24/23 at 8:38 a.m., CMA #3 was observed to prepare medications for Resident #33. CMA #3 stated they did not have the gabapentin medication that was scheduled to be given at that time. They stated the medication had been ordered the previous day and had not arrived. CMA #3 was asked what the protocol was if a medication was unavailable. They stated they would put a progress note in that documented they were awaiting pharmacy. The medication was not administered. Review of the clinical record did not reveal a hold order for the medication had been obtained or that the medication had been administered. On 05/25/23 at 9:13 a.m., the ADON was asked how CMAs were monitored, during administration of eye drops, to ensure they were administered per physician's orders. They stated instructions for eye drops were in the physician's orders and the pharmacy consultant monitored medication administration monthly. The ADON was asked what the protocol was for medication availability. They stated the CMAs documented a progress note, notified the charge nurse and ADON, and called the pharmacy. The ADON stated if the CMA/charge nurse could not call they would call for them. They stated if it was an emergency the pharmacy could send the medication as an immediate delivery. The ADON was asked why the protocol was not followed when the gabapentin was not available for administration on 05/24/23 for Resident #33. They stated they did not know but would find out.

Based on record review and interview, the facility failed to ensure residents with indwelling urinary catheters had documented intake and output measurements, per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON identified five residents with indwelling urinary catheters. Findings: 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The care plan, dated 11/18/20, read in parts, .Focus .The resident has suprapubic catheter r/t neuromuscular dysfunction of bladder .Interventions/Tasks .Monitor and document intake and output .Monitor/record/report to MD for s/sx [CONDITION(S)]: .no output . The resident's quarterly MDS assessment (a resident assessment tool used to identify resident care needs), dated 01/17/22, documented the resident had an indwelling catheter. Physician orders, dated April 2022, documented the facility was to measure intake and output every shift. Review of the April 2022 TAR revealed the resident's intake had not been documented on the night shift of 04/22/22 and the resident's output had not been documented on the night shift of 04/22/22 or the day shift of 04/25/22. 2. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission MDS assessment, dated 03/29/22, documented the resident had an indwelling catheter. The care plan, dated 04/11/22, read in parts, .Focus .The resident has suprapubic catheter related to [CONDITION(S)] and obstructive reflux [CONDITION(S)] .Interventions/Tasks .Monitor and document intake and output .Monitor/record/report to MD for s/sx [CONDITION(S)]: .no output . Physician orders, dated April 2022, documented the facility was to measure intake and output every shift. Review of the March and April 2022 TAR revealed the following: The resident's intake had not been documented on the day shift of 03/29/22, the evening shift of 04/10/22, the day shift of 04/22/22, the day shift of 04/23/22, or the evening shift of 04/23/22; and The resident's output had not been documented on the day shift of 03/29/22, the evening shift of 04/10/22, the night shift of 04/16/22, the day shift of 04/23/22, or the evening shift of 04/23/22. 3. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Physician order, dated 11/22/21, documented the facility was to measure Foley catheter intake and output every shift. The resident's admission MDS assessment, dated 11/25/21, documented the resident had an indwelling catheter. Review of the December 2021 TAR revealed the resident's intake and output had not been documented on the day shift of 12/10/21, the evening shift of 12/14/21, the day shift of 12/16/21, or the evening shift of 12/17/21. On 04/26/22 at 1:05 p.m., LPN #1 stated the nurses were responsible for documenting intake and output on residents with indwelling urinary catheters. LPN #1 stated they did not know why intake and output would not have been documented on the TAR (blank spaces). LPN #1 stated blank spaces on the TAR could indicate that it had not been done. At 2:30 p.m., the DON stated the nurses on the hall were responsible for documenting intake and output on residents with indwelling urinary catheters.

Based on record review and interview, the facility failed to ensure assistance had been provided with activities of daily living in regards to shower/baths as scheduled for three (#2, 7, and #8) of three sampled residents whose records were reviewed for shower/baths. Resident Census and Conditions Report identified 11 residents who were totally dependent on staff with bathing, and 72 who required assistance of one or two staff with bathing. Findings: 1. Resident #2 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 08/18/20, read in part, .resident requires assistance by 2 staff with showering twice weekly and as necessary . A quarterly MDS assessment (a resident assessment tool used to identify resident care needs), dated 01/17/22, documented the resident was totally dependent on staff for bathing. A review of resident #2's electronic task sheet for bathing revealed the resident was scheduled for showers on Monday and Thursday day shift and as needed. A review of the previous two months shower task sheets documented the resident received showers as follows: March 2022 - received five showers out of nine opportunities. Four opportunities documented as NA (not applicable); and April 2022 - received five showers out of seven opportunities. Two opportunities documented as NA. On 04/21/22 at 10:38 a.m., resident #2 stated they usually received showers twice weekly. The resident stated they had occasionally missed a shower due to female staff not being available to assist. 2. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 11/19/21, read in parts, .Resident requires extensive assistance x1 for .bathing .Provide sponge bath when a full bath or shower cannot be tolerated . An admission MDS assessment, dated 11/25/21, documented the resident had no rejection of care behaviors and required physical help in part of the bathing activity. A review of resident #7's electronic task sheet for bathing revealed the resident was scheduled for showers on Monday and Thursday evening shift and as needed. A review of the November and December 2021 shower task sheets documented the resident received showers as follows: November 2021 - received one shower out of three opportunities. One opportunity documented as refused and one documented as NA; and December 2021 - received two showers out of five opportunities. One opportunity documented as refused and two documented as NA. 3. Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 10/03/19, read in part, .resident requires limited assistance by 1 with bathing twice a week and as necessary . A quarterly MDS assessment, dated 03/04/22, documented the resident had no rejection of care behaviors and required physical help in part of the bathing activity. A review of resident #8's electronic task sheet for bathing revealed the resident was scheduled for showers on Monday and Thursday day shift and as needed. A review of the April 2022 shower task sheet documented the resident received showers as follows: April 2022 - received three showers out of seven opportunities. Two opportunities documented as refused, one documented as NA, and one documented as resident not available. On 04/20/22 at 2:50 p.m., CNA #1 stated residents received showers twice a week or at their request. The CNA stated shower schedules were posted. The CNA stated showers were documented in the electronic record. At 3:17 p.m., CNA #2 stated residents received showers twice a week, some scheduled in the morning and some in the afternoon. The CNA stated shower schedules were posted. The CNA stated showers were documented in the electronic record. On 04/21/22 at 9:02 a.m., the DON stated bath sheets were submitted to the DON who audits the shower sheets for resident refusals and staff not offering showers. The DON stated the wound nurse received shower sheets with documented skin issues. The DON stated shower sheets were not kept after the DON and the wound nurse reviewed them. On 04/21/22 at 11:00 a.m. LPN #1 stated they ensured residents received showers by reviewing the shower binder. At 11:50 a.m., LPN #2 stated they ensured residents received their showers by reviewing the shower binder, shower sheets, and communicating with the CNAs. LPN #2 stated a resident's request for female staff to assist with showers would be accommodated by assigning another CNA. On 04/26/22 at 11:34 a.m., CNA #1 stated NA on the TAR would indicate not applicable and possibly would be entered when the resident couldn't get to the shower or a miscommunication in the schedule. The CNA stated if a resident missed a shower they would offer again later. The CNA stated if a resident refused a shower, the shower sheet with documentation of the refusal would be submitted to the charge nurse. At 2:30 p.m., the DON stated a CNA may have documented NA on the shower task sheet instead of documenting refusal. The DON stated the lead CNA was responsible to ensure tasks listed on the TAR were completed. The DON stated they pulled a report daily to audit completion of tasks.

On 06/12/17, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to investigate an injury of unknown origin when a resident was diagnosed with [REDACTED]. At 1:47 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 1:51 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure to investigate an injury of unknown origin. On 06/12/17 at 3:32 p.m., an acceptable plan of removal was provided. The plan of removal documented, .6/12/17 - at 1351 (1:51 p.m.) received 2 Immediate Jeopardy deficiencies, one for Failure to Investigate an Incident of Unknown Origin and one for Failure to follow Policy & Procedures An incident & accident report has been initiated to investigate the fracture. A phone call has been placed to physician for further orders regarding fracture and follow-up. DON &/or designee and Administrator &/or designee began in-servicing all nursing staff at 1412 (2:12 p.m.) on Investigating all injuries and reporting to appropriate staff to investigate and report as appropriate. No employee will be allowed to work until they are inserviced. All nursing staff to be in-serviced by 2300 (11:00 p.m.) tonight, 6-12-17. DON, ADON, and Administrator all reviewed our policy & procedures and went over Investigating all injuries . Anytime there is ever an injury or injury of unknown origin, we MUST always investigate it and follow the chain of command. CNAs/CMAs to report to Nurse, Nurse to begin investigating immediately and notify DON/Administrator AS to further investigate and determine a plan of action and report as necessary. Our policy on ABUSE INVESTIGATION & REPORTING POLICY IS - The Facility will endeavor to protect patients from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of patient property. It recognizes patient rights to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints as defined by federal regulation. All injuries of unknown source will be fully investigated . The immediate jeopardy was removed on 06/12/17 at 10:25 p.m., when all components of the plan of removal were carried out. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on interview and record review, it was determined the facility failed to investigate and report an injury of unknown origin for one (#1) of four sampled residents who were reviewed for accidents. The resident was diagnosed with [REDACTED]. The facility did not conduct an investigation into the cause of the fracture, nor did they report the fracture to the Oklahoma State Department of Health (OSDH). The facility identified 85 residents who resided at the facility. Findings: The facility's policy on abuse investigation and reporting, revised 12/28/06, documented, .The Facility will endeavor to protect patients from maltreatment .All reports of patient maltreatment, including neglect and abuse, injuries of unknown origin, or misappropriation of resident property, shall be promptly reported to Administrator or immediate supervisor and investigated by Facility management . Immediate reporting. ALL incidents of alleged or suspected patient maltreatment, including mistreatment, neglect, or abuse, and misappropriation of patient property must be reported immediately to the Administrator or the Administrative Designee by a Facility employee or immediate supervisor, who will report incidents as required by State law or regulation . Identification and investigation .The Administrator or Administrative Designee will conduct an immediate investigation of all alleged or actual incidents of abuse, neglect, or misappropriation of property. The investigation should determine whether an incident has occurred, to what extent the patient was mistreated, by whom, and the measures needed to protect patients from further incidents. If the patient is able to communicate, the administrator or Administrative designee shall document, in thorough detail, the patient's account of the incident, including a description of the perpetrator . Reporting. ALL alleged or suspected incidents must be reported according to state and federal law . Injuries of unknown source. An injury may be classified as an 'injury of unknown source' when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of the extent of the injury, the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma). the number of injuries observed at one particular point in time, or the incidence of the injuries over time. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed no documentation the resident had a [DIAGNOSES REDACTED]. An annual assessment, dated 01/23/17, documented the resident was cognitively intact and required extensive assistance of staff for bed mobility, dressing, personal hygiene, and bathing. It was documented the resident was dependent on staff for transfers and locomotion on and off the unit and that walking did not occur. It was documented the resident was incontinent of bowel and bladder and was not limited in functional range of motion. It was also documented the resident had no falls since the last assessment. The resident's care plan, dated 01/23/17, documented a problem related to the resident having a self care deficit and requiring staff intervention or assistance with the completion of ADLs due to functional decline. The goal was the resident would be groomed and dressed appropriately daily with staff assistance through the review date. Interventions included to observe, document, and report any changes to the physician; to provide necessary equipment and adequate time for self performance or participation with daily care tasks; to assist or complete bathing, dressing, nail care, mouth care, hair care, and peri-care daily and as needed; to monitor for safety during ADLs; and to use a mechanical lift and two staff members for transfers. The resident's CNA closet care plan, updated 03/10/17, documented the resident was to be transferred using a mechanical lift with the assistance of two staff members. It was also documented the resident used a geriatric chair. Physician monthly orders, dated 04/2017, documented the resident was to use a geriatric chair for comfort and a mechanical lift was to be used for transfers with the assistance of two staff members. A nurse's note, dated 04/17/17 and untimed, documented, .Res is currently c/o (left) foot pain c/o pain 'Like its broke' as res stated to family friend. (No) known injury. res does have slight swelling. Orders for (radiology company name withheld) to xray. Staff will monitor for (changes) .(8:00 p.m.) (family friend name withheld) and (radiology company) notified . A physician's orders [REDACTED].(radiology company name withheld) to xray (left) foot/ankle . A radiology report for x-rays on the resident's left ankle, with a fax date of 04/17/17, documented, .Left ankle, complete, 3+ views .No history of trauma is provided. The bones are osteopenic. There is cortical irregularity along the distal fibular cortex at the level of the syndesmosis and extending distally to the tip. The medial malleolus is intact. The talar dome is unremarkable. There are mild [MEDICAL CONDITION] changes of the tibiotalar and subtalar joints. Soft tissue swelling is seen around the ankle. Impression: There is a suspected acute nondisplaced distal fibular fracture superimposed on fibular trauma. Mild widening of the lateral ankle mortise is compatible with ligamentous insufficiency. Comparison with any prior studies would be of interest . The report was signed by the radiology company's physician on 04/17/17 at 10:51 p.m. It was documented on the report by facility staff that the report was faxed on either 04/17/17 or 04/18/17. The documentation did not identify to whom the report was faxed. There was no documentation the resident's physician was notified of the suspected acute fracture when the report was first obtained. A radiology report for x-rays on the resident's left foot, with a fax date of 04/17/17, documented, .Left foot, complete, 3+ views .No history of trauma is provided. The bones are osteopenic. The Lisfranc articulation and lesser joints are intact. There is a mild bunion deformity. Irregularity of the cortex of the third and fourth metatarsals has the appearance of old healed stress fractures. Moderate multifocal [MEDICAL CONDITION] arthrosis is noted. No foreign bodies are seen. There is mild soft tissue swelling. Impression: 1. There are no radiographically evident acute displaced fractures or dislocations; probable old healed stress fractures of the third and fourth metatarsals . The report was signed by the radiology company's physician on 04/17/17 at 10:52 p.m. It was documented on the report by facility staff that it was faxed on 04/18/17. The documentation did not identify to whom the report was faxed. A nurse's note, dated 04/18/17 on the 11-7 shift, documented, .(radiology company) called reported (negative) fx to (left) foot. (No) c/o pain thru noc. Resident resting in bed c c/l w/in reach . There was no documentation related to the suspected acute fibular fracture. The resident's care plan, updated 04/18/17, documented, .fx unknown origin (left) ankle ortho consult immobilizer . A physician's orders [REDACTED]. A nurse's note, dated 04/19/17 at 11:00 a.m., documented, .Final report rec. There is a suspected acute nondisplaced distal fibula fx superimposed on fibular trauma. Mild widening of lateral ankle mortise is compatible c ligamentous insuficency (sic). N/O obtained from (physician name withheld) - ortho referral/immobilizer to (left) foot/ankle. Also has a n/o for [MEDICATION NAME] 50 mg (one) po q 4 - 6 (hours) prn for pain. To be given c Tylenol. Res (up) for meals in geri chair . Review of the clinical record revealed no x-ray report dated 04/19/17. The results documented in the nurses' note, dated 04/19/17, were the same results listed on the x-ray report, dated 04/17/17. Review of the clinical record revealed no documentation of any type of incident that could have caused a fracture to the resident's left fibula. Review of the clinical record, facility incident reports, state reportable incident reports, and investigative reports revealed no documentation the facility investigated the injury of unknown origin. There was no documentation the incident was reported to the OSDH. There was no documentation the resident, staff, or any concerned party was interviewed in an attempt to discover how the resident's left fibula was fractured. Review of the resident's clinical record revealed no documentation the orthopaedic consult had been completed as ordered by the physician. On 06/12/17 at 10:11 a.m., the DON was asked what treatment the resident received for the fractured fibula. She stated an immobilizer and pain management was ordered. She was asked how the resident was supposed to be transferred prior to receiving the fracture. She stated a mechanical lift was to be used. The DON was asked how the resident received the fracture. She stated they had not been able to determine the cause. She stated there had been no reports of injury. On 06/12/17 at 10:16 a.m., the DON and administrator were asked what investigation was completed when it was identified the resident had a suspected acute fibular fracture. The DON stated she would have to pull the report to see what was documented. At 10:22 a.m., the DON stated there was not an incident report but the resident's physician was talked with. She stated they believed the resident had an old fracture to the left foot. The surveyor explained the results from the left ankle x-ray, where it was documented there was a suspected acute fibular fracture. The DON stated, Yes, it does say that. The DON and administrator were asked if the incident had been investigated as an injury of unknown origin. The administrator stated no. They were asked if the incident had been reported to OSDH. The DON stated no. On 06/12/17 at 10:26 a.m., the DON was asked what follow-up had been done regarding the orthopaedic consult that was ordered by the physician. She reviewed the clinical record and stated she could not find where the nurses made the referral to the orthopaedic physician. On 06/12/17 at 12:12 p.m., the resident was asked if her leg had been fractured. She stated, Yes. She was asked if she knew how the fracture occurred. She stated she did not really know. She stated, Maybe got it caught up in the chair or something. On 06/12/17 at 1:13 p.m., the physician was asked what the results of the left ankle x-ray meant. He stated the resident had stretched ligaments which allowed the ankle to shift around and a fibular fracture. He was asked what the purpose of the orthopaedic consult was. He stated it was for a second opinion. The physician was asked if he was aware the orthopedic consult had not been obtained as ordered. He stated, Not til about five minutes ago. He stated he was disappointed to hear that. He stated it may not have had a significant impact on the resident though. On 06/13/17 at 12:12 p.m., the DON was asked if the nurse who had made the clinical record entries on 04/17/17 and 04/19/17 was still employed by the facility. She stated no. The DON was asked when the x-rays had been ordered. She stated 04/17/17. She was asked when they had been completed. She stated 04/17/17. She was asked when the results were received. She stated it had been on 04/18/17 on the night shift. The DON was asked when the doctor had been notified of the suspected acute fracture. She reviewed the x-ray reports and stated it was documented both reports had been faxed to the physician on 04/18/17, but the nurses' notes documented new orders had been obtained on 04/19/17. She stated the reports would have been faxed on 04/18/17 and new orders obtained on 04/19/17. She was asked if it was the facility's policy to fax reports that contained an acute finding. She stated, No. She stated staff should call the results to the physician. She stated she did not know why the nurse would not have called both reports to the physician. 2. Deficient practice was identified related to the facility's failure to provide safe transfers for two other residents who required the use of a mechanical lift and the assistance of two staff members for transfers. The findings at F323 are incorporated here by reference.

On 06/12/17, a past noncompliance Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to transfer a resident from her chair to her bed by mechanical lift as ordered by the physician. The resident suffered an acute metaphyseal fracture of the distal right femur with moderate displacement. The Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to transfer a resident as ordered by the physician, and the resident suffering a right femur fracture. At 12:55 p.m., the administrator was informed of the past noncompliance IJ related to the facility's failure to transfer a resident using a mechanical lift as ordered by the physician and the resident suffering an acute femur fracture on 05/20/17. The facility put measures in place to prevent the recurrence when all staff had been inserviced related to transferring residents according to their plans of care and the proper use of mechanical lifts. An all staff inservice occurred on 05/22/17. A copy of the inservice was placed in the facility's breakroom inservice book. Staff members were to review the inservice book on each shift worked and document their acknowledgement of reading the inservice material. Another all staff inservice occurred on 06/07/17, and it was at this time that all staff members had been inserviced. The inservices conducted on 05/22/17 and the copy placed in the inservice book documented, .Transfer status must be followed per the closet care plan. No exceptions! When a mechanical lift is to be used TWO staff members must be present. If not following protocol this is grounds for immediate termination. If you are aware this is occurring you are just as responsible . The inservice conducted on 06/07/17 documented staff was to check the inservice book in the breakroom before each shift, and transfer status and closet care plans were reviewed during the inservice. On 06/12/17, staff were interviewed in regard to their knowledge of the inservice. Staff verbalized understanding of the inservice, using transfer methods consistent with physician orders [REDACTED]. Based on interview and record review, it was determined the facility failed to utilize a mechanical lift for transfers as ordered by the physician and/or utilize the mechanical lift in a safe manner for two (#3 and #7) of four sampled residents who were reviewed for accidents. Resident #3 suffered an inoperable acute fracture of the distal right femur when she was transferred without the use of a lift. The facility identified 13 residents who were dependent on staff for transfers and 52 residents who required the assistance of one of more staff for transfers. Findings: The facility's undated policy and procedure for the use of a mechanical lift documented, .(date hand-written on form) 11/19/10 Parks Edge requires 2 staff members c all mechanical transfers . 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's CNA closet care plan, dated 05/22/16, documented the resident was to be transferred with a mechanical lift using a minimum of two staff members. It was documented the resident was to use a geriatric chair for locomotion. A quarterly assessment, dated 03/14/17, documented the resident was severely cognitive impaired; dependent on staff for transfers; and locomotion on and off the unit. It was documented the resident required extensive assistance with bed mobility, dressing, and eating. It was also documented walking did not occur; there were no limitations to functional range of motion; and the resident had no falls since the last assessment. The resident's care plan, updated 03/14/17, documented a problem related to a self care deficit. It was documented the resident required staff intervention or assistance with the completion of ADLs due to a functional decline. The goal was the resident would be groomed and dressed appropriately daily with staff assistance through the review date. Interventions included, .Assist of 2 staff needed for transfers with the use of mechanical lift . Another problem was the potential for pain related to general discomfort and chronic leg pain. The goal was the resident would not experience a decline in overall function related to pain through the review date. Interventions included to monitor and report to the nurse any signs and symptoms of pain or worsening of pain; report changes in pain to the physician; and to administer routine and as needed pain medications as ordered and monitor for effectiveness. A nursing summary, dated 04/27/17, documented the resident frequently had moderate pain. Physician monthly orders, dated 05/2017, documented the resident was to be transferred with a mechanical lift with the assistance of a minimum of two staff members. It was also documented the resident was to receive Ultram 50 mg, one tablet by mouth four times daily for pain and one tablet every six hours as needed for pain MARs, dated 05/20/17, documented the resident received the ordered Ultram at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. A physician's orders [REDACTED].X-ray of the RT knee to r/o fracture . A nurse's note written by LPN #2 (who was no longer employed by the facility), dated 05/21/17 at 3:20 a.m., documented, .This nurse alerted about a change in resident condition by (CNA #1) @ approximately 2345 (05/20/17 at 11:45 p.m.). Upon entering the resident's room, her RT knee was observed to be noticeably larger than the LT - swollen, slightly bruised, and tender to the touch. Resident has been diagnosed with [REDACTED].X-ray of the RT knee ordered. Responsible party for resident, (family member name withheld), notified about findings and about X-ray ordered to r/o fracture . A witness statement form, dated 05/21/17 at 3:55 a.m. and signed by CNA #1, documented, Just after 11 pm (resident #3)'s call light went off, I went into the room where (resident #3) was crying out in pain saying her leg was hurting her, I pulled back the sheets and saw (resident #3)'s right knee was very swollen and Bruised. I made her as comfortable as possible, offered her cold water and went and got the nurse to look her over . MARs, dated 05/21/17 at 6:00 a.m., documented the resident received one Ultram 50 mg tablet for right lower extremity pain that was rated at 10 of 10, on a zero to 10 scale. There was no documentation to show if the medication was effective. A nurse's note, dated 05/21/17 at 11:34 a.m., documented, .(radiology company name withheld) here. X-ray pending at this time. Pt has been resting in bed this morning awaiting .x-ray. Resident has been medicated x 2 c routine pain medication (and) is comfortable currently. Awaiting results . A radiology report, dated 05/21/17 at 12:04 p.m., documented, .Acute metaphyseal fracture of the distal femur with moderate displacement .Impression: moderate arthritic changes of the knee with acute distal femur fracture . An undated and untimed witness statement form, signed by CNA #2, documented, .When I came into work (resident #3) was in her chair inside her room having a fit. We tried to clam (sic) her down didn't work I tried many of time to put her to bed but (roommate) said no. She screamed all that day. I reported it to the nurse a couple of times that she was in pain. The nurse gave her meds around 10 pm (roommate) went to bathroom. We snuck in and put (resident #3) into bed . A witness statement form, dated 05/21/17 at 12:25 p.m. and signed by CNA #3, documented, .(roommate) wanted (resident #3) to go to bed. Me and (CNA #2) also (roommate) was in the room. (CNA #2) transferred (resident #3) into bed to lay her down like (roommate) wanted. After (she) transfer her to bed, she change her brief and we left out of the room. And no lift was in use . A nurse's note, dated 05/21/17 at 1:00 p.m., documented, .Results obtained from (radiology company) via fax. 'Acute metaphyseal fracture of the distal femur with moderate displacement.' DON, POA (and) (physician name withheld) notified of results. New order rec'd: Tylenol 325 mg (one) po qid (c tramadol); straight leg immobilizer to right leg at all times. Ortho consult ASAP. (Family member name withheld) request that pt be sent to hospital in order to expidite (sic) the ortho consult and also so pt can get the immobilizer immediately .Order rec'd from (physician name withheld) to send pt for eval (and) treat. (Family member) at facility during this time . A witness statement form, dated 05/21/17 at 5:20 p.m. and signed by LPN #1, documented, .Resident was not complaining of any abnormal pain or discomfort throughout the day on 5/20/17. Around 9 pm, I was call to resident room by resident (roommate) and pt stated she was 'hurting.' Res unable to give anymore detail about pain or discomfort other than she was 'hurting.' Spoke to (CMA #2) and he administered pt a routine tramadol at this time for pain . A witness statement form, dated 05/22/17 and untimed and signed by CNA #3, documented, .(resident #3) was upset the day on 5/20/17. She was yelling, cussing at (roommate). He didn't want anybody to get out of her chair. At dinner (resident #3) was hitting (roommate) and trying to pull up her leg, by grabbing her pants and trying to kick (roommate) . A hospital physical exam, dated 05/22/17, documented, .AP and lateral views of the femur were obtained .The osseous elements are osteopenic. A comminuted fracture is present involving the distal right femur in the metaphysis, likely extending into the articular surface .Impression .Osteopenia with a fracture of the distal right femoral metaphysis with possible intra-articular extension into the knee .Plan: Nature of injury discussed with patient's family. Her bone is severely osteopenic and primary fracture repair would be impossible. If she were ambulatory, a total knee arthroplasty with distal femoral replacement would be the surgical option to correct the injury. Since she has been non ambulatory for years, there would be little value in conversion to a total knee replacement. I recommend that the leg be placed in a knee immobilizer and that the fracture be allowed to heal in its current position. A state reportable incident form, with a fax date of 05/22/17, documented, .The nurse was alerted about a change in resident condition by CNA at approx. 2345. Upon entering the residents room her right knee was observed to be noticeably larger that the left knee. Right knee swollen, slightly bruised and tender to touch. Pain medication per PRN orders for pain management. Resident has been dx with dementia and is unsure what may have caused this .After investigating it, we found that she was transferred improperly at appr 7pm on 5/20/17. She was transferred without use of the mechanical lift. When the two CNAs that were present for the transfer were questioned both had different descriptions of what occurred. (CNA #2) report that her and (CNA #3) got (resident #3) under her arms and transferred her to the bed. (CNA #3) stated that (CNA #2) transferred (resident #3) to the bed by cradling her. Both (CNA #2) and (CNA #3) denied any injury during transfer. Both CNAs have been terminated and will be turned into the nurse aide registry. In service was immediately initiated on 5/22/17 regarding following closet care plans and regarding Abuse and neglect . The resident was re-admitted to the facility on [DATE] with hospice services. A significant change assessment, dated 06/02/17, documented the resident was totally dependent on staff for bed mobility and eating. It was documented transfers, walking, and locomotion on and off the unit did not occur. It was also documented the resident had limited range of motion of one lower extremity. On 06/08/17 at 11:00 a.m., the resident was observed lying in bed. Her right leg was in an immobilizer. There was a sign above the bed that documented the resident was not to be transferred from the bed. The resident did not exhibit any signs or symptoms of pain. The resident's roommate was in a recliner, resting with his eyes closed. On 06/12/17 at 8:30 a.m., CNA #4 was asked how she knew what method to use when transferring a resident. She stated the information was recorded on the closet care plan, located on the back of each resident's door. She was asked what training she received on transferring residents. She stated the head CNA showed the CNAs how to complete the transfers, did it with them, and they had to sign papers on doing it. She was asked if the nurses ever watched the CNAs complete transfers. She stated some of them did. She was asked what the inservice book was that was kept in the breakroom. She stated each shift was supposed to look at the book before starting their shift and check for inservices and updates on the residents. She was asked if she had received an inservice on transferring residents and the use of the closet care plans recently. She stated yes. On 06/12/17 at 9:00 a.m., the resident was observed lying in bed. No signs or symptoms of pain were noted. The roommate was resting with his eyes closed. On 06/12/17 at 10:43 a.m., the DON was asked what happened with resident #3 to cause the femur fracture. She stated the resident was found with the fracture, and the facility's investigation identified the resident had been transferred without the use of a mechanical lift. The DON was asked how the resident was supposed to be transferred prior to having the fracture. She stated with the mechanical lift. The DON was asked what the facility did after it was identified the resident had been transferred incorrectly. She stated they had everyone who had been involved with the resident's care write statements, and both aides who had been involved with the transfer had been terminated from their positions. She stated they educated some staff one on one at the time of the incident; did two all staff inservices; and put the inservice information in the inservice book in the breakroom. She stated the inservices were on following the closet plan of care and using two staff members any time a resident was transferred with a mechanical lift. On 06/12/17 at 4:30 p.m., the resident was lying in bed. The resident did not show any signs or symptoms of pain. The roommate was resting in his recliner with his eyes closed. On 06/13/17 at 9:30 a.m., CNA #1, who had worked with the resident on 05/21/17, was asked if the resident had been in pain on 05/21/17. She stated yes, the resident was in pain. She stated the resident cried, screamed, and was in agony. She stated it had made the family member, who was the resident's roommate, agitated. She stated the resident had screamed out before, but this was more and completely different. CNA #1 stated she told the nurse and medication aide. She stated they all knew she was waiting for an x-ray to be done. On 06/13/17 at 10:06 a.m., radiology company employee #1 was asked if the facility had ordered the x-ray to be obtained immediately. He stated no. On 06/13/17 at 10:15 a.m., LPN #1 was asked if the resident had been in pain on 05/20/17 and 05/21/17 with her leg. She stated during the day on 05/20/17, the resident had not complained of pain. She stated around 7:30 to 8:00 p.m. on 05/20/17, the aide had told her the resident's family member had wanted to speak with her. She stated the family member told her the resident was having pain. LPN #1 stated the resident had been unable to articulate that she was in pain and she did not see signs or symptoms of pain, but she had instructed the medication aide to administer a pain pill based on the family member's report. LPN #1 was asked if the aides had reported to her the resident was having pain. She stated the only time the aides had said anything about the resident being in pain was on 05/20/17 in the evening when it was reported to her the family member wanted to speak with her. She stated the aides did not report the resident was having any increased pain on 05/21/17. She stated she had instructed the aides to not move the resident until the x-ray was obtained. LPN #1 stated she had monitored the resident's pain closely on 05/21/17. LPN #1 was asked who called the radiology company to order the x-ray. She stated the night shift nurse had called it in. She stated when she started her shift, the x-ray had not been completed. She stated she called the radiology company and asked when they would be at the facility. LPN #1 stated she had been informed the order had not been called in as a stat (immediate) order. She stated the x-ray was completed between 10:00 am and 11:00 a.m. On 06/13/17 at 11:55 a.m, the DON was asked when the x-ray was ordered. She stated the order was received on 05/20/17 at 11:45 p.m. The DON was asked why the x-ray was not obtained until 11:34 a.m. on 05/21/17. She stated she did not know why because they generally came pretty quick. She stated she did not know if it was because it was the weekend or perhaps the order was not called in as a stat. She stated the physician would have to order it stat. She was asked if the x-ray should have been ordered as a stat. She stated, Given the circumstance, yes. 2. Resident #2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A CNA closet care plan, updated 05/01/17, documented the resident was to be transferred with a mechanical lift with a minimum of two staff members. A significant change assessment, dated 05/06/17, documented the resident was severely cognitively impaired; was dependent on staff for transfers and locomotion; and had no limitations in functional range of motion. A physician's orders [REDACTED]. A nurse's note, dated 05/22/17 at 11:45 a.m., documented, .This nurse called to res room by CNA. Res laying on back on the floor. Hoyer lift had flipped over while transferring res. Staff called to room to assist. Res answering questions, res has stated she is 'fine.' .denies pain @ this x has a small hematoma back of head . A state reported final incident report, with a fax date of 05/26/17, documented, .The nurse called to residents room by CNA. Resident laying on floor on back. The lift had flipped over while transferring resident. Staff called to room to assist. Resident answering questions, resident stated she is 'fine.' Able to move all ext. WNL for this resident. Vital signs and neuro checks initiated and WNL for this resident. Denies pain. Resident noted to have a small hematoma to back of head. No other apparent injuries noted. The CNA .was transferring resident from the bed to the WC with the use of the lift, she was the only staff member present during the transfer. Protocol is to have two staff present while the lift is in use. (CNA #5) was terminated for not following protocol. Staff in-servicing was initiated regarding the use of lift and two staff members to be present. Nurse Aide registry notified of report .Nuero (sic) checks completed with no abnormals, no delayed injury. Hematoma to back of head is resolved. Will continue with fall precautions in place . On 06/12/17, between 8:30 a.m. and 8:45 a.m., CNAs #4, #6, #7, and #8 were interviewed regarding their knowledge of the facility's policy on transfers. The aides stated the transfer status of residents was located on the CNA closet care plans that are in each residents' room. They stated all mechanical lift transfers required a minimum of two staff members, and the CNAs stated they had received education on the proper transferring of residents and use of equipment since 05/22/17. On 06/12/17 at 10:57 a.m., the DON was asked what the facility did when the lift tipped over with the resident. She stated it happened the same day the inservices were occurring related to the incident with resident #3. She stated the staff was inserviced on the facility's policy to use two staff members when transferring a resident with a mechanical lift. She stated the facility's investigation showed the CNA had transferred the resident by herself, which was against policy, and that CNA had been terminated.

On 06/12/17, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement their abuse policy and procedure to investigate an injury of unknown origin when a resident was diagnosed with [REDACTED]. At 1:47 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 1:51 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure to investigate an injury of unknown origin. On 06/12/17 at 3:32 p.m., an acceptable plan of removal was provided. The plan of removal documented, .6/12/17 - at 1351 (1:51 p.m.) received 2 Immediate Jeopardy deficiencies, one for Failure to Investigate an Incident of Unknown Origin and one for Failure to follow Policy & Procedures An incident & accident report has been initiated to investigate the fracture. A phone call has been placed to physician for further orders regarding fracture and follow-up. DON &/or designee and Administrator &/or designee began in-servicing all nursing staff at 1412 (2:12 p.m.) on Investigating all injuries and reporting to appropriate staff to investigate and report as appropriate. No employee will be allowed to work until they are inserviced. All nursing staff to be in-serviced by 2300 (11:00 p.m.) tonight, 6-12-17. DON, ADON, and Administrator all reviewed our policy & procedures and went over Investigating all injuries . Anytime there is ever an injury or injury of unknown origin, we MUST always investigate it and follow the chain of command. CNAs/CMAs to report to Nurse, Nurse to begin investigating immediately and notify DON/Administrator AS to further investigate and determine a plan of action and report as necessary. Our policy on ABUSE INVESTIGATION & REPORTING POLICY IS - The Facility will endeavor to protect patients from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of patient property. It recognizes patient rights to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints as defined by federal regulation. All injuries of unknown source will be fully investigated . The immediate jeopardy was removed on 06/12/17 at 10:25 p.m., when all components of the plan of removal were carried out. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on interview and record review, it was determined the facility failed to implement their abuse policy and procedure to investigate and report an injury of unknown origin for one (#1) of four sampled residents who were reviewed for accidents. The resident was diagnosed with [REDACTED]. The facility did not conduct an investigation into the cause of the fracture, nor did they report the fracture to the Oklahoma State Department of Health (OSDH). The facility identified 85 residents who resided at the facility. Findings: The facility's policy on abuse investigation and reporting, revised 12/28/06, documented, .The Facility will endeavor to protect patients from maltreatment .All reports of patient maltreatment, including neglect and abuse, injuries of unknown origin, or misappropriation of resident property, shall be promptly reported to Administrator or immediate supervisor and investigated by Facility management . Immediate reporting. ALL incidents of alleged or suspected patient maltreatment, including mistreatment, neglect, or abuse, and misappropriation of patient property must be reported immediately to the Administrator or the Administrative Designee by a Facility employee or immediate supervisor, who will report incidents as required by State law or regulation . Identification and investigation .The Administrator or Administrative Designee will conduct an immediate investigation of all alleged or actual incidents of abuse, neglect, or misappropriation of property. The investigation should determine whether an incident has occurred, to what extent the patient was mistreated, by whom, and the measures needed to protect patients from further incidents. If the patient is able to communicate, the administrator or Administrative designee shall document, in thorough detail, the patient's account of the incident, including a description of the perpetrator . Reporting. ALL alleged or suspected incidents must be reported according to state and federal law . Injuries of unknown source. An injury may be classified as an 'injury of unknown source' when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of the extent of the injury, the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma). the number of injuries observed at one particular point in time, or the incidence of the injuries over time. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed no documentation the resident had a [DIAGNOSES REDACTED]. An annual assessment, dated 01/23/17, documented the resident was cognitively intact and required extensive assistance of staff for bed mobility, dressing, personal hygiene, and bathing. It was documented the resident was dependent on staff for transfers and locomotion on and off the unit and that walking did not occur. It was documented the resident was incontinent of bowel and bladder and was not limited in functional range of motion. It was also documented the resident had no falls since the last assessment. The resident's care plan, dated 01/23/17, documented a problem related to the resident having a self care deficit and requiring staff intervention or assistance with the completion of ADLs due to functional decline. The goal was the resident would be groomed and dressed appropriately daily with staff assistance through the review date. Interventions included to observe, document, and report any changes to the physician; to provide necessary equipment and adequate time for self performance or participation with daily care tasks; to assist or complete bathing, dressing, nail care, mouth care, hair care, and peri-care daily and as needed; to monitor for safety during ADLs; and to use a mechanical lift and two staff members for transfers. The resident's CNA closet care plan, updated 03/10/17, documented the resident was to be transferred using a mechanical lift with the assistance of two staff members. It was also documented the resident used a geriatric chair. Physician monthly orders, dated 04/2017, documented the resident was to use a geriatric chair for comfort and a mechanical lift was to be used for transfers with the assistance of two staff members. A nurse's note, dated 04/17/17 and untimed, documented, .Res is currently c/o (left) foot pain c/o pain 'Like its broke' as res stated to family friend. (No) known injury. res does have slight swelling. Orders for (radiology company name withheld) to xray. Staff will monitor for (changes) .(8:00 p.m.) (family friend name withheld) and (radiology company) notified . A physician's orders [REDACTED].(radiology company name withheld) to xray (left) foot/ankle . A radiology report for x-rays on the resident's left ankle, with a fax date of 04/17/17, documented, .Left ankle, complete, 3+ views .No history of trauma is provided. The bones are osteopenic. There is cortical irregularity along the distal fibular cortex at the level of the syndesmosis and extending distally to the tip. The medial malleolus is intact. The talar dome is unremarkable. There are mild [MEDICAL CONDITION] changes of the tibiotalar and subtalar joints. Soft tissue swelling is seen around the ankle. Impression: There is a suspected acute nondisplaced distal fibular fracture superimposed on fibular trauma. Mild widening of the lateral ankle mortise is compatible with ligamentous insufficiency. Comparison with any prior studies would be of interest . The report was signed by the radiology company's physician on 04/17/17 at 10:51 p.m. It was documented on the report by facility staff that the report was faxed on either 04/17/17 or 04/18/17. The documentation did not identify to whom the report was faxed. There was no documentation the resident's physician was notified of the suspected acute fracture when the report was first obtained. A radiology report for x-rays on the resident's left foot, with a fax date of 04/17/17, documented, .Left foot, complete, 3+ views .No history of trauma is provided. The bones are osteopenic. The Lisfranc articulation and lesser joints are intact. There is a mild bunion deformity. Irregularity of the cortex of the third and fourth metatarsals has the appearance of old healed stress fractures. Moderate multifocal [MEDICAL CONDITION] arthrosis is noted. No foreign bodies are seen. There is mild soft tissue swelling. Impression: 1. There are no radiographically evident acute displaced fractures or dislocations; probable old healed stress fractures of the third and fourth metatarsals . The report was signed by the radiology company's physician on 04/17/17 at 10:52 p.m. It was documented on the report by facility staff that it was faxed on 04/18/17. The documentation did not identify to whom the report was faxed. A nurse's note, dated 04/18/17 on the 11-7 shift, documented, .(radiology company) called reported (negative) fx to (left) foot. (No) c/o pain thru noc. Resident resting in bed c c/l w/in reach . There was no documentation related to the suspected acute fibular fracture. The resident's care plan, updated 04/18/17, documented, .fx unknown origin (left) ankle ortho consult immobilizer . A physician's orders [REDACTED]. A nurse's note, dated 04/19/17 at 11:00 a.m., documented, .Final report rec. There is a suspected acute nondisplaced distal fibula fx superimposed on fibular trauma. Mild widening of lateral ankle mortise is compatible c ligamentous insuficency (sic). N/O obtained from (physician name withheld) - ortho referral/immobilizer to (left) foot/ankle. Also has a n/o for [MEDICATION NAME] 50 mg (one) po q 4 - 6 (hours) prn for pain. To be given c Tylenol. Res (up) for meals in geri chair . Review of the clinical record revealed no x-ray report dated 04/19/17. The results documented in the nurses' note, dated 04/19/17, were the same results listed on the x-ray report, dated 04/17/17. Review of the clinical record revealed no documentation of any type of incident that could have caused a fracture to the resident's left fibula. Review of the clinical record, facility incident reports, state reportable incident reports, and investigative reports revealed no documentation the facility investigated the injury of unknown origin. There was no documentation the incident was reported to the OSDH. There was no documentation the resident, staff, or any concerned party was interviewed in an attempt to discover how the resident's left fibula was fractured. Review of the resident's clinical record revealed no documentation the orthopaedic consult had been completed as ordered by the physician. On 06/12/17 at 10:11 a.m., the DON was asked what treatment the resident received for the fractured fibula. She stated an immobilizer and pain management was ordered. She was asked how the resident was supposed to be transferred prior to receiving the fracture. She stated a mechanical lift was to be used. The DON was asked how the resident received the fracture. She stated they had not been able to determine the cause. She stated there had been no reports of injury. On 06/12/17 at 10:16 a.m., the DON and administrator were asked what investigation was completed when it was identified the resident had a suspected acute fibular fracture. The DON stated she would have to pull the report to see what was documented. At 10:22 a.m., the DON stated there was not an incident report but the resident's physician was talked with. She stated they believed the resident had an old fracture to the left foot. The surveyor explained the results from the left ankle x-ray, where it was documented there was a suspected acute fibular fracture. The DON stated, Yes, it does say that. The DON and administrator were asked if the incident had been investigated as an injury of unknown origin. The administrator stated no. They were asked if the incident had been reported to OSDH. The DON stated no. On 06/12/17 at 10:26 a.m., the DON was asked what follow-up had been done regarding the orthopaedic consult that was ordered by the physician. She reviewed the clinical record and stated she could not find where the nurses made the referral to the orthopaedic physician. On 06/12/17 at 12:12 p.m., the resident was asked if her leg had been fractured. She stated, Yes. She was asked if she knew how the fracture occurred. She stated she did not really know. She stated, Maybe got it caught up in the chair or something. On 06/12/17 at 1:13 p.m., the physician was asked what the results of the left ankle x-ray meant. He stated the resident had stretched ligaments which allowed the ankle to shift around and a fibular fracture. He was asked what the purpose of the orthopaedic consult was. He stated it was for a second opinion. The physician was asked if he was aware the orthopedic consult had not been obtained as ordered. He stated, Not til about five minutes ago. He stated he was disappointed to hear that. He stated it may not have had a significant impact on the resident though. On 06/13/17 at 12:12 p.m., the DON was asked if the nurse who had made the clinical record entries on 04/17/17 and 04/19/17 was still employed by the facility. She stated no. The DON was asked when the x-rays had been ordered. She stated 04/17/17. She was asked when they had been completed. She stated 04/17/17. She was asked when the results were received. She stated it had been on 04/18/17 on the night shift. The DON was asked when the doctor had been notified of the suspected acute fracture. She reviewed the x-ray reports and stated it was documented both reports had been faxed to the physician on 04/18/17, but the nurses' notes documented new orders had been obtained on 04/19/17. She stated the reports would have been faxed on 04/18/17 and new orders obtained on 04/19/17. She was asked if it was the facility's policy to fax reports that contained an acute finding. She stated, No. She stated staff should call the results to the physician. She stated she did not know why the nurse would not have called both reports to the physician. 2. Deficient practice was identified related to the facility's failure to provide safe transfers for two other residents who required the use of a mechanical lift and the assistance of two staff members for transfers. The findings at F323 are incorporated here by reference.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide supervision of residents who smoked and residents who utilized the courtyard. Resident #1 became overheated while outside n the courtyard, and could not regain entry to the building. Resident #1 received extensive burns while smoking unassisted in the courtyard, when his clothing caught on fire. The resident expired. Resident #3 who utilized a wheelchair, fell and did not receive assistance until a visitor alerted staff that the resident was on the ground in the courtyard. The IJ was verified with the Oklahoma State Department of Health. At 6:30 p.m., the administrator was notified of the IJ situation related to a failure to provide supervision of residents who smoked and who utilized the courtyard. It was explained the IJ was related to all the residents who utilized the courtyard and not just those residents who smoked in the courtyard. The facility had implemented interventions directed toward the use of smoking aprons and direct supervision of residents when smoking. The facility had not implemented interventions to provide supervision of all residents who utilized the courtyard. On [DATE] at 7:30 p.m., a plan of removal for the immediacy of the IJ situation was received from the facility. The plan of removal documented: .At 6:30pm, informed of IJ related to supervision in courtyard. Plan of removal: 1) Beginning [DATE] at 6:30 p.m., the West Desk Charge Nurse and/or Nurse Designee will conduct visual checks of the courtyard every 30 minutes. 2) The visual checks will continue until the security cameras/monitors are in place at each nurse's station. 3) The visual checks will be documented to ensure the interventionis (sic) being implemented and monitored 4) All licensed and non-licensed nursing staff will be in-serviced by the DON/Designee and will be completed by [DATE] at 12:01 a.m. 5) The DON/designee will monitor staff to assure that visual checks are being conducted daily. 6) The Quality Assurance Committee will re-evaluate the effectiveness of the monitoring program in 14 days and make changes as necessary. An inservice record, dated [DATE], documented, .Inservice for q30 minute visual checks for courtyard . The inservice record documented the time staff either attended the inservice or was contacted by phone and provided the information the courtyard was to be visually checked every 30 minutes by nursing staff or designee. The document, entitled Courtyard Visual Checks, was reviewed and documented the facility performed visual checks of the courtyard every 30 minutes from [DATE] at 6:30 p.m. through [DATE] at 10:00 a.m., the current time. On [DATE] at 10:10 a.m., interviews with staff members began regarding the dissemination of the inservice information. All staff interviewed verbalized they had been informed of the responsibility of the nurse or designee from the west nurses station to visually check the courtyard every 30 minutes. The staff log documented there were two staff members not present due to personal leave which would be inserviced prior to returning to duty. The staff log documented the last staff member received the inservice on [DATE] at 11:40 p.m. On [DATE] at 11:40 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a pattern level of actual harm. Based on observation, interview, and record review, it was determined the facility failed to provide supervision of residents who smoked and residents who utilized the courtyard to prevent accidents for two (#1, #3) of nine residents who utilized the courtyard. This resulted in an Immediate Jeopardy Situation for resident # 1 who became overheated in the courtyard when he was unable to regain entry into the facility, and on a separate occasion when the resident was smoking without assistance in the courtyard and caught his clothing on fire. The resident suffered extensive burns and expired during the incident. Resident #3 fell in the courtyard and assistance was not provided until a visitor alerted staff that the resident was on the ground in the courtyard. The facility identified three current residents who smoked and five residents who often frequented the courtyard. Findings: An undated facility policy, titled SMOKING POLICY, documented, .Oklahoma Licensure Regulation 310:[DATE] prohibits the use of tobacco usage within 15 feet of any entrance. Parks Edge Residents and Guests may smoke ONLY in the courtyard under the alcove by the front gates. This includes electronic cigarettes .Residents smokes/lighters/smokeless tobacco are to be checked in to the nurse at the appropriate nurse's station. Residents that are deemed to smoke independently can take their lighter and cigarettes to approved smoking area (courtyard) and return to the nurse for safekeeping. Residents that require smoking assistance will be assisted by Staff per their request on every ,[DATE] hour intervals. [DATE] - IMPLEMENTED HOURLY BEDCHECKS ON RESIDENTS THAT SMOKE FROM 7P TO 7A UNTIL FURTHER NOTICE. (Hand written on form) DC'd [DATE] (changed) to 3AM visual (check) . 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated [DATE], documented the resident was moderately impaired in cognition, required extensive assist of one for transfers, dressing, toileting, and bathing; had limited range of motion on one side for his upper and lower extremities; and utilized a wheelchair for mobility. The careplan, dated [DATE], documented, .Smoking .Problem .Resident wishes to smoke and is designated as: safe smoker .Goal .Resident will smoke safely at designated area(s) at scheduled times through next review .Approach .Resident will ask for smoking materials. Resident keeps lighter. Asks for cigarettes .Resident will demonstrate safe technique for putting out matches or lighter and disposing of ash .Resident will demonstrate ability to physically hold the smoking device while smoking .Resident will demonstrate the ability to verbalize understanding that smoking materials are for use only in designated smoking areas .Smoking policy given to resident and/or responsible party .Safe smoking screen completed on admission and as needed .Resident oriented to smoking procedures and areas .Provide resident with following while smoking: (hand written on form) Indepent .Q1 (hour) visual checks 7p-7a . The resident was in the hospital from [DATE] through [DATE]. A skilled nursing admit sheet, dated [DATE], documented the resident was admitted to skilled services at Parks Edge Nursing Center for [DIAGNOSES REDACTED]. The Physical Therapy Plan of Care, dated [DATE], documented, .Qualifying Hospital Stay: From date: [DATE] to Date: [DATE] .Medical History Related to Diagnosis/Condition: Patient is [AGE] year old male who is LTC resident hospitalized following increased facial drooping, R sided weakness and difficulty speaking. Initial CT negative for acute changes; encephalomalacia present. MRI unable to be performed due to bullet fragments in head. EEG indicated seizure activity .Patient was intubated during early part of hospitalization due to somnolence producing respiratory distress. Per medical chart, CVA questionable with possible differential dx of TIA or TODD's paresis from seizure. PMH: seizure, gunshot (at age 14) to head with resulting L [DIAGNOSES REDACTED], falls (last one x 4 days prior to hospitalization ), hx of CVA, L THA .Other factors: patient experienced multiple petit mal seizures during evaluation; most during sitting, one while ambulating in parallel bars (ambulated x3 feet mod A); nursing running STAT labs; consider treating in early AM or later PM in low stim environment to reduce over-stimulation .Cognition: alert initially and oriented to person, place, and situation; however, patient became less alert with greater difficulty communicating throughout course of evaluation . An OT note, dated [DATE], documented, .Pt demo aphasic speech .Pt fed self 10% with excessive spillage . A skilled nurse's note, dated [DATE], documented, .Pt having small seizures & unresponsive at times. Stat labs ordered for Phenobarb & Keppra level to be drawn .increase Keppra dose from 250mg to 500mg bid .Gave extra 250mg Keppra tonight . An OT note, dated [DATE], documented, .Patient required min A for self feeding to locate items on tray/plate, open containers, bring food to mouth, manage cup/food on utensils. Pt had several seizures during tx session nursing staff notified . A skilled nurse's note, dated [DATE], documented, .Resident had several seizures in his room today gave diazepam rectally as ordered .Staff checking in on him ADON (name withheld) notified of seizure activity . An OT note, dated [DATE], documented, .Due to safety reasons, the patient requires verbal and tactile cues for all functional task at this time .Precautions .seizure precautions, chronic L hemiparesis . A skilled nurse's note, dated [DATE], documented, .09:30 Resident up in w/c. Alert & verbal. CMA reported resident kept spitting out his medication. Respiration even & nonlabored. (No) s/s of distress noted .13:30 At approx. 12:15 CMA asked me to check on resident stating 'he isn't acting right.' Resident slower to respond to questions. Was able to tell me who he was, who I was, and that he was in the dining room but would not answer any other questions asked .Approx ,[DATE] min. later he was assisted to his room to get cleaned up after having thrown up. (Name withheld) contacted N.O. to send to E.R. At approx. 13:15 EMSA arrived to facility. Resident appeared to be having difficulty answering questions. He mostly just stared at the paramedic. The few yes or no question he did respond to he appeared to be struggling to say them . An OT note, dated [DATE], documented, .pt. Verbalized (sic) 'I vomited all over myself on yesterday' pt presented (sic) with an increased amount of unknown substance and pocketing on L side . A skilled nurse's note, dated [DATE], documented, .Pt went outside to smoke after supper. Was unable to get the door open to come back in. Was discovered at 7:45 p.m. trying to get back in. Very hot & red. Immediately covered head & neck (with) cool wash clothes (sic). Pt unable to drink anything at this time. Pt aware of surroundings. Knew where he was. VS ,[DATE], P 86, R 20, Temp 102. Pulse ox 89. Recheck VS 9:45 p.m. ,[DATE], P 76, R 20, 98.4. Pt doing well at this time . The website, www.wunderground.com/history/airport/KTUL/[DATE]/Dai, documented the temperature in Tulsa, Oklahoma on [DATE] at 4:53 p.m. was 96.1 degrees Fahrenheit with a heat index of 101.6 degrees Fahrenheit. At 5:53 p.m., the temperature was 96.1 degrees Fahrenheit with a heat index of 99.9 degrees Fahrenheit. At 6:53 p.m., the temperature was 95 degrees Fahrenheit with a heat index of 99.0 degrees Fahrenheit. At 7:53 p.m., the temperature was 93 degrees Fahrenheit with a heat index of 97.4 degrees Fahrenheit. An OT note, dated [DATE], documented, .Pt was min A and max A with (sic) clothing mgmt with toilet txfer, but additional assistance or rest breaks might be needed following a BM. To err on side of caution for skill of CNA and due to pt's fluctuations due to seizures, OTR wrote orders for ,[DATE]% assist of 1 CNA for stand pivot txfer. Discussed and educated charge nurse and 2 CNA. All were agreeable and confirm with their own experience . A skilled nurse's note, dated [DATE], documented, .Cont SNS for [DIAGNOSES REDACTED], seizure, TBI, and many other Dx. Pt was seen having a pet mal seizure. He eyes rolled to top of head, staring out (eyes didn't move around), and slight shaking. The seizures came & went for about 15 min. I went got valium, which I gave rectally @ 00:20 .At 00:40 he said, 'I feel better.' .Monitoring closely . An OT note, dated [DATE], documented, .Nrsg reports that pt continues to have freq petitti (sic) mal seizures and Dr aware but unable to modify medications . An OT note, dated [DATE], documented, .Grooming and oral care with min A today with Increased confusion and decreased problem solving with Nursing alerted . A physician's telephone order, dated [DATE], documented the resident was discharged from skilled nursing services. A physician's telephone order, dated [DATE], documented, .(Increase) Lactulose 30ml to TID. Recheck Ammonia level in 1 wk .Dx Other [DIAGNOSES REDACTED] . A nurse's note, dated [DATE], documented, .Resident requesting cigarette to go outside and smoke. Nurse refused cigarette. Yesterday resident fell asleep with cigarette in his hand and almost burned himself . A nurse's note, dated [DATE], documented, .Neuro (check) completed on this shift. Resident denies any problems. Has been drooling a lot recently. Not having seizure activity but eyes keep rolling up. Will have (physician) see him tomorrow on rounds . A physician's progress note, dated [DATE], documented, .Chief Complaint: 1) Lethargy 2) Seizure disorder .Hx of seizure disorder. Staff reports pt is not himself. He state that he feels really sleepy. No fever, cough, dysuria .Final [DIAGNOSES REDACTED]. A physician's telephone order, dated [DATE], documented the resident was to be evaluated and treated by a mental health group for the [DIAGNOSES REDACTED]. The annual assessment, dated [DATE], documented the resident was intact in cognition, required extensive one person assist with transfers, personal hygiene and bathing; limited assistance with dressing and toileting; had limited range of motion on one side for his upper and lower extremities; and utilized a wheelchair for mobility. The Care Area Assessment, dated [DATE], documented, .Visual Function .(Resident #1) has impaired vision due to glaucoma. He wears glasses but vision is still impaired .ADL Functional/Rehabilitation Potential .(Resident #1) has hx of seizures and dibility (sic) secondary to gun shot wound. He has left side parlysis (sic) and is unable to care for self safely .Falls .(Resident #1) has hx of falls. He and (sic) impaired gait and uses a wheelchair for self locomotion around facility. He has Dx of seizures and requires one person assistance for transfers and completion of ADL's . The Safety-Smoking Assessment, dated [DATE], documented, .Cognition .Brief Interview for Mental Status (BIMS): ~Score 14 .(Score of 8 or less indicated resident lacks appropriate cognition) . ~Mental Health Diagnosis .Does resident have a current psychiatric diagnosis? .No . ~Neurologic Diagnosis .Does the resident have a current such diagnosis? .Yes .[DIAGNOSES REDACTED]. ~Musculo-skeletal Diagnosis .Does the resident have a current such diagnosis? .No . ~Vision .Does the resident have a vision impairment? .Yes . ~Hand Tremors .Does the resident currently experience hand tremors? .No . ~Smoking Materials Management History . ~Can resident manage ashes on his/her own? .Yes . ~Can resident safely extinguish his/her smoke? .Yes . ~Does resident obtain cigarettes from others? .No . ~Does resident obtain matches/lighter from others? .No . ~Does resident hide smoking materials? .No . ~Does resident have cigarette burn holes in clothing? .No . ~Has resident had a smoking related accident? .No . ~Assessment Outcome .Resident is able to smoke independently . The monthly physician's orders [REDACTED]. The careplan, dated [DATE], documented, . ~Potential for injury related to history of seizures, Hx of hepatic encephelopathy, tramatic (sic) brain injury .Resident will have no injuries related from seizure activity during this assessment period .Monitor Resident for change in level of consciousness .Resident requires staff assistance for safe completion of most ADL's related to left hemiparesis secondary to old gunshot wound, CVA, and hepatic [DIAGNOSES REDACTED] .Residents ADL's will be completed daily maintaining Resident's dignity and autonomy during this assessment period .Monitor for safety during ADL's . ~Resident requires staff assistance for safe completion of most ADL's related to left hemiparesis secondary to old gunshot wound, CVA, and hepatic [DIAGNOSES REDACTED] .Residents ADL's will be completed daily maintaining Resident's dignity and autonomy during this assessment period .Monitor for safety during ADL's . ~RIsk for injury due to glaucoma and resulting visual impairment (sic) .Resident will have no injury related to vision deficits during this assessment period .Keep Residents (sic) environment free of small objects on floor, hot or toxic liquids .Resident is often oblivious to his surroundings and bumps into things and other residents at times . ~Potential for complication AEB short/long term memory problems with impaired decision making r/t Hx of TBI, hepaic (sic) [DIAGNOSES REDACTED], & seizures .Resident will maintain current cognitive ability through review date .Provide cues, prompting, demonstation (sic) if resident is unable to complete task independently. Provide reality orientation and validation prn . ~Potential for abnormal ammonia level due to Hx of elevated ammonia with altered mental status .Resident will maintain ammonia lab levels with in (sic) normal limits through review date .Administer medications as ordered-see current orders and MAR .Observe and report s/sx prn; N/V, HA, confusion, loss of energy, fatigue, irritability, seizures, mental status changes . ~Smoking .Problem .Resident wishes to smoke and is designated as: safe independent smoker .Goal .Resident will smoke safely at designated area(s) at scheduled times through next review .Approach .Resident will ask for smoking materials. Keeps his own lighter, asks staff for his cigarettes .Resident is able to keep smoking materials .Resident will demonstrate safe technique for putting out matches or lighter and disposing of ash .Resident will demonstrate ability to physically hold the smoking device while smoking .Resident will demonstrate the ability to verbalize understanding that smoking materials are for use only in designated smoking areas .Smoking policy given to resident and/or responsible party .Safe smoking screen completed on admission and as needed .Resident oriented to smoking procedures and areas . A nurse's note, dated [DATE], documented, .19:56 Resident went out to smoke a cigarette .20:00 Someone stated 'there was a fire in courtyard' then someone was calling did anyone know CPR he needs CPR. Upon arrival in the courtyard, realized the fire was this resident. W/C had tumbled over backward. Resident and w/c were burnt. Resident checked for pulse & respirations. A passerby had stopped & they called 911 before staff had even gotten to him. Resident (name withheld) in courtyard and witnessed him catching on fire. She tried to help him slap it out but it was to out of hand and she had to get away to keep from getting burnt herself. EMS & Fire dept arrived. Resident pronounced dead @ the scene. Upon arrival of staff, resident did not have resp or pulse. Had severe burns to upper torso . A document, dated [DATE], documented, .Security film reviewed .19:49 Observed (resident #1) returning via w/chair toward center nurse station .19:53:33 Observed (resident #1) being pushed down 500 hall by CMA, (CMA name withheld) .19:54:18 Observed (CMA name withheld) returning to center desk area .20:00 Observed west nurse station nurse and CMA running to front door . A witness statement, dated [DATE], documented, .My husband and I was headed east bound on 51st St. passing Parks Edge. I told him to turn around there is a man in a w/chair on fire. We pulled up. He called 911 while I ran inside to inform them to get a fire extinguisher & man is on fire. When I entered the court yard the man was sitting upright engulfed inflames. After running into the facility informing the staff of the man, we returned to the court yard where the man was lying back on the pavement in his w/chair. When I came out the staff was already using the extinguisher on the man . A witness statement, dated [DATE], documented, .I was at the west desk helping out when I heard someone shout fire I need an extinguisher. A med aide ran to get the nearest extinguisher. I ran outside to see and evaluate what needed to be done immediately. I saw the resident laying on his back in the wheel chair on fire he was not moving. No one else was in danger. I realized I could not remove him from the wheelchair. The med aide showed up with the extinguisher at that time there were no signs of breathing or life, skin was taught (sic) and white, what was left of his shirt was the cuff on his left sleeve, toung (sic) protruding. There was no sign of life at that point .felt neck for a pulse . A witness statement, dated [DATE], documented, .Women (sic) ran inside building screaming there is a man on fire. My nurse (name withheld) went to get the fire exgher (sic) handed it to me so she could call 911. I pulled the pin and aim it at (resident #1). I put the fire out and let the nurse asses him while we waited for help to arrive . A witness statement, dated [DATE], documented, .I was inside the building and one of the nurse from west desk for the fire extinguisher and they stated someone was on fire. I ran outside and one of the residents was on fire and the CMA put him out and I seen him beath (sic) so I was about to do chest comparison (sic) but he was to (sic) hot and they told me to back off . A witness statement, dated [DATE], documented, .A lady ran in and said I need a fire extinguisher. I jumped up ran to center and grabbed the fire extinguisher, I passed it off to my med aide who was waiting at the door to the courtyard. I ran to my desk and called 911. I was placed on hold, when call was answered I told operater (sic) I needed fire, medical, police, they stated they had received several calls to our location and units were on there way. I proceded to call (name withheld) ADON, and (name withheld) administrator to let them know of the incident . A witness statement, dated [DATE], documented, .Statement from (resident #2): (Resident #2) stated that she had been out in courtyard and was returning in to facility moving toward 500 courtyard door. She heard (resident #1) flicking his lighter and heard him patting his leg over and over behind her. She said she asked (resident #1) if he was all right and he stated 'I've set myself on fire.' She said his polyester pants were smoldering at thigh area,, (sic) he was fanning himself, his cuff on sleeve was on fire, he had a polyester cotton and t-shirt. She stated she was going to pull his shirt away from him but was afraid of being burned she said she swung his w/chair around to get around him on the sidewalk. It happened very fast. She also stated then the back of his w/chair was on fire. States she went to the 500 courtyard door, rang the bell, and banged on the door. About that time a lady ran in from parking lot and yelled for help at front door . A smoking policy, dated [DATE], documented, .PLEASE NOTE REVISED CHANGE TO SMOKING POLICY .1. NO RESIDENT CAN GO OUTSIDE TO SMOKE BY THEMSELVES. RESIDENT MUST BE WEARING A SMOKING APRON, AND STAFF MUST BE SUPERVISING EVEN IF FAMILY IS PRESENT. IF PRIVACY IS NEEDED, STAFF CAN STEP AWAY BUT MUST HAVE RESIDENT IN VIEW WHILE RESIDENT IS SMOKING. 2. THE SMOKING POLICY HAS BEEN UPDATED. ALL SMOKING MATERIALS, I.E. CIGARETTES/LIGHTERS WILL BE STORED AT THE NURSE'S STATIONS IN DESIGNATED AREA. 3. ALL DEPARTMENTS WILL ASSIST SUPERVISING THE RESIDENTS THAT SMOKE. A SMOKING SCHEDULE IS POSTED AT THE WEST BULLETIN BOARD ACROSS FROM THE WEST DESK, AT CENTER AND EAST NURSES STATION, ACTIVITY OFFICE, LAUNDRY, AND HOUSEKEEPING CLOSETS . On [DATE] at 4:30 p.m., LPN #2 was asked if he recalled anything happening on [DATE]. He stated, I heard a lady come in and announce there was a fire in the courtyard. Ran to courtyard and saw (resident #1) on back in his wheelchair with the wheelchair on fire. The CMA was right behind me and had the fire extinguisher and put out the fire. I felt for a carotid but the resident was too bloated. I checked the radial and no pulse. On [DATE] at 10:10 a.m., CMA #1 was asked if he recalled anything happening with resident #1 on [DATE]. The CMA stated, Lady came in the door and yelled fire, resident on fire in the courtyard. I told my nurse to run and get the fire extinguisher and I ran toward the courtyard. She handed me the extinguisher and I pulled the pen and put him out. He was on his back in his wheelchair and still breathing. I started toward him to do CPR but nurse stopped me, saying (resident #1) was too hot. (Resident #1) continued to breath until just before the paramedics arrived. The paramedics would not touch the resident, saying he was too hot. On [DATE] at 1:00 p.m., resident #3 was asked what had happened in the courtyard on [DATE]. She stated she was in the courtyard smoking a cigarette when she saw resident #1 exit the 500 hall door. She stated the resident was just out from under the awning when she heard him flick his lighter several times. She stated she asked the resident if he was ok and he stated he had caught himself on fire. She said she observed the resident's pants on fire, his shirt catch fire, and then the wheelchair. She said she rang the door bell and pounded on the 500 hall door for someone to help when a visitor ran through the courtyard and got help. Resident #3 stated she had fallen in the courtyard one evening and layed on the ground until the next morning waiting on someone to come help her. She said she had fallen again out in the courtyard and a visitor found her. Resident #3 stated she was concerned about the lack of supervision of residents in the courtyard. On [DATE] at 1:50 p.m., LPN #1 was asked if resident #1 had an active seizure disorder. She stated, (Resident #1) used to stomp his right foot, turn his head to the right, and his eyes would flutter. When he came back from the hospital, we noticed they were different. We'd catch him sometimes six to eight times a day turning his head the opposite direction and fluttering his eyes. If you attempted to get his attention, he would turn back toward you like he had skipped that moment in time. The LPN was asked if the resident had been assessed as a supervised smoker. She stated the resident had not been assessed as a supervised smoker. She stated, No. Another resident was supervised and while I was out to watch her, I would sometimes see him. He would hold a cigarette and lighter with one hand and light it before it was in his mouth. Sometimes he would hold the cigarette in his mouth and talk with you for a minute then remember it and light it. On [DATE] at 2:45 p.m., therapist #1 was asked if there were safety concerns with resident #1. The therapist stated, Someone who has a head injury like a gun shot wound to the head or a stroke does not have the awareness of potential accidents. That is why I always tell people to use their call light before getting up. (Resident #1) had a good memory but would still have impulsive behavior and an increased risk to injury. The therapist was asked if resident #1, with a history of a gun shot wound to the head and a [DIAGNOSES REDACTED]. She stated, No. On [DATE] at 4:30 p.m., the ADON was asked if the nurse who had performed the last smoking assessment for resident #1 was available for interview. She stated the MDS nurse had been removed from the position after nursing administration had reviewed the resident's chart. She stated, We feel there were a few notes she should have seen which may have changed the smoking assessment and possibly the outcome of what happened. She said the nurse was offered a position on the floor but instead quit. The ADON was asked what documentation she felt may have changed the outcome of the smoking assessment. She stated, There was a note about the resident falling asleep with a cigarette. That note was not put on the 24 hour report so we as a department did not know about it and we have to trust nurses to write it on the 24 hour report because we can not look at all the charting on everyone. That said, she is suppose to review charting and should have seen it. She was asked what information the MDS nurse was to use when performing the resident's smoking assessment. She stated, That was another concern. We feel she missed key things in (resident #1's) chart that may have changed the assessment outcome. On [DATE] at 6:10 p.m., LPN #3 was asked what the evening routine was for resident #1. She stated the resident was served dinner between 5:00 p.m. and 5:30 p.m. and was usually finished with his meal by 6:00 p.m. She stated the resident would then go directly outside to the courtyard to smoke. She stated the resident would have another cigarette just before going to bed, at around 8:30 p.m. or 9:00 p.m. On [DATE] at 1:10 p.m., therapist #2 was asked if there were any safety concerns for resident #1. She stated, His safety awareness was impaired chronically from his long standing traumatic brain injury. He was impulsive but no more than before the hospitalization . The therapist was asked if the resident would have been safe to smoke independently. She stated, I can't answer that. I can say for as long as I have known him, he has smoked independently. On [DATE] at 2:00 p.m., LPN #1 was asked how often resident #1 experienced seizures. She stated, When he came back from the hospital, his seizures were different, more with his eyes and just out and when he came to he was ok. This would happen three to four times a day that we saw. I am sure he had more in his room or other places we didn't see. His meds were adjusted and seizures seemed to improve by late July to August. I'd say he was having them every three days or so that we saw but he could have had more when we weren't around. The LPN was asked if a resident with a history of stroke and traumatic brain injury from gun shot wound to the head and a recent stroke, encephelopathy, and increased seizure activity was a safety risk to himself. She stated, Yes, he would. The LPN was asked if an increased safety risk would be a concern with a resident who smoked independently. She stated, I see what you are saying with those flags and with the increase seizure activity, there is concern for safety. (Resident #1) was able to handle his smoking materials safely but with seizure activity, I see the safety concern. On [DATE] at 3:45 p.m., CNA #1 was asked if she was aware of resident #1 falling asleep with a cigarette. She stated, (CNA name withheld) brought him in and said he fell asleep and had ashes on his pants. I checked him and found burn hole on the left lower area of his shirt which rested on his lap. She was asked if she notified anyone. She stated she had notified the nurse and had written a statement which she gave to the nursing administration. On [DATE] at 11:45 a.m., resident #5 was asked if she knew resident #1. She stated she spent a lot of time with resident #1 and they had planned to marry soon. She was asked if she had recently observed res

On 05/24/16 an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to ensure bed rails were not an accident hazard for a resident who became entrapped between the bed rail and the mattress. Resident #3 had been found hanging halfway out of bed with her head resting on the floor. The resident's legs and feet were between the bed rail on the bed and the mattress. The facility continued to use the bed rails after the resident had become entrapped in the bed rail. On 05/24/16 at 3:25 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 3:30 p.m., the administrator was informed of the IJ situation regarding accident hazards. They were informed this placed the facility in an extended survey and a plan of removal was required. At 5:20 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: .5/24/16 RE: IMMEDIATE JEOPARDY, RELATED TO (resident name deleted) BEDRAIL INCIDENT 4/12/16 3:30PM NOTIFED (sic) OF IJ REGARDING (resident name deleted) 3:31PM REVIEWED INCIDENT REPORT FROM 4/12/16 AND PHYSCIAN'S ORDERS RELATED TO BR X 1 3:35 WENT ASSESSED BSR ON (resident name deleted). BEDRAIL ASSESSMENT COMPLETED, NO NEGATIVE EFFECTS NOTED 3:40 OBTAINED ROOM/BED ROSTER, CHECKING ALL BEDS IN BUILDING FOR BSR IN USE, SIDE RAIL ASSESSMENTS STARTED ON EVERY RESIDENT IN THE BUILDING (hand written in), to be completed by 5/25/16 3:00 pm. 4:00 IN-SERVICES INITIATED PROPER USE OF BEDRAILS FOR 3/11 SHIFT - NURSING DEPT. 4:08pm - MEDICAL DIRECTOR INFORMED OF IJ 4:10PM - NOTIFIED ATTENDING PHYSICIAN, DR. (physician name deleted), OBTAINED DC ORDER FOR (1) BEDRAIL 4:11PM - REMOVED (1) BEDRAIL, WALL ALREADY MARKED FOR APPROPRIATE HT., VISUAL CHECKS STARTED ON (resident name deleted) q 30 min. X 72HOURS, THEN Q HOUR X 4 DAYS 4:12PM - UPDATED CLOSET CARE AND RESIDENT PLAN OF CARE 4:15PM - NOTIFIED RESPONSIBLE PARTY, (name deleted), OF REMOVAL OF BEDRAIL/PHYSICIAN ORDER Note: all nursing staff (Nurses, CMAs, and CNAs) will be in-serviced by 3:00PM BY May 25, 2016 Attachments: 1) Bedrail assessment - 2 pages 2) Telephone order 3) Updated closet care plan 4) Updated plan of care related to bedrail removal 5) Observation/visual checks . On 05/24/16 at 5:25 p.m., the resident's room was observed. The resident was out of the room and no bed rails were observed on the resident's bed. Staff were interviewed on 05/25/16 and 05/26/16 in regard to their knowledge of the in-service relating to the proper use of bedrails. Staff interviewed exhibited an understanding on the proper use of bedrails. The IJ was removed effective 05/25/16 at 3:15 p.m., when all components of the plan of removal had been completed. The deficient practice remained at no actual harm with a potential for more than minimal harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to: ~ Ensure bed rails were not an accident hazard for three (#3, 8 and #19) of six sampled residents reviewed for side rails and accident hazards. Residents #3 and #19 experienced falls from the bed with a limb entrapped between the bed rail and the mattress. The facility continued to utilize the bed rails for resident #3. The ADON identified 94 residents who had a bed rail. ~ Ensure hazardous chemicals were secured and not accessible to residents on one (200 Skilled Hall) of seven halls. The facility identified two residents (#5 and #15) who wandered. Findings: 1. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A monthly physician's orders [REDACTED]. An incident/accident report, dated 08/27/15, documented the resident had been found on the floor in her room, lying on her left side parallel to the bed. The report documented there was no injury and neuro checks had been started. The report documented the follow up measures were to do hourly visual checks times 14 days. A monthly physician's orders [REDACTED]. An annual assessment, dated 12/01/15, documented the resident was moderately impaired cognitively, required extensive assistance of two staff members for transfers, required supervision to extensive assistance with all other ADLs, had one fall without major injury, and had no restraints. A monthly physician's orders [REDACTED]. A monthly nursing summary, dated 03/04/16, documented the resident did not have any restraints. A significant change assessment, dated 03/09/16, documented the resident was severely impaired cognitively, required extensive assistance of two staff members for transfers, required limited to extensive assistance with all other ADLs, had no falls, and had no restraints. A care plan review, dated 03/10/16, documented the resident was at risk for a fall related injury as evidenced by, previous falls, functional deficits, medication usage, and the use of assistive devices. The care plan documented the following fall precautions: Evaluate for and supply adaptive equipment or devices as needed, re-evaluate as needed for continued need or safety, and coordinate with appropriate staff to ensure a safe environment. A fall risk assessment, dated 03/10/16, documented the resident was a high risk for falls. A monthly physician's orders [REDACTED]. An incident/accident report, dated 04/12/16, documented the resident had been found hanging halfway out of her bed. The report documented the resident's head had been resting on the floor and her feet and legs were between the bed rail and the mattress. The report documented neuro checks had been started and were within normal limits. The report documented the follow up measures were to do hourly visual checks times 14 days. A monthly nursing summary, dated 04/14/16, documented the resident had 1/2 bed rails as a restraint. A monthly physician's orders [REDACTED]. A monthly nursing summary, dated 05/13/16, documented the resident had bed rails as a restraint. On 05/23/16 at 10:10 a.m., the resident was observed lying in bed on her back on an air mattress. The resident was alert but unable to answer questions appropriately. A half rail was observed in the center of the bed on the right side. The other side of the bed was against the wall. There was approximately 3 1/2 inches of space between the bed rail and the air mattress. On 05/24/16 at 9:35 a.m., the resident was observed lying in bed with her eyes closed. The half rail remained at the center of the bed. On 05/24/16 at 11:30 a.m., the ADON was asked why residents had bed rails. She stated the residents used the bed rails for turning and repositioning. The ADON was asked if the residents had been assessed for the safe use of bed rails. She stated no, there were no assessments on the residents who used bed rails. The ADON was asked how she determined if the use of a bed rail was a safety hazard for a resident. She stated, I don't know. At 2:10 p.m., CNA #6 was asked if she knew why the resident had a bed rail. She stated she had been told it was for turning and repositioning. She stated she was not aware of the resident ever using the bed rail to turn or reposition. She stated the resident would not try to help when care was being provided. CNA #6 was asked if the resident would try to get up without assistance. She stated yes. She stated on several occasions she had found the resident partially sitting up with her legs hanging off the bed in between the bed rail and the mattress. At 2:15 p.m., CNA #7 was asked if she knew why the resident had a bed rail. She stated she did not know why. She stated the resident had the bed rails when she started working at the facility five months ago. CNA #7 was asked if the resident would try to get up without assistance. She stated yes. She stated she had found the resident sitting on the side of the bed before with her legs between the rail and the mattress. On 05/24/16 at 3:45 p.m., the resident was observed awake and lying in bed. The half rail remained at the center of the bed. The resident was asked if she used the bed rail to help position herself. She stated no. The resident was asked if she could transfer herself from the bed to the chair. She stated yes. 2. Resident #19 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission nursing evaluation, dated 12/07/15, documented the resident was dependent for transfers with the assistance of one staff member. An admission assessment, dated 12/14/15, documented the resident was cognitively intact, required limited assistance of one staff member for transfers, and had experienced a fall at home which resulted in a fracture prior to this admission. A care plan, dated 12/15/15, documented to use half bed rails times two as ordered. The care plan documented the resident was at risk for falls related to previous falls, functional deficits, medication usage, and the use of assistive devices. The care plan documented to evaluate for and supply adaptive equipment or devices as needed and to re-evaluate as needed for continued need or safety. A fall risk assessment, dated 12/15/16, documented the resident had a score of 7. A score of greater than 10 represented the resident was a high risk for falls. A care plan, updated 12/18/15, documented the resident had fallen in his room with no sustained injuries. The care plan documented the resident would be placed on every hour visual checks. An incident/accident report, dated 01/08/16, documented the resident had been found sitting on the floor with his head resting against the foot of the bed. The report documented the resident had stated he had gone to the bathroom and fell on the way back to bed. The report documented the resident was disoriented at times and there were no injuries noted from the fall. The report documented the follow up interventions were to provide a toileting schedule times 14 days. A care plan, updated 01/08/16, documented the resident had fallen in his room with no sustained injuries. The care plan documented a toileting schedule would be started. An incident/accident report, dated 01/11/16 at 11:00 p.m., documented the resident had been found on the floor next to his bed face down with his head pointed toward the bathroom door. The left foot was on the floor and the right foot was caught between the bed rail and the bed. There was bruising noted to the bridge of the resident's nose and chin. The report documented neuro checks had been started. A daily skilled nurse' note, dated 01/12/16 at 8:00 a.m., documented the resident's neuro checks remained within normal limits. The note documented the resident's daughter had requested the resident be sent to the emergency room for an evaluation due to the changes in the resident's mental status prior to the fall. The note documented the physician had been notified and the resident had been transferred to the hospital for an evaluation. A facility discharge summary, dated 01/12/16, documented the resident had been discharged from the facility. A final incident report to the OSDH, dated 01/18/16, documented the resident remained at the hospital with altered mental status. The report documented tests and X-rays done at the hospital had been negative for injuries and the family had chosen to take the resident home when he was discharged from the hospital. 3. Resident #8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 04/12/16, documented the resident was severely impaired cognitively, required limited assistance of one staff member for transfers, and had two non-injury falls. A fall risk assessment, dated 04/13/16, documented the resident was a high risk for falls. A care plan review, dated 04/13/16, documented 1/2 bed rails time two as ordered. The care plan documented the resident was at risk for a fall related injury as evidenced by previous falls, functional deficits, medication usage, and the use of assistive devices. The care plan documented the resident had sustained a fall on 01/26/16 that resulted in a bump on the back of her head. The care plan documented the resident had sustained a non-injury fall on 02/10/16, 02/18/16, 02/23/16, 02/26/16, 03/01/16, 03/07/16, 03/17/16, 05/06/16, 05/11//16, and 05/12/16. A monthly physician's orders [REDACTED]. On 05/24/16, at 9:35 a.m., the resident was observed lying in bed with her eyes closed and the bed rail up. At 9:35 a.m., LPN #1 was asked why the resident had bed rails. She stated to prevent the resident from falling out of bed. At 3:40 p.m., CNA #8 was asked why the resident had a bed rail. She stated to keep the resident from falling out of bed. She stated the resident would climb around the rail because the resident thought she could transfer herself, but she was not suppose to. At 3:43 p.m., RN #2 was asked why the resident had bed rails. She stated the resident used the rail to turn and reposition herself. The RN was asked if the resident had an assessment for the use of bed rails. She stated she had never seen an assessment for bed rails. RN #2 was asked if the resident tried to get out of bed with the rail up. She stated yes. 4. On 05/22/16 at 5:00 p.m., during the entrance tour of the facility, the hopper room door on the skilled 200 hall was observed to be unlocked. A key was observed hanging on the wall next to the door. The hopper room contained a one gallon container of Sani-Care Lemon Quat disinfectant. The container was open and had two tubes from the opening of the container to a device on the wall. No residents were observed in the area. The skilled 200 hall only had two residents who resided in the same room on this hall. Their room was at the beginning of the hallway by the nurse's station. All of the other rooms on this hallway were used for offices. On 05/22/16 at 5:25 p.m., CMA #3 was asked if there were any residents who would wander into other rooms. She stated she had not noticed any residents who wandered on this side (West side) of the facility. She stated there were some residents who wandered on the other side (East side) of the facility. At 5:30 p.m., the DON was asked if there were any residents who wandered in the facility. She stated yes there were two, resident #5 and resident #15. She stated they would pick items up from other rooms, but she did not think they would eat or drink anything they found. The DON was asked if she was aware of any residents eating or drinking anything harmful. She stated no. The DON was asked how she ensured residents were safe from chemicals. She stated the doors to those rooms were kept locked. The DON was shown the hopper room on the skilled 200 hall. She stated the door should always be locked, that is why there is a key hanging here. The DON locked the door. The DON was asked if she was aware of any residents who had been found in the hopper room. She stated, I have been here many years and there has never been a resident found in the hopper room. On 05/23/16 at 9:00 a.m., the hopper room on the skilled 200 hall was observed to be unlocked. No wandering or unattended residents were observed on the hallway. The surveyors were placed in the office directly across the hall from the hopper room. The hopper room was observed by the surveyors throughout the day. At 10:00 a.m., the hopper room door remained unlocked. No residents were observed in the area. At 10:25 a.m., the hopper room door remained unlocked. No residents were observed in the area. At 11:30 a.m., the hopper room door remained unlocked. No residents were observed in the area. At 1:55 p.m., The hopper room door was locked. On 05/24/16 at 8:10 a.m., the hopper room door was observed to be unlocked. No residents were observed in the area. At 8:30 a.m., the DON was observed checking the hopper room door. She stated she did not know who was leaving the door unlocked. She locked the door and stated she was going to have maintenance change the lock on the door to a lock that stayed locked.

An Immediate Jeopardy (IJ) situation was identified regarding the facility's failure to supervise a resident who went outside into a courtyard the night of 10-04-15 when the outside temperature for the area was recorded at 52 degrees Fahrenheit (F). The resident had not been seen by staff for 8 hours and 30 minutes and was found laying on the ground in the courtyard. On 10-26-15 at 8:45 a.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of a past non-compliance IJ related to the facility's failure to supervise the resident. On 10-26-15 at 3:42 p.m., the administrator was informed of the past non-compliance IJ related to the failure to supervise the resident. Based on observation, interview, and record review, it was determined the facility failed to supervise 1 (#1) of 3 sampled residents who regularly went out into the facility's courtyard to smoke independently. On the night of 10-04-15, when the recorded temperature for the area was 52 degrees F., the resident had gone outside to the courtyard to smoke. The resident was found laying on the ground in the courtyard visibly shaking with her body color purple 8 hours and 30 minutes after the last time she had been seen by staff. The resident was transfered to the hospital with an admitting [DIAGNOSES REDACTED]. Findings: A facility in-service record, dated 08-07-15, documented, .Once the resident goes to bed for the night, staff is not to awaken the resident for ADL (activities of daily living) care or medications .CNAs (certified nursing aides) and Nurses must do frequent rounds. CNAs should do at least hourly rounds with flashlights to check residents . A facility in-service record, dated 09-25-15, documented one of the in-service topics was to make rounds every hour. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 03-27-15, documented resident #1 was cognitively intact, required extensive assistance with most activities of daily living (ADLs), and used tobacco. A quarterly assessment, dated 09-10-15, documented the resident was cognitively intact, required extensive assistance with most ADLs, and used tobacco. A smoking care plan, revised on 09-10-15, documented, .Resident wishes to smoke and is designated as: safe smoker .Goal .Resident will smoke safely at designated area(s) at scheduled times through next review . A nurse's note, dated 10-05-15 at 7:55 a.m., documented, .Resident found outside in smoking area laying on L (left) side at 0700 (7:00 a.m.) by staff. Pt (patient) alert and oriented x 4. Pt complained of back pain .Recieved (sic) physician's orders [REDACTED]. R. (emergency room ) . A facility incident/accident report, dated 10-05-15, documented, .Resident found outside in smoking area laying on L side at 0700 by staff. Pt alert and oriented x4 .Contacted EMSA (Emergency Medical Service Ambulance) . A director of nursing (DON) investigation statement, with a fax date of 10-09-15, documented, .For many years, (resident #1 name deleted) has been very active during the night hours. She is assisted to transfer from her w/c to the recliner et back multiple times throughout the 11/7 shift. She reuires minimal assistance of 1 staff member for transfer/ADLs (acitivities of daily living). (Resident name deleted) is a smoker and smokes multiple times during the day and the night. She is able to take herself out into the courtyard to smoke without supervision. (Resident name deleted) wants and is allowed to be very independent. She does not have a specific routine when it comes to her going outside. The facility has five doors that lead into the courtyard. (Resident name deleted) will use all five and usually comes in a different door than she goes out. On October 4, 2015, (resident name deleted) exited the facility @ (at) 2238 (10:38 p.m.) through the 100 hall courtyard door per security film. Security film did not show (resident name deleted) coming back into the facility. The 100 hall, 500 hall, and front door were all monitored for (resident name deleted) to re-enter the facility. (LPN #1 name deleted), LPN (licensed practical nurse) was the charge nurse assigned to (resident name deleted) for the 2300-0700 (11:00 p.m. - 7:00 a.m.) shift. The CNA assigned to (resident name deleted) was (CNA #1 name deleted). Both employees arrived to work after 2300 for their shifts. The staff is educated and in-serviced (4 in-services since August) to make rounds at the beginning of their shift with the off going shift. The staff is educated to verify that all assigned resident (sic) are accounted for and safe. Neither employee chose to do rounds at the beginning of the shift. The staff is also educated to make frequent rounds after residents are asleep. CNA's are to do hourly checks while the residents are asleep. The staff is also educated to make last rounds before doing rounds with the oncoming shift. Again neither staff member chose to make those rounds . The CMA/CNA (certified medication aide/certified nursing aide) reports that (LPN #1 name deleted) said she could not find (resident name deleted) and that she was probably out smoking. The CMA/CNA reports that this concerned her et (and) decided to go find the resident. This is when the resident was found lying on the concrete outside in the courtyard. (Resident name deleted) was responsive when she was found. Her color was purple and she was visibly shaking due to the cold. The temperature dropped down to 52 degrees @ 0300 (3:00 a.m.) with a 4 - 9 mile per hour wind. The resident told the staff she fell around 2300 .The staff called EMSA and covered the resident with multiple blankets .The DON (director of nursing) went out to the courtyard as EMSA was arriving. The resident was still responding to questions at that time. EMSA was unable to obtain an oral temperature on (resident name deleted) .EMSA called for assistance from the local fire department to lift resident from ground .EMSA loaded resident into ambulance et transported her to (hospital name deleted). A social worker from (hospital name deleted) called the facility to get further details of what had occurred. The resident was admitted to the ICU unit to stabilize her body temperature. No further details were provided . The DON interviewed the CNA (CNA #1 name deleted) and the charge nurse, (LPN #1), after reviewing security film. (CNA #1) was asked how often she checked on (resident #1) and when she saw her last. (CNA #1) stated that she knew (resident #1) usually slept in the recliner on West side of the builing. (CNA #1) thought she may have seen (resident #1) while passing through the living room around 0230 (2:30 a.m.). (CNA #1) admitted to not making rounds to check on (resident #1). The DON asked (CNA #1) if she was aware that she was responsible for (resident #1) even if she was not sleeping in her room. (CNA #1) replied yes. The DON terminated (CNA #1) effective immediately for neglect. The Administrator, DON and ADON interviewed the LPN charge nurse. When asked when she last saw (resident #1), (LPN #1) said she was too shaken to accurately remember. (LPN #1) said she thought she saw (resident #1) in the recliner sometime during her shift. The DON asked (LPN #1) why she felt it was acceptable to not check the resident's fasting blood sugar. (LPN #1) response was that she was too busy et she didnt' know where the resident was. (LPN #1) was also terminated effectively immediately for neglect . The nightly midnight census report done by the charge nurses accounted for (resident #1 name deleted) in the building. Plan to prevent incident from reoccurring: Staff to make 'eyes on' rounds and document resident accounted for q (every) 4 hr (hour) In-service all nursing staff Documentation hourly of checking the smoking area Documentation of visual check at shift change On 10-25-15 at 5:45 a.m., resident #1 was observed in her room in her recliner with her eyes closed. On 10-25-15 at 6:00 a.m., the administrator was asked where were the smoking areas located. The administrator stated there was only one designated area to smoke and it was the courtyard located in front of the facility. The administrator was asked about the incident involving resident #1. The administrator stated the nurse and CNA who had been assigned to resident #1 had failed to make rounds during their shift. The administrator was asked what was the facility policy on making resident rounds during the night. The administrator stated the CNAs were to make rounds every hour. The administrator stated resident room rounds were to be made with the oncoming and offgoing nurse at shift change. The administrator was asked what interventions had been put into place to assure this would not happen again to another resident. The administrator stated the nurse and CNA had been terminated. The administrator stated a new hourly visual checks of the smoking area form had been developed. The hourly checks in the smoking area was to be done between the hours of 7:00 p.m. and 7:00 a.m. The administrator stated a new resident visual check at shift change form had been developed. The administrator stated the shift change form was to be completed by the offgoing and oncoming nurses. The administrator stated every 4 hour visual checks had been placed on the facility's room/list form and the charge nurses were responsible for documenting their initials. The administrator was asked if there had been in-services performed with the nursing staff. The administrator stated yes. The administrator stated on 10-05-15 three in-services had been conducted one on each of the shifts. The administrator stated additional in-services were held on 10-07-15 and 10-22-15. The administrator stated she was sickened by the incident as nothing like this had ever happened before in the facility. On 10-25-15 at 3:10 p.m., resident #1 was observed in the courtyard with four other residents sitting in her wheelchair. On 10-26-15 at 3:42 p.m., when this surveyor notified the administrator of the past non-compliance IJ related to failure to supervise the resident, the surveyor asked for a timeline of the measures the facility initiated to correct the non-compliance. On 10-27-15 at 10:00 a.m. the administrator provided a timeline of the measures the facility initiated to correct the non-compliance. They were as follows: 1) Upon learning of the incident, the following steps were taken on 10-05-15: a) After resident transferred to ER via EMSA, the DON reviewed security film to verify when resident entered the courtyard to smoke, initiated at 7:10 a.m. b) Reviewed documentation of resident's nursing notes, medication administrator records (MARs), treatment administration records (TARs), and Incident & Accident (I & A), initiated at 7:45 a.m. c) Interviewed charge nurse and CNA assigned to resident involved, initiated at 8:00 a.m. d) Terminated LPN charge nurse and CNA assigned to resident at 8:05 a.m. e) Obtained room/bed roster from medications in computer and eye to eye checks were made throughout the facility to account for every resident, initiated at 9:00 a.m. f) Policies reviewed regarding Smoking policy and staff responsibilities to include making visual rounds, initiated at 9:00 a.m. g) Implementation of: 1) 7:00 p.m. to 7:00 a.m. one hour of walk through in the smoking area and updated smoking policy to reflect Implementation of hourly bedchecks on residents that smoke from 7:00 p.m. to 7:00 a.m. until further notice, initiated at 7:00 p.m on 10-05-15. 2) Resident Visual Check at Shift Change, initiated at 3:00 p.m. on 10-05-15. 3) Eye to eye visual checks every 4 hours, initiated at 9:00 a.m. on 10-05-15. h) In-services held with 7 p.m. to 3:00 p.m. shift at 10:00 a.m., 3:00 p.m. to 11:00 p.m. shift at 3:00 p.m., and 11:00 p.m. to 7:00 a.m. shift at 11:00 p.m. on 10-05-15. 1) Additional in-services were held on 10-07-15 and 10-22-15 related to resident rounds/bedchecks/eye to eye rounds; in-services held at 10:00 a.m. i) Administrator called resident's next of kin at approximately 10:00 a.m.; note, he had been notified by the charge nurse at 7:30 a .m. that resident had fallen and sent to ER at 7:10 a.m. j) Incident reported to Oklahoma State Department of Health (OSDH), Adult Protective Services (APS), Oklahoma Board of Nursing, Nurse Aide Registry at 3:23 p.m.; and Ombudsman Supervisor at 3:30 p.m. on 10-05-15. On 10-27-15 at 10:30 a.m., the administrator provided documentation all the interventions had been completed on 10-05-15 at 11:00 p.m. Surveyors interviewed 16 staff members to verify their knowledge of the facility's resident visual checks and smoking visual checks policies. The staff verbalized their understanding of the new policies.

Based on observation, record review, and interview, it was determined the facility failed to notify the physician and/or family of a significant change in condition for one (#4) of seven sampled diabetic residents reviewed for blood sugar parameters. Resident #4 had a blood sugar of 22 and was transported to the hospital. The facility list of diabetic residents documented 39 residents received finger stick blood sugar monitoring. Findings: The facility policy for change in condition or status documented the charge nurse would notify the physician when a significant change occurred as defined by a deterioration in the resident's health, mental, or psychosocial status in either life-threatening conditions or clinical complications. The policy documented the responsible party would be notified if the resident was involved in an accident or incident that results in an injury or a significant change in condition occurs. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission physician's orders [REDACTED]. The orders included an order to give [MEDICATION NAME] Insulin as needed per the sensitive sliding scale. The orders did not include instructions if the blood sugar was high or low (normal ranges 70 to 110). The orders documented an order for [REDACTED]. There were no parameters for treating and reporting blood sugars less than 125. The physician's progress note, dated 04/04/11, documented the resident was alert and oriented to person, place, and time. The admission assessment, dated 04/08/11, documented the resident did not have cognitive impairment and had good memory recall. The care plan, dated 04/11/11, documented the resident was at risk for hyper or hypoglycemic episodes secondary to diabetes and the finger stick blood sugar testing would be performed as ordered. The care plan documented the resident received a liberal diabetic diet. A physician's telephone order, dated 04/11/11, documented an order for [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A nurse's note, dated 04/16/11 at 9:00 a.m., documented a general assessment of the resident including how the resident tolerated a treatment to the heel and bottom. The note documented there were no adverse reactions from an antibiotic that was given for a urinary tract infection and the resident could communicate any needs. The note did not document the blood sugar of 58, physician notification, measures taken to resolve the low blood sugar, or additional monitoring. The next nurse's note, dated 04/16/11 at 3:30 p.m., documented the resident was unable to tolerate food and fluids, the physician was contacted, an intravenous (IV) line was established in the resident's left hand, and an IV solution of 5% [MEDICATION NAME] in normal saline was started. The note documented a general assessment of the resident including the treatment for [REDACTED]. The note did not document if the resident had symptoms related to the 11:30 a.m. blood sugar of 58. The daily skilled note checklist documented the resident did not have nausea or vomiting. A nurse's note, dated 04/16/11 at 4:45 p.m., documented the resident's IV was restarted in the left wrist. A nurse's note, dated 04/16/11 at 5:00 p.m., documented the resident's blood sugar was 109 and no insulin was given at that time. A nurse's note, dated 04/16/11 at 7:00 p.m., documented the nurse was notified the resident was not acting right, had pulled her IV out, and could not answer questions appropriately. The note documented the resident's vital signs were taken and the resident was placed on oxygen. The note documented the resident was confused and clammy and the blood sugar was checked with a result of 47. The note documented the resident was unable to consume solid food and had difficulty swallowing liquid and applesauce with extra sugar was given. The note documented the resident's blood sugar was rechecked with a result of 68. The note documented the IV was restarted (the IV insertion site was not documented). The note did not document the physician and family were notified of the resident's condition. A nurse's note, dated 04/16/11 at 8:45 p.m., documented the resident's blood sugar was 100 and the resident aroused easily. The next nurse's note, dated 04/16/11 (may have been intended for 04/17/11) at 2:00 a.m., documented the resident was resting with her eyes closed and responded to verbal stimuli. The note did not document if the resident had symptoms related to the 7:00 p.m. blood sugar of 47. A nurse's note, dated 04/17/11 at 3:40 a.m., documented the IV was infusing in the resident's right wrist. The note documented the resident's blood sugar was checked at 1:00 a.m. with a result of 50. The note documented the resident refused solid food and was given 240 cubic centimeters (cc) of orange juice (OJ). The note documented the blood sugar was rechecked and the result was 122. The note did not document the physician and family was notified of the resident's condition. A nurse's note dated 04/17/11 at 4:00 a.m., documented, "BS (blood sugar)-49. Res (resident) arouse to verbal stimuli for 15-20 seconds & (and) would close eyes. Administered OJ (with) difficulty. Res. refused any solid foods. C/O (complains of) dizziness and nausea. Rechecked BS-51. Attempted sugar water, health shake & syrup (with) poor results. Res. refused anything p.o. (by mouth) BS-48. Called EMSA (Emergency Medical Services Authority). Res. transferred to (name deleted hospital). Physician & daughter in law notified. Res. left facility (with) purse, informed daughter in law." The resident did not return to the facility. The hospital transfer record, dated 04/17/11 (no time specified), documented the reason for transfer was the resident's blood sugar continuously dropped below 50 and the resident refused to eat solid food. The EMSA report, dated 04/17/11, documented the ambulance personnel had obtained the first set of vital signs for the resident at 5:35 a.m. The EMSA note, created on 04/17/11 at 5:56 a.m., documented, "...Nursing home called 911 this morning after they had been unable to keep pt (patient) blood sugar up since approximately 1930 (7:30 p.m.) last evening. Per staff, pt. blood sugar was noticed to be low last evening so facility gave pt. an IV and some glucose. Staff states pt. kept refusing to eat but they did not know why. Upon EMSA arrival, TFD (Tulsa Fire Department first responder) was at bedside giving pt. 25g (grams) D50 (solution of [MEDICATION NAME] 50%) IVP (IV push). TFD stated pt. blood glucose reading was initially 22 and pt. was not very alert or oriented. Post D50, pt. became A/O (alert/oriented) x (times) 4 and stated she has not been eating due to feeling sick to her stomach. Staff states pt. has recently been diagnosed with [REDACTED]." The hospital emergency room report, dated 04/17/11 at 12:55 p.m., documented, "...Chief complaints: Shortness of breath and [DIAGNOSES REDACTED]...Clinically she appears to have a respiratory source of her illness likely causing her [DIAGNOSES REDACTED]...At this point, I do believe that likely her [DIAGNOSES REDACTED] is related to the infection and the fact that at the nursing home she continued to receive her long -acting diabetic medicine, in addition to the D-5 drip...Impressions: 1. Acute pneumonia with respiratory distress and room air hypoxemia. 2. [DIAGNOSES REDACTED]. 3. Acute febrile illness. 4. Leukocytosis...." The hospital discharge summary, dated 04/25/11, documented the admission [DIAGNOSES REDACTED]. The summary documented the discharge [DIAGNOSES REDACTED]. The hospital discharge summary, dated 04/25/11, documented, "The patient was initially admitted to the ICU (intensive care unit) as she had severe [DIAGNOSES REDACTED] requiring IV [MEDICATION NAME] continuous infusion. At that time she was also noted to [MEDICAL CONDITION] secondary to a UTI (urinary tract infection), which [MEDICAL CONDITION] in the culture...." On 06/01/11 at 5:00 p.m., the administrator was asked to provide a policy for monitoring blood sugars. On 06/01/11 at 5:30 p.m., the administrator stated the facility did not have a policy for monitoring blood sugars. On 06/02/11 at 3:40 p.m., the physician was interviewed regarding monitoring and treatment of [REDACTED]. The physician stated if the resident's blood sugar was between 40-60 he wanted the staff to give 1/2 [MEDICATION NAME] of D50. The physician was asked when he should be notified for low blood sugars. The physician stated he should be notified immediately if the resident was symptomatic regardless of the number. The physician was asked if he had been aware the resident's blood sugars had been less than 50 on several occasions before she was transported to the hospital. The physician stated he knew the resident's blood sugars had been up and down, but could not say for sure he had been notified each time the blood sugar was below 50. On 06/02/11 at 4:00 p.m., licensed practical nurse (LPN) #4 was interviewed regarding the resident's condition. The LPN stated the resident had an IV started with D5NS because she couldn't tolerate food and fluids and her blood sugar had been low. The LPN stated the resident's blood sugar had been ok at dinner but the resident started acting different. The LPN stated the resident had been given milk, applesauce, and pudding in an attempt to get the blood sugar to come up. On 06/02/11 at 4:00 p.m., the LPN was asked when she would call the physician if the resident's blood sugar was low. The LPN stated if the blood sugar would come up after being given something by mouth she would not call the physician. The LPN stated she would be concerned if the blood sugar went up and down. The LPN was asked when she would notify the family of a change in condition. The LPN stated she had called whatever family had been on the list and was asked to call them back if there were additional changes in the resident's condition. The LPN stated she could not remember all the details of the incident and could not say for sure if she had contacted the physician. Immediate Jeopardy Identified On 06/02/11 at 5:00 p.m., an Immediate Jeopardy (IJ) situation was identified and verified by the Oklahoma State Department of Health (OSDH) related to the facility's failure to notify a resident's physician of a change in the resident's condition. The facility failed to identify blood sugar parameters for each diabetic resident, monitor a resident with low blood sugars, and notify the physician of low blood sugars in a timely manner. On 06/02/11 at 5:20 p.m., the administrator and assistant director of nurses (ADON) were informed of the IJ related to the facility's failure to notify the physician of a resident's change of condition and of low blood sugars. The administrator was informed the IJ put the facility in an extended survey. On 06/02/11 at 6:30 p.m., the facility submitted an acceptable plan of removal. Facility Plan of Removal for Immediate Jeopardy The facility plan of removal documented, "A list of current residents with a [DIAGNOSES REDACTED]. Contact all attending physicians for parameters for low & high blood sugars. Parameters will be immediately placed for all Residents receiving blood sugar monitoring and parameters will be included in nursing P & P (policy and procedure). In-service all licensed nurses and CMAs (certified medication aides)/CNA (certified nurse aides) for abnormal blood sugars. In-service all nursing staff for parameters for low & high blood sugars. The DON or designee will monitor daily the TARS (treatment administration record sheet) to ensure that parameters are being followed; abnormal B.S. (blood sugar) documentation of nurse notes will be reviewed, and information placed on the 24-hour report. This will be monitored daily until compliance is achieved; then 3 x (times) wk (week) x 30 days, 2 x wk x 30 days, then weekly thereafter; any problems will be reviewed daily in the daily stand-up meeting to make sure the system is working. The QA (quality assurance) team is part of the stand-up committee. In-servicing will begin immediately and go throughout the weekend. We feel we will be in compliance by noon on Monday 06/06/11. Any residents determined to have low/high blood sugars this p.m. would be assessed & physician will be immediately contacted. Care plans will be updated with parameters." On 06/03/11 at 8:15 p.m., LPN #8 was interviewed regarding the circumstances that led up to the resident being transferred to the hospital. The LPN stated she could not remember the details except the resident was having trouble with her blood sugars. The LPN stated she could not remember if she had notified the physician of the repeated times the blood sugar was abnormally low. The LPN was asked what procedures they followed when someone had abnormally low or high blood sugars. The LPN stated she had an inservice on Thursday night (06/02/11) going over the new policy and procedure regarding blood sugar parameters, measures to take to get the blood sugar increased, and when the physician should be notified. Immediacy Removed The IJ was removed on 06/06/11 at 12:00 p.m., after the facility had had implemented the plan of removal and the last employee in-service was completed. The deficient practice remained at a level of actual harm at a pattern that was not an immediate jeopardy. On 06/06/11 at 4:30 p.m., the administrator provided documentation ensuring all staff had been in-serviced on the policy and procedure for monitoring and reporting abnormally low or high blood sugars. On 06/06/11, staff interviews were conducted in regard to their knowledge of the in-service to ensure their understanding of the policy and procedure for blood sugar monitoring and parameters and physician notification related to abnormally low or high blood sugars.

Based on observation, record review, and interview, it was determined the facility failed to provide care and services to maintain the highest well-being for four (#1, #3, #4, and #7) of seven sampled diabetic residents reviewed for blood sugar parameters. Resident #4 had a blood sugar of 22 and was transported to the hospital. The facility list of diabetic residents documented 39 residents received finger stick blood sugar monitoring. Findings: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission physician's orders [REDACTED]. The orders included an order to give [MEDICATION NAME] Insulin as needed per the sensitive sliding scale. The orders did not include instructions if the blood sugar was high or low (normal ranges 70 to 110). The orders documented an order for [REDACTED]. There were no parameters for treating and reporting blood sugars less than 125. The physician's progress note, dated 04/04/11, documented the resident was alert and oriented to person, place, and time. The admission assessment, dated 04/08/11, documented the resident did not have cognitive impairment and had good memory recall. The care plan, dated 04/11/11, documented the resident was at risk for hyper or hypoglycemic episodes secondary to diabetes and the finger stick blood sugar testing would be performed as ordered. The care plan documented the resident received a liberal diabetic diet. A physician's telephone order, dated 04/11/11, documented an order for [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A nurse's note, dated 04/16/11 at 9:00 a.m., documented a general assessment of the resident including how the resident tolerated a treatment to the heel and bottom. The note documented there were no adverse reactions from an antibiotic that was given for a urinary tract infection and the resident could communicate any needs. The note did not document the blood sugar of 58, physician notification, measures taken to resolve the low blood sugar, or additional monitoring. The next nurse's note, dated 04/16/11 at 3:30 p.m., documented the resident was unable to tolerate food and fluids, the physician was contacted, an intravenous (IV) line was established in the resident's left hand, and an IV solution of 5% [MEDICATION NAME] in normal saline was started. The note documented a general assessment of the resident including the treatment for [REDACTED]. The note did not document if the resident had symptoms related to the 11:30 a.m. blood sugar of 58. The daily skilled note checklist documented the resident did not have nausea or vomiting. A nurse's note, dated 04/16/11 at 4:45 p.m., documented the resident's IV was restarted in the left wrist. A nurse's note, dated 04/16/11 at 5:00 p.m., documented the resident's blood sugar was 109 and no insulin was given at that time. A nurse's note, dated 04/16/11 at 7:00 p.m., documented the nurse was notified the resident was not acting right, had pulled her IV out, and could not answer questions appropriately. The note documented the resident's vital signs were taken and the resident was placed on oxygen. The note documented the resident was confused and clammy and the blood sugar was checked with a result of 47. The note documented the resident was unable to consume solid food and had difficulty swallowing liquid and applesauce with extra sugar was given. The note documented the resident's blood sugar was rechecked with a result of 68. The note documented the IV was restarted (the IV insertion site was not documented). The note did not document the physician and family were notified of the resident's condition. A nurse's note, dated 04/16/11 at 8:45 p.m., documented the resident's blood sugar was 100 and the resident aroused easily. The next nurse's note, dated 04/16/11 (may have been intended for 04/17/11) at 2:00 a.m., documented the resident was resting with her eyes closed and responded to verbal stimuli. The note did not document if the resident had symptoms related to the 7:00 p.m. blood sugar of 47. A nurse's note, dated 04/17/11 at 3:40 a.m., documented the IV was infusing in the resident's right wrist. The note documented the resident's blood sugar was checked at 1:00 a.m. with a result of 50. The note documented the resident refused solid food and was given 240 cubic centimeters (cc) of orange juice (OJ). The note documented the blood sugar was rechecked and the result was 122. The note did not document the physician and family was notified of the resident's condition. A nurse's note dated 04/17/11 at 4:00 a.m., documented, "BS (blood sugar)-49. Res (resident) arouse to verbal stimuli for 15-20 seconds & (and) would close eyes. Administered OJ (with) difficulty. Res. refused any solid foods. C/O (complains of) dizziness and nausea. Rechecked BS-51. Attempted sugar water, health shake & syrup (with) poor results. Res. refused anything p.o. (by mouth) BS-48. Called EMSA (Emergency Medical Services Authority). Res. transferred to (name deleted hospital). Physician & daughter in law notified. Res. left facility (with) purse, informed daughter in law." The resident did not return to the facility. The hospital transfer record, dated 04/17/11 (no time specified), documented the reason for transfer was the resident's blood sugar continuously dropped below 50 and the resident refused to eat solid food. The EMSA report, dated 04/17/11, documented the ambulance personnel had obtained the first set of vital signs for the resident at 5:35 a.m. The EMSA note, created on 04/17/11 at 5:56 a.m., documented, "...Nursing home called 911 this morning after they had been unable to keep pt (patient) blood sugar up since approximately 1930 (7:30 p.m.) last evening. Per staff, pt. blood sugar was noticed to be low last evening so facility gave pt. an IV and some glucose. Staff states pt. kept refusing to eat but they did not know why. Upon EMSA arrival, TFD (Tulsa Fire Department first responder) was at bedside giving pt. 25g (grams) D50 (solution of [MEDICATION NAME] 50%) IVP (IV push). TFD stated pt. blood glucose reading was initially 22 and pt. was not very alert or oriented. Post D50, pt. became A/O (alert/oriented) x (times) 4 and stated she has not been eating due to feeling sick to her stomach. Staff states pt. has recently been diagnosed with [REDACTED]." The hospital emergency room report, dated 04/17/11 at 12:55 p.m., documented, "...Chief complaints: Shortness of breath and [DIAGNOSES REDACTED]...Clinically she appears to have a respiratory source of her illness likely causing her [DIAGNOSES REDACTED]...At this point, I do believe that likely her [DIAGNOSES REDACTED] is related to the infection and the fact that at the nursing home she continued to receive her long -acting diabetic medicine, in addition to the D-5 drip...Impressions: 1. Acute pneumonia with respiratory distress and room air hypoxemia. 2. [DIAGNOSES REDACTED]. 3. Acute febrile illness. 4. Leukocytosis...." The hospital discharge summary, dated 04/25/11, documented the admission [DIAGNOSES REDACTED]. The summary documented the discharge [DIAGNOSES REDACTED]. The hospital discharge summary, dated 04/25/11, documented, "The patient was initially admitted to the ICU (intensive care unit) as she had severe [DIAGNOSES REDACTED] requiring IV [MEDICATION NAME] continuous infusion. At that time she was also noted to [MEDICAL CONDITION] secondary to a UTI (urinary tract infection), which [MEDICAL CONDITION] in the culture...." On 06/01/11 at 5:00 p.m., the administrator was asked to provide a policy for monitoring blood sugars. On 06/01/11 at 5:30 p.m., the administrator stated the facility did not have a policy for monitoring blood sugars. On 06/02/11 at 3:40 p.m., the physician was interviewed regarding monitoring and treatment of [REDACTED]. The physician stated if the resident's blood sugar was between 40-60 he wanted the staff to give 1/2 [MEDICATION NAME] of D50. The physician was asked when he should be notified for low blood sugars. The physician stated he should be notified immediately if the resident was symptomatic regardless of the number. The physician was asked if he had been aware the resident's blood sugars had been less than 50 on several occasions before she was transported to the hospital. The physician stated he knew the resident's blood sugars had been up and down, but could not say for sure he had been notified each time the blood sugar was below 50. On 06/02/11 at 4:00 p.m., licensed practical nurse (LPN) #4 was interviewed regarding the resident's condition. The LPN stated the resident had an IV started with D5NS because she couldn't tolerate food and fluids and her blood sugar had been low. The LPN stated the resident's blood sugar had been ok at dinner but the resident started acting different. The LPN stated the resident had been given milk, applesauce, and pudding in an attempt to get the blood sugar to come up. On 06/02/11 at 4:00 p.m., the LPN was asked when she would call the physician if the resident's blood sugar was low. The LPN stated if the blood sugar would come up after being given something by mouth she would not call the physician. The LPN stated she would be concerned if the blood sugar went up and down. The LPN was asked when she would notify the family of a change in condition. The LPN stated she had called whatever family had been on the list and was asked to call them back if there were additional changes in the resident's condition. The LPN stated she could not remember all the details of the incident and could not say for sure if she had contacted the physician. Immediate Jeopardy Identified On 06/02/11 at 5:00 p.m., an Immediate Jeopardy (IJ) situation was identified and verified by the Oklahoma State Department of Health (OSDH) in the provision of care and services to maintain the highest practicable well-being. The facility failed to identify blood sugar parameters for each diabetic resident, monitor a resident with low blood sugars, and notify the physician of low blood sugars in a timely manner. On 06/02/11 at 5:20 p.m., the administrator and assistant director of nurses (ADON) were informed of the IJ in provision of care and services to maintain the highest practicable well-being related to blood sugar monitoring and no parameters for notifying the physician of low blood sugars. The administrator was informed the IJ put the facility in an extended survey. On 06/02/11 at 6:30 p.m., the facility submitted an acceptable plan of removal. Facility Plan of Removal for Immediate Jeopardy The facility plan of removal documented, "A list of current residents with a [DIAGNOSES REDACTED]. Contact all attending physicians for parameters for low & high blood sugars. Parameters will be immediately placed for all Residents receiving blood sugar monitoring and parameters will be included in nursing P & P (policy and procedure). In-service all licensed nurses and CMAs (certified medication aides)/CNA (certified nurse aides) for abnormal blood sugars. In-service all nursing staff for parameters for low & high blood sugars. The DON or designee will monitor daily the TARS (treatment administration record sheet) to ensure that parameters are being followed; abnormal B.S. (blood sugar) documentation of nurse notes will be reviewed, and information placed on the 24-hour report. This will be monitored daily until compliance is achieved; then 3 x (times) wk (week) x 30 days, 2 x wk x 30 days, then weekly thereafter; any problems will be reviewed daily in the daily stand-up meeting to make sure the system is working. The QA (quality assurance) team is part of the stand-up committee. In-servicing will begin immediately and go throughout the weekend. We feel we will be in compliance by noon on Monday 06/06/11. Any residents determined to have low/high blood sugars this p.m. would be assessed & physician will be immediately contacted. Care plans will be updated with parameters." On 06/03/11 at 8:15 p.m., LPN #8 was interviewed regarding the circumstances that led up to the resident being transferred to the hospital. The LPN stated she could not remember the details except the resident was having trouble with her blood sugars. The LPN stated she could not remember if she had notified the physician of the repeated times the blood sugar was abnormally low. The LPN was asked what procedures they followed when someone had abnormally low or high blood sugars. The LPN stated she had an inservice on Thursday night (06/02/11) going over the new policy and procedure regarding blood sugar parameters, measures to take to get the blood sugar increased, and when the physician should be notified. Immediacy Removed The IJ was removed on 06/06/11 at 12:00 p.m., after the facility had had implemented the plan of removal and the last employee in-service was completed. The deficient practice remained at a level of actual harm at a pattern that was not an immediate jeopardy. On 06/06/11 at 4:30 p.m., the administrator provided documentation ensuring all staff had been in-serviced on the policy and procedure for monitoring and reporting abnormally low or high blood sugars. On 06/06/11, staff interviews were conducted in regard to their knowledge of the in-service to ensure their understanding of the policy and procedure for blood sugar monitoring and parameters and physician notification related to abnormally low or high blood sugars. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The daily skilled nurse's note, dated 05/23/11, documented the resident was alert and oriented. The initial assessment had not been completed at the time of the investigation. The comprehensive care plan had not been completed at the time of the investigation. The admission physician's orders [REDACTED]. The orders documented an order for [REDACTED]. On 06/01/11 at 10:20 a.m., the resident was observed and did not exhibit signs or symptoms of hypo or [MEDICAL CONDITION]. The resident was alert and oriented. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 05/24/11, documented the resident was cognitively impaired and was dependent on staff for assistance with activities of daily living (ADLs). The care plan, updated 05/25/11, documented the resident was risk for complications related to diabetes and finger stick blood sugar monitoring was to be done as ordered by the physician. The physician's orders [REDACTED]. The orders documented the resident received sliding scale insulin but did not document parameters for monitoring and reporting abnormally low blood sugars. On 06/02/11 at 9:40 a.m., the resident was observed and did not exhibit signs or symptoms of hypo or [MEDICAL CONDITION]. The resident was alert and confused at that time. 4. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The initial assessment, dated 03/18/11, documented the resident had cognitive impairment and required some assistance with ADLs. The care plan, dated 03/18/11, documented the resident was at risk for complications related to diabetes. The physician's orders [REDACTED]. The orders documented the resident received routine and sliding scale insulin but did not document parameters for monitoring and reporting abnormally low or high blood sugars. On 06/02/11 at 11:30 a.m., the resident was observed and did not exhibit signs or symptoms of hypo or [MEDICAL CONDITION]. On 06/02/11 at 2:00 p.m., the assistant director of nurses (ADON) was interviewed regarding parameters for monitoring and reporting abnormally high or low blood sugars. The ADON looked at the residents' physicians' orders and stated the orders should be clarified to indicate when the physician should be notified.