Every finding on record at Ballard Nursing Center

Based on record review and interview, the facility failed to ensure residents were offered vaccines and received education related to COVID-19 immunizations, and if the vaccine was declined, the required documentation was in place for 1 (#54) of 5 sampled residents reviewed for immunizations. The administrator reported 60 residents resided in the facility. Findings:The admission assessment for Resident #54, dated 06/09/25, showed the resident was admitted to the facility on [DATE] with diagnoses which includes Congestive heart failure, diabetes mellitus, and hypertension. The assessment showed a BIMS score of 12 which indicated moderate cognitive impairment.A facility vaccination consent form dated 05/29/25, read in part, COVID-19 VACCINE CONSENT, followed by I do___ do not___ want resident to receive COVID-19 vaccine or boosters.Resident #54's consent form showed a check mark to indicate they wanted the COVID-19 vaccine. In Resident #54's medical record, there was no documentation to indicate a COVID-19 vaccine was received.On 08/27/25 at 2:50 p.m. the administrator and RN were asked to verify Resident #54 received the injection for the COVID-19 vaccine Resident #54 had given consent for back on 5/29/25. They stated no because they have not had a vaccine clinic. The administrator or RN were unable able to produce a vaccine policy for COVID-19 vaccination education and administration.

Based on observation and interview, the facility failed to ensure food service equipment was free from grease and grime. The dietary manager reported plate warming lids were used for residents who receive their meals in their rooms.Findings: An undated policy General Sanitation of Kitchen, read in part, Food and nutrition services staff will maintain the sanitation of the kitche. On 08/26/25 at 12:15 p.m., during a tour of the kitchen, the metal rack that held multiple plate warming lids were observed with visible buildup of grease and grime. There were no visible signs of the lids containing grease and grime. The residue on the metal rack was sticky to the touch and extended across all shelving levels where the lids were stored.On 08/26/25 at 12:17 p.m., the dietary manager stated the rack had not been cleaned and its proximity to the stove contributed to the accumulation of the grease and grime. The dietary manager stated the buildup of grease and grime on the metal rack was an oversight and needed to be cleaned.

Based on record review and interview, the facility to ensure a food allergy was included on the comprehensive care plan for 1 (#31) of 1 sampled resident reviewed for food allergies.The administrator reported 60 residents resided in the facility.Findings:A nutritional risk assessment, dated 05/20/24, showed Resident 31's diet was regular with an allergy to fish. A quarterly assessment, dated 08/19/25, showed Resident #31 required set-up assistance with eating.On 08/27/25 at 10:01 a.m., Resident #31's dietary card showed a food allergy to fish. An incident report, dated 05/28/25, showed the resident was accidentally given a tuna sandwich and had eaten a couple of bites before the CNA could take it back. The incident report was sent to the emergency room for evaluation due to the known fish allergy. An emergency room report, dated 05/28/25, showed the resident was not in any distress. The emergency room report showed the resident reported feeling funny and was medicated for a known food allergy.A care plan, dated 05/30/25, showed the resident has a known food allergy to fish.On 08/27/25 at 4:02 p.m., LPN #1 reported Resident #31's fish allergy had not been added to the care plan before 05/30/25. The LPN reported the fish allergy should have been on the care plan before 05/30/25.

On 05/20/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent elopement. Based on record review and interview, the facility failed to provide supervision for 1 (#1) of 3 sampled residents reviewed for wandering. The administrator identified 71 residents resided in the facility. Findings: An undated facility policy Elopement, read in part, 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge nurse or Director of Nursing .2. If an employee observes a resident leaving the premises, he/she should: 1. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary, and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises .4. If an employee discovers that a resident is missing from the facility, he/she shall: c. If the the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.). An undated facility Profile Face Sheet for Resident #1 showed they were admitted on [DATE] with diagnoses which included Alzheimer's, dementia, difficulty walking, muscle weakness, heart failure, anxiety, acute kidney failure and a history of repeated falls. Resident #1 Care Plan, revised 05/05/25, read in part, The resident is an elopement risk/wander .The resident will not leave facility unattended through the review date initiated: 08/09/24 target date: 05/04/25 . Resident # Care Plan, revised 05/05/25, read in part, Resident #1 wandering in and out of room since 0100.11/11/24 wandering into other residents room, .Date Initiated ; 08/09/24. Resident #1's Minimum Data Set assessment, with an assessment date of 02/14/25, showed they had a BIMS score of 02 indicating a severe cognitive impairment. An in-service document titled Wandering and Elopement dated, 05/08/25 was conducted. An untitled document, dated 05/08/25, read in part, 6:15 p.m. seen exiting back door by laundry via cctv .elopement Admin notified at 6:30 p.m.6:33 p.m. Resident located by facility staff.6:33 p.m. Resident #1 located by facility staff.6:35 p.m. assisted back into facility & assessed by liscensed nurse with no injuries found. Head to toe assessment completed. Facility initiated investigation 30-minute checks on Resident #1 started. Family Physician and Hospice notified.6:45 p.m. LPN Charge Nurse completed a head count on all residents to ensure everyone was accounted for with no issues identified.7:00 p.m. Charge nurse completed a 100% audit of all doors & windows in the facility. All windows were locked with security devices in place. All doors were functioning properly. All locked doors were unlocked and reset to assure they were working properly.7:15 p.m. Charge nurse completed review of wandering elopement book, MDS RN notifed to update Care Plan; PIP plan iniated .8:00 p.m. Administrator initiated in-services via all group text to all departments on Wander policy & elopement.8:25 p.m. OSDH notified via fax and investigation completed.7:00 a.m. Door Code Changed by maintenance. Roofers will be instructed to use the main entrance when entering or leaving the facility.9:00 a.m. QAPI meeting held with facility Superviors. A nursing note, dated 05/08/25, read in part, a patient followed the construction worker out of a back door. A Elopement and Wandering document, dated 05/08/25, showed an in service for staff with signatures. A 15 Minute Check document, showed a start date of 05/08/25. A QAPI Meeting document, dated 05/09/25, showed an in service was conducted for Resident #1's elopement. An in-service document titled Wandering and Elopement Risks, dated 05/09/25, showed all staff notified via text group reviewed 05/09/25. A 15 Minute Check document, showed a end date of 05/11/25. On 05/29/25 at 6:10 p.m., CNA #1 stated we had a fire drill that day and they didn't tell anyone. The doors became unlocked and thats when I think Resident #1 eloped out the building. On 05/19/25 at 6:11 p.m., CNA #1 stated I went to the dining hall around 5:30 p.m. to serve dinner to Resident # 1 and they was not in the dining hall. and then I went to check bathrooms and notfied nursing staff around 5:45 p.m. because I could not Resident #1. On 05/19/25 at 6:12 p.m., CNA #1 stated Resident #1 got about 3 blocks away. On 05/19/25 at 6:19 p.m., CNA #1 stated Resident #1 is a wander because they always acting like they are leaving and going to work On 05/19/25 at 6:55 p.m., the director of nursing stated during the elopement I believe Resident #1 was at risk for harm and no one knew until the construction workers reported Resident #1 was missing. On 05/20/25 at 9:11 a.m., the Regional Maintenance Director stated Resident #1 acts they are leaving and going to work. On 05/20/25 at 9:12 a.m., the Regional Maintenance Director stated when doors are being tested all the doors will unlock. On 05/20/25 at 9:53 a.m., the DON and LPN #1 stated they didn't know why CNA #1 did not report Resident #1 was missing at 5:30 p.m. On 05/20/25 at 10:20 a.m., the DON stated staff are told when they start working to follow policy and procedures and to notify the Administrator. The Administrator #1 notified me on 05/08/25 at 6:55 p.m On 05/20/25 at 10:27 a.m., Resident #1 stated I left out the building the other day. On 05/20/25 at 5:17 p.m., CMA #1 stated Resident #1's elopement was preventable and was at risk for harm.

Based on observation, record review, and interview, the facility failed to ensure infection control measures were followed during fingerstick glucose monitoring for nine (#7, 13, 20, 24, 29, 33, 42, 52, and #207) of nine residents who were observed during fingerstick glucose monitoring. Corporate nurse consultant #1 identified 12 residents who received fingerstick glucose monitoring. Findings: An Obtaining a Fingerstick Glucose Level policy, dated October 2010, read in parts, .Wear clean gloves .Wash the selected fingertip, especially the side of the finger, with warm water and soap .clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice .Remove gloves . Wash hands . On 03/25/24 at 11:15 a.m., LPN #2 was observed performing fingerstick glucose monitoring. The following observations were made: At 11:21 a.m., LPN #2 washed hands with soap and water, donned gloves, and cleansed the top of the medication cart with a disinfectant wipe. They removed two glucometers from the medication cart and cleansed each glucometer with disinfectant wipes. LPN #2 placed both glucometers on top of a disinfectant wipe that had been placed on the top of the medication cart. LPN #2 doffed gloves but did not perform hand hygiene. At 11:27 a.m., LPN #2 donned gloves and performed a FSBS on Res #20. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #1. Glucometer #1 was placed on the same disinfectant wipe on the top of the medication cart. At 11:31 a.m., LPN #2 donned gloves and performed a FSBS on Res #42. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #2. Glucometer #2 was placed on the same disinfectant wipe on the top of the medication cart. At 11:36 a.m., LPN #2 donned gloves and performed a FSBS on Res #52. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #1. Glucometer #1 was placed on the same disinfectant wipe on the top of the medication cart. At 11:43 a.m., LPN #2 donned gloves and performed a FSBS on Res #24. LPN #2 did not cleanse Res #24's fingertip prior to piercing the skin with a lancet. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #1. Glucometer #1 was placed on the same disinfectant wipe on the top of the medication cart. LPN #2 walked into an employee office and drank out of a personal drink cup before returning to the medication cart without performing hand hygiene. At 11:45 a.m., LPN #2 donned gloves and performed a FSBS on Res #33. LPN #2 did not cleanse Res #33's fingertip prior to piercing the skin with a lancet. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #1. Glucometer #1 was placed on the same disinfectant wipe on the top of the medication cart. At 11:48 a.m., LPN #2 donned gloves and performed a FSBS on Res #7. LPN #2 did not cleanse Res #7's fingertip prior to piercing the skin with a lancet. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #2. Glucometer #2 was placed on the same disinfectant wipe on the top of the medication cart. At 11:52 a.m., LPN #2 donned gloves and performed a FSBS on Res #13. LPN #2 did not cleanse Res #13's fingertip prior to piercing the skin with a lancet. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #2. Glucometer #2 was placed on the same disinfectant wipe on the top of the medication cart. At 12:00 p.m., LPN #2 donned gloves and performed a FSBS on Res #207. LPN #2 did not cleanse Res #207's fingertip prior to piercing the skin with a lancet. LPN #2 cleansed glucometer #1 post procedure with a disinfectant wipe for approximately 5 seconds and then placed glucometer #1 back into the top drawer of the medication cart. They doffed gloves but did not perform hand hygiene. At 12:05 p.m., LPN #2 donned gloves and performed a FSBS on Res #29. LPN #2 did not cleanse Res #29's fingertip prior to piercing the skin with a lancet. LPN #2 cleansed glucometer #2 post procedure with a disinfectant wipe for approximately 5 seconds and then placed glucometer #2 back into the top drawer of the medication cart. They doffed gloves post procedure but did not perform hand hygiene. At 12:08 p.m. corporate nurse consultant #1 approached the medication cart and stated, I am going to stop this observation, I would like to speak to this nurse in private. At 12:15 p.m., corporate nurse consultant #1 stated they had ended the observation due to having observed LPN #2's lack of infection control measures. They stated LPN #2 should have performed hand hygiene before and after wearing gloves. Corporate nurse consultant #1 stated the glucometers should have been cleansed after each use. At 12:20 p.m., LPN #2 stated hand hygiene should be performed before and after every fingerstick blood sugar. They stated having changed gloves but not performed any hand hygiene during the observation. LPN #2 stated they were taught not to cleanse the fingertip with an alcohol pad prior to obtaining a blood sample because the alcohol residue could alter the results, but they probably should have cleansed the fingertips with something to ensure they were disinfected. LPN #2 stated they should have cleansed the glucometers thoroughly between residents and alternated the glucometers while each dried to ensure proper disinfection procedures. At 12:45 p.m., the DON was made aware of the observations. The DON stated LPN #2 should have performed hand hygiene prior to and after each procedure. They stated the glucometers should have been cleansed and allowed to dry in between residents. The DON stated the use of two glucometers was intended to allow time for proper disinfection and drying time between residents. They stated the residents' fingertips should have been cleansed prior to piercing the skin. The DON stated LPN #2 did not ensure proper infection control measures during fingerstick glucose monitoring.

Based on observation, record review, and interview, the facility failed to ensure the physical environment was kept clean and maintained in good repair. The DON identified 53 residents resided in the facility. Findings: A facility policy and procedure titled Homelike Environment, revised 02/2021, read in part, .Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect .homelike setting. These characteristics include .clean, sanitary . On 03/25/24 at 10:49 a.m., the womens visitor/staff restroom was observed. There was black residue on the inside area of the toilet bowl. On 03/25/24 at 10:57 a.m., the shower room on hall 200 was observed. There was black residue on the floor and the wall in the working shower stall. There was black residue on the inside area of the toilet bowl. On 03/25/24 at 10:59 a.m., the resident restroom on hall 100 was observed. There was a strong urine odor. There were floor tiles missing around the toilet. There was brown and yellow residue on the inside area of the toilet bowl. On 03/25/24 at 11:01 a.m., the shower room on hall 100 was observed. There was black and yellow residue on the floor and the walls in the shower stall. There was black residue on the inside area of the toilet bowl. There were floor tiles missing around the toilet and black residue was on the floor. There was material peeling off the ceiling and off of the wall around the hand sink. On 03/25/24 at 11:03 a.m., the shower room on hall 300 was observed. The floor drain cover in the shower stall was missing. There was black residue on the floor around the toilet. There was black residue on the inside area of the toilet bowl and there were multiple gnats flying around the toilet. On 03/25/24 at 11:07 a.m., the mens visitor/staff restroom was observed. There was black residue on the inside area of the toilet bowl. The base board was missing off the wall next to the entry/exit door. On 03/25/24 at 11:09 a.m., the laundry room was observed. There was an accumulation of lint on the washing machines and the dryers. There were pieces of sheetrock and an accumulation of white residue and lint on the floor behind the washing machines. The sheetrock was not sealed/finished near the window air unit. On 03/25/24 at 11:11 a.m., laundry aide #1 was asked how staff maintained the laundry room. They stated they cleaned daily. They stated maintenance concerns were reported to the maintenance department. 03/25/24 at 11:16 a.m., the housekeeping/laundry supervisor was asked how staff ensured the physical environment was kept clean and maintained in good repair. They stated staff cleaned daily. They stated there was a sheet at the nurses' station where they reported maintenance concerns. They were shown and made aware of the above observations. On 03/25/24 at 12:57 p.m., the COO, administrator, and corporate nurse consultant #1 were made aware of the above observations.

Based on observation, record review, and interview, the facility failed to conduct a thorough investigation into allegations of abuse for one (#38) of three sampled residents reviewed for abuse. The DON identified 53 residents who resided in the facility. Findings: An Abuse Policy, undated, read in parts, .Any allegation of abuse will be investigated by the Administrator and the Director of Nursing. The Administrator and the Director of Nursing will as a minimum: review the resident's medical record looking for events leading up to the incident, interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident (if cognitive ability permits), interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident if necessary, interview the resident's roommate, family members, and visitors as able and necessary, interview other residents to whom the accused employee provides care or services and review all events leading up to the incident .Witness reports will be reduced to writing with the witness signing and dating the report on the Witness Report form .The witness will write his/her own report . Res #38 had diagnoses which included nontraumatic intracerebral hemorrhage and dysphagia following cerebral infarction. An annual assessment, dated 10/10/23, documented the resident was severely cognitively impaired and required setup or clean-up assistance with mobility and most ADLs. An OSDH initial incident report form, dated 12/27/23, documented a CMA went into the resident's room and observed the resident kissing a facility employee. The report documented the incident was reported to law enforcement and APS. The report documented the employee was suspended pending an investigation. An OSDH notification of nontechnical service worker abuse, neglect, mistreatment or misappropriation of property report, dated 12/27/23 documented the employee had been suspended on 12/27/23. An OSDH final incident report form, dated 01/03/24, documented an investigation was completed and the employee confessed to the allegation. The report documented the employee was terminated. There was no documentation of an investigation related to the incident. On 03/24/24 at 11:50 a.m., Res #38 was observed sitting in their room. The resident stated they had never been sexually abused while residing in the facility. On 03/26/24 at 10:00 a.m., the administrator was asked for all documentation related to the investigation conducted for Res #38. The administrator stated the employee admitted to the allegation and was fired. They stated an attempt to locate additional documentation other than the OSDH incident forms would be made. On 03/26/24 at 10:23 a.m., the administrator stated camera footage was reviewed the day of the incident and the employee who witnessed the incident completed a witness statement. They stated the appropriate agencies were notified but an interview with Res #38, additional residents, and other staff members was not documented. The administrator stated the CMA witness statement could not be located. They stated the facility's abuse investigation policy was not followed.

Based on observation, record review, and interview, the facility failed to ensure a dialysis resident received monitoring before and after dialysis treatment and failed to ensure communication between the facility and the dialysis center for one (#13) of one sampled residents reviewed for dialysis. The DON identified one resident resided in the facility received dialysis services. Findings: Res #13 admitted on [DATE] with diagnoses which included end stage renal disease. Physician orders, dated 12/14/23, documented to obtain a weight before and after dialysis on Tuesday, Thursday, and Saturday. On 03/24/24 at 1:13 p.m., Res #13 was observed resting in their bed in their room. A white bordered adhesive dressing could be observed above the collar of their shirt on the right side of the chest below the collar bone. The resident stated the facility did not send any sort of communication form with them to dialysis. They stated there is not a form sent back with them when they return from dialysis. The resident stated staff did not assess their dialysis port before or after dialysis. They stated the only people who have anything to do with their dialysis port is the dialysis center. They stated they were not assessed prior to or after dialysis treatments. On 03/25/24 at 1:43 p.m., the DON stated dialysis communication forms were sent with the resident but rarely returned. They stated the forms when returned are filed into the resident's chart. On 03/26/24 at 8:43 a.m., the DON was informed there were no communication forms in the resident's chart. They stated they were unable to recall if they had ever received a communication form from the facility. The DON stated the assessment completed on the resident related to dialysis was a weight before and after the treatment. The DON stated if there are issues that needed to be communicated with the dialysis center there would be a phone call. They stated because the resident had lived in the facility before the staff was familiar with the resident and did not require an order to know when the resident was to go to dialysis. They stated there was no documentation in the chart for an order to monitor or send the resident but the resident probably needed a treatment order related to their dialysis and assessment. When asked where the order for dialysis was in the resident's chart the DON stated they had never had an order for dialysis before.

Based on record review and interview the facility failed to ensure medications were administered as ordered for one (#13) of five sampled residents reviewed for unnecessary medications. The DON identified 53 residents resided in the facility. Findings: Res #13 had diagnoses which included heart failure, hypertension, and diabetes. A physician order, dated 02/09/24, documented to administer insulin aspart according to sliding scale before meals and at bedtime. A physician order, dated 02/09/24, documented to administer metoprolol tartrate 25 mg two times per day for hypertension. The order documented to hold the medication for a heart rate less than 65. A MAR for February 2024 documented the metoprolol was administered when the resident's heart rate was less than 65 five times. A MAR for February 2024 documented the 11:00 a.m. Insulin Aspart was administered greater than one hour after the scheduled time nine times. A physician order, dated 02/09/24, documented to administer Insulin Detemir 5 units twice per day. A MAR for February 2024 documented the 7:00 a.m. insulin detemir was administered greater than one hour after the scheduled time 12 times and the 9:00 p.m. insulin detemir was administered greater then one hour after the scheduled time three times. A MAR for March 2024 documented the insulin detemir was administered greater than one hour after the 7:00 a.m. scheduled time 5 times and the 7:00 p.m. scheduled time 4 times. A physician order, dated 03/13/24 documented to administer Lantus Subcutaneous Solution 5 units subcutaneously two times A MAR for March 2024 documented the Lantus was administered greater than one hour after the 7:00 a.m. scheduled time one time. A physician order, dated 03/13/24, documented to administer Humalog according to sliding scale before meals and at bedtime. A MAR for March 2024 documented the Humalog insulin was administered greater than one hour after the 11:00 a.m. scheduled time one time. On 03/26/24 at 8:47 a.m., the DON stated medications should be administered no later than one hour before or one hour after the scheduled time. On 03/26/24 at 8:56 a.m., CMA #1 stated the blood pressure medications should have been held if the heart rate parameter was not met. They stated the nurse should have been notified and the actions taken documented in the resident's chart.

Based on observation and interview, the facility failed to ensure the kitchen was kept clean and maintained in good repair. The DM identified 51 residents received services from the kitchen. Two residents received nutrition and hydration solely through a feeding tube. Findings: On 03/24/24 at 9:05 a.m., a tour of the kitchen was conducted. The following observations were made. a. there was lint on the ceiling vents and the ceiling around the vents, b. there was an accumulation of lint on the white floor fan, c. there were wall tiles missing behind the stove, d. there were holes and material was peeling off the wall below the three compartment sink, e. a baseboard tile was pulling away from wall near the back door, f. there were gaps and daylight was visible on the side and under the back door, g. baseboards were missing on the walls in the dish machine area, h. there was an accumulation of white residue on and in the dish machine, i. there was black residue inside of the ice machine, j. there was black residue on the floor under equipment, k. there was a box of foam cups stored on the floor in the dry storage area, l. there were multiple boxes of supplements and juice stored on the floor in the dry storage, and m. the baseboard was missing off the wall in the employee storage area. On 03/26/24 at 9:13 a.m., the DM was asked how staff ensured the kitchen was kept clean and maintained in good repair. They stated they cleaned daily and there was a maintenance log where they recorded maintenance concerns. They were asked what was the protocol for the storage of food and single service items. They stated they should be stored off of the floor. They were shown and made aware of the above observations

Based on record review and interview, the facility failed to educate, offer, and screen residents for eligibility to receive the pneumococcal vaccination for one (#34) and failed to educate, offer, and screen residents for eligibility to receive the influenza vaccination for one (#37) of five sampled residents reviewed for immunizations. The DON identified 53 residents who resided in the facility. Findings: A Pneumococcal Vaccine policy, revised April 2012, read in parts, .Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission in not conducted prior to admission . Before receiving the Pneumovax, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine .Provision of such education shall be documented in the resident's medical record .Pneumococcal vaccinations will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician approved pneumococcal vaccination protocol .If refused, appropriate entries will be documented in each resident's medical record indicating the date of refusal of the pneumococcal vaccination . An Influenza Vaccine policy, revised April 2012, read in parts, .Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccination is medically contraindicated or the resident has already been immunized .Prior to the vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine .Provision of such education shall be documented in the resident's medical record .A resident's refusal of the vaccine shall be documented in the resident's medical record . There was no documentation in the medical record indicating Res #34 was screened for eligibility to receive the pneumococcal vaccination, education regarding risks, benefits, side effects, and the consent and/or declination of the vaccination. There was no documentation in the medical record indicating Res #37 was screened for eligibility to receive the influenza vaccination, education regarding risks, benefits, side effects, and the consent and/or declination of the vaccination. On 03/27/24 at 12:11 p.m., the DON stated no documentation could be located indicating Res #34 and Res #37 had been offered, screened, provided education, consented, or declined the vaccinations.

Based on observation and interview, the facility failed to ensure call lights accommodated residents needs for two (#10 and #37) of two sampled residents reviewed for accommodation of needs. The DON identified 53 residents resided in the facility. Findings: 1. Res #10 had diagnoses which included RA and type 2 diabetes mellitus. An admission assessment, dated 03/15/24, documented the resident's cognition was moderately impaired. It was documented the resident had impairment on both sides of their upper extremities. On 03/24/24 at 11:24 a.m., the resident stated they had to hold down the button on their call light to keep the call light activated. They stated they had their roommate activate their call light when needed. They stated their roommates call light was one where you pushed and pulled out the button. On 03/25/24 at 12:06 p.m., CNA #1 was asked what type of call lights the facility used. They stated they had the ones where you pushed the button down and the call light stayed on until the button was pushed up. They stated they did have a few call lights where you had to hold the button down to keep the call light activated. They were asked if Res #10 was able to use their call light. They stated the resident was not able to hold the call light button down. They stated the resident had their roommate push their call light. 2. Res #37 had diagnoses which included peripheral vascular disease, and unspecified symptoms and signs involving functions and awareness. An admission assessment, dated 01/31/24, documented the resident's cognition of moderately impaired. On 03/24/24 at 10:19 a.m., the resident stated they had to hold down the button on their call light to keep the call light activated. They stated their call light had been replaced, because the other one had a short in it. They stated they had their roommate activate their call light when needed. They stated they had one where you pushed the call button down and pulled it back up. On 03/25/24 at 12:12 p.m., CNA #2 was asked what type of call lights the facility used. They stated they had the ones where you pushed the button down and the call light stayed on until the button was pushed up. They stated they did have a few older call lights where you had to hold the button down to keep the call light activated. They were asked if Res #37 was able to use their call light. They stated the resident could hold the button down on their call light, but sometimes had their roommate activate their call light for them. On 03/25/24 at 12:30 p.m., corporate nurse consultant #1 was asked about the type of call lights the facility had. They stated as far as they knew there was only one type of call light. They stated they had the ones where you pushed the button down and the call light stayed on until the button was pushed up. They were made aware of the above observations.

Based on record review and interview, the facility failed to ensure a resident's code status was accurate for one (#21) of one sampled resident reviewed for advance directives. The DON identified 53 residents resided in the facility. Findings: Res #21 had diagnoses which included COPD, HTN, major depressive disorder, hyperlipidemia, osteoarthritis, PTSD, and chronic pain. A DNR Order Acceptance or Declination Report, dated [DATE], documented there was a copy of the resident's DNR order in their chart in the facility. A DNR consent form, dated [DATE], documented the residents gave consent for DNR. A physician order, dated [DATE], documented CPR. An admission assessment, dated [DATE], documented the resident's cognition was intact. On [DATE] at 10:07 a.m., the resident was asked about their code status. They stated they had signed a DNR and it should be on file with the facility. They stated they did not want CPR. On [DATE] at 10:23 a.m., LPN #2 was asked how staff determined what was a residents' code status if there was an emergency. They stated code status was the residents' preference. They stated they looked in the residents' chart. They were asked what was Res #21's code status. They stated they were a full code. They stated the resident had told them they were a DNR, but they did not have a DNR on file. LPN #2 was shown the resident had a signed DNR on file in their EHR.

Based on record review and interview, the facility failed to update the care plan related to hospice services for one (#17) of two sampled resident reviewed for hospice services. The DON identified 12 residents who received hospice services. Findings: Res #17 had diagnoses which included Alzheimer's disease, dementia, and congestive heart failure. A physician order, dated 10/31/23, documented to admit to hospice services related to a diagnosis of congestive heart failure. A significant change assessment, dated 11/10/23, documented the resident was severely cognitively impaired, required partial to moderate assistance with most ADLs, and received hospice services. A care plan, initiated 03/24/24, documented coordinated services between facility and hospice for end-of-life care. All interventions related to hospice care documented an initiation date of 03/24/24. On 03/26/24 at 1:17 p.m., MDS coordinator #1 stated the resident's care plan was not updated to include hospice services when the resident was admitted to hospice in October of 2023 but should have been. They stated the care plan was updated after the error had been found during an audit on 03/24/24.

Based on record review and interview the facility failed to complete a discharge summary that included a recapitulation of the resident's stay for one (#55) of three sampled residents reviewed for discharge. The DON identified 53 residents resided in the facility. Findings: Res #55 discharged from the facility on 03/01/24. A discharge summary, dated 03/01/24, did not document a diagnosis on discharge or a summary of the course of treatment in the facility. On 03/26/24 at 1:32 p.m., corp. nurse consult #1 stated the nurse should have filled out the recapitulation of stay portion of the discharge summary.

Based on record review and interview, the facility failed to ensure an antianxiety medication was monitored for effectiveness and side effects for one (#13) of five sampled residents reviewed for unnecessary medications. The DON identified 53 residents resided in the facility. Res #13 had diagnoses which included anxiety. A physician order, dated 12/07/23, documented to administer buspirone 10 mg three times per day for anxiety. A physician order, dated 03/24/24, documented to monitor side effects of antianxiety medications. On 03/26/24 at 9:04 a.m., corporate nurse consultant #1 was asked to provide documentation of side effect monitoring from 12/07/23 to 03/24/24. On 03/26/24 at 9:21 a.m., corporate nurse consultant #1 stated there was no documentation of side effect monitoring from December to March.

Based on observation, record review, and interview, the facility failed to ensure a resident had a physician order to self-administer medications for one (#37) of one sampled resident reviewed for self-administration of medications. Corporate Nurse Consultant #1 identified there were no residents with physician orders to self-administer medications. Findings: Res #37 had diagnoses which included depression. A physician order, dated 01/24/24, documented trazadone HCL (antidepressant medication) 100 mg tablet by mouth at bedtime. There was no documentation the resident had physician orders to self-administer medications. An admission assessment, dated 01/31/24, documented the resident's cognition was moderately impaired. On 03/24/24 at 10:19 a.m., there was a round white tablet in a clear medicine cup observed on the resident's over the bed table. The resident stated the tablet in the cup was on their table after they returned to their room after breakfast. They stated they did not know what the tablet was or how it got there. On 03/24/24 at 10:26 a.m., LPN #1 was asked if the resident had physician orders to self-administer medications. They stated they did not. They were made aware the resident had a round white tablet in a medicine cup on their over the bed table. On 03/24/24 at 10:32 a.m., LPN #1 was observed removing the medicine cup from the resident's room. They stated the tablet looked like the resident's trazdone they received at bedtime. They stated the resident did not have a physician order to self-administer trazodone.

Based on record review, observation, and interview, the facility failed to ensure a specific condition and diagnosis was documented, based on a comprehensive assessment/evaluation, for the use of a psychotropic medication for one (#16) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented eight residents who received an antipsychotic medication. A facility policy, Psychotropic Medication Use, dated July 2022, documented in parts, .Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record .Consideration of the use of any psychotropic medication is based on comprehensive review of the resident .This includes evaluation of the resident's signs and symptoms in order to identify underlying causes . Resident #16 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and dementia. An MDS Admission Assessment, dated 07/28/22, documented the resident was severely impaired with cognition. The assessment documented the resident received antipsychotic medications seven of seven days previous and antidepressants seven of seven days previous. The assessment documented no behaviors. A monthly Medication Regimen Review, dated 08/05/22, documented a note from the pharmacist to the physician, which read in parts, .resident is currently receiving olanzapine {Zyprexa, an antipsychotic drug} .2.5 mg PO at HS for depression .olanzapine is only indicated for depressive episodes associated w/Bipolar disorder in combination with Fluoxetine . Resident does not have a dx of Bipolar disorder .Could a D/C of this medication be attempted or, if antipsychotic treatment of depression is indicated, could her olanzapine be changed to an antipsychotic with an indication for depression as adjunct therapy (i.e. Abilify 5 mg PO daily or Seroquel 50 mg PO q evening)? Please advise . The physician response documented, Please add dx of Bipolar D.O. A Progress Note, dated 10/19/22, documented an incident in which resident #16 hit another resident. The note documented resident #16 was antagonized and became agitated by the other resident, resulting in the behaviors. The note documented resident #16 was sent to a geri-psych facility for an inpatient stay. A progress note, dated 10/28/22 at 11:47 a.m., documented facility staff had talked with resident #16's physician regarding the resident's increased agitation at night. The note documented an order was received for Ativan (an antianxiety medication) 0.5 mg at night. A social service progress note, dated 12/29/22, documented resident #16 returned to the facility from a local hospital. The note documented facility staff had reported the resident was combative during transport. An MDS Quarterly Assessment, dated 01/28/23, documented the resident was severely impaired with cognition. The assessment documented the resident received antipsychotic medications seven of seven days and antidepressants seven of seven days. The assessment documented no behaviors. A Care Plan, updated 02/03/23, documented resident #16 had exhibited behaviors of being verbally and/or physically aggressive with other residents. The care plan documented incidents involving other residents had occurred on 10/19/22, 10/29/22, 12/18/22, 12/21/22, and 01/09/23. Recommended interventions included redirection, checking labs, checking for UTI, medications as ordered, and cognitive assessments. The care plan documented a behavior of wandering. The care plan documented the resident received routine antidepressant medications, as well as antipsychotic medications related to Alzheimer's dementia and Bipolar disorder. On 02/08/23 at 1:14 p.m., resident #16's physician, as well as the facility Administrator and DON, were interviewed. The physician reported the facility called him every time there was an incident with the resident. The physician stated he had tried to avoid using excessive medications for this resident to avoid over-sedation. The physician and the facility Administrator discussed possible placement in a memory care unit for this resident and stated they would speak with the resident's family to consider it further. The DON reported the resident was currently doing much better now but stated the resident had appeared heavily medicated when she returned from the last geri-psych inpatient stay. On 02/09/23 at 8:25 a.m., the DON was interviewed regarding resident #16's diagnosis of Bipolar disorder. The DON reviewed the Medication Regimen Review from 08/05/22. The DON was asked if the resident had been assessed or received a psychiatric evaluation to determine the diagnosis of Bipolar disorder. The DON reported the resident had been sent out for a geri-psych stay but wasn't sure of the time-frame. The DON reviewed the clinical record and reported the resident was not given the diagnosis of Bipolar disorder related to the geri-psych stay. After review of the clinical record, the DON stated the physician had given the resident the diagnosis of Bipolar disorder for the continued use of olanzapine.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free of unnecessary antipsychotic medications for three (#4, 27 and #37) of five residents reviewed. The facility reported 15 residents received antipsychotic medications. Findings: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/06/19, documented the resident was severely impaired for daily decision making and required extensive assistance with most activities of daily living. The assessment documented the resident received antipsychotic and antidepressant medications. A physician's orders [REDACTED]. A care plan, last updated 09/30/19, documented the resident had impaired cognitive function related to the [DIAGNOSES REDACTED]. The care plan documented for the staff to evaluate for side effects of medications and to monitor, document and report to physician of danger to self and others. The care plan documented the resident received antipsychotic medication routinely. The care plan documented for the staff to administer medications as ordered, monitor and document for side effects and effectiveness. The care plan documented for the staff to monitor and record the occurrence of target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. and document per facility protocol. The clinical record contained no documented behaviors. On 10/09/19 at 10:32 a.m., the resident was observed sitting in a recliner in her room with her eyes closed. On 10/09/19 at 10:54 a.m., the director of nursing (DON) provided the behavior monitoring book for the residents. The DON reported there had been no documentation of behaviors. The DON reported the staff documented behaviors in the nurse notes by exception. On 10/09/19 at 3:00 p.m., LPN #1 reported the resident did not have behaviors, just confusion. On 10/09/19 at 3:08 p.m., the pharmacy consultant reported [MEDICAL CONDITION] was not an acceptable [DIAGNOSES REDACTED]. 2. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medication regimen review, dated 05/16/19, documented the pharmacist asked if [MEDICATION NAME] could be changed from 200 to 100 mg. The physician disagreed and documented the resident would not tolerate the decrease. A quarterly assessment, dated 08/22/19, documented the resident was severely impaired for daily decision making and required supervision with most activities of daily living. The assessment documented the resident received antipsychotic and antidepressant medications. A care plan, last updated 08/26/19, documented the resident had impaired cognitive function. The care plan documented the resident had a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The clinical record contained no documented behaviors. On 10/09/19 at 10:28 a.m., the resident was observed in the activity room with group of residents playing a game. On 10/09/19 at 10:54 a.m., the director of nursing (DON) provided the behavior monitoring book for the residents. The DON reported there had been no documentation of behaviors. The DON reported the staff documented behaviors in the nurse notes by exception. On 10/09/19 at 3:00 p.m., LPN #1 reported the resident did not have behaviors, just confusion. On 10/09/19 at 3:08 p.m., the pharmacy consultant reported [MEDICAL CONDITION] was not an acceptable [DIAGNOSES REDACTED]. 3. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A quarterly assessment, dated 09/08/19, documented the resident was severely impaired for daily decision making and required extensive assistance with most activities of daily living. The assessment documented the resident received an antipsychotic and antidepressant medication. The care plan, last updated 09/30/19, documented the resident had impaired dementia causing impaired thought process. The care plan documented for the staff to monitor, document, and report to the physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. The clinical record contained no documented behaviors. On 10/09/19 at 10:54 a.m., the director of nursing (DON) provided the behavior monitoring book for the residents. The DON reported there had been no documentation of behaviors. The DON reported the staff documented behaviors in the nurse notes by exception. On 10/09/19 at 3:00 p.m., LPN #1 reported the resident did not have behaviors, just confusion. On 10/09/19 at 3:08 p.m., the pharmacy consultant reported [MEDICAL CONDITION] was not an acceptable [DIAGNOSES REDACTED].

Based on observation, interview, and record review, it was determined the facility failed to provide care and services in accordance with professional standards of practice for one (#8) of three residents reviewed with skin breakdown. The facility reported five residents had skin breakdown. Findings: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/14/19, documented the resident was cognitively intact, required extensive assistance with activities of daily living, and was always incontinent of bladder and frequently incontinent of bowel. The assessment documented the resident was at risk for pressure ulcers. The assessment documented the resident had no pressure ulcers. The assessment documented the resident required a pressure reducing device for her bed. A nurse's, note dated 08/05/19, documented the resident had skin break down to top back right thigh and measured 2.4 centimeter (cm) X 3.5 cm and top left thigh 0.5 cm X 0.8 cm cleansed with ns, pat dry and applied protective dressing. The note documented to consult with wound care doctor for wound evaluation. The note documented the resident was up in her wheelchair 13-15 hours a day per her request. A physician's orders [REDACTED]. A care plan, dated 08/05/19, documented the resident had a shear to the top back right and left thigh. The care plan documented for the staff to provide treatments as ordered by the physician. A physician's orders [REDACTED]. A nurse's note, dated 09/03/19, documented, wound treatment complete as ordered, wound measures 4cmx3cmx0.1cm, beefy red, no odor, small amount of Serosanguinous drainage noted. A nurse's note, dated 09/19/19 at 10:34 a.m., documented the physician was there for weekly assessment. The note documented a shear to the left posterior, superior, medial thigh and to apply barrier cream every shift. A wound evaluation and management summary, dated 09/19/19, documented the resident presented with a wound to her left, posterior, superior, medial thigh. The summary documented the wound size was 1.3 X 0.2 X 0.1 cm. The summary documented the dressing treatment plan was for the staff to apply house barrier cream every shift and as needed. A treatment administration record, dated (MONTH) 2019, documented to clean abrasion to top back of right thigh with normal saline solution (nss), cover with protective dressing every day until resolved in the evening for abrasion. The treatment administration record had not been updated to reflect the change in treatment dated 09/19/19. A treatment administration record, dated (MONTH) 2019, documented to clean abrasion to top back of right thigh with normal saline solution (nss), cover with protective dressing every day until resolved in the evening for abrasion. The treatment administration record had not been updated to reflect the change in treatment dated 09/19/19. On 10/07/19 at 11:22 a.m., licensed practical nurse (LPN) #1 was observed to provide wound care to the resident. The LPN cleaned the left hip crease abrasion with normal saline, pat dry, and applied a foam dressing. There was no abrasion to the resident's right thigh. On 10/09/19 at 9:03 a.m., the resident was observed sitting up in her wheelchair in the dining room. On 10/09/19 at 11:54 a.m., the director of nursing (DON) reported the staff should have documented when the right thigh abrasion had resolved. The DON also reported the staff should have called the physician and received a clarification order for left side vs right side abrasion.

On 08/09/18 at 1:16 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to provide supervision for a resident with known wandering behaviors who eloped from the facility. The staff was unaware the resident had eloped from the facility for an unknown amount of time. On 08/09/18 at 1:29 p.m., the OSDH verified an immediate jeopardy situation existed related to the facility's failure to provide supervision for a resident with known wandering behaviors. The resident had eloped and was out of the facility for an unknown amount of time. On 08/09/18 at 1:35 p.m., the ADM was informed of the IJ situation which consisted of substandard quality of care. The ADM was also informed of deficiencies related to the elopement. A thorough investigation had not been completed, the resident had not been assessed on return to the facility, and the resident's care plan had not been updated. On 08/09/18 at 3:12 p.m., the ADM provided the plan of removal for the immediate jeopardy. On 08/09/18 at 3:16 p.m., the plan of removal was accepted and documented the following: Plan of Removal In person checks on the resident every 15 minutes 24-hours until he is accepted into a Veterans Administration (VA) facility as per the family request Update care plan and perform diversion activities Engage resident in activities such as regular walks during the 15 min (sic) check Monitor and/or increase resident participation in scheduled activities Update the identified resident care plan to reflect the resident current functioning level The charge nurse will be responsible for tracking of the rounds check off list during each shift Will reeducate all employed staff at(NAME)Nursing Center either in person or via phone of each potential at risk elopement resident prior to working a new shift. Points to highlight include . What is an elopement risk? What types of actions could indicate the possibility of an elopement risk Where should I seek elopement information in our facility? Who are the current elopement risk? Review the Elopement policy and procedure with staff to ensure awareness Nursing staff will perform a head to toe assessment of each resident upon his or her re-entry into the facility. Plan to be completed by (MONTH) 09, (YEAR) at 6:00 pm On 08/10/18 at 8:50 a.m., a tour of the facility was conducted. Interviews were conducted with staff members from the nursing department, housekeeping, dietary, and maintenance. Staff members were able to explain the in-service education provided for residents with [DIAGNOSES REDACTED]. The staff members were able to discuss what their role was in reporting to the charge nurse when a resident attempted to leave the facility or a change of condition was observed with the residents. All staff members were able to verbalize the plan of removal instituted on 08/09/18. Licensed staff members were able to verbalize their responsibility in assessing, monitoring, intervention, and reporting when a resident attempted to elope or was successful in elopement from the facility. Licensed staff members stated it was the responsibility of the charge nurse to ensure the tracking of the rounds check off list during each shift. The licensed staff members stated the necessity of a head to toe assessment of each resident upon re-entry into the facility. On 08/10/18 at 10:20 a.m., the plan of removal was reviewed and shown to be completed on 08/09/18 at 5:00 p.m. On 08/10/18 at 10:25 a.m., the facility was informed the IJ was removed effective 08/09/18 at 5:00 p.m. The deficient practice remained at a potential for more than minimal harm at an isolated level. Based on observation, record review, and interview, it was determined the facility failed to provide adequate supervision for one (#48) of one resident reviewed for elopement. The facility failed to: a) Assess resident #48 after the resident had eloped and returned to the facility to prevent another elopement. b) Ensure a thorough investigation had been completed after resident #48 had eloped from the facility. c) Update resident #48's care plan with new interventions to prevent another elopement after the resident had eloped and returned to the facility. The resident exited the facility and was unsupervised for an unknown amount of time. The ADM reported no other residents who lived at the facility were at risk for elopement. Findings: Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurses admission assessment, dated 07/27/18, documented the resident was semi-ambulatory, alert, forgetful, and confused. A care plan, dated 08/03/18, documented the resident had potential for wandering and elopement related to hallucinations and [MEDICAL CONDITION]. The care plan documented a goal was for the resident's safety to be maintained. The care plan documented interventions were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. A nurse's note, dated 08/04/18 at 17:36 (5:36 p.m.), documented, Received call that (name deleted) that her husband did see resident outside of building and he did take him to (name deleted restaurant) for lunch because that is where resident stated he was going. Staff did immediately go to (name deleted restaurant) and pick resident up. He was sitting with (town name deleted) patrolman. The note documented the family, physician, DON, and ADM were notified. The clinical record contained no documentation the resident had been assessed upon reentry to the facility. The care plan was reviewed and had not been updated to reflect the resident had eloped. The care plan contained no new interventions for supervision of the resident to prevent future elopements. On 08/06/18, 08/07/18, and 08/08/18, the resident was observed multiple times near the exit doors. The resident was observed to push on the door handles. No staff was observed nearby. On 08/07/18 at 11:45 a.m., the resident was observed coming out of his room with a stack of clothing in his arms. The resident reported he was going home. On 08/08/18 at 2:45 p.m., CNA #2 reported this resident was known to wander. On 08/08/18 at 2:55 p.m., CNA #1 reported this resident was known to wander. On 08/08/18 at 3:00 p.m., CNA #3 reported this resident was the only wanderer and he was new to the facility. On 08/08/18 at 3:05 p.m., CNA #5 reported there were four wanderers, depending on the day, but only resident #48 attempted to leave the facility. On 08/08/18 at 3:15 p.m., the corporate nurse was asked for the resident's baseline care plan. The corporate nurse reported a baseline care plan had not been completed within the 48 hour time frame as required. The corporate nurse reported the date of 08/03/18 was the initiation date of the care plan. On 08/08/18 at 4:40 p.m., the ADM reported no one witnessed the resident when he exited the facility. The ADM was asked who conducted the investigation. The ADM reported the charge nurse initiated the investigation and completed the incident report. The ADM could not provide documentation for staff inservices related to the elopement. The ADM reported the care plan had not been updated to include interventions to prevent recurrence of elopement. On 08/09/18 at 9:15 a.m., the ADM reported a police report had not been completed. On 08/09/18 at 10:10 a.m., CNA #2 was asked when she had last seen the resident on 08/04/18. She reported approximately 3:35 p.m., sitting in the TV room. The CNA reported she had seen the resident trying to exit earlier in the day, at approximately 1:00 p.m. The CNA reported she had told the charge nurse. On 08/09/18 at 10:23 a.m., LPN #3 was interviewed by telephone. The LPN was asked when she first became aware the resident was missing from the facility on 08/04/18. The LPN reported she became aware of the resident's elopement when she received a telephone call from the wife of the man who picked up the resident. The LPN was asked if she updated the resident's care plan to include interventions to prevent future elopements. She reported she had updated the care plan electronically and the care plan update should reflect her name. The clinical record was reviewed and the care plan had not been updated. On 08/09/18 at 10:38 a.m., CNA #3 was interviewed by telephone. CNA #3 was asked if she could remember the last time she had seen resident #48 in the facility on 08/04/18. She reported approximately 3:15 p.m., in the activity room. CNA #3 was asked how many residents in the facility were considered to be wanderers. She reported only resident #48. On 08/09/18 at 10:48 a.m., CMA #1 was interviewed via telephone, she was asked if she could remember the last time she had seen resident #48 in the facility on 08/04/18. She reported she was not aware the resident had been missing until approximately 5:15 p.m. On 08/09/18 at 1:35 p.m., the ADM reported a thorough investigation should have been completed to include supervision and interventions to prevent future elopements.

On 04/10/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure residents were transferred or lifted in a manner to prevent injuries. The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 2:05 p.m., the ADM and the DON were notified of the IJ situation. At 4:15 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal documented the following: "Immediate Jeopardy Plan Of Removal for Resident Current & Correct Transfer Status 1. All current residents will have a head to toe RN assessment. 2. Assessment Data will be updated on the resident care plan and in POC to ensure accuracy. 3. Licensed Nurses will be re-educated by a member of the therapy department and signed off on before they will be able to train other staff members. 4. All nursing staff will be re-educated on proper lifting techniques, the proper use of mechanical lifts, referencing POC for the resident's transferring status. 5. All nursing staff will be re-educated immediately and will not be able to return to duty until they have received the re-education with return demonstration. 6. Completion as of Friday, April 11, 2014 at 12 pm of all available nursing staff." Staff from all shifts were interviewed regarding proper transfers. Observations of proper transfers by staff on all shifts were observed. The staff was aware of POCs for the residents and transferred residents properly. The IJ was removed on 04/11/14 at 5:00 p.m. when it was determined all corrective actions were in place. The deficiency remained at the level of actual harm which was not immediate jeopardy, at a pattern. Based on record review, observation and staff interviews, it was determined the facility failed to: a) Ensure one (#2) of six sampled residents was transferred properly and without injury according to the care plan. This had the potential to affect 62 residents, identified by the Resident Census And Conditions Of Residents form, who required transfer assistance. b) Ensure one (#5) of two sampled residents, who required sit to stand lifts, were not lifted by a sit to stand lift when lethargic. This had the potential to affect seven residents, identified by the DON, who required sit to stand lifts for transfers. c) Ensure a wheelchair was in the locked position and two staff were in attendance before a transfer was completed for one (#8) of six sampled residents who required assistance with transfers and utilized wheelchairs. This had the potential to affect 62 residents, identified by the Resident Census And Conditions Of Residents form, who required transfer assistance. d) Ensure the facility used a maxi lift for transfers for one (#13) of four sampled residents who required maxi lifts for transfers. This had the potential to affect 11 residents, identified by the DON, who required maxi lifts for transfers. e) Ensure eye drops were not left unattended on the medication cart for one (#5) of four sampled residents observed during the medication pass. This had the potential to affect all 65 residents who resided in the facility. f) Ensure water temperatures did not exceed 120 degrees Fahrenheit for one (South shower room and bathroom sink) of three shower rooms with sinks. This had the potential to affect 24 residents, identified by the South Hall shower list, who used the South shower room and bathroom sink. Findings: 1. Resident #2 had been admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. An initial assessment, dated 08/18/13, documented the resident required extensive assistance with two person assist for bed mobility, total assistance with two person assist for transfers, did not ambulate, required extensive assistance with dressing and hygiene, required total assist with bathing, was incontinent of bowel and required an indwelling urinary catheter. A care plan, dated 08/27/13, documented the resident had limited physical mobility r/t neurological deficits, Acute Transverse [DIAGNOSES REDACTED], was non-ambulatory with decreased sensation numbness to bilateral legs. Interventions included a two person assist with transfers using a mechanical lift related to being unable to stand or bear weight. Another intervention was for the staff to monitor, document and report signs and symptoms of immobility, contractures forming or worsening and fall related injury. The Braden Scale For Predicting Pressure Sore Risk, dated 08/28/13, 09/05/13 and 09/12/13, documented the following: "Activity degree of physical activity Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. Mobility ability to change and control body position Very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently." An incident report, dated 11/05/13, documented "While CNA's were transferring resident with sit to stand lift today, the belt slid up on resident and when it did she felt little popping sensation and had pain on left side." The Immediate Action Taken documented, "instructed cnas proper placement of belt on sit to stand lift, and proper transfer." The nurses' notes documented..."11/5/2013 10:45 a.m., pt says she felt a pop in her ribs when she used the lift this morning and her ribs on the left side are kind of sore now, doctor called new order for xray, called and left msg (message) for daughter to call me back. 11/5/2013 11:56 sooner mobile here at this time to xray resident left rib cage 11/5/2013 12:45 xray showed lateral left seventh rib minimally displaced fracture, no pleural collection or pneumothorax results faxed to dr (Name deleted) family informed." On 04/08/14 at 3:45 p.m., CNA #1 and CNA #2 were observed transferring the resident from the bed to the wheelchair. The wheelchair was placed at the side of the bed. The wheels were in an unlocked position. The CNA's assisted the resident to sit on the side of the bed. CNA #2 placed a gait belt around the resident's waist. CNA #1 placed her hands underneath the resident's legs, at the knees. CNA #2 placed her hands under the gait belt and lifted the resident to the wheelchair. At that time, the wheelchair rolled backwards. CNA #2 lost her grip on the gait belt and lifted the resident under the arms, placing the resident's upper body weight on the resident's shoulders. CNA #1 continued to lift the resident under the knees. As the wheelchair continued to roll back, the resident was observed with her body almost to the floor, still being lifted under the arms. The CNAs then lifted the resident into the wheelchair. At that time, CNA #1 reported she usually used a towel under the resident's knees. She stated, "It works better when you do it that way." A current CNA care plan, printed out on 04/10/14 at 10:45 a.m. documented, "transferring-2 person assist with maxi lift." On 04/11/14 at 11:10 a.m., CNA #1 was asked how she should have transferred the resident. She reported she should have used the sit to stand lift, but had been using the towel and under the shoulders to lift the resident. She was asked if she knew what the care plan directed her to do for transfers. She stated, "I don't know what it says. The other girl was telling me what to do." On 04/14/14 at 9:35 a.m., the DON and the corporate nurse were asked how the resident should have been transferred. The DON reported the resident should have been transferred by the maxi lift. The corporate nurse reported the resident should be transferred as directed by the care plan. 2. Resident #13 was admitted on [DATE], with [DIAGNOSES REDACTED]. A care plan, dated 03/10/14, documented the resident had an ADL self care deficit, as a problem. A goal was for the resident to improve current level of function. One intervention listed was the resident required two staff participation with transfers with the use of a mechanical maxi lift. The resident was non-weight bearing to bilateral legs. An assessment, dated 04/07/14, documented the resident was cognitively intact, required extensive assistance with two persons for transfer, bed mobility, dressing and hygiene and required extensive assistance with one person for bathing. The resident was frequently incontinent of bowel and occasionally incontinent of bladder. The resident had impairments on both sides to lower extremities. The resident was admitted to the facility with one stage II pressure ulcer and two unstageable pressure ulcers. On 04/11/14 at 9:05 a.m., as the surveyor passed the south shower room, CNA #9 was overheard to state, "It was a good thing I came around when I did. Isn't anyone helping you?" The resident was observed suspended in a sit-to-stand lift, holding onto the handle of the lift, knees bent and the lift sling under the resident's underarms. CNA #9 assisted CNA #10 to transfer the resident into an electric wheelchair. Two other staff members were asked to assist the CNAs to position the resident in the wheelchair. At 9:40 a.m., CNA #9, was questioned in regard to assisting the resident using the sit to stand lift. The CNA stated, "I was going into use the bathroom and saw that (CNA #10-name deleted) had the resident up in the sit to stand lift." The CNA was then asked if CNA #10 had anyone assisting her. CNA #9 stated, "No other aide was assisting." At 9:45 a.m., the resident was questioned in regard to the CNA transferring her. The resident reported the CNA had asked for help, but no one would help her and I really needed to go to the bathroom. The resident was asked how the CNAs normally transferred her. The resident reported using the sit to stand lift. At 9:55 a.m., CNA #10 was asked if she received the facility inservice about proper resident transfer assistance. The CNA reported she had attended the inservice yesterday. The CNA was asked how the resident was to be transferred. The CNA reported she used the sit-to-stand lift on the resident. At 10:20 a.m., the ADM and the DON were notified of the improper transfer of the resident. The ADM reported the staff should be following the current care plan. 3. Resident #8 was admitted on [DATE], with numerous [DIAGNOSES REDACTED]. An initial assessment, dated 03/17/14, documented the resident was severely impaired with cognition and demonstrated no moods or behaviors. The resident required extensive assistance of two persons to transfer, dress and perform personal hygiene. The resident required total assistance of one person to bathe. The resident did not ambulate in the room or corridor during the look back period. The resident had impairment on one lower extremity and was frequently incontinent of bowel and bladder. A care plan, dated 03/26/14, documented the resident was a 1-2 person extensive assist with ADL care due to a fractured hip, as a problem. The goal was for the resident to work with PT/OT to increase his level of ADL ability through the next review date. An intervention listed was for two persons to assist the resident with transfers. On 04/08/14 at 4:00 p.m., CNA #11 was observed to knock on the resident's door while entering the resident's room. The CNA assisted the resident to sit on the side of the bed. The CNA moved the W/C to the side of the bed. The CNA locked the W/C brakes and reached around the resident to assist the resident to stand. The resident's knees were bent. The CNA moved the resident to sit in the W/C. The W/C's left tire moved and the W/C turned sideways. The CNA had to assist the resident to step two more steps backwards to reach the W/C and use one hand to stabilize the chair. At 4:50 p.m., the DON was informed of the transfer observation. The DON reported the CNA should have used a gait belt and had another staff member present. The DON reported the W/C should have been checked prior to the transfer to ensure it locked. The DON reported the W/C locks would be addressed immediately. 4. Resident #5 had [DIAGNOSES REDACTED]. A care plan, initially dated 07/13/11, documented the resident had a potential for falls/injury r/t vision problems, gait/balance problems, limited mobility, osteoporosis and routine pain medications. The goal was for the resident to sustain no injury from falls though the review date of 04/06/14. An intervention listed was for the staff to lift the resident with the Sit-to-Stand lift. The same care plan documented the resident had an ADL self care performance deficit r/t limited mobility, unsteady gait and blindness. One intervention documented the resident required two person assistance with gait belt and use of the Sit-to-Stand lift and to report changes to the charge nurse. A care plan, initially dated 09/20/12, documented the resident had a problem of [REDACTED]. The care plan focus documented, "Using the Sit-To-Stand lift is the safest and best way to lift the resident." One intervention listed was for the staff to lift the resident using the Sit-to-Stand lift and to make sure the resident kept her hands on the side bars and not the top of the bars if she could. The staff were to watch for the support belt riding up her back and readjust. A care plan, dated 09/25/13, documented the resident had a progressive decline in intellectual functioning characterized by deficit in memory, judgement, decision making and thought process related to short term memory loss. The care plan documented the resident had a potential for impaired communication r/t hearing deficit. One documented goal was for the resident to be able to repeat back information as understood and display the appropriate response to the situation. One intervention listed was for the staff to observe and report changes in cognitive status. A nurse's note, dated 03/10/14 at 12:50 p.m., documented, "resident became lethargic at lunch time. cna used sit to stand and resident was unable to hold on and slipped down to floor. assisted resident to bed x3 assist. resident is still lethargic at this time...instructed cna not to use sit to stand on any resident that unable to hold on....91/67 (blood pressure)..." The resident sustained [REDACTED]. The incident report, dated 03/10/14, documented one CNA assisted the resident to utilize the sit-to-stand lift when the resident experienced the fall. A significant change assessment, dated 03/26/14, documented the resident had severe cognitive impairment with minimal depression. The resident was totally dependent on two persons for bed mobility, transfer and personal hygiene. The resident had not ambulated in the look back period and required two person extensive assistance for locomotion on and off the unit. The resident was mobile per wheelchair. The resident required a mechanical lift for transfers. The resident had range of motion impairment of both lower extremities. On 04/14/14 at 9:15 a.m., the DON was asked if she expected staff to place a resident in a Sit-to-Stand lift when the resident was lethargic. The DON reported the staff should have notified the charge nurse to assess if the resident had the ability to properly use the lift or not when the resident was lethargic or hypotensive. The DON further reported all residents were being assessed for the appropriate lift method to use and the staff were being in-serviced, with return demonstrations, to which mechanical lift and manual lift methods were to be used. 5. On 04/08/14 at 8:30 a.m., an environmental tour of the facility was conducted. The water temperature in the South Hall shower stall was 122.7 degrees F. A female resident entered the shower room. The resident was asked if she used the shower without supervision. The resident reported she used the shower without assistance, but she was supposed to ask for assistance. The female resident was asked if the water in the shower was too hot. The female resident reported if the water became too hot she just adjusted the cold water. A male resident exited the bathroom area of the shower room. The resident reported he had just shaved. The water temperature in the South Hall shower bathroom's sink was 135.7 degrees F. The male resident was asked if the water temperature in the sink was usually very hot. The resident reported the water could get hot. The resident was asked what he would do when the water became too hot. The resident stated, "Just turn on the cold water, of course." The DON was asked for a list of residents who used the South Hall shower and bathroom without assistance. Five residents were identified. The residents were interviewed and reported they would adjust the water temperature as needed. LPN #1 was asked if there were any residents who ever wandered into the shower stall or bathroom. The LPN reported one resident wandered in her wheelchair and had not been seen in the shower room. A maintenance staff member was informed of the water temperature being too hot and was asked for the water temperature log. The maintenance staff member provided the maintenance log book. The maintenance staff member reported the facility's maintenance supervisor was not available due to a hospitalization . The staff member reported he did not know which areas the maintenance supervisor tested , in regard to the shower areas. The maintenance log book contained no specific documentation of water temperatures in the shower areas and bathrooms. On 04/09/14 at 8:30 a.m., the water temperature in the South Hall bathroom sink was 135.1 degrees F. The ADM was notified of the water temperature. The ADM reported he would have the maintenance staff member from another facility, who was in the facility today, readjust the water temperature, again. At 9:30 a.m., the South Hall bathroom sink was 135.7 degrees F. The maintenance staff member was notified the water temperature was still elevated. The maintenance staff member reported he had adjusted the temperature and would investigate if the sink was on a different water heater. The ADM was informed the water temperature remained elevated after the adjustments. The ADM reported the bathroom was a new addition and could be on a different water heater. At 11:00 a.m., the water temperature in the South Hall bathroom sink was 109.9 degrees F. The ADM reported the water temperature log book would be revised to document each area separately. 6. Resident #5 had [DIAGNOSES REDACTED]. The resident's current computerized physician's orders [REDACTED]. "Muro128.5 % Ointment Ophthalmic-three times per day Everyday: Apply 1 drop to left eye TID Macular Degeneration of Retina Unspecified. Refresh Tears 0.5% Solution Ophthalmic-four times per day Everyday: Administer one drop to each eye QID." On 04/07/14 at 12:15 p.m., RN #1 was observed administering medications. She placed the Muro and Refresh eye drop containers on top of the cart. The RN reported the resident was not in her room and she would wait there until the resident came back to the room. At 12:25 p.m., the medication cart was observed unattended, with the eye medications still on the top of the medication cart. At that time, RN #1 was observed coming out of another resident's room. She reported she had an emergency and had to leave the medication cart. On 04/07/14 at 3:30 p.m., the DON and ADM were notified of the medication left unattended on the medication cart. The ADM reported the facility would get it fixed.

Based on observation, record review and staff and resident interviews, it was determined the facility failed to: a) Notify the physician and obtain new orders when two pressure ulcers increased in size and stage for one (#13) of four sampled residents. This resulted in harm to the resident. b) Identify, notify the physician or obtain orders for one pressure sore on the resident's buttock and failed to assess and monitor the pressure ulcers on the resident's heels for one (#9) of four sampled residents. This resulted in harm to the resident. This had the potential to affect all 65 residents who resided in the facility and could develop skin breakdown. Findings: 1. Resident #13 was admitted on [DATE], with [DIAGNOSES REDACTED]. A nurse's note, dated 02/25/14 at 10:09 p.m., documented, "skin assessment done, resident has 0.5x0.2 to coccyx noted. resident has open areas noted to both heals (sic) left heel is 5.4x5.5, right heel is 7x3.5. no other open ares (sic) noted at this time." A Weekly Pressure Ulcer Report, dated 02/27/14, documented,"...Coccyx resolved...Left heel 6.1x5.9x0.3cm stage II...Right heel 6.3x4.0x0.2 stage II..." A Weekly Pressure Ulcer Report, dated 03/06/14, documented "...In hospital...Left heel 6.1x5.9x0.3cm stage II...Right heel 6.3x4.0x0.2 stage II..." A nurse's note, dated 03/10/14, documented the resident had been readmitted to the facility from the hospital. There was no documentation in the clinical record of the size of the pressure ulcers upon the residents readmission to the facility. A care plan, dated 03/10/14, documented, "The resident has (3) pressure ulcers on admit r/t chair bound, diabetes, [MEDICAL CONDITION] receiving [MEDICAL TREATMENT]...On return from hospital has 2 pairs of Pressure relieving heel protectors," as a problem. A goal was for the resident's pressure ulcers to show signs of healing and remain free from infection. Interventions listed, "...Treatments as ordered to pressure ulcers, monitor daily for effects. Notify physician and family of changes..." A nurse's note, dated 03/13/14 at 2:44 p.m., documented, "resident rt heel measurements [MEDICAL CONDITION], left heel measures [MEDICAL CONDITION], residents heels cleaned and dressed as ordered." A Weekly Pressure Ulcer Report, dated 03/13/14, documented, "...right heel 4.0x1.9x0.2cm...left heel 4.3x5.5x0.3cm..." A Weekly Pressure Ulcer Report, dated 03/20/14, documented, "...right heel 3.5x1.7x0.2cm...left heel 3.7x4.8x0.2cm..." A nurse's note, dated 03/27/14 at 2:45 p.m., documented, "rt heel wound measurements [MEDICAL CONDITION], left heel measures [MEDICAL CONDITION], wound care done as ordered." There was no documentation in the clinical record the physician had been notified of the increase in size to the two pressure ulcers. A Weekly Pressure Ulcer Report, dated 03/27/14, documented, "...right heel 4.0x2.0x0.2cm...left heel 6.3x5.7x0.3cm..." There was no documentation on the weekly pressure ulcer report the physician had been notified of the increase in size to the two pressure ulcers. A computerized physicians order, dated 03/31/14, with a start date of 02/25/14, documented "wound care--bilater heels..Topical-TREATMENT DAILY Everyday: cleanse bi-lateral heels with nss pat dry apply Santyl nickle (sic) thick to wound beds cover with gauze wrap with kerlix secure with tape daily." A March 2014 TAR, documented the resident received treatments to bilateral heels on 03/01/14 and 03/02/14. The resident was then out of the facility until 03/10/14 in the hospital. The remaining 21 days contained no documentation the treatments had been completed as ordered. A nurse's note, dated 04/03/14 at 2:25 p.m., documented , "...dressing to bil heel done as ordered rt heel wound measures 4.9x3.5x2, left heel measures [MEDICAL CONDITION]" There was no documentation in the clinical record the physician had been notified of the continued increase in size of the two pressure ulcers over the past two weeks. A Weekly Pressure Ulcer Record, dated 04/03/14, documented, "...Stage III rt heel [MEDICAL CONDITION] III lt heel [MEDICAL CONDITION]" There was no documentation the physician had been notified of the continued increase in size of the two pressure ulcers over the past two weeks. A 30-day assessment, dated 04/07/14, documented the resident was cognitively intact, required extensive assistance with two persons for transfer, bed mobility, dressing and hygiene and required extensive assistance with one person for bathing. The resident was frequently incontinent of bowel and occasionally incontinent of bladder. The resident had impairments on both sides to lower extremities. The resident was admitted to the facility with one stage II pressure ulcer and two unstageable pressure ulcers. On 04/07/14 at 9:10 p.m., resident #13 was interviewed. The resident reported she felt her pressure ulcers on her heels were getting worse. The resident reported she had gone to a wound clinic prior to admission and reported she believed the wounds needed debridement. The resident reported she had asked staff to send her to a wound clinic. The resident stated, "I have asked repeatedly to see Dr. (name deleted)." The resident reported she was told by staff she would have to wait until the 27th of April to see the physician. On 04/10/14 at 9:00 a.m., LPN #2 was asked if she had been aware of the resident asking to be sent out to the wound clinic. The LPN reported she had heard something about that but the resident had not mentioned it to her. The LPN reported she had not been assigned to the residents hall in a long time. At 9:15 a.m., LPN #1 was asked if the resident had ever asked to be sent out to the wound clinic. The LPN stated, "Not that I know of." At 2:45 p.m., Dr. (name deflated) was interviewed in regard to the resident's pressure ulcers. The physician was asked how she classified the wounds on the resident's heels. The physician reported pressure due to diabetes and the resident being very non-compliant. The physician was asked how the pressure wounds to the resident's heels were progressing. The physician stated, "To be honest with you I haven't looked at them. I saw her yesterday but didn't look at the wounds. I rely on the nurses." The physician was asked if the nurses had notified her of the wounds increasing in size over the last couple of weeks. The physician stated, "Could have I don't remember." The physician was asked if she had been made aware of the wounds increasing in size would she have ordered a treatment change. The physician stated, "Whatever the nurses feel needs to be done." The physician reported she thought the resident was going to the wound clinic. There were no physician orders documented in the clinical record for the resident to be sent to the wound clinic for evaluation. At 3:15 p.m. the resident's pressure ulcers were observed by the physician and the surveyor. The measurements of the right heel was 5.5x3x0.6cm and the left heel was 8x5.8x1.2cm. The physician was asked the stage of the pressure ulcers. The physician stated, "Stage III." The physician was then asked if she would change the treatment to the pressure wounds. The physician then turned to the treatment nurse and the DON and asked what they had seen that worked. The physician was asked if the resident would be sent to the wound clinic. The physician asked the DON what she thought. The DON reported the resident would be sent to the wound clinic for an evaluation. At 4:30 p.m., the resident was interviewed in regard to her pressure ulcers. The resident reported she had asked to go to the wound clinic as soon as she arrived at the facility. The resident reported she had asked LPN #1 and the physician. The resident reported she continued to ask LPN #1 up until approximately 2 weeks ago. On 04/11/14 at 10:30 a.m., LPN #1 was shown the nurse's note, dated 04/03/14, and the Weekly Pressure Ulcer Record, dated 04/03/14, and asked for clarification of the pressure sites. At that time, the LPN reported the correct size was documented on the nurse's note. The Weekly Pressure Ulcer Record, dated 04/03/14, with the correct sites and measurements, documented, "Stage III Rt heel [MEDICAL CONDITION] III Lt heel [MEDICAL CONDITION]" An April 2014, TAR contained blank areas in documentation on 04/07/14 and 04/10/14, when the treatments should have been completed. On 04/14/14 at 9:30 a.m., the DON was interviewed in regard to the pressure ulcers increasing in size over the past two weeks and was asked if she thought the nurses should have notified the physician and received a change in treatment. The DON stated, "Yes." 2. Resident #9 was admitted on [DATE] for skilled services and had [DIAGNOSES REDACTED]. A care plan, dated 02/17/14, documented the resident had the potential to develop pressure ulcers related to the resident being chair bound and required assistance with transfers. It documented the resident had no skin breakdown noted on admission. The interventions documented for the staff to conduct weekly skin checks on the resident and document the results and for the staff to follow facility policies/protocols for the prevention/treatment of [REDACTED]. The March 2014 treatment sheet documented, "skin check weekly on Friday Order Date 2/7/2014 3-11 EVENING SHIFT Every Fri." The treatment sheet contained no initials to indicate the resident's skin was assessed during the month of March. The resident was readmitted to the facility, on 03/21/14, following a three day hospitalization . A nurse's note, dated 03/21/14 at 6:55 p.m., documented, "res ret'd (returned) to facility to same room to cont with same meds and treatments assisted to dining room for pm meal denies any pain or discomfort res noted with 2cmx3cm stage 2 to coccyx has order for [MEDICATION NAME]" A "Weekly Pressure Ulcer Record," dated 03/21/14, documented the resident had a stage II 2cm X 3cm X 0.2 cm area on his coccyx with no exudate and with a pink wound bed. The record contained no further documentation of the size or appearance of the wound for the following weeks. The clinical record contained no documentation of the coccyx wound receiving treatment. A re-admission comprehensive assessment, dated 03/28/14, documented the resident had severe cognitive impairment, exhibited minimal depression symptoms and exhibited no behaviors. The resident required limited assistance with transfers, extensive assistance with ambulation, dressing, personal hygiene, toileting and bathing. The resident was occasionally incontinent of urine and bowel. The computerized physician's orders, printed 03/31/14, documented, "apply skin prep to bi-lat (bilateral) heels every shift-EVERY SHIFT Everyday soft heels." The order start date was documented as 03/26/14. The clinical record contained no original physician's order for the treatment to the resident's heels. The nurses' notes contained no documentation of the assessment of the resident's heels and no indications for treatment. The clinical record contained no "Weekly Pressure Ulcer Record" for tracking of the heel areas. The April 2014 treatment sheet contained no section in which to document weekly skin assessment for the resident. On 04/07/14 at 10:00 a.m., during the initial tour, CMA #3 reported the resident had "a sore on his bottom." The CMA reported she did not know what treatment was being done for the resident. On 04/09/14 at 9:10 a.m., the resident was observed to receive treatment of [REDACTED]. The left heel had no red areas or breakdown. The right heel had an area approximately 1.5 cm in size with a dark circumference around a soft area. At 9:30 a.m., LPN #3 was asked to observe the resident's coccyx treatment. The LPN reported the resident did not have a treatment to his coccyx. The LPN was informed the resident's skin assessment form documented the resident had an area to his coccyx. The LPN reported she would obtain assistance to transfer the resident for the surveyor to observe his skin. While the LPN went to obtain assistance, the resident was asked if his bottom hurt. The resident shifted his buttocks in the wheelchair and stated, "No." LPN #3 and an unidentified CNA took the resident to his room and assisted him to a standing position. The resident's pants were pulled down. The resident had no red area or open area on his coccyx. The resident had an open area, stage II, on his left buttock near the anal opening. The LPN and the CNA reported they were not aware of the resident having a sore on his buttocks. At 10:30 a.m., LPN #2 was asked if she was aware the resident had skin breakdown on his buttocks. The LPN reported no knowledge of the resident's skin breakdown. The LPN reported LPN #3 performed the weekly skin checks. At 10:40 a.m., LPN #3 was asked when the last skin assessment had been performed for the resident. The LPN reported she did not remember when the resident was last checked. The LPN stated, "I don't think he is on checks." The LPN reported she had only been working at the facility for the past two weeks. The LPN was asked if she did weekly skin assessments on the resident. The LPN stated, "Not on him." She reported the treatment book did not have a section for the resident to have weekly skin assessments. The LPN reported she had not measured and monitored the resident's heel areas. At 10:50 a.m., CNA #14 was asked if she observed skin breakdown on the resident's buttocks. The CNA reported she had noticed the resident had a place on his bottom when she assisted him with toileting that morning. The CNA was asked if she had reported the open area to the nurse. The CNA reported she had not told anyone yet about the site. At 1:40 p.m., the DON was asked why the resident was not on weekly skin assessments. The DON stated, "Everyone needs weekly skin checks." The DON was informed the resident's current physician orders did not include weekly skin assessment orders. The DON reported she would investigate to why the skin assessments were left off the orders. The DON was asked if the physician should have been contacted and orders obtained for treatment when the pressure ulcer was found. The DON stated, "Yes." The DON was asked if the resident's heels should have been monitored for breakdown and the physician notified of the change in the right heel lesion. The DON stated, "Yes." At 3:15 p.m., LPN #4 was asked if he was aware of an open area on the resident's buttock. The LPN reported the resident's son helped the resident to get ready for bed last night and the son had reported to the LPN of an open area on the resident's buttock. The LPN reported he did not get a chance to follow-up on the son's report of an open area on the resident and did not examine the resident. At 3:45 p.m., LPN #4 reported he was in error when he reported the buttock wound was a new area. He reported the resident had the area on his buttock when he returned from the hospital. The LPN was asked why he documented on the wound sheet and in the nurse's notes the resident had a coccyx wound. The LPN stated, "I got mixed up on the area." The LPN was asked if he notified the physician of the open area and received a treatment order at the time of admission. The LPN reported he had not. On 04/10/14 at 3:15 p.m., the DON and corporate nurse were asked how they monitored the residents for treatment and management of pressure ulcers. The DON reported she completed a skin summary report weekly based on the skin assessment records. She reported she submitted the information to the corporate nurse for review. The corporate nurse reported she reviewed the report and made suggestions for treatment. The DON and corporate nurse were asked how they could monitor the effectiveness of treatment and monitoring if the licensed nurses did not fill out weekly pressure ulcer records or obtain treatments for the areas. The DON and corporate nurse reported they would have to work on the problem.

Based on record review, observation and interviews, it was determined the facility failed to ensure adequate hydration was provided to prevent a hospitalization for dehydration for one (#1) of one sampled resident, who experienced dehydration and hospitalization . This had the potential to affect six residents, identified by the DON, who required fluid intake monitoring. Findings: Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. A RD's progress note, dated 02/22/13, documented the resident's estimated daily calorie requirements were 1841 kcals (kilocalories) and estimated fluid requirements were 1841 ml. The nurse's progress notes, dated 01/03/14, documented the resident continued on an antibiotic for a UTI. The January 2014 nurses' progress notes documented the following fluid intake total amounts: 01/03/14: 120 mls. 01/04/14: 480 ml. 01/08/14: 520 ml. 01/09/14: 1540 ml. 01/10/14: 360 ml. 01/11/14: 1440 ml. 01/12/14: 1840 ml. 01/13/14: 60 ml. 01/14/14: 50 ml. 01/15/14: 440 ml. 01/17/14: 580 ml. 01/18/14: 690 ml. 01/19/14: 30 ml. 01/20/14: 1360 ml. 01/21/14: 180 ml. 01/22/14: 1560 ml. 01/23/14: 1320 ml. 01/24/14: 1220 ml. 01/25/14: 1440 ml. 01/26/14: 60 ml. 01/27/14: 1580 ml. 01/28/14: 1420 ml. 01/29/14: 1400 ml. 01/31/14: 50 ml. The resident's average daily fluid intake documented in the nurses' notes for January was 808.75 ml. The January 2014 CNA documentation was not available to surveyors for determination of further intake. The February 2014 nurses' progress notes documented the following fluid intake amounts: 02/01/14: 50 ml. 02/02/14: 1450 ml. 02/03/14: 780 ml. A nurse's note, dated 02/03/14 at 7:52 p.m., documented, "Resident not like herself, residents brother here and asked if we could please send her to the hospital to be evaluated, resdent (sic) no coherent, drooling on herself and skin turgor very poor. Dr. (name deleted) called and she said to send her to (hospital name deleted). ems called. they arrived at 19:15 (7:15 p.m.) to pick up resident." A nurse's note, at 9:44 p.m., documented, "spoke with (hospital name deleted) ER (emergency room ), they are admitting resident for dehydration." A hospital discharge summary, dated 02/19/14, documented: "...DISCHARGE Diagnosis: [REDACTED]. #1: Metabolic [MEDICAL CONDITION]--improved. #2: Dehydration--improved. #3: [MEDICAL CONDITION], urinary tract infection, positive for E. coli, extended spectrum beta-lactamase. #4: Acute kidney injury due to dehydration--resolved. #5: [DIAGNOSES REDACTED] due to oral intake. #6: Severe progressive dementia..." The resident returned to the facility on [DATE] for skilled services with a [DIAGNOSES REDACTED]. The February 2014 fluid intake amounts were not accessible for the surveyors to review. The MDS dated [DATE], documented the resident's cognitive skills for daily decision making were moderately impaired and she was totally dependant on one staff person for eating and drinking. A care plan, dated 02/24/14, documented the resident was at risk for aspiration and had potential for less than body requirements...Recent hospitalization due to decline in condition..refusing to open mouth to eat and liquids..." A care plan goal documented, "Will consume enough foods/fluids to maintain weight and meet nutritional needs, tolerates prescribed diet, Lab WNL on Lab days..." One intervention documented for the charge nurse to monitor every shift that nectar thick water was at the bedside. A care plan note by the then DON, dated 02/26/14, documented the brother attended the care plan meeting and expressed concerns about the resident's hydration status and eating assistance. The note documented, "...he is really concerned about resident's hydration status and eating...brother stated the reason she was in the hospital was due to not being given liquids...sheet was placed in residents room to list all liquids offered and amount consumed..." The February and March 2014 nurses' notes did not consistently document the amount of fluid intake the resident received. The March 2014 combined totals for fluid intake with meals and between meals, as provided by the facility from the CNA documentation, was as follows: 03/12/14: 1840 ml. 03/13/14: 820 ml. 03/14/14: 1420 ml. 03/15/14: 1720 ml. 03/16/14: 3140 ml. 03/17/14: 1350 ml. 03/18/14: 2170 ml. 03/19/14: 2780 ml. 03/20/14: 1520 ml. 03/21/14: 1740 ml. 03/22/14: 2130 ml. 03/23/14: 2620 ml. 03/24/14: 1280 ml. 03/25/14: 860 ml. 03/26/14: 960 ml. 03/27/14: 240 ml. A nurse's note, dated 03/27/14 at 10:19 p.m. documented the resident drank 680 ml of fluid, which would bring the resident's documented intake total to 940 ml. 03/28/14: 720 ml. 03/29/14: 2340 ml. 03/30/14: 1980 ml. 03/31/14: 1410 ml. The resident's documented fluid intake for March was below 1000 ml. for five of the twenty days of documentation provided. The April 2014 combined totals for fluid intake with meals and between meals, as provided by the facility from the CNA documentation, was as follows: 04/01/14: 720 ml. 04/02/14: 840 ml. 04/03/14: 810 ml. 04/04/14: 1440 ml. 04/05/14: 2950 ml. 04/06/14: 2530 ml. The resident's documented fluid intake for three days in April 2014 were below 1000 ml. The resident's fluid intake requirements were not re-evaluated by the dietitian or the nursing staff. On 04/07/14 at 3:20 p.m., the resident was observed during incontinent care provided by CNA #3 and CNA #4. Following the incontinent care and repositioning the resident, the CNAs did not offer the resident a drink of fluid. Two full glasses of fluid were on the resident's overbed table. A clipboard with a sheet to document the resident's fluid intake was noted on the resident's overbed table. The fluid intake sheet did not contain documentation of intake amounts for every day of the current month. On 04/08/14 at 9:30 a.m., the resident was observed during transfer assistance. Following the transfer, the CNAs did not offer the resident a drink of fluid. A full styrofoam glass of thickened fluid was on the resident's bedside table. At 3:20 p.m., the DON was asked for the documentation of fluid intake for the resident, due to the surveyors not having access to the CNAs documentation. At 4:00 p.m., MDS coordinator #2 reported the computer program would only let her look back for the past 30 days. She reported she could copy and paste the information to a program to allow her to print the information. On 04/14/14 at 9:30 a.m., the DON was asked which residents were monitored for intake and output amounts. The DON reported any resident on tube feedings, with indwelling urinary catheters, on [MEDICAL TREATMENT] and with [DIAGNOSES REDACTED]. The DON was asked who monitored the resident's fluid intake. The DON reported the charge nurses were to review the CNAs documentation of the residents' meal and fluid intake. The DON was asked how she knew if the charge nurses were monitoring the resident's intake. The DON reported she was not aware of any problems with the charge nurses monitoring the residents.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure residents were properly assessed, monitored and interventions were implemented. The Oklahoma State Department of Health was notified and verifed the existence of the IJ situation. At 5:40 p.m., the ADM and the corporate RN were notified of the IJ situation. At 5:50 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal, dated [DATE], documented the following: "Immediate Jeopardy Plan of Removal 1. Resident is not in the facility 2. All nursing staff will be re-educated on proper reporting of resident pain, and resident change in condition. All nurses will be re-educated regarding documentation related to changes in condition and complaints of pain until issue resolves. 3. All nursing staff will be re-educated immediately and will not be able to return to duty until they have received the re-education. 4. All residents who have had changes in condition in the past 30 days will receive an RN assessment 5. Completion as of Wednesday, [DATE] at 12:00 p.m. of all available staff. Re-education will be completed: 1. [DATE] 3p-11p (names deleted) RN and/or NHA (nursing home administrator) 2. [DATE] 11p-7a (names deleted) RN and/or NHA 3. [DATE] 7a-3p (names deleted) RN and/or NHA 4. [DATE] Phone Education started immediately (names deleted) 5. Missed re-education will be followed up by (name deleted) RN, (name deleted) NHA and/or (name deleted)" On [DATE] at 9:30 a.m., a copy of the facility's in-service on the subject of resident changes in condition which included reporting, a complete evaluation and documentation, incident reports, pain screens, notification of the charge nurse/DON and physician were received. Handouts were received titled, "Pain Recognition and Reporting," "Pain Management" and "Acute Changes-Clinical Protocol." A copy of the resident's progress record (with the resident's name blocked out) was used as an in-service tool. The last in-service was conducted at 12:00 p.m. on [DATE]. The ADM reported all staff would be in-serviced prior to returning to work. The names on the in-service form were compared to the staffing roster. Staff members from various shifts of the nursing department were interviewed in regard to the in-service. The staff members reported they received information including reporting, assessment, monitoring and intervening for changes in condition. The staff answered questions appropriately in regard to the in-service. The IJ was removed on [DATE] at 12:00 p.m. The deficiency remained at the level of actual harm that is not immediate jeopardy, at a pattern. Based on record review and staff interviews, it was determined the facility failed to ensure assessments, monitoring and intervention was conducted in a timely manner for one (#2) of four sampled residents who had changes in conditions that required hospital admission. This had the potential to affect all 72 residents who resided in the facility. Findings: Resident #2 had [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented the resident was at risk for [MEDICAL CONDITION]. One care plan intervention listed was for the staff to monitor for and document any [MEDICAL CONDITION] and to notify the physician. The care plan documented the resident had a potential for constipation r/t medication side effects, aging and slowed peristalsis. The goal listed was for the resident to be able to be free from constipation. An intervention was for the staff to monitor and document the amount and frequency of stools for early intervention. Another intervention was for the staff to report to the charge nurse if the resident complained of abdominal pain, poor appetite or refusing meals, loose stools or no BM within three days and medicate as ordered. The care plan documented the resident had a history of [REDACTED]. An intervention listed was for the staff to report to the charge nurse if the resident complained of abdominal pain, inability to void or voiding small amounts, not voiding well or dark concentrated urine. The intervention further listed "Lab, UA with C&S, and Antibiotics as/when ordered." The care plan documented the resident needed some assistance at times with ADLs such as bathing, dressing and personal hygiene as a focus problem. An intervention listed was for the staff to observe skin daily during care for redness, open areas, scratches, cuts, bruises and report changes to the charge nurse. An annual assessment, dated [DATE], documented the resident had moderately impaired cognition and exhibited minimal depression. The resident required supervision with set up assistance only for bed mobility, transfer, ambulation, eating and bathing. The resident required supervision with one person assistance for toilet use. The resident required one person limited assistance for dressing and personal hygiene. The assessment documented the resident was always continent of bowel and bladder. A nurse's progress note, dated [DATE] at 10:39 a.m., documented, "RESIDENT C/O HAVING DIARRHEA ALL NIGHT AND ALL DAY TODAY. RESIDENT GIVEN A PRN [MEDICATION NAME] UNTIL PHYSICIAN IS ABLE TO CALL BACK FOR NEW ORDER." At 12:00 p.m., a nurse's progress note documented, "physician called back to have a new prn medication ordered for resident. resident also stated that medication helped with diarrhea." On [DATE] at 1:59 p.m., a nurse's progress note documented, "and order has been put in for a collection of stool to be checked for [DIAGNOSES REDACTED]. i tried collecting sample but resident was unable to use bathroom." A nurse's progress note, dated [DATE] at 8:29 p.m., documented, "DAY SHIFT REPORTED REDNESS ON TIP OF PENIS. UPON LOOKING APPEARED VERY SWOLLEN. UNABLE TO PULL FORESKIN BACK TO VIEW HEAD. REDNESS VIEWED ON INNER FORESKIN. REPORTED TO DR. (name deleted) WHO SAYS HE WILL COME LOOK AT IT TOMORROW. WILL CONTINUE TO MONITOR." No documentation of the day shift's findings for [DATE] was found in the clinical record. A nurse's progress note, dated [DATE] at 11:57 a.m., documented, "SPOKE WITH DR. (name deleted) THIS AM RE: PENILE REDNESS, RESIDENT STATED THAT HAS BEEN LIKE THAT FOR A LONG TIME, STATES IT DOESN'T HURT NOR DOES HE HAVE DIFFICULT WITH URINATING, DR. (name deleted) STATED HE WILL COME LOOK AT AREA THIS AFTERNOON." No entry was made in the progress notes which addressed any further monitoring of the resident between the two above nurses' notes. The resident's weekly skin assessments for [DATE] documented the resident's skin was intact. A nurse's progress note, dated [DATE] at 3:34 p.m., "DR. (name deleted) IN BUILDING RECEIVED ORDERS FOR RESIDENT TO SEE A UROLOGIST OF FAMILY CHOICE. DR. DX [MEDICAL CONDITION]= PENIS [MEDICAL CONDITION]. FAMILY HAS BEEN NOTIFIED." A physician's progress note, dated [DATE], documented, "Has a lot of penile [MEDICAL CONDITION] = sore = & C/O up a lot = problem c voiding-prob [MEDICAL CONDITION] = refer to urologist." A nurse's progress note, dated [DATE] at 7:56 a.m., documented, "5:45 UP TO BR WITH ROLLING WALK COLOR PALE. ASSIST BACK TO ROOM C/O BEING VERY TIRED AND WEAK SPO2 94 BP ,[DATE] 76 WANTS TO REST TO BED HOB..." A nurse's progress note, dated [DATE] at 2:34 p.m., documented, "Resident told his (family member) that a male doctor told him he needs to go to a urologist. (Family member) called about this and said that she wants to make the appointment to fit around her schedule. Checked resident's chart and a note was made in the physician's progress notes to get urology appointment but was not noted by a nurse nor carried out. Call Dr. (name deleted) to notify and she said it was ok with her to get an appt. with Dr. (name deleted, urologist). Called (name deleted) family member and asked her to let facility know what day and time appt is made for. Explained to (name deleted) family member what happened to cause order to not be carried out as of yet." No entries were in the nurses' progress notes of monitoring the resident's [MEDICAL CONDITION], redness or voiding patterns. The November weekly skin assessment, dated [DATE], had no documentation other than the nurse's initials as being completed. A nurse's progress note, dated [DATE] at 2:21 p.m., documented by RN #1, "WEAK UNABLE TO GO BR NEEDS TO BE HELPED TO AND FROM BR SCROTUM IS VERY ENLARGED AND [MEDICAL CONDITION]. CAN HARTLY (sic) WALK OR SET DOWN. HAS A PENDING APP. (appointment) WITH URO. (urologist). (Name deleted family member) HERE MAY NEED TO TRY AND GET PA TO COME AND SEE ALSO NEED MAKE SURE HE IS VOIDING OK." At 9:06 p.m., a nurse's progress note, documented by LPN #1, "RESIDENT SCROTUM IS VERY [MEDICAL CONDITION]. RESIDENT HAS RESTED IN HIS RECLINER FOR MOST OF THE SHIFT. RESIDENT STATED IT HURT A LITTLE BUT NOT BAD, TYLENOL WAS OFFERED BUT DID REFUSE, RESIDENT DID TAKE ROUTINE [MEDICATION NAME] AND IS RESTING QUIETLY IN HIS RECLINER, WILL CONTINUE TO MONITOR FOR CHANGES." No nurses' progress notes were entered in the clinical record again until [DATE]. No monitoring of the resident's condition was documented from [DATE] on the 3:00 p.m.-11:00 p.m. shift until the day shift on [DATE]. A nurse's progress note, dated [DATE] at 1:35 p.m., documented, "RESIDENT BEING SENT TO (name deleted) HOSPITAL FOR ENLARGE SCROTUM/PROSTATE/PENIS. RESIDENT SAID IT HURTS WHEN HE SITS UP OR STANDS AND HASN'T BEEN VOIDING. RESIDENT AGREED TO GO VIA AMBULANCE ..." The resident was admitted to the hospital on [DATE]. A nurse's progress note, dated [DATE] at 1:29 p.m., documented the resident had been admitted to the hospital for "[MEDICAL CONDITION], renal obstruction, [MEDICAL CONDITION], and constipation at this time..." On [DATE] at 2:40 p.m., CNA #1 was interviewed in regard to the resident's condition and [MEDICAL CONDITION]. The CNA reported on the evening of [DATE], LPN #1 asked him to observe the resident's penis and scrotum since the resident wanted only a male to take care of him. The CNA cupped his hands apart with fingers spread and reported the resident's penis and scrotum "were huge." The CNA reported to the charge nurse the findings. The CNA reported the resident said the staff knew about the redness and swelling three to four days previously. The CNA reported the resident told him the swelling had not been that large previously. The CNA reported LPN #1 did not go look at the resident and had learned of the situation in report. The CNA reported the resident would never ask for help before that night. At 2:45 p.m., CNA #2 was asked about the resident's condition. The CNA reported the resident had seemed very tired. The CNA reported the resident was very modest and asked for a male to care for him. At 2:55 p.m., LPN #1 was interviewed about the resident's condition. The LPN reported the resident was in the shower and she had asked CNA #1 to observe the resident. The LPN reported she had heard about the resident's [MEDICAL CONDITION] in report and the resident would not let her look at him. The LPN reported they were getting a physician's appointment. At 3:20 p.m., RN #1 (the acting DON in the DON's absence) was interviewed in regard to the resident's condition. RN #1 reported she told the charge nurse on the next shift on [DATE] to monitor the resident since he was weak and his scrotum was swollen. The RN reported she was worried about the resident's voiding status. The RN reported she had learned of the resident's condition on [DATE]. The RN reported the resident said he was voiding dark urine. The RN reported when she asked the resident how much he was voiding, the resident did not know. The RN reported she did not know if anyone elevated the scrotum for comfort or fluid return. The RN reported when the resident was seated she first noticed a bulging between his legs which she thought was a saturated brief. The RN reported she realized the bulging was from the resident's swollen scrotum. The RN reported the resident would be incontinent at times and wanted to wear a brief sometimes. The RN reported an appointment with the urologist had been scheduled, but the physician's office called and rescheduled the appointment for December. The RN reported she had told the family member the resident needed to go to the urologist before December. The RN reported the resident did not complain of pain, but the resident was weaker. The RN reported the resident never said how long this had gone on. The RN reported she had noticed the resident had a little confusion, but not like one usually notices with a UTI. The RN reported the resident looked sick and was not his usual self. The RN reported when she observed the resident to have continued scrotal and penile swelling on [DATE], she told the staff the resident needed something done for him and needed to go the hospital. The RN reported she explained to the resident he needed to go get checked. The resident's hospital records were obtained and reviewed. The following findings were in the resident's hospital clinical record: The emergency department's history and physical, dated [DATE], documented the resident "...PRESENTS TO ER VIA EMS GROUND WITH COMPLAINTS OF URINARY ET RETENTION...PRESENTS WITH SWELLING, OF THE HEAD OF PENIS, SHAFT OF PENIS, LEFT TESTICLE, RIGHT TESTICLE AND MEATUS, OF BOTH INGUINAL AREAS. ONSET: THE SYMPTOMS. EPISODE BEGAN/ OCCURRED AT AN UNKNOWN TIME. AND BECAME WORSE TODAY. ASSOCIATED SIGNS AND SYMPTOMS: PERTINENT POSITIVES: ABDOMINAL PAIN, CONSTIPATION...PATIENT HAS NOT VOIDED TODAY AT ALL. HE BEGAN TO C/O ABDOMINAL PAIN SO WAS SENT TO THE ED. PAIN SCALE UPON ASSESSMENT ,[DATE]... GU ([MEDICAL CONDITION]): POSITIVE FOR URINARY SYMPTOMS, DIFFICULTY URINATING, SWELLING OF PENIS AND SCROTUM. MS (musculoskeletal)/EXTREMITY: POSITIVE FOR [DIAGNOSES REDACTED], [MEDICAL CONDITION] CARDIOVASCULAR: [MEDICAL CONDITION]: 3+ [MEDICAL CONDITION] TO LEVEL OF PUBIC AREA, LEFT UPPER THIGH, LEFT LOWER THIGH, LEFT KNEE, LEFT MIDCALF, LEFT ANKLE, RIGHT UPPER THIGH, RIGHT LOWER THIGH, RIGHT KNEE, RIGHT MIDCALF AND RIGHT ANKLE. ABDOMEN/GI INSPECTION: DISTENSION... PROCEDURE: FECAL DISIMPACTION: DIGITAL DISIMPACTION WAS PERFORMED, WITH A MODERATE AMOUNT OF STOOL ET EXPRESSED... XRAY OF ABDOMEN 2 VIEWS...INTERPRETATION: LOADED WITH STOOL... CT ABDOMEN AND PELVIS... INTERPRETATION: ABNORMAL: HUGE FECAL IMPACTION; LARGE VOLUME OF STOOL WHICH IS CAUSING DISTENTION OF RECTUM AND CAUSING EXTRINSIC COMPRESSION OF BILATERAL URETERS AND BLADDER CAUSING HYDRO[DIAGNOSES REDACTED]... DISPOSITION: Diagnosis: [REDACTED]. MUSCULOSKELETAL/EXTREMITY: EXTREMITIES WITH SWELLING BILATERALLY. SKIN: APPEARANCE: COLOR: [DIAGNOSES REDACTED]TOUS... Diagnosis: [REDACTED]. PROBLEM IS AN ONGOING PROBLEM. SYMPTOMS HAVE WORSENED." The CT scan of the abdomen and pelvis showed a "very large amount of formed fecal material throughout the colon and rectum." The resident's hospital laboratory test results documented the resident's BUN (blood urea nitrogen) level was 86 on [DATE]. The normal reference range for BUN is ,[DATE] MG/DL. The resident's last BUN level in [DATE] was 56 mg/dl. The resident had received physician ordered medications of [MEDICATION NAME] three times a day for [MEDICAL CONDITION] and had received [MEDICATION NAME], a diuretic, for [MEDICAL CONDITION] daily, at the facility prior to hospitalization . The resident had a physician's orders [REDACTED]. The October and [DATE] MARs had no documentation the resident received a medication for constipation. The resident had a physician ordered standard treatment for [REDACTED]. The resident had not received an enema for constipation in October or November. The resident's [DATE] bowel movement record was reviewed. Three entries ([DATE], [DATE] and on [DATE]) documented the resident had small bowel movements each day. The corporate nurse reported the staff documented "NA" on other entries when the resident reported he had a bowel movement. The staff reported the resident was independent and would report when he had a bowel movement. There was no documentation to show the facility monitored his bowel movements or his urine output. The staff relied on the resident, who was moderately cognitively impaired to report this himself. On [DATE] at 4:30 p.m., the administrator reported the issues with reporting, assessment, monitoring and intervention would be remedied .

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure residents were properly assessed and monitored with interventions. At 5:30 p.m.,Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified at 6:00 p.m. At 6:10 p.m., the ADM and the DON were notified of the IJ situation. At 7:15 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal, dated [DATE], documented the following: "Immediate Jeopardy Plan of Removal 1. Resident is not in the facility 2. All nursing staff will be re-educated on proper reporting of resident falls/incidents, resident pain, and resident change in condition related to pain and/or the need for increased pain medication. 3. All nursing staff will be re-educated immediately and will not be able to return to duty until they have received the re-education. 4. All residents who have fallen in the past 30 days will receive an RN pain assessment 5. Completion as of Tuesday, [DATE] at 8 am of all available staff. Re-education will be completed: 1. [DATE] 3p-11p (names deleted) DON and/or NHA (nursing home administrator) 2. [DATE] 11p-7a (names deleted) DON and/or NHA 3. [DATE] 7a-3p (names deleted) DON and/or NHA 4. [DATE] Phone Education started immediately (named deleted) 5. Missed re-education will be followed up by (names deleted) DON, NHA and/or (name deleted) RN" On [DATE] at 8:45 a.m., a copy of the facility's in-service on the subject of resident changes in condition which included reporting, a complete evaluation and documentation, incident reports, pain screens, notification of the DON and physician, x-rays and requests for additional pain medication. Handouts were received titled, "Pain Recognition and Reporting," "Pain Management" and "Falls-Clinical Protocol." The last in-service was conducted at 3:30 p.m. on [DATE]. The ADM reported all staff were in-serviced prior to returning to work. The names on the in-service form were compared to the staffing roster. Staff members from various shifts and departments were interviewed in regard to the in-service. The staff members reported they received information of reporting, assessment, monitoring, intervening for changes in condition. The staff answered questions appropriately in regard to the in-service. The IJ was removed on [DATE] at 3:30 p.m. The deficiency remained at the level of actual harm that is not immediate jeopardy, at a pattern. Based on record review and staff interviews, it was determined the facility failed to ensure assessment, monitoring and intervention was completed for one (#2) of three sampled residents who had changes in conditions. This had the potential to affect all 72 residents who resided in the facility. Findings: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A "Fall Risk Assessment" in the nurses' notes, dated [DATE], documented the resident was a high risk for falls. The assessment documented the resident had fallen one to two times in the last six months. A physician's orders [REDACTED]. A care plan, dated [DATE], documented the resident was a high risk for falls r/t being unaware of safety needs, psychoactive drug use, gait/balance problems which required limited assistance for transfers and ambulation. The goal listed for the resident was to be free of falls through the review date. A fourteen day assessment, dated [DATE], documented the resident was moderately impaired with cognition with [MEDICAL CONDITION] and exhibited mild depression. The resident required one person limited assistance for bed mobility, transfer, ambulation, dressing and personal hygiene. The resident required one person extensive assistance for bathing. The resident had no impairment in function of range of motion in the upper or lower extremities. The resident was always continent of bowel and occasionally incontinent of bladder. A physician's orders [REDACTED]. The care plan did document a fall on [DATE], with the [DIAGNOSES REDACTED]. An intervention was to obtain a mobile x-ray of the left shoulder and place a left arm sling which was to be removed only to shower. The above fall with injury had been properly reported to the OSDH. A significant change assessment, dated [DATE], documented the resident was moderately impaired in cognition with [MEDICAL CONDITION]. The assessment documented the resident exhibited mild depression. The resident required limited one person assistance for bed mobility, transfer, ambulation in the room, dressing and personal hygiene. The resident required one person extensive assistance for ambulation in the corridor, off/on the unit and for bathing. The resident had functional range of motion impairment of one upper extremity. The resident was occasionally incontinent of bowel and bladder. An updated care plan, dated [DATE], documented the resident had a self-care deficit after a fall ([DATE]) with a closed fracture of her left shoulder/arm. Care plan interventions listed included for PT/OT to evaluate and treat as per physician's orders [REDACTED]. A nurse's note, dated [DATE] at 7:20 a.m., "On floor at bedside. Call light on floor beside resident. Vitals and neuro checks performed. No change in cognitive condition noted." An incident report, dated [DATE] at 7:20 a.m., documented the nurse was called to the resident's room per a CNA's request and the resident was on the floor. The report documented the resident was trying to get out of bed without calling for assistance. The immediate action taken was documented as vital signs taken and neuro checks obtained. The section, "Injuries Observed at Time of Incident," was blank. The level of pain was checked, "Hurts a Whole Lot." The report documented the resident was oriented to person, place, time and situation. The report note documented, "Hx of falls. Left shoulder broken from previous fall is tender to touch and sudden movement." The interventions listed were for the staff to monitor the resident for trying to get up without help and encourage the resident to use the call light. At 10:17 a.m., a nurse's note documented the resident denied pain. An occupational therapy ancillary services report, dated [DATE] to [DATE], documented a change in the resident's sitting static ([MEDICATION NAME] or balance at rest) from fair minus on [DATE], to "very poor" on [DATE] and [DATE]. The report documented, "pt states she fell [DATE] & [DATE] Confirmed [DATE] fall c nursing. Pt states her L hip "out of place"- reported to nursing." There was no entry in the nurses' notes which referred to the notification from occupational therapy on [DATE] or [DATE]. There was no evidence in the nurses' notes which indicated x-rays had been obtained, after the fall. A nurse's note, dated [DATE] at 4:10 p.m., documented, "...No complaints of pain..." The resident was to be seen by an orthopedist on [DATE], in regard to the resident's shoulder. The appointment was rescheduled by the orthopedist. At 10:03 p.m., a nurse's note documented the "...resident shows no s/s of pain or distress..." The resident was taken to another physician's appointment (orthopedist) on [DATE], and the physician was out of the office. The orthopedist appointment was rescheduled for [DATE]. There was no entry in the nurses' notes of any complaints of pain or problems with the resident's left leg. An occupational therapy report, dated [DATE] to [DATE], documented "...Attempted EOB sit [DATE] pt tolerated (symbol for less than) 1 min (secondary) pain. Educated pt c possible need to place her on hold c therapy services if unable to tolerate @ this time [DATE]. She wants to cont but hurts. Tx limited to pt supine in bed [DATE] & [DATE] (secondary) refusal to transfer to w/c (secondary) c/o severe pain LLE. Position of least discomfort is LLE adduct & slight internal rotation c L ankle crossed over R..." The resident's hospital records were obtained and reviewed. The resident was admitted to the hospital on [DATE], with abdominal pain from an incarcerated hernia. A consultant report (orthopedic), dated [DATE], documented, "...On evaluation on admission to the emergency room , she was found to have a chronic left proximal humeral fracture, nondisplaced, and [MEDICAL CONDITION] greater trochanter..." The humeral fracture showed minimal displacement with early callus formation. The fracture of of the left greater trochanter was nondisplaced. The report documented, "...ASSESSMENT: Chronic left proximal humeral fracture, left greater trochanter fracture..." The report documented, "PLAN: At this point, I think the risks of displacement of her humeral fracture, greater trochanter fracture are minimal. I recommend active use as tolerated once the patient is able. I think she can safely participate in full weight bear bed to chair transfers once she had recovered enough for this to be carried out. Ambulation will follow, depending on her condition..." On [DATE] at 3:50 p.m., the DON was interviewed and asked if she would have done anything differently with the resident. The DON reported she would have x-rayed her hip after the fall. The DON reported the COTA had reported the resident had told the COTA her leg was dislocated. The DON reported she had talked with LPN #1 and requested an x-ray to be obtained. The DON reported LPN #1 had assessed the resident and found the resident had full ROM, after the fall. At 4:00 p.m., the attending physician was interviewed by telephone. The physician was asked if she had known anything in regard to the resident's left hip prior to hospitalization . The physician stated, "No," and reported the hip being fractured surprised her. At 4:15 p.m., the COTA was interviewed in regard to the resident. The COTA reported on [DATE], the resident required much more assistance than previously to transfer. The COTA reported the resident could not bear as much weight on the left leg during therapy. The COTA reported the resident told her she had fallen. The resident told the therapy assistant she needed to go back to her room since the resident stated, "I hurt." The COTA reported she went to the charge nurse, LPN #1 and reported what the resident had said. The COTA reported LPN #1 had told her the hip was not fractured. The COTA reported on [DATE], a PTA (physical therapy assistant) had reported the resident had told him she couldn't eat and couldn't stand to get up. The COTA reported she had talked to the nurses, the DON and LPN on both days, [DATE] and [DATE]. The COTA reported the resident's left ankle lying was over the right ankle. The COTA reported, when she tried to help the resident move her leg from adduction to a neutral position, the resident cursed and stated she hurt. At that time, the COTA reported she went to LPN #1 and was told there was no x-ray completed since the resident was able to bear weight and move the leg. The COTA reported LPN #1 had told her the resident could not have borne weight or moved the leg, if broken. The COTA reported she informed LPN #1 there were different types of fractures. The COTA reported she had notified the DON and LPN #1 about the resident hurting and stating her leg was out of socket. The COTA reported the resident told her, it was not that she didn't want to participate with therapy, but the resident reported she felt "awful." The COTA reported she did not attempt to get the resident up on [DATE] and [DATE]. The COTA reported the resident went to the hospital on [DATE], for another medical condition. At 4:40 p.m., CNA #2 was asked if the resident had complained about her left leg. The CNA reported the resident had complained about her leg being broke since her last fall. The CNA reported she had reported this to the charge nurse. The CNA could not remember what day she reported it or who the charge nurse was. At 4:45 p.m., CNA #3 was asked by another surveyor, if the resident had complained of her left leg. The CNA reported the resident complained of her leg being sore. The CNA stated she reported it to LPN #4 since it was a different complaint. The CNA reported the resident had more pain in her shoulder, but some in her leg as well. At 4:45 p.m., the DON was shown the nurses' note on [DATE] and [DATE], and asked if she could locate a documented assessment on the resident's left leg, after the therapy department had reported changes. The DON stated, "No." The DON reported LPN #1 was present, when the resident was assessed, after her fall. The DON reported she was told the resident did not complain of pain at that site, had no bruising and had no limitation in ROM in her legs. The DON reported the charge nurse assessed the resident and she was told the resident demonstrated full range of motion. The resident's [DATE], Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE], the resident received three doses of [MEDICATION NAME] as follows: At 7:00 a.m. on [DATE], the first dose was given for generalized pain at a level of 9 on a ,[DATE] scale. The results documented was "little help." At 11:30 a.m., [MEDICATION NAME] was given for generalized pain at a level of 9. The results documented was "little help." At 4:00 p.m., [MEDICATION NAME] was given for complaint of pain ,[DATE]. At 5:20 p.m., the results documented "relieved ,[DATE]." On [DATE] at 12:00 a.m., the resident received [MEDICATION NAME] for c/o ,[DATE] pain. The results were blank. At 6:00 a.m., the resident received [MEDICATION NAME] for a complaint of generalized pain at a level of 9. The results documented, "helped." The resident was not medicated again for pain per the MAR indicated [REDACTED]. On [DATE] at 8:45 a.m., the COTA was asked who was the charge nurse she communicated with about the resident's leg. The COTA named LPN #1. At 8:50 a.m., LPN #1 was interviewed about the resident's fall and left leg. The LPN reported on the morning of [DATE], before change of shift report, CNA #1 came and reported the resident was in the floor. LPN #1 reported she, RN#1 and LPN #2 went to the resident's room. LPN #1 stated RN #1 assessed the resident. The LPN reported the resident denied pain and was able to lift her legs without complaint. The LPN reported the resident bore weight on her left leg and no bruising was evident. The LPN reported a personal alarm was placed on the resident. LPN #1 was asked if the therapy department had notified her concerning the resident's left leg. The LPN stated, "No." The LPN stated, "I know for a fact I was never told anything about her hip." At 9:05 a.m., the DON was asked which charge nurse she communicated with about the resident's leg. The DON named LPN #1. At 9:25 a.m., LPN #4 was interviewed by telephone. The LPN was asked if anyone had reported to her about the resident's leg. The LPN stated, "No." The LPN reported the resident would complain of her arm when moved. The LPN reported the resident was able to tell her when she was in pain. At 10:25 a.m., LPN #3 was asked if the resident had complained about her left leg or hip. The LPN reported, after the resident's fall on [DATE], the resident was not up on her leg. The LPN reported the resident would complain of left arm pain, but not leg pain. At 3:30 p.m., the ADM reported all the in-service had been completed. The ADM reported the issues with reporting and assessment would be remedied .

Based on record review and staff interviews, it was determined the facility failed to ensure a resident received sufficient fluids to maintain hydration for one (#1) of five sampled residents who required thickened liquids. This resulted in actual harm to resident #1. This had the potential to affect five residents, identified by the DON, who required thickened liquids in the past three months. Findings: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A speech therapy evaluation, dated 07/02/12, documented the resident coughed when thin liquids were taken and did not cough with nectar thick liquids. The resident's diet was changed to include the thickened liquids. A care plan, dated 07/16/12, documented the resident had a problem with altered nutrition. The goal documented for the resident to have no aspiration pneumonia and to consume enough food/fluids to maintain weight and nutritional needs. Interventions documented were for the staff to monitor/document/report to the physician the signs of dysphagia and for the staff to monitor intake and record at each meal. There was no specific care plan to address the risk of dehydration related to the nectar thick liquid. A nutritional assessment, dated 07/28/12, documented the resident's estimated fluid needs were 2175 ml. daily. The fluid intake documentation for August 2012 through October 2012 contained the meal fluid intake totals. No other fluid intake amounts were documented in the medical record for those months. The fluid intake amounts documented were below 1000 ml for 43 of the 92 days. A significant change assessment, dated 10/06/12, documented the resident had moderate impairment in decision making skills, exhibited mild depression symptoms and exhibited no behavioral symptoms. The resident required extensive assistance of two persons for transfers, bed mobility and personal hygiene and one person assistance with eating. The documented resident's average daily fluid intake for 11/01/12 through 11/05/12 was 1084 ml. On 11/06/12, the physician was notified because the resident was spitting out his food at breakfast and lunch. The physician ordered a chest x-ray and the results were faxed to the physician. The documented resident's fluid intake was as follows: 11/06/12: 1200 ml. 11/07/12: 960 ml. 11/08/12: 1168 ml. 11/09/12: 720 ml. 11/10/12: 990 ml. 11/11/12: 660 ml. The resident's documented meal intake was 0-25% at breakfast and lunch and 51-75% for the evening meal. 11/12/12: 360 ml. The resident's documented meal intake was 0-25% at breakfast and 26-50% at lunch. The resident refused the evening meal. The resident's documented average daily fluid intake for 11/06/12 through 11/12/12 was 865 ml. There was no documentation in the medical record to show the facility monitored the resident's intake or provided interventions for the decreased intake. A nurse's note, dated 11/12/12 at 10:17 p.m., documented, "Resident refused meal this pm respirations are shallow. O2 is in place via n/c. Unable to sit up straight in wheelchair. Bruising remains to both hands. Shows no s/s of discomfort..." A nurse's note, dated 11/13/12 at 1:43 a.m., documented, "Resident is resting in bed with eyes closed, resp. are even, skin WDI, bruising noted to right hand finger. No S/S of discomfort..." A nurse's note, dated 11/13/12 at 9:40 a.m., documented, "Resident in bed eyes open but glassy. Resident is not responding to verbal or tactile stimuli. Lung sounds moist with rattle. Resp even slightly labored. It was reported from night shift that resident hasn't had any output and so far on dayshift no output. Staff unable to get resident to eat or drink this am. Skin cold to touch. Resident mouth breathing. Dr. (name deleted) paged. Family notified of resident's decline in condition. Will continue to monitor for changes..." The resident was sent to the emergency department and admitted to the hospital with [REDACTED]. The resident's sodium level was 170 MMOL/L (normal level 136-145) and chloride level was 129 MMOL/L (normal level 98-107). The admitting physician's history and physical documented: "...ASSESSMENT: 1. Probable pneumonia. 2. Dehydration, severe, possibly secondary to #1. 3. [MEDICAL CONDITION] secondary to #2. 4. Acute [MEDICAL CONDITION] secondary to #2. 5. Severe dementia. PLAN: IV fluids with normal saline and oral free fluids. Will treat with [MEDICATION NAME] and [MEDICATION NAME] as there is a possibility that this represents aspiration pneumonia..." On 03/01/12, at 10:50 a.m., CNA #3 and CNA #2 were asked if residents, who had thickened liquids ordered, had water kept at bedside. CNA #3 reported, "They usually do, but not today." CNA #2 reported the CNAs documented the amounts of fluid the residents take during the meals, in the computer. CNA #3 reported there was no other area on the computer to document other fluid intake amounts. At 10:55 a.m., LPN #1 was asked how she monitored the amount of fluid intake the residents received. The LPN reported she would ask the CNAs. The LPN reported the CNAs were supposed to tell the charge nurses if the resident was not taking fluids. The LPN reported there was no routine monitoring. At that time, the DON reported the nurses could look on the computer to check if the residents were getting enough fluids. At 11:00 a.m., the MDS coordinator provided the resident's ADL and fluid intake record. The ADL documentation contained initials and times of entries but no amounts of food or fluids. The MDS coordinator reported there was a separate screen in the computer, which was available for seven days for a look back period. She reported the discharged residents' intake amounts were not accessible and she would have to figure out how to obtain those records. At 2:10 p.m., LPN #2 was asked how residents on thickened liquids were provided fluids. The LPN reported the thickened liquids came from the dietary department. She reported there were packets in the dining room for the nurses to provide thickened liquids for the residents. At that time, LPN #2 was asked how she monitored the fluid intake of the residents. The LPN reported she checked on the CNAs' documentation. The LPN reported she monitored the intake and output for the residents with feeding tubes and indwelling urinary catheters. LPN #2 was asked what she would do when a resident was not getting enough fluid. The LPN reported she would call the doctor. The LPN reported the facility did not administer IV fluids and a resident would have to go to the hospital for IV fluids. At 3:00 p.m., the resident's family member was interviewed. The family member reported the resident never had fluid at the bedside when he visited. At 3:30 p.m., the fluid intake and meal intake records were received. The MDS coordinator reported the reports could only be generated a week at a time using an override to the system. On 03/04/13 at 11:00 a.m., LPN #1 was asked about the resident's condition before he was sent to the hospital on [DATE]. The LPN reported the resident had spit out his food at breakfast and lunch on 11/06/12. The LPN reported the physician was notified and an x-ray was obtained. The LPN reported she did not work the weekend and did not know how he did over the weekend. At 11:30 a.m., the DON was asked if there was a system in place for the licensed nursing staff to monitor the amounts of fluid intake for at risk residents. The DON reported the charge nurses were to check the fluid intake amounts, documented by the CNAs, on a daily basis. The DON was asked if she expected residents on nectar thick liquids to be monitored for adequate fluid intake. The DON stated, "Yes." At that time, the DON was shown the documentation of the fluid intake by the CNAs for the resident. The DON reported there was a problem with the computer system. The DON reported there was no way to document any fluid intake beside those with the meal documentation. The DON was asked if the resident received adequate fluid intake based on the intake documentation and the resident's [DIAGNOSES REDACTED]. The DON reported the resident's intake should have been monitored more closely.