Every finding on record at Bradbury Commons

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 02/21/23 related to the facility's failure to ensure a resident was administered medication as ordered in the discharge instructions. The facility failed to ensure Plavix and Aspirin were not continued upon admission when the Resident had a diagnosis of traumatic subdural hematoma. (A serious condition where blood collects between the skull and the surface of the brain.) Resident #1's CT scan of the head, dated 03/04/23 documented the resident's subdural hematoma had increased in size and had an increased right to left midline shift which measured 1.4 cm. (A displacement of brain tissue across the center line of the brain.) On 03/21/23,the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to ensure medications were administered as ordered to prevent worsening of a subdural hematoma. The past noncompliance IJ was removed effective 03/07/23 after the facility put measures in place to prevent recurrence. On 03/07/23 a QAPI meeting was conducted, leadership was educated by the Director of Clinical Operations on the policies and procedures for completion of medication reconciliation upon admission, physician order entry and transcription, admission review, and event investigation including timely reporting. Staff were inserviced about the policy and procedures for admissions, medication reconciliation, adverse effects and medication errors, and event reporting on 03/07/23 or prior to their next scheduled shift. The facility performed medication reconciliation for current residents who were admitted in the last 30 days. The IDT reviewed new admission daily during the clinical meeting. The facility put the following action plan in place to prevent recurrence: Action plan Going Forward .Residents newly admitted to the community will have a medication reconciliation opened and will be reviewed by the Interdisciplinary Team during daily clinical huddle and will audit all new admissions within 24 hours of admission to assure DC orders coincide with our MAR. The Interdisciplinary Team will always review all new admissions .on a weekly basis .If a resident comes over from Assisted Living or Memory Care all orders are to be discontinued and re-entered per DC orders from hospital stay. Any discrepancies found upon admission will require clarification from the doctor that provided care or primary care provider . On 03/21/23 CMAs and Nursing staff were interviewed and verified they had received the in-service relating to medication error. Nurses verified they knew how to perform medication reconciliation with new admissions and readmissions and what the process was if they found a discrepancy. The audits for medication reconciliation were reviewed. Based on record review and interview, the facility failed to ensure discharge instructions for medication administration was followed for one (#1) of three sampled residents who were admitted or readmitted to the facility in the past 6 months. The Resident Census and Conditions of Residents report, dated 03/17/23 documented 54 residents resided in the facility. Findings: A facility policy titled Reconciliation of Medication of Admission, dated 12/2017, read in parts, .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications .upon admission or readmission to the community .Gather the information needed to reconcile the medication list .Approved medication reconciliation form .Discharge summary from referring community .Admission order sheet .All prescription medication and supplement information obtained from the resident/family during the medication history .Most recent medication administration record .if this is a readmission .Medication reconciliation helps to ensure that all medications .on the list are appropriate for the resident and his/her condition .Review the list carefully to determine if there are discrepancies/conflicts .If there is a discrepancy .Contact the resident's primary physician in the community .Document findings and actions .Contact the attending physician to verify the orders . Resident #1 was admitted to the facility on [DATE] from the hospital with diagnoses which included dehydration and subdural hematoma. A hospital discharge summary, dated 02/21/23 read in parts, .hospitalization Diagnoses .DATES OF hospitalization [DATE] discharge date [DATE] .Admit DX/Problem List .Dehydration .Subdural hematoma .Discharge Medication List .Continue taking these medications: Benzonatate Cap .100 MG .BY MOUTH TWICE DAILY AS NEEDED .for COUGH . Loratadine .10 MG TAB BY MOUTH DAILY . levETIRAcetam .Tab 250 MG .TWICE DAILY . Acetaminophen Tab .325 MG .TWICE DAILY . Midodrine 10 MG .DAILY . Acetaminophen .325 MG .1-2 TABLET .EVERY 4 HOURS AS NEEDED for temp GREATER THAN 100.4 . Omeprazole .20 MG .DAILY . LEVOTHYROXINE SODIUM .100MCG DAILY Guaifenesin-Codeine Liquid .5 MILLILITER .EVERY 4 HOURS AS NEEDED . for COUGH . Magnesium Hydroxide Liquid 400 MG/5ML .DAILY AS NEEDED for CONSTIPATION Physician's orders, dated 02/21/23, documented the following medications were in Resident #1's electronic record for administration and not documented to be continued on the hospital discharge orders: Plavix 75 mg daily for TIA prevention with an original order date of 12/30/19 and Aspirin 81 mg delayed release tablet for platelet aggregation with an original order date of 02/18/21. Plavix is a drug that inhibits the ability of platelets to clump together. Plavix prevents blood clots. Plavix could make the blood thinner and increase the risk of brain hemorrhage. A MAR, dated 02/21/23 through 02/28/23, documented the Plavix 75 mg and Aspirin 81 mg were administered without a physician's order on 02/22/23, 02/23/23, 02/25/23, 02/26/23, and 02/28/23. A MAR, dated 03/01/23 through 03/31/23, documented Plavix 75 mg and Aspiring 81 mg were administered without a physician's order on 03/01/23 03/03/23, and 03/04/23. A nurse's progress note, dated 02/26/23, read in parts, .Patient continues on SNF for trauma subdural hemorrhage. She is alert and oriented x2. Patient is able to voice needs .She is mobile via wheelchair. Patient requires moderate assistance with ADL's . A nurse's note, dated 02/28/23, read in parts, .Resident has been weak and having difficulty working with therapies and difficult to stand for transfers. Resident is confused x3 for the past 2 days. Called [primary care physician] and received order for UA obtained via straight cath and send to C&S if indicated Urine is dark and amber and with a lot of sediment .Resident had to have someone feed her . A nurse's note, dated 03/03/23, read in parts, .[primary care physician] in facility to see resident. Gave this nurse new orders .discontinue ASA and Plavix due to recent brain bleed. MAR updated .LPN notified of new orders. Aspirin and Plavix removed from cart . Resident #1 received the Plavix and Aspirin eight times after admission without a physician's order. A physician's order, dated 03/03/23, documented to discontinue the Plavix and Aspirin. A physician's progress note, dated 03/03/23, read in parts, .chart and medications have been reviewed .recently in the hospital after a fall with hitting her head and brain bleed .Current Medications Milk of Magnesia .Tylenol .Levsin .Midodrine .Omeprazole .Levothyroxine .Keppra Claritan .Medical History .atrial fibrillation hypertension .She is lethargic Plan .D/C Plavix and Aspirin .Changed/Discontinued Medication(s) .Discontinued By Other MD: ASPIRIN 81 MG TABLET .Discontinued By Other MD: PLAVIX 75 MG TABLET . A nurse's note, dated 03/04/23 at 12:48 p.m., read in parts, .Resident had a decline in health since this AM. Aides came to nurse reporting that resident was not responding to commands. This nurse walked in and tried verbal and minimal painful stimuli. Resident opened eyes briefly and then rolled them back. This nurse attempted to call [primary care physician] for orders to send out with no return phone call. This nurse called [medical director] and he gave approval to send out only if I had attempted [primary care physician] .This nurse called [ambulance service] to send out to ER . An ED Physician Documentation Note, dated 03/04/23, read in parts, .presents to ED via [ambulance service]-Ground with complaints of S/S of Possible Stroke .The symptoms/episode began/occurred last month. Associated signs and symptoms .This patient did not experience any loss of consciousness .The patient has experienced a previous episode, last month .seen here last month, dx with brain bleed. [Physician] has already called telling me the bleed is worse and there is 1.4 cm midline shift .Symptoms have worsened .Diagnosis Traumatic subarachnoid hemorrhage .Nontraumatic subarachnoid hemorrhage, unspecified .Hospice set up by nursing home/nurse . A nurse's progress note, dated 03/13/23 at 3:15 p.m., read in parts, . The DPOA was notified of resident was on Plavix and aspirin for 8 days, but was discontinued from hospital . On 03/17/23 at 12:28 p.m., the DON stated Resident #1 was admitted to the facility after having a fall in the facility's assisted living center which resulted in a subdural hematoma. The DON stated Resident #1 was not supposed to have continued their Aspirin and Plavix when they were admitted to the skilled nursing facility on 02/21/23. The DON stated they identified the medication error 10 days later. The DON stated on 03/03/23 the resident's primary care physician saw the resident and discontinued the Aspirin and Plavix. They stated the resident was sent to the hospital on 03/04/23. The DON stated they had a QAPI meeting on 03/07/23 and put measures in place to prevent the recurrence. They stated Resident #1 was now on hospice. They stated the medical director had seen the resident on 02/23/23 and knew the resident was on Plavix and Aspirin. The DON was asked if the medical director had been notified on 02/23/23 the Aspirin and Plavix were discontinued at the hospital. They stated they would have to ask the medical director. On 03/17/23 at 3:11 p.m., LPN #3 stated Resident #1 arrived at facility and their orders were in the computer before they had arrived to work on 02/21/23. The LPN was asked if they had reconciled the medications for Resident #1 when they were admitted to the facility. They stated they clicked the No Discrepancy button but did not reconcile the medications. They stated they did not know how to do it until they had the inservice. The LPN was asked if they reviewed the medications ordered in the computer with the discharge medication list. They stated, No. On 03/17/23 at 3:56 p.m., the DON stated the order for the Aspirin and Plavix were in the computer system because Resident #1 lived in the assisted living prior to going to the hospital. The DON was asked if Resident #1's primary care physician had been notified of the discrepancy in the hospital discharge orders. They stated, Not to my knowledge. The DON stated they should have reviewed the medications in computer against the discharge orders and notified Resident #1's primary care physician. On 03/17/23 at 4:29 p.m., the medical director was asked if they were aware the hospital had discontinued Resident #1's Aspirin and Plavix prior to admission to the facility. They stated they could not recall. The medical director stated Resident #1 was not their patient and Resident #1's primary care physician was adamant they would handle their patients. The medical director was asked if they would have continued Aspirin and Plavix if a patient had a subdural hematoma. They stated it would be a case by case basis and they would have to consider the risks and benefits. They stated they would probably hold off until the subdural hematoma had healed a bit. On 03/21/23 at 10:55 a.m., the MDS coordinator stated they had received a fax from the hospital with Resident #1's discharge orders. They stated they put them in the computer. The MDS coordinator was asked if they had put in the Aspirin or Plavix. They stated no, the medications were in the computer because the resident had lived in the assisted living prior to going to the hospital. They stated they thought they had marked discontinue in the computer for the Aspirin and Plavix. The MDS coordinator stated the charge nurse who admitted the resident was responsible for reviewing the discharge paper work and the physician's orders. The MDS coordinator stated on 03/03/23, Resident #1's primary care physician had asked them if the resident was on Aspirin and Plavix and asked them to discontinue the medications.

Based on record review, observation, and interview, the facility failed to ensure ADL care was provided in a timely manner for two (#1 and #3) of three sampled residents reviewed for ADL care. The Resident Census and Conditions of Residents report, dated 03/17/23, documented 46 residents required assistance with toileting and 47 residents required assistance with eating. Findings: 1. Resident #1 had diagnoses which included traumatic subdural hematoma and sarcopenia. An admission assessment, dated 02/26/23 documented the resident's cognition was moderately impaired, required limited to physical assistance of one person with eating. A nutrition care plan, dated 02/24/23, documented the resident needed limited to extensive assistance with meals. On 03/18/23 at 8:35 a.m., the breakfast cart was observed on the hall. On 03/18/23 at 9:23 a.m., CNA #2 was observed taking Resident #1's breakfast tray to the room. CNA #2 stated they were going to assist Resident #1 with eating. The breakfast trays had been on the hall 48 minutes before Resident #1 was served and assisted with breakfast. On 03/18/23 at 9:34 a.m., CNA #1 was asked what time breakfast was served. They stated the dining room served breakfast at 7:30 a.m., and the hall trays were served after the dining room was served. CNA #1 was asked why Resident #1 was fed 48 minutes after the trays were sent to the hall. They stated they were busy answering call lights, passing trays, and Resident #1 needed to be fed. On 03/18/23 at 11:16 a.m., the DON stated they expected the staff to deliver the meal trays within 10-15 minutes of the trays arriving to the floor. The DON stated Resident #1 would have been served last because they needed to be fed. 2. Resident #3 had diagnoses which included cerebral infarction. An admission assessment, dated 03/08/23, documented the resident's cognition was intact, and required extensive assistance of one person for toileting and transfers. An ADL care plan, dated 03/03/23, read in parts, .[Resident #3] needs assistance with daily ADL care .will have daily care needs met through next review period .TRANSFER: I need extensive assistance with 1 person staff support .TOILETING: I need extensive assistance with 1 person staff support . On 03/18/23 at 7:52 a.m., LPN #1 was administering medications to Resident #3. Resident #3 reported to the LPN they were told to use the call light when they needed to get up and nobody answered their bathroom call light when they were finished. On 03/18/23 at 7:57 a.m., Resident #3 was observed in their bed. They stated the staff assisted them to the bathroom and failed to answer the bathroom call light when they were finished. They stated they had to walk back without assistance. On 03/18/23 at 7:59 a.m., CNA #1 entered the resident's room and stated they were going to turn the bathroom call light off. On 03/18/23 at 9:34 a.m., CNA #1 stated they did not assist Resident #3 back to bed from the bathroom and did not know who had assisted Resident #3.

Based on record review, observation, and interview, the facility failed to ensure the care plan was implemented for toileting and tranfers assistance for one (#3) of three sampled residents who were reviewed for ADL care. The Resident Census and Conditions of Residents report, dated 03/17/23, documented 46 residents required toileting assistance. Findings: Resident #3 had diagnoses which included cerebral infarction. An admission assessment, dated 03/08/23, documented the resident's cognition was intact, and required extensive assistance of one person for toileting and transfers. An ADL care plan, dated 03/03/23, read in parts, .[Resident #3] needs assistance with daily ADL care .will have daily care needs met through next review period .TRANSFER: I need extensive assistance with 1 person staff support .TOILETING: I need extensive assistance with 1 person staff support . On 03/18/23 at 7:52 a.m., LPN #1 was administering medications to Resident #3. Resident #3 reported to the LPN they were told to use the call light when they needed to get up and nobody answered their bathroom call light when they were finished. On 03/18/23 at 7:57 a.m., Resident #3 was observed in their bed. They stated the staff assisted them to the bathroom and failed to answer the bathroom call light when they were finished. They stated they had to walk back without assistance. On 03/18/23 at 7:59 a.m., CNA #1 entered the resident's room and stated they were going to turn the bathroom call light off. On 03/18/23 at 9:34 a.m., CNA #1 stated they did not assist Resident #3 back to bed from the bathroom and did not know who had assisted Resident #3. On 03/18/23 at 11:16 a.m., the DON stated according to the care plan Resident #3 required assistance of one staff with transferring and toileting.

Based on record review and interview, the facility failed to: (a) ensure there was sufficient nursing staff to meet the residents' needs for three (#2, #3, and #4) of three sampled residents reviewed for care needs being met, and (b) have a licensed nurse to serve as a charge nurse for six (10 p.m. - 6 a.m. on 01/01/23, 01/17/23, 01/21/23, 02/22/23 and 02/24/23 and 2 p.m. - 10 p.m. on 02/28/23) of 177 shifts reviewed for sufficient staffing during the months of January and February 2023. The Resident Census and Conditions of Residents report, submitted 03/02/23, documented 56 residents resided in the facility. A minimum of 40 residents required the assistance of one or two staff for bathing, dressing, transferring, toileting, and eating. Findings: The Daily Staffing Sheets, dated 01/01/23 and 01/17/23, documented LPN #1 was the licensed nurse on the 10 p.m. - 6 a.m. shift. The Daily Staffing Sheets, dated 01/21/23 and 02/24/23, documented LPN #2 was the licensed nurse on the 10 p.m. - 6 a.m. shift. The Daily Staffing Sheets, dated 02/22/23, documented LPN #3 was the licensed nurse on the 10 p.m. - 6 a.m. shift. The Daily Staffing Sheet, dated 02/28/23, documented LPN #4 was the licensed nurse on the 2 p.m. - 10 p.m. shift. PBJ reports for staff and agency personnel, received from the Dir of Business Operations, for 01/01/23 through 02/28/23, had no hours documented for LPN #1 on 01/01/23 nor 01/17/23, no hours documented for LPN #2 on 01/21/23 nor 02/24/23, no hours documented for LPN #3 on 02/22/23, and no hours documented for LPN #4 on 02/28/23. The Resident Council Meeting minutes, dated 02/13/23, read in part, .Nursing Concerns .Staffing issues having people called in on a day off. Nursing staff is aware we are short staffed . (a) (1) Res #2 had diagnoses that included lumbar intervertebral disc degeneration and chronic pain syndrome. On 03/01/23 at 4:21 p.m., Res #2 was observed in their room in bed with family member present at bedside. When asked how their care needs were being met, Res #2 stated, They don't respond fast enough. It takes a long time to get pain medicine sometimes. On 03/01/23 at 4:22 p.m., Res #2's family member was asked about the facility staffing and stated, It seems like they only have two people on the whole floor and they need more. When we come back to the room from dinner no one can come and help get [Res #2] into bed until they clean up the entire dining room. [Res #2] has to sit here in pain and it takes a really long time to get help. The Medication Record for 02/2023 for Res #2 read in parts, .01/09/2023 .[8:00 a.m.] .Med Not Administered .No one was here to pass meds this morning . (2) Res #3 had diagnoses that included vascular dementia, anxiety disorder, and HTN. On 03/03/23 at 1:11 p.m., Res #3 was observed up in recliner in their room listening to music. The Medication Record for 02/2023 for Res #3 read in parts, .01/09/2023 .[8:00 a.m.] .Med Not Administered .No one was here to pass meds this morning . (3) Res #4 had diagnoses that included Parkinson's disease, CHF, and COPD. On 03/03/23 at 12:02 p.m., Res #4 was observed sitting in the common area. Res #4 was asked if they had any problems with staffing. They stated sometimes you have to wait to be put to bed, but the staff works hard to take care of us. There's usually only one or two of them so we could always use more. The Medication Record for 02/2023 for Res #4 read in parts, .01/09/2023 .[8:00 a.m.] .Med Not Administered .No one was here to pass meds this morning . On 03/02/23 at 3:05 p.m., the DON was asked about documentation that residents did not receive medications on 01/09/23 due to a lack of staffing. The DON stated the charge nurse had pulled the CMA off of the medication cart to work the floor because they were short staffed. (b) On 03/02/23 at 12:45 p.m., the Administrator was asked to review Daily Staffing Sheets for the 10 p.m. - 6 a.m. shift on 01/01/23, 01/17/23, 01/21/23, 02/22/23, and 02/24/23 and for the 2 p.m. - 10 p.m. shift on 02/28/23. The administrator was asked if there had been LPN or RN coverage on these shifts. They pointed out there were nurses names listed on the Daily Staffing Sheets for the shifts in question, and stated, You will have to ask the Dir of Business Operations about the accuracy of those hours. On 03/02/23 at 3:05 p.m., the DON was asked what happens if there is no licensed nurse to serve as charge nurse on a particular shift. They stated there is always an LPN or RN on each shift. The DON was asked to review Daily Staffing Sheets for the shifts that had no LPN or RN coverage. They stated, There must be a mistake. Give me the dates and I will look into it. On 03/03/23 at 9:40 a.m., the Dir of Business Operations was asked what the numbers and the blank spaces beside an employee's name meant on the PBJ report. They stated the numbers indicated the amount of hours an employee worked on a particular day. The Dir of Business Operations was asked about the accuracy of the PBJ report. They stated, I don't know. On 03/03/23 at 12:15 p.m., no documentation had been provided verifying a licensed nurse served as the charge nurse on each shift for the dates in question.

Based on record review and interview the facility failed to ensure medications were administered according to physician's orders for three (#2, #3, and #4) of three sampled residents whose medication profiles were reviewed. The Resident Census and Conditions of Residents report, submitted 03/02/23, documented 56 residents resided in the facility. Findings: An Administering Medications policy, last revised 12/2021, read in part, .Medications shall be administered in accordance with the orders . The Resident Council meeting minutes, dated 01/10/23, read in part, .Nursing Concerns .Medicine not passed 1-10-23 during the morning . A Past Non-Compliance Plan of Correction, dated 01/10/23, documented a Plan of Correction related to medication administration was completed on 01/10/23. An In-Service Training, dated 01/10/23, documented 24 staff received education on administering medications. The Quality Assurance Performance Improvement AdHoc Meeting Minutes, dated 01/10/23, documented medication administration policies, education related to administering medications, and findings/regulatory concerns related to administering medications were reviewed and facility compliance date was 01/10/23. (1) Res #2 had diagnoses that included GERD, HTN, and IBS. Res #2's Medication Record for 01/2023 documented that on 01/09/23 at 8:00 a.m., Metoclopramide 10mg for GERD, Preservision AREDS 2 1cap for dietary supplement, Glucosamine 1000mg for dietary supplement, Cetirizine 10mg for allergies, Pantoprazole 40mg for GERD, Calcium + D3 600mg/800 IU for dietary supplement, Amlodipine 5mg for HTN, Irbesartan 150mg for HTN, Miralax 17g for IBS, and Senekot 8.6mg for laxative were not administered to the resident as ordered. On 03/01/23 at 4:21 p.m., Res #2 was observed in their room in bed with family member present at bedside. Res #2's family member was asked if they experienced any problems with Res #2 getting their medications as ordered. They stated they were notified a few weeks ago that [Res #2] did not get medications at all. They were asked if Res #2 experienced any harmful effects from this incident. Res #2's family member stated, Not that I seen. I just hope it wasn't [Res #2's] pain medicine. (2) Res #4 had diagnoses that included Parkinson's disease, CHF, and COPD. Res #4's Medication Record for 01/2023 documented that on 01/09/23 at 8:00 a.m., Rytary 48.75mg-195mg ER for Parkinson's disease was not administered to the resident as ordered. Documentation in Res #4's progress notes, written 01/10/23, stated resident's representative and MD were informed Res #4 did not receive their prescribed medications the morning of 01/09/23. (3) Res #3 had diagnoses that included vascular dementia, anxiety disorder, and HTN. Res #3's Medication Record for 01/2023 documented that on 01/09/23 at 8:00 a.m., Donepezil 10mg for vascular dementia, Loratadine 10mg for allergies, Multivitamin 1 tab for dietary supplement, Lasix 20mg for edema, Docusate Sodium 50mg for constipation, and Losartan 100mg-hydrochlorothiazide 12.5mg for HTN were not administered to the resident as ordered. Documentation in Res #3's progress notes, written 01/10/23, stated resident's representative and MD were informed Res #3 did not receive their prescribed medications the morning of 01/09/23. On 03/02/23 at 3:05 p.m., the DON was asked to review the EHR and verify if medications were administered to Res #2, Res #3, and Res #4 on 01/09/23 at 8:00 a.m. as ordered. The DON confirmed, according to documentation on the MAR, no medications were given for these residents at that time. The DON was asked if the medications should have been administered. They stated yes.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor and intervene when a resident had an abnormal blood pressure. Resident #1 had blood pressure readings of ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Resident #1' medical record revealed the blood pressure was not rechecked, the resident was not assessed, and the physician had not been notified of the blood pressure readings. Resident #1 had a [CONDITION(S)] on [DATE] which resulted in death on [DATE]. On [DATE] at 2:40 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 2:45 p.m., the DON and the regional director of operations were notified of the IJ situation related to the facility's failure to notify the physician when Resident #1's blood pressures were below normal and cardiac medications were held. The administrator was not present at the time of the initial notification. The administrator was notified of the IJ situation on [DATE] at 2:51 p.m. On [DATE] at 5:26 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Abatement Plan- Physician notification Ascension Living VCV Ponca City 21 [DATE] Failure to assess monitor and intervene/ Abatement Plan: 1. Corrective action for residents noted to have been affected by the deficient practice. Resident #1 expired on [DATE] no further follow up on identified resident. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? Other current residents residing in the community have the potential to be affected by the cited practice. Community review completed by the interdisciplinary team on [DATE] 16:21 to identify residents who may be experiencing a change in condition. No further residents identified as having a change in condition that did not have completed required assessments, documentation completion, and physician notification already in place or completed. 3. The measures the facility will take or systems the facilty will alter to ensure that the problem will be corrected and will not recur. Adhoc QAPI meeting was held with the interdisciplinary team on [DATE] at 16:00 where this IJ removal plan was developed and implemented. The Medical Director of the community was notified by the community's Executive Director on [DATE] at 16:43. Current licensed clinical associates and certified medication technicians will be re-educated by the DON and/or designee on [DATE] by 2359 or prior to next scheduled shift on community policy Change in Resident Condition or Status specific to assessment requirements for residents experiencing a change, follow up requirements after identification of change, documentation requirements, and physician notification. Education will also include assessment requirements prior to notifying the health care provider, the licensed nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form. Interdisciplinary team has reviewed the Change in Condition policy and procedure and it is in compliance with the CMS regulation requirements. Residents identified with antihypertensive/cardiac medication have been reviewed and administration parameters added per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Completion Date: [DATE] at 2359. On [DATE] interviews were conducted with the nurses and medication aides. The staff stated they had received in-service training related to changes in condition. The staff were able to identify what to do in the event a resident had a change in condition. The facility completed audits on all resident's medications and conditions to identify if the resident had a change in condition. Blood pressure parameters were put in place, staff were able to identify blood pressures which were considered out of the parameters. On [DATE] at 10:20 a.m., the DON and the regional director of operations was notified the immediacy was lifted effective [DATE] at 11:59 p.m. and the deficiency remained at a harm level. Based on record review and interview the facility failed to ensure a resident was assessed, monitored and interventions were put in place when the blood pressure was below normal for one (#1) of three sampled resident who were reviewed for death. Resident #1 expired in the emergency room after being found unresponsive in the facility. The Resident Census and Conditions of Residents report, documented 46 residents resided in the facility. Findings: Resident #1 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 to skilled level of care under services of physician #1. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A vital stats report, dated [DATE] at 8:00 a.m., documented Resident #1's vital signs as temperature: 98.7 degrees Fahrenheit, pulse: 63, respiratory rate: 20 breaths per minute, blood pressure: ,d+[DATE], and oxygen saturation: 93% on room air. A cardiovascular care plan, dated [DATE], read in parts, .has elevated blood pressure .blood pressure will remain stable .potential for fluid imbalance and activity intolerance related to CHF .[Resident #1] will not experience signs/symptoms of fluid overload .CARDIOVASCULAR DISEASE .has potential for complications .[Resident #1] will have no complications for cardiovascular disease and will not require outside medical intervention . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[Resident #1] has diseases and conditions which are treated with medications .Medication will be overseen and managed by the nursing and Physician team during the stay . A MAR, dated [DATE] through [DATE] documented [MEDICATION(S)] 20 mg was to be administered three times a day for pulmonary hypertension. The [MEDICATION(S)] was not administered six of 15 opportunities due to low blood pressure. A nurse's interdisciplinary note, dated [DATE] at 4:23 p.m., documented the CMA notified the LPN that Resident #1's blood pressure was ,d+[DATE] taken with an electronic blood pressure machine. The note documented the LPN rechecked the blood pressure with a manual cuff and the blood pressure reading was ,d+[DATE] and notified the medical director and were given orders for the staff to recheck Resident #1's blood pressure in two hours and report to the physician if the condition worsened send Resident #1 to the emergency room for evaluation and treatment. A nurse's interdisciplinary note, dated [DATE] at 5:49 p.m., documented Resident #1's blood pressure was retaken and was ,d+[DATE], resident denied pain, anxiety, shortness of breath, nausea, and vomiting. The note documented the medical director was notified and gave orders to recheck the blood pressure in two hours. A nurse's interdisciplinary note, dated [DATE] at 7:14 p.m., documented Resident #1's blood pressure was rechecked and was ,d+[DATE]. The note documented the medical director was notified and the physician stated to recheck Resident #1's blood pressure during the night and once in the morning. There was no documentation the attending physician for Resident #1 had been contacted prior to contacting the medical director. A Daily Skilled Care Nursing Evaluation, dated [DATE] at 12:35 a.m.,read in parts, .Increase in Heart Rate and/or Decrease in Systolic BP? .Physician notified? .Cyanosis? . The documentation revealed the questions were left blank by LPN #1 who performed the assessment. There was no documentation the blood pressure was checked throughout the night A MAR, dated [DATE] at 3:16 p.m., documented [MEDICATION(S)] 20 mg was held due to blood pressure reading of ,d+[DATE]. The MAR, read in part, .LPN notified, asked to hold this medication . A nurse's interdisciplinary note, dated [DATE] at 3:59 p.m., revealed LPN #3 assessed Resident #1's surgical site, cognition, speech, anticoagulant use, pain management, infection with antibiotic use, and IV therapy. The documentation did not address Resident #1's blood pressure, medication held, or notification to the physician and did not document Resident #1's blood pressure or other vital signs were rechecked. A Daily Skilled Care Nursing Evaluation, dated [DATE] at 1:27 a.m., read in parts, .Cardiovascular: Increase in Heart Rate and/or Decrease in Systolic BP? .Physician Notification? .Cyanosis? . The documentation revealed the questions were left blank by LPN #1 who performed the assessment. A MAR, dated [DATE] at 2:57 p.m., documented the [MEDICATION(S)] was held. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .LPN notified . There was no documentation Resident #1 was assessed or the blood pressure was rechecked at the time the blood pressure was reported as being low. A Daily Skilled Care Nursing Evaluation, dated [DATE] at 12:20 a.m.,read in parts, .Cardiovascular: .Heart Rate .Pedal Pulses .Increase in Heart Rate and/or Decrease in Systolic BP? .Cyanosis? . The documentation revealed the questions on the evaluation were left blank by RN #2 who performed the assessment. A vital stats report, dated [DATE] at 10:24 a.m., documented Resident #1's vital signs were temperature: 98.4 degrees Fahrenheit, pulse: 84, respiratory rate: 18 breaths per minute, blood pressure: ,d+[DATE], and oxygen saturation: 92% on oxygen. A 5-day MDS assessment, dated [DATE], documented Resident #1's cognition was intact, and required limited physical assistance for ADLs. The assessment documented the Resident was administered anticoagulants four days, was on oxygen, and had shortness of breath with exertion. The assessment documented Resident #1 planned to discharge to the community. A MAR, dated [DATE] at 2:51 p.m., documented the [MEDICATION(S)] was held. The MAR, read in part, .BP ,d+[DATE]. Medication held .LPN notified . There was no documentation Resident #1 was assessed or the blood pressure was rechecked at the time the blood pressure was reported as low. A Daily Skilled Care Nursing Evaluation, dated [DATE] at 2:11 a.m., read in parts, .Cardiovascular: .Pedal Pulses .Increase in Heart Rate and/or Decrease in Systolic BP? .Physician Notified? .Cyanosis? . The documentation revealed the questions on the evaluation were left blank by LPN #1 who performed the assessment. A MAR, dated [DATE] at 7:17 a.m., documented the [MEDICATION(S)] was held. The MAR, read in part, .b/p is to [sic] low ,d+[DATE] . There was no documentation Resident #1 was assessed or the blood pressure was rechecked at the time Resident #1's blood pressure was reported as low. PT Daily Treatment Note, dated [DATE], read in parts, .Assisted the pt [patient] with ble [bilateral lower extremity] ex [exercises] supine seated and standing .pt was not feeling well today and declined to ambulate today . A fire department report, dated [DATE], read in parts, .Arrive at patient and find patient in his recliner unresponsive with CPR and breathing for the patient with a BVM was in progress .Nursing home stated the [sic] found him unresponsive in the chair and still warm to the touch .EMS resumed CPR and moved the patient to a back board on the floor . The nurse's progress note, dated [DATE] at 5:28 a.m., read in parts, .[DATE] 2330 [11:30 p.m.] Notified by CNA that resident is unresponsive to verbal and tactile stimuli. This nurse went to assess resident. Resident sitting in recliner .Unable to auscultate heart tones or lung sounds. Called the nurse on nursing 1 to assist with CPR and EMS called. CPR initiated and continued until EMS arrived at 2335 [11:35 p.m.] .2355 [11:55 p.m.] EMS transferred to resident to ambulance. Resident left facility for .ER . An emergency department nurse's hospital report, dated [DATE], read in parts, .Arrival Date [DATE] Time: 00:06 [12:06 a.m.] .Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Presenting complaint: EMS states: pt found down at nursing home .Code Blue in Progress . A emergency department disposition summary, dated [DATE], read in parts, .Patient Expired .Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 4:02 p.m., LPN #3 was asked if they had called the physician when Resident #1's blood pressure was ,d+[DATE] on [DATE] at 3:16 p.m. LPN #3 stated, I should have. LPN #3 stated the physician stated to hold the medication and recheck Resident #1's blood pressure. LPN #3 was asked for documentation the blood pressure was rechecked and the physician had been notified. LPN #3 looked in the computer for documentation. LPN #3 stated they could not find the documentation in the computer to indicate the physician had been notified or the blood pressure had been rechecked. There was no documentation Resident #1's blood pressure had been rechecked. On [DATE] at 4:31 p.m., LPN #1 stated they did not recall being notified of Resident #1's blood pressure readings of ,d+[DATE] on [DATE] or [DATE] when the blood pressure reading was ,d+[DATE]. On [DATE] at 4:57 p.m., CMA #2 stated they notified the nurse working on that hall, when the blood pressure was low on [DATE] and [DATE]. CMA #2 stated the resident agreed to have the medication withheld. On [DATE] at 10:52 a.m., the medical director stated Resident #1 had not been admitted under their services. The medical director stated they had not had any phone calls or messages on [DATE], [DATE], or [DATE] from the nursing home. The medical director stated systolic blood pressure readings in the 70's and 80's would have warranted additional attention and monitoring or the need to send the Resident to the hospital On [DATE] at 11:37 a.m., PTA #1 stated on [DATE] Resident #1 was teary eyed was having a little trouble breathing. PTA #1 stated they knew Resident #1 had a lot of personal things going on at home. PTA #1 stated Resident #1 refused to ambulate, and wanted to do seated exercises on [DATE]. PTA #1 was asked if they had reported Resident #1's condition to the nurse. PTA #1 stated, I believe so. On [DATE] at 11:43 a.m., RN #1 was asked if they had rechecked Resident #1's blood pressure when they had documented Resident #1 was hypotensive on [DATE]. RN #1 stated they could not verify they rechecked Resident #1's blood pressure. RN #1 was asked if the physician had been notified when Resident #1's blood pressure was ,d+[DATE] on [DATE]. RN #1 stated they did not remember. They were asked if they documented in the resident's record when they notified the physician. RN #1 stated, I try to. RN #1 was asked if they had documentation they rechecked Resident #1's blood pressure and/or assessed Resident #1 on [DATE] at 7:17 a.m., after the blood pressure was ,d+[DATE]. They stated no. RN #1 was asked how Resident #1 was feeling on [DATE]. They stated Resident #1 was having a good day and was upbeat. No documentation was found or provided by the facility Resident #1's blood pressure had been rechecked and/or an assessment had been done. On [DATE] at 12:02 p.m., CMA #1 stated they had reported the blood pressure of ,d+[DATE] on [DATE] at 7:17 a.m. to RN #1. CMA #1 was asked about the blood pressure documented as too low on [DATE]. CMA #1 stated,I probably wrote it down and gave it to my nurse. CMA #1 stated if a blood pressure was low, they would go back and recheck it in thirty minutes. CMA #1 was asked for the documentation Resident #1's blood pressure was rechecked. CMA #1 was unable to provide documentation the blood pressure was rechecked. On [DATE] at 12:33 p.m., Physician #1 stated they had not been contacted about Resident #1's blood pressure readings and were not aware the medications had been held. Physician #1 stated they were not contacted about Resident #1's condition until the resident was sent to the hospital. Physician #1 stated if they had been made aware of Resident #1's blood pressure, they would have absolutely changed the treatment plan. Physician #1 stated they would have made a visit to evaluate Resident #1 or sent Resident #1 to the hospital. Physician #1 stated the staff should have called them about the low blood pressures because of Resident #1's high risk for cardiac complications. Physician #1 stated Resident #1 could have deteriorated quickly, Resident #1 had significant [CONDITION(S)] when they first started providing services to the resident. Physician #1 stated the resident had significant bleeding with the last surgery and had to have blood [CONDITION(S)]. On [DATE] at 8:23 a.m., Physician #1 stated they should have been contacted on [DATE] rather than the medical director concerning Resident #1's blood pressure readings. Physician #1 stated the staff knew they could call them anytime. Physician #1 stated they had come to see another one of their patients about six months ago and found the resident hypotensive and pale and sent the resident out to the hospital. The physician stated the facility staff had not recognized the resident's decline. Physician #1 stated if they had been notified of Resident #1's abnormal blood pressures, that would have triggered them to come see Resident #1 or send Resident #1 to the hospital due to Resident #1's medical history.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to notify the physician when a resident had an abnormal blood pressure and medication was held. Resident #1 had blood pressure readings of ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Resident #1' medical record revealed the physician was not notified when the resident's blood pressure was low and when the cardiac medication was held. Resident #1 had a [CONDITION(S)] on [DATE] which resulted in death on [DATE]. On [DATE] at 2:40 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 2:45 p.m., the DON and the regional director of operations were notified of the IJ situation related to the facility's failure to notify the physician when Resident #1's blood pressures were below normal and cardiac medications were held. The administrator was not present at the time of the initial notification. The administrator was notified of the IJ situation on [DATE] at 2:51 p.m. On [DATE] at 5:26 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Abatement Plan- Physician notification Ascension Living VCV Ponca City 21 [DATE] Physician Notification Abatement Plan: 1. Corrective action for residents noted to have been affected by the deficient practice. Resident #1 expired on [DATE] no further follow up on identified resident. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? Other current residents residing in the community have the potential to be affected by the cited practice. Community review completed by the interdisciplinary team on [DATE] 16:21 to identify residents who may be experiencing a change in condition. No further residents identified as having a change in condition that did not have completed required assessments, documentation completion, and physician notification already in place or completed. 3. The measures the facility will take or systems the facilty will alter to ensure that the problem will be corrected and will not recur. Adhoc QAPI meeting was held with the interdisciplinary team on [DATE] at 16:00 where this IJ removal plan was developed and implemented. The Medical Director of the community was notified by the community's Executive Director on [DATE] at 16:43. Current licensed clinical associates and certified medication technicians will be re-educated by the DON and/or designee on [DATE] by 2359 or prior to next scheduled shift on community policy Change in Resident Condition or Status specific to assessment requirements for residents experiencing a change, follow up requirements after identification of change, documentation requirements, and physician notification. Education will also include assessment requirements prior to notifying the health care provider, the licensed nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form. Interdisciplinary team has reviewed the Change in Condition policy and procedure and it is in compliance with the CMS regulation requirements. Residents identified with antihypertensive/cardiac medication have been reviewed and administration parameters added per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Completion Date: [DATE] at 2359. On [DATE] interviews were conducted with the nurses and medication aides. The staff stated they had received in-service training related to notifying the physician with change in conditions. The staff were able to identify when to contact to the physician. The audits of every residents medications and change in condition were reviewed. On [DATE] at 10:20 a.m., the DON and the regional director of operations was notified the immediacy was lifted effective [DATE] at 11:59 p.m. and the deficiency remained at a harm level. Based on record review and interview the facility failed to ensure the physician was notified when a resident's blood pressure was low on four days and failed to notify the physician when cardiac medications were held for one (#1) of one sampled resident who was reviewed for physician notification. Resident #1 expired in the emergency room after being found unresponsive in the facility. The Resident Census and Conditions of Residents, report documented 46 residents resided in the facility. Findings: The facility's policy for Change in a Resident's Condition or Status, dated ,d+[DATE], read in parts, .Our community shall promptly notify the resident, his or her health care provider .of changes in the resident's medical .condition .The nurse will notify the resident's Health care provider or physician on call when there has been a(an) .significant change in the resident's physical .condition .need to alter the resident's medical treatment significantly .need to transfer the resident to a hospital .specific instructions to notify the health care provider of changes in the resident's condition . The facility's policy for Medication Holds, dated ,d+[DATE], read in parts, .Temporary medication holds may be ordered by the resident's Health Care Provider .The Attending Physician must provide an explicit order as to when to restart a medication that has been held, either at the time the order is given to hold the medication or subsequently . Resident #1 was admitted on [DATE] had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 to skilled level of care under the care of physician #1. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A cardiovascular care plan, dated [DATE], read in parts, .has elevated blood pressure .blood pressure will remain stable .potential for fluid imbalance and activity intolerance related to CHF .[Resident #1] will not experience signs/symptoms of fluid overload .CARDIOVASCULAR DISEASE .has potential for complications .[Resident #1] will have no complications for cardiovascular disease and will not require outside medical intervention . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[Resident #1] has diseases and conditions which are treated with medications .Medication will be overseen and managed by the nursing and Physician team during the stay . A MAR, dated [DATE] through [DATE] documented [MEDICATION(S)] 20 mg was to be administered three times a day for pulmonary hypertension. The [MEDICATION(S)] was not administered six of 15 opportunities due to low blood pressure. The documentation revealed the physician had not been notified five of the six times the [MEDICATION(S)] had been held due to Resident #1's low blood pressure. A nurse's interdisciplinary note, dated [DATE] at 4:23 p.m., documented the CMA notified the LPN that Resident #1's blood pressure was ,d+[DATE] taken with an electronic blood pressure machine. The note documented the LPN rechecked the blood pressure with a manual cuff and the blood pressure reading was ,d+[DATE] and the medical director was notified and gave orders for the staff to retake Resident #1's blood pressure in two hours and report the reading to the physician if the condition worsened send the resident to the emergency room for evaluation and treatment. A nurse's interdisciplinary note, dated [DATE] at 5:49 p.m., documented Resident #1's blood pressure was retaken and was ,d+[DATE], resident denied pain, anxiety, shortness of breath, nausea, and vomiting. The note documented the medical director was notified and gave orders to recheck the blood pressure in two hours. A nurse's interdisciplinary note, dated [DATE] at 7:14 p.m., documented Resident #1's blood pressure was rechecked and was ,d+[DATE]. The note documented the medical director was notified and the physician stated to recheck Resident #1's blood pressure during the night and once in the morning. A Daily Skilled Care Nursing Evaluation, dated [DATE] at 12:35 a.m.,read in parts, .Increase in Heart Rate and/or Decrease in Systolic BP? .Physician notified? .Cyanosis? . The documentation revealed the questions were left blank by LPN #1 who performed the assessment. There was no documentation the blood pressure was checked through the night A nurse's interdisciplinary note, dated [DATE] at 7:03 a.m., documented Resident #1 was hypotensive today with a blood pressure of ,d+[DATE] was asymptomatic and had a heart rate of 60. There was no documentation the physician had been notified of the blood pressure reading. A MAR, dated [DATE] at 3:16 p.m., documented [MEDICATION(S)] 20 mg was held due to blood pressure reading of ,d+[DATE]. The MAR, read in part, .LPN notified, asked to hold this medication . A nurse's interdisciplinary note, dated [DATE] at 3:59 p.m., revealed LPN #3 assessed Resident #1's surgical site, cognition, speech, anticoagulant use, pain management, infection with antibiotic use, and IV therapy. The documentation did not address Resident #1's blood pressure, medication held, and/or notification to the physician. A Daily Skilled Care Nursing Evaluation, dated [DATE] at 1:27 a.m., read in parts, .Cardiovascular: Increase in Heart Rate and/or Decrease in Systolic BP? .Physician Notification? .Cyanosis? . The documentation revealed the questions were left blank by LPN #1 who performed the assessment. A MAR, dated [DATE] at 2:57 p.m., documented the [MEDICATION(S)] was held. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .LPN notified . A Daily Skilled Care Nursing Evaluation, dated [DATE] at 12:20 a.m.,read in parts, .Cardiovascular: .Heart Rate .Pedal Pulses .Increase in Heart Rate and/or Decrease in Systolic BP? .Cyanosis? . The documentation revealed the questions on the evaluation were left blank by RN #2 who performed the assessment. A MAR, dated [DATE] at 2:51 p.m., documented the [MEDICATION(S)] was held. The MAR, read in part, .BP ,d+[DATE]. Medication held .LPN notified . A 5-day MDS assessment, dated [DATE], documented Resident #1's cognition was intact, and required limited physical assistance for ADLs. The assessment documented the Resident was administered anticoagulants four days, was on oxygen, and had shortness of breath with exertion. The assessment documented Resident #1 planned to discharge to the community. A Daily Skilled Care Nursing Evaluation, dated [DATE] at 2:11 a.m., read in parts, .Cardiovascular: .Pedal Pulses .Increase in Heart Rate and/or Decrease in Systolic BP? .Physician Notified? .Cyanosis? . The documentation revealed the questions on the evaluation were left blank by LPN #1 who performed the assessment. A MAR, dated [DATE] at 7:17 a.m., documented the [MEDICATION(S)] was held. The MAR, read in part, .b/p is to [sic] low ,d+[DATE] . A fire department report, dated [DATE], read in parts, .Arrive at patient and find patient in his recliner unresponsive with CPR and breathing for the patient with a BVM was in progress .Nursing home stated the [sic] found him unresponsive in the chair and still warm to the touch .EMS resumed CPR and moved the patient to a back board on the floor . The nurse's progress note, dated [DATE] at 5:28 a.m., read in parts, .[DATE] 2330 [11:30 p.m.] Notified by CNA that resident is unresponsive to verbal and tactile stimuli. This nurse went to assess resident. Resident sitting in recliner .Unable to auscultate heart tones or lung sounds. Called the nurse on nursing 1 to assist with CPR and EMS called. CPR initiated and continued until EMS arrived at 2335 [11:35 p.m.] .2355 [11:55 p.m.] EMS transferred to resident to ambulance. Resident left facility for .ER . An emergency department nurse's hospital report, dated [DATE], read in parts, .Arrival Date [DATE] Time: 00:06 [12:06 a.m.] .Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Presenting complaint: EMS states: pt found down at nursing home .Code Blue in Progress . A emergency department disposition summary, dated [DATE], read in parts, .Patient Expired .Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:35 p.m., the DON stated if the staff held the blood pressure medication, the staff were supposed to notify the physician and document in the interdisciplinary notes. The DON was asked to provide the documentation of physician notification and Resident #1's vital signs. The DON provided all documentation the facility had of Resident #1's vital signs. There was no documentation the blood pressures were rechecked or the physician had been notified of the blood pressure readings on [DATE], [DATE], [DATE], or [DATE]. On [DATE] at 4:02 p.m., LPN #3 was asked if they had called the physician when Resident #1's blood pressure was ,d+[DATE]. LPN #3 stated, I should have. LPN #3 looked in the computer for documentation. LPN #3 stated they could not find the documentation in the computer to indicate the physician had been notified. There was no documentation the physician had been notified. On [DATE] at 4:31 p.m., LPN #1 was asked if they had notified the physician when Resident #1's blood pressure was ,d+[DATE] on [DATE] and when the blood pressure reading was ,d+[DATE] on [DATE]. LPN #1 stated they did not recall being notified of the blood pressure readings. On [DATE] at 4:57 p.m., CMA #2 stated they notified the LPN when the blood pressure was low on [DATE] and [DATE]. CMA #2 stated the resident agreed to have the pulmonary hypertension medication withheld. On [DATE] at 10:52 a.m., the medical director stated Resident #1 had not been admitted under their services. The medical director stated they had not had any phone calls or messages on [DATE], [DATE], or [DATE] from the nursing home. The medical director stated there were no text messages or emails concerning Resident #1 on [DATE]. The medical director stated they had a record of several phone calls from the nursing home on [DATE], but could not verify who the calls were concerning. The medical director stated a systolic blood pressure readings in the 70's and 80's would have warranted additional attention and monitoring or the need to send Resident #1 to the hospital. On [DATE] at 11:37 a.m., PTA #1 stated Resident #1 on [DATE] Resident #1 was teary eyed was having a little trouble breathing. PTA #1 stated they knew Resident #1 had a lot of personal things going on at home. PTA #1 stated Resident #1 refused to ambulate, and wanted to do seated exercises on [DATE]. On [DATE] at 11:43 a.m., RN #1 who had worked on [DATE] and [DATE], was asked if they had notified the physician when Resident #1 was hypotensive on [DATE]. RN #1 stated they did not document they had spoken to the physician about it. RN #1 was asked if the physician had been notified when Resident #1's blood pressure was ,d+[DATE] on [DATE]. RN #1 stated they did not remember. They were asked if they usually documented in the resident's record when they notified the physician. RN #1 stated they tried to. RN #1 was not able to provide documentation the physician had been notified. On [DATE] at 12:02 p.m., CMA #1 stated they had reported the blood pressure of ,d+[DATE] on [DATE] at 7:17 a.m. to RN #1. CMA #1 was asked about the blood pressure documented as too low on [DATE]. CMA #1 stated, I probably wrote it down and gave it to my nurse. CMA #1 stated if a blood pressure was low, they rechecked it in thirty minutes. CMA #1 was unable to provide documentation Resident #1's blood pressures had been rechecked. On [DATE] at 12:33 p.m., physician #1 stated they had not been contacted about Resident #1's blood pressure readings and were not aware the medications had been held. Physician #1 stated they were not contacted about Resident #1's condition until the resident was sent to the hospital. Physician #1 stated if they had been made aware of Resident #1's blood pressure, they would have absolutely changed the treatment plan. Physician #1 stated the staff should have called about the low blood pressures. The physician stated Resident #1 was at high risk for cardiac issues. On [DATE] at 8:23 a.m., Physician #1 stated they should have been contacted on [DATE] rather than the medical director concerning Resident #1's blood pressure. Physician #1 stated the staff knew they could call them anytime. Physician #1 stated if they had been notified of Resident #1's abnormal blood pressures, that would have triggered them to come see Resident #1 or send Resident #1 to the hospital due to Resident #1's cardiac history and history of bleeding after a previous surgery.

Based on record review and interview the facility failed to ensure staff performed CPR on a flat surface for one (#1) of one sampled resident who was reviewed for CPR. The Residents Census and Conditions of Residents report, documented 46 residents resided in the facility. Findings: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Resuscitation Level: CPR . A fire department report, dated [DATE], read in parts, .Arrive at patient and find patient in his recliner unresponsive with CPR and breathing for the patient with a BVM was in progress .Nursing home stated the [sic] found him unresponsive in the chair and still warm to the touch .EMS resumed CPR and moved the patient to a back board on the floor . The nurse's progress note, dated [DATE] at 5:28 a.m., read in parts, .[DATE] 2330 [11:30 p.m.] Notified by CNA that resident is unresponsive to verbal and tactile stimuli. This nurse went to assess resident. Resident sitting in recliner .Unable to auscultate heart tones or lung sounds. Called the nurse on nursing 1 to assist with CPR and EMS called. CPR initiated and continued until EMS arrived at 2335 [11:35 p.m.] . On [DATE] at 2:30 p.m., LPN #2 stated they had assisted LPN #1 with CPR for Resident #1 on [DATE]. LPN #2 stated they laid the recliner back all the way to perform the chest compressions. LPN #2 stated they did not put a back board under Resident #1. On [DATE] at 4:31 p.m., LPN #1 was asked how they performed CPR on Resident #1 on [DATE]. They stated Resident #1 was in the recliner and they laid the recliner back and performed CPR. LPN #1 was asked if they had put a back board under Resident #1. They stated they did not recall. On [DATE] at 8:25 a.m., the DON was asked if chest compressions performed during CPR would be effective if done on a soft surface. They stated no. The DON stated they were not aware the staff had not placed the back board under Resident #1. The DON stated the staff should have placed the back board under Resident #1 when they performed CPR.

Based on record review, observation, and interview the facility failed to provide supervision to prevent accidents for one (#2) of three sampled resident who were reviewed for choking hazards. The Resident Census and Conditions of Residents report documented 13 residents were on a mechanically altered diet. Findings: The facility's policy for assistance with meals, dated 11/2019, read in parts, .Meals are prepared by the Nutrition & Dining Service associates according to specific physician orders, and are served by Nursing .Residents who require assistance with eating should be .provided help as needed . Resident #2 had diagnoses which included unspecified dementia and dysphagia. A care plan for cognitive loss/dementia, dated 04/26/21, read in parts, .impaired ability to comprehend communication and impaired memory related dementia .Cue, reorient and supervise as needed . A care plan for ADL function for eating, dated 02/02/22, read in parts, .EATING: I need supervision assistance with set up staff support . A nurse's interdisciplinary note, dated 07/20/22 at 6:12 p.m., read in parts, Resident began choking at dinner table. Face became flush, no coughing or air passage heard. This nurse performed [MEDICATION(S)] maneuver .resident began coughing and color returned to his face. Blockage was dislodged. Orange saliva is noted coming from residents mouth. Resident had been eating cheetos prior to choking incident . A physician's order, dated 07/20/22, read in part, .DIET: Pureed diet- Resident to have pureed diet until speech therapy is able to perform an evaluation . A speech therapy evaluation, dated 07/26/22, read in parts, .TREATMENT DIAGNOSIS .Dysphagia, unspecified .Reason For Referral: Choking during meal time .Swallowing .Moderate/Severe (Able to complete 25% of task.) .Swallowing .Diet Level .pureed meats and vegetables .Rehab Potential: Fair .due to: Able to follow routines . An annual MDS assessment, dated 07/28/22, documented resident #2's cognition was severely impaired, required supervision and physical assistance of one person for eating. On 09/19/22 at 5:34 p.m., Resident #2 was observed with a pureed meal in the dining area. Resident #2's diet card documented the resident was on a pureed diet. Resident #2 was attempting to open a package of crackers with his teeth. At 5:35 p.m., CNA #1 assisted Resident #2 with opening the package of crackers. CNA #1 left the dining area. Resident #2 ate the cracker. No other staff members were in the dining area. LPN #3 was at the nurses's station assisting a resident with eating. On 09/19/22 at 5:43 p.m., LPN #3 observed the cracker package on Resident #2's tray. LPN #3 stated Resident #2 was on a pureed diet because they choked easily and the staff should not have given Resident #1 a cracker. On 09/19/22 at 5:44 p.m., CNA #1 stated they opened the cracker package and gave the cracker to Resident #2 because the resident was struggling to open the package. CNA #1 was asked if Resident #2 had swallowing problems. CNA #1 stated no. On 09/21/22 at 8:25 a.m., the DON stated the nurse should have been in the dining room with Resident #2 during the meal time. The DON stated Resident #2 was on a pureed diet and should not have been given a cracker. On 09/21/22 at 10:30 a.m., the SLP stated Resident #2 was not able to chew up their food small enough to safely swallow it without choking due to cognition. The SLP stated a cracker was not on a pureed diet and should not have been served to Resident #2. On 09/22/22 at 10:05 a.m., the DON was asked how the facility oriented the agency staff to the facility. The DON stated agency staff signed the agency orientation book indicating they reviewed the orientation book prior to working their first shift. The DON was asked how the agency staff knew what diet the residents' were prescribed. The DON stated the orientation book provided instructions on how to access Resident information. The DON was asked to provide documentation CNA #1 reviewed the orientation book. No documentation was provided CNA #1 reviewed the agency orientation book.

On 08/10/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have an effective infection control program to properly prevent and/or contain the spread of COVID-19. Staff members were not conducting COVID-19 screenings. Staff were not utilizing proper PPE when caring for COVID-19 positive residents and were not wearing face masks properly. COVID-19 positive resident rooms did not have the appropriate transmission based precautions signage and staff were not able to identify which residents were COVID-19 positive. COVID-19 testing was not conducted per facility policy and CDC/CMS guidance for staff and residents. The facility had no tracking of signs and symptoms of COVID-19 to ensure proper isolation timeframes. This resulted in 31 residents testing positive for COVID-19 from 07/20/22 to 08/08/22. On 08/10/22, the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 7:15 p.m., the director of nursing was notified of the IJ situation. On 08/11/22 at 2:44 p.m., an acceptable plan of removal was provided. The plan of removal documented: Immediate Jeopardy Removal Plan: 1. How will the facility identify other residents having the potential to be affected by the same deficient practice? Current residents with Covid-19 will have signs and symptoms logged to determine isolation time frames on 8/11/22 by Infection Preventionist or designee. Other current residents at risk for Covid-19 will be reviewed for signs and symptoms of Covid-19 on 8/10/2022 by DON or designee. 2. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. Current clinical associates will be re-educated by the DON or designee on infection prevention and control as it relates to all infectious disease to include COVID-19, proper use and wear of personal protective equipment that includes goggles/face shields, transmission-based precautions including Donning and Doffing of PPE for COVID-19 positive resident care, signage for COVID-19 positive residents, and isolation time frames, identification of resident ' s and associate ' s COVID-19 status per the community ' s policy and CDC guidelines, and on the infection prevention screening and testing process on 8/11/2022 or prior to working their next shift. For staff that are unavailable for onsite education currently, education and competencies to be completed prior to the next scheduled shift. Infection Preventionist will be educated as to the duties and responsibilities of the Infection Preventionist to include a surveillance plan to identify early signs and symptoms of Covid-19, track signs and symptoms of Covid-19 for positive staff and residents to determine isolation time frames and that the community ' s COVID-19 testing process and frequency is conducted per the community ' s Covid-19 testing policy and CDC guidance on 8/11/2022 by the Ascension Living Director of Infection Prevention and Quality. Current residents and associates were tested for Covid-19 on 8/11/22 and next scheduled testing will be 8/15/22. Interdisciplinary team has reviewed the community's Infection Prevention and Control Program and the Covid -19 Testing policy and procedure on 8/10/2022 and it is in compliance with the CMS regulation F880. Community ' s Infection Preventionist will complete daily infection prevention surveillance daily and share this with the IDT during Clinical Huddle. The interdisciplinary team will complete high reliability infection control rounding daily for observations of associate ' s PPE use, associate screening and transmission based precautions with signage and results discussed at Clinical Huddle. Residents with new and continued infections or change of condition will be reviewed by the Interdisciplinary Team during the daily clinical meeting for compliance of infection prevention assessments, precautions and interventions by 8/10/22. Next review to be completed by 8/12/22. During weekly Resident at Risk meetings, the interdisciplinary Team will review the clinical record of residents with new and continued infections or change of conditions. The review will be documented in the Resident ' s clinical record by 8/10/22. New review to be completed by 8/12/22. 3. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. Monthly review of completed the interdisciplinary team high reliability infection control rounding, associate screening, testing and infection surveillance results and trends will be completed by the DON or designee and reported to the facility ' s QAPI Committee for the next 3 months and then re-evaluated to determine if further monitoring is indicated. 4. Completion Date:8/11/2022 On 08/13/22 at 3:00 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a potential for harm. On 08/15/22, interviews were conducted with nursing, housekeeping, laundry and dietary staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on record review, observation, and interview, the facility failed to properly prevent and/or contain COVID-19 by not ensuring the following: a. staff screenings were completed and monitored for five sampled staff from 07/01/22 to 08/08/22, b. appropriate PPE was utilized by direct care staff for COVID-19 positive residents, goggles/face shields were not utilized, one staff wore a surgical mask below her nose when caring for a COVID-19 positive resident, c. COVID-19 testing was completed per facility policy and CDC guidance in and out of out-break status for all staff and all residents, d. a surveillance plan was in place to identify early signs and symptoms of COVID-19, and to track signs and symptoms of COVID-19 for positive staff and residents to ensure appropriate isolation time frames, e. all staff were able to identify positive COVID-19 residents, and f. appropriate transmission based precautions with signage were implemented for COVID-19 positive residents, to include the use of gloves, goggles/face shields, and N95 masks. The Resident Census and Conditions of Residents report, dated 08/09/22, documented 54 residents resided in the facility. The DON identified 31 residents were currently COVID-19 positive. Findings: The CDC guidance titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated Feb. 2, 2022, read in part, .Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as [CONDITION(S)]-CoV-2 .A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP) .Even as nursing homes resume normal practices, they must sustain core IPC practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death .Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a [CONDITION(S)] test as soon as possible . A COVID-19 Testing policy, last approved 03/2022, read in part, .Testing will be implemented in addition to recommended Infection Prevention and Control measures and includes testing: * symptomatic residents and associates/staff, * asymptomatic residents and associates/staff as part of the COVID-19 outbreak response, * asymptomatic associates/staff without COVID-19 outbreak as required by CMS recommendations, and * residents and associates/staff who had close contact to persons with COVID-19 . Routine testing .routine associate/staff testing is based on the facility's county level of community transmission rate and vaccination status of associates . A COVID-19 Infection and Prevention guidelines, last approved 06/2022, read in part, .The primary mode of transmission is person-to-person through the droplet transmission route, however airborne transmission is a potential route . Screening .Each associate/contract provider is screened upon entry to the community .Department leader or designee monitors screening reports each shift .Screen includes symptoms screening, recent exposure to person with COVID-19 question, and temperatures .Associates with positive screens are not able to work and are reported to community leaders .for tracking . Universal Masking .used to prevent transmission from asymptomatic or presymptomatic residents and HCP .Keep well fitting mask on at all times, covering the nose and mouth Universal masking is practiced because there are people who are infected with COVID-19 who do not have symptoms .The residents we serve live in a communal environment, the highest risk comes from associates and visitors entering the community . Initiation of Precautions .COVID positive .Droplet and Contact Precautions + Eye Protection upon entry to the community . The facility's undated, untitled, spread sheet, documented the previous IP tested positive for COVID-19 on 06/30/22. This would have caused the facility to start outbreak testing and procedures. An Infection Prevention and Control Program policy, last approved 07/2022, read in part, .The elements of the IPCP consist of coordination/oversight, policies/procedures, surveillance, data analysis .outbreak management, prevention of infection, education .The IPCP is designed .to help prevent the development and transmission of communicable diseases and infections .coordinated and overseen by the Infection Preventionist .Signs and symptoms of suspected infections are entered into a surveillance tool upon identification .The Infection Preventionist .reviews initiated surveillance tool to identify .Health-care Acquired Infections .Potential Outbreaks .Reportable Infections . Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring associate infections .Monitoring for similar symptoms among residents and associates .Data gathered during surveillance is used to identify infections and trends . Facility Outbreak Management .Symptomatic residents and associates are to be considered potentially infected and will be assessed for appropriate actions .An outbreak is the occurrence of more cases/condition that expected in a given area .Outbreak management is a process that consists of: a. Determining the presence of an outbreak; b. Managing the impacted residents and associates; c. Preventing the spread to other residents and associates . f. Educating associates and visitors . Education .Infection control training topics will include .Transmission-Based Precautions . The facility's undated, untitled, spread sheet, documented the previous IP tested positive for COVID-19 on 06/30/22. This would have caused the facility to start outbreak testing and procedures. CMA #1's July 2022 time card documented they worked: 2nd through the 5th and 11th through 14th. There was no documentation CMA #1 had been tested . There was no documentation CMA #1 screened in prior to shifts. CNA #2's July 2022 time card documented they worked: 1st through 3rd, 6th through 10th, and 12th through 13th. There was no documentation CNA #2 had been tested . There was no documentation CNA #2 screened in prior to shifts. CNA #4's July 2022 time card documented they worked: 6th, 8th through 12th, and 14th. There was no documentation CNA #4 had been tested . There was no documentation CNA #4 screened in prior to shifts. CNA #3's July 2022, time card documented they worked: 2nd through 4th, 6th through 8th, and 13th. There was no documentation CNA #3 had been tested . There was no documentation CNA #3 screened in prior to shifts. RN #1's July 2022 time card documented they worked: 2nd through 3rd, and 9th through 10th. There was no documentation RN #1 had been tested . There was no documentation RN #1 screened in prior to shifts. CMA #1's July 2022 time card documented they worked: 16th through 19th. There was no documentation CMA #1 screened in prior to shifts. CNA #2's July 2022 time card documented they worked: 15th through 16th, and 18th through 19th. There was no documentation CNA #2 screened in prior to shifts. CNA #4's July 2022 time card documented they worked: 18th through 20th. There was no documentation CNA #4 screened in prior to shifts. CNA #3's July 2022, time card documented they worked: 16th through 18th, and 20th. There was no documentation CNA #3 screened in prior to shifts. RN #1's July 2022 time card documented they worked: 16th through 17th. There was no documentation RN #1 screened in prior to shifts. The facility's undated, untitled, spread sheet, documented Resident #12 tested positive for COVID-19 on 07/20/22. This would have caused the facility to restart outbreak testing and procedures. CMA #1's July 2022 time card documented they worked: 21st through 22nd, 25th through 28th, and 30th through 31st. There was no documentation CMA #1 screened in prior to shifts. CMA #1 tested positive for COVID-19 on 08/01/22. CNA #2's July 2022 time card documented they worked: 22nd, 29th through 30th. There was no documentation CNA #2 had been tested . There was no documentation CNA #2 screened in prior to shifts. CNA #4's July 2022 time card documented they worked: 22nd through 24th, and 28th through 29th. There was no documentation CNA #4 screened in prior to shifts. CNA #3's July 2022, time card documented they worked: 21st through 22nd, 25th through 28th, and 30th through 31st. There was no documentation CNA #3 screened in prior to shifts. RN #1's July 2022 time card documented they worked 23rd. RN #1 tested positive for COVID-19 on 07/23/22. RN #1's July time card documented they worked 30th through 31st. There was no documentation RN #1 screened in prior to shifts. Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .[Resident #1] has no chest discomfort .does have a little sore throat. There was no documentation the resident had been tested for COVID-19 immediately following the outbreak or when they became symptomatic. They tested positive for COVID-19 on 08/01/22. Resident #2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Covid test performed with negative result . The test had not been conducted until 10 days after the outbreak began. Testing should have been conducted initially and again within seven days after the outbreak began on 07/20/22. Resident #4 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The test had not been conducted until 10 days after the outbreak began. Testing should have been conducted initially and again within seven days after the outbreak began on 07/20/22. CNA #2's August 2022 time card documented they worked 4th through 6th. There was no documentation CNA #2 screened in prior to shifts. CNA #4's August 2022 time card documented they worked 1st through 4th and 7th. There was no documentation CNA #4 screened in prior to shifts. CNA #4 tested positive for COVID-19 on 08/08/22. RN #1's August 2022 time card documented they worked 2nd, 6th, and 7th. There was no documentation RN#1 screened in prior to shifts. On 08/09/22 at 10:00 a.m., a plastic three drawer chest was observed outside Resident #21's room. The drawer contained gowns and hair covers. There was no signage on the resident's door to inform staff of the need for TBP. CNA #7 was asked if the resident #21 was COVID positive. They stated, I'm not sure, I'm agency. They were observed to ask another staff member who informed them the resident was COVID positive. Resident #5 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A precaution sign was observed on the dresser and was blocked by a box of gloves. CNA #1 was asked if the resident was on isolation precautions. CNA #1 stated they hadn't worked in a couple of days and didn't know. Resident #9 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The drawer contained gowns and gloves There was no signage on the resident's door to indicate TBP. The activity director was observed in the resident's room and had donned a gown, gloves, and an N95 mask. She was not observed wearing goggles or a face shield. The activity director confirmed the resident was COVID positive. Resident #6 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no sign observed on the dresser. Resident #7 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The sign observed on top of the dresser documented standard, airborne and contact isolation. It documented to clean hands and use gowns, N95 or PAPR, gloves, and hand sanitizer. It didn't indicate to wear eye protection. Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The drawer contained gowns, gloves and red biohazard bags. There was a sign on the door that documented airborne and contact precautions. The sign did not document to use goggles/face shields. Resident #1 was asked if the staff utilized gowns, gloves, masks and goggles/face shields. They stated, I haven't noticed the eye things. Resident #4 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #1 and CNA #2 was observed to come out of the shower room on the unit. They were observed pushing Resident #4 in the wheelchair from the shower room. Both CNA's were only wearing KN95 masks. They were not wearing eye protection. Resident #4 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . They were not wearing eye protection. Resident #4 was observed coughing when CNA #2 went in the room. A three drawer plastic dresser with PPE was observed outside Resident #4's room. The sign observed on top of the dresser documented standard, airborne and contact isolation. It documented to clean hands and use gowns, N95 or PAPR, gloves, and hand sanitizer. The sign did not indicate to wear eye protection. Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #2 had a gown and KN95 mask on. They were not wearing eye protection or gloves. On 08/09/22 at 10:23 a.m., LPN #1 was observed to walk onto the COVID-19 positive unit. They were wearing a KN95 mask. They donned on a gown and gloves and walked into Resident #2's room to assist the resident. LPN #1 was not observed to wear eye protection. Resident #16 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #2 was observed wearing gown, gloves, and KN95 mask. CNA #2 was not wearing eye protection. The three drawer plastic dresser with PPE was observed outside the room. Goggles were observed sitting on top of the dresser. On 08/09/22 at 10:32 a.m., CNA #2 was asked what PPE was worn when taking care of COVID-19 positive residents. They stated gown, gloves, and mask. CNA #2 was asked if they wore eye protection. They shook their head no. CNA #2 stated they don't wear the PPE except for the mask because they don't have time to apply it. They stated they had too many high fall risk residents to attend to. Resident #20 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #3 was observed to be inside the resident's room with their surgical face mask below their nose, a gown, gloves, and had no goggles/faceshield on. On 08/09/22 at 10:50 a.m., the interim ADON/IP provided a binder with staff COVID testing results. They stated staff had not been compliant with testing when the ADON/IP first came to work here on 07/26/22. They stated now if staff don't test, they can't work. On 08/09/22 at 12:33 p.m., CMA #1 was asked when the COVID outbreak had started. They stated about two weeks ago. They were asked what the facility had done after the outbreak started. They stated they started testing all the residents and then the staff. They stated they personally started having symptoms of allergies or a head cold on 07/30/22. They stated they tested positive two days later. The CMA's time record for July 2022 documented the CMA worked July 30th and July 31st, 2022. CMA #1 worked for two days with symptoms consistent with COVID-19. On 08/09/22 at 1:27 p.m., housekeeper #1 was observed exiting resident #9's room with a mop, removed a washable mop head and placed it in a clear trash bag tied to the housekeeping cart, then doffed gown and gloves outside of the room and placed them in the housekeeping cart trash. The housekeeper was utilizing goggles and a KN95. On 08/09/22 at 1:37 p.m., housekeeper #1 was observed exiting Resident #20's room and placed a bag of trash in the housekeeping cart trash. The housekeeper was observed to exit the room at 1:41 p.m. and doffed the gown and gloves outside the room and placed them in the housekeeping cart trash. On 08/09/22 at 1:37 p.m., LPN #2 was observed to don a gown, gloves and hairnet and entered Resident #20's room. Resident #20 had been identified as COVID-19 positive. LPN #2 had on a surgical mask. They did not utilize goggles or a face shield. On 08/09/22 at 1:40 p.m., CNA #3 was observed to don a gown and gloves and entered Resident #9's room. Resident #9 had been identified as COVID-19 positive. The CNA had on a surgical mask. They did not utilize goggles or a face shield. On 08/09/22 at 1:45 p.m., housekeeper #1 was observed to don gown and gloves and entered Resident #1's room. Resident #1 had been identified as COVID-19 positive. They were observed to bring a toilet bowl brush out of the room and placed it on the housekeeping cart. They were observed to place a washable mop head onto the mop and took it into the room. They were observed to exit the room with the mop, removed the washable mop head and placed it in a clear trash bag tied to the housekeeping cart. At 1:50 p.m., the housekeeper was observed exiting the room and doffed the gown and gloves and placed them in the housekeeping cart trash. On 08/09/22 at 1:45 p.m., LPN #2 and CNA #3 were observed to don gowns and gloves and entered Resident #20's room. LPN #2 had a KN95 on and CNA #3 had on a surgical mask. They did not utilize goggles or face shields. At 1:57 p.m., LPN #2 was observed to open the door and exit the room. CNA #3 was observed in the resident's room with their surgical mask below their nose. They were observed to exit the room. Resident #13 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A precaution sign was observed on the outside of the resident's room. The sign observed documented standard, airborne and contact isolation. It documented to clean hands and use gowns, N95 or PAPR, gloves, and hand sanitizer. On 08/11/22 at 9:40 a.m., the interim ADON/IP stated Resident #13 had tested positive for COVID-19. Resident #15 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A precaution sign was observed on the outside of the resident's room. The sign observed documented standard, airborne and contact isolation. It documented to clean hands and use gowns, N95 or PAPR, gloves, and hand sanitizer. Resident #17 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no sign observed on the dresser. On 08/09/22 at 1:55 p.m., CNA #1 was observed going in to Resident #18's room on North 1 side hall. They were asked what residents were COVID-19 positive on this hall. They stated they thought Resident #7, #17, and #19. CNA #1 was asked how residents were identified as being positive. They stated they usually received report about the hall they were working. They stated they weren't scheduled down on this hall today so they weren't completely sure who was positive. CNA #1 was asked what PPE was used for COVID-19 positive residents. They stated gown, gloves, mask, and goggles. They stated their goggles were currently in their vehicle. On 08/09/22 at 2:10 p.m., LPN #2 was observed in the resident living area with their mask below their chin. There were residents in the living area. On 08/09/22 at 2:11 p.m., housekeeper #1 was observed again in Resident #20's room. They had on appropriate PPE. They were observed to bring a toilet bowl brush out of the room and placed it on the housekeeping cart. They were observed to place a washable mop head onto the mop and took it into the room. They were observed to exit the room with the mop, removed the washable mop head and placed it in a clear trash bag tied to the housekeeping cart. They were observed to doff gown and gloves and placed them in trash on housekeeping cart. At 2:17 p.m., the housekeeper was asked what they did with the washable mop heads after they were used. They stated they tied them up and took them to the housekeeping room. The housekeeping room was observed to have five or six clear bags on the floor with soiled mop heads and rags in them. They stated at the end of the shift, they took them to the laundry. On 08/10/22 at 8:20 a.m., a staff member was observed standing with the door to the COVID positive hall open. They were observed without goggles or a face shield. On 08/10/22 at 8:35 a.m., CNA #3 was asked how frequently staff were tested for COVID-19. They stated, Recently, it became two times a week. They were asked if PPE was always available. They stated, Yes. They were asked how often they screened. They stated they used a kiosk and they screened daily. They stated they didn't know until today the screens were to be conducted every day. CNA #3 was asked if they had been screening daily prior to today. They stated, No. CNA #3 was asked when the COVID outbreak had started. They stated they had a few cases here and there, but when the DON went on vacation it spread to staff and residents. They were asked what they did in response. They stated, [ADON/IP] told us to gown up and keep [the residents] isolated in their rooms. They stated when the DON returned, they moved positive residents to halls one and two until they were full. CNA #3 was asked if they took care of both COVID positive and negative residents on the hall. They stated they did. They were asked what PPE they had been instructed to utilize in COVID positive rooms. They stated an N95, yellow gowns and gloves. They stated they swapped out masks. They stated they put an N95 on when going in a COVID positive room. The CNA was asked if they had been instructed to use goggles or face shield. They stated it had been mentioned, but had not been made mandatory. They were asked how they were instructed to wear a face mask. The stated, They tell you to keep it up past your nose. They were asked about the observations made of them with their mask below their nose. They stated, Just me breathing. They stated there was no designated staff and they think that was the reason for all the positives. They stated, That's airborne and I'm afraid I'm taking it into the other rooms. On 08/10/22 at 2:18 p.m., CNA #3 was observed on skilled hall with their face mask below their nose. On 08/10/22 at 4:08 p.m., the DON was asked how the residents' COVID-19 vaccination was tracked. They stated the previous IP had a spread sheet but they weren't sure if it has been kept updated. The previous IP's last day was 06/30/22. The DON identified they were the IP overseeing the infection control program after the previous IP left, on 06/30/22, and before the interim ADON started on 07/26/22. On 08/10/22 at 4:10 p.m., the DON was asked how staff identified COVID-19 positive residents. They stated by the signs and they have an updated list they receive at the beginning of their shift. They stated signs are on the doors of COVID-19 positive and PUI residents. The DON was informed of staff unaware how to identify COVID-19 positive residents from other residents, and staff were unable to tell if a resident was under isolation. The DON stated the CNA should have received report on who was positive and who wasn't. The DON was asked how the facility ensured staff were able to identify COVID-19 positive residents. They stated they utilized signs, walking rounds, and education. The DON was asked when the last time education had been provided. They stated they provided some yesterday and today. They were asked when was the last time prior to survey. They stated they would have to look. Education completed prior to survey was not provided. The DON was asked what PPE was to be worn for COVID-19 positive residents. They stated gown, gloves, KN95 and goggles. They were asked if staff wore goggles yesterday, 08/09/22. They stated a couple had them on. They were asked why all staff were wearing goggles today. They stated, It was suggested staff wore them. The DON was asked if there was a shortage of PPE, including face shields/goggles. They shook their head no. The DON was asked why the precaution signs didn't indicate to wear eye protection. They stated the signs were made when they were gone, sometime between 07/26/22 to 08/05/22. The DON was asked if staff should wear eye protection when taking care of COVID-19 positive residents. They stated, Yes. The DON was asked how long the isolation period was for COVID-19 positive staff and residents. They stated 10 days for the residents. They stated the staff were isolated for five days and then could return to work on day six. The DON stated the facility was in crisis staffing. They stated that indicated COVID-19 positive staff could work with COVID-19 positive residents. They were asked, with COVID-19 positive resident on all halls, how would facility be staffed. They stated, I haven't used it yet. The DON was asked how COVID-19 staff and residents were monitored for symptoms. They stated they checked on them daily but did not document. They were asked if symptoms were tracked. They stated they would ask the interim ADON/IP. The DON was asked when a resident should be tested for COVID-19. They stated, If they have signs and symptoms. They were asked if a resident should been tested if they had a sore throat. They stated, I would. They were asked who should be tested in an outbreak. They stated all staff and residents. There was no COVID-19 symptom tracking provided to ensure staff and residents isolation period could end per guidelines. The DON was asked how the facility was monitoring staff screenings. They stated corporate was able to pul [TRUNCATED]

Based on interview and record review, the facility failed to ensure the rights of residents to receive visitors for one ( #1) of three residents reviewed for visitation. The ADON identified 52 residents resided in the facility. Findings: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An Admission Assessment, dated 09/06/21, read in part, the resident's cognition was intact and they required a walker for mobility. A care plan, read in part, the resident was at risk for isolation related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A nursing note, dated 09/17/21, read in part, Pt has been dc'd from the COVID unit et moved to room (# withheld) . On 09/30/21 at 11:40 a.m., resident #1 was asked if she had received visitors. She stated she had been COVID positive but had Face-timed with her grandchildren and great grandchildren. She stated her family had come to the window for window visits and that she used her cell phone to call them when she wanted to talk with them. She had received no indoor visitation. Staff interviewed stated the residents had been able to have outdoor visitation and window visits. Most residents were able to communicate on cell phones with their families. Compassionate care visits had been allowed, but no visitation was allowed at meal times. They stated the facility had just re-opened on 09/29/21 for indoor visitation. The facility's COVID+ Log, documented the facility's last COVID positive resident tested positive on 09/02/21 with the results received 09/05/21. On 09/07/21, per the ADON, all residents and staff tested negative. The positive residents had been placed on the COVID unit away from all other residents. Based on the negative test results for all other residents, visitation could have resumed on 09/08/21. A letter sent to family members, titled Visitation Guidelines for Nursing, Memory Support, & Assisted Living Updated September 29, 2021, read in part, We are now able to facilitate indoor visits as long as all participants are wearing face masks and maintaining a physical distance of at least six feet .General Guidelines for All Visitation .Visitation times (seven days a week): 9:00 AM - 11:00 AM, 1:00 PM - 3:00 PM, 6:00 PM - 8:00 PM, No Visitation during mealtimes . The ADON was asked the date of the last COVID positive resident, she stated four residents received positive results on 09/05/21. The facility locked down for outbreak testing which began on 09/07/21. She stated they were required to wait 14 days with no negative test results before visitation could begin. She stated the official re-opening date for visitation was 09/29/21. Based on the dates provided, a 14 day window would have had visitation resuming on 09/21/21. The facility failed to re-open officially for visitation until 09/29/21. At 1:30 p.m., the ADON was made aware of guidelines last updated 08/02/21, by the Centers for Medicare and Medicaid Services which read in part, if the first round of testing reveals no positive cases, visitation can resume in areas with no COVID cases. She reiterated the facility's corporate guidance was they must do outbreak testing until they had no positive cases for 14 days.

Based on observation, interview, and record review, it was determined the facility failed to ensure staff was competent and possessed the necessary skills to provide care for a resident who was left unsupervised resulting in a fall with severe injuries for one (#1) of four residents reviewed for nursing services. The facility reported 48 residents resided in the facility. Findings: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated, 01/15/2020, documented, Problem: The resident has memory problems, impaired decision making skills and impaired ability to comprehend. Goal: The resident will have basic needs met daily. Intervention .(3) Provide cues to promote independence and ensure safety .(5) Anticipate needs and observe for nonverbal cues. (6) Assess my decisions to ensure my safety . Problem: The resident needs assistance with daily ADL care. Goal: The resident will have daily ADL care needs met. Intervention .(14) I need extensive assistance with transfers. I need 1 person staff support with transfer .(15) I need extensive assistance x1 staff with locomotion when ambulating with a walker .(24) I need extensive assistance with toileting. I need 1 person staff support with toileting. Problem: The resident has potential for falls related to confusion. Goal: Resident will have no major injuries from a fall. Intervention: (1) Increase supervision with toileting and transferring during night hours. Offer toileting before leaving resident's room .(6) Monitor resident more frequently to anticipate basic needs . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ~ [MEDICATION(S)] 25 mg tablet - 1 tab by mouth twice daily for A-fib, ~ [MEDICATION(S)] 5 mg tablet - 1 tab by mouth twice daily for A-fib, ~ [MEDICATION(S)] 100 mg tablet - 1 by mouth every day for depressive disorder, ~ [MEDICATION(S)] 7.5 mg-acetaminophen 325 mg 1 tab by mouth every 6 hours for chronic pain, ~ [MEDICATION(S)] 7.5 mg-325 mg 1 tab by mouth every 6 hours as needed for breakthrough pain relief measures. ~ [MEDICATION(S)] 20 mg 1 tab by mouth twice daily for heart failure. ~ [MEDICATION(S)] 62.5 mcg/hour transdermal patch, apply 1 patch transdermal every 72 hours for pain. A comprehensive assessment, dated 01/22/21, documented the resident's cognition was moderately impaired, she required staff assistance for all ADLs, was frequently incontinent of bladder but continent of bowel. The resident required one person assist for toileting, used a walker or wheelchair for mobility. The resident received, an antidepressant, anticoagulant, a diuretic, routine and PRN pain medications. An Oklahoma State Department of Health incident report form, dated 06/23/21, documented, .Certain Injuries . Part B: 81 yo female fall in private room, resulting in injury & sent to emergency room , Initial ER reports indicate Acute fx of the distal radius and ulnar styloid of the right wrist; Acute fx of the anterior right maxillary wall & inferior orbital floor. Right periorbital soft tissue hematoma; Hemorrhage in the maxillary atrium. Small acute subdural hematoma along the right frontal lobe 1 mm in thickness. admitted to the hospital for observation at this time. Part C: 06/26/21: [Name withheld] was assisted by a newly hired CNA, who may require additional training to the POC, a tool for CNAs showing care plan interventions for residents. CNAs are required to review the POC at the beginning of a shift. POC indicates do not leave unattended in the bathroom. The charge nurse was aware of precaution and immediately went to [name withheld] room when she realized the resident had been left alone. [Name withheld] was already standing up and the nurse was unable to reach her before the fall occurred . The CNA caring for this resident was from an agency and not a regular staff member. On 07/22/21 at 8:42 a.m., CMA #1 was asked where resident's care plans were located. She stated they were in the electronic health record and there was a care plan book kept at the nurse's station. CMA #1 was asked if she was relieved by an agency staff member, what procedure was followed. She stated, We give step by step instructions on each resident. We sit with them at the computer and show them how to access the resident's chart and care plan. We tell them if they don't understand something to get help from the charge nurse. CMA #1 was asked who was responsible for ensuring agency staff was familiar with the residents and their needs, or plans of care. She stated, when they arrive we introduce them to the charge nurse and we walk the floor with them going from room to room and talk about each resident, making sure we highlight any special instructions for that resident. At 8:51 a.m., LPN #1 was asked where care plans were located. He stated, for nurses they are on the computer, but there is also a care plan book at the nurse's station. LPN #1 was asked if he was giving report to an agency staff member, how he ensured the nurse reviewed the care plans. He stated he sat down with them, showed them the care plans and went through each resident assigned to them one by one. At 10:22 a.m., the DON was asked who was responsible for ensuring agency staff were oriented and reviewed resident care plans. She stated the facility had an orientation manual. The charge nurses showed the notebook to the agency staff member, sat down with them and went through it before they took the floor. She was asked if the agency staff came to the facility for a specific orientation or when were they oriented to the facility, the notebook and the residents. She stated generally the day they came to work in the facility. The DON was asked, shift to shift, how the facility ensured agency staff were aware of special instructions or interventions, such as special hydration or fall risks, for certain residents. She stated that was the responsibility of the off-going shift. They were to give verbal report and special instructions to the on-coming staff. She stated if the agency staff did not know where to get patient information the staff were to instruct them. The DON acknowledged, based on the incident report submitted to the Oklahoma State Department of Health, the CNA did not receive education on the special instructions, located on the plan of care, which resulted in the resident's fall with injuries.

Based on record review and staff interview, it was determined the facility failed to ensure physicians' orders were obtained to conduct COVID-19 testing for two (#1 and #2) of three sampled residents reviewed for infection control related to COVID-19. The facility identified 54 residents who resided in the facility. Findings: The CDC (Centers for Disease Control and Prevention) guidance titled, Symptoms of Coronavirus, dated 05/13/20, documented: People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness .People with these symptoms may have COVID-19: .Fever or chills .Cough .Shortness of breath or difficulty breathing .Fatigue .Muscle or body aches .Headache .New loss of taste or smell .Sore throat .Congestion or runny nose .Nausea or vomiting .Diarrhea . Influenza (Flu) and COVID-19 are both contagious respiratory illnesses, but they are caused by [MEDICAL CONDITION] .Because some of the symptoms of flu and COVID-19 are similar, it may be hard to tell the difference between them based on symptoms alone, and testing may be needed to help confirm a diagnosis . Resident #1 had COVID-19 testing conducted on 11/17, 11/23, 11/30, 12/04 and 12/10/20 due to the facility being in an outbreak. There were no physician's orders to conduct the tests. Resident #2 had COVID-19 testing conducted on 10/05, 10/08, 10/12, 10/22, 10/27, 11/02, 11/17, 11/23, 1130, and 12/03/20 due to the facility being in an outbreak. There were no physician's orders to conduct the tests. On 12/11/20 at 1:50 p.m, the infection preventionist (IP) was asked for physicians' orders for COVID-19 testing for residents #1 and #2. At 2:10 p.m., the IP stated physician's orders would be obtained for a resident if they had signs and symptoms of COVID-19. She was informed that there were no orders for residents #1 and #2. She stated they did not have one. She stated they had received a blanket verbal order for testing the residents.

Based on observation, record review and interviews, it was determined the facility failed to provide necessary respiratory care to one (#56) of one sampled resident reviewed for respiratory services. From 06/19/19 through 07/09/19, it was documented resident #56 had complaints of shortness of breath, a productive cough and adventitious lungs sounds. There was no documentation to indicate the resident was administered respiratory treatments or seen by a physician. The resident required in-patient critical care treatment for [REDACTED]. The facility identified 16 residents who received respiratory treatments. Findings: Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated 06/20/19, documented the resident was at risk for shortness of breath and respiratory complications due to bronchiectasis, pseudomonas colonization and pneumonia. Staff was to administer medications and treatments per the physician's orders [REDACTED]. Oxygen was to be administered and oxygen saturation levels were to be monitored. The resident was to be monitored for complications such as dyspnea, shortness of air, cyanosis and tachypnea. The staff was also to assess lung sounds as needed, monitor for signs and symptoms of infection, and report any concerns to the physician. A nurse's note, dated 06/21/19 at 5:31 p.m., documented the resident's lung sounds had rales and rhonchi in all fields upon auscultation. The resident complained of shortness of breath with exertion, required continuous oxygen at two liters per minute and had a non-productive cough. It was also documented the resident did not require use of nebulizer treatments. A nurse's note, dated 06/24/19 at 6:48 p.m., documented the resident had intermittent confusion and a non-productive cough. The resident required continuous oxygen at two to three liters per minute to keep her oxygen saturation in the 90's. The resident had rhonchi in the bases of both lungs upon auscultation which would not clear with cough. It was also documented the resident reported continuing dyspnea on exertion. An admission assessment, dated 06/26/19, documented the resident was independent in cognitive skills for daily decision making and required extensive assistance with activities of daily living. The resident was at risk for coughing or choking during meals or with swallowing medication and required the use of oxygen. A nurse's note, dated 06/26/19 at 9:19 p.m., documented the resident presented with wheezing in the lungs upon auscultation, confusion and complaints of shortness of breath with exertion. It was also documented the resident did not require use of nebulizer treatments but had orders for as needed (PRN) treatments if needed. A nurse's note, dated 06/27/19 at 4:22 p.m., documented the resident complained of shortness of breath while lying flat and with exertion. She required continuous oxygen at two to three liters per minute at all times. The resident had crackles upon auscultation of the lungs and a productive cough. A nurse's note, dated 06/28/19 at 7:03 p.m., documented the resident complained of shortness of breath lying flat, with exertion and at rest. She required continuous oxygen at two to three liters per minute at all times. The resident had crackles upon auscultation of the lungs and a productive cough. A nurse's note, dated 07/01/19 at 7:07 p.m., documented the resident was confused and complained of shortness of breath lying flat, with exertion and at rest. She required continuous oxygen at two to three liters per minute at all times and a productive cough. It was also documented the resident did not require use of nebulizer treatments but had orders for PRN treatments if needed. A nurse's note, dated 07/02/19 at 6:47 p.m., documented the resident was confused and complained of shortness of breath lying flat, with exertion and at rest. She required continuous oxygen at two to three liters per minute at all times and had a productive cough. It was also documented the resident did not require use of nebulizer treatments but had orders for PRN treatments if needed. A nurse's note, dated 07/04/19 at 7:01 p.m., documented the resident complained of shortness of breath while lying flat and with exertion. She required continuous oxygen at two liters per minute. A nurse's note, dated 07/07/19 at 6:05 p.m., documented the resident was confused and complained of shortness of breath lying flat, with exertion and at rest. She required continuous oxygen at two to three liters per minute and a productive cough. It was also documented the resident did not require use of nebulizer treatments but had orders for PRN treatments if needed. A nurse's note, dated 07/08/19 at 5:40 p.m., documented the resident had rales upon auscultation of the lungs, an intermittent productive cough and required continuous oxygen. There was no documentation in the resident's clinical record to indicate the resident was administered a nebulizer treatment or aerosol inhaler from 06/19/19 through 07/09/19. A nurse's note, dated 07/09/19 at 2:55 p.m., documented the nurse was notified by the occupational therapist the resident was not acting right and was sick. The nurse documented the resident was drooling from the nose and mouth with clammy skin. Coarse wheezes and rales were auscultated throughout the lungs. The resident's heart rate was documented at 143-145 beats per minute and respirations were 32 breaths per minute. Her oxygen was continuous at three liters per minute. Emergency services were notified. A nurse's note, dated 07/09/19 at 3:25 p.m., documented the resident was transported to the hospital by ambulance. An emergency physician documentation record, dated 07/09/19, documented the resident arrived at the hospital at 3:27 p.m. Upon examination, the physician documented the resident was in severe respiratory distress. Respirations were shallow, labored and tachypneic. Severe and scattered rales, rhonchi and wheezing of the lungs were documented. The resident's vital signs at 3:44 p.m. were documented as blood pressure 93/66, pulse 128, respirations 30, temperature 100 degrees and oxygen saturation level of 91 at three liters. The record further documented the resident was admitted at 6:00 p.m. for treatment of [REDACTED]. On 07/11/19 at 11:55 a.m., licensed practical nurse (LPN) #4 was asked who was responsible for assessing a resident who required respiratory services. She stated any licensed nurse. She was asked what interventions would be put in place for a resident with abnormal lung sounds or complaints of shortness of breath. She stated the lung sounds should be documented and breathing treatments administered. Position changes, deep breathing and pursed lip breathing could also be implemented. The LPN was asked who she would notify if a resident had a change in their respiratory condition. She stated the physician and family would be notified. At 12:20 p.m., LPN #2 was asked who was responsible for assessing a resident who required respiratory services. She stated the licensed nurses. She was asked what interventions would be put in place for a resident with abnormal lung sounds or complaints of shortness of breath. She stated the orders should be checked. She had been trained on respiratory medications, including nebulizer treatments and inhalers. The LPN stated the resident should also be assessed by listening to the lungs and checking the oxygen saturation level and pulse. The physician should then be contacted if there were no changes. At 12:25 p.m., the director of nursing (DON) was asked the training provided to staff regarding respiratory services. She stated a respiratory skills lab was provided to staff upon hire and annually. The training included the assessment of lung sounds using a high tech manikin with setting changes for the identification of abnormal lung sounds. The DON was asked who was responsible for assessing a resident who required respiratory services. She stated the licensed nurses. She was asked what interventions would be put in place for a resident with abnormal lung sounds or complaints of shortness of breath. She stated breathing treatments should be administered and the resident should be assessed and monitored. The DON stated the physician should be notified if there was no improvement with the resident. The DON was asked to review the clinical record of resident #56. She was asked if the necessary respiratory care was provided to the resident to treat the symptoms documented by the licensed nurses. She stated no, she understood.

Based on record review and interview, it was determined the facility failed to ensure the code status was accurately identified for three (#7, 55 and #257) of three sampled residents who were reviewed for advanced directives. This had the potential to affect all 54 residents who resided in the facility. Findings: 1. The face sheet in the clinical record for resident #7, dated [DATE], documented, .resuscitate: no info provided . A DNR consent form, dated [DATE], was in the clinical record. The physician's orders [REDACTED].>On [DATE] at 11:16 a.m., the name plate on the resident's door was observed to be white in color. At 5:16 p.m., LPN #3 was asked if the resident had a DNR consent form. He stated, Yes. He was asked what the physician's orders [REDACTED]. He stated, I don't see an order. He was asked what was documented on the face sheet related to the code status. He stated, No info provided. The LPN was asked what the white name plate on the resident's door indicated. He stated, DNR. On [DATE] at 9:07 a.m., the DON was asked who was responsible for the documentation of the code status. She stated the admission coordinator reviewed the admission paperwork for the code status and then verbally coordinated with the social services director. The social services director then initiated the order for the code status. The DON stated when they put the physician's orders [REDACTED]. The DON was asked where the DNR status was documented in the clinical record. She stated on the face sheet, advance directive section and the physician's orders [REDACTED]. She stated, Yes. She was asked if the resident had a DNR consent form, should she have had a physician's orders [REDACTED]. She was then asked if the DNR should have been documented on the face sheet. She stated, Yes. 2. The face sheet in the clinical record for resident #55 documented the resident was a do not resuscitate (DNR) status and was to receive no cardiopulmonary resuscitation (CPR). A physician's orders [REDACTED]. There was no DNR consent form found in the clinical record. On [DATE] at 5:10 p.m., licensed practical nurse (LPN) #3 was asked how staff determined a resident's code status. He stated it was posted on the face sheet of the clinical record. He also stated the color of the resident's name plate on the door indicated the resident's code status. The name plate would be white if the resident was a DNR and green if CPR was to be performed. The LPN was asked the code status for the resident. He stated DNR was documented on her face sheet and physician orders, however there was not a DNR consent form in the clinical record. The LPN then observed the name plate on the resident's door and stated it was green which would mean CPR was to be performed. The LPN was asked if he knew the resident's code status. He stated, No. On [DATE] at 9:07 a.m., the director of nursing (DON) was asked the process for documenting a resident's code status in the clinical record. She stated they had a recent change in staff and the process had changed. The DON reviewed the clinical record of resident #55 and was asked if the resident's code status was accurately documented. She stated the door was correct and staff was trained to identify status at the door. 3. The face sheet in the clinical record for resident #257 documented, .Resuscitate: CPR (cardiopulmonary resuscitation) . A DNR consent form, dated [DATE], was in the clinical record. A care plan, dated [DATE], documented, Advanced Directives .will have advance directives reviewed upon admission . will have their preferences followed and reviewed through next review period Obtain Advanced Directive .Consult physician for verification of code status . A physician's orders [REDACTED].CPR . On [DATE] at 4:52 p.m., LPN #1 was asked how she determined a resident's code status. She stated the name plate outside the resident's door was color coded. She stated white meant DNR and green meant full code. She stated the code status was also on the face sheet and in the physician's orders [REDACTED]. LPN #1 was asked to review the resident's clinical record. She was asked what the resident's code status was. She stated, Code status is CPR. She was asked if that meant a full code. She stated, Yes. LPN #1 was asked to review the resident's clinical record. She was then asked the code status of the resident. She stated, DNR. She was asked if the code status was correct. She stated, Apparently not. At 4:59 p.m. the DON was asked how a resident's code status was determined. She stated they had a process in place. If the resident had a DNR, it was scanned into the clinical record and the code would be documented by the nurse. She also stated a resident would remain a CPR code until the nurse changed the status. The DON was asked to review the resident's clinical record. She was then asked the resident's current code status. She stated, Initiate CPR. The DON was asked to review the advance directive section of the record. She was then asked what was documented. She stated, A DNR. The DON was asked if the resident's code status was accurately documented. She stated, No.

Based on observation, record review and interview, it was determined the facility failed to ensure pain medication was available as ordered by the physician for one (#7) of five sampled residents who were reviewed for pharmacy services. This had the potential to affect all 54 residents who resided in the facility. Findings: Resident #7 had [DIAGNOSES REDACTED]. An undated pharmacy policy, documented, .DELIVERY INFORMATION .Refills faxed before the pharmacy closes will be delivered the next business day with your regular evening delivery. Order when a 4 day supply remains . A physician's orders [REDACTED]. A care plan, dated 04/21/19, documented the resident had the potential for pain. The staff was to assess for pain and provide medication as ordered by the physician. A pharmacy record, dated 05/30/19, documented the facility had received 60 doses of the [MEDICATION NAME] from the pharmacy. It documented the resident had received 49 doses in (MONTH) and 11 doses from 07/01/19 through 07/07/19. The Medication Administration Record [REDACTED]. The resident was administered [MEDICATION NAME]. On 07/08/19 at 11:16 a.m., the resident was observed sitting in her room. She stated the facility was out of her pain pills and she was hurting. A Nurse/Physician Faxed Communication form, dated 07/08/19 at 12:50 p.m., documented, .We are needing a script for her [MEDICATION NAME] ([MEDICATION NAME]) 7.5mg/325mg 1 PO (by mouth) Q (every) 6* (hours) PRN . A nurse's note, dated 07/08/19 at 3:44 p.m., documented the physician's office confirmed the prescription for the [MEDICATION NAME] would be sent to the pharmacy that evening. It was also documented the nurse was notified by the medication aide the facility was completely out of the medication. At 3:47 p.m., the resident was observed sitting in her room. The resident stated the facility ran out of her pain medication and forgot to order it. The last dose she had been administered was the day before. A nurse's note, dated 07/08/19 at 6:59 p.m., documented the facility contacted the pharmacy to verify the prescription for the [MEDICATION NAME] was received from the physician. The pharmacy stated it had not been received. It was documented the director of nursing (DON) was notified and contacted the medical director. The treatment administration record, dated 07/08/19 on the evening shift, documented the resident rated her pain a seven. There was no documentation on the MAR indicated [REDACTED]. A nurse's note, dated 07/09/19 at 12:20 p.m., documented a new order was received for the resident to be administered Tylenol 500 mg every six hours as needed for pain. There was no documentation to indicate the resident was administered Tylenol for her pain. On 07/09/19 at 2:10 p.m., the resident was asked if she had been administered her PRN pain medication. The resident stated, No, they keep telling me it will come. She stated, They said they were late on ordering it. The TAR, dated 07/09/19 on the evening shift, documented the resident rated her pain a seven. There was no documentation on the MAR indicated [REDACTED]. A pharmacy record, dated 07/09/19, documented the facility had received 60 doses of [MEDICATION NAME] from the pharmacy. The MAR, dated 07/10/19 at 12:20 a.m., documented the resident rated her pain a six and she was administered the [MEDICATION NAME]. On 07/10/19 at 8:55 a.m., licensed practical nurse (LPN) #2 was asked how she ensured a resident's pain was controlled. She stated the resident would be assessed for pain, then non-pharmacological interventions would be attempted before pain medication was administered. She stated routine pain medication would be administered. If the resident stated the use of other interventions were not effective, PRN pain medication would then be administered. LPN #2 was asked the protocol to ensure a resident did not run out of pain medication. She stated the medication aide was to check the count routinely to verify at least a week supply was in stock, including PRN medications. The LPN was asked why the resident had ran out of the PRN [MEDICATION NAME]. She stated the medication was not reordered by staff in a timely manner. The physician did not send the prescription until 07/09/19. At 9:14 a.m., the DON was asked the protocol for ordering PRN medications. She stated staff was to reorder when the resident had at least a five day supply left. The DON was asked how long it took to receive medications once they were reordered. She stated medications were received after 7:00 p.m. on the same day they were ordered if ordered early in the day. She stated the local pharmacy would be used if the medication was not reordered in time. The DON was asked if the resident's PRN medication was reordered according to their protocol. She stated she had contacted the medical director on 07/08/19 at 11:00 p.m. due to not receiving the prescription from the resident's primary care physician. The DON was asked why they had ran out of the PRN pain medication for 53 hours. She stated, I presume because it was a holiday and somebody miscounted.

Based on record review and interview, it was determined the facility failed to ensure the physician's response was received in a timely manner for the gradual dose reduction recommendations for two (#27 and #55) of five sampled residents reviewed for unnecessary medication . This had the potential to affect 32 residents identified as receiving psychoactive medications. Findings: 1. Resident #27 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, revised 04/11/19, documented the resident had the potential for drug related complications due to the use of [MEDICAL CONDITION] medications. The staff was to observe for signs and symptoms of drug related complications, maintain behavior monitoring and report to the physician as needed. The pharmacy consultant was to review the drug regimen. A pharmacist's Consultant Report, dated 04/22/19, documented the resident had [MEDICATION NAME] 0.5 mg two times a day for expressions or indications of distress related to dementia. The pharmacy consultant recommended, .Please attempt a gradual dose reduction (GDR) to [MEDICATION NAME] 0.25 mg q (every) am 0.5 mg q hs (bedtime) while concurrently monitoring for reemergence of target behaviors and/or withdrawal symptoms . A fax transmission sheet, dated 04/25/19, documented the consultant's report had been faxed to the resident's physician. There was no documentation to indicate the physician had responded to the recommendation. A pharmacist's Consultant Report, dated 06/27/19, documented the resident had [MEDICATION NAME] 0.5 mg two times a day for expressions or indications of distress related to dementia. The pharmacy consultant recommended, .Please attempt a gradual dose reduction (GDR) to [MEDICATION NAME] 0.25 mg q am 0.5 mg q hs while concurrently monitoring for reemergence of target behaviors and/or withdrawal symptoms . A fax transmission sheet, dated 06/27/19, documented the consultant's report had been faxed to the resident's physician. There was no documentation to indicate the physician had responded to the recommendation. On 07/10/19 at 3:42 p.m., the director of nursing (DON) was asked the facility's procedure to ensure physician responses were received for the GDR recommendations. She stated the recommendations were faxed to the physician if a response was not received within seven days, then again at two weeks. The physician's office would also be contacted by phone if it had been two weeks. The DON was asked what action was taken when a response had not been received at three weeks. She stated the request was resent by fax, the medical director would be contacted and staff would go to the physician's office. At 4:00 p.m., the DON was asked to review the Pharmacist Consultant report, dated 04/22/19. She was asked when it had been sent to the physician. She stated it had been sent to the physician on 04/25/19. She was asked if the physician had responded to the recommendation. She stated, No. The DON was asked if the physician had been contacted according to the facility's procedure. She stated, I did today. She was asked if the physician had been contacted before today. She stated, No. The DON was asked to review the Pharmacist Consultant report, dated 06/27/19. She was asked when it had been sent to the physician. She stated it had been sent to the physician on 06/27/19. She was asked if the physician had responded to the recommendation. She stated, No, he has not. The DON was asked if the physician had been contacted according to the facility's procedure. She stated, I did today. She was asked if today was the first time she had contacted the physician. She stated, Yes. 2. Resident #55 had [DIAGNOSES REDACTED]. A physician order, dated 05/08/17, documented the resident was to be administered [MEDICATION NAME] 20 milligrams (mg) one time a day. A pharmacist's Consultant Report, dated 05/28/19, documented the pharmacy consultant recommended a gradual dose reduction for the [MEDICATION NAME]. It was documented the physician agreed to decrease the resident's [MEDICATION NAME] to 10 mg a day and signed the report on 06/03/19. The Medication Administration Record [REDACTED]. It was documented the resident was administered [MEDICATION NAME] 20 mg from 06/01/19 through 06/25/19. A physician order, dated 06/25/19, documented the resident was to be administered [MEDICATION NAME] 10 mg one time a day. On 07/10/19 at 3:42 p.m., the DON was asked to review the pharmacist's Consultant Report and the MAR. She was then asked why the reduction was not initiated until 06/25/19 if the report for the order was signed by the physician on 06/03/19. She stated the letter was probably not received back until 06/25/19 even though the physician had signed it on 06/03/19. She was asked if 28 days was considered timely for the response from the physician. She stated it was not.

Based on record review and interview, it was determined the facility failed to ensure a discharge summary was completed upon transfer to the hospital for one (#57) of three sampled residents who were reviewed for discharge. This had the potential to affect all 54 residents who resided in the facility. Findings: Resident #57 had [DIAGNOSES REDACTED]. A nurse's note, dated 05/11/19, documented the resident was sent to the hospital related to abnormal lab results. A nurse's note, dated 05/11/19, documented the resident was discharged from the facility. A discharge summary was not located in the clinical record. On 07/11/19 at 1:48 p.m., the director of nursing was asked who was responsible for completing the discharge summary. She stated the charge nurse was supposed to complete the discharge summary at the time of the discharge. She was asked if a discharge summary had been completed when the resident was discharged on [DATE]. She stated, No, we did not do one.

Based on interview and record review, it was determined the facility failed to complete a discharge summary for one (#58) of three sampled residents who were reviewed for discharge. This had the potential to affect all 54 residents who resided in the facility. Findings: Resident #58 had [DIAGNOSES REDACTED]. A nurse's note, dated 06/13/19, documented the resident was to be discharged to home. The clinical record contained an undated and incomplete discharge summary for the resident. On 07/11/19 at 11:30 a.m., the director of nursing (DON) was asked if the discharge summary was to be completed in full upon a resident's discharge from the facility. She stated, Yes. The DON was asked to review the discharge summary for resident #58. She was asked if the discharge summary had been completed for the resident. She stated, Some of it is there. She was asked if the form was complete. She stated, It's not totally filled out. She was asked if it should have been. She stated, Yes.

Based on observation and interview, it was determined the facility failed to ensure contact isolation precautions were followed for one (#257) of two sampled residents on isolation precautions. This had the potential to affect all 54 residents who resided in the facility. Findings: Resident #257 had [DIAGNOSES REDACTED]. A nurse's note, dated 06/25/19, documented, the resident was on isolation precautions due to [MEDICAL CONDITIONS] ([MEDICAL CONDITION]) On 07/08/19 at 3:35 p.m., the door outside of the resident's room was observed to have personal protective equipment (PPE) for the contact isolation in a container. A sign on the container gave instructions regarding hand hygiene, gowning and gloving before entering and upon leaving the resident's room. At 3:57 p.m., no red biohazard bags were observed inside the room to dispose of contaminated gowns and gloves. At 3:59 p.m., certified nursing assistant (CNA) #1 was asked why the resident was on contact isolation precautions. She stated, He has [MEDICAL CONDITION]. She was asked if there should have been biohazard bags to dispose of gowns and gloves upon exiting the room. She stated, Yes. She was asked why there had not been any in the room. The CNA stated the previous shift must have removed one and not replaced it. On 07/11/19 at 8:28 a.m., the director of nursing (DON) was asked what equipment was required for a resident on contact isolation precautions. She stated containers would be placed outside of the room with signs containing PPE instructions to be followed. A red biohazard bag and a yellow soiled linen bag should be in the room to discard the equipment after use. The bags were to be changed out at every shift. The DON was asked how she ensured contact isolation precautions were followed. She stated staff was in-serviced and constantly educated. The equipment was monitored and stocked. Staff was to make sure the bags were changed out at the end of every shift. The DON was asked why resident #257 was on contact isolation precautions. She stated he was admitted with [MEDICAL CONDITION]. The DON was asked if she had been made aware the resident did not have a biohazard bag in his room to dispose of gowns and gloves on 07/08/19. She stated the staff had informed her. She was asked if one should have been there. She stated, Yes.

On 04/12/18, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have an effective system for the care of a resident with a pressure ulcer. The facility failed to implement medical interventions to promote the healing of pressure ulcers; conduct accurate and thorough pressure ulcer assessments; and ensure competent nursing staff to care for residents with pressure ulcers. The resident was assessed to have no pressure ulcers on 03/06/18. The resident was sent to the hospital on [DATE]. Physician records and hospital records documented upon arrival to the hospital, the resident was found to have a 6 to 6.5 cm full thickness pressure ulcer on the left heel. The pressure ulcer had black eschar, drainage, and was infected. The pressure ulcer required surgical debridement of an area measuring approximately 20 cm squared. The resident was found to have a 3 to 4 cm full thickness pressure ulcer on the right heel that required surgical debridement. The resident subsequently required intravenous antibiotic treatment of [REDACTED]. At 1:21 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 1:25 p.m., the administrator and Director of Nursing were notified of the IJ situation related to the facility's failures in caring for a resident with pressure ulcers. On 04/12/18 at 5:00 p.m., an acceptable plan of removal, with addendum, was provided. The plan of removal documented, .The DON or designee will conduct a skin sweep for all residents to ensure that all skin issues are identified and appropriate treatment is in place. The DON/designee will conduct mandatory in service to nurse's, nurse aides, medication aides. For all employees that do not attend the in service, they will not be allowed to provide resident care until in service is completed. The DON/designee will conduct in service to nurse's on how to conduct full skin assessment, how to properly document in the clinical record under skin assessment. The DON/designee will in service on what to do if new wound present or change in wound that is present. The DON/designee will in service on how to properly measure all wounds, staging of wounds, identify type of wound and document properly in the clinical record. The DON/designee will in service on timely initiation of notification of physician and family ember. In service over communication with physician in reporting all wounds and documenting in the clinical record. The DON/designee will in service CNA of identifying wounds, communication with nurse, DON and/or ADON. The DON /designee will in service all nursing staff over all components of all wound prevention and promotion of wound healing. The DON/designee will be conduct daily audits to ensure that all in service content is documented and conducted properly. The Plan of Removal will be accomplished by 4/13/18 at Midnight. The immediate jeopardy was removed on 04/13/18 at 7:00 p.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on observation, interview, and record review, it was determined the facility failed to: ~ perform initial and ongoing thorough skin and pressure ulcer assessments; ~ implement medical interventions to aid in the healing of pressure ulcers; and/or ~ obtain physician orders [REDACTED]. for three (#31, #44, and #109) of four sampled residents who had pressure ulcers. The facility identified five residents as having pressure ulcers. Findings: 1. Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. It was documented the boots were to be changed every three days. A quarterly assessment, dated 01/08/18, documented the resident was totally dependent on staff for bed mobility and transfers; did not walk; required extensive assistance with dressing, toilet use, and bathing; and was occasionally incontinent of bowel and bladder. It was documented the resident was at risk for developing pressure ulcers. A Braden Scale for Predicting Pressure Sore Risk, dated 01/17/18 at 10:04 a.m., documented the resident scored a 15. It was documented if a resident's total score was 12 or less, the resident should be considered to be at risk for pressure ulcer development. A nurse's note, dated 01/17/18 at 6:21 p.m., documented, .At (9:30 a.m.) full skin assessment complete, Unna boots absent from lower exts bilat for complete assessment noting skin integrity is intact with no redness, warmth or drainage present .Unna boots with [MEDICATION NAME] vs 2 layer compression therapy per medline . A skin evaluation, dated 03/06/18 at 4:25 p.m., documented, .Skin inspected/assessed and no remarkable observations noted: Yes . Treatment sheets, dated 03/06/18, documented the Una boots were applied to the resident's bilateral lower extremities. A physician's telephone order, dated 03/08/18 at 1:50 p.m., documented to discontinue the use of the Una Z boots and begin using ACE wraps on the bilateral lower extremities. It was documented to apply the ACE wraps every morning and take them off at bedtime. It was also documented to monitor for [MEDICAL CONDITION] and to contact the physician if [MEDICAL CONDITION] occurred. A nurse's note, dated 03/08/18 at 2:04 p.m., documented, .Upon (family member)'s request (Physician name withheld), DC Una Z guard boots with [MEDICATION NAME] on BLE q 3 days due to residents (sic) swelling has decreased. Started resident on ACE wraps on BLE q daily AM and Off HS to keep swelling down. Family was notified of new orders .ETAR updated . Review of the clinical record revealed no documentation a skin assessment was completed on the resident's lower extremities when the Una boots was taken off. There was no documentation of any skin breakdown. Treatment sheets, dated 03/09/18 through 03/11/18 on the morning shift, documented the ACE wraps were applied every morning and removed each night at bedtime. Review of the clinical record revealed no documentation a skin assessment was completed on the resident's lower extremities when the ACE wraps were applied or taken off on 03/09/18 or 03/10/18. A facsimile, dated 03/11/18 at 10:30 p.m., documented, .pressure areas noted to bilat heels. unstageable. both are observed with stable eschar. Both areas are present to posterior aspect of bilat heels, free from redness, warmth (and) drainage. Treatment initiated for skin prep BID, leave OTA, apply heel protectors and float heels as tolerated. Any further orders? .(Right) heel - 3 cm x 4.5 cm (Left) heel 5 cm x 7.5 cm . Review of treatment sheets, dated 03/11/18, revealed the ACE wraps were applied and removed as ordered by the physician. There was no documentation any type of treatment was completed on the bilateral heel pressure ulcers. There was no documentation heel protectors were used or that the heels were floated as tolerated. The resident's care plan, updated 03/12/18, documented a problem related to unstageable pressure ulcers to bilateral heels. The goal was the resident's skin would heal without complication. Interventions included to float heels when in bed to keep pressure off, use of a foot support cradle on wheelchair, and to follow protocol for bilateral heel skin care and to document weekly on the progress of the wounds. A skin evaluation form, dated 03/12/18 at 5:45 p.m., documented, .heel left .full thickness wound .pressure ulcer .skin prep heels bilat bid, leave open to air, provide heel protectors bilat .area presents with circular black area to posterior heel that this (sic) soft to touch. black eschar is stable with no active drainage, redness, warmth yet resident does complain of mild tenderness with assessment .Cause: Pressure .Size Length: 5.0 cm Width: 7.5 cm Depth UTO .necrotic/eschar . Review of treatment sheets, dated 03/12/18, revealed the ACE wraps were applied and removed as ordered by the physician. There was no documentation any type of treatment was completed on the bilateral heel pressure ulcers. There was no documentation heel protectors were used or that the heels were floated as tolerated. A physician's orders [REDACTED].skin prep bilat heels bid .apply heel protectors to bilat feet as tolerated .float heels as tolerated .unstageable wound . There were no orders to clean the pressure ulcers before the application of the skin prep. A skin evaluation form, dated 03/13/18 at 5:50 p.m., documented, .heel right .full thickness wound .pressure ulcer .skin prep bid to eschar area, open to air, heel protectors bilat .area is circular area to posterior heel, wound bed is obscured with black/brown eschar that is stable and firm to touch, no redness, drainage or warmth present. resident does complain of mild tenderness with assessment .Size Length: 3.0 cm Width: 4.5 cm Depth: UTO .necrotic/eschar . A nurse's note, dated 03/13/18 at 5:54 p.m., documented, .On 03/12/18, full skin assessment complete noting of pressure related areas to heels bilat, uinstageble (sic) as both are obscured with stable eschar. Both areas are present to posterior aspect of heels bilat, free from redness, warmth and drainage, resident does report of mild tenderness upon assessment but denies pain once heel protectors applied. (Physician name withheld) as been advised and family contacted direclty (sic) after assessment with no return of call at that time. Treatment will be provided for skin prep pad BID over eschar area, leave open to air, apply heel protectors and float heels as resident will tolerate . A nurse's note, dated 03/13/18 at 10:16 p.m. as a late entry for 03/11/18, documented, .This nurse observed pressure areas to bilat heels when removing ACE wraps. Areas are present to bilat heels, covered in stable eschar, no redness or warmth noted to heels. Resident denies pain/discomfort at this time. Applied skin prep to bilat heels, floated with pillow to remove pressure and heel protectors in place. Physician and DON notified. Will update skin conditions and EMAR with orders . A skin evaluation form, dated 03/13/18 at 10:19 p.m., documented, .heel left .skin prep bilat heels, heel protectors, heels floated .round pressure areas, wound bed obscured by stable eschar. No redness or [MEDICAL CONDITION] noted to surrounding tissue, Resident currently denies pain/discomfort . A skin evaluation form, dated 03/13/18 at 10:27 p.m., documented, .heel right .skin prep bilat heels, heel protectors, float heels .round pressure area noted to posterior heel, stable eschar obscuring wound bed . Review of treatment sheets revealed no documentation a treatment had been completed on the bilateral heel pressure ulcers until the evening shift on 03/13/18. The directions for the application of the skin prep twice daily, floating the heels as tolerated, and the use of heel protectors had start dates documented as 03/13/18. A nurse's note, dated 03/14/18 at 7:17 a.m. as a late entry for 03/12/18, documented, .Bil heels noted with unstageable pressure areas. Stable eschar noted. No open areas noted. No warmth, swelling, or redness noted. No drainage noted. Heel protectors on and feet offloaded at all times. Complain of tenderness up touch. Skin prep applied . A nurse's note, dated 03/14/18 at 10:27 p.m., documented, .wound consultant will be at facility on 3/15/18 for wound evalution (sic) . A physician notification of wound treatment progress, dated 03/14/18 at 10:45 p.m., documented, .wound type: bilat unstageable pressure ulcers to posterior heels. Current treatment: skin prep bid to eschar areas of both heels, heel protectors to (lower) exts as res tolerates. offload pressure as res will tolerate .May we add .Vitamin C (one) tab po qd .Zinc .(one) tab po qd .Ensure Clear (with) Protein (one) can po bid . The notification was signed by the physician, and it was documented, .pt needs appt to be seen appt made on 3/22/18 . A nurse's note, dated 03/14/18 at 10:47 p.m., documented, .fax communication sent to (physician name withheld) at this time to update on status of wounds to heels bilat, to request for Vitamin C, Zinc and Ensure clear Protein supplement BID to promote wound healing . A nurse's note, dated 03/15/18 at 4:21 a.m., documented, .ACE wraps removed and small amount yellowish-red drainage noted to nonadherent dressing to left heel . Review of the clinical record revealed no documentation the physician was notified of the drainage. Review of the clinical record revealed the facsimile sent to the physician on 03/11/18 was returned to the facility on [DATE] at 8:59 a.m. The facsimile was signed by the physician. Wound care skin integrity evaluation sheets, dated 03/15/18 and signed by the medical suppy company representative (referred to as the wound consultant by the facility), documented the left heel pressure ulcer had a wound bed that was 15% red, 85% black eschar, with small serosanguinous drainage noted upon palpation. It was documented the ulcer measured 4 cm x 7.5 cm. It was also documented the right heel pressure ulcer had a wound bed that was 40% red, 60% black, and serous drainage. It was documented the ulcer measured 3 cm x 4.5 cm. A patient order sheet from the wound care consultant, dated 03/15/18, documented the resident had a full thickness, right heel, unstageable pressure ulcer that measured 3 cm x 4.5 cm and a full thickness, left heel, unstageable pressure ulcer that measured 4 cm x 7.5 cm. It was documented the ulcers had minimal exudate. It was documented each pressure ulcer needed non-adherent pads, gauze rolls, and retention tape. The form documented, .Verbal Order Accepted By: (name of wound care consultant withheld) .Physician's Signature: (physician's name withheld . A nurse's note, dated 03/16/18 at 12:39 a.m., documented, .Return fax from (physician name withheld) received in regards to resident's wounds to bilat heels. No new orders at this time . Review of the clinical record revealed the facsimile sent to the physician on 03/11/18 and returned to the facility on [DATE] at 8:59 a.m. was noted by the nurse on 03/16/18. Physician's telephone orders, dated 03/16/18 and untimed, documented orders to clean the pressure ulcers to the resident's left and right heels with Dermal wound cleanser, pat dry, apply Skin prep, cover with a nonadherent pad, and wrap with kerlix and secure. A nurse's note, dated 03/16/18 at 5:41 p.m., documented, .Upon dressing change to bil lower ext. no drainage noted to right heel and scant amount of bloody drainage noted to left heel. No odor noted at this time. Heels to be offloaded at all times . Review of the clinical record revealed no documentation the physician was notified of the drainage. A skin evaluation form, dated 03/17/18 at 6:49 a.m., documented, .heel right .cleanse right heel with Dermal wound cleanser, pat dry with 4x4 gauze, apply skin prep to affected area, cover with non adherent pad, wrap with kerlix and secure with tape .Size Length: 3 cm Width 4.5 cm Depth: (left blank) . A skin evaluation form, dated 03/17/18 at 7:29 a.m., documented, .heel left .Cleanse left heel with dermal wound cleanser, pat dry with 4x4 gauze, apply skin prep to affected area, cover with non adherent pad, wrap with kerlix, and secure with tape qd .Size Length: 4 cm Width: 7.5 cm Depth: (left blank) . A nurse's note, dated 03/17/18 at 8:37 a.m., documented, .New wound care orders received (sic) as follows: Cleanse right and left heel with dermal Wound Cleanser, pat dry with 4x4 gauze, apply skin prep to eschar area, cover with non adherent pad, wrap with kerlix and secure with tape .Upon dressing change this am right heel noted with no drainage, left heel noted with very small amount of bloody drainage noted. No s/s of infection noted . Review of the clinical record revealed no documentation the physician was notified of the drainage. Review of treatment sheets revealed the order to clean the pressure ulcers with Dermal wound cleanser prior to the application of the skin prep was not initiated until 03/17/17 on the day shift. A nurse's note, dated 03/21/18 at 10:35 a.m., documented, .dressing changed to bilat heels. Resident denies pain or tenderness upon cleansing wound. No drainage noted. No open areas noted. Eschar noted bil heels. Appointment to see (physician name withheld) 3/22/18 @ (2:30 p.m.). Instructed staff on heels to be off loaded at all times. heel protectors on bil heels and re positioning q 2 h . A skin evaluation form, dated 03/22/18 at 2:52 p.m., documented, .heel left .Unstageable pressure area noted to left heel. scant amount of bloody drainage noted. No odor. No redness or swelling noted. Eschar noted . A nurse's note, dated 03/22/18 at 2:54 p.m., documented, .Dressing changed to bil heels. Left heel 4 x 5.8 necrotic tissue noted. No open areas or drainage noted. Right heel 2.5 x 4.2 necrtic (sic) tissue noted with no drainage or open areas noted. Denies pain or tenderness upon dressing change. Heels offloaded at all times. Heel protectors on . A physician's visit note, dated 03/22/18, documented, .Time 02:52 PM .Patient has a stage IV decubitus wound on his left heel with significant necrotic tissue foul odor mild drainage patient as a stage III to stage IV necrotic wound on his right heel covered by eschar. With some surrounding tissue necrosis no drainage noted. This also has a foul odor .Patient was brought from the nursing home for evaluation of wounds to bilateral heels the nursing home and call me (sic) and stated that he had nonsustainable ulcers to both heels requesting treatment options advised I need to see him in the office patient comes in he has a stage IV decubitus ulcer to the left and a stage 3 to 4 decubitus to the right the left has a very deep necrotic tissue basically down to the bone. The ride (sic) is covered with eschar but has some mild fluctuance underneath as well. The wound on the left and right were a (sic) sharply debrided wounds were wrapped patient will be admitted to the hospital for wound care for their evaluation and podiatry or orthopedics consul . A hospital history and physical, dated 03/22/18, documented, .the nursing home was reported over the last week that he has had some redness to his heels they then called me a few days ago and stated that he had non state tubal (sic) pressure ulcers. Which made me concerned that these were worsening. Had the (sic) make him appointment to bring him to the office on evaluation in the office today he has stage IV pressure ulcer to his left heel with the foul smelling odor he has a stage 3-4 pressure ulcer to his right heel both of these have black eschar and necrosis. The left heel was partially debrided in my office and it was found to have necrotic tissue all the way down to the bone. There was foul-smelling drainage as well patient is going to be admitted for wound care IV antibiotics and further evaluation .Patient is admitted with stage IV decubiti I (sic) have both heels with infection and necrosis noted to the left heel. He will be admitted placed on IC antibiotics broad-spectrum laboratory studies are reviewed he is elevated [MEDICAL CONDITION] markers white count is elevated as well . Hospital laboratory tests, dated 03/22/18 at 6:24 p.m., documented the resident's white blood count was 14.34, with a normal count being 4.0 to 10.8. A hospital podiatrist consultation, dated 03/23/18, documented, .consulted me for possible surgical debridement and wound care .He demonstrates pain response significantly around the left heel with palpation .On the right posterior lateral heel, there is an approximately 4.5 to 5 cm in greatest diameter decubitus ulceration that is partial and full thickness. There is mild [DIAGNOSES REDACTED] surrounding but no significant odor or [MEDICAL CONDITION]. On the left foot, there is a 6 to 6.5 cm full thickness ulceration with black eschar., Mild flexion remaining status [REDACTED]. There is [MEDICAL CONDITION] and odor with drainage. The ulceration penetrates through the periosteum and is high-grade .Assessment .High-grade decubitus ulcerations, bilateral heels, left with infection and [MEDICAL CONDITION] . A hospital operative report, dated 03/23/18, documented, .Attention was drawn to the right plantar lateral ulceration which is approximately 3 to 4 cm in greatest diameter. The central part is full-thickness which was then sharply debrided .into the most necrotic and dark black region which is approximately 2 cm in diameter. The remainder of the wound was relatively healthy with minimal skin slough and no deep region .Attention was then redirected to the left, more substantial ulceration which is greater than 6 cm in greatest diameter and plantar lateral and posterior of the left heel .more extensive debridement of greater than 20 sq cm was excised from the region. Some periosteum was exposed in the central region, but appeared to be intact and no deep probe to bone or through bone, no penetration noted. There was some foul-smelling necrosis deep to the dark eschar. Remainder of the devitalized tissue was at least nonfluctuant . A discharge note, dated 03/28/18, documented, .will discharge to LTAC for wound care for bilateral heels sp surg debridement .[MEDICATION NAME] (an antibiotic) . 2 gm . q 8 h IV .[MEDICATION NAME] (an antibiotic) 1000 mg . q 12 h IV . On 04/12/18 at 8:35 a.m., CNA #1 was asked if the resident was able to reposition himself in bed. She stated, No. She was asked if the resident was at high risk for the development of pressure ulcers. She stated she would say yes since he was unable to turn himself. CNA #1 was asked what she was supposed to do to help prevent pressure ulcers. She stated turn every two hours, use bunny shoes but she did not think the resident had any, keep the feet elevated with the heels hanging off the edge, and use pillows to help position. She was asked if the resident had pressure ulcers. She stated she was not aware of any but that his heels were bad. On 04/12/18 at 9:04 a.m., LPN #1 was asked how often skin assessments were completed. She stated weekly. She stated the nurses completed the assessments. She was asked where the information was documented. She stated in the skin conditions screen of the electronic medical record. LPN #1 was asked what the nurse was supposed to do if new breakdown or skin issues were identified. She stated they were supposed to measure, notify the DON, notify the doctor, and put the order in for the treatment, if indicated. She was asked how the physician was notified of changes in skin condition. She stated the physicians were notified via fax unless it was a dire need. She stated they preferred faxes. She was asked what was considered dire. She stated foul odor, pain, or necrotic tissue. She was asked where the notification was documented. She stated in the ID (interdisciplinary) notes. LPN #1 was asked what was the purpose of Una boots. She stated they were used to help with [MEDICAL CONDITION], to push the fluid out. She was asked what types of adverse consequences were monitored for with the use of Una boots. She stated when the boots were changed every three days, staff should be checking the skin, making sure all was good. She was asked when skin assessments were completed for a resident with Una boots. She stated the assessment should be done every three days when the boots were removed because the boot itself could cause breakdown if it was not done correctly. LPN #1 was asked if resident #109 could ambulate, reposition, transfer, dress, or toilet himself. She stated, No. She stated he required full assistance with everything and a hoyer lift was used for transfers. On 04/12/18 at 9:16 a.m., the ADON was asked if the resident had breakdown. She stated yes. She stated he had breakdown on his heels. She was asked when the breakdown was first identified. She stated 03/11/18. She was asked how often his Una boots were changed. She stated every three days. The ADON was asked what was used as a treatment on the resident's lower extremities after the Una boots were discontinued. She stated ACE wraps were used. She was asked when staff began using the ACE wraps. She stated the morning of 03/09/18. The ADON was asked how often the legs were wrapped with ACE wraps. She stated they were put on in the morning and taken off at night. The ADON was asked when the physician was first notified of the breakdown. She stated the first fax was sent on 03/11/18 and it was sent back on 0 3/15/18. She was asked when the returned fax was noted by the nurse. She stated 03/16/18. The ADON was asked why the doctor was notified by fax. She stated the doctor wanted to be notified by fax. She stated sometimes staff could call the doctor's office and the nurse would say to fax the information. The ADON was asked what kind of breakdown the resident had. She stated pressure ulcers. She was asked what the ulcers measured when they were first documented on. She stated the right heel pressure ulcer measured 3 cm x 4.5 cm and the left heel pressure ulcer measured 5 cm x 7.5 cm. The ADON was asked when the physician responded to the fax sent on 03/11/18. She stated 03/15/18. She was what the staff did to try and communicate with the physician before 03/15/18. She stated she did not know. The ADON was asked why a complete and thorough assessment of the left heel pressure ulcer was not done until 03/12/18 at 5:45 p.m., and the right heel pressure ulcer until 03/13/18. She stated she could not answer that question. The ADON was asked when the pressure ulcers were first treated with skin prep. She stated she wrote the order on 03/16/18 to include cleansing the ulcers. She was shown the order dated 03/13/18. She was asked why no treatments were done on the pressure ulcers from 03/11/18, when first identified, until the evening of 03/13/18. She stated, I don't know. She stated staff was offloading the heels after the pressure ulcers were found. The ADON was asked if the physician was notified of the drainage from the left heel on 03/15/18. She stated she was not 100% sure he was. She was asked if it was documented the physician was notified. She stated, I don't see where it was. She was asked if the physician was notified of the drainage from the left heel on 03/16/18. She stated, No. She stated she was the nurse that day and she did not notify the physician. The ADON was asked if the physician was notified of the drainage from the left heel on 03/17/18. She stated there was no documentation the physician was notified. She was asked what the drainage from a pressure ulcer with eschar could be a sign of. She stated, An infection possibly. The ADON was asked what was being done to prevent the development of pressure ulcers before 03/11/18. She stated he was repositioned every two hours and the heels were off loaded. She was asked where that was documented. She stated the nurses had staff do that with all residents. She was asked how the resident went from no skin breakdown on 03/06/18 to having unstageable pressure ulcers with eschar on 03/11/18 without staff noting a change in condition, considering the Una boots were removed on 03/08/18 and ACE wraps were applied and taken off daily from 03/09/18 through 03/11/18. She stated she did not know how to answer that question. She was asked who was looking at the resident's feet when the ACE wraps were applied and taken off each day. She stated the nurses applied the ACE wraps. On 04/12/18 at 10:23 a.m., the DON was asked where it was documented the physician was notified of the drainage from the pressure ulcer on the left heel on 03/15/18, 03/16/18, and 03/17/18. She stated she saw where it was noted there was drainage but the notes did not specifically state the physician was notified. She was asked what drainage could be a sign of. She stated depending on the drainage, it could be a change in wound status. She was asked how the resident developed pressure ulcers to both his heels. She stated they had interventions in place but if it was not documented, it was not done. On 04/12/18 at 11:18 a.m., the DON stated she had notified the physician of the wound treatments on 03/14/18 and had asked for vitamin C, zinc, and Ensure to be added to the resident's medication regimen. She stated the documentation from the wound consultant, dated 03/15/18, documented the resident had minimal exudate from the pressure ulcers and that documentation was signed by the physician on 03/20/18. The DON was asked what the facility was doing before 03/11/18 to prevent the development of pressure ulcers. She stated the resident's heels were floated and the lower extremities were assessed with [REDACTED]. She was asked where that was documented. She stated the treatment sheet indicated when the staff applied the Una boots and ACE wraps and when they took them off and checked for placement, they were assessing the skin. She was asked if that was what the treatment sheet documented. She stated, No. On 04/12/18 at 11:54 a.m., the wound consultant was asked what her credentials were. She stated she was a registered nurse, with the credentials of a Clinical Wound Specialist. She was asked what type of drainage was noted from the resident's pressure ulcers on 03/15/18. She stated the right heel pressure ulcer had light serous drainage and the left heel pressure ulcer had light serosanguinous drainage. She was asked what the descriptions of the ulcers were on that day. She stated she did not have a description of the ulcers because she did not assess the ulcers. She stated the measurements that were documented were the measurements taken by the facility nurse and she had only observed the assessment, not completed it. She stated she came to the facility monthly and saw specific residents selected by the DON. She stated she observed the nurses performing wound care and educated on the different supplies her company provided. She stated if the nurses needed some education on various aspects of wound care, like measuring, she would provide that education. She stated she did not assess the pressure ulcers. She stated, I am here as an educator for supplies my company provides, not as a consultant. She was asked what the verbal order was for that was signed as accepted by her on 03/15/18. She stated that was a verbal order authorizing the shipment of supplies, nothing else. 2. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 12/20/17, documented the resident was severely cognitively impaired in daily decision making, required extensive assistance for bed mobility and transfers, and was not at risk for the development of pressure ulcers. It was documented she did not have any pressure ulcers. The resident's care plan, dated 12/20/17, documented a problem related to being at risk for pressure ulcers and other skin related injuries. The goal was the the resident would maintain skin integrity without new skin related injuries over the next review date. Interventions included to keep bed linens wrinkle free and not use excess pads; observe skin for redness and breakdown during routine care; and to use (TRUNCATED)

On 07/24/17, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure allegations of abuse were immediately reported to administration, ensure residents were protected from potential further abuse pending completion of an investigation, and to investigate an allegation of resident abuse. The Oklahoma State Department of Health (OSDH) verified the existence of the past non-compliance IJ. At 5:18 p.m., the administrator and director of nurses (DON) were notified of the past-noncompliance IJ situation related to the facility's failure to ensure allegations of abuse were immediately reported to administration, ensure residents were protected from potential further abuse pending completion of an investigation, and the failure to investigate an allegation of resident abuse reported to a charge nurse by a resident's family member on 05/23/17. The following corrective measures were completed as of 06/02/17 at 10:00 p.m. a. The incident was immediately reported to the OSDH. b. A thorough investigation was initiated and recorded by the administrator. c. Residents were protected from potential further abuse pending the outcome of the investigation. d. All facility staff who were working were inserviced regarding the facility's abuse policy and procedure and, specifically, to inform their supervisor or the administrator/designated person of any allegation of abuse, neglect, mistreatment, exploitation, or misappropriation. All staff who were not inserviced on 06/02/17 were inserviced when they arrived at the facility for their next scheduled shift and before they reported to their assigned work station. On 07/24/17, the surveyor verified the reporting and investigation of the allegation of abuse. Interviews were conducted with seven facility staff to verify their attendance at the inservice and their understanding of the facility's abuse policy and procedure. The surveyor reviewed four allegations of abuse/neglect which had been reported at the facility since 06/02/17. In all cases, the facility had followed its abuse policy and procedure to report, protect and investigate. Thorough investigations had been conducted. The past non-compliance IJ was determined to exist from 05/23/17 at 8:46 a.m., when the charge nurse documented in a nurse's note a resident's family member had reported an allegation of abuse, to 06/02/17 at 10:00 p.m., when all staff had been inserviced regarding the facility's abuse policy and procedure. Based on record review and interview, it was determined the facility failed to: a. ensure an allegation of abuse was reported immediately to the administrator/designee; b. report the allegation of abuse to the OSDH within 24 hours; c. ensure residents were protected from potential further abuse pending the outcome of an investigation; d. conduct a thorough investigation; and e. report the results of the investigation to the OSDH within 5 working days. for one (#1) of seven sampled residents for whom abuse or neglect was alleged. Fifty-six residents resided in the facility. Findings: The Abuse Investigation and Reporting policy and procedure documented the following: All reports of resident abuse, neglect, exploitation of resident property, mistreatment .shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported. Role of the Administrator or designee: A. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator or designee will assign the investigation to an appropriate individual .E. The Administrator or designee will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented . Reporting A. All reports of resident abuse, neglect .mistreatment .will be reported by the community Administrator, or his/her designee, to the following persons or agencies: 1. The State licensing/certification agency responsible for surveying/licensing the community .If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours .F. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident . The Abuse, Neglect and Exploitation Prevention Program policy and procedure documented: .As part of the resident abuse prevention, the administration will: .Develop and implement policies and procedures to aid our community in preventing abuse, neglect, or mistreatment of [REDACTED].Investigate and report any allegations of abuse within time frames as required by federal requirements .protect resident during abuse investigations . Resident #1 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 05/26/17, documented the resident had moderate cognitive impairment and required staff assistance to perform activities of daily living (ADL). The care plan, most recently reviewed/revised on 06/09/17, documented the resident had problems related to memory, impaired decision making skill and impaired ability to comprehend; requirement for assistance with ADL care; and potential for complications from diabetes. A nurse's note, dated 05/23/17 at 8:46 a.m., written by a licensed practical nurse (LPN) documented the resident's granddaughter had .verbalized concern that the resident states that there was a woman in her room attacking her, pulling at her clothes on Sunday (05/21/17). Resident was not able to verbalize time, or identity who was 'attacking' her. This nurse assure her that we would monitor more frequently and we would look further into the matter. There was no documentation which indicated the LPN had informed the administrator/designee about the allegation of abuse on 05/23/17. There was no documentation which indicated the alleged victim had been assessed/examined for signs of abuse. During review of the facility's reportable incidents, the surveyor found a combined initial and final report of the above allegation of abuse which had allegedly occurred on 05/21/17 and was reported to facility staff on 05/23/17. The report had been faxed to the OSDH on 06/02/17 at 6:24 p.m. and documented the allegation had not been substantiated. Attached to the report was documentation of the full investigation of the incident. On 07/24/17 at 2:53 p.m., the surveyor asked the current DON why the allegation of abuse had not been reported and investigated until 06/02/17. She stated she had read the nurse's note, dated 05/23/17, about the allegation of abuse on 05/30/17 and had reported it to the previous DON and to the corporate registered nurse (RN). She stated the corporate RN told the DON to start the investigation. The current DON stated the facility did not have a licensed administrator at the time and the previous DON had been the designated person for the abuse protocol. The current DON stated the previous DON had approached her on 06/02/17 and stated she had not reported the allegation of abuse or began an investigation. The current DON stated she then went to the new administrator and reported the allegation of abuse to her. The administrator, who started to work at the facility on 05/30/17, stated she was not informed about the allegation of abuse until 06/02/17, when the current DON informed her. The administrator was asked how long the facility did not have a licensed administrator. She stated the previous administrator's last day to work was 05/05/17 and she had started to work on 05/30/17. At 5:11 p.m., during an interview with the administrator and the DON, the surveyor asked who, in the absence of a licensed administrator, was the person designated to be responsible for the abuse protocol and to implement the facility's abuse policy and procedure if necessary. She stated, The DON. The administrator was asked if the allegation of abuse had been reported to the DON on 05/23/17, when it became known to the LPN. She stated, Not that we know of. The surveyor asked if the allegation of abuse was reported to the OSDH within 24 hours after the facility became aware of it. The administrator stated, No. The surveyor asked if residents had been protected from further potential abuse between 05/23/17 and 06/02/17. She stated, No. The administrator was asked if a thorough investigation had been conducted and the final report sent to OSDH within 5 working days. She stated, No. The administrator was asked if the facility's abuse policy and procedure to immediately report an allegation of abuse to the administrator/designee, protect residents from further potential abuse, and to report the findings of a thorough investigation of the allegation to the OSDH within 5 working days had been followed. She stated, No. The surveyor asked if the facility was administered effectively and efficiently regarding the allegation of abuse and the implementation of the facility's abuse policy and procedure. The administrator stated, No.

On 07/24/17, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement their abuse policies to ensure allegations of abuse were immediately reported to administration, ensure residents were protected from potential further abuse pending completion of an investigation, and to investigate an allegation of resident abuse. The Oklahoma State Department of Health (OSDH) verified the existence of the past non-compliance IJ. At 5:18 p.m., the administrator and director of nurses (DON) were notified of the past-noncompliance IJ situation related to the facility's failure to implement their abuse policies to ensure allegations of abuse were immediately reported to administration, ensure residents were protected from potential further abuse pending completion of an investigation, and the failure to investigate an allegation of resident abuse reported to a charge nurse by a resident's family member on 05/23/17. The following corrective measures were completed as of 06/02/17 at 10:00 p.m. a. The incident was immediately reported to the OSDH. b. A thorough investigation was initiated and recorded by the administrator. c. Residents were protected from potential further abuse pending the outcome of the investigation. d. All facility staff who were working were inserviced regarding the facility's abuse policy and procedure and, specifically, to inform their supervisor or the administrator/designated person of any allegation of abuse, neglect, mistreatment, exploitation, or misappropriation. All staff who were not inserviced on 06/02/17 were inserviced when they arrived at the facility for their next scheduled shift and before they reported to their assigned work station. On 07/24/17, the surveyor verified the reporting and investigation of the allegation of abuse. Interviews were conducted with seven facility staff to verify their attendance at the inservice and their understanding of the facility's abuse policy and procedure. The surveyor reviewed four allegations of abuse/neglect which had been reported at the facility since 06/02/17. In all cases, the facility had followed its abuse policy and procedure to report, protect and investigate. Thorough investigations had been conducted. The past non-compliance IJ was determined to exist from 05/23/17 at 8:46 a.m., when the charge nurse documented in a nurse's note a resident's family member had reported an allegation of abuse, to 06/02/17 at 10:00 p.m., when all staff had been inserviced regarding the facility's abuse policy and procedure. Based on record review and interview, it was determined the facility failed to implement their abuse policies to: a. ensure an allegation of abuse was reported immediately to the administrator/designee; b. report the allegation of abuse to the OSDH within 24 hours; c. ensure residents were protected from potential further abuse pending the outcome of an investigation; d. conduct a thorough investigation; and e. report the results of the investigation to the OSDH within 5 working days. for one (#1) of seven sampled residents for whom abuse or neglect was alleged. Fifty-six residents resided in the facility. Findings: The Abuse Investigation and Reporting policy and procedure documented the following: All reports of resident abuse, neglect, exploitation of resident property, mistreatment .shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported. Role of the Administrator or designee: A. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator or designee will assign the investigation to an appropriate individual .E. The Administrator or designee will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented . Reporting A. All reports of resident abuse, neglect .mistreatment .will be reported by the community Administrator, or his/her designee, to the following persons or agencies: 1. The State licensing/certification agency responsible for surveying/licensing the community .If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours .F. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident . The Abuse, Neglect and Exploitation Prevention Program policy and procedure documented: .As part of the resident abuse prevention, the administration will: .Develop and implement policies and procedures to aid our community in preventing abuse, neglect, or mistreatment of [REDACTED].Investigate and report any allegations of abuse within time frames as required by federal requirements .protect resident during abuse investigations . Resident #1 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 05/26/17, documented the resident had moderate cognitive impairment and required staff assistance to perform activities of daily living (ADL). The care plan, most recently reviewed/revised on 06/09/17, documented the resident had problems related to memory, impaired decision making skill and impaired ability to comprehend; requirement for assistance with ADL care; and potential for complications from diabetes. A nurse's note, dated 05/23/17 at 8:46 a.m., written by a licensed practical nurse (LPN) documented the resident's granddaughter had .verbalized concern that the resident states that there was a woman in her room attacking her, pulling at her clothes on Sunday (05/21/17). Resident was not able to verbalize time, or identity who was 'attacking' her. This nurse assure her that we would monitor more frequently and we would look further into the matter. There was no documentation which indicated the LPN had informed the administrator/designee about the allegation of abuse on 05/23/17. There was no documentation which indicated the alleged victim had been assessed/examined for signs of abuse. During review of the facility's reportable incidents, the surveyor found a combined initial and final report of the above allegation of abuse which had allegedly occurred on 05/21/17 and was reported to facility staff on 05/23/17. The report had been faxed to the OSDH on 06/02/17 at 6:24 p.m. and documented the allegation had not been substantiated. Attached to the report was documentation of the full investigation of the incident. On 07/24/17 at 2:53 p.m., the surveyor asked the current DON why the allegation of abuse had not been reported and investigated until 06/02/17. She stated she had read the nurse's note, dated 05/23/17, about the allegation of abuse on 05/30/17 and had reported it to the previous DON and to the corporate registered nurse (RN). She stated the corporate RN told the DON to start the investigation. The current DON stated the facility did not have a licensed administrator at the time and the previous DON had been the designated person for the abuse protocol. The current DON stated the previous DON had approached her on 06/02/17 and stated she had not reported the allegation of abuse or began an investigation. The current DON stated she then went to the new administrator and reported the allegation of abuse to her. The administrator, who started to work at the facility on 05/30/17, stated she was not informed about the allegation of abuse until 06/02/17, when the current DON informed her. The administrator was asked how long the facility did not have a licensed administrator. She stated the previous administrator's last day to work was 05/05/17 and she had started to work on 05/30/17. At 5:11 p.m., during an interview with the administrator and the DON, the surveyor asked who, in the absence of a licensed administrator, was the person designated to be responsible for the abuse protocol and to implement the facility's abuse policy and procedure if necessary. She stated, The DON. The administrator was asked if the allegation of abuse had been reported to the DON on 05/23/17, when it became known to the LPN. She stated, Not that we know of. The surveyor asked if the allegation of abuse was reported to the OSDH within 24 hours after the facility became aware of it. The administrator stated, No. The surveyor asked if residents had been protected from further potential abuse between 05/23/17 and 06/02/17. She stated, No. The administrator was asked if a thorough investigation had been conducted and the final report sent to OSDH within 5 working days. She stated, No. The administrator was asked if the facility's abuse policy and procedure to immediately report an allegation of abuse to the administrator/designee, protect residents from further potential abuse, and to report the findings of a thorough investigation of the allegation to the OSDH within 5 working days had been followed. She stated, No. The surveyor asked if the facility was administered effectively and efficiently regarding the allegation of abuse and the implementation of the facility's abuse policy and procedure. The administrator stated, No.

On 07/24/17, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have a licensed administrator between 05/06/17 and 05/29/17; and to ensure administration was effective and efficient to implement their abuse policies to ensure allegations of abuse were immediately reported to administration, ensure residents were protected from potential further abuse pending completion of an investigation, and to investigate an allegation of resident abuse. The Oklahoma State Department of Health (OSDH) verified the existence of the past non-compliance IJ. At 5:18 p.m., the administrator and director of nurses (DON) were notified of the past-noncompliance IJ situation related to the facility's failure to have a licensed administrator and to ensure the facility was administered effectively and efficiently to ensure allegations of abuse were immediately reported to administration, ensure residents were protected from potential further abuse pending completion of an investigation, and to investigate an allegation of resident abuse reported to a charge nurse by a resident's family member on 05/23/17. The following corrective measures were completed as of 06/02/17 at 10:00 p.m. a. The incident was immediately reported to the OSDH. b. A thorough investigation was initiated and recorded by the administrator. c. Residents were protected from potential further abuse pending the outcome of the investigation. d. All facility staff who were working were inserviced regarding the facility's abuse policy and procedure and, specifically, to inform their supervisor or the administrator/designated person of any allegation of abuse, neglect, mistreatment, exploitation, or misappropriation. All staff who were not inserviced on 06/02/17 were inserviced when they arrived at the facility for their next scheduled shift and before they reported to their assigned work station. On 07/24/17, the surveyor verified the reporting and investigation of the allegation of abuse. Interviews were conducted with seven facility staff to verify their attendance at the inservice and their understanding of the facility's abuse policy and procedure. The surveyor reviewed four allegations of abuse/neglect which had been reported at the facility since 06/02/17. In all cases, the facility had followed its abuse policy and procedure to report, protect and investigate. Thorough investigations had been conducted. The past non-compliance IJ was determined to exist from 05/23/17 at 8:46 a.m., when the charge nurse documented in a nurse's note a resident's family member had reported an allegation of abuse, to 06/02/17 at 10:00 p.m., when all staff had been inserviced regarding the facility's abuse policy and procedure. Based on record review and interview, it was determined the facility failed to have a licensed administrator between 05/06/17 and 05/29/17; and to ensure administration was effective and efficient to implement their abuse policies to: a. ensure an allegation of abuse was reported immediately to the administrator/designee; b. report the allegation of abuse to the OSDH within 24 hours; c. ensure residents were protected from potential further abuse pending the outcome of an investigation; d. conduct a thorough investigation; and e. report the results of the investigation to the OSDH within 5 working days. for one (#1) of seven sampled residents for whom abuse or neglect was alleged. Fifty-six residents resided in the facility. Findings: The Abuse Investigation and Reporting policy and procedure documented the following: All reports of resident abuse, neglect, exploitation of resident property, mistreatment .shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported. Role of the Administrator or designee: A. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator or designee will assign the investigation to an appropriate individual .E. The Administrator or designee will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented . Reporting A. All reports of resident abuse, neglect .mistreatment .will be reported by the community Administrator, or his/her designee, to the following persons or agencies: 1. The State licensing/certification agency responsible for surveying/licensing the community .If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours .F. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident . The Abuse, Neglect and Exploitation Prevention Program policy and procedure documented: .As part of the resident abuse prevention, the administration will: .Develop and implement policies and procedures to aid our community in preventing abuse, neglect, or mistreatment of [REDACTED].Investigate and report any allegations of abuse within time frames as required by federal requirements .protect resident during abuse investigations . Resident #1 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 05/26/17, documented the resident had moderate cognitive impairment and required staff assistance to perform activities of daily living (ADL). The care plan, most recently reviewed/revised on 06/09/17, documented the resident had problems related to memory, impaired decision making skill and impaired ability to comprehend; requirement for assistance with ADL care; and potential for complications from diabetes. A nurse's note, dated 05/23/17 at 8:46 a.m., written by a licensed practical nurse (LPN) documented the resident's granddaughter had .verbalized concern that the resident states that there was a woman in her room attacking her, pulling at her clothes on Sunday (05/21/17). Resident was not able to verbalize time, or identity who was 'attacking' her. This nurse assure her that we would monitor more frequently and we would look further into the matter. There was no documentation which indicated the LPN had informed the administrator/designee about the allegation of abuse on 05/23/17. There was no documentation which indicated the alleged victim had been assessed/examined for signs of abuse. During review of the facility's reportable incidents, the surveyor found a combined initial and final report of the above allegation of abuse which had allegedly occurred on 05/21/17 and was reported to facility staff on 05/23/17. The report had been faxed to the OSDH on 06/02/17 at 6:24 p.m. and documented the allegation had not been substantiated. Attached to the report was documentation of the full investigation of the incident. On 07/24/17 at 2:53 p.m., the surveyor asked the current DON why the allegation of abuse had not been reported and investigated until 06/02/17. She stated she had read the nurse's note, dated 05/23/17, about the allegation of abuse on 05/30/17 and had reported it to the previous DON and to the corporate registered nurse (RN). She stated the corporate RN told the DON to start the investigation. The current DON stated the facility did not have a licensed administrator at the time and the previous DON had been the designated person for the abuse protocol. The current DON stated the previous DON had approached her on 06/02/17 and stated she had not reported the allegation of abuse or began an investigation. The current DON stated she then went to the new administrator and reported the allegation of abuse to her. The administrator, who started to work at the facility on 05/30/17, stated she was not informed about the allegation of abuse until 06/02/17, when the current DON informed her. The administrator was asked how long the facility did not have a licensed administrator. She stated the previous administrator's last day to work was 05/05/17 and she had started to work on 05/30/17. At 5:11 p.m., during an interview with the administrator and the DON, the surveyor asked who, in the absence of a licensed administrator, was the person designated to be responsible for the abuse protocol and to implement the facility's abuse policy and procedure if necessary. She stated, The DON. The administrator was asked if the allegation of abuse had been reported to the DON on 05/23/17, when it became known to the LPN. She stated, Not that we know of. The surveyor asked if the allegation of abuse was reported to the OSDH within 24 hours after the facility became aware of it. The administrator stated, No. The surveyor asked if residents had been protected from further potential abuse between 05/23/17 and 06/02/17. She stated, No. The administrator was asked if a thorough investigation had been conducted and the final report sent to OSDH within 5 working days. She stated, No. The administrator was asked if the facility's abuse policy and procedure to immediately report an allegation of abuse to the administrator/designee, protect residents from further potential abuse, and to report the findings of a thorough investigation of the allegation to the OSDH within 5 working days had been followed. She stated, No. The surveyor asked if the facility was administered effectively and efficiently regarding the allegation of abuse and the implementation of the facility's abuse policy and procedure. The administrator stated, No.

On 02/01/17 an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to ensure a resident with heart failure received medication as ordered by the physician. At 12:30 p.m., the administrator, DON, corporate nurse, and PRN RN were informed of the IJ situation related to the facility's failure to provide the necessary care and services to the resident. At 5:00 p.m., the administrator provided the survey team with an acceptable plan of removal. The plan of removal documented the following: Via Christi Village Ponca City strives to ensure that necessary care and services are provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all residents who reside within the community. Via Christi Village Ponca City strives to ensure that residents are free from medication errors. Via Christi Village Ponca City strives to ensure that pharmaceutical services meet the needs of each resident. In order to prevent future occurrence of the noted deficient practice, education will be provided to the clinical team regarding completion of accurate assessments including physical assessments, documentation requirements of these assessments and development of the plan of care and interventions related to assessment findings. Education will be provided to the clinical team regarding processing of physician orders [REDACTED]. Education will also be provided regarding documentation requirements of medication administration and a shift to shift auditing expectation for missing documentation. The community will complete an accurate and comprehensive physical assessment for all residents. Documentation of the assessment will be placed in the clinical record. A plan of care will be reviewed and revised if needed for each resident according to the assessment results and interventions initiated as necessary. The community will complete an audit of current physician orders, electronic medical record and medication administration record to ensure accuracy. Any identified errors will be corrected immediately. A process will be put in place and include an order auditing process that consist of a night shift order check review and a triple check process that will be completed by nursing leadership and or assigned designee. This will involve all orders being placed in a processed order folder that will be checked by the night shift and then sent to community leadership for the triple check. A shift to shift hand off process to identify missing documentation in the administration records will be put in place in order to prevent future occurrence. The items defined above will be completed by midnight on 02/01/2017. Staff interviews were conducted on 02/02/17 at 11:00 a.m. related to the content of the inservice they attended on 02/01/17. The immediate jeopardy was removed on 02/01/17 at 12:00 a.m., after all components of the plan of removal were carried out. The deficient practice remained at a level of actual harm, isolated. Based on record review and staff interviews, it was determined the facility failed to have pharmacy procedures in place to ensure: ~ Lasix was administered as ordered by the physician for two (#20 and #86) of 11 sampled residents who were reviewed for medication administration; and ~ the time of administration for Ditropan was changed from morning to bedtime as ordered by the physician for one (#86) of 11 sampled residents who were reviewed for medication administration. The facility identified 60 residents who received medications, 24 residents who received Lasix and five residents who received Ditropan. Findings: A Charting of Medications policy, dated 04/30/10, documented, .Medications administered to a resident will be documented in the resident's medical records .The record must include, as a minimum .Reason medication withheld or not administered . An Administration of Medications-General policy, dated 10/30/12, documented, .Medications must be administered as prescribed by the ordering physician .Medications must be administered in accordance with the written orders of the ordering physician .Should a medication be withheld, the licensed nurse or CMA must initial and circle the MAR space provided for that particular drug .An explanatory note is entered on the reverse side of the record provided for PRN documentation .The person administering must enter an explanatory note on the reverse side of the MAR when drugs are withheld .Nursing staff should notify the ordering physician when medications are .withheld consistently . 1. Resident #20 had [DIAGNOSES REDACTED]. An admission assessment, dated 11/17/16, documented the resident was independent in cognitive skills for daily decision making. He required limited assistance for transfers, dressing, personal hygiene, bathing, bed mobility, and toilet use. He had taken a diuretic the last seven days. A care plan, effective 11/23/16, documented, .Problems .DISEASES AND CONDITIONS .Goals .I will have my health care needs met through interventions from staff .Interventions .DX: HEART FAILURE .CHRONIC OBSTRUCTIVE PULMONARY DISEASE .HYPERTENSION .EDEMA .administer meds as directed . The resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. A post-hospital physician's orders [REDACTED].Diagnosis .Heart Failure .Daily wt . The resident was to be administered 80mg of Lasix in the morning and 40mg of Lasix at noon. A Record of Physician's Office Visit, dated 01/05/17, documented, .mild edema .New Orders .Lasix 40 mg 3 daily for 5 days, then back to 2 daily. A MAR for January 2017, documented an order, dated 01/05/17, for Lasix 40 mg three times daily at 8:00 a.m., 2:00 p.m., and 8:00 p.m., for five days with the dates 01/06/17-01/10/17 marked to be given. No doses were documented as given on 01/06/17 in these entries. (It was documented the resident received the previously ordered dose of 80mg of Lasix at 8:00 a.m.) The 8:00 a.m. and 8:00 p.m. doses were documented as given on 01/07/17. The 8:00 p.m. dose was documented as given on 01/08/17. OOF (out of facility) was documented for the 8:00 p.m. dose on 01/09/17. No doses were documented as given on 01/10/17. Eleven doses were left blank. The PRN Administration Record did not document why the doses of Lasix were not given. A significant change assessment, dated 01/08/17, documented the resident was independent in cognitive skills for daily decision making. He required limited assistance for transfers, dressing, personal hygiene, bathing, bed mobility, and toilet use. He had taken a diuretic the last seven days. A nurse's note, dated 01/09/17, documented the resident had a fall and was complaining of being short of breath. His oxygen saturation was in the 70's. It documented, .resident transported to ER .@ 1120 . A nurse's note, dated 01/09/17 at 2:12 p.m., documented, .Returned to facility . A nurse's note, dated 01/09/17 at 8:20 p.m., documented the resident was gulping for air .O2 Sat obtained at 69%. Unresponsive. Pale. Flaccid .EMT's arrived .Resident .verbalize that he wanted to go ahead and go to ER . A nurse's note, dated 01/10/17 at 9:08 a.m., documented, .spoke to .med /surg .She stated he is under Observation at this time came to us from ER At 11:40pm . A nurse's note, dated 01/11/17 at 9:01 a.m., documented, .spoke to .med surg this morning to see how he is .has fluid on his lungs .should be changed to admitted today . A nurse's note, dated 01/11/17 at 2:47 p.m., documented, .spoke to med /surg .now is inpatient .will be having a drain placed Friday to drain fluid off lungs . A readmission nurse's note, dated 01/13/17 at 1:40 p.m., documented, .Resident stated that he had fluid removed from lungs at hospital. Dismissed with DX of pleural effusion . A post-hospital physician's orders [REDACTED].Weight .HEART FAILURE .One Time Daily .Lasix 80mg .am .40mg .noon . On 01/16/17 the resident was sent to the hospital for a chest x-ray. He was diagnosed with [REDACTED]. A nurse's note, dated 01/26/17 at 1:45 a.m., documented, .Resp. have stopped. no heartbeat noted .order to release body to funeral home . The nurses' notes did not document why the doses of Lasix 40 mg three times a day were not given from 01/06/17 through 01/09/17. On 01/31/17 at 3:22 p.m., LPN #1 was asked how many doses of Lasix the resident received between 01/06/17 and 01/10/17. She looked at the MAR and stated it looked like he only got three. She was asked how many doses he missed. She stated he was supposed to get 15, so he missed 12. She was asked why he missed the doses. She stated he had left for the hospital on the ninth. She was asked why he missed the other doses. She looked at the previous Lasix order and stated he had received the old dose of 80 mg on the morning of the sixth as it was initialed by staff, he did get 80 mg on the sixth all in one dose, so he missed 40 mg that day. She was asked how they documented when a resident missed a dose of medication. She stated they would write it on the prn sheet, but from looking at this, there was nothing written on the prn sheet. She stated around that time they had sent him out multiple times. At 3:42 p.m., LPN #2 was asked if the resident received his Lasix between 01/06/17 and 01/10/17. She looked at the MAR and stated there was no way of knowing if it was given or not. It was either given and not signed out or it was missed. If it was a pharmacy problem, they would have documented on the prn sheet they were waiting on the pharmacy. At 4:54 p.m., the DON was asked if the resident received Lasix from 01/06/17 through 01/10/17. She looked at the MAR and stated he missed two doses on the sixth because he took it that morning at the old dosage, he missed one on the seventh, two on the eighth, and she would have to look at the times he was in the hospital on the ninth and tenth. On 02/02/17 at 9:35 a.m., the DON was asked if it was acceptable if a resident missed a dose of medication and no documentation was found to explain why. She stated no, the entry should have been initialed and circled and documented on the PRN sheet why it was not given. 2. Resident #86 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Ditropan ER (Oxybutynin) 5 mg (1) Oral .One Time Daily .URINARY INCONTINENCE . A form, titled Consultant Pharmacist Recommendations, dated 10/11/16, documented, .(resident name deleted) is currently taking oxybutynin for urinary incontinence. This medication is on the BEERS list due to its anticholinergic effects .Would you like to change to another medication for this indication or change the time of administration to bedtime so that if there are anticholinergic effects then they would be most likely be when the patient is asleep? .Modifications as follows: may (change) dosing time to q HS . It was signed by the physician and dated 11/01/16. A Record of Physician's Office Visit, dated 11/02/16, documented, .New Orders .Lasix 20 mg q AM PRN Wt > 170 lbs hold for Wt < 160 lbs . A clinical note, dated 11/02/16, documented, .res returned from phys. order for Lasix 20 mg one every am wt greater than 170. Hold for wt below 160 . The MAR for November 2016 documented, .Ditropan ER (Oxybutynin) 5 mg (1) One Time Daily AM . It was documented as given in the morning every day in November. The Lasix 20 mg q AM PRN was not documented on the MAR. A quarterly assessment, dated 11/16/16, documented the resident had not been administered a diuretic in the last seven days. She was occasionally incontinent of urine. The care plan, dated 11/28/16, documented, .Problems .BLADDER AND BOWEL STATUS .Goals .Will maintain current level of urinary function .Interventions .I take Ditropan ER for my urinary incontinence . The MAR for December 2016 documented, .Ditropan ER (Oxybutynin) 5 mg (1) One Time Daily AM . It was documented as given in the morning every day she was in the facility in December. A PRN Administration Record, dated 12/01/16, documented, .Lasix 20 mg PO not given, awaiting pharmacy . A Nurse/Physician Fax Communication, dated 12/07/16, documented, .We received your order for Lasix 20 mg daily for weights greater than 170 lbs, but it was not written on the MAR and the resident didn't receive the Lasix from the order date (11-2-16) until the new MAR printed on December 1st . It was signed by the physician and dated 12/09/16. A Safety Event Entry, dated 12/07/16, documented, .On 11/2/2016 an order was received for Lasix 20 mg to be given for weight above 170# and held if weight less than 160#. (LPN name deleted) signed the order, but it was not written on the November MAR, and wasn't given until the MAR for December was printed and the error discovered . A physician's orders [REDACTED].Clarification order- Lasix 20 mg 1 PO q AM hold Lasix if wgt less than 160 lbs . The MAR for December 2016 documented, .Lasix 20 mg 1 PO q AM hold if weight less than 160 lbs 12-7-16 . It was documented as given in the morning from 12/07/16 through 12/27/16 and 12/31/16. It was documented that she was out of the facility from 12/28/16 through 12/30/16. The MAR for January 2017 documented, .Ditropan ER (Oxybutynin) 5 mg (1) One Time Daily AM . It was documented as given in the morning every day in January. On 01/30/17 at 3:31 p.m., CMA #1 was asked when the Lasix was ordered. She stated, 11/02/16. She was asked when the resident started taking the Lasix. She stated, 12/03/16. She was asked if the resident received the Lasix in November. She stated, It's not on the November MAR. She was asked why the Lasix was not given in November. She stated she did not know. She then reviewed the December PRN Administration Record and stated, Not given, waiting on pharmacy on the first and it doesn't say anything about the second. She further stated it meant they had ordered the medication, but was waiting on the pharmacy to deliver it and they usually received it on the same day. She was asked when the Lasix should have been started. She stated, 11/02/16. She was asked what time the Ditropan was being given. She stated, In the morning. She was asked if the Ditropan had always been given in the morning. She stated, Yes. At 3:40 p.m., LPN #4 was asked what their process was for transcribing orders. She stated they took the order, faxed the order to the pharmacy, made a copy of the order and put the order inside the DON's box. They put a nurse notation in the computer, notified the family and resident, put it on the order section in the computer to allow it to print on the new MAR, and wrote it on the MAR or TAR. She was asked how they ensured medications were given as ordered. She stated new orders were flagged on the MAR and the pharmacy was notified to deliver the medication that day. She was asked what waiting on pharmacy meant. She stated sometimes they had to wait a few days for medications for different reasons. She was asked how long they waited before they called the pharmacy again. She stated if there was a circled notation documenting they were awaiting the pharmacy to deliver the medication, she would call about it to find out what was going on and why they had not received the medication. She was asked why the Lasix was not started until December. She stated, I guess somebody forgot to put it on the MAR. She was asked when the Lasix should have been started. She stated, 11/02/16. She was asked what their process was for transcribing orders. She stated they took the order, faxed the order to the pharmacy, made a copy of the order and put the order inside the DON's box. They put a nurse notation in the computer, notified the family and resident, put it on the order section in the computer to allow it to print on the new MAR, and put it on the MAR or TAR. She was asked what the physician replied on the consultant pharmacist recommendations, dated 10/11/16, for Oxybutynin/Ditropan. She looked at the form and stated, Change the time to HS. She was asked what time the Ditropan was being given. She stated, AM, they never changed it. She was asked when the Ditropan should be given. She stated, HS. She was asked who was responsible for making sure orders were noted and carried out. She stated the charge nurse that noted the order. When they noted an order, it meant everything had been taken care of for that order. At 4:01 p.m., the DON was asked what their process was for transcribing orders. She stated the nurse took the order and noted it, put it into the computer under orders, handwrote it on the MAR and/or TAR, noted it in the computer and faxed the order to the pharmacy. She was asked about the resident not receiving the Lasix when the order was received on 11/02/16. She stated the error was found while reconciling the December MARs. The nurse reported it to the physician on 12/07/16. She was asked what their process was for transcribing orders. She stated the nurse took the order and noted it, put it into computer under orders, handwrote it on the MAR and/or TAR, noted it in the computer and faxed the order to the pharmacy. She was asked what their process was when a physician wrote an order on the consultant pharmacist recommendattion. She stated it was the charge nurse's responsibility to note any orders. On 02/02/17 at 9:35 a.m., the DON was asked if it was acceptable if a resident missed a dose of medication and no documentation was found to explain why. She stated no, the entry should have been initialed and circled and documented on the PRN sheet why it was not given.

On 02/01/17 an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to ensure a resident with heart failure was free from a significant medication error. The facility failed to provide services to administer [MEDICATION NAME] as ordered by the physician. At 12:30 p.m., the administrator, DON, corporate nurse, and PRN RN were informed of the IJ situation related to the facility's failure to provide the necessary care and services to the resident. At 5:00 p.m., the administrator provided the survey team with an acceptable plan of removal. The plan of removal documented the following: Via Christi Village Ponca City strives to ensure that necessary care and services are provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all residents who reside within the community. Via Christi Village Ponca City strives to ensure that residents are free from medication errors. Via Christi Village Ponca City strives to ensure that pharmaceutical services meet the needs of each resident. In order to prevent future occurrence of the noted deficient practice, education will be provided to the clinical team regarding completion of accurate assessments including physical assessments, documentation requirements of these assessments and development of the plan of care and interventions related to assessment findings. Education will be provided to the clinical team regarding processing of physician orders [REDACTED]. Education will also be provided regarding documentation requirements of medication administration and a shift to shift auditing expectation for missing documentation. The community will complete an accurate and comprehensive physical assessment for all residents. Documentation of the assessment will be placed in the clinical record. A plan of care will be reviewed and revised if needed for each resident according to the assessment results and interventions initiated as necessary. The community will complete an audit of current physician orders, electronic medical record and medication administration record to ensure accuracy. Any identified errors will be corrected immediately. A process will be put in place and include an order auditing process that consist of a night shift order check review and a triple check process that will be completed by nursing leadership and or assigned designee. This will involve all orders being placed in a processed order folder that will be checked by the night shift and then sent to community leadership for the triple check. A shift to shift hand off process to identify missing documentation in the administration records will be put in place in order to prevent future occurrence. The items defined above will be completed by midnight on 02/01/2017. Staff interviews were conducted on 02/02/17 at 11:00 a.m. related to the content of the inservice they attended on 02/01/17. The immediate jeopardy was removed on 02/01/17 at 12:00 a.m., after all components of the plan of removal were carried out. The deficient practice remained isolated at a level of actual harm. Based on record review and staff interviews, it was determined the facility failed to ensure a resident was free from a significant medication error. The facility failed to administer [MEDICATION NAME] as ordered by the physician for a resident with a [DIAGNOSES REDACTED].#20) of 11 sampled residents who were reviewed for medication administration. The facility identified 60 residents who received medications and 24 residents who received [MEDICATION NAME]. Findings: A Charting of Medications policy, dated 04/30/10, documented, .Medications administered to a resident will be documented in the resident's medical records .The record must include, as a minimum .Reason medication withheld or not administered . An Administration of Medications-General policy, dated 10/30/12, documented, .Medications must be administered as prescribed by the ordering physician .Medications must be administered in accordance with the written orders of the ordering physician .Should a medication be withheld, the licensed nurse or CMA must initial and circle the MAR space provided for that particular drug .An explanatory note is entered on the reverse side of the record provided for PRN documentation .The person administering must enter an explanatory note on the reverse side of the MAR when drugs are withheld .Nursing staff should notify the ordering physician when medications are .withheld consistently . Resident #20 had [DIAGNOSES REDACTED]. An admission assessment, dated 11/17/16, documented the resident was independent in cognitive skills for daily decision making. He required limited assistance for transfers, dressing, personal hygiene, bathing, bed mobility, and toilet use. He had taken a diuretic the last seven days. A care plan, dated 11/23/16, documented, .Problems .DISEASES AND CONDITIONS .Goals .I will have my health care needs met through interventions from staff .Interventions .DX: HEART FAILURE .[MEDICAL CONDITION] .HYPERTENSION .[MEDICAL CONDITION] .administer meds as directed . The resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. A post-hospital physician's orders [REDACTED].Diagnosis .Heart Failure .Daily wt . The resident was to be administered 80mg of [MEDICATION NAME] in the morning and 40mg of [MEDICATION NAME] at noon. A Record of Physician's Office Visit, dated 01/05/17, documented, .mild [MEDICAL CONDITION] .New Orders .[MEDICATION NAME] 40 mg 3 daily for 5 days, then back to 2 daily. A MAR, dated January 2017, documented an order, dated 01/05/17, for [MEDICATION NAME] 40 mg three times daily at 8:00 a.m., 2:00 p.m., and 8:00 p.m., for five days with the dates 01/06/17-01/10/17 marked to be given. No doses were documented as given on 01/06/17 in these entries. (It was documented the resident received the previously ordered dose of 80mg of [MEDICATION NAME] at 8:00 a.m.) The 8:00 a.m. and 8:00 p.m. doses were documented as given on 01/07/17. The 8:00 p.m. dose was documented as given on 01/08/17. OOF (out of facility) was documented for the 8:00 p.m. dose on 01/09/17. No doses were documented as given on 01/10/17. Eleven doses were left blank. The PRN Administration Record did not document why the doses of [MEDICATION NAME] were not given. A significant change assessment, dated 01/08/17, documented the resident was independent in cognitive skills for daily decision making. He required limited assistance for transfers, dressing, personal hygiene, bathing, bed mobility, and toilet use. He had taken a diuretic the last seven days. A nurse's note, dated 01/09/17, documented the resident had a fall and was complaining of being short of breath. His oxygen saturation was in the 70's. It documented, .resident transported to ER .@ 1120 . A nurse's note, dated 01/09/17 at 2:12 p.m., documented, .Returned to facility . A nurse's note, dated 01/09/17 at 8:20 p.m., documented the resident was gulping for air .O2 Sat obtained at 69%. Unresponsive. Pale. Flaccid .EMT's arrived .Resident .verbalize that he wanted to go ahead and go to ER . A nurse's note, dated 01/10/17 at 9:08 a.m., documented, .spoke to .med /surg .She stated he is under Observation at this time came to us from ER At 11:40pm . A nurse's note, dated 01/11/17 at 9:01 a.m., documented, .spoke to .med surg this morning to see how he is .has fluid on his lungs .should be changed to admitted today . A nurse's note, dated 01/11/17 at 2:47 p.m., documented, .spoke to med /surg .now is inpatient .will be having a drain placed Friday to drain fluid off lungs . A readmission nurse's note, dated 01/13/17 at 1:40 p.m., documented, .Resident stated that he had fluid removed from lungs at hospital. Dismissed with DX of pleural effusion . A post-hospital physician's orders [REDACTED].Weight .HEART FAILURE .One Time Daily .[MEDICATION NAME] 80mg .am .40mg .noon . On 01/16/17 the resident was sent to the hospital for a chest x-ray. He was diagnosed with [REDACTED]. A nurse's note, dated 01/26/17 at 1:45 a.m., documented, .Resp. have stopped. no heartbeat noted .order to release body to funeral home . The nurses' notes did not document why the doses of [MEDICATION NAME] 40 mg three times a day were not given from 01/06/17 through 01/09/17. On 01/31/17 at 3:22 p.m., LPN #1 was asked how many doses of [MEDICATION NAME] the resident received between 01/06/17 and 01/10/17. She looked at the MAR and stated it looked like he only got three. She was asked how many doses he missed. She stated he was supposed to get 15, so he missed 12. She was asked why he missed the doses. She stated he had left for the hospital on the ninth. She was asked why he missed the other doses. She looked at the previous [MEDICATION NAME] order and stated he had received the old dose of 80 mg on the morning of the sixth as it was initialed by staff, he did get 80 mg on the sixth all in one dose, so he missed 40 mg that day. She was asked how they documented when a resident missed a dose of medication. She stated they would write it on the prn sheet, but from looking at this, there was nothing written on the prn sheet. She stated around that time they had sent him out multiple times. At 3:42 p.m., LPN #2 was asked if the resident received his [MEDICATION NAME] between 01/06/17 and 01/10/17. She looked at the MAR and stated there was no way of knowing if it was given or not. It was either given and not signed out or it was missed. If it was a pharmacy problem, they would have documented on the prn sheet they were waiting on the pharmacy. At 4:54 p.m., the DON was asked if the resident received [MEDICATION NAME] from 01/06/17 through 01/10/17. She looked at the MAR and stated he missed two doses on the sixth because he took it that morning at the old dosage, he missed one on the seventh, two on the eighth, and she would have to look at the times he was in the hospital on the ninth and tenth. On 02/02/17 at 9:35 a.m., the DON was asked if it was acceptable if a resident missed a dose of medication and no documentation was found to explain why. She stated no, the entry should have been initialed and circled and documented on the PRN sheet why it was not given.

On 02/01/17 an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to provide timely and adequate monitoring and assessment of a resident with heart failure. The facility failed to provide the services of medication administration and daily weights as ordered by the physician. The facility failed to develop a complete comprehensive care plan for heart failure and adequately implement the plan of care for daily weights and medication administration. At 12:30 p.m., the administrator, director of nursing, corporate nurse, and prn registered nurse were informed of the IJ situation related to the facility's failure to provide the necessary care and services to the resident. At 5:00 p.m., the administrator provided the survey team with an acceptable plan of removal. The plan of removal documented the following: Via Christi Village Ponca City strives to ensure that necessary care and services are provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all residents who reside within the community. Via Christi Village Ponca City strives to ensure that residents are free from medication errors. Via Christi Village Ponca City strives to ensure that pharmaceutical services meet the needs of each resident. In order to prevent future occurrence of the noted deficient practice, education will be provided to the clinical team regarding completion of accurate assessments including physical assessments, documentation requirements of these assessments and development of the plan of care and interventions related to assessment findings. Education will be provided to the clinical team regarding processing of physician orders [REDACTED]. Education will also be provided regarding documentation requirements of medication administration and a shift to shift auditing expectation for missing documentation. The community will complete an accurate and comprehensive physical assessment for all residents. Documentation of the assessment will be placed in the clinical record. A plan of care will be reviewed and revised if needed for each resident according to the assessment results and interventions initiated as necessary. The community will complete an audit of current physician orders, electronic medical record and medication administration record to ensure accuracy. Any identified errors will be corrected immediately. A process will be put in place and include an order auditing process that consist of a night shift order check review and a triple check process that will be completed by nursing leadership and or assigned designee. This will involve all orders being placed in a processed order folder that will be checked by the night shift and then sent to community leadership for the triple check. A shift to shift hand off process to identify missing documentation in the administration records will be put in place in order to prevent future occurrence. The items defined above will be completed by midnight on 02/01/2017. Staff interviews were conducted on 02/02/17 at 11:00 a.m. related to the content of the inservice they attended on 02/01/17. The immediate jeopardy was removed on 02/01/17 at 12:00 a.m., after all components of the plan of removal were carried out. The deficient practice remained isolated at a level of actual harm. Based on record review and staff interviews, it was determined the facility failed to ~ provide timely and adequate monitoring and intervention, ~ assess weight, [MEDICAL CONDITION], and lung sounds, ~ develop a care plan for heart failure with interventions to maintain the resident's highest practicable well-being, ~ adequately implement the plan of care for daily weights and medication administration; and ~ provide the services for daily weights and medication administration as ordered by the physician for one (#20) of 31 sampled residents whose clinical records were reviewed for maintaining the resident's highest practicable well-being. The facility identified 60 residents who resided in the facility. Findings: A Charting of Medications policy, documented, .Medications administered to a resident will be documented in the resident's medical records .The record must include, as a minimum .Reason medication withheld or not administered . A Care Plans-Goals and Objectives policy, dated 05/03/10, documented, .It is the policy .that care plans incorporate goals and objectives which lead to the resident's highest obtainable level of independence . An Administration of Medications-General policy, documented, .Medications must be administered as prescribed by the ordering physician .Medications must be administered in accordance with the written orders of the ordering physician .Should a medication be withheld, the licensed nurse or CMA must initial and circle the MAR space provided for that particular drug .An explanatory note is entered on the reverse side of the record provided for PRN documentation .The person administering must enter an explanatory note on the reverse side of the MAR when drugs are withheld .Nursing staff should notify the ordering physician when medications are .withheld consistently . A Care Plans-Use of policy, documented, .Procedure .Staff members providing direct care for the resident are responsible for the information on the care plan relevant to their discipline . Resident #20 had [DIAGNOSES REDACTED]. An admission physician's orders [REDACTED].Weight .HEART FAILURE .One Time Daily . An admission assessment, dated 11/17/16, documented the resident was independent in cognitive skills for daily decision making. He required limited assistance for transfers, dressing, personal hygiene, bathing, bed mobility, and toilet use. He had taken a diuretic the last seven days. A care plan, dated 11/23/16, documented, .Problems .NUTRITION .Goals .I will maintain my current weight or gain weight .Interventions .Weigh me daily . Problems .DISEASES AND CONDITIONS .Goals .I will have my health care needs met through interventions from staff .Interventions .DX: HEART FAILURE .[MEDICAL CONDITION] .HYPERTENSION .[MEDICAL CONDITION] .administer meds as directed . The care plan did not include interventions for Heart Failure to assess the resident for [MEDICAL CONDITION] or adventitious lung sounds to monitor for fluid overload. The resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. A post-hospital physician's orders [REDACTED].Diagnosis .Heart Failure .Daily wt . The resident was to be administered 80mg of [MEDICATION NAME] in the morning and 40mg of [MEDICATION NAME] at noon. A Record of Physician's Office Visit, dated 01/05/17, documented, .mild [MEDICAL CONDITION] .New Orders .[MEDICATION NAME] 40 mg 3 daily for 5 days, then back to 2 daily. A MAR, dated January 2017, documented an order, dated 01/05/17, for [MEDICATION NAME] 40 mg three times daily at 8:00 a.m., 2:00 p.m., and 8:00 p.m., for five days with the dates 01/06/17-01/10/17 marked to be given. No doses were documented as given on 01/06/17 in these entries. (It was documented the resident received the previously ordered dose of 80mg of [MEDICATION NAME] at 8:00 a.m.) The 8:00 a.m. and 8:00 p.m. doses were documented as given on 01/07/17. The 8:00 p.m. dose was documented as given on 01/08/17. OOF (out of facility) was documented for the 8:00 p.m. dose on 01/09/17. No doses were documented as given on 01/10/17. Eleven doses were left blank. The PRN Administration Record did not document why the doses of [MEDICATION NAME] were not given. A significant change assessment, dated 01/08/17, documented the resident was independent in cognitive skills for daily decision making. He required limited assistance for transfers, dressing, personal hygiene, bathing, bed mobility, and toilet use. He had taken a diuretic the last seven days. A nurse's note, dated 01/09/17, documented the resident had a fall and was complaining of being short of breath. His oxygen saturation was in the 70's. It documented, .resident transported to ER .@ 1120 . A nurse's note, dated 01/09/17 at 2:12 p.m., documented, .Returned to facility . A nurse's note, dated 01/09/17 at 8:20 p.m., documented the resident was gulping for air .O2 Sat obtained at 69%. Unresponsive. Pale. Flaccid .EMT's arrived .Resident .verbalize that he wanted to go ahead and go to ER . A nurse's note, dated 01/10/17 at 9:08 a.m., documented, .spoke to .med /surg .She stated he is under Observation at this time came to us from ER At 11:40pm . A nurse's note, dated 01/11/17 at 9:01 a.m., documented, .spoke to .med surg this morning to see how he is .has fluid on his lungs .should be changed to admitted today . A nurse's note, dated 01/11/17 at 2:47 p.m., documented, .spoke to med /surg .now is inpatient .will be having a drain placed Friday to drain fluid off lungs . A readmission nurse's note, dated 01/13/17 at 1:40 p.m., documented, .Resident stated that he had fluid removed from lungs at hospital. Dismissed with DX of pleural effusion . A post-hospital physician's orders [REDACTED].Weight .HEART FAILURE .One Time Daily .[MEDICATION NAME] 80mg .am .40mg .noon . On 01/16/17 the resident was sent to the hospital for a chest x-ray. He was diagnosed with [REDACTED]. A nurse's note, dated 01/26/17 at 1:45 a.m., documented, .Resp. have stopped. no heartbeat noted .order to release body to funeral home . The nurses' notes did not document why the doses of [MEDICATION NAME] 40 mg three times a day were not given from 01/06/17 through 01/09/17. The weight records, dated 11/10/16 through 01/22/17, documented the resident was was only weighed 26 of 71 opportunities. Forty five entries documented, Not scheduled this time period. The nurses' notes, dated 11/10/16 through 01/26/17, only documented assessment of [MEDICAL CONDITION] three times and assessment of lung sounds eight times. The care plan did not include interventions for Heart Failure to assess the resident for [MEDICAL CONDITION] or adventitious lung sounds to monitor for fluid overload. On 01/31/17 at 3:22 p.m., LPN #1 was asked how many doses of [MEDICATION NAME] the resident received between 01/06/17 and 01/10/17. She looked at the MAR and stated it looked like he only got three. She was asked how many doses he missed. She stated he was supposed to get 15, so he missed 12. She was asked why he missed the doses. She stated he had left for the hospital on the ninth. She was asked why he missed the other doses. She looked at the previous [MEDICATION NAME] order and stated he had received the old dose of 80 mg on the morning of the sixth as it was initialed by staff, he did get 80 mg on the sixth all in one dose, so he missed 40 mg that day. She was asked how they documented when a resident missed a dose of medication. She stated they would write it on the prn sheet, but from looking at this, there was nothing written on the prn sheet. She stated around that time they had sent him out multiple times. At 3:42 p.m., LPN #2 was asked if the resident received his [MEDICATION NAME] between 01/06/17 and 01/10/17. She looked at the MAR and stated there was no way of knowing if it was given or not. It was either given and not signed out or it was missed. If it was a pharmacy problem, they would have documented on the prn sheet they were waiting on the pharmacy. At 4:28 p.m., LPN #1 was asked what interventions were in the care plan for heart failure. She looked at the care plan and stated to obtain labs, do vital signs, administer medications and treatments as directed, and report abnormals. She was asked what should be assessed for a resident with heart failure, who was prescribed [MEDICATION NAME]. She stated to listen to his lungs, check for [MEDICAL CONDITION], listen to his heart, and check his pulses. She was asked if his weight was obtained daily. She stated without seeing the TAR, she could not say. She was asked if he should have been assessed for [MEDICAL CONDITION] and lung sounds. She stated, Of course. She was asked if [MEDICAL CONDITION] and lung sounds were assessed, should it be documented. She stated, Yes. At 4:33 p.m., the MDS/Care Plan Coordinator was asked what interventions were in place for heart failure. She looked at the care plan and stated oxygen, medications, CBC every six months, to weigh daily a and heart healthy diet. She was asked if he was weighed daily. She looked in the computer and stated he was not weighed every day. She was asked what the interventions were for the use of [MEDICATION NAME]. She looked at the nutrition care plan and stated to encourage fluids, obtain labs and administer medications. She was asked if a resident with heart failure and prescribed [MEDICATION NAME] should be assessed for [MEDICAL CONDITION] and adventitious lung sounds. She stated, Yes. At 4:54 p.m., the DON was asked if the resident received [MEDICATION NAME] from 01/06/17 through 01/10/17. She looked at the MAR and stated he missed two doses on the sixth because he took it that morning at the old dosage, he missed one on the seventh, two on the eighth, and she would have to look at the times he was in the hospital on the ninth and tenth. She was asked if his weight was obtained daily. She stated, No, it was not done daily. She was asked if the care plan included interventions for assessing for [MEDICAL CONDITION] and listening to his lung sounds. She stated, No. She was asked if she thought it should include these interventions. She stated, Yes. On 02/02/17 at 9:35 a.m., the DON was asked if it was acceptable if a resident missed a dose of medication and no documentation was found to explain why. She stated no, the entry should have been initialed and circled and documented on the PRN sheet why it was not given. She was asked if a resident with heart failure and prescribed [MEDICATION NAME] should be assessed for [MEDICAL CONDITION] and lung sounds. She stated, Yes. She was asked how often it should be assessed. She stated every shift if they were in distress. She was asked if it should be documented. She stated yes, in the clinical notes. She was asked how they ensured care plans were implemented. She stated a resident care summary went into the computer so the aide and nurses could see it and document it. She was asked who was responsible for obtaining the resident's weights. She stated the aide could get the weights, but the charge nurse was responsible for making sure they were done. She was asked if the charge nurse was responsible for ensuring the weights were obtained daily. She stated, Yes.

Based on record review, observation and interview it was determined the facility failed to: ~ promote the healing of pressure ulcers for one (#1) of three sampled residents with pressure ulcers, ~ provide interventions to prevent the development or reoccurrence or worsening of pressure ulcers for one (#1) of three sampled residents with pressure ulcers, and ~ provide interventions to effectively promote the healing of pressure ulcers for one (#1) of three sampled residents with pressure ulcers. This had the potential to affect 17 of 58 residents identified by the facility as being at risk for developing pressure ulcers. Findings: The facility policy for skin care protocol documented, "...Policy: It is the policy of Via Christi Villages, Inc. (VCV) promotes healthy and intact skin. This ministry will identify and implement appropriate interventions for residents at risk and for those residents with actual skin integrity concerns..." Resident #1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A 30-day assessment dated [DATE], documented the resident was at risk for pressure ulcers. The assessment documented the resident had six Stage II pressure ulcers and one worsening pressure ulcer. The assessment documented the resident received pressure ulcer care. A quarterly assessment dated [DATE], documented the resident was at risk for pressure ulcers. The assessment documented the resident had three Stage II pressure ulcers. The assessment documented the resident received pressure ulcer care. A careplan dated 07/03/13 documented, "... Problems: 9. I have skin breakdown/; at risk for infection 7/3/13 Bilate heels... Goals: I will be compliant with pressure relieving measures to pressure areas and pressure ulcers will be healed within the next 90 days... Interventions: 1. Complete wound treatments per order 2) Monitor for s/s of infection or worsening 3) Notify physician of s/s of infection or wound worsening if noted 5) Educate resident and private care staff of pressure relieving positioning and measures to increase tissue perfusion and healing..." A weekly skin report dated July 5, 2013, documented, "...right heel, Stage 2, 4.5 x 6.5 partial wound bed with blackened area that measures 3 x 3.5 cm. Dry wound perimeter, scant serosanguineous drainage and foul odor. A wound to the left heel, Stage 2, 2.2 cm x 1.4 cm with pink wound bed. Normal perimeter. S no odor..." A weekly skin report dated July 12, 2013, contained no documentation for the resident's heels. A record of physician's office visit dated 07/12/13, documented, "... Progress Notes: Must offload heels at all times... New Orders: R needs antibacterial scrub/continue soak then rinse apply Santyl and gauze dressing DC [MEDICATION NAME] BID, L cleanse c saline and continue current care..." A record of physician's office visit dated 07/19/13, documented, "... New Orders: Must have no sustained pressure on heels!..." A weekly skin report dated July 26, 2013, contained no documentation for the resident's heels. A weekly skin report dated August 2, 2013, contained no documentation for the resident's heels. A weekly skin assessment record dated August 08, 2013 documented, "...Right heel 5.5 x 6.5 cm x 0.3 cm x 0.04 cm. Eschar noted with dry perimeter. X-large (extra large) amount of foul smelling odor upon dressing change. Left heel 2.5 cm x 1.7 cm x 0.001. Gray area noted to right heel 1 cm x 1 cm. Scant amount of SS drainage noted upon dressing change..." A record of physician's office visit dated 08/14/13, documented, "... New Orders: No pressure on heels ever- suspend/offload etc..." A weekly skin assessment record dated August 15, 2013 documented, "...Left heel 2 x 4 cm x 1.5 cm x 0.001 cm. Wound surface pink in color. No drainage noted. Right heel 5.5 x 6.4 cm x 0.3 cm. Eschar noted to wound surface. Extra large amount of foul smelling drainage noted upon dressing change..." A record of physician's office visit dated 08/23/13, documented, "...New orders: -Saline wound wash b/l heel ulcers -Apply Santyl to the necrotic areas -Apply saline wet to dry dressing ... New Orders: Must offload/No pressure on heels or will recur... do not constrict dressing..." A weekly skin assessment record dated August 29, 2013, documented, "... Left heel 2 cm x 1.2 cm x 0.001 cm. Wound surface pink in color with dry wound perimeter. No drainage noted upon dressing change. Right heel 5.5 cm x 6.4 x 0.3 cm. Wound surface noted with Eschar areas noted. Wound perimeter dry. Medium amount of bloody drainage noted upon dressing change. No odor noted at this time..." A record of physician's office visit dated 08/30/13, documented, "...Progress Notes: New pressure necrosis R plantar, lateral L New medial pressure ulcer and plantar lateral necrosis...New Orders: Will order metal offload boots..." A weekly skin assessment record dated, September 6, 2013, documented, "... Right heel measurements 7 cm x 6.7 cm x 0.5 cm. 30% of wound surface noted Eschar. 0.7 cm greenish area noted in depth area. No odor noted. Med. amount of SS drainage noted. Left heel 3 cm x 5 cm with 0.1 x 0.1 cm Eschar noted. Other area of wound pink. Small amount of SS drainage noted with no odor noted..." A record of physician's office visit dated 09/09/13 documented, "...Progress Notes: R plantar lateral necrosis...odor no dressing soiled foam protectors with no lift in protectors, Left heel full return of pressure necrosis new area plantar medially neglected offloading...New Orders: Follow orders NO Weight/Pressure on POSTERIOR Heels..." A weekly skin assessment record dated, September 12, 2013, documented, "...Right heel 7 cm x 0.5 cm with 4.5 cm x 2 cm Necrotic tissue area noted. Large amount of foul smelling bloody/green drainage noted. Left heel 4 cm x 7 cm x 0.001 cm with 1.6 cm x 2.6 cm Necrotic tissue noted. Foul smelling greenish drainage noted. Recurrent non-healing wounds..." Treatment records dated July, August and September 2013, documented, " ...Wound Care Notes: Bilate heels: Wash with Saline, pat dry. Apply Santyl to the necrotic areas, then apply saline wet to dry dressing over wound bed only. Keep all pressure off the heels at all times..." A July 2013, treatment record documented, "...R heel- 15 min (minute) soaks H202/[MEDICATION NAME]. Rinse c NSS. [MEDICATION NAME] to necrotic areas. Wrap c gauze..." There was no documentation for this treatment for [REDACTED]. A July 2013, treatment record documented, "... Raise heels while in bed et use heel protectors..." There was no documentation of this intervention for July 7, 2013 and July 14, 2013 NOC. There was no documentation of this intervention for July 22, 2013, July 24, 2013 and July 30, 2013 in the AM. There was no documentation of this intervention on July 29, 2013 in the PM. There was no documentation on the treatment records for this intervention for the months of August and September 2013. An August 2013, treatment record documented, "...Pressure Ulcer, Heel Notes: Left Heel: clean with NS, pat dry. Apply foam dressing and wrap loosely with Kling wrap..." There was no documentation of this treatment for [REDACTED]. A September 2013, treatment record documented, "... Wound Care () One Time Daily Starting 08/26/2013, Order Date: 8/26/2013, Notes: Bilate heels: Wash with Salin (sic), pat dry. Apply Santyl to the necrotic areas, then apply saline wet to dry dressing over wound bed only. Keep all pressure off the heels at all times..." There was no documentation for this treatment for [REDACTED]. There was no documentation in the nurse's notes or clinical record the resident refused to wear heel protectors. On 09/16/13 at 2:40 p.m., LPN #1 was observed providing wound care for the resident. After applying Santyl to the wounds, the LPN washed his hands and donned a pair of gloves. The LPN was observed opening a sterile package of Hydrogel Impregnated Gauze, he folded the gauze in half and squeezed the Hydrogel from the gauze into the trash can. The LPN unfolded the gauze and placed it on the resident's heels. The LPN took off the gloves, washed his hands, donned another pair of gloves and opened a package of sponge foam and placed it over the gauze. The LPN wrapped the heels with Kling wrap and secured it with tape. At 3:10 p.m., an interview was conducted with LPN #1. He was asked about the physician's wound care treatment order to the resident's heels being different from the treatment he provided. The LPN was asked why he did not apply saline wet to dry dressing, over the wound beds as ordered by the physician. The LPN stated, "We use the Hydrogel impregnated gel instead of the saline wet to dry dressing." At 3:20 p.m., an interview was conducted with the resident's physician. He was asked what kind of wounds were on the resident's heels. The physician stated the wounds were Stage II, pressure ulcers. He stated the resident did have arterial insufficiency but the wounds to the residents heels were directly related to pressure. The physician stated someone at the nursing facility was not following his orders related to the residents heels. He stated the resident had vascular intervention done a month ago in August, and the circulation in the resident's right foot/side had improved and the right heel was healing. But by the next office visit at the end of August, the residents right heel was infected and had large amounts of malodorous bloody, pus drainage coming from it. The physician stated this infection was a result of the nurses not following his wound care orders and the orders given to offload the resident's heels while the resident was up and when in bed. He stated the resident was not to have pressure on his heels at anytime. The physician stated on 09/09/13, the resident was sent to his office with no dressings on his heels. He stated bloody yellow drainage was all over the heels of the resident's socks and in the heel protectors. He stated the shell that helps to suspend the heels was not in the heel protectors. The physician was informed that on 09/16/13 at 2:40 p.m., the nurse was observed to use Hydrogel impregnated gauze while providing wound care to the resident's heels. He was asked if he had given an order for [REDACTED]. At 4:00 p.m., an interview was conducted with the Director of Nursing. The DON was asked if there was an order for [REDACTED].