Every finding on record at Brookwood Skilled Nursing and Therapy

Based on observation, record review, and interview, the facility failed to ensure PICC line dressings were changed, and mid-arm circumference measurements were completed and documented every 7 days for 2 (#2 and #5) of 3 sampled residents reviewed for PICC line care and maintenance. The DON identified six residents with PICC lines.Findings: 1. On 09/29/25 at 9:40 a.m., Res #2 was observed lying in bed. A PICC line was observed to the upper right arm. No redness or drainage was observed underneath the transparent dressing. The dressing covering the PICC line was dated 09/19/25. A policy titled Care and Removal of Peripherally Inserted Central Catheters (PICC) and Midline Catheters, revised 06/01/11, read in part, Mid-arm circumference will be measured in centimeters and recorded weekly.Sterile dressing changes will be performed every 7 days and immediately if the integrity of the dressing is compromised.Responsibility: Registered Nurse and IV Trained LPN.An undated medical diagnosis list showed Res #2 had diagnoses which included orthopedic aftercare following surgical amputation and severe protein-calorie malnutrition.A PICC insertion record, dated 09/19/25, showed a PICC line was inserted into Res #2's upper right arm. The record showed mid-arm circumference was measured at 26 centimeters. An admission assessment, dated 09/23/25, showed Res #2 had a BIMS score of 5 and was severely cognitively impaired. The assessment showed Res #2 received IV medications.There were no physician orders for PICC line sterile dressing changes or mid-arm circumference measurements found in the medical record.There were no documentation of mid-arm circumference measurements or PICC line sterile dressing changes on Res #2's treatment administration record or nurse notes since the insertion of the PICC line on 09/19/25.On 09/29/25 at 9:50 a.m., Res #2 stated they weren't sure why they had a tube in their arm, but it was not causing them discomfort. On 09/29/25 at 10:10 a.m., LPN #1 was shown the date on Res #2's PICC line dressing. LPN #1 was asked how often a PICC line dressing should be changed. LPN #1 stated they thought it was every 48 hours, but they were not certain. They stated the date written on the dressing indicated the date a new dressing had been placed. LPN #1 stated they did not know why Res #2's PICC line dressing had not been changed since 09/19/25. 2. On 09/29/25 at 10:20 a.m., Res #5 was observed lying in bed. A PICC line was observed to the upper right arm. No redness or drainage was observed underneath the transparent dressing. The dressing covering the PICC line was dated 09/20/25.An undated medical diagnosis list showed Res #5 had diagnoses which included acquired absence of right leg below knee and chronic systolic heart failure.A physician order, dated 09/09/25, showed PICC line sterile dressing change every seven days and as needed if the integrity of the dressing was compromised. The physician order had been discontinued on 09/22/25. An admission assessment, dated 09/14/25, showed Res #5 had a BIMS score of 11 and was moderately cognitively impaired. The assessment showed Res #5 received IV medications.A PICC insertion record, dated 09/15/25, showed a PICC line was inserted into Res #5's upper right arm. The record showed mid-arm circumference was measured at 28 centimeters.There was no documentation of mid-arm circumference measurements on Res #5's treatment administration record or nurse notes since the insertion of the PICC line on 09/15/25.A treatment administration record, dated 09/17/25, showed Res #5 received a sterile PICC line dressing change.There was no documentation of a PICC line sterile dressing change on Res #5's treatment administration record or nurse notes since 09/17/25.On 09/29/25 at 10:25 a.m., Res #5 stated they were receiving IV antibiotics through their PICC line. They stated the staff had changed the PICC line dressing but couldn't remember how long ago. Res #5 stated they were not sure if the staff had measured their arm since the PICC line was inserted.On 09/30/25 at 10:49 a.m., the DON stated all residents with PICC lines should have standard orders in place for care and maintenance to include a sterile dressing change weekly and as needed by an RN or IV trained LPN. They stated nursing staff should monitor the PICC line site daily and document findings including measurements and dressing changes on the treatment administration record or nurse notes. The DON stated Res #2 should have had a physician order for a weekly dressing change. They stated Res #2's PICC line dressing should have been changed on 09/26/25. The DON stated Res #5's PICC line dressing change order was discontinued on 09/22/25 after they had been transferred to the hospital. They stated the physician order should have been resumed when Res #5 returned to the facility on [DATE]. The DON stated Res #5's PICC line dressing should have been changed on 09/27/25 per the policy.

Based on observation, record review and interview, the facility failed to ensurea. residents received pain medication in a timely manner for 1 (#122) of 2 sampled residents reviewed for pain management. The prolonged wait time despite verbalizing increased pain to multiple staff resulted in harm for Resident #122 as evidenced by not wanting to complete ADL's due to pain; and,b. residents were consistently evaluated for the effectiveness of regularly scheduled pain medication for 1 (#101) of 2 sampled residents reviewed for pain management assessment and monitoring.The regional nurse consultant identified 42 residents received pain medication.Findings:1.On 09/16/25 at 5:55 a.m., Resident #122 was observed telling CNA #3 somebody get me some pain pills, my back is killing me. Any movement about kills me and it has been that way all night. Resident #122 would not allow CNA #3 to provide incontinent care due to the severity of the pain. On 09/16/25 at 5:57 a.m., CNA #3 was observed telling LPN #1, who was charting at the computer, Resident #122 needed a pain pill because they said they couldn't move. LPN #1 stated okay. On 09/16/25 at 7:31 a.m., CMA #1 was observed providing Tylenol to Resident #122. Resident #122 was observed rubbing their back and stating ow! Resident #122 verbalized they did not think Tylenol was strong enough and would like something stronger. A policy titled Administering Pain Medications, revised 10/2022, read in part, Administer pain medications as ordered. A physician order, dated 09/09/25 at 12:35 p.m., showed Tylenol 325 mgs. Give 2 tablets by mouth every 6 hours as needed for pain. A review of the hospital discharge showed Resident #122 was admitted from the hospital on [DATE] for UTI (urinary tract infection), had a PICC line, and went to the emergency room because of chronic back pain that worsened to the point of being unable to ambulate. An undated care plan for Resident #122 showed the staff were to anticipate Resident #122's need for pain relief and respond immediately to any complaint of pain. On 09/15/25 at 9:13 a.m., a family member of Resident #122, stated the only concern they had was about pain management because they believed Resident #122 was in pain. On 09/16/25 at 6:18 a.m., CNA #3 stated Resident #122 did not use their call light, so staff had to routinely check on them. On 09/16/25 at 6:52 a.m., LPN #1 was asked if they were the nurse for Resident #122. They stated LPN #2 was. LPN #1 was asked if they had alerted LPN #2 Resident #122 needed pain medication. LPN #1 stated they had forgotten, but they would. LPN #1 then asked the ADON to get Resident #122 some Tylenol. On 09/16/25 at 7:03 a.m., Resident #122 told the wound nurse they were in so much pain they couldn't move. On 09/16/25 at 7:14 a.m., the ADON stated Resident #122 should have received the pain medication once LPN #2 took the medication cart keys. The ADON stated when someone was in pain they should be responded to immediately. The ADON stated Resident #122 complained of pain quite often but did not like to take anything stronger than Tylenol. They stated Resident #122 did not like to get up because of their pain. On 09/16/25 at 1:29 p.m., the DON stated, We watch for nonverbal as well as asking if they are hurting and then pain assessments are done on admission and per MDS schedule. The DON stated staff should give pain meds as soon as possible that doesn't interrupt other care. An hour and a half is not an acceptable time frame. 2. An undated Care Plan, read in part, [Resident #101] is at risk for pain due to diagnosis of chronic pain, muscle spasm, and right below the knee amputation. [They] have medication in place. Assess and record pain characteristic. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating symptoms, and resident satisfaction with results. A Physician's Order, dated 07/19/25, read in part, Oxycodone (an opioid) 5mg Give 1 every 6 hours for pain. A Physician's Order, dated 07/19/25 read in part, Baclofen (a muscle relaxant) 10mg Give 1 tablet by mouth 1 time daily. A Physician's Order, dated 07/21/25 read in part, Pregablin (an anticonvulsant prescribed for neuropathic pain) 75mg Give 150mg by mouth one time a day every Monday, Wednesday, Friday for neuropathy. A review of Resident #101's MAR for July, August, and September 2025, showed Resident #101 received these medications as prescribed. A Pain Assessment, dated 07/20/25 showed Resident #101 rated their pain seven out 10 at its worst and at the time of assessment rated it between a four and seven out of 10. The Pain Assessment showed Resident #101 reported a change in their pain as, is same and worse. The resident reported a feeling of depression caused by their pain. A Pain Assessment, dated 09/14/25 showed Resident #101 rated their pain 10 out 10 at its worst and at the time of assessment rated it at a 7 out of 10. The Pain Assessment, showed Resident #101 reported their pain as same. The resident reported a feeling of depression caused by their pain. Resident #101 reported the pain medication did not help. A review of Resident #101's medical chart and MAR did not show any consistent pain assessment or monitoring. On 09/15/25 at 8:18 a.m., Resident #101 stated, I have bad neuropathy pain. The Oxycodone and Pregablin, none of it helps. The resident denied being regularly assessed or monitored for pain. On 09/16/25 at 11:45 a.m., CNA #4 was asked what the process was when a resident's pain was identified. They stated, I tell the med [medication] aide and I tell the nurse. They were asked if they documented a resident's pain. CNA #4 stated, No, that's not part of my charting. On 09/16/25 at 1:07 p.m., RN #2 was asked what was the process for assessing and monitoring Resident #101's pain. They stated, We ask [them]. RN #2 was asked where the pain assessment and monitoring was documented. They stated, Sometimes in progress notes, but if [they're] in pain we tell the med aides to give [them] a pain pill if its time. RN #2 was asked what intervention was provided if Resident #101 was unable to have pain medication. They stated, We try distracting [them]. On 09/16/25 at 1:13 p.m., the DON was asked what the process was for assessing and monitoring pain. They stated, It pops up on the vital signs on the MAR every shift and when rounding the staff watches for physical signs and symptoms. The DON was shown Resident #101's MAR and asked if there was pain monitoring on their MAR. They stated, No, because we only monitor the pain on the MAR if it's a PRN pain medication. The DON was asked if Resident #101 had a pain assessment completed since 07/20/25 and they stated, I'm not sure. They were asked if Resident #101's pain was being assessed and monitored consistently. They stated, No. On 09/16/25 at 1:49 p.m., the corporate nurse consultant was showed a Pain Assessment, dated 09/14/25, for Resident #101. They reported that was the only other pain assessment Resident #101 had.

Based on record review and interview, the facility failed to ensure residents were provided with an option to not sign the arbitration agreement for 6 (#24, 31, 38, 46, 53, and #96) of 6 sampled residents reviewed for arbitration agreements.The administrator identified 114 residents had entered into a binding arbitration agreement.Findings:An undated document titled An Explanation to the Resident/Family, read in part, By signing our admission contract your electronic signature will be placed on the following forms, which you will receive copies of after signing. admission Agreement/Consent to Treat/Medical Records Release Form: This agreement allows for admission into the facility, gives the facility consent to provide medical care/treatment, consent to have your medical records, and bill for your medical care. Dispute Resolution/Arbitration agreement.An admission packet, revised 11/29/22, showed DocuSign (signature) was set up in which the resident/resident's legal representative agreed to everything inside of the admission packet with just one signature. The arbitration agreement was part of the admission packet and was agreed to upon admission for everyone admitted to the facility.1. Resident #24 was admitted on [DATE] and signed the arbitration agreement on 12/31/21.2. Resident #31 was admitted on [DATE] and signed the arbitration agreement on 09/27/22.3. Resident #38 was admitted on [DATE] and signed the arbitration agreement on 02/10/24. 4. Resident #46 was admitted on [DATE] and signed the arbitration agreement on 04/08/19.5. Resident #53 was admitted on [DATE] and signed the arbitration agreement on 07/31/25. 6. Resident #96 was admitted on [DATE] and signed the arbitration agreement on 03/28/25. On 09/16/2025 at 12:38 p.m., during the Resident Council meeting, Residents #24, 31, 38, 46, 53, and #96 denied knowing what an arbitration agreement was, or that they had signed one.On 09/16/25 at 12:52 p.m., the admissions director stated an E (electronic) signature was used, and the admission process cannot continue without a signature. When asked if you can't go forward without a signature, is it really an option? The admissions director stated they had not thought about that, and they did not know the full extent of what an arbitration agreement was. The admissions director stated, I am pretty positive that the only page you can skip is the DNR/Advance Directive page.On 09/17/25 at 11:00 a.m., the regional nurse stated the residents do have to sign to move through the admission process, but the process to rescind within 30 days is explained to them.On 09/17/25 at 2:01 p.m., the administrator stated all residents had signed the arbitration agreement.

Based on observation, record review, and interview, the facility failed to ensure:a. EBP was followed during an incontinent care observation for 1 (#122) of 6 sampled residents reviewed for incontinent care; andb. ensure nasal cannulas were bagged when not in use and oxygen tubing was labeled with the date administered in order to prevent infections for 1 (#53) of 3 sampled residents reviewed for oxygen services.The regional nurse consultant identified 11 residents had O2 orders and 32 were on EBP. Findings: 1. On 09/16/25 at 8:08 a.m., CNA #1 and CNA #2 were observed to provide incontinent care for Resident #122. CNA #1 and #2 did not have on gowns during the provision of care. Resident #122 was observed with a PICC line in their upper right arm. A facility policy titled Infection Control and Isolation Guideline, dated 07/2025, read in part, Enhanced Barrier Precautions (EBP) apply to residents with: .wounds and/or indwelling medical devices. Gloves and gown during high-contact care. Continue for the duration of the stay or until wound heals/device is removed.high-contact care activities include:.changing briefs or assisting with toileting.Indwelling Medical Devices that DO require EBP:.PICC line. A physician's order, revised 09/10/25, showed EBP related to PICC line were to be utilized. On 09/16/25 at 12:21 p.m., CNA #1 stated EBP, including gown, mask, and gloves, were to be used when taking care of someone that was on isolation. CNA #1 stated they did not have any residents that required precautions, but if they did, they would put a sign on the door. CNA #1 stated there was no sign on Resident 122's door to indicate the need for any type of precautions. On 09/16/25 at 1:27 p.m., the DON stated EBP was one of the newer things that had been put into place, and the purpose was to protect the patients that had a greater risk of getting an infection. The DON stated a tile magnet was to be placed outside of the door to indicate what type of precautions were to be utilized. The DON stated admissions, the IP, and RN #1 helped put up the signage, so staff were aware of the need for EBP. The DON stated they were not sure when the last infection prevention in-service was provided. 2. On 09/15/25 at 9:06 a.m., Resident #53 was observed in bed wearing a nasal cannula attached to an oxygen concentrator. There was no date observed on the oxygen tubing or nasal cannula. On 09/17/25 at 8:34 a.m., Resident #53's nasal cannula was hanging on the bed rail attached to an oxygen concentrator not in use. The nasal cannula was not in a bag. There was no date on the oxygen tubing indicating when it was administered. Resident #53's annual assessment, dated 07/31/25, showed Resident #53's cognition was intact with a BIMS score of 15. Resident #53's electronic health admission records, dated 07/31/25, showed Resident #53 had diagnoses which included acute pulmonary edema and chronic obstructive pulmonary disease. Resident #53's physician orders dated 09/11/25, read in part, O2 @ 2 L NC to maintain stats > 92 % PRN every shift for SHOB [shortness of breath] or distress. On 09/17/25 at 8:34 a.m., Resident #53 stated they used oxygen as needed. On 09/17/25 at 8:41 a.m., CNA #4 stated Resident #53 wore oxygen, and the nasal cannula should be bagged when not in use. On 09/17/25 at 8:42 a.m., LPN #3 was asked about Resident #53's respiratory needs. LPN #3 stated Resident #53 had physician orders for PRN oxygen. LPN #3 was asked what the nursing standard for oxygen tubing and nasal cannulas being administered. LPN #3 stated oxygen tubing and nasal cannulas should be changed and labeled with the date they were administered. LPN #3 was asked what they observed in Resident #53's room. LPN #3 stated the nasal cannula, and tubing was hanging on bed side not bagged and not labeled with the date administered. LPN #3 stated the regulations were not followed because the nasal cannula was not bagged when not in use. LPN #3 stated not bagging the nasal cannula when not in use and not dating the oxygen tubing could cause can cause contamination. On 09/17/25 at 9:09 a.m., the IP was asked how oxygen tubing and nasal cannulas should be handled. The IP stated they should be bagged when not in use and labeled with the date to prevent infections. On 09/17/25 at 9:20 a.m., the DON stated all nasal cannulas and oxygen tubing should be labeled with the date they were administered. The DON stated the nasal cannula should be bagged when not in use. The DON stated they label, date and bag the nasal cannulas when not in use to prevent infections.

Based on observation, record review, and interview, the facility failed to ensure;a. oxygen tubing was dated with the administration date, andb. a nasal cannula was bagged when not in use for 1 (#53) of 3 sampled residents reviewed for oxygen services.The corporate nurse identified 11 residents had physician orders for oxygen therapy.Findings:On 09/15/25 at 9:06 a.m., Resident #53 was observed in bed wearing a nasal cannula attached to an oxygen concentrator. There was no date observed on the oxygen tubing or nasal cannula. On 09/17/25 at 8:34 a.m., Resident #53's nasal cannula was observed hanging on the bed rail attached to an oxygen concentrator. The oxygen tubing and nasal cannula were not labeled with the date it was administered. The nasal cannula was not in a bag. The facility's' policy titled Respiratory Therapy Policies and Procedures, revised 11/23/99, read in part, It will be the policy of this department to select disposable items that allow us to utilize our resources responsibly and still offer the highest quality care and treatment to our residents.When this equipment is changed out the equipment needs to be dated. Resident #53's annual assessment, dated 07/31/25, showed Resident #53's cognition was intact with a BIMS score of 15. Resident #53's electronic health admission records, dated 07/31/25, showed Resident #53 had diagnoses which included acute pulmonary edema and chronic obstructive pulmonary disease. Resident #53's physician orders, dated 09/11/25, read in part, O2 @ 2 L NC to maintain stats > 92 % PRN every shift for SHOB or distress. On 09/17/25 at 8:34 a.m., Resident #53 stated they used oxygen as needed. On 09/17/25 at 8:38 a.m., CMA #2 stated Resident #53 used oxygen. On 09/17/25 at 8:42 a.m., LPN #3 was asked about Resident #53's respiratory needs. LPN #3 stated Resident #53 had physician orders for PRN oxygen. LPN #3 was asked what the nursing standard for oxygen tubing and nasal cannulas being administered. LPN #3 stated oxygen tubing and nasal cannulas should be changed and labeled with the date they were administered. LPN #3 was asked what they observed in Resident #53's room. LPN #3 stated the nasal cannula, and tubing was hanging on bed side not bagged and not labeled with the date administered. LPN #3 stated the regulations were not followed because the nasal cannula was not bagged when not in use. LPN #3 stated not bagging the nasal cannula when not in use and not dating the oxygen tubing could cause contamination. On 09/17/25 at 9:09 a.m., the IP was asked how oxygen tubing and nasal cannulas should be handled. The infection preventionist stated oxygen tubing and nasal cannulas should be bagged when not in use and labeled with the date to prevent infections. The infection preventionist stated they were unaware Resident #53 had physician orders for oxygen. On 09/17/25 at 9:20 a.m., the DON stated the oxygen tubing attached to the oxygen concentrator should be labeled with the date it was administered, and the nasal cannula should be bagged when not in use to prevent infections.

Based on record review and interview, the facility failed to implement a comprehensive care plan intervention regarding pain monitoring for 1 (#101) of 18 sampled residents reviewed for care plan implementation.Findings:An undated Care Plan, read in part, [Resident #101] is at risk for pain due to diagnosis of chronic pain, muscle spasm, and right below the knee amputation. [They] have medication in place. Assess and record pain characteristic. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating symptoms, and resident satisfaction with results.A Physician's Order, dated 07/19/25, read in part, Oxycodone (an opioid) 5mg Give 1 every 6 hours for pain.A Physician's Order, dated 07/19/25, read in part, Baclofen (a muscle relaxant) 10mg Give 1 tablet by mouth 1 time daily.A Physician's Order, dated 07/21/25, read in part, Pregablin (an anticonvulsant prescribed for neuropathic pain) 75mg Give 150mg by mouth one time a day every Monday, Wednesday, Friday for neuropathy.A review of Resident #101's MAR for July, August, and September 2025, showed Resident #101 was receiving these medications as prescribed.A Pain Assessment, dated 07/20/25 showed Resident #101 rated their pain a seven out of 10 at its worst and at the time of assessment rated it between a four and seven out of 10. The Pain Assessment showed Resident #101 reported a change in their pain as, is same and worse. The resident reported a feeling of depression caused by their pain.A Pain Assessment, dated 09/14/25 showed Resident #101 rated their pain 10 out 10 at its worst and at the time of assessment rated it at a 7 out of 10. The Pain Assessment, showed Resident #101 reported their pain as same. The resident reported a feeling of depression caused by their pain. Resident #101 reported the pain medication dis not help.A review of Resident #101's medical chart and MAR did not show consistent pain assessment or monitoring.On 09/16/25 at 1:07 p.m., RN #2 was asked what was the process for assessing and monitoring Resident #101's pain. They stated, We ask [them]. RN #2 was asked where the pain assessment and monitoring was documented. They stated, Sometimes in progress notes, but if [they're] in pain we tell the med aides to give [them] a pain pill if its time. RN #2 was asked what intervention was provided if Resident #101 was unable to have pain medication. They stated, We try distracting [them].On 09/16/25 at 1:13 p.m., the DON was asked what the process was for assessing and monitoring pain. They stated, It pops up on the vital signs on the MAR every shift and when rounding the staff watches for physical signs and symptoms. The DON was shown Resident #101's MAR and asked if there was pain monitoring on their MAR. They stated, No, because we only monitor the pain on the MAR if it's a PRN pain medication. The DON was asked if Resident #101 had a pain assessment completed since 07/20/25. They stated, I'm not sure. The DON was asked if Resident #101's pain was being assessed and monitored consistently. They stated, No. The DON was asked if based on no consistent assessment and monitoring of pain, was Resident #101's care plan followed. They stated, No.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to promptly notify the physician of Resident #2's laboratory results which fell outside of clinical reference ranges and showed a deterioration in their condition. Resident #2 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection (ESBL) and pneumonia and was receiving antibiotic therapy. Resident #2's admission lab results, dated [DATE], documented WBC 11.3 (Ref range 3XXX,d+[DATE].04) and Neutrophil # 7.7 (Ref range 1XXX,d+[DATE].13). The report was signed by the physician. Resident #2's follow-up lab results, dated [DATE], documented WBC 26.2 (Ref range 3XXX,d+[DATE].04) and Neutrophil # 19.7 (Ref range 1XXX,d+[DATE].13). There was no documentation the results were reported to the physician. On [DATE], Resident #2 was transferred to the emergency room . They were admitted to the hospital on [DATE] with admitting diagnoses of severe sepsis with septic shock, pyelonephritis, and C-difficile colitis. Resident #2 expired in the hospital on [DATE]. On [DATE] at 12:15 p.m., the DON reviewed Resident #2's clinical records and reported no documentation could be found to confirm the follow-up lab results were reported to the physician. On [DATE] at 2:27 p.m., Resident #2's physician reported no abnormal lab results were reported for the resident regarding labs completed on [DATE]. They stated the resident would have been started on IV antibiotics or immediately sent out to the hospital. On [DATE] at 4:52 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 1:54 p.m., the administrator was notified of the IJ situation and the IJ template was provided. On [DATE] at 8:10 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal, read in parts, a. How facility will ensure harm will not occur or recur .In-service regarding immediate physician notification of change in condition/abnormal laboratory results .All current laboratory results reviewed to ensure physician notification has been made. b. Date of implementation - planned implementation (actions do not need fully resolved prior to the survey team exiting the organization); [DATE] c. Identify those residents who have suffered or are likely to suffer, a serious adverse outcome as a result of the noncompliance .Residents with orders for laboratory tests. d. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete .In-service with all licensed nursing staff regarding immediate physician notification of change in condition/abnormal laboratory results .All current laboratory results reviewed to ensure physician notification has been made .The likelihood for serious harm to any resident no longer exists effective [DATE]. e. How is facility addressing assessment, intervention, documentation and evaluation .In-service with all licenses nursing staff. On [DATE] it was determined the immediacy was lifted, effective [DATE] at 8:00 p.m., when all components of the plan of removal had been completed. The deficient practice remained as isolated with potential for harm to the resident. Based on observation and interview, the facility failed to promptly notify the physician of a resident's laboratory results which fell outside of clinical reference ranges and showed a deterioration in the resident's condition for one (#2) of three sampled residents whose clinical records were reviewed for physician notification of lab results. The administrator identified 111 residents resided in the facility. Findings Resident #2 was admitted to the facility on [DATE] with diagnoses of urinary tract infection (ESBL) and pneumonia and was receiving antibiotic therapy. Resident #2's admission lab results, dated [DATE], documented WBC 11.3 [Ref range 3XXX,d+[DATE].04] and Neutrophil # 7.7 [Ref range 1XXX,d+[DATE].13]. Report was signed by physician. Resident #2's follow-up lab results, dated [DATE], documented WBC 26.2 [Ref range 3XXX,d+[DATE].04] and Neutrophil # 19.7 [Ref range 1XXX,d+[DATE].13]. There was no documentation that results were reported to the physician. A hospital report, dated [DATE] through [DATE], documented Resident #2 was transferred to the emergency room . It documented they were admitted to the hospital on [DATE] with admitting diagnoses of severe sepsis with septic shock, pyelonephritis, and C-difficile colitis. It was documented Resident #2 expired in the hospital on [DATE]. On [DATE] at 12:15 p.m., the DON reviewed Resident #2's clinical record and reported no documentation could be found to confirm that follow-up lab results had been reported to the physician. On [DATE] at 2:27 p.m., Resident #2's physician reported no abnormal lab results were reported for the resident regarding labs done [DATE]. They stated, if the results had been reported, the resident would have been started on IV antibiotics or immediately sent out to the hospital. On [DATE] at 4:20 p.m., LPN #3 was asked if they had reviewed the results of Resident #2's labs received during their shift on [DATE] and reported the abnormal results to the physician. They stated they had not seen the results because only critical results would be faxed over or called into the facility during the evening shift. On [DATE] at 8:00 a.m., the DON was asked the process for ensuring lab results were reviewed and reported to the physician. They stated lab results were printed from the lab company's electronic system each morning and reviewed in the morning meeting. The DON stated there was no way to confirm if the abnormal lab results received for Resident #2 on [DATE] had been reviewed in the morning meeting on [DATE], or if their abnormal results had been reported to the physician. The DON was asked if the facility had a system of communication or documentation in place to ensure staff knew when abnormal lab results were reviewed and reported to the physician. They stated, Sometimes the nurse may document it in the notes or on the lab itself, but not always.

On 01/02/25 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #2 who had insulin dependent type 2 diabetes mellitus with hypoglycemia was assessed, monitored, and provided medication for hypoglycemia as ordered by the physician and outlined in their care plan. Resident #2 was admitted to the facility on [DATE] with orders for routine insulin administration and insulin to be administered per sliding scale. Resident #2 also had orders for blood sugar to be checked via fingerstick twice a day and as needed for signs or symptoms of hypoglycemia and to give Glucagon (oral gel or IM) (glycogenolytic agent) if blood sugar was less than 70. On 12/26/24 at 6:09 a.m., Resident #2 had a blood sugar reading of 68 and the nurse did not administer the Glucagon gel as ordered. On 12/26/24, at change of shift, the night nurse provided the oncoming dayshift nurse Resident #2's status and low blood sugar level. The oncoming nurse failed to provide any assessment, monitoring, or interventions for the low blood sugar level. On 12/26/24 at 8:12 a.m., the attending physician saw Resident #2 during rounds and provided a verbal order to send them to the emergency room . The nurse took Resident #2's blood sugar reading while awaiting the arrival of EMSA and the reading was 49. The nurse did not administer the Glucagon gel as ordered. The emergency room report, dated 12/26/24, documented Resident #2's blood sugar reading on their initial encounter with EMSA was 21. It documented Resident #2 was admitted to the hospital on 12/26/24. On 01/02/25 at 4:52 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 01/03/25 at 1:57 p.m., the administrator was notified of the IJ situation and the IJ template was provided. On 01/06/25 at 8:10 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal, read in parts, a. How facility will ensure harm will not occur or recur .In-service all staff on signs and symptoms of hypoglycemia and treatment .Review of all residents with hypoglycemia or diabetes .Monitoring orders will be added for appropriate residents for signs and symptoms of hypoglycemia. b. Date of implementation - planned implementation (actions do not need fully resolved prior to the survey team exiting the organization); 1/3/2025 c. Identify those residents who have suffered or are likely to suffer, a serious adverse outcome as a result of the noncompliance .Residents with history of hypoglycemia or diabetes. d. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete .In-service all staff on signs and symptoms of hypoglycemia and treatment .Review of all residents with hypoglycemia or diabetes .Monitoring orders will be added for appropriate residents for signs and symptoms of hypoglycemia .The likelihood for serious harm to any resident no longer exists effective 1/3/2025. e. How facility will monitor physicians orders being followed .Physician's orders, MAR's, Tar's and FSBS records will be monitored daily in Q2. f. How are you addressing assessment, intervention, documentation, and evaluation .In-service with all licensed nursing staff. On 01/07/25 it was determined the immediacy was lifted, effective 01/02/2025 at 8:00 p.m., when all components of the plan of removal had been completed. The deficient practice remained as isolated with potential for harm to the resident. Based on interview and record review, the facility failed to ensure a resident with insulin dependent type 2 diabetes mellitus with hypoglycemia was assessed, monitored, and provided medication for hypoglycemia as ordered by the physician and outlined in the resident's care plan for one (#2) of three sampled residents whose blood sugars were reviewed. The MDS Resident Matrix, submitted 12/31/24, documented there were 22 insulin dependent diabetic residents residing in the facility. Findings Resident #2 had diagnoses that included type 2 diabetes with hypoglycemia. Resident #2's physician's order, dated 12/10/24, documented for their blood sugar to be checked via fingerstick twice a day and as needed for signs or symptoms of hypoglycemia and to give Glucagon (oral gel or IM) if blood sugar was less than 70. A Progress Note, dated 12/26/24 at 6:09 a.m., documented Resident #2's FSBS was 68. There was no documentation in Resident's clinical record glucagon gel was administered as ordered at that time. There was no documentation in the clinical record Resident #2 was assessed, monitored, nor provided interventions as ordered for FSBS of 68 reported by the night nurse to the oncoming dayshift nurse on 12/26/24. A Progress Note, dated 12/26/24 at 8:12 a.m., documented the attending physician saw Resident #2 during rounds and provided a verbal order to send them to the emergency room . The nurse took Resident #2's blood sugar reading while awaiting the arrival of EMSA and the reading was 49. Theere was no documentation the Glucagon gel was administered as ordered at that time. The emergency room report, dated 12/26/24, documented Resident #2's blood sugar reading on their initial encounter with EMSA was 21. It documented Resident #2 was admitted to the hospital on 12/26/24. On 01/02/25 at 4:30 p.m., the DON was asked to review the records for Resident #2 outlined above. After reviewing the documents, the DON acknowledged Resident #2 was not assessed, monitored, or administered Glucagon as ordered during an episode of hypoglycemic crisis.

Based on record review and interview, the facility failed to ensure the physician was notified for blood sugars outside of parameters as ordered for two (#1 and #3) of three sampled residents whose clinical records were reviewed for notification of changes. The administrator identified 111 residents resided in the facility. Findings: A Blood Glucose Monitoring Guideline, revised 08/24, read in parts, Follow physician orders based on finger stick result .notify physician of noted signs/symptoms of hypo/hyperglycemia. 1. Resident #1 had diagnoses which included type 2 diabetes mellitus. Resident #1's physician's order, dated 12/13/24, documented for the resident to receive insulin aspart (insulin) per sliding scale 10 units if blood sugar 301-999, then call provider and recheck in two hours. The December 2024 MAR documented the following blood sugars for Resident #1, a. 12/14/24 at 8 a.m. FSBS 307, b. 12/14/24 at 4 p.m. FSBS 400, c. 12/15/24 at 11 a.m. FSBS 385, d. 12/15/24 at 4 p.m. FSBS 339, e. 12/15/24 at 9 p.m. FSBS 328, f. 12/16/24 at 8 a.m. FSBS 301, g. 12/16/24 at 4 p.m. FSBS 309, h. 12/19/24 at 4 p.m. FSBS 303, i. 12/20/24 at 4 p.m. FSBS 336, j. 12/20/24 at 9 p.m. FSBS 318, k. 12/21/24 at 9 p.m. FSBS 336, l. 12/22/24 at 9 p.m. FSBS 335, and m. 12/24/24 at 4 p.m. FSBS 348. There was no documentation in Resident #1's clinical record the physician was notified of the FSBS's. 2. Resident #3 had diagnoses which included type 2 diabetes mellitus. Resident #3's physician's order, dated 11/25/24, documented to notify the physician of FSBS 0-69 or 401-999. The December 2024 MAR documented the following blood sugars for Resident #3, a. 12/12/24 at 8 a.m. FSBS 430, b. 12/16/24 at 8 a.m. FSBS 430, c. 12/18/24 at 12 p.m. FSBS 64, and d. 12/22/24 at 5 p.m. FSBS 65. There was no documentation in Resident #3's clinical record the physician was notified of the FSBS's. On 01/02/25 at 1:56 p.m., the DON reviewed the clinical records for Resident #1 and Resident #3 described above and acknowledged there was no documentation the physician had been notified of FSBS's outside of parameters as ordered.

Based on record review and interview, the facility failed to report an allegation of resident to resident abuse to OSDH for two (#1 and #2) of three sampled residents reviewed for abuse. The administrator identified 104 residents resided in the facility. Findings: A Resident Abuse, Neglect and Misappropriation of Property policy, dated 11/2022, read in part, The resident has the right to be free fro verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy also read, Protection All employees of a nursing facility are mandated reporters of resident abuse, to appropriate personnel, neglect or misappropriation and must report any and all incidents. All employees shall report any reasonable suspicion of a crime against any individual who is a resident of the facility without fear of retaliation. The policy also read, Procedure for Investigating Facility Incidents All allegations and incidents of abuse, neglect or misappropriation of resident's property be reported to QAPI committee, appropriate Federal and State Agencies including OSDH and investigated to establish a reasonable conclusion about the validity of the allegation. 1. Resident #1 had diagnoses which included acute on chronic CHF, atrial fib, and cerebral infarct. A Resident to Resident event document, regarding Resident #1, dated 02/24/24, read in part, This nurse observed [Resident #1] being verbally abusive to what [Resident #1] thought was [their person] having an affair. [Resident #1] was also getting very close to [Resident #2] pointing and talking loudly in [their] face. When [Resident #2]attempted to re direct conversation or move away [Resident #1] would follow and get closer. This nurse after attempting to let residents resolve issue (which they often do) observed [Resident #2] become highly agitated and angry. This nurse immediately separated the two however prior to fully separate the two [Resident #2] was able to throw magazines at [Resident #1's] face. It also read, Immediate Action Taken Once completely separated by this nurse's body, [Resident #2] was able to leave and return to their room. This nurse was able to assess [Resident #1's] face and nothing was visible or assessed at this time. [Resident #1] denied pain or discomfort. This nurse accompanied [Resident #1] to [their] room as [they] were up most the night. A MDS assessment, dated 09/10/24, documented Resident #1 had moderately impaired cognition with a BIMS of 10. On 11/08/24 at 1:24 p.m., Resident #1 was in their room in their recliner and unable to answer interview questions. 2. Resident #2 had diagnoses which included ESRD, DM, and bilateral aka. A MDS assessment, dated 09/19/24, documented Resident #2 was cognitively intact with a BIMS of 15. On 11/8/24 at 1:41 p.m., Resident #2 stated they had a lot of interaction with Resident #1 up until they had a stroke. They stated Resident #1 was mean towards them and their family was mean towards them. They stated Resident #1 was [AGE] years old and would chase them and wanted to date them. They stated the administrator was aware. There was no report to OSDH located. On 11/12/24 at 11:54 a.m., the DON stated they did not report the event on 02/24/24 to OSDH because the residents were friends and had a weird relationship where they got along, then were frustrated, then were fine again. They stated the residents had not been around each other recently. The corporate nurse consultant stated the event should not have been reported to OSDH because of the nature of their relationship. On 11/12/24 at 1:39 p.m., the DON and administrator were asked if a resident hitting another resident with a magazine was a reportable incident due to the act of physical violence. They stated, yes, and that they concluded it did not happen and that the magazines were pushed off the table. They stated they had trouble figuring out if made contact. On 11/13/24 at 9:16 a.m., the administrator was asked to review the incident report that documented The other resident became highly agitated and angry, and was asked if the actions of throwing an object by someone who stated those words, fall under abuse. They stated, normally but once the investigated was an accident when pushed off the table and because that was normal behavior for them.

Based on record review and interview, the facility failed to ensure a resident was free from verbal and willful physical abuse from another resident with uncontrolled abusive behavior for one (#1) of three sampled residents reviewed for abuse. The administrator identified 104 residents resided in the facility. Findings: A Resident Abuse, Neglect and Misappropriation of Property policy, dated 11/2022, read in part, The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy also read, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. The policy also read, Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy also read, Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. 1. Resident #1 had diagnoses which included CHF and cerebral infarct. A MDS assessment, dated 08/10/24, documented the resident's cognition was moderately impaired with a BIMS score of 10. An initial OSDH Incident Report Form, received at OSDH on 10/14/24 at 3:01 p.m., read in part, Allegation of verbal abuse from [Resident #1's family representative] regarding [Resident #2]. The family representative was told by someone anonymously that [Resident #2] had yelled at [Resident #1]. Investigation initiated. Physician and [Resident #2] family representative notified. [Resident #2] sent to hospital for evaluation. It documented APS and law enforcement were notified. On 11/08/24 at 1:24 p.m., Resident #1 was in their room in their recliner and unable to answer interview questions. 2. Resident #2 had diagnoses which included ESRD, sepsis, DM, bilateral AKA, and PTSD. A MDS assessment, dated 09/19/24, documented Resident #2 was cognitively intact with a BIMS score of 15. An incident note, dated 02/24/24 at 5:02 a.m., documented Resident #2 threw magazines at Resident #1 after Resident #1 was close to Resident #2's face. It documented Resident #2 did not think the way they reacted was inappropriate. A progress note, dated 02/24/24 at 11:18 a.m., documented Resident #2 stated they were not trying to be mean or intended to harm Resident #1. It documented they wanted Resident #1 to move away. It documented Resident #2 was educated to go the other way when they saw Resident #1 and not to engage with them or to get a staff member. A care plan focus area for Resident #2, revised 03/01/24, documented they used antidepressant medication related to depression. It documented the resident had behaviors of yelling and cursing at staff, and a history of getting upset and throwing magazines. It documented the interventions were PHQ2-9 score: 0 (initiated 09/09/24), administer Zoloft (SSRI) as prescribed (initiated 12/24/23), every shift document number of episodes/interventions/outcome and side effects (revised 06/12/24), and monitor/document/report to MD PRN ongoing s/sx of depression initiated 12/24/23). A progress note, dated 03/14/24 at 7:11 a.m., documented Resident #2 was given an order to discontinue Zoloft due to multiple refusals. A behavior note, dated 05/08/24 at 2:41 p.m., documented Resident #2 was in the hall yelling out loud for the CNA to make their bed. It documented the resident followed the CNA to the restroom yelling about their bed not being made. It documented the nurse tried to redirect Resident #2. It documented the resident stated they did not care how they were acting and wanted their bed made. It documented the resident was calmed down by a third party staff member. A progress note, dated 06/05/24 at 9:00 p.m., documented Resident #2 stated their right arm was hurting. It documented the resident refused PRN medication and demanded to go to the emergency room . It documented the resident was extremely rude to EMSA screaming and swinging their fist at them because the hospital was on diversion. It documented Resident #2 stated, That is [verbiage withheld] you will take me to [hospital name withheld]. It documented the nurse educated the resident on speaking to EMSA. An incident note, dated 06/09/24 at 12:00 p.m., documented there was a report of a resident to resident verbal altercation. It documented Resident #2 was frustrated over waiting for a long time for food. It documented Resident #2's explanation did not reveal the other resident's role in the food delay. It documented the resident received guidance on conflict resolution and indicated understanding without needing further instruction. A care plan focus area for Resident #2, revised on 06/10/24, documented they had impaired cognitive function/dementia or impaired thought process r/t cardiac and diabetic disease process. It documented the resident exhibited attention seeking behaviors and had verbal outbursts towards staff at times. It documented the resident was difficult to redirect and refused medications at times. It documented the resident would yell about their bed not being made, but would go back to bed and then get in and out throughout the day. It documented the resident would state they were joking with another resident and start yelling. It was documented the interventions were BIMS score 15 (revised 09/09/24), communication (revised 10/20/22), keep routine consistent (revised 10/20/22), observe/assess/document/report changes in cognitive function (revised 12/24/23), provide a homelike environment (revised 10/20/22), reminisce with resident (revised 10/20/22), and review medication and record possible causes (initiated 10/20/22). An order note, dated 06/27/24 at 1:39 p.m., documented to reorder of Zoloft 50 mg at bedtime. A progress note, dated 07/07/24 at 5:11 p.m., documented Resident #2 was in the dining room arguing with another male resident and both residents became loud across the dining room. It documented both residents were redirected and were put in separate areas. A behavior note dated, 10/23/24 at 2:30 p.m., documented Resident #2 was outside of another residents door screaming at the other resident. It documented the nurse intervened by explaining they were not allowed to go and yell at another resident no matter the circumstances. It was documented the resident stated they wanted to call 911 to get help for the other resident. It was documented after Resident #2 was informed staff would assist the other resident, Resident #2 then continued to yell for the nurse to get the resident out of the room. It documented the nurse stated to Resident #2 that they were yelling just like the other resident they were upset about. It documented the resident wheeled off to their room and slammed the door. A progress note, dated 11/01/24 at 8:01 p.m., documented Zoloft was discontinued for refusals. A behavior note, dated 11/10/24 at 10:07 p.m., documented while the nurse was down another hall, Resident #2 went down the hall in their power chair yelling and cursing. It documented several attempts made to calm the resident and try to speak with them, but they continued to yell and curse and started going into other residents' rooms yelling and cursing. It documented when staff attempted to redirect Resident #2 and ask them to not go in other residents rooms, they attempted to run staff over with their power chair. It documented the resident refused to go to the hospital for an evaluation. A progress note, dated 11/11/24 at 12:30 a.m., documented Resident #2 wanted to harm themselves and requested to go to the hospital for a psych evaluation. A progress note, dated 11/11/24 at 3:58 a.m., documented Resident #2 returned with no new orders. It documented the nurse removed two pair of scissors from the resident's drawer due to statements of harming themselves. It documented they informed the resident they could have them back after speaking with the DON/administrator. It documented Resident #2 stated they would just ram the administrator's door with their chair. On 11/12/24 at 12:49 p.m., Resident #2 stated staff took over an hour to answer a call light and they got up to their chair to look for staff and heard someone yell, and saw a resident had fallen. Resident #2 stated they went to look for staff and no one wanted to help them. Resident #2 stated staff said they Threw poo, but I didn't. I don't do stuff like that. Resident #2 stated, They said I put my hands down my diaper and threw it. On 11/12/24 at 1:24 p.m., Resident #1's family representative stated they were informed by staff, that Resident #2 had been in Resident #1's room on the evening of 11/10/24. The family representative stated CNA #1 was taking care of Resident #1 to get them ready for bed. and Resident #2 went to Resident #1's door and demanded staff stop what they were doing and take care of them. The family representative stated when CNA #1 told Resident #2 they would have to wait they pushed the door closed. The family representative stated Resident #2 then hit the door open, screamed, yelled, and was cursing. The family representative stated CNA #1 was helping Resident #1 to the bathroom and went into the bathroom and shut the door. The family representative stated Resident #2 then was pounding on the bathroom door. The representative stated Resident #2 hit CNA #1 several times. The family representative stated CNA #1 made Resident #2 leave the room then CNA #1 called the police. The family representative stated Resident #2 also called the police. The family representative stated they had a camera in Resident #1's room and it did not capture the events. The family representative stated Resident #2 had threatened them, hit them and staff. The family representative stated the administrator and the police were at the facility. The family representative stated they were scared of Resident #2 hurting them, Resident #1, or someone else. The family representative stated Resident #2 was getting by with all this and Resident #1 was intimidated by them and they were trespassing in their room. On 11/12/24 at 1:39 p.m., the administrator stated the incident on 10/14/24 was discussed with the fall weekly meeting and at the end of the month. On 11/12/24 at 2:15 p.m., the administrator stated they had to come to the facility on Sunday 11/10/24 because Resident #2 was going in and out of resident rooms and Resident #1 may have been one of them. They stated they came up to the facility and Resident #2 was not dressed appropriately. Resident #2 was sent out for a psych evaluation and the police was called since Resident #2 would not calm down. They stated they did not know if Resident #2 went into Resident #1's room, but since they were on the same hall they very well could have. On 11/12/24 at 2:22 p.m., the administrator stated Resident #1's family representative told them of the events on 11/10/24 and they did not call the administrator about it or tell the nurse. The administrator stated they put Resident #2 on 1:1 until they figured out what to do. They stated they would see about discharging Resident #2. An orders note, dated 11/12/24 at 2:44 p.m., documented the provider had reviewed the resident's chart and started Zoloft 50 mg for depression again. A progress note, dated 11/12/24 at 3:14 p.m., documented the psych/counseling would be at the facility the next day to see Resident #2. On 11/12/24 at 3:28 p.m., CNA #1 stated they had two incidents with Resident #2 on 11/10/24. The first incident of the day was when Resident #2 became upset with having to wait for staff to finish with the resident they were with, and began yelling and cursing, and dug into their diaper and took it off and threw it. CNA #1 stated when they returned from their lunch break, Resident #2 was yelling saying y'all gone change me now and y'all let me sit here and is all on my bed. CNA #1 stated they checked on them before they went on break and they were fine. CNA #1 stated they went to get Resident #1 ready for bed that evening and Resident #2 busted through the door in their electric wheelchair. CNA #1 stated they put Resident #1 in their wheelchair, turned around and Resident #2 was in their face and started punching them in the stomach and arm. They stated they grabbed Resident #2's arm to stop them from hitting them. CNA #1 stated Resident #2 slapped and punched them and was cursing at them. CNA #1 stated they told Resident #2 they were going to call the police when they were done with Resident #1. CNA #1 stated when they walked out of Resident #1's room there were police in the hall. CNA #1 stated they were told Resident #2 had called the police and said they were abusing them. CNA #1 stated they spoke to the administrator and told them they only touched the resident to get them to stop hitting them. CNA #1 stated they did not feel comfortable working with Resident #2. CNA #1 stated Resident #2 taunts and made faces. CNA #1 stated the administrator stated they were going to talk to the corporate office to see about discharging the resident. CNA #1 stated the administrator told Resident #2 they had to go and Resident #2 became upset and started cursing and yelling. On 11/13/24 at 9:16 a.m., the administrator was asked what had been done to address Resident #2's behaviors of yelling and cursing prior to the recent events. The administrator stated they made multiple medication changes, but the resident was not compliant. The administrator stated Resident #2 previously had counseling. On 11/13/24 at 9:30 a.m., the administrator stated they were trying to figure out where to move Resident #2 as they had thought about it before. The administrator stated there was no where to move that Resident #2 wanted to move to. The administrator stated they may try to discharge Resident #2, but it could be difficult. The administrator stated they were to re-start with psych this evening. On 11/13/24 at 12:51 p.m., the corporate nurse consultant stated they do not conduct behavior monitoring unless the resident was on psych meds. The corporate nurse consultant stated they just added an order and added yelling to it. The corporate nurse consultant stated normally if a resident had behaviors it was documented in progress notes. On 11/13/24 at 12:55 p.m., the DON stated the interventions for Resident #2's behavior were to talk and deescalate, and if that did not work, the administrator was good at talking and settling the resident down. There were no new interventions on the care plan to address the resident's increasing behavior. The last update to the care plan related to behaviors/cognition/use of an antidepressant was the BIMS score and PHQ2-9 score on 09/09/24.

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained during medication pass, when staff were observed to touch medications with their bare hands for two (CMA #1 and CMA #2) of three CMA's observed preparing medications. The Administrator identified 104 residents resided in the facility. Findings: A Specific Medication Administration procedure, dated January 2022, read in part, .Pour or push the correct number of tablets or capsules into the souffle cup, taking care to avoid touching the tablet or capsule, unless wearing gloves . 1. On 05/03/24 at 9:37 a.m., CMA #3 was observed preparing medications for a resident. They were observed to pop a pill from a medication blister pack, it fell on to the medication cart, they picked it up with their bare hands, placed it in the medication cup, and administered it to a resident. On 05/03/24 at 9:40 a.m., CMA #3 was asked if the pill had dropped on the cart. They stated, Yes. CMA #3 was asked how they put the pill in the medication cup. They stated with their fingers. CMA #3 was asked what the the policy was for touching medications with bare hands. They stated they should not do that. 2. On 05/03/24 at 9:41 a.m., CMA #1 was observed popping medications out of 14 blister packs into their bare hand. On 05/03/24 at 9:45 a.m., CMA #1 was asked what the policy was for administering medications. They stated they looked at the MAR, sanitized their hands before they entered a residents' room, and introduce them self. CMA #1 stated they come out and sanitize their hands again. CMA #1 was asked what the policy was for touching medications with their bare hands. They stated they don't touch the medications, they pop them into a medicine cup. CMA #1 was asked if they popped medications out of the blister packs, into their hand, and placed them into the medicine cup. CMA #1 stated, No, I popped them into a cup. On 05/03/24 at 10:321 a.m., Corp Nurse Consultant #1 was asked if staff should touch medications with their bare hands. They stated no. They were asked what staff should do if the medications falls on the cart. They stated, staff should discard the pill and get another one.

Based on observation, record review, and interview, the facility failed to ensure: a. an individual narcotic count sheet was correct for one (#59) of three narcotic counts completed, and b. eight hour verification sheets was signed by staff at shift change for one of four sampled medication carts. The Administrator identifed 106 residents resided in the facility. Findings: A Controlled Substance Storage policy, dated January 2022, read in part .At each shift change, or when keys are transferred, a physical inventory of all controlled substances including refrigerated items is conducted by two licensed nurses/CMA's and is documented . A physician order, dated 11/15/23, documented to administer Oxycodone 5 mg every eight hours as needed for pain. Resident #59's MAR, dated 05/01/24 through 05/02/24 documented Resident #59 had received a prn dose on 05/01/24 and 05/02/24. a. On 05/03/24 at 9:51 a.m., a narcotic count was completed with CMA #2. Resident # 59's narcotic count sheet documented there were 37 pills left. The medication card had 38 pills remaining in the card. Resident #59's individual narcotic record, dated 05/02/24 documented 37 Oxycodone 5 mg pills remained. On 05/03/24 at 10:31 a.m., Corp Nurse Consultant #1 was informed about narcotic count sheet discrepancy on cart 200. They stated they reviewed Resident #59's MAR and it was documented it had been given, but may have not been punched out. They were unsure if Resident #59 had received the medication. b. An Eight Hour Verification form, dated 04/27/24 through 05/03/24, did not have signatures, shift change counts had been completed for seven of thirty seven times. An eight hour verification sheet, dated 03/01/24 through 03/31/24 had missing signatures for 22 different shift changes out of 31 days. An eight hour verification sheet, dated 04/01/24 through 04/30/24 had missing signatures for 21 different shift changes out of 30 days. An eight hour verification sheet, dated 05/01/24 through 05/02/24, had missing signatures for one different shift change out of two days. On 05/03/24 at 11:11 a.m., Pharmacy Consultant #1 was shown the eight hour verification sheets for March, April and May 2024. They were asked if there should be blanks (signatures) on the verification report. They stated, No. On 05/06/24 at 9:21 a.m., Corp Nurse Consultant #1 was shown the eight hour verification sheets, they stated if staff work doubles they should have put a slash in the blank spots. They were asked if the sheets had been filled out correctly according to policy. They stated, No.

Based on observation, record review, and interview, the facility failed to ensure MDS assessments were accurate for four (#59, 6, 34, and #61) of 22 sampled residents reviewed for MDS accurate assessments. The Administrator identified 106 residents resided in the facility. The DON identified four residents with diabetic ulcers. Findings: 1. Resident #59 had diagnoses which included, right BKA, diabetic ulcer, diabetes mellitus and high cholesterol. A skin/wound note, dated 12/27/23, documented an open area to left medial foot/left medial fifth toe area the wound bed was noted to have a a hard brown colored area. A skin/wound note, dated 01/03/24, documented the wound was to the left lateral side of the foot. A skin/wound note, dated 01/18/24, documented the resident was on antibiotics for a diabetic wound. A quarterly assessment, dated 03/30/24, documented Resident #59 had no cognitive impairment and one unstageable pressure injury as a deep tissue injury. The MDS did not document Resident #59 had a diagnosis of a diabetic foot ulcer. A wound care note, dated 04/04/24 documented the wound as a [NAME] Grade 1 diabetic ulcer not healed with a moderate amount of serous drainage noted with mild odor. The diagnosis was documented as a Type 2 diabetes mellitus with foot ulcer and non-pressure chronic ulcer of other part of left foot. On 05/02/24 at 10:48 a.m., MDS coordinator #1 was asked how they coded pressure ulcer wounds on the MDS. They stated, they got their information from the wound care team. They were asked to review the wound care note which documented a diabetic ulcer and asked if the MDS was accurate. They stated No. 21731 2. Resident #6 had diagnosis to include psychotic disorder, anxiety, atherosclerotic heart disease, depressive disorder, and bipolar disorder. A Physician Order, dated 11/09/22, documented Resident #6 was to be administered Thiothixene, an antipsychotic medication every evening for bipolar disorder. A Quarterly Assessment, dated 01/12/24, documented Resident #6 had been administered a diuretic. A Quarterly Assessment, dated 04/09/24, documented Resident #6 had been administered an antidepressant and a diuretic medication. The clinical record did not contain physician orders for an antidepressant or diuretic medication. On 05/07/24 at 8:30 a.m., the DON, MDS coordinator, and Corporate RN were asked to verify what orders were in place for Resident #6 to be administered a diuretic or an antidepressant medication, as documented on the assessments dated -1/12/24 and 04/09/24. The Corporate RN stated, I am not seeing orders for those medications, appears to be miscoded. 3. Resident #34 had diagnosis to include anxiety. A Physician Order, dated 10/16/23, documented Resident #34 was to be administered Hydroxyzine, an antihistamine, twice a day for anxiety. A Quarterly Assessment, dated 02/07/24, documented Resident #34 had been administered a antianxiety medication. On 05/02/24 at 11:07 a.m., the MDS coordinator and Corporate RN were asked if Resident #34 had been ordered or administered an antianxiety classified medication as documented on the Quarterly assessment on 02/07/24. The Corporate RN stated the orders are for Hydroxyzine, but it is classified as an antihistamine, there is not a medication classified as an antianxiety medication. They stated, the assessment is not correct. 4. Resident #61 had diagnoses to include senile degeneration of the brain, and dementia. A Significant Change of Status Assessment, dated 02/06/24, documented Resident #61: a. had clear speech, understood others and made themselves understood, b. had severe cognitive impairment for daily decision making, c. a brief interview for mental status should be conducted, and d. a resident mood interview should not be conducted due to Resident #61 is rarely or never understood. On 04/30/24 at 9:38 a.m., Resident #61 sat on the side of the bed during an interview with a family member. Resident #61 would smile when spoken to but did not engage in converstion. On 05/01/24 at 2:00 p.m., the MDS coordinator was asked how Resident #61 was assessed for communication. They stated, I spoke with [the resident]. They were asked to clarify if the resident understood others and was able to make themselves understood. They stated the resident does understand and is able to understand others. The MDS coordinator was asked how the assessment dated [DATE], would be correctly coded regarding the resident mood interview should not be conducted due to the resident is rarely or never understood. The MDS coordinator stated a correction needed to be completed.

Based on observation, record review, and interview, and the facility failed to consult/notify the physician of missed antibiotic therapy for a resident with possible osteomyelitis for one (#59) of one sampled resident reviewed for antibiotic use. The Administrator identified 106 residents resided in the facility. The DON identified 13 residents received antibiotics. Findings: A Notification of Change Guideline policy, dated 12/01/09, read in part The facility will consult with the resident's physician of the following events .A need to alter treatment significantly . Resident #59 had diagnoses which included, right BKA, diabetic ulcer, diabetes mellitus and high cholesterol. Resident #59 had dialysis on Mondays and Fridays. An x-ray report, dated 03/20/24, read in part .Impression .Question osteomyelitis vs severe osteopenia of the fifth metatarsal head . A quarterly assessment, dated 03/30/24, documented Resident #59 had no cognitive impairment. A MAR, dated 04/11/24 through 04/17/24 documented the resident had not been administered Cipro 500 mg morning dose ordered twice a day for two of fifteen doses ordered. A MAR, dated 04/19/24 through 04/26/24, documented the resident had not been administered Cipro 250 mg daily morning dose for three of eight doses ordered. A physician order, dated 04/11/24, documented Resident #59 was to be administered Cipro 500 mg tablet twice a day. On 05/03/24 at 10:31 the Corp Nurse Consultant #1 was asked what should have been done when the resident had not been given their antibiotics. They stated the doctor should have been notified and the dose changed to night.

Based on observation, record review, and interview, the facility failed to ensure: a. coordination of care with hospice for one (#61) of one sampled resident reviewed for hospice, b. wound care treatments were administered as ordered for two (#56 and #59), c. a referral was made to a wound care center as ordered for one (#59) of five sampled residents reviewed for wounds, d. a resident was in the dining room for all meals related to weight loss for one (#18) of 22 sampled residents reviewed for following physicians' orders, and e. lab tests were obtained as ordered for HgBA1C every three months for one (#8) of 22 sampled residents reviewed for following physicians orders. The Administrator identified 106 residents resided in the facility. The DON identified four resident had diabetic ulcers and 21 had hospice services. Findings: 1. Resident #61 had diagnosis to include senile degeneration of the brain. A Care Plan, dated 07/15/22, documented Resident #61: a. was to receive baths on Tuesday and Fridays during the day shift; b. nails were to be trimmed and cleaned on bath day and as necessary; c. a sponge bath would be provided when a full bath or shower could not be tolerated; and d. Resident #61 required limited staff participation with bathing. A Significant Change of Condition Assessment, dated 02/06/24, documented Resident #61 had severe cognitive impairment, and required supervision or touching to complete the bathing process. A Care Plan, dated 03/06/24, documented Resident #61 had a terminal illness and was admitted to hospice on 02/06/24. The care plan did not document how the care would be coordinated between the nursing facility and hospice providers. An undated, Visual/Bedside Kardex Report documented, as of 05/01/24, Resident #61 would receive baths on Tuesdays and Fridays during the day shift. The report did not identify that Resident #61 was on hospice services, or what care would be provided by hospice services. The February 2024, bathing records for Resident #61, documented five baths were provided by hospice, on Tuesdays and Fridays. The clinical record and hospice records did not contain documentation that hospice staff were in the facility during the month of February 2024. The Hospice Staff Visit Sign-in Sheet And Communication Note, logs did not contain documentation that hospice staff had visited Resident #61 during February 2024. The March 2024, bathing records for Resident #61, documented nine baths were provided by hospice on Tuesdays and Fridays. The Hospice Staff Visit Sign-in Sheet And Communication Note, logs did not contain documentation that hospice staff had visited Resident #61 on five dates that the facility had documented hospice had provided a bath. The sign-in log documented a hospice aide had signed-in 13 days to provide care. The clinical record and hospice record, did not contain documentation by the hospice aid to indicate what care had been provided on the 13 days they had signed-in at the facility to see Resident #61. The April 2024, bathing records for Resident #61, documented eight baths were provided by hospice staff on Tuesdays and Fridays. The Hospice Staff Visit Sign-in Sheet And Communication Note, logs did not contain documentation that hospice staff had visited Resident #61 on two dates that the facility had documented hospice had provided a bath. The sign-in log documented a hospice aid had signed in 15 days to provide care. The clinical record and hospice record, did not contain documentation by the hospice aide to indicate what care had been provided on the 15 days they had signed-in at the facility to see Resident #61. The clinical record and hospice record, did not contain a hospice care plan, or provider notes to indicate coordination of care was in place. On 04/30/24 at 9:38 a.m., Resident #61's family member stated the resident had dementia that created a challenge for bathing, and the resident was placed on hospice to assist with bathing. On 05/01/24 at 2:04 p.m., the DON was asked who is responsible to ensure a resident is provided a bath. They stated the CNA or if on hospice, the CNA and the hospice. They stated Resident #61, per the care plan, was to receive a bath every Tuesday and Friday. The DON was asked where is the documentation that hospice provided bathing for Resident #61. They stated, We will need to call to get it. The DON was asked what does the hospice care plan document regarding if and when hospice staff are to provide bathing assistance. They stated, We just got the care plan. The DON was asked how was the care coordinated with hospice for resident #61. They stated, It hasn't been for this resident. 35749 2. Resident #8 had diagnoses which included Diabetes Mellitus. A Physician's Progress note, dated 06/30/23, documented to obtain a HgBA1C every three months. A Physician's Progress note, dated 02/21/24, documented to continue to monitor HgBA1C every three to six months as indicated. A Physician's Progress note, dated 03/19/24, documented to continue to monitor HgBA1C every three to six months as indicated. Resident #8's clinical records were reviewed. There where no HgBA1C labs in Resident #8's records. On 05/01/24 at 10:44 a.m., the DON was asked for lab orders for Resident #8's lab orders. The DON stated Resident #8 did not have any current lab orders. On 05/01/24 at 1:14 p.m. the DON was asked to locate any HgBA1Cs for Resident #8. On 05/02/24 at 8:51 a.m., the DON was shown the physician's progress note, dated 06/30/23. They were asked if they considered this a physician's order. The DON stated, Yes. No HgBA1C labs were provided. 3. Resident #56 had diagnoses which included chronic non-pressure ulcer. A Physician's Order, dated 04/26/24, documented to cleanse the right dorsal foot with NS, pat dry, apply Dakin's moistened gauze, loosely cover with border dressing daily and prn every day shift related to a non-pressure chronic ulcer of the right dorsal foot. An April 2024 Treatment Administration Record, documented ulcer treatment had been provided for the right dorsal foot as ordered. On 04/29/24 at 1:34 p.m. Resident #56 was observed in bed, positioned toward their right side. A dressing, dated 04/26/24, was observed to the top of their right foot. Resident #56 was asked how often staff changed the dressing. They stated every few days. On 04/29/24 at 2:45 p.m., CNA #3 was asked to observe Resident #56. CNA #3 was asked what date was on the dressing to Resident #56's top of right foot. They stated 04/26/24. On 04/2924 at 2:51 p.m., LPN #2 was asked who was responsible for providing wound care. They stated the wound care nurse did wound care Monday through Friday and the charge nurses did it on the weekends. LPN #2 was asked what the frequency was for Resident #56's top of right foot wound. They stated daily. On 04/29/24 at 2:55 p.m., LPN #2 was shown Resident #56's dressing to the top of the right foot. They were asked the date on the dressing. LPN #2 stated 04/26/24. LPN #2 was asked what the policy was for providing wound care. They stated wound care to the right dorsal foot was to be provided daily. 41872 4. Resident #59 had diagnoses which included, right BKA, diabetic ulcer, diabetes mellitus and high cholesterol. A quarterly assessment, dated 03/30/24, documented Resident #59 had no cognitive impairment A wound care note, dated 04/04/24 documented the wound as a [NAME] Grade 1 diabetic ulcer not healed with a moderate amount of serous drainage noted which has a mild odor. The wound is deteriorating. The diagnosis was documented as a Type 2 diabetes mellitus with foot ulcer and non-pressure chronic ulcer of other part of left foot. A physician order, dated 04/11/24, documented Resident #59 was to be administered Cipro 500 mg one tablet twice a day. To clean the wound with normal saline apply silvadene, cover with fibracol and secure with a clean bandage. A physician note, dated 04/19/24, documented to refer to wound care center for wounds to left foot and to follow wound care instructions as ordered. The physician note dated 04/19/24, was not available to staff, until requested by surveyor on 05/03/24. A physician order, dated 04/29/24, documented to clean the wound with saline, apply a thin layer of silvadene, then fibracol and secure with bandage. Resident #59's TAR dated 05/01/24 through 05/31/24, dressing change did not have initials (was blank) on 05/02/24. The clinical health record did not document why the residents wound care had not been changed on 05/02/24. On 05/03/24 at 8:03 a.m., Resident #59 stated RN #1 or LPN #4 usually changed their dressing, but it had not been changed yesterday. On 05/03/24 at 8:13 a.m., CNA #5 was asked what date did they observe on Resident #59's dressing. They stated there was no date. On 05/03/24 at 846 a.m. LPN #4 was observed to complete wound care to Resident #59's left foot. On 05/03/24 at 855 a.m., LPN #4 was asked what date was on the dressing they had removed. They stated they did not know. They were asked to review the May TAR and asked what did the blank mean on 05/02/24. They stated that it means it wasn't clicked off. They were unsure. On 05/03/24 at 11:07 a.m., RN #1 was asked if they had changed Resident #59's dressing yesterday (05/02/24). They stated No. On 05/06/24 at 9:35 a.m., the DON provided a copy of the physician note from the foot and ankle clinic, dated 04/18/24. They were asked if the resident had been seen by wound care. They stated they had just got the report. They were asked if the resident had been referred to a wound care center for the wound to their left foot. They stated, I just got this. There was no documentation Resident #59 had been referred to a wound care center as ordered by the physician on 04/18/24. 5. Resident #18 has diagnoses which included dementia, type two diabetes mellitus, high blood pressure and mood disorder. A physician order, dated 03/28/23, documented Resident #18 was to be in the dining room for all meals related to weight loss. Resident #18's care plan, date initiated 07/26/23, documented the resident was to in the dining room for each meal due to weight loss. A significant change in status assessment, dated 11/07/23, documented supervision or touching assistance with eating. On 04/30/24 at 11:57 a.m., Resident #18 was observed with their hall tray on their over the bed table. On 04/30/24 at 12:04 p.m., Resident #18 was observed to have eaten one bite of their rice. On 04/30/24 at 1:35 p.m., Resident #18 was still sitting in their bed with the plate of food on the over the bed table. On 05/01/24 at 845 a.m., Resident #18 was observed in their bed with a breakfast tray in front of resident on the over the bed table. On 05/02/24 at 9:36 a.m., the DON was shown the order to be in the dining room for all meals and asked if the order was still active. They stated, If it is still on here then it would be. The DON was asked how staff knew the resident should be taken to the dining room for all meals. They stated, the charge nurse needs to make sure and let them know and ensure the resident is taken to the dining room. They were asked if the resident had been in the dining room. They stated, No. They were asked if the physician orders had been followed. They stated the resident had not been up for meals.

Based on observation, record review, and interview, the facility failed to ensure pressure ulcer treatment were provided as ordered for one (56) of three sampled residents reviewed for pressure ulcers. The Resident Matrix, dated 04/30/24, documented 13 residents had pressure ulcers. Findings: A Pressure Ulcer policy, dated 03/25/11, read in part, .Purpose .To provide a systematic, standardized approach to the prediction, prevention, and management of pressure ulcers . Resident #56 had diagnoses which included chronic non-pressure ulcers and DTI. A Physician's Order, dated 04/26/24, documented to cleanse the right lateral foot with NS, pat dry, apply nickel thick Santyl, durafiber, and cover with border foam dressing daily and prn. An April 2024 Treatment Administration Record, documented pressure ulcer treatment for the right lateral foot had been provided as ordered. On 04/29/24 at 1:34 p.m. Resident #56 was observed in bed, positioned toward their right side. A dressing, dated 04/26/24, was observed to the top of their right foot. A bed pad under Resident #56's right foot was observed to have yellow, tan, and pink colored drainage. Resident #56 was asked how often staff changed the dressing. They stated every few days. On 04/29/24 at 2:45 p.m., CNA #3 was asked to observe Resident #56. CNA #3 was asked what date was on the dressing to Resident #56's top of right foot. They stated 04/26/24. CNA #3 stated they would go tell the nurse about the drainage. On 04/2924 at 2:51 p.m., LPN #3 was asked who was responsible for provided pressure ulcer care. They stated the wound care nurse did wound care Monday through Friday and the charge nurses did it on the weekends. LPN #2 was asked what the frequency was for Resident #56's top of right foot wound. They stated daily. On 04/29/24 at 2:55 p.m., LPN #2 was shown Resident #56's dressing to the top of the right foot. They were asked the date on the dressing. LPN #2 stated 04/26/24. LPN #2 lifted Resident #56's right foot off of the bed pad. An open area, approximately the size of a silver dollar with necrotic tissue to approximately 80% of the wound, and red peri-wound, was observed to the right lateral foot. no dressing in place. The bed pad under Resident#56's right lateral foot was tan, yellow, and pink tinged. LPN #2 was asked what the policy was for providing wound care. They stated wound care to the right dorsal foot and right lateral foot were to be provided daily. LPN #2 was asked what staff would do if a wound dressing came off. They stated they would put on in place. LPN #2 was asked how staff ensured wound treatments were provided. They stated a wound care nurse does the dressing Monday through Friday and a charge nurse would do them on the weekends.

Based on record review and interview, the facility failed to ensure information was offered to formulate an advanced directive for one #(61) of three sampled residents reviewed for advance directives. The Administrator identified 106 residents resided in the facility. Findings: Resident #61 was admitted to the facility on [DATE]. A Physician Order, dated 08/04/21, documented Resident #61 was a full code status. A Physician Order, dated 02/07/24, documented Resident #61 was to be admitted to hospice services for senile degeneration of the brain. On 04/30/24 at 12:13 p.m. the clinical record did not contain documentation that information had been offered to Resident #61, or their representative, to formulate an advanced directive. 05/01/24 at 10:30 a.m., the clinical record did not contain documentation that information had been offered to Resident #61, or their representative, to formulate an advanced directive. On 05/01/24 at 1:55 a.m., the DON was asked if information had been provided to Resident #61 or their representative to formulate an advanced directive. They stated, That should have been reviewed when hospice was ordered. On 05/01/24 at 2:10 p.m., the DON reported the facility was waiting for the daughter signature on the forms, the information had not been offered prior to hospice services and the paper work is still pending.

Based on observation and interview, the facility failed to ensure a mattress was not soiled for one (#70) of eight mattresses observed for homelike environment. The administrator identified 106 residents resided in the facility. Findings: On 04/30/24 at 11:48 a.m., Resident #70's bed was observed to be unmade and without linens. The mattress was observed with brown residue and brown rings. On 04/30/24 at 11:51 a.m., CNA #2 was asked how they ensured mattresses were kept clean. CNA #2 stated they inspected mattresses when they did linen changes. CNA #2 stated they would disinfect the mattresses twice a week. CNA #2 was shown Resident #70's bed. CNA #2 put gloves on to feel if the mattress was wet. They stated the mattress was not wet and brown ring was dried urine. CNA #2 stated the brown substance was poop.

Based on record review and interview, the facility failed to ensure a comprehensive assessment was completed every 12 months for one (#73) of 22 sampled residents reviewed for assessments. The Administrator identified106 residents resided in the facility. Findings: Resident #73 was admitted to the facility on [DATE]. The summary of assessments documented the following: a. An Admission Assessment, was completed on 04/24/23; b. Quarterly Assessments, were completed on 07/11/23, 10/11/23; 01/09/24; and 03/29/24. On 05/23/24, at 11:10 a.m., the DON, MDS coordinator, and Consultant RN, were asked when an Annual or other comprehensive assessment had been completed for Resident #73. The Consultant RN stated, It should have been completed on 03/29/24, instead of a quarterly assessment.

Based on observation, interview and record review, it was determined the facility failed to prevent the development of an avoidable moisture-associated skin damage (MASD) area for one (#16) of three sampled residents reviewed for assistance with activities of daily living. The facility's failure to provide incontinent care according to the resident's needs resulted in harm with MASD area to the peri-anal area. The director of nurses identified 40 residents who were dependant on staff for assistance with incontinent care. The facility census was 102. Findings: Resident #16 was readmitted to the facility with [DIAGNOSES REDACTED]. A care plan, last updated 08/05/16, documented: Focus; (Resident) requires assist x (times) 2 with ADLS (activity of daily living). He has had a [MEDICAL CONDITION] has left him paralyzed and weak. Depends on others for care. He requires total assist with all dressing of x 1-2. Goal; He will be clean, comfortable and odor free consistently over the next review period. Interventions; .change him through the day if he gets soiled. Personal hygiene; Requires total assist with all care. Does need 1:1 (one on one) assist with meals. A quarterly assessment, dated 08/24/16, documented the resident was cognitively intact and able to make his needs known. The assessment further documented the resident required extensive assistance from two staff members for all aspects of ADLs, including eating and was always incontinent of bowel and bladder. On 09/07/16 at 1:10 p.m., the resident was observed in the main dining area seated upright in a reclining positioning chair. He was observed to eat a meal as he was assisted by a family member. They were asked if his needs were being met in a timely manner by the staff. The family member responded the care was good, except she wished he could be changed more often. She was asked how often did they change him. She stated, I'm sure it's only done when they get him up and when they put him back in bed. The resident was observed to be covered from his chest to his ankles with a blanket as he ate. He was asked if he was cold. He stated, I'm freezing. The family member repositioned the blanket covering the resident. When the blanket was moved a strong odor of urine permeated the immediate area. The spouse was asked to raise the blanket covering the resident's lower body. As the blanket was raised the resident's pants were observed to have a darkened wet spot covering the entire crotch area. The odor of urine was very strong. The family member was observed to fan her face with her hands to clear the odor from her face. The family member stated, This is how I find him every time I come in to feed him his lunch. She was asked how often she came in to assist him with his meal. She stated she came every day. The resident was asked when he had last been repositioned or had incontinent care provided. He stated he had not been provided care or repositioned since he had been assisted out of bed that morning. He was then asked if he could recall what time he was assisted out of bed, and he stated, They usually get me up around 8:00 a.m., if not before. The resident was asked if he thought being wet was contributing to his being so cold. He stated he hadn't thought about that but it made sense. They were asked why they thought he was only changed once or twice a day. The family member stated, Because it takes them a long time to put him to bed and there has to be two of them. At 1:30 p.m., certified nurse aide (CNA) #1 was interviewed and asked if she was the CNA on hall 100. She stated she was. She was asked how often dependent residents were to be checked for incontinence and/or repositioning. She stated, I check them all the time, but at least every 2 to 3 hours. She was then asked when resident #16 had last been checked, changed or repositioned in his positioning chair. She stated she had last provided incontinent care prior to taking him to activities. She was asked who had assisted her with the care. The CNA walked away without answering the question. The surveyor had observed the resident in the activity room from 9:00 a.m. to 9:45 a.m., participating in Bible study. On 09/07/16 at 1:35 p.m., licensed practical nurse (LPN) #1 was interviewed regarding the resident's care. She was asked if she was the nurse caring for him on the present shift. She stated she was. She was asked what his daily routine was. She stated he usually was given a bath before breakfast and then he went to activities. She stated, We reposition him every so often. She was asked at what point incontinent care was provided, and she stated, When we lay him down. The LPN was asked if the resident was up for breakfast, activities and then lunch, how many hours did that include. The LPN didn't answer the question, but stated, We can change him sooner, but he usually isn't ready. At 1:45 p.m., the LPN was asked if the resident could be returned to his room and provided incontinent care so an observation of his skin could be made. At 2:00 p.m., CNA #1 and the restorative aide (RA), entered the room and placed the resident in bed using a mechanical lift. When the resident was lifted from the positioning chair, the cushion on the chair was observed to be wet and odorous. The sling used to transport the resident from the chair to the bed, was also wet and odorous. As the resident was positioned on the bed, his blue sweat pants were observed to be wet over the entire crotch area and odorous. The pants were removed, and then the brief. The brief was completely saturated with urine and feces. The RA provided peri-care as the CNA positioned the resident for the care. The RA was observed to wipe and clean the peri-area thoroughly around the penis and top of the scrotal area. The resident was then repositioned onto his left and right side to cleanse the buttock area of feces. He was then positioned supine in bed and the two aides stopped and looked at the surveyor. They were asked if they were finished. The RA stated, Well no. They were asked if the residents right leg could be lifted to expose the crease of the leg at the hip area. The resident's leg was lifted as the RA cleansed the crease in a downward motion with a slightly damp incontinent wipe. The RA was observed to wipe the area very gently. The resident was observed to tense up and grimace when the staff member wiped toward the bottom of the anus area. The CNA then stated the resident had, Had the runs the past couple of days. The aides were asked to raise the resident's left leg so the anus area could be viewed as the area was cleansed. The anus area was observed to have three dime-sized open, bleeding, excoriated areas on the left side of the buttock near the anal area. As the staff cleansed the feces from the anal area, the resident was heard to say, You talk about something that hurt, now. Whew. that's sore. The scrotum was also observed to be reddened and tender as it was cleansed. The CNA was asked if those areas were there when he was changed earlier in the day, before going to activities. The CNA stated she wasn't sure. The care provided was observed to take 25 minutes to complete. At 2:30 p.m., LPN #2 was interviewed and asked when the resident's last skin assessment was completed and what her findings were. She stated she had not completed one for the current week. She was asked if she knew of any wounds the resident may have. She stated the resident previously had only some blisters along his hip areas and on the lower back area. She was asked what she thought could have caused the blisters she found. She stated, Probably from his briefs rubbing. Weekly skin assessments, dated 08/30/16 and 09/05/16, documented the resident's Braden score (an assessment to evaluate the risk of pressure ulcer development) was 12, indicating high risk, and had left sided paralysis, decreased mobility, weakness and a history of wounds. Interventions included a low air loss mattress, cushion for the positioning chair and skin prep to the heels. The assessments further documented there were no new skin issues identified and no changes to identify. Monthly ADLS records were reviewed for the month of August 2016 and September 2016. The records documented the resident was provided with incontinent care three times a day, every day during the months reviewed. The times for which incontinent care was provided, documented one time during each shift for each day. Daily medications administered included a diuretic ([MEDICATION NAME] 20 milligrams) which was administered as ordered. On 09/07/16 at 2:54 p.m., the director of nurses (DON) and corporate nurse #1 was interviewed. The DON was advised of the above observations and asked what their policy was regarding incontinent care and repositioning dependent residents. She stated all residents were to be provided with care every two hours or more often if necessary. She further stated she generally watched out for dependant residents to ensure they were not being left too long in their chairs, and that staff repositioned and changed them on a regular basis. She was advised the resident was observed from 9:00 a.m., until 2:30 p.m., with no incontinent care or assistance with repositioning provided during that time. She was asked if she was aware of the resident's skin impairment. She stated the wound nurse had advised her of the MASD area on his bottom.

Based on record review and interview, it was determined the facility failed to ensure residents were free of any significant medication errors related to [MEDICATION NAME] for one (#7) of four sampled residents who were being administered [MEDICATION NAME] daily. This resulted in an actual harm for resident #7. This had the potential to affect an additional eight residents in the facility who were receiving the medication [MEDICATION NAME]. Findings: A facility policy entitled "Medication Orders" documented, "The nurse will also list any changes on a telephone order...discontinuing any medication...the admitting licensed nurse will complete the Medication Administration Record...entering the order exactly word or (sic) word..." The policy for "Medication Orders" documented, "Special Circumstances; the following...drugs ....anti-coagulants ...require the following special attention. Laboratory tests should be documented in the resident's chart." In the section titled "Preventing and Detecting Adverse consequences" the facility policy documented, "The facility employs a system to assure that medication usage is evaluated on an ongoing basis. When a resident has a change in condition, medication related problems are considered." According to Drugs.com, [MEDICATION NAME] has the possible side effects of...easy bruising...confusion...severe bleeding... back pain..." Resident #7 was admitted with [DIAGNOSES REDACTED]. On 06/09/12, a hospital physician discharge order documented, "[MEDICATION NAME] 75 mg By Mouth Every Day Resume after rechecking H/H in one week from d/c to make show (sic) it is stable before continuing [MEDICATION NAME]." Also noted on the discharge instructions were "Discontinue These Medications: [MEDICATION NAME] 75 mg By Mouth Every Day." A review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A handwritten entry written above the initiation of the medication read, "Check /c nurse if lab is (H/H) 8.3 then resume [MEDICATION NAME]." The medication was given until 07/31/12 for a total of 41 daily doses. A telephone order dated 06/09/12, signed by physician on 06/13/12, documented, "Have CBC re (check) in 1 wk before resuming [MEDICATION NAME], D/C hemoglobin 8.3 mg/dl." The resident's clinical record had two results for lab work dated 06/19/12. One lab result was timed at 5:14 a.m. with the H/H results of 8.8/28.3 (low, indicative of [MEDICAL CONDITION]). The second lab result for the same date, but untimed, had results of 9.3/29.6 (low, indicative of [MEDICAL CONDITION]). There was no evidence the facility reacted or responded to the low H/H by notifying the physician or stopping the medication. Review of facility incident reports and/or nurses' notes, documented the resident had falls on the following dates: An incident report dated 06/20/12: at 6:10 a.m., documented the resident fell and sustained an abrasion on her R lower back, R finger and redness to the left cheek. A nurse's note dated 06/20/12 at 6:30 a.m., documented, "Assist (up) & to Bathroom, res. had X-lg loose stool." A nurse's note at 11:30 (no a.m. or p.m.) documented a QM, "head to toe assessment done and she has bruising on L side of face by temple and DON notified for reporting. small abrasions x 3 on both ankles in front bilater (sic) midway between knee and foot. Bruising to 4th & 5th fingers of the R hand and 1-3 of the L hand." An incident report dated 06/28/12 at 4:30 a.m., documented the resident fell with bruises noted on the L hand and little finger. A nurse's note dated 06/28/12 at 12:00 p.m., documented a QM head-to-toe assessment. The note documented, "limited ROM on lower extremities, resident c/o hip pain. Two nickel sized abrasions bilat on knees and bruises on L small finger..." An incident report dated 07/13/12 at 7:30 p.m., documented the resident was found on the floor and that no injuries were sustained. The nurse's note for that date documented the resident sustained [REDACTED]. A QM head to toe assessment dated [DATE], documented the resident sustained [REDACTED]. An comprehensive significant change assessment dated [DATE], documented the resident had moderate cognitive impairment and required limited to extensive assist with ADLs. She was frequently or occasionally incontinent. A care plan last updated on 07/20/12, documented the resident was on a falling star program (a program to address her falls). The care plan discussed the resident's falls, her impaired O2 exchange, and the potential for injury related to the use of a diuretic medication. There was no documentation found addressing the resident's low blood count, what contributed to the decreased blood count, or the effects of [MEDICATION NAME] to potentially contribute to impaired O2 exchange and the potential for injury. An incident report dated 07/28/12 at 5:30 a.m., documented the resident was observed on floor and that she sustained a skin tear to the L elbow. A nurse's note for 07/28/12, documented the resident sustained [REDACTED]. An assessment completed by the DON at 3:00 p.m. documented a L elbow skin tear. A QM assessment of the resident on 07/30/12 at 1:00 p.m., documented a small tear on L elbow. An incident report dated 07/31/12 at 11:15 (no a.m. or p.m. indicated) documented the resident was found on the floor. No injuries were documented. Nurses' note entries after this fall do not indicate if a QM assessment was completed. An incident report dated 08/02/12 at 8:30 a.m., documented the resident was found laying on the floor with no apparent injuries. A QM assessment completed on the same day at 1:30 p.m. documented no new injuries noted. A nurse's note entry at 2:00 p.m., indicated the resident had a skin tear on her right forearm. In an interview with the DON on 08/14/12 at 11:35 a.m., she was asked about the resident's order for [MEDICATION NAME], the abnormal H/H results and regarding the resident being administered [MEDICATION NAME] for 41 daily doses. She replied, "I need to check on this further. I guess I need a telephone order to discontinue or some lab results." On 08/15/12 at 7:55 a.m., the DON was asked about her findings on the resident's medication. She stated, "I talked with Dr. (Name withheld) and he said he was glad she was off of it because she had had some falls and she didn't need to be on it." On 08/15/12 at 2:15 p.m., the resident's primary care physician was interviewed regarding the resident. He stated the resident had vascular disease and dementia, which was worsening. He stated the resident was now on hospice and the family did not want to do any aggressive treatments. He further stated, "With [MEDICATION NAME], your damned if you do and damned if you don't." He was asked what the [MEDICATION NAME] was being used for. He stated the [MEDICATION NAME] was used to treat vascular problems, but then will cause [MEDICAL CONDITION]. On 08/15/12 at 4:10 p.m., an interview was conducted with LPN #6 regarding notification of the physician when laboratory results were abnormal. She stated, "Usually if lab is abnormal, I call doctor and then fax." The clinical record was reviewed. Documentation indicated the abnormal lab dated 06/19/12, was faxed, but no other documentation was located to indicate a response was received from the physician or a follow-up call from the nurse to the doctor. The LPN stated, "I guess doctor was not notified verbally, normally I call and fax and put note in nurses' notes." On 8/15/12 at 4:15 p.m., an interview was conducted with LPN #5. She indicated she did not remember taking the order from the discharge orders, nor did she remember where she got the 8.3 value from on the telephone orders dated 6/9/12. She was asked if she could tell what some of the side effects of [MEDICATION NAME] were. She responded, "Irritation, agitation, bleeding and bruising." On 08/15/12 at 4:25 p.m., the DON was asked if the facility had a policy to notify the physician regarding abnormal laboratory results on residents. She stated there was not a facility policy for the process to notify the physician of abnormal labs.