Every finding on record at Carnegie Nursing Home, Inc.

Based on observation, record review, and interview, the facility failed to develop and implement an infection control plan for enhanced barriers precautions for 2 (#3 and #4) of 2 sampled residents reviewed for enhanced barrier precautions.The ADON reported two residents on enhanced barrier precautions. Findings: 1. On 09/04/25 at 10:58 a.m., LPN #1 was observed to perform catheter care for Resident #3. LPN #1 washed their hands and applied gloves, then started the resident's catheter care. LPN #1 was not observed to wear a gown during the resident's catheter care. The resident's room was observed to have no PPE supplies near the room or enhanced barrier precaution signage. On 9/05/25 at 9:16 a.m., LPN #1 was observed to perform wound care for Resident #3. LPN #1 and CNA #1 performed hand hygiene and applied gloves to perform wound care to the resident's left buttock. LPN #1 and CNA #1 were not observed to wear a gown while they performed the wound care. On 09/05/25 at 9:29 a.m., CNA #1 was observed to put on gloves and empty Resident #3's catheter bag into a urinal. CNA #1 emptied the urinal into the resident's toilet, removed their gloves, and performed hand hygiene. CNA #1 was observed not wearing a gown while they emptied the catheter bag. Resident #3's care plan was reviewed and showed no interventions of enhanced barrier precautions. A physician's order for Resident #3, dated 02/10/25, showed wound care to the left buttock and thigh: cleanse with normal saline solution, pat dry, and apply a Xeroform cover (wound dressing) with a superabsorbent silicone dressing on Monday, Wednesday, and Friday. A physician's order for Resident #3, dated 06/13/25, showed catheter care every shift. A quarterly assessment, dated 06/30/25, showed Resident #3's cognition was severely impaired with a BIMS score of 06. The assessment showed an indwelling catheter and moisture-associated skin damage. On 09/05/25 at 9:33 a.m., CNA #1 reported they were not required to wear a gown to empty a catheter bag. CNA #1 reported no knowledge of enhanced barrier precautions. 2. On 09/04/25 at 9:50 a.m., Resident #4 was observed sleeping in bed. Their urinary catheter was draining to gravity, and a dignity bag was observed to cover the catheter bag. The resident's room was observed to have no PPE supplies near the room or enhanced barrier precaution signage. On 09/05/25 at 10:34 a.m., LPN #1 was observed to perform hand hygiene, apply gloves, and perform wound care to Resident #4's right buttock. LPN #1 was observed not to wear a gown during the resident's wound care. A physician's order for Resident #4, dated 05/23/25, showed to clean the wound to the right upper buttock with normal saline solution, pat dry, pack with Iodoform (compound to treat wounds), and cover with island dressing Monday, Wednesday, and Friday. A physician's order for Resident #4, dated 06/13/25, showed catheter care every shift. An annual assessment, dated 08/29/25, showed Resident #4's cognition was severely impaired with a BIMS score of 01. The assessment showed an indwelling catheter and moisture-associated skin damage. A care plan, dated 08/29/25, showed urinary catheter care and wound care. The care plan showed no interventions for enhanced barrier precautions. On 09/05/25 at 10:37 a.m., LPN #1 reported no knowledge of enhanced barrier precautions. On 09/05/2025 at 11:28 a.m., the ADON reported no policy for enhanced barrier precautions was available. On 09/05/25 at 12:12 p.m., the ADON reported Residents #3 and #4 should be on enhanced barrier precautions. The ADON reported staff should wear gloves and a gown when performing wound care and catheter care. The ADON reported the facility had not implemented enhanced barrier precautions.

Based on record review and interview the facility failed to accurately code minimum data set (MDS)assessments for three (#13, 24, and #84) of 12 sampled resident reviewed for accurate MDS assessments. The facility administrator reported 31 residents resided in the facility. Findings: The facility's MDS policy, dated 10/08/20, read in part, To provide key information unique to the resident. 1. Resident #13 had diagnoses which included congestive heart failure. A physician's order, dated 02/15/24, documented the resident had been prescribed Lasix [a diuretic medication] one and one half tablets of Lasix 40 mg tablets was to be taken daily for congestive heart failure. An administration record, dated 03/01/24 through 03/31/24, documented the resident was administered Lasix tablets each day on 03/01/24 through 03/28/24. A quarterly MDS assessment, dated 04/01/24, did not document in section N that the resident had been administered a diuretic medication during the seven day look-back period. 2. Resident #24 had diagnoses which include major depressive disorder. A physician's order, dated 03/26/24, documented the resident had been prescribed Remeron [an antidepressant medication] one tablet of 15 mg was to be taken every 12 hours for a depressive disorder. A medication administration record, dated 03/26/24 through 03/31/24, documented the resident had been administered Remeron 15 mg tablets on each day from 03/36/24 through 03/31/24. A quarterly MDS assessment, dated 04/01/24, did not document in section N that the resident had been administered an antidepressant medication during the seven day look-back period. 3. Resident #84 had diagnoses which included pain. A physician's order, dated 03/25/24, documented the resident had been prescribed Hydrocodone [an opioid pain medication] 10-325 mg 1 tablet to be taken once every 4 hours as needed for pain. A medication administration record, dated 03/25/24 through 03/31/24, documented the resident had been administered Hydrocodone 10-325 mg tablets on 03/28/24, 03/29/24, and 03/31/24. An admission MDS assessment, dated 04/03/24, documented the resident had entered the facility on 03/25/24. Section J did not document the resident had received as needed pain medication during the five day look-back period. Section N of the assessment did not document the resident had been administered an opioid medication since admission. On 04/17/24 at 11:59 a.m. the ADON stated they had not documented section N correctly in the MDS assessments of the three residents [#13, 24, and #84] because they had just missed them. They stated they had a process where LPN #1 and the DON would check their work with the MDS assessments. At 12:06 p.m., LPN #1 stated they did not double check the work of the ADON regarding the MDS assessments and does not believe anyone does. On 04/18/24 at 8:47 a.m., the DON stated it was important the MDS assessments be completed correctly. They stated they do not believe there was a process to current process to check the work of the ADON regarding the completion of MDS assessments but they believed their needed to be one.

Based on observation, record review, and interview the facility failed to ensure residents were free from accident hazards for two (#27 and #7) of four sampled residents. The ADON reported 31 residents resided in the facility. Findings: 1. Res #27 admitted to the facility with diagnoses of multiple sclerosis, diabetes mellitus, and pressure ulcer of the sacrum. On 04/15/24 at 10:50 a.m., the resident was observed resting in bed with bedrails observed on the resident's bed with a low loss air flow mattress in use. The resident's record did not contain a risk assessment for the use of bedrails with an air flow mattress. 2. Res #7 admitted to the facility with diagnoses of multiple sclerosis, congenital malformation, acquired absence of left leg, and acquired absence of right leg. The resident's record did not contain a risk assessment for the use of bedrails with an air flow mattress. On 04/15/24 at 8:30 a.m., Res #7 was observed in bed. The bed was observed with full bedrails raised on both sides. An air flow mattress was observed on the bed. A motor for an air flow mattress was observed on the foot of the bed powered on and functioning. On 04/15/24 at 11:49 a.m., Res #7 was observed in bed. The bed was observed with full bedrails raised on both sides. An air flow mattress was observed on the bed. A motor for an air flow mattress was observed on the foot of the bed powered on and functioning. On 04/16/24 at 8:12 a.m., Res #7 was observed in bed. The bed was observed with full bedrails raised on both sides. An air flow mattress was observed on the bed. A motor for an air flow mattress was observed on the foot of the bed powered on and functioning. on 04/16/24 at 1:33 p.m., the ADON/LPN reported Resident #7 has had the low loss air flow mattress for 2 years, reports he just got a new one. Reports had had bed rails for positioning since 07/20/23. On 04/16/24 at 1:39 p.m., the ADON she did not have a risk assessment completed regarding the use of bedrails with an air flow mattress. On 04/18/24 at 8:47 a.m., the DON stated they did not assess residents prior to their use of bed rails. They stated the charge nurses were to do that and report any problems to them. They stated informed consent and assessments had to precede the use of bed rails and they did not believe the nurses understood that process.

Based on record review and interview, the facility failed to perform annual nurse aid performance reviews. The ADON reported 31 residents resided in the facility. Findings: An employee staff list documented five CNA's who had hire dates greater than one year. On 04/15/24 at 2:00 p.m. the annual nurse aid perform reviews were requested. On 04/17/24 at 1:55 p.m., the assistant administrator stated she could not find the performance reviews.

Based on observation, interview, and record review, the facility failed to develpo/implement a care plan for one (27) of 16 residents review for care plans. The ADON reported 31 residents resided inthe facility. Findings: A care plan, dated 04/01/24, contained no documentation of bedrails. On 04/15/24 at 10:50 a.m., the resident was observed resting in bed with bedrails observed to be in use for both sides of the resident's bed. On 04/16/24 at 1:39 p.m., the ADON reported the bed rails should have been care planned.

Based on record review and interview the facility failed to conducted interdisciplinary team [IDT] meetings following quarterly assessments for the purpose of review and revision of the comprehensive care plan for two (#21 and #22) of 12 sampled residents reviewed for care plans. The administrator reported 31 residents resided at the facility. Findings: 1. Resident #21's admission summary documented the resident was admitted to the facility on [DATE]. A review of the resident's medical record did not locate documentation of care plan meetings having occurred for Resident #21 for the period of 04/15/23 through 04/15/24. 2. Resident #22's admission summary documented the resident was admitted to the facility on [DATE]. A review of the resident's medical record did not located documentation of care plan meetings having occurred for Resident #22 for the period of 04/15/23 through 04/15/24. On 04/15/24 at 10:19 a.m., Resident # 22 stated they were not aware what care plan meetings were or if they had attended. On 04/17/24 at 9:28 a.m., the ADON stated there had been no quarterly meetings of the IDT following MDS assessments in the past year. They stated the person that had taken care of those meeting no longer worked at the facility and the duty needed to be assigned to someone else. On 04/17/24 at 9:46 a.m., Resident #21 stated they were unsure if they had attended care plan meetings. On 04/18/24 at 8:47 a.m., the DON stated they did not know who planned and conducted the care plan meetings. They stated they had not attended any care plan meetings. They stated they did not believe the facility had a policy and procedure for care plan meetings. They stated the facility needs to start having care plan meetings.

Based on observation, record review, and interview the facility failed prevent the use of bed rails until: a. alternatives to the use of bed rails had been attempted, and b. informed consent had been obtained and documented, and c. an assessment of the resident's ability to safely use a bed rail was conducted for one (#84) of three sampled residents reviewed for accident hazards. The ADON stated seven residents had side rails attached to their beds and in use. Findings: A facility Restraint policy and procedure, dated 06/01/2017, documented resident were to be assessed for their ability to reposition themselves using bed rails and the bed rails were to be checked monthly for safety. The policy and procedure did not document the requirements for using alternative methods to using bed rails prior to their use, assessing the residents for safety prior to the use of bed rails, or obtaining informed consent prior to the use of bed rails. A review of Resident #84's records contained no documentation of the attempted use of alternatives to the use of bed rails, a safety assessment related to bed rails, or informed consent. On 04/15/24 at 10:43 a.m., Resident #84 was observed to have full bed rails attached to each side of their bed. The resident stated they did no like the bed rails and preferred they not be there. They stated they think the staff put them there to keep them from falling out of bed. They stated they were unsure if the staff had tried alternative to the bed rails prior to them being put on the bed. The resident did not know if they had signed a consent form or had been assessed for safety. On 04/17/24 at 9:55 a.m., CMA #2 stated the resident's bed rails were for them to position themselves. They were unaware of the procedures required prior to the use of bed rails. At 2:16 p.m., the ADON stated no alternative to bed rails had been attempted prior to Resident #83 using the bed rails. They stated they did not have any documentation of the resident being assessed for safety related to the use of bed rails prior to their use. They stated they did not have documentation of informed consent for the use of bed rails having been obtained. On 04/18/24 at 8:47 a.m., the DON stated they had not performed a bed rail safety assessment for Resident #84. They stated they knew there was a procedure for using bed rails but did not believe the charge nurses were aware of what was required. They stated the facility needed to put a procedure in place for the use of bed rails and do some education.

Based on observation and interview the facility failed to ensure a medication/storage closet was locked when left unsupervised. The ADON reported 31 residents resided in the facility. Findings: On 04/15/24 at 8:45 a.m., a medication/storage closet on the north hall was observed to be unlocked and unsupervised. The closet was observed to contain over-the-counter medications and medical supplies. On 04/15/24 at 8:51 a.m., CMA #1 was asked if the medication/storage closet door is supposed to be locked. CMA #1 reported yes.

Based on record review and interview, the facility failed to create a water management plan to prevent water borne pathogens. The facility administrator reported 31 residents resided in the facility. Findings: Facility policy and procedures were reviewed. No water management plan to prevent waterborne pathogens was located. On 04/18/24 at 9:59 a.m., the assistant administrator stated they had not heard of the water management plan to prevent waterborne pathogens. At 10:07 a.m., the assistant administrator stated the facility had not created a water management plan as of that time.

Based on record review and interview, the facility failed to: a. ensure accurate coding of MDS assessments for medication use for two (#5 and #28) of 12 residents whose MDS assessments were reviewed, and; b. ensure accurate coding of MDS assessments for diagnoses for two (#5 and #28) of 12 residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents documented a facility census of 29 residents. Findings: 1. Resident #5 was admitted with diagnoses which included edema, dementia, and Schizoaffective disorder. Physician Orders for resident #5, dated March 2023, documented the resident was ordered a diuretic and an antianxiety medication for daily use. A Quarterly Assessment for resident #5, dated 03/04/23, had no documentation to show the resident received a diuretic and antianxiety medication for seven out of the seven days look back period. 2. Resident #28 was admitted with diagnoses which included cerebral infarction and chronic obstructive pulmonary disease. A Quarterly Assessment for resident #28, dated 03/04/23, documented the resident received an anticoagulant seven out of seven days during the review period. Physician Orders for resident #28, dated March 2023, were reviewed and did not document an order for an anticoagulant medication. On 03/08/23 at 11:13 a.m., the MDS coordinator reviewed the clinical records and reported the medications were not accurately documented on the resident assessments.

Based on record review, observation, and interview, the facility failed to ensure kitchen sanitation was performed for: ~ sanitary ice machine was maintained ~ clean and free of residue coffee maker ~ clean and free of dust on portable fans ~ clean and free of grease residue on vent hood was maintained The Resident Census and Condition of Residents form documented 28 residents received nourishment from the kitchen. Findings: The facility policy, Dietary Policy and Procedure for Cleaning and Infection Control, read in parts .monitor the cleaning .signed by employee .if soap or chemical cleaners are used be sure they are completely rinsed away .wipe interior and all surface areas . On 03/07/23 at 9:30 a.m., an initial tour of the kitchen was conducted. The dietary manager provided documentation of the cleaning schedule for the ice machine which documented it had been cleaned March 2023. The ice machine was observed to have brown spots of residue on the inside ice guard. The dietary manager was shown the area of brown residue that was easily removed with a paper towel. The coffee maker was observed to have a thick white substance build-up on the water screen on top of the coffee maker. Three portable fans were in use in the clean dish drying and prep area of the kitchen. The fans were observed to have dust/debris build up on the fan blades and cover screens. Dietary aide #1 reported she had just cleaned them. No documentation of cleaning was provided. The vent hood above the range was observed to have a greasy film coating on the exhaust panels. The dietary manager reported it needed to be cleaned. On 03/07/23 at 11:30 a.m., the dietary cook was observed pouring water into the screen on top of the coffee machine to provide coffee for residents for the noon meal. On 03/10/23 at 11:00 a.m., the dietary manager provided the Dietary Policy and Procedures for Cleaning of the kitchen equipment, and reported the staff had stayed late to clean the kitchen.

Based on record review and interview, the facility failed to refer a resident to the appropriate state-designated authority for PASARR, who was later identified with a newly related condition, for one (#4) of one resident who was reviewed for PASARR. The Resident Census and Condition of Residents documented the facility had eight residents with behavioral healthcare needs. Findings: Resident #4 was admitted on [DATE]. A level one PASARR, dated 08/26/15, read in parts, .Level one PASRR screen . 2. 0 yes 0 no Diagnosis of a serious mental illness (for example, schizophrenic, paranoid, panic, mood or other severe anxiety or depressive disorder .0. No had been checked. Physician Orders for resident #4, dated March 2023, documented the resident received a diagnosis of major depressive disorder on 12/12/19 and a diagnosis of Schizoaffective disorder on 08/31/20. The clinical record contained no documentation to show resident #4, who was later identified with a possible serious mental disorder or related condition, was referred for a Level II PASARR evaluation and determination. A Quarterly Assessment for resident #4, dated 03/04/23, documented the resident's cognition was severely impaired. The assessment documented active diagnoses of major depressive disorder and Schizophrenia. The assessment documented the resident received an antipsychotic and an antidepressant seven of seven days previous. On 03/08/23 at 2:30 p.m., an interview with the audit nurse and the Administrator was conducted. They were asked if resident #4 had been referred to the appropriate state-designated authority for Level II PASARR evaluation. The audit nurse and Administrator reported they did not know an evaluation was required to be done again after the initial one on admission.

Based on record review, observation, and interview, the facility failed to ensure a resident received care in accordance with professional standards of practice, by using two-person assist when transferring a resident with a Hoyer lift, for one (#18) of one resident sampled who required a Hoyer lift. The Administrator identified 9 residents who required Hoyer lifts for transfers. Findings: A facility policy titled Policy and Procedure for Hoyer Mechanical Lift, revision date 10/08/20, read in parts, .the purpose for using a mechanical lift is to keep residents free of falls and injuries and to protect skin from bruising and tearing .one-person position resident in center of Hoyer lift and guide resident while second person pushes lift . Resident #18 was admitted with diagnoses which included cerebral infarction, anxiety disorder, and hemiplegia. A Quarterly MDS Assessment, dated 02/13/23, documented the resident was severly cognitively impaired and required total assistance with transfers. A Care Plan, dated 08/01/22, documented resident #18 was a high fall risk and required a Hoyer lift used for transfers by two person assist. On 03/08/23 at 1:18 p.m., CNA #1 was observed to enter resident #18's room by herself with a Hoyer lift. She reported she used the Hoyer lift to transfer resident #18 to the bed, with one person, and she could use the lift with one person per the facility policy. On 03/08/23 at 1:51 p.m., the infection preventionist reported all of the Hoyer lifts used in the facility were a two person assist. She stated anytime a resident was transferred with a Hoyer lift, two people should be in the room for assistance. On 03/08/23 at 2:10 p.m., the interim DON reported she expected two people to use the Hoyer lift to transfer residents. On 03/08/23 at 2:15 p.m., the Administrator stated two staff members should assist when transferring a resident with a Hoyer lift. The Administrator stated, I will educate staff.

Based on record review and interview, the facility failed to ensure the physician provided a clinical rationale for disagreeing to a gradual dose reduction of [CONDITION(S)] medications for three (#12, 2, and #20) of five residents reviewed for unnecessary medications. The Resident Census and Condition of Residents form documented 15 residents received [CONDITION(S)] medications. Findings: The facility policy, Policy and Procedures: Unnecessary Drugs/Prn Use read in parts .residents who have not used [CONDITION(S)] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record .residents who use [CONDITION(S)] drugs receive gradual dose reductions, and behavior interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 1. A physician order for Resident #12, dated 10/15/20, documented to give [MEDICATION(S)] (an anticonvulsant) 200 mg, one by mouth twice a day, for [CONDITION(S)]. A monthly Medication Regimen Review, dated 10/20/21, documented a recommendation by the pharmacist to consider a GDR (gradual dose reduction) of [MEDICATION(S)] 200 mg, twice a day, for [CONDITION(S)]. The physician documented, disagree, and provided no clinical rationale for not considering a dose reduction. An MDS assessment, dated 02/16/22, documented no GDR had been attempted and the physician had not documented a GDR was clinically contraindicated. 2. A monthly Medication Regimen Review for Resident #2, dated 09/22/21, documented a recommendation by the pharmacist to consider a GDR of [MEDICATION(S)], 1 mg every 12 hours, for anxiety. The physician documented, disagree, and provided no clinical rationale for not considering a dose reduction. A monthly Medication Regimen Review, dated 11/29/21, documented a recommendation by the pharmacist to consider a GDR of [MEDICATION(S)], 0.25 mg twice a day, for [CONDITION(S)]. The physician documented, disagree, and provided no clinical rationale for not considering a dose reduction. An MDS assessment, dated 03/16/22, documented the resident had exhibited no behaviors. A Care Plan, dated 04/01/22, documented the resident was prescribed [CONDITION(S)] medications for anxiety and depression. The care plan documented the facility would consult with the pharmacist and physician to consider dosage reduction when clinically appropriate at least quarterly. A monthly Medication Regimen Review, dated 04/29/21, documented a recommendation by the pharmacist to consider a GDR of Cycobenzaprine 5 mg, every 12 hours, for muscle spasm. The pharmacist suggested a small decrease to 2 mg, once a day, when current supply was complete. The physician documented, disagree, with no clinical rationale given. 3. A monthly Medication Regimen Review for Resident #20, dated 05/19/21, documented a recommendation by the pharmacist to consider a GDR of [MEDICATION(S)] 0.25mg, twice a day, for [CONDITION(S)] with delusions. The physician documented, disagree, with no clinical rationale given. An MDS assessment, dated 02/16/22, documented the resident had exhibited no behaviors. The assessment documented a GDR had not been attempted. A Care Plan, dated 02/16/22, documented the resident received medications for a [CONDITION(S)] with delusions. The care plan documented, pharmacy checks for a reduction every 3 months. On 04/14/22 at 2:00 p.m., the Administrator reported the facility had worked with the medical director regarding the monthly medication reviews and providing a clinical rationale for disagreeing with a recommendation for a GDR. The Administrator reported they would continue to work with the physician to provide a rationale as required.

Based on record review and interview, the facility failed to ensure gradual dose reductions of [CONDITION(S)] medications were attempted for three (#12, 2, and #20) of five residents reviewed for unnecessary medications. The Resident Census and Condition of Residents documented 15 residents received [CONDITION(S)] medications. Findings: The facility policy, Policy and Procedures: Unnecessary Drugs/Prn Use read in parts .residents who have not used [CONDITION(S)] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record .residents who use [CONDITION(S)] drugs receive gradual dose reductions, and behavior interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 1. A Physician Order for Resident #12, dated 10/15/20, documented [MEDICATION(S)] (an anticonvulsant) 200 mg, twice a day for [CONDITION(S)]. An MDS assessment, dated 08/02/21, documented the resident received antidepressants, anticoagulants, diuretics, and opioids seven of seven days previous. The assessment documented no GDR had been attempted and the physician had not documented a reduction would be clinically contraindicated. A monthly Medication Regimen Review, dated 10/20/21, documented the pharmacist recommended consideration of a gradual dose reduction (GDR) for [MEDICATION(S)] 200 mg, twice a day for [CONDITION(S)]. The physician documented, disagree, with no clinical rationale provided. An MDS assessment, dated 02/16/22, documented the resident received antidepressants, anticoagulants, diuretics, and opioids seven of seven days previous. The assessment documented no GDR had been attempted and the physician had not documented a reduction would be clinically contraindicated. 2. A monthly Medication Regimen Review for Resident #2, dated 09/22/21, documented a recommendation by the pharmacist to consider a GDR of [MEDICATION(S)], 1 mg every 12 hours, for anxiety. The physician documented, disagree, and provided no clinical rationale for not considering a dose reduction. A monthly Medication Regimen Review, dated 11/29/21, documented a recommendation by the pharmacist to consider a GDR of [MEDICATION(S)], 0.25 mg twice a day, for [CONDITION(S)]. The physician documented, disagree, and provided no clinical rationale for not considering a dose reduction. An MDS assessment, dated 03/16/22, documented the resident had exhibited no behaviors. A Care Plan, dated 04/01/22, documented the resident was prescribed [CONDITION(S)] medications for anxiety and depression. The care plan documented the facility would consult with the pharmacist and physician to consider dosage reduction when clinically appropriate at least quarterly. A monthly Medication Regimen Review, dated 04/29/21, documented a recommendation by the pharmacist to consider a GDR of Cycobenzaprine 5 mg, every 12 hours, for muscle spasm. The pharmacist suggested a small decrease to 2 mg, once a day, when current supply was complete. The physician documented, disagree, with no clinical rationale given. 3. A monthly Medication Regimen Review for Resident #20, dated 05/19/21, documented a recommendation by the pharmacist to consider a GDR of [MEDICATION(S)] 0.25 mg, twice a day, for [CONDITION(S)] with delusions. The physician documented, disagree, with no clinical rationale given. An MDS assessment, dated 02/16/22, documented the resident had exhibited no behaviors. The assessment documented a GDR had not been attempted. A Care Plan, dated 02/16/22, documented the resident received medications for a [CONDITION(S)] with delusions. The care plan documented, pharmacy checks for a reduction every 3 months. On 04/14/22 at 2:00 p.m., the Administrator reported the facility had worked with the medical director regarding the monthly medication reviews and GDR's. The Administrator reported they would continue to discuss the need for attempts in gradual dose reductions as indicated for individual residents.

Based on record review and staff interview, it was determined the facility failed to ensure PRN (as needed) antianxiety medications were not used beyond 14 days for one (#15) of five sampled residents reviewed for unnecessary medications. The facility identified there were no residents with current orders for PRN antianxiety medications. Findings: Resident #15 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) Tab(s) (tablets) 0.5 MG (milligrams) 1 TAB PO (by mouth) Q (every) 4 HRS (hours) PRN DX (diagnosis): ANXIETY . The (MONTH) 2019 PRN medication sheet documented 32 doses of the [MEDICATION NAME] had been administered past the 14 day limit without the indication to continue. The (MONTH) 2019 PRN medication sheet documented 14 doses of [MEDICATION NAME] had been administered past the 14 day limit without indication to continue. A physician's orders [REDACTED].DC (discontinue) [MEDICATION NAME] 0.5 mg .(one) tab PO (every) 4 (hours) (increased) anxiety . A physician's orders [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) 0.5mg/mL (milliliters), PLO (pluronic lecithin organogel) -Apply 1mL Topically to wrist Q4H (hours) PRN (and) .DX: Anxiety . The (MONTH) 2019 PRN medication sheet documented eight doses of [MEDICATION NAME] had been administered past the 14 day limit without indication to continue. A physician's orders [REDACTED].Clarification ORDERS .[MEDICATION NAME] plo 0.5mg/ml Apply 1ml topically to wrist Q4 (hours) PRN Anxiety X (times) 14 days D/C on 9-17-19 . On 10/16/19 at 9:18 a.m., the assistant director of nursing (ADON) was asked what the policy was for administering as needed antianxiety medications. She stated they were administered as needed and per time constraints. She was asked if there should be an indication for continued use past 14 days for an as needed antianxiety medication. She stated, Yes. The ADON was shown the above documentation. She was acknowledged the findings.

Based on record review and staff interview, it was determined the facility failed to ensure PRN (as needed) antianxiety medications were accurately documented when administered for one (#15) of five sampled residents reviewed for unnecessary medications. The facility identified there were no residents with current orders for PRN antianxiety medications. Findings: Resident #15 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) Tab(s) (tablets) 0.5 MG (milligrams) 1 TAB PO (by mouth) Q (every) 4 HRS (hours) PRN DX (diagnosis): ANXIETY . A physician's orders [REDACTED].DC (discontinue) [MEDICATION NAME] 0.5 mg .(one) tab PO (every) 4 (hours) (increased) anxiety . A physician's orders [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) 0.5mg/mL (milliliters), PLO (pluronic lecithin organogel) -Apply 1mL Topically to wrist Q4H (hours) PRN (and) .DX: Anxiety . The (MONTH) 2019 PRN medication sheet documented [MEDICATION NAME] was administered instead of [MEDICATION NAME] 14 times. The controlled drug administration record documented the correct medication had been administered. The (MONTH) 2019 PRN medication sheet documented [MEDICATION NAME] was administered instead of [MEDICATION NAME] eight times. The controlled drug administration record documented the correct medication had been administered. On 10/16/19 at 9:18 a.m., the assistant director of nursing was shown the above documentation and asked if it was correct. She stated it was not. She acknowledged the findings.

Based on record review and staff interviews, it was determined the facility failed to ensure: ~ residents were invited to care plan meetings for two (#17 and #33) of two sampled residents reviewed for care plan meetings and ~ a care plan was revised to reflect the current status of the resident for one (#17) of 11 sampled resident reviewed for care plans. The Resident Census and Conditions of Residents report, dated 09/10/18, documented 38 residents. Findings: 1. Resident #33 had resident assessments completed on 08/22/18, 05/18/18 and 02/15/18. There was no documentation in the clinical record to show care plan meetings had been conducted. 2. Resident #17 had resident assessments completed on 12/17/17, 03/21/18 and 06/21/18. There was no documentation in the clinical record to show care plan meetings had been conducted. The care plan had not been updated with the 03/21/18 and 06/21/18 resident assessments. On 09/11/18 at 2:14 p.m., the minimum data set (MDS) nurse was asked how often the care plans were updated. She stated quarterly, every three months with a new one every year. The MDS nurse was asked to review the care plan. She was asked if the care plan was updated to reflect the resident's current status. She stated it was not updated, no. At 2:16 p.m., the MDS nurse was asked what the procedure was for inviting residents and families to care plan meetings. She was asked for documentation for the care plan meetings for residents #17 and #33. She stated the director of nursing (DON) had documentation in her office. At 2:56 p.m., the DON was asked what the procedure was for inviting residents and families to care plan meetings. She stated she talked with them (family members) when they were in the facility if they were from out of town. She stated another nurse used to send out letters but she called the families for specific issues and set a day which was good for the family. The DON was asked if she had any documentation of the care plan meetings for residents #17 and #33. She stated, No.

Based on record review and staff interviews, it was determined the facility failed to complete a facility assessment. The Resident Census and Conditions of Residents report, dated 09/10/18, documented 38 residents. Findings: On 09/10/18 at 9:15 a.m., during an entrance conference with the director of nursing (DON), she was asked if the facility had a facility assessment. She stated, What's that? She stated she would have to ask the administrator (ADM). On 09/11/18 at 9:44 a.m., the ADM was asked if they had a facility assessment. She stated, No.

Based on record review and resident and staff interviews, it was determined the facility failed to report a resident to resident altercation as abuse for one (#1) of three sampled residents reviewed for abuse. The Resident Census and Conditions of Residents report, dated 09/10/18, documented 38 residents. Findings: An abuse investigation protocol policy, last revised 05/25/07, documented, .Should the investigation reveal that abuse occurred, the administrator will report such findings to the local police department, the ombudsman, the state licensing agency and others as may be required by date of local laws within (eight) 8 hours of the results of the completion of the investigation . Resident #1 had [DIAGNOSES REDACTED]. An Oklahoma State Department of Health (OSDH) incident report form, dated 04/20/18 at 8:05 a.m., documented Certain Injuries. The form should have been marked as Allegations of Abuse/Mistreatment. The incident report documented, .This resident states he went to his room, his roommate asked several times if he was staying in or going out, he wanted the door shut then roommate came at him and hit him in the face 2-3 times. SN (skilled nurse) heard resident holler from room, CNA (certified nurse aide) also heard it, headed to room, this resident was coming into hall, Rt (right) eye watering. Resident reports roommate hit him 3 times wants to call the police, SN took VS (vital signs .Resident upset, but in no immediate, concerning distress . On 09/12/18 at 11:00 a.m., the DON was asked if this incident was considered resident-to-resident abuse. She stated, No, you almost have to know these two guys. She stated, No, I don't with these two guys. She stated, But because it was reported I followed through on it and reported it.

Based on record review and staff interviews, it was determined the facility failed to notify the physician of foul odor, drainage, redness, and increased necrosis of a pressure ulcer for one (#1) of one sampled resident reviewed for pressure ulcers. The wound became infected and required surgical debridement. The resident expired on [DATE]. The facility identified no residents with pressure ulcers. Findings: A facility skin care and treatment policy, undated, documented, It is the policy of this facility to maintain the integrity of every patients skin at it's maximum. And to aggressively treat any skin conditions that arise . Any skin condition is to be reported immediately to the charge nurse and to the physician as needed . Any skin condition will be documented on a decubitus report form weekly. To be assessed for healing, progress, or deterioration .They are to be measured at this time weekly . Treatment which is ordered by a physician will be carried out on a timely basis and with correct procedure . A facility doctor's telephone orders policy, undated, documented, .Obtain doctor's order .Fill in all blanks .Date order .State route .medication, length of time, frequency .Medication and/or treatment must be placed on medication and/or treatment sheet . A facility notification of changes in residents policy, undated, documented, The Director of Nursing or Charge Nurse will notify the physician and residents family when there is .A significant change in the resident physical, mental, or psychosocial status .life threatening condition or clinical complications .A need to alter treatment significantly . Resident #1 had [DIAGNOSES REDACTED]. A February 2017 treatment sheet, documented, .CLEANSE AREA TO UPPER MIDDLE COCCYX, APPLY SKIN PREP TO SURROUNDING AREA, APPLY COLLEGEN (sic) POWDER, APPLY DERMA GUAZE (sic) AND FOAM PAD AND DERMA VIEW 11 DAILY . A comprehensive resident assessment, dated [DATE], documented the resident was at risk for pressure ulcers and had one unhealed Stage one pressure ulcer with granulation tissue. A weekly skin report/decubitus report, dated [DATE], documented the resident had a wound to the upper middle coccyx measuring 1.5 cm (centimeters) long by 2 cm wide and was a Stage 2. It documented the color was pink with minimal drainage, healing slowly, and an air mattress was used as a special device. A physician's orders [REDACTED]. A nurse's note, dated [DATE] at 6:00 p.m., documented the resident was sent to the emergency room to be evaluated related to respiratory concerns. A hospital admission note, dated [DATE] at 9:31 p.m., documented the resident had a Stage 2 pressure ulcer to the coccyx. It documented urinary tract infection, severe dehydration, malnutrition, weakness, decubitus, and altered mental status as the admission diagnoses. A hospital physical therapy wound initial evaluation, dated [DATE] at 11:00 a.m., documented, .pressure ulcer with likely infection .WOUND LOCATION: coccyx .WOUND SIZE .LENGTH: 4 cm .WIDTH: 3 cm .DEPTH: black eschar covering, unable to stage. Eschar is firm to touch and right over the bone .ODOR: strong odor . A hospital discharge note, dated [DATE] at 11:34 a.m., documented, .We will arrange for appointment to Wound Care clinic as an outpatient . A hospital patient education summary, dated [DATE], documented, .WOUND CARE REFFERAL (sic) (physician) WILL GET THIS NEXT WEEK . A nurse's note, dated [DATE] at 12:55 p.m., documented, .Resident returned to facility from (local hospital) (with) dx (diagnosis) of UTI (urinary tract infection) and dehydration. Has wound to coccyx measuring 9cm diameter (with) center 5cm that is necrotic (with) foul odor .Wound care referal (sic) by (physician) next week .Order received to just keep wounds clean and dry until appointment at wound care clinic . A pre/post transfer skin evaluation sheet, dated [DATE] at 1:00 p.m., documented, .Wound to coccy (sic) 9cm diameter (with) 5cm center necrotic tissue and other tissue sloughing off around it .Coccyx wound (with) very foul odor. (physician) to make appointment (with) wound care clinic . There was no documentation of the physician being notified of the wound change. A weekly skin report/decubitus report, dated [DATE], documented the resident had a wound to the upper middle coccyx measuring 5 cm long by 9 cm wide and was a Stage 3. It documented the wound had a black center, foul odor and moderate drainage. It documented an air mattress was used as a special device. There was no documentation of the physician being notified of the status of the wound. A nurse's note, dated [DATE] on the 7 a.m. to 3 p.m. shift, documented, .Wound to coccyx necrotic (with) foul odor. Dr (doctor) is aware of condition. Wound care provided per Dr order . A physician's orders [REDACTED].wound to coccyx .keep clean (and) dry until wound care can evaluate . A nurse's note, dated [DATE] on the 7:00 a.m. to 3:00 p.m. shift, documented, .LE (late entry) .Reviewed discharge orders from hospital stay. (Physician) has not yet notified facility of wound care orders for resident. SN (skilled nurse) called (physician's) office and spoke (with) him on the phone. He advised to get in touch (with) wound care consultant and have her evaluate wound for wound care treatment orders. Called (name deleted wound care nurse) on cell phone. She is in (city name deleted) but will come by facility on her way back to her office. Residents wound has necrotic tissue that is increased in size to 7cm diameter and has a very foul odor. Redness (with) sloughing skin around necrotic tissue. SN did receive order from (physician) may cleanse area (with) wound cleanser. Apply Santyl to necrotic area cover (with) [MEDICATION NAME] and secure (with) clear occlusive dressing . A physician's orders [REDACTED].Cleanse wound to coccyx (with) wound cleanser, pat dry, apply Santyl ointment to necrotic area, cover (with) [MEDICATION NAME], secure (with) clear occlusive dressing . The physician's orders [REDACTED]. This was the first order to treat the wound since she returned from the hospital on [DATE], which was six days prior. A nurse's note, dated [DATE] on the 7:00 p.m. to 7:00 a.m. shift, documented, .Wound care nurse here to evaluate coccyx wound, wound presents as a Kennedy ulcer, unable to stage, area is necrotic, (with) black eschar et (and) foul odor present . There was no documentation of the physician being notified of the status of the wound. There was no documentation in the clinical record by the wound care nurse to show she had evaluated the resident's wound. A weekly skin report/decubitus report, dated [DATE], documented the resident had a wound to the upper middle coccyx measuring 5 cm long by 9 cm wide and was a Stage 3. It documented the wound was dark with eschar, foul odor and had moderate drainage. It documented an air mattress was used as a special device. There was no documentation of the physician being notified of the continued foul odor and the moderate drainage of the wound. A care plan, updated [DATE], documented, .Cleanse wound to coccy (sic) (with) wound cleanser, pat dry apply Santyl to necrotic area cover (with) [MEDICATION NAME] secure (with) clear occlusive drsg (dressing) .Hospital .Pressure ulcer .Assess location, size, stage, presence and type of drainage, presence of odors, condition of surrounding skinAssess (sic) for signs of infection, such as the presence of a foul odor, increasing pain, surrounding skin is reddened ([DIAGNOSES REDACTED]) or warm, or there is a presence of purulent drainage .Approach .PERE (SIC) (perineal) CARE AFTER EACH INCONTIENCE (sic) STAFF TO OBSERVE FOR SKIN BREAKDOWN AND REPORT TO CHARGE NURSE .REPOSITION AS NEEED (sic) .TREATMENT AS ORDERED . A physician's orders [REDACTED].Send to (local hospital) ER (emergency room ) for Eval (evaluation) (and) possible admit . A hospital assessment, dated [DATE] at 11:22 a.m., documented, .Concave area of necrosis and missing tissue, black in color, largest measurements of irregular/semi-circular wound are 8cm x 8cm. Foul smelling odor, loose stool leaking out of rectum. Culture obtained - RESULTS PENDING .Progress notes .(Physician) examined patient's decubitus at sacral area - recommend transfer for surgical debridement . A hospital history and physical note, dated [DATE] at 8:36 p.m., documented, .was transferred to our ER here at (hospital name deleted) from (hospital name deleted) emergency room for altered mentation, UTI and a huge sacral decubital ulcer .There at the (hospital name deleted) she received [MEDICATION NAME] (intervenous antibiotic) and was transferred to us here because of worsened sacral decubital ulcer that has been chronic with the patient for a while .The patient has a 5 inch-diameter and 3 inch-deep malodorous Sacral ulcer . A hospital operative report, dated [DATE] at 1:51 p.m., documented, .Procedure: Excisional Debridement Sacral Decubitus Ulcer . A hospital daily progress note, dated [DATE] at 9:53 a.m., documented, .Assessment:[MEDICAL CONDITION] .due to UTI and Sacral Decubitus Ulcer .Sacral Decubitus Ulcer stage 4 .s/p (status [REDACTED]. A hospital laboratory result, dated [DATE], documented a culture obtained from the coccyx wound had moderate gram positive bacilli, moderate gram negative bacilli, and abundant gram negative bacilli. It documented escherichia coli confirmed positive extended-spectrum beta-lactamase and that these organisms are uniformly resistant to all [MEDICATION NAME], cephalosporins and azetreonam. Facility re-admission orders [REDACTED].[MEDICATION NAME] 250 unit/gram oint. (ointment) Apply Topical daily . There was no documentation of this treatment ever being done. A [DATE] treatment sheet did not document the order for [MEDICATION NAME]. It documented an order for [REDACTED]. It was documented as provided through [DATE]. A nurse's note, dated [DATE] at 1:07 p.m., documented, .Resident admitted back to facility .Wound care daily to cleanse area (with) wound cleanser and apply a wet to dry drsg (with) SNS (sterile normal saline), cover area with a sponge. Resident to be repositioned (every) 2 (hours) .Wound to coccyx (with) yellowish-greenish slough . A pre/post transfer skin evaluation, dated [DATE] at 1:07 p.m., documented, .Resident (with) wound on coccyx surgical measuring 8.5cm x (by) 6.5cm x 3.5cm deep . A nurse's note, dated [DATE] at 2:00 p.m., documented, .Wet to dry dressing to coccyx . A physician's orders [REDACTED].Cleanse coccyx wound (with) wound cleanser, apply wet to dry drsg, cover (with) 4 x 4 sponge pad x (times) 2 . The physician's orders [REDACTED]. A nurse's note, dated [DATE] at 10:20 a.m., documented, .Drsg (change) to coccyx was provided today by Hospice RN (registered nurse). Wound has a foul odor and greenish tint slough . There was no documentation of the physician being notified of the foul odor and the greenish tint slough. A physician's orders [REDACTED].Clarification orders on wound care .Cleanse coccyx wound (with) wound cleansers. apply wet to dry drsg. cover (with) 4x4 sponge pad x 2 QD (every day) and PRN (as needed) . A nurse's note, dated [DATE], documented Wound (with) very foul odor. Large amount of greenish slough noted . There was no documentation of the physician being notified of the status of the wound. A nurse's note, dated [DATE] on the 7:00 a.m. to 3:00 p.m. shift, documented, .Wound to coccyx is starting to get necrotic at edges. Redness around wound . There was no documentation of the physician being notified of the status of the wound. A nurse's note, dated [DATE] at 4:15 p.m., documented the resident expired. On [DATE] at 3:50 p.m., the quality assurance (QA) nurse was asked what the policy was for pressure ulcer prevention. She stated staff would turn the resident every two hours, utilize booties if needed, get residents up in wheelchair to change their positions, and administer arginade and meal replacements for increased nutrition. She was asked what the policy was if a resident developed a wound or pressure ulcer. She stated to notify the physician. She was asked what the policy was for physician notification. She stated they do nurse to doctor fax communications, call the physician, and sometimes hand delivered messages. She was asked what the policy was for obtaining a physician's orders [REDACTED]. Staff also transcribed the order to the treatment sheet. She was asked what the policy was if a resident's wound or pressure ulcer worsened. She stated, Notify doctor immediately. She was asked what the policy was if a resident returned from the hospital with instructions the hospital or physician would arrange for outpatient wound care. She stated they would call the doctor and make sure it had been done. She stated if it hadn't been done, they would do it themselves. The QA nurse was asked when they would contact the hospital or physician to see if arrangements had been made. She stated, We like to take them at their word that the order was put in place before leaving the hospital. She stated if staff didn't hear anything within 48 hours, they would follow up. She was shown the nurse's notes on [DATE] and asked if the physician had been notified of the foul odor from the wound and the increase in the size of the wound. She stated, He discharged her from the hospital to facility, so I hope he would know. She was asked to review the nurse's note dated [DATE] and the two nurse's notes dated [DATE] prior to being hospitalized for [REDACTED]. She was asked if the physician had been notified of the foul odor and increase in necrosis. She stated, No. She was shown the nurse's notes dated [DATE], [DATE], and [DATE] after the resident returned from the hospital for wound infection and surgical debridement. She was asked if the physician had had been notified of the foul odor or increased necrosis. She stated, No. She was asked if staff had communicated with the physician would there be documentation. She stated they would document on a nurse's note or nurse to doctor communication sheet. She stated her understanding was when the resident came back from the hospital the wound was so much larger, her nutrition was poor, she didn't want to turn, was very depressed and they were fighting a losing battle. She was asked if a resident had a wound with foul odor, redness, necrosis, or worsened conditions, should the resident's physician have been notified. She stated, Yes.

Based on record review and staff interviews, it was determined the facility failed to provide the necessary care to prevent the worsening of a pressure ulcer for one (#1) of one sampled resident reviewed for pressure ulcers. The wound became infected and required surgical debridement. The resident expired on [DATE]. The facility identified no residents with pressure ulcers. Findings: A facility skin care and treatment policy, undated, documented, It is the policy of this facility to maintain the integrity of every patients skin at it's maximum. And to aggressively treat any skin conditions that arise . Any skin condition is to be reported immediately to the charge nurse and to the physician as needed . Any skin condition will be documented on a decubitus report form weekly. To be assessed for healing, progress, or deterioration .They are to be measured at this time weekly . Treatment which is ordered by a physician will be carried out on a timely basis and with correct procedure . A facility doctor's telephone orders policy, undated, documented, .Obtain doctor's order .Fill in all blanks .Date order .State route .medication, length of time, frequency .Medication and/or treatment must be placed on medication and/or treatment sheet . A facility notification of changes in residents policy, undated, documented, The Director of Nursing or Charge Nurse will notify the physician and residents family when there is .A significant change in the resident physical, mental, or psychosocial status .life threatening condition or clinical complications .A need to alter treatment significantly . Resident #1 had [DIAGNOSES REDACTED]. A February 2017 treatment sheet, documented, .CLEANSE AREA TO UPPER MIDDLE COCCYX, APPLY SKIN PREP TO SURROUNDING AREA, APPLY COLLEGEN (sic) POWDER, APPLY DERMA GUAZE (sic) AND FOAM PAD AND DERMA VIEW 11 DAILY . A comprehensive resident assessment, dated [DATE], documented the resident was at risk for pressure ulcers and had one unhealed Stage one pressure ulcer with granulation tissue. A weekly skin report/decubitus report, dated [DATE], documented the resident had a wound to the upper middle coccyx measuring 1.5 cm (centimeters) long by 2 cm wide and was a Stage 2. It documented the color was pink with minimal drainage, healing slowly, and an air mattress was used as a special device. A physician's orders [REDACTED]. A nurse's note, dated [DATE] at 6:00 p.m., documented the resident was sent to the emergency room to be evaluated related to respiratory concerns. A hospital admission note, dated [DATE] at 9:31 p.m., documented the resident had a Stage 2 pressure ulcer to the coccyx. It documented urinary tract infection, severe dehydration, malnutrition, weakness, decubitus, and altered mental status as the admission diagnoses. A hospital physical therapy wound initial evaluation, dated [DATE] at 11:00 a.m., documented, .pressure ulcer with likely infection .WOUND LOCATION: coccyx .WOUND SIZE .LENGTH: 4 cm .WIDTH: 3 cm .DEPTH: black eschar covering, unable to stage. Eschar is firm to touch and right over the bone .ODOR: strong odor . A hospital discharge note, dated [DATE] at 11:34 a.m., documented, .We will arrange for appointment to Wound Care clinic as an outpatient . A hospital patient education summary, dated [DATE], documented, .WOUND CARE REFFERAL (sic) (physician) WILL GET THIS NEXT WEEK . A nurse's note, dated [DATE] at 12:55 p.m., documented, .Resident returned to facility from (local hospital) (with) dx (diagnosis) of UTI (urinary tract infection) and dehydration. Has wound to coccyx measuring 9cm diameter (with) center 5cm that is necrotic (with) foul odor .Wound care referal (sic) by (physician) next week .Order received to just keep wounds clean and dry until appointment at wound care clinic . A pre/post transfer skin evaluation sheet, dated [DATE] at 1:00 p.m., documented, .Wound to coccy (sic) 9cm diameter (with) 5cm center necrotic tissue and other tissue sloughing off around it .Coccyx wound (with) very foul odor. (physician) to make appointment (with) wound care clinic . There was no documentation of the physician being notified of the wound change. A weekly skin report/decubitus report, dated [DATE], documented the resident had a wound to the upper middle coccyx measuring 5 cm long by 9 cm wide and was a Stage 3. It documented the wound had a black center, foul odor and moderate drainage. It documented an air mattress was used as a special device. There was no documentation of the physician being notified of the status of the wound. A nurse's note, dated [DATE] on the 7 a.m. to 3 p.m. shift, documented, .Wound to coccyx necrotic (with) foul odor. Dr (doctor) is aware of condition. Wound care provided per Dr order . A physician's orders [REDACTED].wound to coccyx .keep clean (and) dry until wound care can evaluate . A nurse's note, dated [DATE] on the 7:00 a.m. to 3:00 p.m. shift, documented, .LE (late entry) .Reviewed discharge orders from hospital stay. (Physician) has not yet notified facility of wound care orders for resident. SN (skilled nurse) called (physician's) office and spoke (with) him on the phone. He advised to get in touch (with) wound care consultant and have her evaluate wound for wound care treatment orders. Called (name deleted wound care nurse) on cell phone. She is in (city name deleted) but will come by facility on her way back to her office. Residents wound has necrotic tissue that is increased in size to 7cm diameter and has a very foul odor. Redness (with) sloughing skin around necrotic tissue. SN did receive order from (physician) may cleanse area (with) wound cleanser. Apply Santyl to necrotic area cover (with) [MEDICATION NAME] and secure (with) clear occlusive dressing . A physician's orders [REDACTED].Cleanse wound to coccyx (with) wound cleanser, pat dry, apply Santyl ointment to necrotic area, cover (with) [MEDICATION NAME], secure (with) clear occlusive dressing . The physician's orders [REDACTED]. This was the first order to treat the wound since she returned from the hospital on [DATE], which was six days prior. A nurse's note, dated [DATE] on the 7:00 p.m. to 7:00 a.m. shift, documented, .Wound care nurse here to evaluate coccyx wound, wound presents as a Kennedy ulcer, unable to stage, area is necrotic, (with) black eschar et (and) foul odor present . There was no documentation of the physician being notified of the status of the wound. There was no documentation in the clinical record by the wound care nurse to show she had evaluated the resident's wound. A weekly skin report/decubitus report, dated [DATE], documented the resident had a wound to the upper middle coccyx measuring 5 cm long by 9 cm wide and was a Stage 3. It documented the wound was dark with eschar, foul odor and had moderate drainage. It documented an air mattress was used as a special device. There was no documentation of the physician being notified of the continued foul odor and the moderate drainage. A care plan, updated [DATE], documented, .Cleanse wound to coccy (sic) (with) wound cleanser, pat dry apply Santyl to necrotic area cover (with) [MEDICATION NAME] secure (with) clear occlusive drsg (dressing) .Hospital .Pressure ulcer .Assess location, size, stage, presence and type of drainage, presence of odors, condition of surrounding skinAssess (sic) for signs of infection, such as the presence of a foul odor, increasing pain, surrounding skin is reddened ([DIAGNOSES REDACTED]) or warm, or there is a presence of purulent drainage .Approach .PERE (SIC) (perineal) CARE AFTER EACH INCONTIENCE (sic) STAFF TO OBSERVE FOR SKIN BREAKDOWN AND REPORT TO CHARGE NURSE .REPOSITION AS NEEED (sic) .TREATMENT AS ORDERED . A physician's orders [REDACTED].Send to (local hospital) ER (emergency room ) for Eval (evaluation) (and) possible admit . A hospital assessment, dated [DATE] at 11:22 a.m., documented, .Concave area of necrosis and missing tissue, black in color, largest measurements of irregular/semi-circular wound are 8cm x 8cm. Foul smelling odor, loose stool leaking out of rectum. Culture obtained - RESULTS PENDING .Progress notes .(Physician) examined patient's decubitus at sacral area - recommend transfer for surgical debridement . A hospital history and physical note, dated [DATE] at 8:36 p.m., documented, .was transferred to our ER here at (hospital name deleted) from (hospital name deleted) emergency room for altered mentation, UTI and a huge sacral decubital ulcer .There at the (hospital name deleted) she received [MEDICATION NAME] (intervenous antibiotic) and was transferred to us here because of worsened sacral decubital ulcer that has been chronic with the patient for a while .The patient has a 5 inch-diameter and 3 inch-deep malodorous Sacral ulcer . A hospital operative report, dated [DATE] at 1:51 p.m., documented, .Procedure: Excisional Debridement Sacral Decubitus Ulcer . A hospital daily progress note, dated [DATE] at 9:53 a.m., documented, .Assessment:[MEDICAL CONDITION] .due to UTI and Sacral Decubitus Ulcer .Sacral Decubitus Ulcer stage 4 .s/p (status [REDACTED]. A hospital laboratory result, dated [DATE], documented a culture obtained from the coccyx wound had moderate gram positive bacilli, moderate gram negative bacilli, and abundant gram negative bacilli. It documented escherichia coli confirmed positive extended-spectrum beta-lactamase and that these organisms are uniformly resistant to all [MEDICATION NAME], cephalosporins and azetreonam. Facility re-admission orders [REDACTED].[MEDICATION NAME] 250 unit/gram oint. (ointment) Apply Topical daily . There was no documentation of this treatment ever being done. A [DATE] treatment sheet did not document the order for [MEDICATION NAME]. It documented an order for [REDACTED]. It was documented as provided through [DATE]. A nurse's note, dated [DATE] at 1:07 p.m., documented, .Resident admitted back to facility .Wound care daily to cleanse area (with) wound cleanser and apply a wet to dry drsg (with) SNS (sterile normal saline), cover area with a sponge. Resident to be repositioned (every) 2 (hours) .Wound to coccyx (with) yellowish-greenish slough . A pre/post transfer skin evaluation, dated [DATE] at 1:07 p.m., documented, .Resident (with) wound on coccyx surgical measuring 8.5cm x (by) 6.5cm x 3.5cm deep . A nurse's note, dated [DATE] at 2:00 p.m., documented, .Wet to dry dressing to coccyx . A physician's orders [REDACTED].Cleanse coccyx wound (with) wound cleanser, apply wet to dry drsg, cover (with) 4 x 4 sponge pad x (times) 2 . The physician's orders [REDACTED]. A nurse's note, dated [DATE] at 10:20 a.m., documented, .Drsg (change) to coccyx was provided today by Hospice RN (registered nurse). Wound has a foul odor and greenish tint slough . There was no documentation of the physician being notified of the foul odor and greenish tint slough. A physician's orders [REDACTED].Clarification orders on wound care .Cleanse coccyx wound (with) wound cleansers. apply wet to dry drsg. cover (with) 4x4 sponge pad x 2 QD (every day) and PRN (as needed) . A nurse's note, dated [DATE], documented Wound (with) very foul odor. Large amount of greenish slough noted . There was no documentation of the physician being notified of the status of the wound. A nurse's note, dated [DATE] on the 7:00 a.m. to 3:00 p.m. shift, documented, .Wound to coccyx is starting to get necrotic at edges. Redness around wound . There was no documentation of the physician being notified of the status of the wound. A nurse's note, dated [DATE] at 4:15 p.m., documented the resident expired. On [DATE] at 3:50 p.m., the quality assurance (QA) nurse was asked what the policy was for pressure ulcer prevention. She stated staff would turn the resident every two hours, utilize booties if needed, get residents up in wheelchair to change their positions, and administer arginade and meal replacements for increased nutrition. She was asked what the policy was if a resident developed a wound or pressure ulcer. She stated to notify the physician. She was asked what the policy was for physician notification. She stated they do nurse to doctor fax communications, call the physician, and sometimes hand delivered messages. She was asked what the policy was for obtaining a physician's orders [REDACTED]. Staff also transcribed the order to the treatment sheet. She was asked what the policy was if a resident's wound or pressure ulcer worsened. She stated, Notify doctor immediately. She was asked what the policy was if a resident returned from the hospital with instructions the hospital or physician would arrange for outpatient wound care. She stated they would call the doctor and make sure it had been done. She stated if it hadn't been done, they would do it themselves. The QA nurse was asked when they would contact the hospital or physician to see if arrangements had been made. She stated, We like to take them at their word that the order was put in place before leaving the hospital. She stated if staff didn't hear anything within 48 hours, they would follow up. She was shown the nurse's notes on [DATE] and asked if the physician had been notified of the foul odor from the wound and the increase in the size of the wound. She stated, He discharged her from the hospital to facility, so I hope he would know. She was asked to review the nurse's note dated [DATE] and the two nurse's notes dated [DATE] prior to being hospitalized for [REDACTED]. She was asked if the physician had been notified of the foul odor and increase in necrosis. She stated, No. She was shown the nurse's notes dated [DATE], [DATE], and [DATE] after the resident returned from the hospital for wound infection and surgical debridement. She was asked if the physician had had been notified of the foul odor or increased necrosis. She stated, No. She was asked if staff had communicated with the physician would there be documentation. She stated they would document on a nurse's note or nurse to doctor communication sheet. She stated her understanding was when the resident came back from the hospital the wound was so much larger, her nutrition was poor, she didn't want to turn, was very depressed and they were fighting a losing battle. She was asked if a resident had a wound with foul odor, redness, necrosis, or worsened conditions, should the resident's physician have been notified. She stated, Yes. On [DATE] at 9:00 a.m., the QA nurse was shown the [DATE] physician's orders [REDACTED]. She stated, No. She was asked if the order should indicate the frequency the treatment should have been provided. She stated, Yes. At 9:30 a.m., the wound care educator (wound care nurse) was interviewed via telephone. She was asked if she had provided services to the resident. She stated, No, not officially. At 11:20 a.m., the acting director of nursing (DON) was asked if the facility had a wound care book. She stated, No. She was asked if the facility had a wound care nurse. She stated, No. She was shown the physician's orders [REDACTED]. She stated, No. She was asked how staff were to determine the frequency if it was not indicated on the order. She stated, No specific way by orders you can tell what frequency needs to be done. She was asked if a frequency should be on the orders. She stated, Definitely. That is a mistake. No one knows unless it's written. She was shown the [DATE] order for [MEDICATION NAME] and asked to locate the order on the March treatment sheet. She stated, No, I do not see it. She was asked if physician's orders [REDACTED]. She stated, Can't say it was because it's not on the treatment sheet. She was asked if the order should have been on the treatment sheet. She stated, Yes. She stated if they didn't have the supplies for that order, it would be an issue. She stated if the facility doesn't have the supplies, such as Collagen, they can't do the treatment. She was asked to locate any documentation to show a reason the order was changed or not followed. She was shown the [DATE] nurse's note which documented a wet to dry dressing had been applied to the resident's wound. She was asked if this wound care had been provided per physician orders. She stated, Not as orders said. She was asked if nurses should provide wound care that is not physician ordered. She stated, No.

On [DATE] at 10:25 a.m., an Immediate Jeopardy (IJ) situation was identified related to the failure of the facility to provide supervision, during a meal service, for a resident who had a history of [REDACTED]. At 10:30 a.m., the existence of an I.J. was verified with the Oklahoma State Department of Health (OSDH). At 10:45 a.m., the administrator, the assistant administrator, and the director of nurses were notified of the existence of an IJ pertaining to the lack of supervision for a resident with a history of swallowing problems/choking. At 3:00 p.m., the plan of removal was received and accepted. The facility had in-serviced 40 of 47 staff members. The facility's "Plan of Removal" documented: "1. All staff will be inserviced on supervising (Resident #1) at all times during meals, snacks, activities, alone time- any snacks brought by family or visitors, bingo snacks, anytime, anything. 2. All other residents that have swallowing issues or orders for thickened liquids will have a swallowing study recommended by physician. 3. (Resident #1) will be supervised in dining and drinking until swallowing evaluation results and orders received." At 3:40 p.m., the administrator and assistant administrator were informed the IJ was lifted as of 3:00 p.m. on [DATE]. The deficient practice remained at a level of isolated actual harm. Based on observation, record review, and interview, it was determined the facility failed to adequately supervise one (#1) of four sampled residents, with swallowing difficulties, during a meal service. The Roster/Matrix, dated [DATE], identified three additional residents who had difficulty with swallowing/choking. Findings: Resident #1 had [DIAGNOSES REDACTED]. The resident's clinical record contained a Clinical Dysphagia Evaluation Form, dated [DATE]. It documented: ~ it was reported the resident coughed during meals. ~ the resident had slight weakness on her right side during oral manipulations, ground meat would be helpful. ~ The resident complained that she occasionally felt food stuck in her throat. ~ the recommendations were (a) ground meat to assist with oral phase of swallow, and (b) repeat evaluation if the resident experiences difficulty with swallowing. The clinical record contained no documentation of subsequent swallow evaluations having been conducted. The resident's assessment, dated [DATE], documented she was severely impaired in cognition, she coughed or choked during meals or when swallowing medications, and she received set-up help during meals. The physician order [REDACTED]. It also documented the resident was to receive lite salt and not to be served Frito chips. On [DATE] at 5:30 p.m., the evening meal was observed. The resident was observed eating her meal in the dining room. She was observed to have coughed/choked while consuming her meal. She was coughing violently, her face was turning red, and she was unable to take a breath during the episode. She was asked if she choked on food often. She stated she did. She was asked if she had spoken with the staff about the problem. She stated she had not, but the staff knew about it. She stated that sometimes food got stuck in her throat. The dining room staff offered no assistance to the resident. She finished her meal and returned to her room accompanied by her son. On [DATE] at 12:00 p.m., the noon meal was observed. The resident was observed eating her meal in the dining room. She was observed to have coughed/choked after eating a bite of taco casserole. Her son put a straw in her drink and offered her a drink. She attempted to drink from the straw. This worsened the coughing/choking. The resident managed to correct the problem by coughing until her throat was clear. The dining room staff continued with serving and assisting the other residents. She finished her meal and returned to her room accompanied by her son. On [DATE] at 7:50 a.m., CNA #1 served the resident a breakfast tray in her room. The resident sat on the side of her bed, which was placed next to a wall. The CNA positioned a table with the tray on it in front of the resident. The CNA left the room, the resident was left unsupervised. The menu card on the resident's tray documented the resident was on a controlled carbohydrate, no added salt, no Fritos, and ground meat diet. At 7:52 a.m., the resident took a bite of the crispy bacon and started violently coughing/choking for about ,[DATE] seconds. Her face was bright red and she was unable to take a breath. At that point her body went limp and she collapsed across the bed. She struck the back of her head on the wall. She revived and immediately started coughing violently again. Help had been summoned by the surveyor and staff arrived just after she started coughing again. At 7:53 a.m., LPN #1 entered the resident's room, looked at the resident's tray and said, "They served her bacon again." The DON also entered the resident's room. They were both asking the resident if she was OK. The resident was unable to speak, due to the coughing, but nodded her head affirmatively. The resident managed to correct the problem by coughing until her throat was clear. At 8:30 a.m., the dietary manager and the certified dietary manager were asked if the resident was on a ground meat diet. They both stated the physician had not ordered a ground meat diet. They were asked why the tray card documented the resident was to be served ground meat. They stated a family member was concerned about the resident choking and had requested the resident be placed on ground meat. They both stated they could not remember when the request had been made. They were asked if they had notified the physician of the change of the resident's diet. They stated they had not. They were asked why the resident had been served bacon. They stated she refused ground sausage and requested bacon. They were asked if she always refused ground sausage and requested bacon. They stated that she always requested bacon. They were asked if the physician had been notified of the resident's refusal to eat ground meat. They stated no because he hadn't ordered it anyway. At 9:42 a.m., CNA #2 was asked if the resident had problems coughing/choking with meals. She stated the resident usually fed herself and she did cough sometimes while eating. She stated the nurses knew and usually stayed close to her because of the coughing problem. At 9:43 a.m., LPN #3 was asked if she had ever observed resident #1 coughing. She stated, "It scared me the first time I heard it because I thought she was choking." She was asked how often this occurred. She stated, "About one to two times during the shift." She was asked when the coughing/choking occurred. She stated it occurred when she ate or drank something. At 9:45 a.m., the MDS coordinator/ADON was asked if Section K of the MDS was correct. She reviewed it and stated it was correct. She was asked how she conducted her assessment for that section. She stated she had observed the resident cough or get choked on food and/or water. She was asked if she had interviewed the resident about her problem with foods and liquids. She stated she had not. She was asked if she had ever discussed this problem with any of the other staff. She stated everyone knew about it, she had done this for years. The LPNs and CMAs gave her cough medicine and she would quit coughing a few minutes later. She was asked if she had ever discussed this with the resident's physician. She stated she had not but he must know because the resident had choked on a Frito chili pie a couple of years ago. He added a new order to her diet. She was not to be served Fritos anymore. She was asked if she had recommended the resident have a swallow evaluation performed. She stated she had not. At 10:02 a.m., LPN #1 was asked if she had ever seen the resident choke on bacon before. She stated she had noticed her choking on bacon before and anything hard seemed to be a problem; a sip of water could start it. The LPN stated she had seen her choke while she was chewing gum. She was asked if she had ever reported this to the physician. She stated she had not. She was asked if she had reported this to other staff members. She stated everyone knew; the resident had done this for years. At 10:08 a.m., LPN #2 was asked if she was aware of the resident having trouble swallowing. She stated the resident just coughed. She had coughed for a long time. She was asked if she had spoken with the resident's physician about the resident's coughing or choking. She said she had not. She was asked if she had ever requested the resident have a swallow study performed. She stated she had not because she just "coughed." At 10:45 a.m., the assistant administrator said, "The resident coughs all the time. That's her. That is just what she does." At 2:30 p.m., the director of nurses was asked if she reviewed the MDS for accuracy before signing the assessment. She stated she had. She was asked if section K of the assessment, which documented the resident coughed or choked during meals and/or administration of medications was correct. She stated it was correct. The clinical record did not contain documentation the resident had been evaluated for a swallowing problem since the 2004 evaluation. There was no documentation a care plan had been developed for coughing/choking during meals. There was no documentation the physician had been notified of the swallowing problem. The resident was unsupervised while eating breakfast in her room.