Every finding on record at Checotah Nursing Center

Based on observation, record review, and interview, the facility failed to ensure hot liquids were served at a safe temperature for 2 (#1 and #2) of 4 sampled residents reviewed for handling of hot liquids.The assisted director of nursing identified four residents were at risk for burns with hot liquids.Findings:1.On 02/18/26 at 11:38 a.m., Res #1 was observed sitting at a table alone. They were observed to drink an unknown fluid from a brown coffee cup without a lid, and there was no lid observed on the table. On 02/19/26 at 3:55 p.m., a physician visit with Res #1 was observed. The physician described the wound as a 99% 1st degree and 1% 2nd degree burn.On 02/20/26 at 9:04 a.m., the surveyor obtained a temperature of the coffee as 160.9 degrees Fahrenheit. An undated Hot Liquid Safety policy, read in part, The temperature of hot liquids will be checked in the dietary department prior to distribution. If the temperature is greater than 140 degrees Fahrenheit hold the liquid in the dietary department until it reaches an appropriate temperature.A care plan for Res #1, dated 04/23/25, showed the resident had mildly impaired vision. An intervention showed to ensure Res #1 was aware of hot liquids and to provide lids as needed.A Food Temperature Record, dated 02/2026, showed the holding temperature for coffee on 02/07/26 and 02/10/26 was 180 degrees Fahrenheit.A quarterly assessment for Res #1, dated 02/05/26, showed the resident had a BIMS of 99 which indicated they were unable to complete the interview. The assessment showed diagnoses which included vascular dementia with behavioral disturbance and unspecified psychosis not due to a substance or known physiological condition.A state incident report form, dated 02/07/26, showed the Oklahoma State Department of Health received the report on 02/12/26 at 10:40 a.m. The form showed Res #1 spilled a hot fluid on themselves which caused scalding to their bilateral thighs and a blister to their left thigh.2.On 02/18/26 at 11:38 a.m. Res #2 was observed in the dining room. They were observed to drink an unknown fluid from a brown coffee cup, without a lid and there was no lid observed on the table.On 02/20/26 at 9:04 a.m., the surveyor obtained a temperature of hot water as 166.9 degrees Fahrenheit. A care plan for Res #2, dated 12/15/25, showed the resident received propranolol (beta-blocker to treat tremors). An intervention, dated 12/15/25, showed to report increased tremors to the physician.A quarterly assessment for Res #2, dated 01/21/26, showed the resident had diagnoses which included unspecified convulsions, other reduced mobility, cognitive functions and awareness, and muscle weakness. The assessment showed Res #2 had a BIMS of 13 which indicated they were cognitively intact for daily decision making.A nurse's note for Res #2, dated 02/10/26, showed the resident alerted staff they had spilled hot tea on their lap before breakfast. The note showed the wound measured 6.0 x 2.5 inches and the blistered section was 4.0 x 1.5 inches. The note showed the physician was notified and an order for Silvadene (ointment for burns) was to be applied and covered with an abdominal pad.During a physician telehealth visit with Res #2 on 02/20/26 at 3:02 p.m., licensed practical nurse #1 obtained measurements of the wound for Res #2. The wound measured 6 cm x 2 cm x 0.1 cm. The physician stated the wound was a 2nd degree burn.On 02/18/26 at 2:42 p.m., cook #1 stated they did not temp the coffee or tea before serving to the residents. [NAME] #1 stated they gave the drinks to the certified nurse aides.On 02/20/26 at 9:21 a.m., the dietary manager stated they did not know the policy for serving hot liquids to the residents.

Based on record review and interview, the facility failed to ensure residents with money held in a trust received quarterly statements for 16 of 16 residents reviewed for money managed in a trust. The BOM identified 16 residents had monies managed by the facility in a trust. Findings: An undated facility document titled Resident Rights Regarding Personal Trust Funds, read in part, To protect each resident's funds, the facility: .Shall provide each resident, or their representative with a written itemized statement at least quarterly, of all financial transactions involving the resident funds; An undated facility policy titled Quarterly Accounting of Resident Funds, read in part, 1. Each resident with personal funds entrusted to the facility will receive an individual quarterly accounting of funds managed by the facility. On 12/11/25 at 10:28 a.m., the BOM stated they managed 16 residents who had money a trust. The BOM stated they did not know what the policy was for providing residents with statements. The BOM stated they were not providing residents with trust statements quarterly and they just showed the residents the ledger when they inquired about their balance. On 12/11/25 at 10:52 a.m., the administrator stated the facility had not been issuing resident trust statements quarterly and only gave residents their balance when the residents inquired about their trust balance.

Based on observation, record review, and interview, the facility failed to:a. ensure the kitchen area was kept clean, andb. not serve unpasteurized eggs that were not fully cooked for residents who ate meals prepared by the kitchen.The director of nursing identified 39 residents received meals prepared by the kitchen. Findings:On 12/08/25 at 10:26 a.m., unpasteurized shell eggs were observed in the refrigerator in the kitchen. On 12/08/25 at 10:36 a.m., the floor was observed with a brown substance up against the walls and around the table legs in the kitchen. The floor under the dish machine had a brown caked substance against the wall and under the dish machine. A facility document titled Daily Cleaning Checklist for AM Cook, dated December 2025, read in part, Sweep and Mop Kitchen. The document did not have dates or identify the task had been completed.A facility receipt from a food source company, dated 12/06/25, showed an order for unpasteurized medium shell eggs. The receipt did not show pasteurized eggs had been ordered. On 12/08/25 at 10:27 a.m., the DM stated the shell eggs were used for soft/over medium eggs served to the residents. The DM stated they did not know if the shell eggs were pasteurized or unpasteurized. The DM stated they should probably use pasteurized eggs. On 12/08/25 at 10:37 a.m., the DM stated the kitchen floors were not clean. The DM stated the floor looked like it had not been swept and mopped in about a week. The DM stated the cleaning schedule had not been completed for December 2025.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week during the month of October 2025. The administrator identified 43 residents resided in the facility. Findings:A facility schedule, dated October 2025, showed no RN was scheduled to work on 10/10/25, 10/11/25, 10/12/25, 10/17/25, 10/18/25, or 10/19/25.On 10/30/25 at 8:30 a.m., the administrator stated they did not have an RN working in the facility on those days.

Based on observation and interview, the facility failed to maintain a clean comfortable environment for 1 (#4) of 3 sampled residents reviewed for homelike environment.The administrator identified 43 residents resided in the facility. Findings:On 10/29/25 at 1:30 p.m., an observation of Res #4's room was made. The window had a 10 to12 inch crack in the glass and a build-up of dirt and grime.On 10/30/25 at 815 a.m., the housekeeping supervisor stated resident windows were supposed to be cleaned weekly and cracks should be reported to maintenance for repair.On 10/30/25 at 8:30 a.m., the maintenance supervisor stated they were unaware of the crack in the window and that it should be repaired.

Based on record review and interview, the facility failed to provide adequate assistance to prevent a resident from sliding out of a mechanical lift for 1 (#7) of 3 sampled residents reviewed for accident hazards.The administrator identified 43 residents resided in the facility. Findings: An undated facility policy titled Safe Lifting and Movement of Residents, read in part, In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents.A significant change assessment, dated 08/19/25, showed Res #7 had a brief interview for mental status score of 7, which was indicative of severe cognitive impairment. The assessment showed Res #7 was totally dependent on staff for transfers.An incident report, dated 10/17/25, showed Res #7 had slipped out of the sit-to-stand mechanical lift and was assisted to the ground. The report showed staff were to be educated on using two people when using a mechanical lift.On 10/28/25 at 2:15 p.m., CNA #3 stated they were on duty at the time of the fall assisting another resident. They stated they heard Res #7 yell out and went to their room to investigate. They stated when they entered Res #7's room they observed the resident on the floor and CNA #5 standing over the resident with the sit-to-stand mechanical lift. CNA #3 stated CNA #5 reported they knew they were supposed to have a second staff member when using the sit-to-stand mechanical lift, but they could not find anyone to help.On 10/28/25 at 8:40 a.m., licensed practical nurse #2 stated they were on duty at the time of the incident. They stated the facility policy was to use two staff members for any transfer involving the sit-to-stand mechanical lift.On 10/29/25 at 12:45 p.m., the assistant director of nursing stated a transfer involving a sit-to-stand mechanical lift should always involve two staff members.

Based on record review and interview, the facility failed to ensure interventions were put in place to protect one (#1) of three residents reviewed for abuse. This had the potential to affect all residents. The DON identified 29 residents who resided in the facilty. Findings: Res #2 had diagnoses which included other sexual disorders, recurrent depressive disorders, and anxiety. Res #2's quarterly resident assessment dated , 09/11/24, documented the resident was severely cognitively impaired and wandered four to six days a week. An incident report form, dated 08/09/24, documented Res #2 touched Res #1 inappropriately. A progress note, dated 08/12/24 at 11:18 a.m., documented Res #2 was admitted to a geri-psych facility for inappropriate sexual behaviors. A progress note, dated 08/22/24 at 4:07 p.m., documented Res #2 returned to the facility from the geri-psych facility. The care plan for Res #2 was not updated with interventions to prevent reoccurrence of inappropriate sexual behaviors. Progress notes, dated 08/25/24 between 11:04 a.m. and 1:56 p.m., documented Res #2 had aggressive and inappropriate sexual behaviors and was transferred to a geri-psych facility for treatment. On 10/14/24 at 1:48 p.m., the DON reported the staff knew what to do when Res #2 had inappropriate sexual behaviors, but there wasn't a plan in place to prevent Res #2's behaviors. The DON reported the care plan should have been updated with new interventions to prevent behaviors.

Based on observation, record review, and interview, the facility failed to implement their abuse policy regarding an allegation of abuse which has the potential to affect all residents. The director of nursing identified 29 residents who resided in the facility. Findings: The Reporting Resident Abuse policy, undated, documented in part, Should the allegations be true, the employee(s) will be terminated from employment. Records of the allegations will be filed in the accused employee's personnel record. An Incident Report Form, dated 06/02/24, documented Res #23 reported the evening the gospel singers were to perform at the facility, CNA #1 took them out on the front porch prior to the singing. Res #23 reported CNA #1 started cursing, saying God damn, fuck, and shit. Res #23 reported they could handle the F word, but the use of God damn was upsetting to them especially with gospel singers at the facility. Res #23 reported CNA #1 kept cursing and they had to tell CNA #1 to zip it. The resident reported CNA #1 has cursed in front of them before and reported CNA #1 walks down the hall cursing. The report also documented other staff reported to the DON, CNA #1 does curse while working in the facility. The DON documented the allegation of verbal abuse was substantiated and CNA #1 was terminated. There was no record of the allegation/disciplinary action documented in CNA #1's employee file. An employee roster, not titled or dated, which documents status changes of employees, did not document CNA #1 was terminated. An Incident Report Form, dated 06/27/24, documented CNA #1 who had been working in the dietary department since 06/25/24, was accused of being aggressive with residents. The investigation was not substantiated and the employee was allowed to continue to work. The form also documented CNA #1 was allowed to return to work after the 06/02/24 incident of substantiated verbal abuse after CNA #1 went through training on proper language use. The July nursing schedule documented CNA #1 started back working the nursing departments on 07/09/24. On 08/07/24 at 2:30 p.m., CNA #1 was observed to be passing ice to residents. On 08/08/24 at 3:50 p.m., CNA #1 was observed to be working. On 08/08/24 at 2:00 p.m. several anonymous employees were interviewed and reported CNA #1 was to be terminated on 06/03/24 by the administrator. The employees reported CNA #1 was not terminated and did not go through any training prior to returning to work in the dietary department on 06/25/24.

Based on record review, and interview, the facility failed to complete a investigation regarding an allegation of abuse which has the potential to affect all residents. The director of nursing identified 29 residents who resided in the facility. Findings: The Reporting Resident Abuse policy, undated, documented in part, The facility must complete an incident report form .and include when possible statements of any witnesses. An Incident Report Form, dated 06/02/24, documented Res #23 reported the evening the gospel singers were to perform at the facility, CNA #1 took them out on the front porch prior to the singing. Res #23 reported CNA #1 started cursing, saying God damn, fuck, and shit. Res #23 reported they could handle the F word, but the use of God damn was upsetting to them especially with gospel singers at the facility. Res #23 reported CNA #1 kept cursing and they had to tell CNA #1 to zip it. The resident reported CNA #1 has cursed in front of them before and reported CNA #1 walks down the hall cursing. The report also documented other staff reported to the DON, CNA #1 does curse while working in the facility. The DON documented the allegation of verbal abuse was substantiated and CNA #1 was terminated. An Incident Report Form, dated 06/27/24, documented CNA #1 was accused of being aggressive with residents. The investigation was not substantiated and the employee was allowed to continue to work. There was no documented witness statements, interviews, or investigation to review. On 08/08/24 at 2:00 p.m., several anonymous employees were interviewed and reported there were no witness statements or documentation of their interviews and investigation. They reported they did an investigation but did not document it.

Based on observation, record review, and interview, the facility failed to employ enough staff to carry out the functions of the food and nutrition service. The dietary manager identified 28 residents who received meals prepared by the kitchen and one resident who received nutrition via tube feeding. Findings: A dietary schedule for August 2024, documented one cook and one dietary aide for the morning shift, one cook and one aide for a split shift (covering part of morning and evening shift alternating days), and one cook with no dietary aide for evening shift. On 08/06/24 at 7:10 a.m., a tour of the kitchen was completed. While walking down the resident hall to the kitchen, a cart was observed with eight disposable trays on it with no staff present on the hall. In the dining room, three residents were observed eating from disposable trays. On 08/06/24 at 7:13 a.m., the DM stated the reason breakfast was served on disposable trays was due to short of staff. The DM stated only one staff member to serve breakfast this morning. On 08/06/24 at 9:15 a.m., the DM provided menus for the week. The DM stated the lunch and supper menu had been switched due to more time and staff was required to prepare the lunch menu. The DM stated more staff was needed in the kitchen.

Based on record review and interview, the facility failed to have a system of surveillance and monitoring designed to identify and prevent Legionnaires' disease. The director of nurses identified 29 residents resided in the facility. Findings: A policy titled Legionella Surveillance, documented .Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella .In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies .Primary prevention strategies: a. Diagnostic testing . On 08/07/24 at 10:07 a.m., the DON provided a Legionella Policy. The DON was unaware of any documentation for monitoring for the prevention of Legionnaires' disease.

Based on observation, record review, and interview, the facility failed to ensure respiratory care was provided with professional standards of practice for four (#9, 19, 23, and #24) of four sampled residents reviewed for respiratory care. The director of nurses identified 5 residents who received respiratory care. Findings: 1. Resident #9 had diagnoses which included congestive heart failure, chronic respiratory failure, and cerebral infarction. A physician order, dated 12/07/23, documented the resident was to receive oxygen 2-3 liters via nasal cannula to maintain oxygen saturation greater than 92% related to chronic respiratory failure with hypoxia. A physician order, dated 05/06/24, documented the staff was to change the oxygen tubing and humidifier every Sunday night and as needed related to chronic respiratory failure with hypoxia. On 08/06/24 at 11:36 a.m., the resident was sleeping and had oxygen infusing at 2 liters via nasal cannula. The oxygen tubing was not dated. On 08/08/24 at 9:26 a.m., the resident was sitting in a wheelchair watching television and had oxygen infusing at 3 liters per nasal cannula. The oxygen tubing was not dated. 2. Resident #19 had diagnoses which included chronic obstructive pulmonary disease, heart failure, and pneumonia. A physician order, dated 07/02/24, documented the resident was to receive oxygen at 5 liters via nasal cannula to wean/titrate to keep oxygen saturation above 90% related to acute and chronic respiratory failure with hypoxia. A physician order, dated 07/05/24, documented the staff was to change the oxygen tubing and humidifier every Sunday night and as needed related to chronic obstructive pulmonary disease. On 08/06/24 at 8:38 a.m., the resident was lying in bed and had oxygen infusing at 4 liters per nasal cannula. The oxygen tubing was not dated. On 08/08/24 at 9:17 a.m., the resident was lying in bed with oxygen infusing at 4 liters per nasal cannula. The oxygen tubing was not dated. 3. Resident #23 had diagnoses which included pneumonia, chronic obstructive pulmonary disease, congestive heart failure, and obesity. A physician order, dated 05/06/24, documented to change the resident's oxygen tubing and humidifier every week on Sunday and as needed. A physician order, dated 05/07/24, documented the resident was to receive oxygen 2-4 liters during sleep and as needed related to chronic obstructive pulmonary disease. On 08/06/24 at 8:52 a.m., the resident was lying in bed watching television and had oxygen at 2 liters via nasal cannula infusing. The oxygen tubing was not dated. On 08/08/24 at 9:23 a.m., the resident was lying in bed watching television and had oxygen in place per nasal cannula infusing at 2 liters. The oxygen tubing was not dated. 4. Res #24 had diagnoses which included chronic obstructive pulmonary disease. A physician's order, dated 04/21/24, documented to change oxygen and humidifier tubing weekly on Tuesday and as needed. A physician's order, dated 04/21/24, documented Res #24 was to receive oxygen at 2 liters via nasal cannula continuously to keep oxygen saturation above 80. On 08/07/24 at 12:19 p.m. the resident was lying in bed with oxygen infusing at 2 liters via nasal cannula The oxygen tubing and humidifier was dated 07/20/24. On 08/08/24 at 2:26 p.m., the resident was lying in bed with oxygen infusing at 2 liters via nasal cannula. The oxygen tubing and humidifier was dated 07/20/24. On 08/09/24 at 11:44 a.m., the DON stated the staff was to change and date the oxygen tubing as ordered. The DON stated if the tubing was not dated, staff would not know if the tubing was changed as ordered. 45913

Based on observation and interview, the facility failed to store food with professional standards for food service safety. The DM identified 27 residents who ate meals prepared by the kitchen and one resident who received nutrition via tube feeding. Findings: On 08/06/24 at 7:10 a.m., a tour of the kitchen was completed. The refrigerator had two plastic bowls sitting on the top rack with a liquid in them. Drops of liquid from the ceiling were observed falling into the bowls. The DM stated the refrigerator had been dripping for about four to five days. The DM stated the ice machine was also broke and ice was brought in from an outside source. On 08/08/24 at 11:24 a.m., a meal service was observed. The refrigerator still had two bowel on the top shelf to catch the drips from the ceiling of the refrigerator. The staff was observed moving the bowls to obtain other items in the refrigerator and to catch the drops. The refrigerator door had a piece of the gasket sticking out around the door. On 08/08/24 at 11:30 a.m., the DM stated the refrigerator needed some work done and the ice machine needed a part.

Based on record review and interview, the facility failed to ensure information regarding an advance directive was correct and legal for two (#9 and #20) of 10 residents reviewed for advance directives. The director of nurses identified 29 residents resided in the facility. Findings: 1. Resident #9 had diagnoses which include congestive heart failure, chronic respiratory failure, type 2 diabetes mellitus, and cerebral infarction. The care plan, dated 12/19/23, documented the resident was a full code status. The care plan did not document an advance directive for the resident. An ADVANCE DIRECTIVE, DNR, POA ACKNOWLEDGMENT form, dated 06/18/24, documented the resident #9 had not executed a DNR, had executed an advance directive, and had executed a Power of Attorney/Guardianship. The form was signed by the resident. On 08/09/24 at 12:52 p.m., the DON reviewed the residents clinical record. The DON stated they could not locate an advance directive or POA documentation for the resident. 2. Resident #20 had diagnoses which included congestive heart failure, type 2 diabetes mellitus, and hypertension. A DURABLE POWER OF ATTORNEY form, dated 03/02/21, documented the resident had appointed a person as POA. The document was not notarized. An ADVANCE DIRECTIVE, DNR, POA ACKNOWLEDGMENT form, dated 08/07/23, documented the resident had not executed a DNR, had executed an advance directive, and had executed a Power of Attorney/Guardianship. The document was signed by the POA. The care plan, dated 08/15/23, documented the resident was a full code status. The care plan did not document an advance directive for the resident. On 08/09/24 at 10:48 a.m., the DON reviewed the residents clinical records and stated an advance directive was not available/documented in the resident's records. The DON reviewed the residents POA documentation. The DON stated the POA form had not been notarized and was not a legal document.

Based on record review and interview, the facility failed to administer medications as ordered for two (#1 and #4) of seven sampled residents reviewed for medication administration. The MDS Coordinator identified 35 residents resided in the facility. Findings: A Medication Administration and General Guidelines policy, dated 2021, read in part, .medications are prepared, administered and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications . in accordance with written orders of the attending physician . 1. Resident #4 had diagnoses which included anxiety, major depression, hyperlipidemia, disc degeneration lumbar region, dementia and DMII. A physician's order, dated 09/21/23, documented baclofen 10 mg give one tablet by mouth three times daily for low back pain. A physician's order, dated 10/25/23, documented mirtazapine 15 mg give one tablet by mouth every night for major depressive disorder. A physician's order, dated 10/25/23, documented tramadol hydrochloride 50 mg give 0.5 tablet by mouth three times daily for low back pain. A physician's order, dated 10/25/23, documented atorvastatin calcium 20 mg give one tablet by mouth every night for hyperlipidemia. A physician's order, dated 10/26/23, documented levemir 100 units per ml inject five units subcutaneously twice daily. A physician's order, dated 01/03/24, documented trazodone hydrochloride 50 mg take one tablet by mouth nightly. A physician's order, dated 01/03/24, documented acetaminophen 325 mg administer two tablets by mouth every six hours for pain. A physician's order, dated 02/07/24, documented divalproex sodium extended release 500 mg give one tablet by mouth at hours of sleep for dementia. A Medication Administration record for February 2024, had no documentation for the following medications on 02/11/24 at 3:00 p.m.: a. baclofen 10 mg, b. tramadol hydrochloride 50 mg, and c. acetaminophen 325 mg A Medication Administration record for February 2024, had no documentation for divalproex sodium extended release 500 mg on 02/11/24 and 02/18/24 at 8:00 p.m. A Medication Administration record for February 2024, had no documentation for the following medications on 02/11/24 at 9:00 p.m.: a. baclofen 10 mg, b. mirtazapine 15 mg, c. tramadol hydrochloride 50 mg, d. atorvastatin calcium 20 mg, e. trazodone hydrochloride 50 mg, and f. acetaminophen 325 mg. A Medication Administration record for February 2024, had no documentation for levemir 100 units per ml 02/15/24 at 9:00 p.m., 02/16/24 at 9:00 p.m., 02/17/24 at 9:00 a.m., and 02/20/24 at 9:00 a.m. A Medication Administration record for February 2024, had no documentation for the following medications on 02/18/24 at 9:00 p.m.: a. baclofen 10 mg, b. mirtazapine 15 mg, c. tramadol hydrochloride 50 mg, d. atorvastatin calcium 20 mg, e. trazodone hydrochloride 50 mg, and f. acetaminophen 325 mg. On 02/21/24 at 9:03 a.m., the ADON stated a blank means either the medication was not given or it was documented in the paper medication administration book. On 02/21/24 at 9:11 a.m., the paper medication administration book was reviewed, and it had no documentation of any of the medications being given. 2. Resident #1 had diagnoses which included atrial fibrillation, hypertension, and depression. A physician's order, dated 01/26/24, documented budesonide 0.5 mg per 2 ml give one unit dose via nebulizer twice daily for chronic obstructive pulmonary disease. A physician's order, dated 01/26/24, documented ipratropium bromide 0.02% give one unit dose via nebulizer every 8 hours chronic obstructive pulmonary disease. A physician's order, dated 01/26/24, documented refresh celluvisc 1% give one drop to each eye every six hours for dry eye syndrome of bilateral lacrimal glands. A physician's order, dated 01/26/24, documented senna-plus 8.6-50 mg give one tablet by mouth twice daily for constipation. A physician's order, dated 01/26/24, documented eliquis 2.5 mg give one tablet by mouth twice daily for history of pulmonary embolism. A physician's order, dated 01/26/24, documented folic acid 1 mg give one tablet by mouth daily for supplement. A physician's order, dated 01/26/24, documented diltiazem hydrochloride extended release 360 mg give one cap by mouth daily for atrial fibrillation. Hold medication if pulse is under 60. A physician's order, dated 01/26/24, documented hydralazine hydrochloride 25 mg give one tablet by mouth daily for hypertension. Hold blood pressure medication if blood pressure below 100/60. A physician's order, dated 01/26/24, documented famotidine 20 mg give one tablet by mouth daily for gastroesophageal reflux. A physician's order, dated 01/26/24, documented levothyroxine sodium 125 mcg give one tablet by mouth daily for hypothyroidism. A physician's order, dated 01/26/24, documented levalbuterol hydrochloride 1.25 mg per 3 ml give one unit dose via nebulizer every eight hours. The January 2024 MAR had no documentation of time given for Resident #1's budesonide for the 12:00 p.m. administration on the 27th, 28th, and 29th. The January 2024 MAR had no documentation of time given for Resident #1's ipratropium bromide for the 12:00 p.m. administration on the 27th, 28th, and 29th. The January 2024 MAR had no documentation of time given for Resident #1's refresh celluvisc for the 12:00 p.m. administration on the 28th, and 29th. The January 2024 MAR had no documentation of time given for Resident #1's senna-plus for the 12:00 p.m. administration on the 28th, and 29th. The January 2024 MAR had no documentation of time given for Resident #1's eliquis for the 12:00 p.m. administration on the 28th, and 29th. The January 2024 MAR had no documentation of time given for Resident #1's folic acid for the 12:00 p.m. administration on the 28th, and 29th. The January 2024 MAR had no documentation of time given for Resident #1's diltiazem hydrochloride for the 12:00 p.m. administration on the 28th, and 29th. The January 2024 MAR had no documentation of time given for Resident #1's hydralazine hydrochloride for the 12:00 p.m. administration on the 29th, and 31st. The January 2024 MAR had no documentation of time given for Resident #1's famotidine for the 12:00 p.m. administration on the 28th, and 29th. The January 2024 MAR had no documentation of time given for Resident #1's levothyroxine sodium for the 12:00 p.m. administration on the 28th, and 29th. The January 2024 MAR had no documentation of time given for Resident #1's levalbuterol hydrochloride for the 12:00 p.m. administration on the 29th and the 8:00 p.m. administration on the 30th. On 2/22/24 at 9:09 a.m., the ADON reviewed Resident #1's January 2024 MAR. They stated the medications listed above were not administered on specified dates and times. They stated there would be a time on the administration record for administered medications. 49701

Based on record review and interview, the facility failed to ensure a baseline care plan was completed within 48 hours for one (#7) of seven sampled resident reviewed for baseline care plan. The MDS Coordinator identified 35 residents resided in the facility. Findings: A Care Plans-Baseline policy, undated, read in part, .A baseline plan of care to meet the resident's immediate needs shall be developed by the IDT for each resident within 48 hours of admission . Resident #7 admitted on [DATE], with diagnoses which included UTI, cerebral infarct, A-fib, dysarthria, heart failure, hemiplegia right dominant side, and aphasia. There was no care plan located in the resident's clinical record. On 02/21/24 at 9:41 a.m., the MDS Coordinator stated the care plan has not been put together yet.

Based on observation and interview the facility failed to ensure food was served in a sanitary manner. The Resident Census and Conditions of Residents report, documented 35 residents resided in the facility. It documented 1 resident who had a feeding tube. Findings: 1. On 06/29/23 at 12:02 p.m., the stacked lid covers for the rectangle trays were observed to be wet when used to cover meals for the hall cart. The DM was asked if the covers should be wet. The DM stated they should not be wet and at that time stopped the cooks from using them. The DM stated the cooking utensils could not be dried with a cloth. At that time the staff changed to plating the meal on round plates. On 06/29/23 at 12:04 p.m., Cook #1 was observed to touch the inside the round plate covers as they retrieved them one at a time from the shelf to cover the food. Cook #2 was observed to touch the eating surfaces of some the round plates with his thumb. On 06/29/23 at 12:08 p.m., Cook #2 was observed to touch the inside of the bowls used for the dessert. On 06/29/23 at 12:21 p.m., Cook #1 was observed to wipe out a pan with a paper towel for the gravy to be placed in. On 06/29/23 at 12:23 p.m., Cook #1 was observed to touch the inside of bowls while moving them to the serving area. On 06/29/23 at 12:30 p.m., the DM stated the staff should not touch the eating surfaces of the plates, covers, or bowls while serving the resident meals. On 06/29/23 at 1:45 p.m., the dietitian stated the dishes all should have been air dried and confirmed the eating surfaces of the dishes should not have been touched while plating the food. 2. An undated facility policy, titled Hand Washing/Hand Hygiene read in part, .2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .c. after contact with . body fluids, secretions, mucous membranes .i. after contact with objects (eg., medical equipment) in the immediate vicinity of the resident . On 06/29/23 at 12:22 p.m., the staff were observed while serving hall trays. During passing the meals, staff were observed to touch multiple door knobs, set up meals for resident, touched the top of milk cartons, and drinking cups. Observations were made of staff passing drinks from the hydration cart, touching door knobs and drinking cups. Hand hygiene was not observed during this observation of the meal pass or hydration pass. On 06/29/23 at 12:29 p.m., trays were passed to three residents and hand hygiene was not observed. On 06/29/23 at 12:36 p.m., CNA #5 stated they were supposed to use hand hygiene but and confirmed they did not use any while passing resident meals. On 06/29/23 at 12:37 p.m., CNA # 3 stated they just remembered hand hygiene should have been performed between residents while passing meals. On 06/29/23 at 12: 45 p.m., the DON stated when the CNAs were passing trays they should always use hand sanitizer in between the residents. 34945 3. On 06/29/23 at 11:59 a.m., during an observation of the noon meal, two staff members observed assisting resident's to eat. CNA #8 was observed to assist two residents to eat by giving a bite to one resident, then giving a bite to the second resident, without performing hand hygiene between residents. On 06/29/23 at 12:01 p.m., CNA #8 was observed to stand up from feeding two residents, go to another table, unroll a third residents silverware, and cut up their food, without first performing hand hygiene. When the CNA was completed with cutting up the third resident's food, the CNA sat back down at the assisted feeding table and started to feed residents without first performing hand hygiene. On 06/30/23 at 12:40 p.m., the DON stated it was the policy of the facility staff feed only one resident at a time. The DON stated they were not supposed to feed two or assist another resident with cutting up their food without first performing hand hygiene.

Based on observation, record review, and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for three (#8, 11, and #29) of 20 sampled residents whose assessments were reviewed. The Resident Census and Condition of Residents form documented 35 residents resided in the facility. Findings: 1. Res #29's physician order, dated 02/08/23, documented the facility was to administer clopidogrel (an antiplatelet medication) 75 mg daily for a diagnosis of cerebral infarction due to thrombosis of left middle cerebral artery. At that time, the remaining resident's medication orders were reviewed and did not document an order for the facility to administer an anticoagulant medication. An annual assessment for Res #29, dated 04/12/23, documented the resident received an anticoagulant medication for seven days of the seven day assessment period. 2. A physician order for Res #8, dated 04/01/23, documented the facility was to administer clopidogrel 75 mg daily for a diagnosis of cerebral infarction. At that time the remaining physician orders were reviewed and did not document the facility was to administer an anticoagulant medication to Res #8. A significant change assessment, dated 04/05/23, documented Res #8 received an anticoagulant medication for four days of the seven day assessment period. On 07/03/23 at 2:22 p.m., MDS Coordinator #1 stated until this survey they thought clopidogrel was an anticoagulant. The MDS coordinator confirmed the MDS assessments for Res #8 and #29 were coded incorrectly related to the use of an anticoagulant medication. 3. Res #11's physician order, dated 10/18/22, documented to administer Eliquis (an anticoagulant medication) tab 2.5 mg one tablet daily for a diagnosis of atrial fibrillation. A significant change assessment, dated 02/04/23, documented the resident did not receive an anticoagulant medication during the assessment period. A quarterly assessment, dated 05/02/23, documented the resident did not receive an anticoagulant medication during the assessment period. On 06/29/23 at 3:52 p.m., Res #11 was observed ambulating in the hall way and sat down next to another resident. Res #11 was unable to be interviewed. On 06/29/23 at 4:21 p.m., MDS coordinator #1 stated Eliquis was missed for coding as an anticoagulant on the quarterly and significant change assessment.

Based on observation, record review, and interview, the facility failed to develop and implement care plans which reflected the residents' needs for five (#3, 11, 13, 28, and #32) of 20 sampled residents whose records were reviewed. The facility failed to develop care plans for: a. psychotropic medication use; pain; atrial fibrillation; and the use of Eliquis, furosemide, and levothyroxine for Res #11. b. Lasix for Res #32. c. ADLs for Res #13. d. pain and pain medication refusals for Res #3. e. ADL cares for #13 and #28. The Resident Census and Conditions of Residents form documented 35 residents resided in the facility. Findings: 1. Res #11 had diagnoses which included chronic atrial fibrillation, hypothyroidism, pain, and edema, dementia without behavioral disturbance, and senile degeneration of the brain. A physician order, dated 10/18/22, documented to administer Eliquis (an anticoagulant medication) 2.5 mg daily for a diagnosis of atrial fibrillation. A care plan, dated 11/08/22 and updated continuously, did not document a plan of care regarding the resident's diagnosis of atrial fibrillation or the use of Eliquis; pain or the use of pain medications; hypothyroidism or the use of levothyroxine; or edema or the use of furosemide. The care plan documented the resident was on psychotropic medications but did not document the classification of medication, side effects, or target behaviors. A significant change assessment, dated 02/04/23, documented the resident was moderately impaired in cognition and was independent to requiring supervision with most ADLs A physician order, dated 04/22/23, documented the facility were to administer as needed hydrocodone/acetaminophen 5 mg/325 mg every six hours, morphine sulfate 1 mg every six hours, and/or Tramadol 50 mg every six hours for pain. A quarterly assessment, dated 05/02/23, documented the resident was severely impaired in cognition, required supervision with most ADLs, and was receiving hospice care. A physician order, dated 06/08/23, documented to increase the resident's dose of Eliquis tab 2.5 mg daily to twice daily for a diagnosis of chronic atrial fibrillation. A physician order, dated 06/08/23, documented to administer furosemide (a medication used to treat edema) 20 mg daily for a diagnosis of edema. A physician order, dated 06/08/23, documented to administer mirtazapine (an antidepressant medication) 7.5 mg every night for a diagnosis of dementia without behaviors. A physician order, dated 06/19/23, documented to administer Levothyroxine 25 mcg every morning for a diagnosis of hypothyroidism. A physician order, dated 06/19/23, documented to administer sertraline (an antidepressant medication) 50 mg daily for a diagnosis of dementia without behaviors. A physician order, dated 06/25/23, documented to administer risperidone (an antipsychotic medication) 0.5 mg twice daily for a diagnosis of dementia without behaviors. On 06/29/23 at 11:01 a.m., Res #11 was observed walking in the hallway utilizing a walker, wearing clean purple sweat pants and a long sleeve gray tee shirt, and was caring a large cup of fluids. On 06/29/23 at 1:58 p.m., an interview with MDS coordinator #1, the DON, and a corporate nurse was conducted regarding the care plan for the resident. The MDS coordinator and the corporate nurse reviewed the care plan and confirmed the care plan did have a use of psychotropic medication plan of care but and that it was not specific to the classification of medication and the diagnoses they were used for did not concur with the care plan. The MDS coordinator stated the care plan was not developed for pain or the use of pain medication; atrial fibrillation or the use of Eliquis; hypothyroidism or the use of levothyroxine; and edema or the use of fursomide. The MDS coordinator stated there should have been a care plan developed to include these diagnoses and medications. On 06/29/23 at 3:52 p.m., Res #11 was observed ambulating in the hall way and sat down next to another resident. Res #11 was unable to be interviewed. 2. Res #32's care plan, dated 09/16/22, did not document a plan of care for furosemide or congestive heart failure. A physician order, dated 06/17/23, documented the facility was to administer furosemide (a diuretic medication) 40 mg at 8:00 a.m., and 12:00 p.m., for a diagnosis of congestive heart failure. A quarterly assessment, dated 06/12/23, documented the resident was intact in cognition and was independent to requiring limited assistance with ADLs. The assessment documented the resident received a diuretic medication for seven days of the seven day assessment period. On 06/30/23 at 2:48 p.m., MDS coordinator #1 stated the care plan did not document a plan of care for the use of furosemide. The MDS coordinator stated they now knew they should have formulated a care plan for the use of the medication. On 06/30/23 at 4:10 p.m., Res #32 was observed in their room. The resident stated the physician had put them on different medications but had no issues with the medication in use. 3. Res #3 had diagnoses which included chronic pain syndrome. A quarterly assessment, dated 05/08/23, documented the resident was intact in cognition, was independent to requiring limited assistance for most ADLs, and experienced frequent moderate pain. The resident's care plan was reviewed and did not document a plan of care regarding pain control. A physician order, dated 05/19/23, documented the facility was to administer two tablets of acetaminophen 325 mg every six hours as needed for pain. A nurse note, dated 06/23/23, documented the resident refused medications. The note documented the resident was aware of the medications they were refusing, what they were for, and the physician was aware. On 06/28/23 at 8:41 a.m., the resident was observed and interviewed. Res #3 stated they always had pain. On 06/29/23 at 3:46 p.m., CMA #1 stated Res #3 did have pain medication ordered but would not request it when they were in pain. On 06/29/23 at 4:17 p.m., MDS coordinator #1 stated they should have added a pain management care plan to the resident's plan of care. The MDS coordinator stated the care plan should have included the resident refused pain medications. 38495 4. Res #13 had diagnoses which included age related physical disability and dementia. A quarterly assessment, dated 05/18/23, documented the resident was severely impaired with cognition and required extensive to total care with most ADLs. A care plan, last reviewed 05/23/23, did not document a plan for the resident's ADL care. On 06/29/23 at 4:55 p.m., the MDS coordinator confirmed the resident did not have an ADL care plan and required extensive assistance. 5. Res #28 had diagnoses which included traumatic brain injury, seizures, and history of TIA. A quarterly assessment, dated 04/10/23, documented the resident was severely impaired with cognition and required total care with ADLs. A care plan, dated 07/19/22, did not document an ADL plan of care for the resident. On 06/29/23 at 2:57 p.m., the MDS coordinator stated the resident's care plan was one of the fist completed after starting in the MDS/care plan position. The MDS coordinator confirmed the care plan did not have ADLs care planed for the resident.

Based on record review and interview, the facility failed to ensure the right to request, refuse, or formulate an advanced directive for four (#16, 26, 28, and #33) of 15 residents sampled for advanced directives. The facility failed to ensure: a. residents were offered the choice to formulate advance directives for Res #26, and #28. b. a code status form was valid for Res #16 and #33. The Resident Census and Conditions of Residents report, documented 23 residents had advanced directives. Findings: 1. Res #26 had diagnoses which included delusional disorder and Alzheimer's disease. An annual assessment, dated 06/12/23, documented the resident was severely impaired with cognition. A care plan, dated 06/13/23, documented the resident was a full code. The resident's EHR did not contain documentation of information to develop an advance directive was offered to the resident or resident representative. On 06/29/23 at 9:48 a.m., the BOM stated they could not find documentation the resident or resident representative had been offered information on formulating an advanced directive. On 06/30/23 at 12:50 p.m., the DON stated the resident or resident representative should have been offered information and/or assistance with formulating an advanced directive on admission if they wanted one. 2. Res #28 had diagnoses which included traumatic brain injury, seizures, and history of TIA. A care plan, dated 07/19/22, documented the resident was a full code. A quarterly assessment, dated 04/10/23, documented the resident was severely impaired with cognition. On 06/28/23 at 12:00 p.m., the BOM stated they could not find documentation the resident or resident representative had been offered information on formulating an advanced directive. The BOM stated the formulation of an advanced directive should have been offered and completed on admission. On 06/28/23 at 12:20 p.m., Res #28's family member stated they could not remember if an advance directive was offered on admission or not. On 06/30/23 at 12:50 p.m., the DON stated the resident or resident representative should have been offered information and/or assistance with formulating an advanced directive on admission if they wanted one. 3. Res #33 had diagnoses which included malaise. An annual assessment, dated 05/02/23, documented the resident was moderately impaired with cognition. A care plan, dated 05/03/23, documented the resident's code status was DNR. An undated DNR form was present in the resident's hard chart. On 06/30/23 at 12:56 p.m., the DON stated the DNR would have to dated to be a legal document. 4. Res #16 had diagnoses which included chronic pain, depressive disorder, and heart disease. An annual assessment, dated 06/07/23, documented the resident was intact with cognition. An undated DNR was present in the resident's hard chart. On 06/30/23 at 12:57 p.m., the DON stated the DNR needed to be dated to be a legal document.

On 08/31/17 a past noncompliance Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to respond appropriately for resident #2, who was taking [MEDICATION NAME] (an anticoagulant medication), when the resident experienced critically elevated laboratory test values. The facility failed to ensure treatment and/or services were provided to address the elevated laboratory results. On 07/29/17 at 2:34 a.m., [MEDICATION NAME] time/international normalized ratio (PT/INR) results for the resident were faxed to the facility with critical results. The PT was documented as greater than (>) 200 and the INR was documented as > 18. The laboratory (lab) report documented the suggested INR therapeutic range for routine oral anticoagulation therapy as 2.0 to 3.0. The lab report documented the suggested INR therapeutic range for infarction or mechanical prosthetic valves as 2.5 to 3.5. The facility failed to ensure the physician was aware of the lab results. The resident was admitted to the hospital on [DATE]. A discharge summary from the hospital, dated 08/03/17, documented the resident was admitted to the hospital for [MEDICATION NAME] (an anticoagulant) induced coagulopathy and an acute INR elevation greater than 18. On 08/31/17 the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to respond appropriately for resident #2 when the resident experienced critically elevated laboratory test values. At 12:20 p.m., the administrator was informed of the past noncompliance IJ related to the facility's failure to respond appropriately for resident #2 when the resident experienced critically elevated laboratory test values on 07/29/17. The facility put measures in place to prevent the recurrence when staff had been inserviced on 07/31/17 related to appropriate measures when a resident had a critically elevated laboratory test value. Two staff members were counseled on 07/31/17 related to failure to respond appropriately to the critically elevated laboratory test values on 07/29/17. A performance improvement plan was initiated by the director of nursing (DON). The performance improvement plan documented the physician was faxed and had not been called on a critical lab, was not addressed in shift report, and no follow-up was completed. The performance improvement plan documented the doctor was notified and staff were educated. The performance improvement plan action steps to implement the plan documented the doctor was notified of the lab results and the nursing staff have been educated on the requirement for notification. The action steps documented critical labs would be called to the doctor, an audit would be completed to ensure lab results had been communicated to the doctor, and the DON or designee would audit lab notifications daily in the daily clinical meeting. The action steps documented the results of the audits would be presented to the facility Quality Assurance Performance Improvement (QAPI) committee for further evaluation monthly for no less than 90 days. The plan documented the objective measures to evaluate effectiveness was the doctor would be notified of critical labs timely. The plan documented the person responsible for oversight was the DON. Based on observation, interview, and record review, it was determined the facility failed to respond appropriately for resident #2, who was taking [MEDICATION NAME] (an anticoagulant medication), when the resident experienced critically elevated laboratory test values. The facility failed to ensure treatment and/or services were provided to address the elevated laboratory results. On 07/29/17 at 2:34 a.m., [MEDICATION NAME] time/international normalized ratio (PT/INR) results for the resident were faxed to the facility with critical results. The PT was documented as greater than (>) 200 and the INR was documented as > 18. The lab report documented the suggested INR therapeutic range for routine oral anticoagulation therapy as 2.0 to 3.0. The lab report documented the suggested INR therapeutic range for infarction or mechanical prosthetic valves as 2.5 to 3.5. The facility failed to ensure the physician was aware of the lab results. The resident was admitted to the hospital on [DATE]. A discharge summary from the hospital, dated 08/03/17, documented the resident was admitted to the hospital for [MEDICATION NAME] induced coagulopathy and an acute INR elevation greater than 18. The facility identified four residents received anticoagulant therapy. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order, dated 11/21/16, documented to obtain a PT/INR every month. A significant change assessment, dated 05/05/17, documented the resident's cognition was moderately impaired. the assessment documented the resident required limited assistance with activities of daily living. The assessment documented the resident was frequently incontinent of bowel and bladder. A care plan, dated 06/14/17, documented the resident was on anticoagulant therapy. The car plan documented to monitor, document, and report as needed adverse reactions of anticoagulant therapy. The care plan documented to obtain lab as ordered and report abnormal lab results to the physician. The care plan documented medication adjustments per physician orders. A physician order, dated 07/24/17, documented an order to obtain a PT/INR on 07/27/17. The lab report, dated 07/28/17, documented a PT/INR was obtained. The laboratory was unable to test the blood sample due to quantity was not sufficient. A progress note, dated 07/28/17 at 9:30 p.m., documented the PT/INR was obtained and transported to the lab for processing. On 07/29/17 at 2:34 a.m., the PT/INR results were faxed to the facility with critical results. The PT was documented as greater than > 200 and the INR was documented as > 18. The lab report documented the suggested INR therapeutic range for routine oral anticoagulation therapy as 2.0 to 3.0. The lab report documented the suggested INR therapeutic range for infarction or mechanical prosthetic valves as 2.5 to 3.5. The clinical record was reviewed. The nurse progress notes did not document physician notification of the critical PT/INR on 07/29/17. A facility investigation report, dated 07/31/17, documented during the daily clinical meeting a charge nurse brought the lab results for the resident's PT/INR report dated 07/29/17. The charge nurse was instructed to immediately notify the physician and family. The investigation report documented an order was obtained to send the resident to the emergency room . The investigation report documented the incident and in-service training related to notifying the physician immediately with any critical lab results. The investigation report documented employee counseling and a performance improvement plan. A physician order, dated 07/31/17, documented to send the resident to the hospital emergency room for critical PT/INR. A discharge summary from the hospital, dated 08/03/17, documented the admit [DIAGNOSES REDACTED].> 18. The summary documented the resident was admitted for [MEDICATION NAME] induced coagulopathy without acute bleeding. The summary documented the resident received Vitamin K for reversal and [MEDICATION NAME] was held. The summary documented INR resolved to therapeutic range and [MEDICATION NAME] was restarted. The summary documented the resident was discharged on anticoagulant therapy of [MEDICATION NAME] 5 milligrams every day at 1800. The summary documented an order to notify the physician of the results. On 08/04/17 the lab result for the INR was documented as INR 1.4. A facilimile (fax), dated 08/04/17 documented the physician was notified of the INR results. On 08/04/17 the physician documented an order for [REDACTED]. On 08/08/17 the lab result for the INR was documented as INR 3.1. A facilimile (fax), dated 08/08/17 documented the physician was notified of the INR results. On 08/08/17 the physician documented an order to continue the same dose of [MEDICATION NAME] and to recheck PT/INR on 08/10/17 on the laboratory test result. On 08/10/17 the lab results for the PT/INR were documented as PT 59.8 and the INR 5.2 (critical). The physician was called via telephone on 08/11/17 at 11:45 a.m. A verbal physician order [REDACTED]. On 08/14/17 the lab results for the PT/INR were documented as PT 16.6 and the INR 1.4. The physician was notified of the results via fax. A physician's telephone orders, dated 08/14/17, documented to hold [MEDICATION NAME]. On 08/22/17 at 1:00 p.m., the DON was interviewed related to the critical PT/INR on 07/29/17. The DON reported she was made aware of the critical values on 07/31/17 during the daily clinical meeting on Monday morning. The DON reported the critical lab values were given to the charge nurse on Saturday morning, 07/29/17. The DON stated the nurse had reported to her she had made two attempts to call the physician without a response and then faxed the lab results to his office. The DON reported she immediately assessed the resident and reported the resident did not have any signs of [MEDICATION NAME] toxicity such as bruising or blood in the urine. The DON reported a full investigation was initiated and documented. The DON reported the staff responsible for notifying the physician was in-serviced and employee counseling was performed. The DON reported the issue had been documented on a performance improvement plan for follow-up and evaluation during the quality assurance meetings. On 08/31/17, the DON reported other residents receiving [MEDICATION NAME] therapy was assessed and lab results were reviewed at the time the incident was known. On 08/22/17 and 08/31/17, interviews and record reviews were conducted to verify the interventions to prevent future occurrences of inappropriate responses to critical laboratory reports had been completed by the facility.

Based on observation, record review, and interview, it was determined the facility failed to ensure residents did not develop avoidable pressure sores for two (#1 and #3) of four sampled residents reviewed for pressure sores. The facility failed to accurately and consistently assess skin integrity; implement measures to prevent the development or worsening of avoidable stage III pressure sores; provide interventions, care, and treatment to existing pressure sores to promote healing; and notify physicians of change in condition. Resident #1 developed a stage III pressure sore. The facility census and condition report documented four residents had pressure sores. Findings: The facility policy for pressure ulcer prevention and wound care documented every resident would be assessed for pressure ulcer risk on admission and quarterly. The policy documented the residents at risk would be turned at least every two hours unless contraindicated. The policy documented if the resident could not be positioned off the pressure ulcer, a pressure reduction/pressure relief surface would be required. The policy documented the physician would be consulted for management of stage II, III, and IV pressure ulcers. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission narrative weekly skin assessment, dated 05/23/12, documented the resident's skin had no areas of concern. A pressure sore risk assessment, dated 05/23/12, documented the resident was at severe risk for pressure sores. A [MEDICAL CONDITION] risk assessment, dated 05/23/12, documented the resident was at high risk for [MEDICAL CONDITION]. An updated temporary care plan, dated 06/03/12, documented the resident had a stage I pressure sore on the resident's coccyx and a treatment order was received for [MEDICATION NAME] to be applied each shift and as needed (PRN). The weekly skin assessment, dated 06/03/12, documented the following pressure sores and treatments: a. The resident's right heel had a fluid filled area of 2 cm x 3 cm (centimeters) and was soft to the touch. The physician had ordered for the resident's heels to be floated (elevated to prevent the heels from resting on a surface) and to apply [MEDICATION NAME] (a barrier cream) to the right heel. b. The left heel had developed a stage II pressure sore which measured 2 cm x 2 cm. The physician had ordered [MEDICATION NAME] (promotes healthy tissue growth) to be applied to the left heel each shift. c. The left buttock had developed a stage II pressure sore which measured 1.3 cm x 1.5 cm. The physician had ordered [MEDICATION NAME] treatment continued to the coccyx. The comprehensive admission assessment, dated 06/04/12, documented the resident was admitted from the hospital without any skin breakdown. The assessment documented the resident was severely impaired for daily decision making and required assistance with activities of daily living (ADLs). The assessment documented the resident required nectar thick liquids. The assessment documented the resident was to be turned every two hours for preventive skin care. The comprehensive care plan, dated 06/08/12, documented the resident was at risk for skin breakdown due to impaired mobility. The care plan documented the resident had pressure sores. The interventions included to monitor the skin during all ADL care, perform wound care per physician's orders [REDACTED]. The care plan documented an air mattress would be placed on the resident's bed. The care plan documented the resident was to have both heels floated at all times. A weekly skin assessment, dated 08/16/12, documented the left heel pressure sore was healed, the right heel pressure sore had scabbed over, the left buttock was a stage II pressure sore, the coccyx pressure sore had worsened to a stage II, and [MEDICATION NAME] was the continued treatment. A significant change assessment, dated 08/24/12, documented the resident had developed a stage II pressure sore to the coccyx and a stage II pressure sore to the left buttock. The assessment documented the resident had a pressure reducing device for bed, was on the turning program, received pressure ulcer care, and had non-surgical dressings. The assessment documented there were no pressure sores on the prior assessment. A care plan, dated 08/24/12, documented the resident had an air mattress on the bed and the resident's heels were to be floated at all times. The care plan documented no change for the pressure sore treatment. A weekly skin assessment, dated 11/03/12, documented the resident had developed a new pressure sore on the right buttock which measured were 1.5 cm x 1.5 cm. The assessment documented the resident's right heel remained intact. The assessment documented the pressure sore on the coccyx continued at a stage II, and the left buttock continued at a stage II. No measurements were documented for the left buttocks. A dietary progress note, dated 11/30/12, documented the need for increased calories related to the pressure sores. A weekly skin assessment, dated 12/15/12, documented the coccyx pressure sore had improved, the right buttock was healed, and the pressure sore on the left buttock had worsened. The assessment did not document measurements of the pressure sores. A weekly skin assessment, dated 01/11/13, documented treatment to left buttocks continued and remained an area of concern. The left buttocks measured 1 cm x 1.5 cm x 1 cm depth. A weekly skin assessment, dated 01/26/13, documented the resident's left buttock pressure sore was worse and the treatment remained the same. The assessment did not document the physician was notified of the worsened condition of the pressure sore. On 01/29/13 at 11:50 a.m., the resident was observed in bed. A pressure reducing device was not on the resident's bed and the resident's heels were not floated. The resident was lying on her left side. There were no positioning devices in use for the resident. On 01/29/13 at 1:00 p.m., the wound assessment nurse was asked if the resident had a pressure reducing device on the bed and if the resident's heels were floated. The wound assessment nurse stated the resident did not have a pressure reducing device and the resident's heels were not floated. The wound assessment nurse was ask if the resident should have had a pressure reducing device on the bed and the heels floated. The wound assessment nurse stated the resident should have a pressure reducing device on the bed and the resident's heels should be floated. On 01/29/13 at 3:00 p.m., the resident was observed in bed. The bed did not have the pressure reducing device and the resident's heels were not floated. On 01/29/13 at 5:00 p.m., the wound nurse was interviewed regarding the measurements and the stage of the resident's left buttock pressure sore. The wound assessment nurse stated on 01/26/13 the left buttocks measured 2.6 cm x 4 cm x 1 cm and was a stage II. The wound nurse was asked to explain how the pressure sore was staged. The wound assessment nurse stated the RN staged the pressure ulcers. On 01/30/13 at 9:00 a.m., the treatment for [REDACTED]. The pressure sore on the resident's left buttock measured at 2.6 cm x 4 cm x 2 cm. The depth of the pressure sore had increased by 1 cm. The RN observed the treatment as well and stated the left buttock pressure sore had worsened to a stage III. On 01/30/13 at 9:25 a.m., the director of nurses (DON) and the wound care nurse were asked what measures had been put in place to prevent the development of the pressure sores for the resident. The DON stated the day before was her first day working at the facility. The wound nurse stated residents at risk for pressure sores were turned every two hours. The wound nurse stated the resident should have had an air mattress on the resident's bed and the resident's heels should have been floated. On 01/30/13 at 1:00 p.m., the certified nurse aide (CNA) #2 was interviewed regarding the resident's care plan for the pressure sores. The CNA stated the resident should have had an air mattress and the resident's heels should have been floated at all times. On 01/31/13 at 11:25 a.m., the physician was interviewed regarding notification that the resident's pressure sores had worsened. The physician stated he had not been notified of the resident's pressure sore worsening. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Braden Scale for predicting pressure sore risk, dated 12/03/12, documented the resident was at low risk for developing a pressure sore. The admission assessment, dated 12/14/12, documented the resident was moderately impaired for daily decision making and had some difficulty understanding. The assessment documented the resident required moderate assistance with the activities of daily living (ADLs) which included moderate assistance with bed mobility and transfers and maximum assistance with ambulation. The assessment documented the resident was frequently incontinent of bowel and bladder, experienced frequent pain, had fallen two times since admission, received physical therapy (PT), and did not have a pressure sore or skin redness. The physician's orders [REDACTED]. The skin assessment note, dated 01/12/13, documented the resident's skin was intact. A physician's orders [REDACTED]. The order documented the [DIAGNOSES REDACTED]. The care plan, dated 01/22/13, documented the stage II pressure sore with the goal for the sore to be healed in 30 days. The care plan interventions included the treatment per the physician's orders [REDACTED]. The clinical record did not document interventions of a pressure relieving device for the resident's wheelchair or bed. On 01/29/13 at 8:00 a.m., the resident was observed sitting on her bed. A personal alarm was in the wheelchair seat. The wheelchair did not have a pressure reducing cushion. On 01/29/13 at 9:55 a.m., the resident was observed lying on her back, on her bed, asleep. The bed did not have a pressure reducing device. On 01/29/13 at 2:00 p.m., the resident was observed lying on her back, on her bed, asleep. The bed did not have a pressure reducing device. On 01/29/13 at 4:00 p.m., the resident was observed sitting in her wheelchair and wheeling herself down the hall. On 01/29/13 at 5:35 p.m., the resident was observed lying on her back, on her bed in her room. The bed did not have a pressure reducing device. On 01/30/13 at 10:30 a.m., the assistant director of nurses (ADON) was interviewed regarding the resident's stage II pressure sore. The ADON was asked what interventions were initiated for the resident. The ADON stated the interventions were skin treatments and repositioning the resident every two hours. The ADON was asked if the resident had pressure reducing devices for the wheelchair and bed. The ADON stated the resident did not have pressure reducing devices for the wheelchair or the bed.

Based on record review, observation, and staff interview, it was determined the facility failed to: a) attain pain medication and treat pain in a timely manner for one (#2) of one sampled resident with a fracture. This resulted in actual harm for the resident who had a pain rating of eight on a faces scale. The facility identified one resident who required pain medication after an incident. b) ensure a peripherally inserted central catheter (PICC) was discontinued after the completion of antibiotic therapy for one (#3) of one sampled resident identified as having had a PICC line. This had the potential to affect one resident identified by the facility as having had a PICC line during the month of November 2010. Findings: An undated facility nursing protocol titled Pain documented, "...The leadership of the long-term care facility must ensure that a commitment to resident comfort permeates all aspects of the facility's operation. Managers must develop and implement policies and procedures that facilitate the recognition, assessment, treatment, and monitoring of pain...Prevention is better than treatment...Base the initial choice of [MEDICATION NAME] on the severity and type of pain..." A faces scale in the protocol documented, "...7-8 hurts a whole lot..."(sic) 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/16/10, documented the resident had problems with short and long term memory, had severely impaired cognitive skills, was totally dependent with activities for daily living, and had no pain. An incident report, dated 11/16/10, documented, "...left leg below the knee was Swollen. It is unknown when this happened or how...X Ray was taken of Resident @ (at) 6:30pm - XRay Report back @ 8:30pm..." (sic) An x-ray report, dated 11/16/10, documented, "...Acute [MEDICAL CONDITION] fibular head...There is a suggestion of a possible nondisplaced lateral tibial plateau fracture..." A nurse's note, dated 11/16/10 at 2:30 p. m., documented, "...XRay ordered of chest & left leg d/t (due to) coughing & (and) L (left) Leg being swollen - Resident crying out in pain when leg is moved even the slightest bit - XRay Report back @ 8:38 pm & showed lungs to be clear & L leg to be fractured in one place for sure & possibly another - DR. (name deleted) called & aware N/O (new order) given for [MEDICATION NAME] 5/500 1 per gtube (gastrostomy tube) Q 4-6 (hours) PRN (as needed) - ace bandage was applied to L Leg per dR. (doctor) (name deleted) he Said the hospital can't do anything for her So She Should Remain here..."(sic) A nurse's note on 11/16/10 at 2:30 p. m. identified the resident was crying out in pain when leg is moved even the slightest bit. The nursing staff identified the resident's pain level as an 8 (hurts a whole lot) on the faces scale. A nurse's note, dated 11/16/10 for the 3-11 shift, documented, "...d/t Residents condition She is unable to tell you how bad She is hurting So we use the wongBaker faces & she Scored a 8 So She had gotten a Tylenol (2) 500mg Tabs to equal 1000mg Per gtube @ 4Pm..."(sic) A nurse's note, dated 11/17/10 at 4:00 a. m., documented, "...4A (a. m.) PRN [MEDICATION NAME] given per peg (percutaneous endoscopic gastrostomy) d/t resident grimacing a lot...5A resident settled down & is resting..."(sic) The resident received 1000 mg of Tylenol at 4:00 p. m. She did not receive further pain medication until 4:00 a. m. on 11/17/10. The Nursing Drug Handbook documents Tylenol as prescribed for mild pain. The resident received [MEDICATION NAME] 5/500 mg (milligrams) at 4:00 a. m. The resident was without pain medication for 12 hours. The Nursing Drug Handbook documents [MEDICATION NAME] was indicated for moderate to moderately severe pain. A nurse's note, dated 11/17/10 for the 3-11 shift, documented, "...Slight Rash Noted to trunk from Allergic Reaction to [MEDICATION NAME] - [MEDICATION NAME] DC'd & N/O for [MEDICATION NAME] Faxed & ordered - Grimaces upon face Several X's this Shift..."(sic) A nurse's note, dated 11/18/10 (11/17/10) for the 11/7 shift, documented, "...Fracture to L leg below knee very swollen & bruised...grimacing to face..NO for [MEDICATION NAME] q 4 (hours) for pain received and started on this shift..."(sic) The Nursing Drug Handbook documents [MEDICATION NAME] was indicated for moderate to moderately severe pain. On 11/17/10 at 12:00 p. m., the resident received the last dose of [MEDICATION NAME] 5/500 mg. She did not receive further medication for moderate and moderate to severe pain until 11/18/10 at 12:00 a. m. A Medication Administration Record, [REDACTED] A nurse's note, dated 11/18/10 for the 7-3 shift, documented, "...Fracture to L leg, very swollen & bruised...Facial grimacing cont [MEDICATION NAME] given q 4 (hours) for pain..." A nurse's note, dated 11/18/10 for the 3-11 shift, documented, "...L leg wrapped (with) ace bandage - Taken off & reapplied as it was too tight - facial grimace made often - L leg (below) knee very Swollen & blue & yellow in color - [MEDICATION NAME] 50mg given Q 4 (hours) Routine per orders..."(sic) A nurse's note, dated 11/19/10 (11/18/10) for the 11-7 shift, documented, "... Fracture to L leg very swollen & bruised...Facial grimacing cont (continued) this shift..." A Medication Administration Record, [REDACTED]. m., 4:00 a. m., 8:00 a. m., 12:00 p. m., and 4:00 p. m. A nurse's note, dated 11/19/10 for the 3-11 shift, documented, "...resident cryed out in pain & had tears in her eyes when i assessed her L leg - N/O Received for DCN ([MEDICATION NAME] N)100/650 will inform oncoming Nurse to give one when medication arrives-[MEDICATION NAME] Discontinued..."(sic) The Nursing Drug Handbook documents [MEDICATION NAME] N was indicated for mild to moderate pain. A nurse's note, dated 11/20/10 (11/19/10) for the 11-7 shift, documented, "...Has N/O for DCN. I gave as soon as it arrived 1:50am...2:45am. Showing some signs of relief. not as much facial grimacing..." The resident received [MEDICATION NAME] 50 mg on 11/19/10 at 4:00 p. m. She did not receive further pain medication ([MEDICATION NAME] N) until 11/20/10 at 1:50 a. m. The resident went 9 hours and 50 minutes without receiving pain medication. On 01/05/11 at 9:00 a.m., the director of nursing (DON) was asked if the facility had a policy to obtain medications in a timely manner. She stated medications come from the consulting pharmacy and are delivered around midnight and 1:00 a.m. each night. In an emergency, medications could be obtained from an in town pharmacy to receive them quicker. The DON was asked if the pain medication [MEDICATION NAME] should have been obtained and given in a timely manner on 11/16/10. She stated the staff should have called an in town pharmacy and obtained the medication for the resident. The DON stated the nurse for the 11-7 shift that began on 11/16/10 should have given the [MEDICATION NAME] as soon as the medication arrived and not waited until 4:00 am on 11/17/10 to give the medication. The DON was asked if the pain medication [MEDICATION NAME] N should have been obtained and given in a timely manner on 11/19/10. She stated the staff should have called an in town pharmacy and obtained the medication for the resident. 2. The medical record for resident #3 documented the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's medical record documented the resident had returned from a hospital stay on 10/21/10, with an order for [REDACTED]. The resident's care plan, which had been updated on 10/21/10, documented the resident had a surgical wound infection and was to receive intravenous (IV) medication every 12 hours for 20 days. The care plan documented the central line was to be discontinued after the [MEDICATION NAME] was completed. The November 2010, treatment sheet documented [MEDICATION NAME] IV 1.25 mg twice daily times 20 days. The medication was documented as having been completed on 11/02/10 at 9:00 p.m. The treatment sheet documented the resident had a PICC line which was to be flushed before and after each use. A medicare assessment, dated 11/17/10, documented the resident had memory problems with severely impaired cognition. The assessment documented the resident required total assist with all activities of daily living (ADLs). The assessment documented the resident used an indwelling urinary catheter. The assessment documented the resident received IV medications while in the facility. The assessment also documented the resident was in isolation. A nurse's note, dated 11/17/10 for the 11-7 shift, documented the resident was sleeping with no signs or symptoms of pain or discomfort. The nurse's note also documented, "PICC line patent." The PICC line should have been removed on 11/02/10. A nurse's note 11/17/10 at 7:00 a.m., documented the resident was pale, shaking all over with decreased level of consciousness. The nurse's note documented the resident was sent to the hospital. On 01/04/11 at 10:00 a.m., the resident was observed up in a geri chair, in his room. An indwelling urinary catheter drainage bag was observed on the side of the geri chair. On 01/04/11 at 2:30 p.m., the administrator (ADM) was shown the order to discontinue the PICC line after the [MEDICATION NAME] was completed (11/02/10). The ADM was asked why the PICC line had not been discontinued on November 2nd, after the antibiotic was completed. The ADM reported the PICC line should have been discontinued and she was not sure why it had not been. On 01/04/11 at 5:00 p.m., the director of nurses (DON) was interviewed regarding the PICC line not being discontinued after the [MEDICATION NAME] antibiotic was completed. The DON was asked if the resident still had the PICC line when discharged on [DATE]. The DON reported the PICC line was still present when the resident was discharged to the hospital. The DON reported the PICC line was discontinued at the hospital. The DON reported the central line should have been discontinued after the antibiotic was completed. The DON reported she did not know why the PICC line had not been discontinued (DC'd).