Every finding on record at Cimarron Pointe Care Center

Based on observation, record review, and interview, the facility failed to ensure:a. a resident assessed as a wandering risk was included in the comprehensive care plan for 1 (#5); andb. preventative devices for impaired range of motion were included in the comprehensive care plan for 1 #27) of 16 sampled residents reviewed for comprehensive care plans.The DON identified four residents had range of motion impairments and 5 residents were at risk for wandering. Findings: 1. On 04/13/26 at 12:41 p.m., Resident #5 was observed on the memory care unit to get up from their wheelchair, ambulate without assistance, and attempt to open the exterior door. CNA #3 was observed to place a gait belt on Resident #5 and redirected the resident back to their wheelchair. Resident #5 continued to ask to exit the exterior door and had to be redirected with a Velcro activity book. A facility policy titled Wandering and Elopements, revised 03/2019, read in part, The facility will identify residents who are at risk of unsafe wandering, and strive to prevent harm while maintaining the lease restrictive environment for residents.If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A facility policy titled Care Plans, Comprehensive Person-Centered, revised 03/2022, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents, physical, psychosocial and functional needs is developed and implemented for each resident.3.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. An annual assessment, dated 12/31/25, showed Resident #5 was severely impaired in cognition and was unable to complete the assessment. The assessment showed Resident #5 had diagnoses which included Alzheimer's disease, violent behavior, and senile degeneration of the brain. The assessment showed Resident #5 was a wandering risk one to three days during the look back period and ambulated with a wheelchair. A quarterly assessment, dated 04/02/26, showed Resident #5 was severely impaired in cognition and was unable to complete the assessment. The assessment showed Resident #5 was a wandering risk one to three days during the look back period and ambulated with a wheelchair. A care plan, updated 04/17/26, showed Resident #5 had a focus added for being and elopement risk with interventions dated 04/17/26 which included:a. administer medications as ordered and monitor for side effects,b. asses for a fall risk,c. resident will attempt to find an exit, ande. monitor for fatigue and weight loss. The care plan did not include a focus for wandering prior to 04/17/26. On 04/16/26 at 1:54 p.m., CNA #3 stated Resident #5 wandered frequently and required redirection. On 04/16/26 at 1:56 p.m., LPN #2 stated Resident #5 wandered frequently, and they kept eyes on the resident. On 04/16/26 at 1:59 p.m., the DON stated Resident #5 wandered and was on the locked memory care unit. On 04/20/26 at 11:37 a.m., the minimum data set coordinator stated the annual assessment dated [DATE] and the quarterly assessment dated [DATE] showed Resident #5 wandered during the look back period. They stated the elopement/wandering should have been care planned and had not been care planned prior to 04/17/26. On 04/20/26 at 12:05 p.m., corporate nurse #1 stated wandering identified in assessments should be care planned. They stated wandering was identified on the last two assessments on 12/31/25 and on 04/02/26. They stated the elopement/wandering risk had not been cared planned prior to 04/17/26. 2. On 04/14/26 at 10:02 a.m., Resident #27 was observed with a brace on their right wrist, and their right hand was observed to be contracted. A facility policy titled Resident Mobility and Range of Motion, revised 07/2017 read in part, 4. The care plan will be developed by the inter disciplinary team based on the comprehensive assessment and will be revised as needed.5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. A physician order, dated 08/05/24, read in part, Resident to wear palm protector as tolerated. An annual assessment, dated 10/27/25, showed they were admitted with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, cognitive communication deficit, and type 2 diabetes. The assessment showed Resident #27 was moderately impaired in cognition with a basic interview for mental status score of 9. The assessment showed Resident #27 had upper and lower extremity impairments on one side. The assessment showed they were dependent for sit to lying while in bed and was bedfast. A quarterly assessment, dated 01/25/26, showed Resident #27 had upper and lower extremity impairments on one side. The assessment showed they were dependent for sit to lying while in bed and was bedfast. A care plan, dated 04/16/26, showed a focus for neurological was added to the care plan and an intervention was added on 04/16/26 to include a brace to be worn on the right hand due to a contracture. On 04/14/26 at 10:02 a.m., Resident #27 stated they wore a brace on their right wrist all the time. On 04/16/26 at 9:42 a.m., CNA #4 stated Resident #27 could not open their right hand, wore a splint, and kept a sock rolled up in their hand. On 04/16/26 at 9:56 a.m., LPN #3 stated Resident #27 always wore a blue brace on their wright wrist due to a contracture. On 04/16/26 at 10:09 a.m., the DON stated Resident #27 wore a brace on their right wrist due to a contracture causing a limited range of motion. They stated the brace should have been in the care plan. The DON stated Resident #27 had a physician order for a brace. They stated the brace was not included in the care plan prior to 04/16/26.

Based on observation and interview, the facility failed to ensure expired supplies were removed from the medication/supply storage room. The DON reported 34 residents resided in the facility. Findings: On [DATE] at 10:45 a.m., a tour of the medication/supply storage was conducted with corporate nurse #1. The following supplies were found to be expired: 4 NPWT Contour Med TR Kit with an expiration date of [DATE], 1 NPWT Contour Med TR Kit with an expiration date of [DATE], 1 Box of Covid-19 AG Cards with an expiration date of [DATE], 1 Box of Covid-19 AG Cards with an expiration date of [DATE], 6 Entraflo H2O 1000ml Feeding/H2O bag pump set with an expiration date of [DATE], 1 Entraflo H2O 1000ml Feeding/H2O bag pump set with an expiration date of [DATE], 6 Kangaroo Epump Set with flush bag with an expiration date of [DATE], 11 Kangaroo Epump Set with flush bag with an expiration date of [DATE], 5 V.A.C. Freedom 300ml canister with gel having an expiration date of [DATE], 1 V.A.C. Freedom 300ml canister with gel having an expiration date of [DATE], 1 box of lubricating jelly packets with an expiration date of [DATE]. On [DATE] at 11:00 a.m., Corporate nurse #1 stated the expired supplies should have been removed.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 25 opportunities were observed with two errors. The total medication error rate was 8%. The DON identified 34 residents who received medications in the facility. Findings: 1. Res #10 had diagnoses which included diverticulosis, osteoarthritis, and muscle weakness. A physician order, dated 02/19/24, documented buprenorphine sublingual tablet 8 mg - give one tablet sublingually (under the tongue) two times a day for chronic pain. On 06/12/24 at 8:00 a.m., CMA #1 was observed to administer buprenorphine 8 mg to Res #10. CMA #1 did not instruct the resident to place the tablet under their tongue for absorption. Res #10 was observed to swallow the tablet whole. 2. Res #32 had diagnoses which included dementia and hypertension. A physician order, dated 05/31/24, documented lisinopril 5 mg tablet - given one tablet by mouth for hypertension - hold if systolic blood pressure is less than 120 or the heart rate is less than 60. The nurse must be notified of held meds. On 06/12/24 at 8:10 a.m., CMA #1 was observed to obtain Res #32's blood pressure and heart rate. Res #32's heart rate was 58. CMA #1 then administered lisinopril 5 mg by mouth to Res #32. On 06/12/24 at 8:58 a.m., CMA #1 was asked if the buprenorphine was given sublingual to Res #10. CMA #1 stated the resident would have chewed the pill up anyway, so they just allowed them to swallow it. They stated not having been aware of the heart rate parameters on the lisinopril for Res #32. They stated the medication should have been held and the nurse notified. On 06/12/24 at 10:30 a.m., PN #1 stated CMA #1 should have given the pain medication the appropriate route and should have held the blood pressure medication according to the heart rate parameters. On 06/12/24 at 11:15 a.m., corporate nurse consultant #1 was made aware of the medication administration observations with CMA #1 and the medication error rate. They stated CMA #1 was new to administering medication and would use this as a learning experience.

Based on observation, record review, and interview, the facility failed to ensure meal consumption percentages and weights were documented on a resident who experienced significant weight loss for one (#9) of two sampled residents reviewed for nutrition. The DON identified 34 residents who resided in the facility. Findings: Res #9 had diagnoses which included type II diabetes mellitus and senile degeneration of the brain. A physician order, dated 11/21/23, documented regular diet with mechanical soft texture. A physician order, dated 11/29/23, documented weekly weights times four weeks and then monthly. An admission assessment, dated 12/04/23, documented the resident was severely cognitively impaired, required setup assistance with eating, and had no weight loss or gain. A care plan, dated 12/05/23, documented the resident had a nutrition problem or potential problem related to diabetes with interventions to weigh per orders, monitor intake, and record every meal. A quarterly assessment, dated 05/03/24, documented the resident was severely cognitively impaired, required supervision with eating, and had weight loss of 5% or more in one month or 10% or more in the last six months and not on a prescribed weight-loss regimen. A Dietician's Recommendation, dated 05/22/24, documented significant weight loss of 10.2% in three months with a recommendation of weekly weights until recovery from weight loss. A physician order, dated 05/22/24, documented to obtain weight weekly. Resident #9's Weight Summary documented: a. 151.4 pounds on 11/27/23, b. 153.4 pounds on 12/27/23, c. 150.2 pounds on 01/04/24, d. 141.0 pounds on 04/02/24, e. 137.4 pounds on 05/02/24, and f. 137.0 pounds on 06/04/24. There were no weights documented from 01/04/24 until 04/02/24 and only one weight documented from 05/22/24 through 06/12/24. There was no documentation of Resident #9's meal consumption amount in May 2024 for: a. breakfast on the 23rd, 24th, 27th, 28th, or the 31st, b. lunch on the 15th, 22nd, 23rd, 24th, 27th, or the 31st, and c. dinner on the 16th, 18th, 19th, 22nd, or the 25th. There was no documentation of Resident #9's meal consumption amount in June 2024 for: a. breakfast on the 4th or the 5th, b. lunch on the 4th or the 5th, and c. dinner on the 6th or the 7th. On 06/10/24 at 10:30 a.m., CNA #1 stated Res #9 had been eating independently and consumed 75-100% of most meals. They stated Res #9 received double portions with all meals and supplements daily. On 06/12/24 at 10:24 a.m., the DON stated Res #9's weight and meal percentages had not been monitored and documented appropriately and there was no way to ensure proper nutrition had been maintained. They stated every meal should have had the percentage consumed documented.

Based on record review and interview, the facility failed to update the care plan related to significant weight loss for one (#9) of two sampled residents reviewed for nutrition. The DON identified 34 residents who resided in the facility. Findings: Resident #9 had diagnoses which included type II diabetes mellitus and senile degeneration of brain. A physician order, dated 11/21/23, documented regular diet with mechanical soft texture. A physician order, dated 11/29/23, documented weekly weights times four weeks and then monthly. An admission assessment, dated 12/04/23, documented the resident was severely cognitively impaired, required setup assistance with eating, and had no weight loss or gain. A care plan, dated 12/05/23, documented the resident had a nutrition problem or potential problem related to diabetes with interventions to weigh per orders, monitor intake, and record every meal. A quarterly assessment, dated 05/03/24, documented the resident was severely cognitively impaired, required supervision with eating, and had weight loss of 5% or more in one month or 10% or more in the last six months and not on a prescribed weight-loss regimen. A Dietician's Recommendation, dated 05/22/24, documented significant weight loss of 10.2% in three months with a recommendation of weekly weights until recovery from weight loss, house supplement three times daily, and an appetite stimulant. A physician order, dated 05/22/24, documented to obtain weight weekly and house supplement with each meal. A physician order, dated 05/22/24, documented Mirtazapine 7.5 mg at bedtime for appetite stimulation. The care plan had not been updated to reflect Res #9's current weight loss and nutritional interventions. On 06/12/24 at 10:49 a.m., the DON stated the care plan should have been updated to reflect Res #9's weight loss and current nutritional interventions.

Based on record review and interview, the facility failed to ensure a resident's room and belonging were not searched without their consent for one (#1) of three sampled residents reviewed for abuse. The administrator identified 37 residents resided in the facility. Findings: Res #1 had diagnoses which included adjustment disorder with depressed mood and insomnia. A facility Personal Property policy, read in part, .facility staff does not conduct searches of a resident or their personal belongings, unless the resident or representative agrees the search and understands the reason for the search . A quarterly MDS, dated [DATE], documented the resident was cognitively intact, had moderate depression, and had no behaviors. A behavior note, dated 08/21/23 at 8:33 a.m., documented the resident was out of the facility for an appointment and the nurse searched their room for medications and/or contraband. The note documented the DON was notified. There was no documentation the resident gave consent for the search of their belongings. On 12/28/23 at 10:19 a.m., the administrator stated they were not aware of a search of the resident's room on 08/21/23. They stated they had no documentation the resident had consented to the search. On 12/28/23 at 10:55 a.m., Res #1 stated they did not consent to a search of their room on 08/21/23.

Based on observation, record review and interview, the facility failed to ensure food was served at a palatable temperature for one (breakfast meal) of one meal observed for palatable temperature. The Residents Census and Condition of Residents report, dated 07/12/23, documented 31 residents resided in facility. Findings: The facility's Food and Nutrition Services policy, revised 10/2017, read in parts, .Food and nutrition services staff will inspect food trays to ensure .the food appears palatable and attractive, and it is served at a safe and appetizing temperature . The following concerns related to cold food were identified during resident council meetings: Resident council meeting minutes, dated 02/07/23, documented the breakfast was served cold. Resident council meeting minutes, dated 05/04/23, documented they would like hot coffee and the breakfast was cold. On 07/12/23 at 1:10 p.m., Resident #79 stated the food was served cold. They stated the sausage, bacon, eggs, and coffee served at the breakfast meal were cold. On 07/12/23 at 2:02 p.m., CNA #2 was asked if the residents complained about the food. They stated, Yes. On 07/12/23 at 3:39 p.m., Resident #12's family stated their family member had stated in the past the food was awful and they had heard other residents say the food was terrible. On 07/13/23 at 8:06 a.m., a tray was requested from the kitchen. On 07/13/23 at 8:38 a.m., the hall trays were taken to the hall in a heated cart. On 07/13/23 at 8:45 a.m., Resident #14 was served their breakfast tray. Resident #14 placed their hand above their breakfast plate and stated it was barely warm. On 07/13/23 at 8:56 a.m., all the hall breakfast trays had been served to the residents and the last tray on the heated cart contained scrambled eggs with a temperature reading of 113.5 degrees Fahrenheit and was lukewarm to touch, the sausage was 102.0 degrees Fahrenheit and was cool to touch, the bacon was 92.0 degrees Fahrenheit and was cold to touch, the toast was cold, and the coffee was 101.4 degrees Fahrenheit and was lukewarm. On 07/13/23 at 9:02 a.m., the DON observed the food temperatures and the breakfast tray. They were asked if the breakfast had been served at a palatable temperature. They stated, No. The DON stated the food should be warmer. On 07/14/23 at 11:20 a.m., Resident #6 was asked about the food. They stated the facility had a resident council meeting that morning (07/14/23) and they reported the morning food was cold at times.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for two (#14 and #79) of three sampled residents reviewed for medication administration. The Resident Census and Conditions of Residents report, dated 07/12/23, documented 31 residents resided in the facility. Findings: The facility's Pharmacy Services policy, revised 04/2019, read in parts, .Pharmacy services are available to residents 24 hours a day, seven days a week .Residents .receive medications (routine, emergency or as needed) in a timely manner . The facility's Medication Orders policy, revised 11/2014, read in parts, .Orders must be written .When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered . 1. Resident #14 had diagnoses which included essential tremors and urinary tract infection. A physician's progress note, dated 06/28/23, read in parts, .Chief Complaint: Tremors .Acute UA obtained 06/26/23 .Positive Enterococcus Klebsiella. Patient does note some symptoms. Patient is open to antibiotic therapy Patient also notes increased tremors. Patient feels the propranolol is not helping .Plan: Macrobid 100 mg .twice daily x 7 days .DC propranolol .Start primidone 50 mg .twice daily for essential tremors . A MAR, dated 06/01/23 through 06/30/23, documented Resident #14 was administered the Propranolol three times a day on 06/28/23 through 06/30/23 after the physician had written an order for the medication to be discontinued; the Macrobid and the Primidone had not been administered on 06/28/23 through 06/30/23 as ordered. An electronic physician's order, dated 07/01/23, documented to administer Macrobid 100 mg twice a day for urinary tract infection for seven days, Primidone 50 mg by mouth twice a day for essential tremors, and discontinue Propranolol. The order was in the physician's progress notes on 06/28/23 and was transcribed and put in the computer system by the nurse on 07/01/23. A MAR, dated 07/01/23 through 07/14/23, documented the Propranolol was administered two times on 07/01/23; the Macrobid 100 mg had been administered twice on 07/02/23 through 07/08/23; the Primidone 50 mg was administered on 07/01/23. The Propranolol had been administered two times after the order was written to discontinue the medication on 06/28/23, the antibiotic was started five days after it had been ordered by the physician, and the Primidone was not administered until three days after it was ordered by the physician. On 07/13/23 at 1:45 p.m., the DON stated the physician's orders are synced to their computer system and they would put the orders in the electronic charting system and give a copy of the orders to the nurse. They stated they had been new to the facility on [DATE] when the physician made their visit. The DON stated the antibiotic should have been started within 24 hours, and the physician's orders were not followed for the Propranolol or the primidone. 2. Resident #79 had diagnoses which included diabetes and diabetic neuropathy. A physician's progress note, dated 06/28/23, read in parts, .Chief Complaint: Follow-up skilled visit, elevated blood sugars, wheezing .Acute problem addressed .Slightly elevated blood sugars, 200s .Patient does note some daytime somnolence .Plan: Increase Lantus to 35 units .twice daily .Decrease gabapentin to 300 mg .twice a daily. Reducing the midday dose should help with the daytime somnolence . Resident #79's TAR, dated 06/01/23 through 06/30/23, documented the resident was administered 32 units of Lantus two times a day on 06/28/23 through 06/30/23. The physician's order to increase the Lantus to 35 units had not been documented on the TAR. Resident #79's MAR, dated 06/01/23 through 06/30/23, documented the Gabapentin 300 mg was administered three times a day on 06/28/23 through 06/30/23. The physician's order to decrease the Gabapentin to two times a day had not been documented on the MAR. Resident #79's electronic physician order, 07/01/23, documented to administer 35 units of Lantus (long acting insulin) two times a day for diabetes and administer Gabapentin 300 mg two times a day for diabetic neuropathy. The order was in the physician's progress notes on 06/28/23 and was transcribed and put in the computer system by the nurse on 07/01/23. Resident #79's TAR, dated 07/01/23 through 07/14/23, documented Lantus 32 units was administered at 6:30 a.m. A nurse's progress note, dated 07/01/23, documented, Resident #79 reported to the nurse their dosage of Lantus had been increased. The note documented the new order was not updated in the computer. On 07/12/23 at 1:10 p.m., Resident #79 stated the physician had changed their insulin orders on 06/28/23 and by 07/01/23 the new orders had not been put in the computer. On 07/13/23 at 3:35 p.m., LPN #1 stated they had administered 35 units of Lantus and had signed the TAR as administered 32 units. They stated they knew the order had changed but were not allowed to put the order in the computer. They stated the DON was responsible for putting the orders in the computer. On 07/13/23 at 1:45 p.m., the DON stated the LPN who had worked the day shift on 06/28/23 through 06/30/23 had administered 35 units of Lantus but had signed out they administered 32 units of Lantus. The DON stated the orders for the medication changes had been ordered on 06/28/23 and were not put in the computer by the nurse on 07/01/23.

Based on record review and interview, the facility failed to ensure a care plan was revised for one (#12) of three sampled residents reviewed for care plans. The Residents Census and Condition of Residents report, dated 07/12/23, documented 31 residents resided in facility and 19 residents required toileting assistance. Findings: The Care Plans, Comprehensive Person-Centered policy, revised March 2022, read in part, .assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Resident #12's ADL care plan, revised on 03/27/23, documented the resident required one staff participation to use the toilet. Resident #12's Hematological care plan, dated 07/10/23, documented the resident was at risk for anemia related to possible gastrointestinal bleed. The interventions included to monitor, document and report to the physician any signs or symptoms of anemia which included weakness, syncope, pallor, and dizziness. The care plan did not document the resident had a history of having vasovagal response (A stimulation of the vagus nerve which causes symptoms such as lightheadedness, sweating, blurred vision and could result in syncope which is a brief episode of passing out.) while on the toilet and required supervision during toileting. On 07/12/23 at 3:39 p.m., Resident #12's family member stated Resident #12 could not be left alone on the toilet because they would faint. They stated Resident #12 had fainting episodes more than once and the staff knew not to leave the resident on the toilet without supervision. Resident #12's family member stated the resident had a fainting episode on the toilet on 05/02/23 when a staff member had left Resident #12 on the toilet without supervision and left the building. They stated the nurse assured them it would be reported and would not happen again. On 07/13/23 at 3:24 p.m., LPN #1 stated Resident #12 had a history of syncopal episodes while in the bathroom and required staff supervision while toileting. They were asked how they were made aware the resident required supervision. LPN #1 stated they were made aware verbally by the former DON. LPN #1 stated the care plan did not document a staff was required to remain with the resident while they were in the bathroom due to the syncopal episodes. On 07/13/23 at 4:05 p.m., CNA #3 stated they had worked at the facility for approximately three weeks. CNA #3 stated they had left Resident #12 on the toilet on 07/12/23, while they took Resident #11 to the dining room. They stated when they returned to the bathroom Resident #12 was reaching for their walker and started to pass out. They stated they were not aware Resident #12 was not supposed to be left alone in the bathroom. CNA #3 was asked if the care plan had documented the resident could not be left alone in the bathroom. They stated, No. On 07/13/23 at 4:25 p.m., the MDS coordinator was asked if the care plan should have been updated after the resident had a syncopal episode in the bathroom to include the need for supervision while in the bathroom. They stated that depended if the episodes had occurred more than one time. The MDS coordinator was asked if the care plan included the need for supervision while in the bathroom. They stated the care plan documented Resident #12 required toileting assistance of one staff member.

Based on record review and interview, the facility failed to ensure an allegation of neglect had been investigated for one (#12) of three sampled resident reviewed for abuse and neglect. The Resident Census and Conditions of Residents report, dated 07/12/23, documented 31 residents resided in the facility. Findings: An Abuse and Neglect policy, dated 10/05/22, read in parts, .It is the policy of this facility that the residents of this facility will be free of abuse .neglect .The facility will implement the following steps .Identify .The facility will teach the staff signs to identify abuse, to include .necessary care that is not rendered timely . Resident #12 had diagnoses which included sequelae of cerebral infarction, pacemaker, vascular dementia, and anemia. Resident #12's quarterly assessment, dated 04/07/23, documented the resident had moderate cognitive impairment, required extensive assistance of one staff member for transfers, utilized a wheelchair for ambulation, was dependent on one staff for toileting assistance, was incontinent of urine, and occasionally incontinent of bowel. An undated written employee statement, read in parts, [CNA #5] was removed from care of two residents .because she would repeatedly leave a resident on the toilet and leave the room. Resident had a Vasovagal response and would pass out .the 2-10 [2:00 p.m.-10:00 p.m.]nurse and CNAs would come in where multiple residents who were not changed the urine on Residents beds have been there so long it had turned brown [NAME] ringed .[CNA #5] claimed she is [AGE] years old and the residents are too heavy . A nurse's note, dated 05/02/23 at 3:55 p.m., read in part, .Resident was in the restroom unattended. residents [family member] stated that the aide put [them] in the restroom . A grievance report, dated 05/03/23, documented Resident #12's family member reported they had been notified by Resident #12's roommate, CNA #5 left Resident #12 on the toilet unsupervised and Resident #12 had an Episode. The grievance report documented CNA #5 denied taking Resident #12 to the bathroom, and the family member did not believe CNA #5's statement. The grievance report documented the DON and the SSD watched Resident #12 take herself to the bathroom with the walker the next day on 05/04/23 and notified the family. The grievance report documented the family continued to believe CNA #5 left Resident #12 on the toilet unattended. An individual counseling record for CNA #5, dated 05/18/23, read in parts, .Refusing to provide resident care .fell ow CNA requested [CNA #5]'s assistance to toilet a resident when [CNA #5] stated she was not and will not toilet that resident followed with just wait 5 minutes maybe [they'll] forget .formal write up . An individual counseling record for CNA #5, dated 05/19/23, read in parts, .Inadequate Resident Care Practices .Incontinent care not provided during scheduled shift as assigned .formal write up . An employee counseling form for CNA #5, dated 05/22/23, documented CNA #5 was being terminated for complaints of poor care on 05/18/23 and 05/19/23 and previous complaints of poor care. A typed statement from the former DON, dated 06/08/23, read in parts, .[CNA #5] was .written up several times for poor resident care and job performance. [They] frequently refused to provide care to difficult residents .Residents in [their] care were often found to be saturated in urine, literally from head to toe; requiring complete bed changes and showers. [They] also refused to do showers assigned to [them] and would document resident's refusal despite the resident's inability to refuse. [They] was very curt with some of the residents and had several of them request that [they] not be their care giver due to her attitude and bedside manner . On 07/12/23 at 3:39 p.m., Resident #12's family member stated CNA #5 had taken Resident #12 to the restroom on 05/02/23 and then left the building for the day without notifying anyone. They stated Resident #12's roommate yelled for help. Resident #12's family member stated they spoke to the administrator and the SSD about what had happened. On 07/13/23 at 3:24 p.m., LPN #1 was asked about the incident on 05/02/23. They stated CNA #5 assisted Resident #12 to the bathroom and left them in the bathroom and did not tell anybody. LPN #1 stated Resident #14 came down the hall telling the staff a resident had fallen in the bathroom. LPN #1 was asked if CNA #5 was questioned about leaving Resident #12 in the bathroom. They stated, Yes, LPN #1 reported CNA #5 stated, I am [AGE] years old and couldn't remember some things. LPN #1 stated at the time of the incident on 05/02/23, they did not feel Resident #12 was capable of ambulating to the bathroom on their own. LPN #1 stated the family did not believe the resident was capable of taking themselves to the bathroom. LPN #1 was asked if they considered what the family stated was an allegation of neglect. They stated, Yes. LPN #1 stated they notified the DON. LPN #1 was asked if they had given any written statements. They stated, No. On 07/14/23 at 10:53 a.m., the SSD stated Resident #12's roommate told Resident #12's family member, CNA #5 assisted Resident #12 to the bathroom and left the resident in the bathroom without notifying anybody the resident was on the toilet. The SSD stated they notified the former administrator and they filled out a grievance report. The SSD was asked if Resident #12's roommate was alert and oriented enough to know if CNA #5 took Resident #12 to the bathroom and left. They stated, Yes, for the most part she should. On 07/14/23 at 12:07 p.m., the administrator was asked for the documentation of the incident involving Resident #12 and CNA #5 on 05/02/23. They stated they would look through the files and the computer. On 07/14/23 at 1:14 p.m., Resident #14 was asked if they had remembered a time they had alerted the staff a resident was yelling for help. They stated they remembered Resident #12's roommate yelling for help. They stated they walked down to the nurse's station and told the nurse they thought a resident had fallen in the bathroom. Resident #14 was asked if they had seen Resident #12 walking in the room. They stated, No. On 07/14/23 at 1:22 p.m., Resident #11 (Resident #12's roommate) stated, I think I hollered for somebody to get her. Resident #11 identified CNA #5 as the staff member who assisted Resident #12 to the bathroom. Resident #11 stated they guessed it had been time for CNA #5 to get off work so they left. Resident #11 was asked if Resident #12 had attempted to take themselves to the bathroom. They stated, No. Resident #11 stated they did not believe CNA #5 worked at the facility anymore. On 07/14/23 at 1:30 p.m., the administrator stated they could not find the state reportable incident report for the allegation of neglect. There was no documentation provided the residents involved, staff or other residents had been interviewed about the incident or the care provided by CNA #5. There was no documentation the video footage requested by the family had been reviewed to reveal if a staff member had gone into the room to assist the resident.

Based on record review and interview, the facility failed to ensure an allegation of neglect had been reported to OSDH for one (#12) of three sampled resident reviewed for abuse and neglect. The Resident Census and Conditions of Residents report, dated 07/12/23, documented 31 residents resided in the facility. Findings: An Abuse and Neglect policy, dated 10/05/22, read in parts, .It is the policy of this facility that the residents of this facility will be free of abuse .neglect .The facility will implement the following steps .Identify .The facility will teach the staff signs to identify abuse, to include .necessary care that is not rendered timely .Reporting .The facility will send a report to all reporting agencies as required by OSDH . Resident #12 had diagnoses which included sequelae of cerebral infarction, pacemaker, vascular dementia, and anemia. Resident #12's quarterly assessment, dated 04/07/23, documented the resident had moderate cognitive impairment, required extensive assistance of one staff member for transfers, utilized a wheelchair for ambulation, was dependent on one staff for toileting assistance, was incontinent of urine, and occasionally incontinent of bowel. A nurse's note, dated 05/02/23 at 3:55 p.m., read in part, .Resident was in the restroom unattended. residents [family member] stated that the aide put [them] in the restroom . A nurse's note, dated 05/03/23 at 9:58 p.m., read in part, .Residents [family member] was here tonight wanting to know what happened about [their] [loved one] being left in the restroom alone. Resident has a history of vasovagal effect. Residents [family member] was told that the resident was up walking to the bathroom alone and that's why no one was aware [they] was in the bathroom. Residents [family member] claims that is impossible and a downright lie [Family member] state that the resident is not strong enough to put [their] shoes on, walk to [their] walker, then to the bathroom and then pull [their] pants down to sit on the toilet. its physically impossible. Resident [family member] wants to watch the video of who was in the room. I advised [them] to call or come back in the morning. nurse doesn't have access. DON was notified, [physician] was notified . A grievance report, dated 05/03/23, documented Resident #12's family member reported they had been notified by Resident #12's roommate, CNA #5 left Resident #12 on the toilet unsupervised and Resident #12 had an Episode. The grievance report documented CNA #5 denied taking Resident #12 to the bathroom, and the family member did not believe CNA #5's statement. On 07/12/23 at 3:39 p.m., Resident #12's family member stated CNA #5 had taken Resident #12 to the restroom on 05/02/23 and then left the building for the day without notifying anyone. The family member stated they notified the former administrator and the SSD. On 07/14/23 at 10:53 a.m., the SSD stated Resident #12's daughter reported CNA #5 left Resident #12 on the toilet without supervision. The SSD stated they notified the former administrator. The SSD was asked if they had submitted the allegation of neglect to the OSDH. They stated, Not that I am aware of. On 07/14/23 at 12:07 p.m., the administrator was asked if the facility had reported an allegation of neglect to the OSDH involving Resident #12 and CNA #5 for the incident on 05/02/23. They stated they would look through the files and the computer. On 07/14/23 at 1:30 p.m., the administrator stated they could not find any paperwork the allegation was submitted to the OSDH.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for two (#7 and #10) of six sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 05/03/23, documented 28 residents resided in the facility. Consultant #3 identified 16 residents with blood pressure parameter orders. Findings: A Documentation of Medication Administration policy, revised 04/07, read in parts, .The facility shall maintain a medication administration record to document all medications administered .Administration of medication must be documented immediately after .it is given . 1. Resident #7 had diagnoses which included chronic obstructive pulmonary disease and chronic pain. Resident #7's Physician Orders, dated 04/07/22, documented voltaren gel one percent apply to left hip topically two times a day, and advair diskus 50MCG/dose one inhalation orally two times a day for shortness of breath. The February 2023 TAR documented blanks for Resident #7's advair and voltaren gel morning doses on the 2nd, 8th, 13th, 14th, 16th, 23rd, and 24th and the evening doses on the 28th. The March 2023 TAR documented blanks for Resident #7's advair and voltaren gel morning doses on the 3rd, 9th, 15th and 22nd and the evening doses on the 10th and 30th. On 05/04/233 at 2:34 p.m., LPN #1 was asked how staff documented a medication was administered. They stated staff documented a medication was administered in the electronic health record. On 05/04/23 at 2:36 p.m., LPN #1 and LPN #2 were asked what staff documented if a medication was refused. LPN #2 stated staff would document on the medication administration record and notify the nurse if a medication was refused. Both LPN #1 and #2 stated the physician would be notified if a medication was refused. On 05/04/23 at 2:37 p.m., LPN #1 and #2 were asked if there were blanks on the TAR next to the scheduled medication, what did that mean. LPN #1 stated, They did not receive it. On 05/04/23 at 2:41 p.m., the DON was asked the policy for documenting a medication was administered. They stated staff should pull out the medication, check the medication with the physician order to ensure they match, then punch the medication and give it to the resident. On 05/04/23 at 2:42 p.m., the DON was asked where the information would be documented. They stated on the MAR or TAR depending on the order. The DON was asked if a scheduled medication had blanks, what did that mean. The DON stated, It means that they didn't click it, and I can't prove that they gave it. On 05/04/23 at 2:44 p.m., the DON was asked to review Resident #7's February 2023 TAR and identify if the voltaren gel and advair were administered as ordered. The DON stated, Eight blanks in there on both of them is what I am seeing. On 05/04/23 at 2:45 p.m., the DON was asked to review Resident #7's March 2023 TAR and identify if the voltaren gel and advair were administered as ordered. The DON stated, Six blanks on both of them. 2. Resident #10 had diagnoses which included hypertension and pneumonia. A Physician Order, dated 5/18/21, documented symbicort aerosol 80-4.5 MCG/ACT inhale two puffs orally two times a day related to pneumonia to decrease shortness of breath. A Physician Order, dated 10/19/21, documented metoprolol tartrate 25mg give one tablet by mouth two times a day, hold if blood pressure below 120/70. A Physician Order, dated 01/27/23, documented mupirocin external ointment two percent apply to right nare topically two times a day for sore nare. The March 2023 TAR documented blanks for the morning dose of the mupirocin ointment and the simbicort on the 3rd and the 9th and the evening dose of the mupirocin on the 10th. The April 2023 TAR documented Resident #10's blood pressure was below the holding parameters for the morning dose of metoprolol on the 10th, 11th, 18th, and 26th. The medication was documented as given. On 05/05/23 at 8:36 a.m., the DON was asked the policy for administering blood pressure medications with holding parameters. They stated if the blood pressure was outside of the parameters, it was supposed to be held. The DON stated the medication aide was to notify the nurse and the nurse would double check the blood pressure. The DON stated if the blood pressure was still outside the parameters, the medication would be held and the physician would be notified. The DON was asked to review Resident #10's April 2023 TAR and determine if the morning dose of metoprolol had been administered on the 10th, 11th, 18th, and 26th. The DON stated, Yes. The DON was asked if staff had followed the physician's orders for medication administration. The DON stated, No. On 05/05/23 at 8:44 a.m., the DON reviewed Resident #10's March 2023 MAR/TAR for the mupirocin and symbicort and stated there shouldn't be blanks. On 05/05/23 at 8:45 a.m., the DON stated there was nothing documented on the 3rd, 9th, or 10th.

Based on record review and interview, the facility failed to ensure: a. meal consumption percentages were documented on a resident who experienced weight loss for two (#7 and #13) and b. ordered supplement consumption was documented on a resident who experienced weight loss for one (#13) of three sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 05/03/23, documented 28 residents resided in the facility. Findings: A Guidelines for Charting and Documentation policy, revised 04/12, read in parts, .General Rules for Charting and Documentation .Be concise, accurate, and complete .Nutritional Status .document the diet, appetite, food consumption . 1. Resident #7 had diagnoses which included hypertension and hyperlipidemia. Resident #7's Weight Summary documented they weighed: a. 198.8 pounds on 11/03/22, b. 195.6 pounds on 01/17/23, c. 190 pounds on 03/01/23, and d. 177.8 pounds on 04/01/23. There was no documentation of Resident #7's meal consumption amount in February 2023 for: a. breakfast on the 3rd, 9th, 10th, 14th, or 21st, b. lunch on the 3rd, 6th, 9th, 10th, 14th, 15th, 17th, 20th, 21st, 22nd, 23rd, 24th, 26th and 27th, and c. dinner on the 1st, 3rd, 6th, 7th, 9th, 11th, 15th, 17th, 18th, 20th, 24th, 26th, or the 28th. The form documented staff were to offer a meal replacement if the resident consumed less than 50% of the meal. All of the above dates were blank on the meal replacement section for February 2023. There was no documentation of Resident #7's meal consumption amount in March 2023 for: a. breakfast on the 16th, b. lunch on the 2nd, 7th, 16th or 17th, and c. dinner on the 2nd, 3rd, 6th, 9th, 10th, 13th, or 15th. The form documented staff were to offer a meal replacement if the resident consumed less than 50% of the meal. All of the above dates were blank on the meal replacement section for March 2023. A Dietary Note, dated 04/07/23, documented Resident #7's April weight was 177.8 pounds and the resident had experienced a 6.4% weight loss in one month, a 9.1% weight loss in three months, and an 11.3% weight loss in six months. A Physician Order, dated 04/07/23, documented the resident was to receive a regular diet, regular texture, regular thin consistency, no added salt with double protein. There was no documentation of Resident #7's meal consumption amount in April 2023 for: a. lunch on the 3rd and b. dinner on the 10th and 20th. On 05/04/23 at 1:35 p.m., CNA #1 and Consultant #1 were asked the policy for documenting meal percentages. CNA #1 stated staff wrote down meal percentages, supplements, and fluids after each meal on a paper form. CNA #1 stated they would document the totals for their shift in the computer. CNA #1 was asked to review Resident #7th meal consumption amounts for February, March and April 2023. They were asked if there was any way to know how much the resident had eaten or if they were offered a supplement when there was nothing documented for the above dates. CNA #1 stated staff had neglected their charting. CNA #1 stated it should have been documented on the form. They were asked if the paper documentation was still available for these dates. Consultant #1 stated they would try to locate the paper charting. On 05/04/23 at 2:25 p.m., LPN #1 was asked how staff monitored residents for weight loss. They stated residents were typically weighed monthly, however some residents did have orders for more frequent weights. LPN #1 was asked how staff knew how much food a resident had eaten at each meal. They stated there were forms the CNAs would document meal percentages on, and then they would put the information in the electronic health record. On 05/04/23 at 2:29 p.m., LPN #1 was asked if the meal percentage area was blank, how staff know how much the resident consumed. LPN #1 stated if the area was blank, there was no way of knowing how much the resident consumed, unless they were able to find the staff member who picked the tray up. On 05/04/23 at 2:31 p.m., LPN #1 was asked to review Resident #7's meal percentage forms for February, March, and April 2023 and determine how much the resident consumed and whether or not the resident was offered a meal replacement for the above dates where nothing was documented. They stated, back that far, there was no real way of figuring that out. On 05/04/23 at 2:32 p.m., LPN #1 was asked to review Resident #7's record and identify if the resident had experienced weight loss. LPN #1 stated they could say without looking at the record, the resident had experienced weight loss. On 05/04/23 at 3:04 p.m., the DON and Consultant #1 stated they were not able to locate any additional meal percentages for Resident #7. 47453 2. Resident #13 had diagnoses which included depression, impulse disorder, and dysphagia. Resident #13's Weight Summary documented they weighed: a. 239 pounds on 01/17/23, b. 216 pounds on 02/22/23, c. 217 pounds on 03/19/23, d. 225 pounds on 04/01/23, and e. 217 pounds on 05/02/23. A Dietary Note dated, 02/16/23, documented a current weight of 216.8 pounds. It documented the resident had experienced a 9.3% weight loss in one month, 15.2% loss in three months and 18.4% loss in six months. It documented to notify the physician. It documented the resident had a recent diet order change to regular pureed diet with nectar thick liquids. It documented staff reported the resident's by mouth intake had decreased, and a recommendation of a house supplement three times a day was made. There was no documentation of Resident #13's meal consumption amount in March 2023 for: a. breakfast on the 28th b. lunch on the 15th, 20th, 28th, and c. dinner on the 2nd, 3rd, 8th, 9th, 10th, or 14th. The form documented staff were to offer a meal replacement if the resident consumed less than 50% of the meal. All of the above dates were blank on the meal replacement section for March 2023. There was no documentation of how much of the ordered house supplements three times a day the resident consumed. A Dietary progress note, dated 03/28/23 , read in parts, .March Diet Report: Resident comes down to the dining room for all meals. Resident is on regular/pureed diet, nectar thick liquids. Resident has a low cholesterol, low fat, low sodium order. Resident get a house supplement TID with meals. Resident eats 50%-75% of his meal . A Dietary Progress note, dated 04/07/2023, read in parts, .April wt- 225.4 [pounds]. 12.4% wt loss in 6 months. PCP aware. Wt gain noted [times] 2 months. Fair to good [by mouth] intake on regular pureed diet with [nectar thick liquids] and house supplement TID .Monitor and continue POC . A Physician Progress Note, dated 05/03/23, read in part, .Appetite is satisfactory. No significant weight change . On 05/05/23 at 11:51 a.m., Consultant #2 and the Administrator, stated Resident #13's supplements were documented at the time of each meal on the meal percentage paper form. They stated when staff went into the electronic record for the resident, they combined the meal and supplement total percentage. They were asked if they could provide documentation of how much of the supplement Resident #13 consumed. They stated, no because they had thrown them away. On 05/05/23 at 11:52 a.m., Consultant #2 and the Administrator were asked if a resident that experienced weight loss was ordered supplements three times day, how would staff determine supplements where an affective intervention for weight loss if there was no documentation of how much Resident #13 consumed. They both nodded and stated they would work on that.

Based on record review and interview, the facility failed to implement and maintain an infection control tracking and trending program. The Resident Census and Conditions report, dated 05-03-23, documented 28 residents resided in facility. Findings: The Infection Control policy, revised October 2018, read in part, .Maintain records of incidents and corrective actions related to infections .shall establish, review, and revise infection control policies and practices, and help department heads and managers ensure that they are implemented and followed . On 05/03/23 at 8:05 a.m., the only tracking and trending provided to the survey team by the DON was a folder containing facility maps for February, March and April of 2023. Each map had a highlighted color grid for different types of infections. The maps did not document the name of the resident with an infection, the date the infection resolved, how the infection was treated, or any facility response to trends identified. On 05/04/23 at 7:13 a.m., the DON was asked how they tracked the infections within the facility. They stated they did not track it on a spread sheet. The DON stated they just used the map of the facility and marked it with different color markers for different types of infections. The DON was asked if there were any other types of forms to keep track of infections or the type of organism associated with infection. They stated, No.

Based on record review and interview, the facility failed to ensure MDS Resident Assessments were accurate for two (#7 and #13) of 14 sampled residents reviewed for MDS resident assessments. The Resident Census and Conditions of Residents report, dated 05/03/23, documented 28 residents resided in the facility. Findings: 1. Resident #7 had diagnoses which included hypertension and hyperlipidemia. Resident #7's Weight Summary documented they weighed: a. 198.8 pounds on 11/03/22, b. 195.6 pounds on 01/17/23, c. 190 pounds on 03/01/23, and d. 177.8 pounds on 04/01/23. A Dietary Note, dated 04/07/23, documented Resident #7's April weight was 177.8 pounds and the resident had experienced a 6.4% weight loss in one month, a 9.1% weight loss in three months, and an 11.3% weight loss in six months. An Admission Resident Assessment, dated 04/27/23, documented Resident #7's weight was 178 pounds and the resident had not experienced a weight loss of 5% or more in the the last month or 10% or more in the last six months. On 05/04/23 at 12:27 p.m., MDS Coordinator #1 was asked the policy for completing MDS Resident Assessments. They stated most of the information could be pulled from activities of daily living and nursing assessments, and the activities and social services department completed their parts. MDS Coordinator #1 stated MDS Resident Assessments were completed quarterly and annually. They were asked to Review Resident #7's Resident assessment dated [DATE] and were asked if it documented the resident had experienced weight loss. They stated, No. They were asked to review the resident's weight history and determine if the assessment was accurate. MDS Coordinator #1 reviewed the weights and stated they had made a mistake. 47453 Resident #13 had diagnoses which included depression, impulse disorder, and dysphagia. A Dietary Note dated, 02/16/23, documented a current weight of 216.8 pounds. It documented the resident had experienced a 9.3% weight loss in one month, 15.2% loss in three months and 18.4% loss in six months. It documented to notify the physician. It documented the resident had a recent diet order change to regular pureed diet with nectar thick liquids. An Admission Resident Assessment, dated 05/03/23, documented Resident #13's weight was 218 pounds and the resident had not experienced a weight loss of 5% or more in the the last month or 10% or more in the last six months. On 05/05/23 11:11 a.m., the DON was asked, what was the process for ensuring the information that was put into a MDS was accurate. The DON stated, I print off all the new and discontinued orders and cross match them to the care plan and make changes like that. The DON reviewed Resident #13's MDS dated [DATE] and acknowledged the weight loss section was inaccurate.

Based on observation, record review, and interview, the facility failed to: a. prepare food in a manner to prevent cross contamination for one (the lunch meal service) of one meal service observed, and b. ensure food items in the refrigerator were dated, and covered. The Resident Census and Conditions of Residents report, dated 05/03/23, documented 28 residents resided in the facility. LPN #1 identified one resident with orders for nothing by mouth. Findings: A Preventing Foodborne Illness policy, dated 10/17, read in parts, .Employees must wash their hands .Before coming in contact with any food surfaces .During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or .After engaging in other activities that contaminate the hands . A Food Receiving and Storage policy, revised 10/17, read in parts, .Food shall be received and stored in a manner that complies with safe food handling practices .All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date.) . A Food Preparation and Service policy, revised 04/19, read in parts, .Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices .Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-born illness . Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use . On 05/02/23 at 10:20 a.m., there were two bags of raw chicken observed in a clear container on the bottom shelf of the the first refrigerator located on the left side of the kitchen. There was no date observed on the bags other than from the manufacturer. The DM was asked when the chicken was placed in the refrigerator. They stated the chicken was frozen and placed into the refrigerator yesterday for thawing. On 05/02/23 at 10:23 a.m., there was an uncovered clear pitcher containing a white liquid observed on the shelf of the refrigerator on the right side of the kitchen next to the freezer. There was no label or date observed on the uncovered pitcher. The DM stated it was from breakfast. On 05/03/23 at 11:13 a.m., the DM was asked the policy for labeling/dating food items in the refrigerator. They stated staff placed a date on the items when they came in, when the items where opened, and when staff pulled frozen items out they would place a thawing date on them. The DM was asked about the uncovered, undated pitcher with white liquid in it. They stated they threw it out because they didn't know how long it had been sitting there because it wasn't dated. On 05/03/23 at 11:17 a.m., the DM was observed placing a large white piece of paper they identified as pan liner into the metal container located in the second compartment of the steam table. The DM was observed pushing the liner with their bare hands into the pan. The DM pushed the center of the liner into the pan and then ran their hands to the edges and up the sides to push the liner into the pan with their bare hands. On 05/03/23 at 11:19 a.m., the DM was observed picking up a flat metal serving spatula and began placing cooked hamburger patties onto the pan liner they had just placed with their bare hands in the metal container on the steam table. The DM then picked up a large metal lid and placed it halfway over the metal container of hamburger patties. On 05/03/23 at 11:21 a.m., the DM added additional patties to the hamburger tray using the same metal spatula. On 05/03/23 at 11:25 a.m., the DM was observed placing the plastic container onto the mixing machine with their bare hands. The DM was observed touching the inside of the plastic container as they pressed the container into place. The DM then picked up the blade with their bare hand and pushed it down inside the same mixing container. On 05/03/23 at 11:27 a.m., the DM picked up the metal spatula again with their bare hands and placed seven hamburger patties into the mixing container and added two ketchup packets, put the lid on and pulsed the machine until a mechanical soft texture was achieved. The DM then picked up two green handled scoops with their bare hands out of the drawer. On 05/03/23 at 11:24 a.m., the DM transferred the ground meat using the green handled scoop into a small metal container on the far right side of the steam table. On 05/03/23 at 11:38 a.m., the DM was asked the policy for touching food contact surfaces with bare hands. The DM stated, Have to wash hands afterwards and put gloves on. On 05/03/23 at 11:41 a.m., the DM used oven mitts to transfer a metal container of baked beans from the oven to the steam table. The DM then placed a metal lid on the container with their bare hands. On 05/03/23 at 12:08 p.m., the DM donned a pair of disposable gloves, grabbed a meal tray and placed a plate and meal card on it. The DM then used their gloved hands to reach into a bag and pull out a hamburger bun, opened it with gloved hands, placed it on the plate, put a hamburger patty on the bun, and closed the bun with their gloved hands. The DM opened the bean container with gloved hand, put a scoop of beans on the tray, opened the cabinet next to the tray line, pulled out a lid and placed it on the plate all with the same gloved hands. The DM then handed the tray out the window. On 05/03/23 at 12:10 p.m., the DM grabbed another tray, and placed a meal card and plate on the tray with the same gloved hands. The DM then reached into the bag of buns and obtained two buns with their gloved hands, opened them on the plate with the gloved hands, placed hamburger patties on the buns, then closed them with their gloved hands. The DM then placed beans on the plate using the scoop and a lid with the same gloved hands. On 05/03/23 at 12:11 p.m., the DM grabbed another tray, and placed a meal card and plate on the tray with the same gloved hands. The DM opened the bun with their gloved hands, placed a scoop of mechanically soft meat on the bun, then pressed down the meat with their gloved hand, and put the top of the bun on with the other gloved hand. The DM placed a scoop of beans and a lid on the plate with the same gloved hands. On 05/03/23 at 12:12 p.m., The DM grabbed another tray, placed a meal card and plate on the tray with the same gloved hands. The DM removed a bun from the bag with gloved hands, opened it, placed a scoop of mechanical meat on the bun and used a gloved hand to hold the side of the bun and keep the meat from falling off. The DM then placed the top of the bun on with their other gloved hand. The DM placed a scoop of beans and a lid on the plate and handed the tray out the window with the same gloved hands. On 05/03/23 at 12:20 p.m., the DM used the same gloved hands to get another tray, placed a meal card and plate on the tray, opened a new bag of buns and placed a bun on the plate with the gloved hands. The DM placed a scoop of mechanical meat on the bun, pressed the meat down with their gloved hand and placed the top of the bun on with the other gloved hand. The DM placed a scoop of beans and lid on the plate with the same gloved hands. On 05/03/23 at 1:05 p.m. the DM was asked the policy for touching food with bare hands. They stated staff were to wash hands before and afterwards. The DM was asked if staff could touch food with their bare hands. They stated, No. On 05/03/23 at 1:07 p.m., the DM was asked the purpose of using gloves during meal service. They stated gloves were used to keep germs from your body away from food items. On 05/03/23 at 1:08 p.m., the DM was asked if the gloved hands they used to pick up the meal trays, meal cards, plates, serving utensils they had previously touched with their bare hands, hamburger buns, lids, and mechanically soft meat were still considered clean. They sated, No. On 05/03/23 at 1:09 p.m., the DM was asked if gloves were still considered clean once they touched a surface. They stated, No, they are dirty.

Based on observation and interview, the facility failed to ensure the steam table located in the kitchen was maintained in a safe operating condition. The Resident Census and Conditions of Residents report, dated 05/03/23, documented 28 residents resided in the facility. LPN #1 identified one resident with orders for nothing by mouth. Findings: On 05/03/23 at 11:45 a.m., during the lunch meal service, the steam table was observed to have two temperature knobs missing. The DM was asked how they knew what temperature the steam table was set at if the knobs were missing. They stated they would check the food with a thermometer and adjust the temperature up or down as needed. On 05/03/23 at 11:47 a.m., the DM was asked if there was any way to know what temperature steam table compartments three and four were set on with the knobs missing. No response was given. The DM was asked how long the knobs had been missing. They stated they did not know.

Based on observation, record review, and interview, the facility failed to utilize a safe technique to transfer a resident to the bathroom for one (#2) of three sampled residents reviewed for accident hazards. The Resident Census and Conditions of Residents report, dated 05/03/23, documented 15 residents required the assistance of one or two staff members for transfers and 13 residents required the assistance of one or two staff members for toilet use. Findings: A Safe Lifting and Movement of Residents policy, revised 07/17, read in parts, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devises to lift and move residents .Manual lifting of residents shall be eliminated when feasible .Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices . Resident #2 had diagnoses which included anoxic brain damage and unspecified convulsions. An Annual Resident Assessment, dated 02/22/23, documented Resident #2 required extensive assistance of two plus persons physical assist for transfers and toilet use. A Care Plan, revised 04/03/23, documented staff may use a sit to stand lift for transfers as needed. On 05/02/23 at 11:06 a.m., LPN #1 was observed walking over to Resident #2 who was seated at the activity table in the main living area. LPN #1 stated the resident needed to go to the bathroom. On 05/02/23 at 11:10 a.m., CMA #1 and LPN#1 assisted the resident into the community bathroom located on Hall D. Both staff members donned gloves, LPN #1 removed the foot pedals from the resident's wheelchair and pulled the wheelchair towards the toilet located in the bathroom. LPN #1 placed Resident #2's feet flat on the floor. CMA #1 was observed grabbing Resident #2's gray pants, and used them to hoist the resident out of the wheelchair. Resident #2 held onto the grab bar next to the toilet while LPN #1 pulled down the resident's pants and brief. Resident #2 sat on the toilet with verbal command by staff. On 05/02/23 at 11:18 a.m., both LPN #1 and CMA #1 donned gloves. LPN #1 moved the wheelchair back close to the toilet. LPN #1 stood on the left side of the toilet between the resident and the wheelchair On 05/02/23 at 11:19 a.m., Resident #2 and LPN #1 grabbed some toilet paper, and CMA #1 grabbed some disposable wipes. On 05/02/23 at 11:20 a.m., Resident #2 reached for the grab bar on the left side of the toilet. LPN #1 was observed grabbing underneath the resident's left arm and CMA #1 was observed grabbing underneath the resident's right arm and hoisted the resident to a standing position next to the toilet. LPN #1 used disposable wipes to clean the resident. CMA #1 pulled up the resident's disposable brief and pants. Both LPN #1 and CMA #1 continued to hold underneath the resident's armpits to turn the resident in front of the wheelchair. LPN #1 held onto the back side of the residents gray pants and took steps toward the resident's wheelchair where the resident sat down. On 05/02/23 at 11:22 a.m., LPN #1 reached under the resident's right arm and CMA #1 reached underneath Resident #2's left arm, and hoisted the resident up in their wheelchair by their arms. On 05/02/23 at 11:24 a.m., LPN #1 and CMA #1 were asked what type of assistance Resident #2 required for transfers. LPN #1 stated the resident required two person assist or a sit to stand lift. LPN #1 stated the resident was reluctant to use a machine. On 05/02/23 at 11:26 a.m., LPN #1 and CMA #1 were asked what the policy was for assisting Resident #2 from a wheelchair to a standing position. CMA #1 stated staff were to make sure the wheelchair was locked, and start on the resident's strong side to their best ability. On 05/02/23 at 11:27 a.m., they were asked to explain the reason they grabbed the resident's gray pants and hoisted them to a standing position. LPN #1 stated a gait belt should have been used rather than the resident's pants. On 05/02/23 at 11:28 a.m., LPN #1 and CMA #1 were asked about putting their arms under the residents' arms to lift them. LPN #1 stated that was not the proper technique. On 05/04/23 at 1:14 p.m., the DON was asked the policy for transferring a resident who required one person physical assistance. They stated staff should be using gait belts. The DON was asked the policy for transferring a resident who required two person physical assistance. The DON stated if the resident was able to bear weight, staff should use gait belts. They stated if the resident was unable to bear weight, staff should not be trying to stand them up.

Based on record review and interview, the facility failed to revise the nutritional care plan for one (#13) of three sampled residents reviewed for nutrition. The Residents Census and Condition of Residents report, dated 05/03/23, documented 28 residents resided in facility. Findings: The Care Plans, Comprehensive Person-Centered policy, revised March 2012, read in part, .assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change . A Physician Order, dated 10/07/22, documented the resident had a regular diet ordered. Resident #13's Care Plan, dated 12/28/22, read in parts, .Concern: Nutrition- I am on a Regular diet, Regular Texture, regular/Thin liquids. I require assist with tray set up . A Physician Order, dated 02/14/23, documented the resident had a mechanical soft diet ordered. Resident's #13's care plan was not revised/updated to reflect the diet change. A Physician Order, dated 04/19/23, documented the resident had a regular diet, pureed texture, with honey consistency liquids. It documented the resident was to receive a low cholesterol, low sodium and low fat diet for dysphasia. Resident's #13's care plan was not revised/updated to reflect the diet change. On 05/05/23 at 11:11 a.m., the DON was asked what the process was for updating care plans. They stated, I print off all the new and discontinued orders and cross match them to the care plan and make changes like that.

Based on observation, interview, and record review, the facility failed obtain orders for surgical wound care for one (#87) of four residents who were reviewed for non-pressure related skin conditions. The DON reported six residents residing in the facility had orders for wound care of any type. Findings: Resident (Res) #87 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital discharge records, dated 01/26/22, documented Res #87 had surgical wounds from removal of cancerous [CONDITION(S)] on her face and buttocks. An admission/readmission assessment, dated 01/26/22, documented Res #87 had Steri-strips in place on her forehead, and a bandage to her right buttock related to skin cancer removal. The assessment stated the nurse uncovered the bandage to observe the surgical wound on Res #87's buttock then recovered the wound. The clinical records did not document wound care orders at this that time. A physician order, dated 02/01/22, documented to cleanse area to right buttock with normal saline, pat dry, apply [MEDICATION(S)], and cover with island dressing every Tuesday, Thursday, and Saturday. On 02/01/22 at 3:07 p.m., Res #87 was observed during the provision of wound care. On 02/01/22 at 4:30 p.m., the DON stated she had no knowledge of Res #87's wound until 01/31/22. The DON stated the admitting nurse made note of Res #87's surgical wound and should have obtained orders and passed the information on to the oncoming shifts.

On 10/24/13, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to assess and monitor a resident after the resident began complaining that he had lost function of his legs. The Oklahoma State Department of Health verified the existence of the IJ related to the facility's failure to assess and monitor a resident with a change in condition. At 3:19 p.m., the administrator, DON, and Director of Clinical Operations were informed of the IJ related to the facility's failure to assess and monitor a resident who was experiencing a change in condition when he began complaining of loss of function to his legs. At 5:12 p.m., an acceptable plan of removal was provided. The plan of removal documented, "Failure to assess resident 1. All license nursing staff will be in-serviced on completing a systems head to toe assessment. 2. All license nursing staff will be in-serviced on completing a thorough systems head to toe assessment following any and all incidents at time of incident and a minimum of every shift x 72 hours after a non injury incident and every shift for injury incidents until injury resolved. 3. All licensed nursing will be trained on signs and symptoms of neurological changes and/or neurological injury. 4. All licensed nursing will be trained on notifying physician of any and all incidents and any and all acute changes of residents. 5. All license nursing will be trained to notify DON or DOCO immediately of sudden changes in resident condition. 6. All licensed nursing will be trained to chart any and all: assessments, evaluations, and communication to the physician, Director of Nursing or Director of Clinical Operations. 7. All licensed nurses will be in-serviced by 6 pm October 24, 2013. 8. The DON or DCO will conduct an audit of all 24 hour reports and acute progress notes to ensure that the nurses charted completely and thoroughly all problems and changes by 10 am Oct. 25, 2013. 9. Future monitoring will include the DON or DCO will audit point Click dashboard and Progress Notes for accuracy with assessing acute needs. This will be at least 5 times a week. On 10/25/13 at 10:00 a.m., the DOCO provided documentation to show the plan of removal had been implemented as described. Staff were interviewed on 10/25/13 in regards to their knowledge of the inservice; to ensure their understanding of all aspects of the plan of removal. The IJ was removed, effective 10/24/13 at 10:00 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on interview and record review, it was determined the facility failed to: A. Assess and monitor one (#15) of six sampled residents who were reviewed for changes in condition and falls. This resulted in an Immediate Jeopardy situation for resident #15 who had suffered two falls and then lost function of his legs. The resident suffered fractures of two vertebrae that resulted in [MEDICAL CONDITION]. The facility identified 38 residents who had suffered falls during the last three months. The facility identified five residents with acute changes in condition within the last two weeks; and B. Provide urinary catheter care in a manner to prevent infection for two (#5 and #10) of four sampled residents with urinary cathetesr. The facility identified nine residents with an indwelling urinary catheter. Findings: The facility's policy on acute condition changes, dated 04/2009, documented, "...Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the Physician; for example, history of present illness and previous and recent test results for comparison...The nursing staff will contact the Physician based on the urgency of the situation...The nursing staff and physician will discuss possible causes based on resident history, current symptoms, medication regimen, and existing test results...The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly..." The facility's policy on catheter care, dated 04/2010, documented, "...Be sure the catheter tubing and drainage bag are kept off the floor...assist the female resident into the dorsal recumbent position...Change the position of the washcloth with each downward stroke...Use a clean washcloth...to cleanse and rinse the catheter from insertion site to approximately four inches outward..." 1. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 08/05/13 at 12:59 p.m., documented, "...Resident is alert and oriented (sic) to name, season, and year. Resident is able to move all extremities (sic) with no pain or discomfort..." A nurse's note, dated 08/10/13 at 8:34 a.m., documented, "...overall generalized pain rated 6 on 0-10 scale - mainly where he had back surgery..." An admission assessment, dated 08/12/13, documented the resident was cognitively intact and had no behaviors. It was documented the resident required supervision for bed mobility, transfers, walking in the room and corridor, and for locomotion on and off the unit. It was documented the resident required supervision for toileting, had no functional limitations in range of motion, and used a walker and wheelchair for locomotion. It was documented the resident was always continent of bowel and bladder. The resident's care plan, dated 08/28/13, documented a problem, "...I am at risk for falls d/t medication side effects with potential to cause balance problems..." The goal was, "...I will be free of falls through the review date..." Interventions included, "...Assess medications for contributing factors...Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility..." Another problem was, "...I have back pain frequently. Prefers narcotic medication vs OTC..." The goal was, "...I will not have an interruption in normal activities due to pain through the review date..." Interventions included, "Evaluate the effectiveness of pain interventions when needed...Monitor/record pain characteristics...Ask resident if having pain or has had pain in last 12 hours. If yes, document via progress note and notify charge nurse for further interventions..." A behavioral note, dated 08/28/13 at 11:24 a.m., documented, "...is a new admission to the facility from psychiatric facility. He is alert and aware. He does have behaviors of inappropiate (sic) sexual comments, narcotic pain med seeking..." A nurse's note, dated 08/29/13 at 8:00 a.m., documented, "...at (6:45 a.m.) resident up at nurses desk stating he is in pain. Resident was walking without his walker..." A nurse's note, dated 09/04/13 at 12:06 a.m., documented, "...up and about with electric w/c without diff. Amb in hall with no problems..." A nurse's note, dated 09/25/13 at 9:49 a.m., documented, "...Resident will walk and also use his electric wheel chair..." A nurse's note, dated 09/26/13 at 12:32 p.m., documented, "...Stated he had a sharp stabbing pain in his back at a level of 8 on a 1-10 scale..." A nurse's note, dated 09/26/13 at 1:40 p.m., documented, "...c/o sharp stabbing low back pain 10/10..." A nurse's note, dated 09/27/13 at 7:15 a.m., documented, "...At (7:10 a.m.) resident complained of pain in back between shoulders at a level of 10 on a 1-10 scale. Res stated his pain was beyond a 10. Described pain as a stabbing pain..." A nurse's note, dated 09/28/13 at 7:30 p.m., documented, "...Resident stood up quickly and then said he woke up on the floor, no s/s on injury noted at this time. VS stable, with [MEDICAL CONDITION] states his bed was wet and had to get out..." A nurse's note, dated 09/29/13 at 6:36 p.m., documented, "...Res in hallway on electric wc and noted inappropriate moaning and with labored breathing. When this nurse tried to assess him, he said that it didn't matter he'd be fine..." A nurse's note, dated 09/29/13 at 7:00 p.m., documented, "...(Physician name withheld) notified of behaviors at this time..." A nurse's note, dated 09/29/13 at 10:54 p.m., documented, "...Continue with intermittent labored breathing..." A nurse's note, dated 09/30/13 at 11:49 a.m., documented, "...Intermittent labored breathing..." A nurse's note, dated 09/30/13 at 11:58 a.m., documented, "...At (6:30 a.m.) resident shouting in room with door closed. Upon entry resident laying in bed continuing to holler. When asked what was wrong res stated he was hurting, when asked where res shouted even louder. When asked again as to where, res stated he just needed a breathing tx..." A nurse's note, dated 09/30/13 at 9:30 p.m., documented, "...Res up ad lib to smoke numerous times. Cont's with moaning out. When asking him why he's moaning, he doesn't have an answer..." A nurse's note, dated 10/01/13 at 12:50 p.m., documented, "...Stated he was hurting a little in his back but not because of the fall..." A nurse's note, dated 10/01/13 at 12:57 p.m., documented, "...SOB noted immeditely (sic) upon exertion..." A nurse's note, dated 10/01/13 at 9:45 p.m., documented, "...Moans out at times but doesn't seem to know why..." A nurse's note, dated 10/02/13 at 5:30 a.m., documented, "...resident observed making grunting like noises at times..." A nurse's note, dated 10/02/13 at 1:03 p.m., documented, "...Grunting noises noted at all times when staff attending to residents. Easily gets SOB upon exertion, while smoking, and during breathing tx..." A nurse's note, dated 10/03/13 at 8:51 a.m., documented, "...During change of shift, this nurse was told that res stated 'I can't walk.' Upon rounds this AM, 2 CNAs entered this res room to assist resident in changing from soiled clothes. CNAs instructed res that he needed to help them, res began shouting at CNAs stating his legs don't work. CNAs stated they understood but he still needed to try to help them. Res continued to shout about legs not working and stated he would use his arms on his electric wheelchair arm bars, to lift him self up so they could change him. CNAs notified this nurse. Nurse assessed res., res stated he can't use his legs, when asked why, res stated he doesn't know, they quit last night..." Review of the clinical record revealed no documentation of the assessment or that the physician was notified of the change in condition. There was no documentation the resident was monitored for the change in condition. A nurse's note, dated 10/03/13 at 11:34 a.m., documented, "...Had meeting with resident, his mother, ADON, Admin, SSD and charge nurse regarding resident's behavior with staff. Resident stated that staff was not nice to him when they came down to change him that they were wanting him to stand up and he couldn't because he couldn't feel his legs as of last night and he reported it to nurse on duty. Charge nurse agreed that it was passed on the (sic) her this morning. ADON is going to call DR to see what needs to be done. Mother stated this has happened before after his back surgery...." Review of the clinical record revealed no documentation to show the ADON assessed the resident's legs or that the physician was notified of the change in condition. A nurse's note, dated 10/03/13 at 8:00 p.m., documented, "...Cont's to moan out without knowing why. C/O not being able to pee and his pee pee hurting. Res had been incontinent earlier in shift. Came to this nurse and wanted a breathing tx and for me to cath him. Call (physician name withheld) and rec'd order to cath and if greater than 250cc to leave cath in..." A nurse's note, dated 10/03/13 at 8:30 p.m., documented, "...Before going in to cath him, he stated to an aid that he pulled and squeezed his pee pee and he urinated all over himself and his bed. Bed was soaked with urine. Upon cathing him out came 250cc clear yellow urine, 16fr/5cc inserted and drainage bag attached. 750cc urine into bag. Tubing clamped at this time for an hour. When unclamped another 700cc urine into drainage bag. Res stated his belly felt better. No furthur (sic) urinary discomfort voiced..." A nurse's note, dated 10/04/13 at 10:55 a.m., documented, "...at (10:55 a.m.) CNA called the nurse to resident's room. When nurse arrived the resident was sitting on the electric wheelchair foot pedal resting his right side against the wheelchair. Resident had his knees bent. Call light was activated. Resident stated he was trying to get into his wheelchair. Resident stated that he turn (sic) the call light on after he fell . Resident stated he fell on his hands and knees and that his left hand hit the end table. Head to toe assessment completed. Able to move all extremities with no pain or discomfort at this time. No redness or bruising noted. Resident has abrasion on his left 4th and 5th knuckle. Resident stated he didn't hit his head. Transfer to wheelchair x 2 assistance. Educated resident that he is weak and that he need (sic) use the call light that is located on his bed for his safety..." A nurse's note, dated 10/04/13 at 1:33 p.m., documented, "...Excessive urine output noted this shift from (5:00 a.m. - 12:00 p.m.), 2500ml of clear yellow urine drained from drainage bag and tubing..." A nurse's note, dated 10/04/13 at 1:43 p.m., documented, "...from (12:00 p.m. - 1:45 p.m.), 1000ml emptied from drainage bag..." A nurse's note, dated 10/04/13 at 9:18 p.m., documented, "...C/O not being able to move legs. (Physician name withheld) notified. When assessed he had reflexes in R foot and c/o burning in L foot. Total assist with transfers. F/c patent draining with hematuria noted this pm..." A nurse's note, dated 10/05/13 at 7:15 a.m., documented, "...Resident making moaning sound with each breath. Resident using electric scooter for mobility. Leaning to the right at times and states can't hold self up. Note that the rest of the time he can hold himself up without issues. Talking excessively. Talking with voice of small child instead of his usual voice. Decreased eye contact. Demanding. Wants to be taken care instantly and becomes a little irritable if care isn't instantly (sic)..." Review of the clinical record revealed no documentation to show the resident was assessed when it was noted he was leaning to the right and stating he could not hold himself up. There was no documentation staff monitored the change in condition. There was no documentation the physician was notified of the change in condition. A nurse's note, dated 10/06/13 at 1:45 p.m., documented, "...Resident has decided that he can't move his legs any longer. As the day progresses pt has now decided that he can't sit up, states I have to use my arm to sit up. Continues to go out and smoke every 30 minutes to an hour. Continues with open mouth panting type breathing, shallow breaths. Note that the panting behavior increases when his (family member) is present in the building. Increasingly demaining (sic) of staff. Hollers at staff then takes child like a quit (sic). Resident then states I am just not on enough pain meds after all I got 30mg of oxy before. Resident also states my chest just hurts since I've lost my legs. Resident with good pedal pulses. VS T96.4, (B/P) 169/100, p106, resp 28 SaO2 80 with panting behavior. Applied O2 2L per N/C SaO2 87 within 5 minutes with decrease in the panting breathing. Resident now fell s (sic) his arms are just giving out. peaning (sic) to left and then to the right. (Physician name withheld) notified of changing complaints of resident. One time order received for a now [MEDICATION NAME] (an antipsychotic medication)..." Review of the clinical record revealed no documentation the physician was notified of the resident's change in physical condition or that the resident was assessed and monitored related to the change in condition. A nurse's note, dated 10/06/13/ at 8:58 p.m., documented, "...Resident continues to be very demanding, wanting lifted into electric (sic) to smoke then to be lifted back to bed. Wants staff to drop whatever they are doing and attend to him and his needs only. Smoking at least once an hour. When speaking one way doesn't get it, he then speaks like a child. Frequently calling his (family member) to come to the facility and take care of him and wait on him. (Family member) has been her (sic) at least 2 times since (2:00 p.m.). Continues to say his legs don't work. When I touch hi (sic) feet he withdraws his feet from the light touch. Resident says that he has this feel (sic) of electric shooting through him. Say (sic) can't move legs yet staff watches him move when he is unaware of their presence..." A nurse's note, dated 10/07/13 at 1:55 a.m., documented, "...has been up in motorized w/c most of shift...requesting to get up and down to go out to smoke. Refuses to assist staff with transfers. Hoyer lift utilized..." A nurse's note, dated 10/07/13 at 12:53 p.m., documented, "...stated he is having soreness on his right side...Dr notified of v/s and right side soreness..." A nurse's note, dated 10/07/13 at 1:08 p.m., documented, "...Resident has been having shortness or (sic) breath. PRN breathing treatments given...Congestion heard throughout...Resident stated he is having pain when he coughs and breathes..." A nurse's note, dated 10/07/13 at 9:50 p.m., documented, "...At (2:30 p.m.) resident requested a cigarette and went outside to smoke. After smoking this nurse went outside to check on resident. Noted labored breathing with SpO2 at 76% Resp at 32 and pulse 112. Taken to room O2 put on at 3L/M via NC, prn [MEDICATION NAME] and atrovent given also with SpO2 up to 90%...Declined to go outside to smoke just wanted to sit for a bit d/t back pain..." A nurse's note, dated 10/08/13 at 3:15 a.m., documented, "...res requested to get up in his chair. CNA's (sic) x 2 assisted him up in chair. Res very agitated, sob, making grunting sound with resperations (sic). SaO2 77% on 3L/O2/nc. CHOOSES NOT TO GO TO HOSPITAL. Demanded a prn br. tx and was given. SaO2 came up to 83%, v/s 171/92 114 30. Cont to decline going to hospital stated our pulse ox is not correct and that he feels fine..." A nurse's note, dated 10/08/13 at 1:42 p.m., documented, "resident outside to smoke then put to bed via hoyer lift x 2..." A nurse's note, dated 10/08/13 at 8:56 p.m., documented, "...At (1:45 p.m.) resident's (family member) came to desk and said she thought her (resident #15) had a temp. This nurse went to room to take temp resident noted to be flushed and having labored breathing. T 99.9 R 32...At approx (3:00 p.m.) resident requested this nurse come to his room. Upon entering room resident stated 'I want to go to the hospital.'...(Physician name withheld) notified of resident wanting to go to hospital. Orders received to transport to (hospital name withheld) for resp distress..." A hospital history and physical, dated 10/08/13 at 9:17 p.m., documented, "...Incidentally the patient states that he has been unable to move his legs for about the last 5-6 days. He fell and hit his back. After that, he had loss of bowel and bladder continence. He has had a (sic) indwelling Foley since then. He had immediate essential total paralysis of his left lower extremity, then his right lower extremity became progressively more weak to the point that he is not even able to wiggle his toes on that foot anymore. He also has a diminished sense of sensation essentially from a few inches below the nipple line...NEUROLOGIC: Cranial nerves II through XII are intact. Sensation to light touch is diminished to the level of approximately T5. Sensation to pain is virtually absent to level T5. Patient has normal strength in his upper extremities and is completely unable to move his lower extremities at all. Babinski is negative bilaterally. Hypo-reflexes in the lower extremities bilaterally..." A [MEDICATION NAME] spine MRI, dated 10/09/13 at 12:24 a.m., documented, "...Compression [MEDICAL CONDITION] level, with a vertebra plana appearance and posterior displacement of fracture fragments from the vertebral body, causing severe spinal canal stenosis and abnormal signal with in the [MEDICATION NAME] spinal cord, presumably myelopathic change. Abnormal signal within the posterior element region of the T6 level is also suspicious for nondisplaced fracture. I suspect that there is interspinous ligament injury at the T5-6 and T6-7 levels. Abnormal bone marrow signal within the inferior vertebral endplate of T5 could indicate reactive change or subtle fracture..." A neurosurgery consult, dated 10/09/13 at 8:45 a.m., documented, "...CT of the spine: Shows a T6 vertebral body fracture that is severe. There is another retropulsed piece of bone into the spinal canal with cord signal change. Assessment and Plan: 1. T6 vertebral body fracture. 2. [MEDICAL CONDITION], secondary to number 1..." A nurse's note, dated 10/15/13 at 4:38 p.m. as a late entry, documented, "...Hospital and facility discussing resident's return to the facility. Resident currently has a T5 and T6 fracture..." On 10/24/13 at 10:04 a.m., CNA #1 was asked what the resident could do for himself. She stated, "Pretty much everything for himself until right at the end. Then we were using the hoyer (lift)." CNA #1 was asked why they were utilizing the hoyer lift. She stated, "He quit standing up. He wouldn't bear any weight, so for safety we used the hoyer lift." CNA #1 was asked if she informed the nurses the resident would not bear weight. She stated, "Yes." She was asked what the nurses did. CNA #1 stated, "We reported it and they told us to use the hoyer. They charted it I guess." CNA #1 was asked what nurse she reported it to. She stated, "(LPN #2)." CNA #1 was asked if the resident could move his legs. She stated, "He would move in bed but wouldn't bear weight." On 10/24/13 at 10:23 a.m., LPN #2 was asked if she assessed the resident's legs on 10/03/13 when she first charted the resident's legs were not working. She stated, "Yes, I assessed." She stated the overnight nurse had reported the resident could not walk. LPN #2 was asked where the documentation of the assessment was. She stated, "I just do morning rounds. I just talked to him. He was having a bunch of behaviors. I was thinking it was behaviors." LPN #2 was asked how she assessed the resident's legs. She stated, "I just spoke with him. He was lying in bed." LPN #2 was asked what the resident said. She stated the resident told her his legs had quit working and he didn't know why. LPN #2 was asked if that was a new condition for the resident. She stated, "Yes." LPN #2 was asked what she did when she noted he had quit using his legs. She stated, "Implemented two CNAs be in there." She was asked what she did to determine what was wrong with his legs. She stated, "I helped him transfer to bed, and he flopped into bed. I asked him to scoot up . I bent his legs for him and he pushed himself up." LPN #2 was asked if the resident was in a lying position. She stated, "Yes." LPN #2 was asked if the resident quit walking. She stated, "Yes, he quit using his legs entirely and quit trying to use them." LPN #2 was asked what the resident's normal functional status was. She stated he was walking down the hall with a family member the day before and had to stop half-way. She stated he needed a breathing treatment and a wheelchair. On 10/24/13 at 10:34 a.m., the ADON was asked if she called the physician regarding the resident's legs as the 10/03/13 documentation stated she would. She stated, "No." She stated she spoke with the charge nurse about the resident. She stated they had gone into a meeting about his smoking and his legs were brought up then. She stated the doctor came every Wednesday and she was going to tell him then. The ADON stated, "It had been an issue right after he first came. He was having some problems with his back and legs. And with him, it was always something. I think he wound up going to the hospital before that Wednesday. I did tell (physician name withheld) but I'm pretty sure he had already gone to the hospital before then." The ADON was asked what charge nurse she spoke with. She stated she thought it was the 2-10 shift charge nurse but was not for sure. The ADON stated, "He had been going a couple of days saying he couldn't feel his legs. They were numb. I talked to the charge nurse and I think she had talked to (physician name withheld) later that afternoon and let him know what was going on." The ADON was asked if this was a new condition for the resident. She stated, "Yes and no. He complained of his back and different things and he kept complaining about it. He started having trouble with his bladder and it developed into other problems." The ADON was asked what other problems developed. She stated, "His bladder. Said he couldn't urinate. We wound up putting a catheter in him." The ADON was asked if the resident had behaviors. She stated, "Yes. He would start talking to the nurses like a little kid or baby to get his way. If he didn't get his way, he would start yelling and cussing." The ADON was asked what the facility did to help identify why the resident could not use his legs. She stated, "I don't know. I really don't know. We talked to (physician name withheld). That's all I can think of. We got (physician name withheld) involved." The ADON was asked if she assessed the resident's legs. She stated, "No I didn't. That day in the office, I did look at his feet. I didn't go any further than that." The ADON was asked when she spoke with the physician. She stated, "The following Wednesday (10/09/13) is when I spoke to (physician name withheld)." On 10/24/13 at 11:02 a.m., LPN #3 was asked if she witnessed the fall on 10/04/13 as she had documented the fall in the nurses' notes. She stated she did not see the fall but did respond to it. LPN #3 was asked how she assessed the resident after the fall. She stated, "I touched him, moved his legs and arms. He complained of pain to the knuckles." LPN #3 was asked if she did the manipulation of the legs and arms or if the resident moved the extremities on his own. She stated she manipulated the extremities herself. LPN #3 was asked if the resident was able to walk normally. She stated, "Yes." She stated before the fall on 10/04/13, staff was lifting him. She stated, "In report, they said he was becoming paralyzed. He was having them transfer him. He was telling them he was paralyzed." LPN #3 was asked if the resident had ever told her his legs were not working. She stated, "No. He told me he couldn't stand like he used to." On 10/24/13 at 11:34 a.m., RN #1 was asked if she did an assessment of the resident on 10/05/13 at 7:15 a.m., when the resident was leaning and stating he could not hold himself up. She stated, "I'm sure I did. I can tell you his (family member) had stated he fell the day before. There were no signs that he had fallen." She stated, "If you fell and hit your face, there would be marks. He was telling us he couldn't move his legs but we would walk by his room and he would bend his legs up. He was laying flat in the bed." RN #1 stated, "I walked by his room once and tickled his foot and he moved his foot." RN #1 was asked if she did an assessment when she saw the resident leaning to the right. She stated, "Not that I remember." RN #1 was asked if she assessed the resident on 10/06/13 at 1:45 p.m., when she had documented the resident refused to move anything. She stated, "I can't answer that. I don't remember. I'm sure I touched his legs and moved them." RN #1 was asked what she notified the physician of on 10/06/13 at 8:58 p.m. She stated, "His increased anxiety, the progressing I can't move, I can't move my body." RN #1 stated, "We hadn't seen any changes in his muscle strength." RN #1 was asked if the resident was able to transfer himself. She stated, "Yes." She was asked why the aides were using the hoyer lift to transfer the resident. She stated, "Because when they transferred him, he said it hurt so we used the hoyer lift." RN #1 was asked what she did when she noted the decline in transfer abilities. She stated she questioned him on it, did hand grasps, and talked to him about it. She stated, "I called (family member) about the increasing psychotic behaviors. It just seemed to follow along with it." RN #1 was asked when the resident became unable to transfer himself. She stated, "That weekend (10/05/13 - 10/06/13). Up until then he had always been able to (transfer self)." RN #1 was asked how she assessed and monitored the resident after he began to complain that his legs were not working. She stated, "When the aides were in, watched transfers. Checked quite often, watched him when he went out to smoke. Observed him." RN #1 was asked if she documented any of the assessments. She stated, "If it's not there, I guess I didn't." She stated, "He was still having them get him up to go smoke and could sit in the chair just fine." RN #1 was asked why the physician ordered a one time dose of [MEDICATION NAME] on 10/06/13. She stated, "Because of the increased anxiety and breathing. [MEDICATION NAME] had worked for him in the past." On 10/24/13 at 12:16 p.m., the DON was asked what the staff did when the resident began to complain of being unable to move his legs. She stated, "When I talked to them, (LPN #3) said he moved all his extremities and there was no pain. (ADON) said she had checked for movement. I talked to (RN #1). She said he was moving his extremities when staff wasn't around. He was not really walking. Said he would reposition his feet." The DON was asked if staff felt he was trying to hide his movements. She stated, "No." The DON was asked how staff assessed the resident to determine if there was something wrong with his legs. The DON stated, "(LPN #3) assessed after the fall and said he was moving all his extremities. (ADON) said she went down and touched the bottom of his feet. As far as standing, bearing weight, I don't believe anyone actually tried to do that." The DON was asked how staff monitored the resident. She stated, "I don't have an answer for that." The DON was asked what the staff notified the physician of. She stated, "His complaints." She was asked if staff contributed his complaints about his legs and the inability to hold himself upright to his behaviors. She sated, "I think a lot of it was. Prior to that, he had complained of arm paralysis and it wasn't." Review of the clinical record revealed no documentation of complaints of arm paralysis. The DON was asked what she would expect the staff to do when a resident presented with these complaints. She stated she did not understand. She was asked if she expected the staff to assess and monitor a resident's physical complaints, irregardless of any behavioral components. She stated, "Yes, but I didn't either." The DON was asked what she had done to educate her staff on assessing and monitoring since the incidents were brought to her attention. She stated, "Nothing. We still do what we've been doing. Transfer training." On 10/24/13 at 2:55 p.m., the physician was asked what the facility notified him of concerning the resident. He stated, "Numbness and trouble using his left leg." He was asked what the facility notified him of on 10/06/13 when the one time dose of [MEDICATION NAME] was ordered. He stated staff had reported the resident was refusing care and having behaviors. The physician was asked if the staff reported the resident stated he could not use his legs and that he could not hold himself upright in the wheelchair. He stated, "I don't recall that. I think it was a behavioral problem." 2. Resident #5 was

On 10/24/13, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to notify the physician of acute and progressing changes in condition after a resident began complaining that he had lost function of his legs. The Oklahoma State Department of Health verified the existence of the IJ situation related to the facility's failure to notify the physician of a resident's change in condition. At 3:19 p.m., the administrator, DON, and Director of Clinical Operations were informed of the IJ related to the facility's failure to notify the physician of acute and progressing changes in condition after the resident began complaining that he had lost function of his legs. At 5:12 p.m., an acceptable plan of removal was provided. The plan of removal documented, "Failure to Notify Physician of Changes 1. All licensed staff will be trained on notifying physician with any and all resident changes in condition. 2. All licensed nursing staff will be in-serviced on information to be given to physician when report is called in; i.e. Vital signs, focal assessment or evaluation of body systems involved, current medication and changes from baseline. 3. All licensed nursing trained on check list to use when calling physician, DON or DCO. 4. This nursing initial training will be done by 6pm October 24, 2013. 5. All electronic 24 hour reports and dashboard information on changes will be reviewed by 10am October 25, 2013. 6. Future monitoring will include the DON or DCO will review PCC dashboard at least 5 times a week, for Progress notes and Physician orders [REDACTED]." On 10/25/13 at 10:00 a.m., the DOCO provided documentation to show the plan of removal had been implemented as described. Staff were interviewed on 10/25/13 in regards to their knowledge of the inservice; to ensure their understanding of all aspects of the plan of removal. The IJ was removed, effective 10/24/13 at 10:00 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on interview and record review, it was determined the facility failed to notify the physician of changes in condition for two (#7 and #15) of six sampled residents who were reviewed for changes in condition. This resulted in an Immediate Jeopardy situation for resident #15 who had suffered two falls and then lost function of his legs. The resident suffered fractures of two vertebrae that resulted in [MEDICAL CONDITION]. The facility identified 38 residents who had suffered falls during the last three months. The facility identified five residents with acute changes in condition within the last two weeks. Findings: The facility's policy on acute condition changes, dated 04/2009, documented, "...Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the Physician; for example, history of present illness and previous and recent test results for comparison...The nursing staff will contact the Physician based on the urgency of the situation...The nursing staff and physician will discuss possible causes based on resident history, current symptoms, medication regimen, and existing test results...The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly..." 1. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 08/05/13 at 12:59 p.m., documented, "...Resident is alert and oriented (sic) to name, season, and year. Resident is able to move all extremities (sic) with no pain or discomfort..." A nurse's note, dated 08/10/13 at 8:34 a.m., documented, "...overall generalized pain rated 6 on 0-10 scale - mainly where he had back surgery..." An admission assessment, dated 08/12/13, documented the resident was cognitively intact and had no behaviors. It was documented the resident required supervision for bed mobility, transfers, walking in the room and corridor, and for locomotion on and off the unit. It was documented the resident required supervision for toileting, had no functional limitations in range of motion, and used a walker and wheelchair for locomotion. It was documented the resident was always continent of bowel and bladder. The resident's care plan, dated 08/28/13, documented a problem, "...I am at risk for falls d/t medication side effects with potential to cause balance problems..." The goal was, "...I will be free of falls through the review date..." Interventions included, "...Assess medications for contributing factors...Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility..." Another problem was, "...I have back pain frequently. Prefers narcotic medication vs OTC..." The goal was, "...I will not have an interruption in normal activities due to pain through the review date..." Interventions included, "Evaluate the effectiveness of pain interventions when needed...Monitor/record pain characteristics...Ask resident if having pain or has had pain in last 12 hours. If yes, document via progress note and notify charge nurse for further interventions..." A behavioral note, dated 08/28/13 at 11:24 a.m., documented, "...is a new admission to the facility from psychiatric facility. He is alert and aware. He does have behaviors of inappropiate (sic) sexual comments, narcotic pain med seeking..." A nurse's note, dated 08/29/13 at 8:00 a.m., documented, "...at (6:45 a.m.) resident up at nurses desk stating he is in pain. Resident was walking without his walker..." A nurse's note, dated 09/04/13 at 12:06 a.m., documented, "...up and about with electric w/c without diff. Amb in hall with no problems..." A nurse's note, dated 09/25/13 at 9:49 a.m., documented, "...Resident will walk and also use his electric wheel chair..." A nurse's note, dated 09/26/13 at 12:32 p.m., documented, "...Stated he had a sharp stabbing pain in his back at a level of 8 on a 1-10 scale..." A nurse's note, dated 09/26/13 at 1:40 p.m., documented, "...c/o sharp stabbing low back pain 10/10..." A nurse's note, dated 09/27/13 at 7:15 a.m., documented, "...At (7:10 a.m.) resident complained of pain in back between shoulders at a level of 10 on a 1-10 scale. Res stated his pain was beyond a 10. Described pain as a stabbing pain..." A nurse's note, dated 09/28/13 at 7:30 p.m., documented, "...Resident stood up quickly and then said he woke up on the floor, no s/s on injury noted at this time. VS stable, with [MEDICAL CONDITION] states his bed was wet and had to get out..." A nurse's note, dated 09/29/13 at 6:36 p.m., documented, "...Res in hallway on electric wc and noted inappropriate moaning and with labored breathing. When this nurse tried to assess him, he said that it didn't matter he'd be fine..." A nurse's note, dated 09/29/13 at 7:00 p.m., documented, "...(Physician name withheld) notified of behaviors at this time..." A nurse's note, dated 09/29/13 at 10:54 p.m., documented, "...Continue with intermittent labored breathing..." A nurse's note, dated 09/30/13 at 11:49 a.m., documented, "...Intermittent labored breathing..." A nurse's note, dated 09/30/13 at 11:58 a.m., documented, "...At (6:30 a.m.) resident shouting in room with door closed. Upon entry resident laying in bed continuing to holler. When asked what was wrong res stated he was hurting, when asked where res shouted even louder. When asked again as to where, res stated he just needed a breathing tx..." A nurse's note, dated 09/30/13 at 9:30 p.m., documented, "...Res up ad lib to smoke numerous times. Cont's with moaning out. When asking him why he's moaning, he doesn't have an answer..." A nurse's note, dated 10/01/13 at 12:50 p.m., documented, "...Stated he was hurting a little in his back but not because of the fall..." A nurse's note, dated 10/01/13 at 12:57 p.m., documented, "...SOB noted immeditely (sic) upon exertion..." A nurse's note, dated 10/01/13 at 9:45 p.m., documented, "...Moans out at times but doesn't seem to know why..." A nurse's note, dated 10/02/13 at 5:30 a.m., documented, "...resident observed making grunting like noises at times..." A nurse's note, dated 10/02/13 at 1:03 p.m., documented, "...Grunting noises noted at all times when staff attending to residents. Easily gets SOB upon exertion, while smoking, and during breathing tx..." A nurse's note, dated 10/03/13 at 8:51 a.m., documented, "...During change of shift, this nurse was told that res stated 'I can't walk.' Upon rounds this AM, 2 CNAs entered this res room to assist resident in changing from soiled clothes. CNAs instructed res that he needed to help them, res began shouting at CNAs stating his legs don't work. CNAs stated they understood but he still needed to try to help them. Res continued to shout about legs not working and stated he would use his arms on his electric wheelchair arm bars, to lift him self up so they could change him. CNAs notified this nurse. Nurse assessed res., res stated he can't use his legs, when asked why, res stated he doesn't know, they quit last night..." Review of the clinical record revealed no documentation of the assessment or that the physician was notified of the change in condition. There was no documentation the resident was monitored for the change in condition. A nurse's note, dated 10/03/13 at 11:34 a.m., documented, "...Had meeting with resident, his mother, ADON, Admin, SSD and charge nurse regarding resident's behavior with staff. Resident stated that staff was not nice to him when they came down to change him that they were wanting him to stand up and he couldn't because he couldn't feel his legs as of last night and he reported it to nurse on duty. Charge nurse agreed that it was passed on the (sic) her this morning. ADON is going to call DR to see what needs to be done. Mother stated this has happened before after his back surgery...." Review of the clinical record revealed no documentation to show the ADON assessed the resident's legs or that the physician was notified of the change in condition. A nurse's note, dated 10/03/13 at 8:00 p.m., documented, "...Cont's to moan out without knowing why. C/O not being able to pee and his pee pee hurting. Res had been incontinent earlier in shift. Came to this nurse and wanted a breathing tx and for me to cath him. Call (physician name withheld) and rec'd order to cath and if greater than 250cc to leave cath in..." A nurse's note, dated 10/03/13 at 8:30 p.m., documented, "...Before going in to cath him, he stated to an aid that he pulled and squeezed his pee pee and he urinated all over himself and his bed. Bed was soaked with urine. Upon cathing him out came 250cc clear yellow urine, 16fr/5cc inserted and drainage bag attached. 750cc urine into bag. Tubing clamped at this time for an hour. When unclamped another 700cc urine into drainage bag. Res stated his belly felt better. No furthur (sic) urinary discomfort voiced..." A nurse's note, dated 10/04/13 at 10:55 a.m., documented, "...at (10:55 a.m.) CNA called the nurse to resident's room. When nurse arrived the resident was sitting on the electric wheelchair foot pedal resting his right side against the wheelchair. Resident had his knees bent. Call light was activated. Resident stated he was trying to get into his wheelchair. Resident stated that he turn (sic) the call light on after he fell . Resident stated he fell on his hands and knees and that his left hand hit the end table. Head to toe assessment completed. Able to move all extremities with no pain or discomfort at this time. No redness or bruising noted. Resident has abrasion on his left 4th and 5th knuckle. Resident stated he didn't hit his head. Transfer to wheelchair x 2 assistance. Educated resident that he is weak and that he need (sic) use the call light that is located on his bed for his safety..." A nurse's note, dated 10/04/13 at 1:33 p.m., documented, "...Excessive urine output noted this shift from (5:00 a.m. - 12:00 p.m.), 2500ml of clear yellow urine drained from drainage bag and tubing..." A nurse's note, dated 10/04/13 at 1:43 p.m., documented, "...from (12:00 p.m. - 1:45 p.m.), 1000ml emptied from drainage bag..." A nurse's note, dated 10/04/13 at 9:18 p.m., documented, "...C/O not being able to move legs. (Physician name withheld) notified. When assessed he had reflexes in R foot and c/o burning in L foot. Total assist with transfers. F/c patent draining with hematuria noted this pm..." A nurse's note, dated 10/05/13 at 7:15 a.m., documented, "...Resident making moaning sound with each breath. Resident using electric scooter for mobility. Leaning to the right at times and states can't hold self up. Note that the rest of the time he can hold himself up without issues. Talking excessively. Talking with voice of small child instead of his usual voice. Decreased eye contact. Demanding. Wants to be taken care instantly and becomes a little irritable if care isn't instantly (sic)..." Review of the clinical record revealed no documentation to show the resident was assessed when it was noted he was leaning to the right and stating he could not hold himself up. There was no documentation the staff monitored the change in condition. There was no documentation the physician was notified of the change in condition. A nurse's note, dated 10/06/13 at 1:45 p.m., documented, "...Resident has decided that he can't move his legs any longer. As the day progresses pt has now decided that he can't sit up, states I have to use my arm to sit up. Continues to go out and smoke every 30 minutes to an hour. Continues with open mouth panting type breathing, shallow breaths. Note that the panting behavior increases when his (family member) is present in the building. Increasingly demaining (sic) of staff. Hollers at staff then takes child like a quit (sic). Resident then states I am just not on enough pain meds after all I got 30mg of oxy before. Resident also states my chest just hurts since I've lost my legs. Resident with good pedal pulses. VS T96.4, (B/P) 169/100, p106, resp 28 SaO2 80 with panting behavior. Applied O2 2L per N/C SaO2 87 within 5 minutes with decrease in the panting breathing. Resident now fell s (sic) his arms are just giving out. peaning (sic) to left and then to the right. (Physician name withheld) notified of changing complaints of resident. One time order received for a now [MEDICATION NAME] (an anti-psychotic medication)..." Review of the clinical record revealed no documentation the physician was notified of the resident's change in physical condition or that the resident was assessed and monitored related to the change in condition. A nurse's note, dated 10/06/13 at 8:58 p.m., documented, "...Resident continues to be very demanding, wanting lifted into electric (sic) to smoke then to be lifted back to bed. Wants staff to drop whatever they are doing and attend to him and his needs only. Smoking at least once an hour. When speaking one way doesn't get it, he then speaks like a child. Frequently calling his (family member) to come to the facility and take care of him and wait on him. (Family member) has been her (sic) at least 2 times since (2:00 p.m.). Continues to say his legs don't work. When I touch hi (sic) feet he withdraws his feet from the light touch. Resident says that he has this feel (sic) of electric shooting through him. Say (sic) can't move legs yet staff watches him move when he is unaware of their presence..." A nurse's note, dated 10/07/13 at 1:55 a.m., documented, "...has been up in motorized w/c most of shift...requesting to get up and down to go out to smoke. Refuses to assist staff with transfers. Hoyer lift utilized..." A nurse's note, dated 10/07/13 at 12:53 p.m., documented, "...stated he is having soreness on his right side...Dr notified of v/s and right side soreness..." A nurse's note, dated 10/07/13 at 1:08 p.m., documented, "...Resident has been having shortness or (sic) breath. PRN breathing treatments given...Congestion heard throughout...Resident stated he is having pain when he coughs and breathes..." A nurse's note, dated 10/07/13 at 9:50 p.m., documented, "...At (2:30 p.m.) resident requested a cigarette and went outside to smoke. After smoking this nurse went outside to check on resident. Noted labored breathing with SpO2 at 76% Resp at 32 and pulse 112. Taken to room O2 put on at 3L/M via NC, prn [MEDICATION NAME] and atrovent given also with SpO2 up to 90%...Declined to go outside to smoke just wanted to sit for a bit d/t back pain..." A nurse's note, dated 10/08/13 at 3:15 a.m., documented, "...res requested to get up in his chair. CNA's (sic) x 2 assisted him up in chair. Res very agitated, sob, making grunting sound with resperations (sic). SaO2 77% on 3L/O2/nc. CHOOSES NOT TO GO TO HOSPITAL. Demanded a prn br. tx and was given. SaO2 came up to 83%, v/s 171/92 114 30. Cont to decline going to hospital stated our pulse ox is not correct and that he feels fine..." A nurse's note, dated 10/08/13 at 1:42 p.m., documented, "resident outside to smoke then put to bed via hoyer lift x 2..." A nurse's note, dated 10/08/13 at 8:56 p.m., documented, "...At (1:45 p.m.) resident's (family member) came to desk and said she thought her (resident #15) had a temp. This nurse went to room to take temp resident noted to be flushed and having labored breathing. T 99.9 R 32...At approx (3:00 p.m.) resident requested this nurse come to his room. Upon entering room resident stated 'I want to go to the hospital.'...(Physician name withheld) notified of resident wanting to go to hospital. Orders received to transport to (hospital name withheld) for resp distress..." A hospital history and physical, dated 10/08/13 at 9:17 p.m., documented, "...Incidentally the patient states that he has been unable to move his legs for about the last 5-6 days. He fell and hit his back. After that, he had loss of bowel and bladder continence. He has had a (sic) indwelling Foley since then. He had immediate essential total paralysis of his left lower extremity, then his right lower extremity became progressively more weak to the point that he is not even able to wiggle his toes on that foot anymore. He also has a diminished sense of sensation essentially from a few inches below the nipple line...NEUROLOGIC: Cranial nerves II through XII are intact. Sensation to light touch is diminished to the level of approximately T5. Sensation to pain is virtually absent to level T5. Patient has normal strength in his upper extremities and is completely unable to move his lower extremities at all. Babinski is negative bilaterally. Hypo-reflexes in the lower extremities bilaterally..." A [MEDICATION NAME] spine MRI, dated 10/09/13 at 12:24 a.m., documented, "...Compression [MEDICAL CONDITION] level, with a vertebra plana appearance and posterior displacement of fracture fragments from the vertebral body, causing severe spinal canal stenosis and abnormal signal with in the [MEDICATION NAME] spinal cord, presumably myelopathic change. Abnormal signal within the posterior element region of the T6 level is also suspicious for nondisplaced fracture. I suspect that there is interspinous ligament injury at the T5-6 and T6-7 levels. Abnormal bone marrow signal within the inferior vertebral endplate of T5 could indicate reactive change or subtle fracture..." A neurosurgery consult, dated 10/09/13 at 8:45 a.m., documented, "...CT of the spine: Shows a T6 vertebral body fracture that is severe. There is another retropulsed piece of bone into the spinal canal with cord signal change. Assessment and Plan: 1. T6 vertebral body fracture. 2. [MEDICAL CONDITION], secondary to number 1..." A nurse's note, dated 10/15/13 at 4:38 p.m. as a late entry, documented, "...Hospital and facility discussing resident's return to the facility. Resident currently has a T5 and T6 fracture..." On 10/24/13 at 10:04 a.m., CNA #1 was asked what the resident could do for himself. She stated, "Pretty much everything for himself until right at the end. Then we were using the hoyer (lift)." CNA #1 was asked why they were utilizing the hoyer lift. She stated, "He quit standing up. He wouldn't bear any weight, so for safety we used the hoyer lift." CNA #1 was asked if she informed the nurses the resident would not bear weight. She stated, "Yes." She was asked what the nurses did. CNA #1 stated, "We reported it and they told us to use the hoyer. They charted it I guess." CNA #1 was asked what nurse she reported it to. She stated, "(LPN #2)." CNA #1 was asked if the resident could move his legs. She stated, "He would move in bed but wouldn't bear weight." On 10/24/13 at 10:23 a.m., LPN #2 was asked if she assessed the resident's legs on 10/03/13 when she first charted the resident's legs were not working. She stated, "Yes, I assessed." She stated the overnight nurse had reported the resident could not walk. LPN #2 was asked where the documentation of the assessment was. She stated, "I just do morning rounds. I just talked to him. He was having a bunch of behaviors. I was thinking it was behaviors." LPN #2 was asked how she assessed the resident's legs. She stated, "I just spoke with him. He was lying in bed." LPN #2 was asked what the resident said. She stated the resident told her his legs had quit working and he didn't know why. LPN #2 was asked if that was a new condition for the resident. She stated, "Yes." LPN #2 was asked what she did when she noted he had quit using his legs. She stated, "Implemented two CNAs be in there." She was asked what she did to determine what was wrong with his legs. She stated, "I helped him transfer to bed, and he flopped into bed. I asked him to scoot up . I bent his legs for him and he pushed himself up." LPN #2 was asked if the resident was in a lying position. She stated, "Yes." LPN #2 was asked if the resident quit walking. She stated, "Yes, he quit using his legs entirely and quit trying to use them." LPN #2 was asked what the resident's normal functional status was. She stated he was walking down the hall with a family member the day before and had to stop half-way. She stated he needed a breathing treatment and a wheelchair. On 10/24/13 at 10:34 a.m., the ADON was asked if she called the physician regarding the resident's legs as the 10/03/13 documentation stated she would. She stated, "No." She stated she spoke with the charge nurse about the resident. She stated they had gone into a meeting about his smoking and his legs were brought up then. She stated the doctor came every Wednesday and she was going to tell him then. The ADON stated, "It had been an issue right after he first came. He was having some problems with his back and legs. And with him, it was always something. I think he wound up going to the hospital before that Wednesday. I did tell (physician name withheld) but I'm pretty sure he had already gone to the hospital before then." The ADON was asked what charge nurse she spoke with. She stated she thought it was the 2-10 shift charge nurse but was not for sure. The ADON stated, "He had been going a couple of days saying he couldn't feel his legs. They were numb. I talked to the charge nurse and I think she had talked to (physician name withheld) later that afternoon and let him know what was going on." The ADON was asked if this was a new condition for the resident. She stated, "Yes and no. He complained of his back and different things and he kept complaining about it. He started having trouble with his bladder and it developed into other problems." The ADON was asked what other problems developed. She stated, "His bladder. Said he couldn't urinate. We wound up putting a catheter in him." The ADON was asked if the resident had behaviors. She stated, "Yes. He would start talking to the nurses like a little kid or baby to get his way. If he didn't get his way, he would start yelling and cussing." The ADON was asked what the facility did to help identify why the resident could not use his legs. She stated, "I don't know. I really don't know. We talked to (physician name withheld). That's all I can think of. We got (physician name withheld) involved." The ADON was asked if she assessed the resident's legs. She stated, "No I didn't. That day in the office, I did look at his feet. I didn't go any further than that." The ADON was asked when she spoke with the physician. She stated, "The following Wednesday (10/09/13) is when I spoke to (physician name withheld)." On 10/24/13 at 11:02 a.m., LPN #3 was asked if she witnessed the fall on 10/04/13 as she had documented the fall in the nurses' notes. She stated she did not see the fall but did respond to it. LPN #3 was asked how she assessed the resident after the fall. She stated, "I touched him, moved his legs and arms. He complained of pain to the knuckles." LPN #3 was asked if she did the manipulation of the legs and arms or if the resident moved the extremities on his own. She stated she manipulated the extremities herself. LPN #3 was asked if the resident was able to walk normally. She stated, "Yes." She stated before the fall on 10/04/13, staff was lifting him. She stated, "In report, they said he was becoming paralyzed. He was having them transfer him. He was telling them he was paralyzed." LPN #3 was asked if the resident had ever told her his legs were not working. She stated, "No. He told me he couldn't stand like he used to." On 10/24/13 at 11:34 a.m., RN #1 was asked if she did an assessment of the resident on 10/05/13 at 7:15 a.m., when the resident was leaning and stating he could not hold himself up. She stated, "I'm sure I did. I can tell you his (family member) had stated he fell the day before. There were no signs that he had fallen." She stated, "If you fell and hit your face, there would be marks. He was telling us he couldn't move his legs but we would walk by his room and he would bend his legs up. He was laying flat in the bed." RN #1 stated, "I walked by his room once and tickled his foot and he moved his foot." RN #1 was asked if she did an assessment when she saw the resident leaning to the right. She stated, "Not that I remember." RN #1 was asked if she assessed the resident on 10/06/13 at 1:45 p.m., when she had documented the resident refused to move anything. She stated, "I can't answer that. I don't remember. I'm sure I touched his legs and moved them." RN #1 was asked what she notified the physician of on 10/06/13 at 8:58 p.m. She stated, "His increased anxiety, the progressing I can't move, I can't move my body." RN #1 stated, "We hadn't seen any changes in his muscle strength." RN #1 was asked if the resident was able to transfer himself. She stated, "Yes." She was asked why the aides were using the hoyer lift to transfer the resident. She stated, "Because when they transferred him, he said it hurt so we used the hoyer lift." RN #1 was asked what she did when she noted the decline in transfer abilities. She stated she questioned him on it, did hand grasps, and talked to him about it. She stated, "I called (family member) about the increasing psychotic behaviors. It just seemed to follow along with it." RN #1 was asked when the resident became unable to transfer himself. She stated, "That weekend (10/05/13 - 10/06/13). Up until then he had always been able to (transfer self)." RN #1 was asked how she assessed and monitored the resident after he began to complain that his legs were not working. She stated, "When the aides were in, watched transfers. Checked quite often, watched him when he went out to smoke. Observed him." RN #1 was asked if she documented any of the assessments. She stated, "If it's not there, I guess I didn't." She stated, "He was still having them get him up to go smoke and could sit in the chair just fine." RN #1 was asked why the physician ordered a one time dose of [MEDICATION NAME] on 10/06/13. She stated, "Because of the increased anxiety and breathing. [MEDICATION NAME] had worked for him in the past." On 10/24/13 at 12:16 p.m., the DON was asked what the staff did when the resident began to complain of being unable to move his legs. She stated, "When I talked to them, (LPN #3) said he moved all his extremities and there was no pain. (ADON) said she had checked for movement. I talked to (RN #1). She said he was moving his extremities when staff wasn't around. He was not really walking. Said he would reposition his feet." The DON was asked if staff felt he was trying to hide his movements. She stated, "No." The DON was asked how staff assessed the resident to determine if there was something wrong with his legs. The DON stated, "(LPN #3) assessed after the fall and said he was moving all his extremities. (ADON) said she went down and touched the bottom of his feet. As far as standing, bearing weight, I don't believe anyone actually tried to do that." The DON was asked how staff monitored the resident. She stated, "I don't have an answer for that." The DON was asked what the staff notified the physician of. She stated, "His complaints." She was asked if staff contributed his complaints about his legs and the inability to hold himself upright to his behaviors. She sated, "I think a lot of it was. Prior to that, he had complained of arm paralysis and it wasn't." Review of the clinical record revealed no documentation of complaints of arm paralysis. The DON was asked what she would expect the staff to do when a resident presented with these complaints. She stated she did not understand. She was asked if she expected the staff to assess and monitor a resident's physical complaints, irregardless of any behavioral components. She stated, "Yes, but I didn't either." The DON was asked what she had done to educate her staff on assessing and monitoring since the incidents were brought to her attention. She stated, "Nothing. We still do what we've been doing. Transfer training." On 10/24/13 at 2:55 p.m., the physician was asked what the facility notified him of concerning the resident. He stated, "Numbness and trouble using his left leg." He was asked what the facility notified him of on 10/06/13 when the one time dose of [MEDICATION NAME] was ordered. He stated staff had reported the resident was refusing care and having behaviors. The physician was asked if the staff reported the resident stated he could not use his legs and that he could not hold himself upright in the wheelchair. He stated, "I don't recall that. I think it was a behavioral problem." 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 09/20/13 at 9:26 a.m., documented, "...Noted by CNA and observed on 09/19/13, pressure area to right hand middle finger. 0.5 x 0.5 round area lateral right middle finger proximal to ring finger. Area cleansed and foam put between fingers to reduce pressure. Noted a foul odor to hand. Nurse reports the bath aide and CNA was (sic) instructed to wash and dry the hand well. May use a non rinse soap if indicated. Will notify hospice..." Review of the clinical record revealed no documentation the physician was notified of the new pressure ulcer. Review of treatment sheets, dated 09/2013 and 10/2013, revealed no documentation of any treatments to the resident's fingers or hands. The resident's care plan, last updated 10/14/13, documented a problem, "...I am at risk for skin breakdown secondary to limited physical mobility..." The goal was, "...I will have intact skin, free of redness, blisters or discoloration by/through review date..." In

Based on observation, interview and record review, it was determined the facility failed to recognize pain, develop and/or implement pain management interventions, and/or monitor the effectiveness of pain management interventions for two (#1and #6) of three sampled residents with pain issues. The facility's failure to manage pain resulted in actual harm for residents #1 and #6. The facility identified 40 residents as being on a pain management program and three residents with indwelling urinary catheters. Findings: 1. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan, dated 06/10/12, documented a problem of pain. The problem was, "...I am on pain medication therapy r/t [DIAGNOSES REDACTED]. ordered...Review (Freq) for pain medication efficacy. Assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely; Controlled when therapeutic regimen followed, but not always followed as ordered; Therapeutic regimen followed, but pain control not adequate, changes required..." Physician monthly orders, dated 09/2012, documented the resident was to receive [MEDICATION NAME] (a pain medication), 5-325 mg one tablet by mouth three times daily for pain. It was also documented the resident could have [MEDICATION NAME] 325 mg two tablets by mouth every four hours as needed for mild pain. A quarterly assessment, dated 09/24/12, documented the resident was cognitively intact, was on a scheduled pain management program, had no as needed pain medications, and had experienced frequent pain in the preceding five days. It was documented the resident stated her pain made it difficult to sleep and it limited her day to day activities. The resident rated her pain as a "6" on a scale of zero to ten, with zero being no pain and ten being the worst pain imaginable. Review of the resident's clinical record revealed no documentation to show the resident's complaints of pain at a six, pain interfering with sleep, and pain limiting day-to-day activities were addressed. Medication administration records, dated 09/2012, documented the resident received her physician ordered [MEDICATION NAME] 5-325 mg at 8:00 a.m., 12:00 p.m., and 5:00 p.m. There was no documentation to show the resident had any scheduled pain medications between 5:00 p.m. and 8:00 a.m. There was no documentation to show the resident received any as needed [MEDICATION NAME] during the month of 09/2012. Physician monthly orders, dated 10/2012, documented the resident was to receive [MEDICATION NAME], 5-325 mg one tablet by mouth three times daily for pain. It was also documented the resident could have [MEDICATION NAME] 325 mg two tablets by mouth every four hours as needed for mild pain. A pain assessment, dated 10/03/12, documented the resident had experienced frequent pain in the previous five days. It was documented the pain made it difficult for the resident to sleep at night and limited her day to day activities. It was documented the resident rated her pain a "5." It was documented the resident had vocal complaints of pain and was on a scheduled pain medication regimen of [MEDICATION NAME] 5-325 mg one tablet by mouth three times a day with Tylenol 325 mg two tablets by mouth every four hours as needed for pain. Review of the resident's clinical record revealed no documentation to show the resident's complaints of pain at a five, pain interfering with sleep, and pain limiting day-to-day activities were addressed. Medication administration records, dated 10/2012, documented the resident received her physician ordered [MEDICATION NAME] 5-325 mg at 8:00 a.m., 12:00 p.m., and 5:00 p.m. There was no documentation to show the resident had any scheduled pain medications between 5:00 p.m. and 8:00 a.m. There was no documentation to show the resident received any as needed [MEDICATION NAME] during the month of 10/2012. Physician monthly orders, dated 11/2012, documented the resident was to receive [MEDICATION NAME], 5-325 mg one tablet by mouth three times daily for pain. It was also documented the resident could have [MEDICATION NAME] 325 mg two tablets by mouth every four hours as needed for mild pain. Medication administration records, dated 11/01/12 through 11/26/12, documented the resident received her physician ordered [MEDICATION NAME] 5-325 mg at 8:00 a.m., 12:00 p.m., and 5:00 p.m. There was no documentation to show the resident had any scheduled pain medications between 5:00 p.m. and 8:00 a.m. There was no documentation to show the resident received any as needed [MEDICATION NAME] during the time period. Review of the resident's clinical record revealed no documentation to show the resident's pain was assessed on a daily basis or that the resident's complaints of pain at a five or six were addressed. There was no documentation to show the resident was asked if she was in pain except on 09/24/12 and 10/03/12. On 11/26/12 at 4:15 p.m., the resident was observed lying in bed. Her brow was furrowed, and she was grimacing. The resident was asked if she was in pain. She stated, "Yes." The resident was asked what her pain level was on the zero to ten scale. She stated, "A five." The resident was asked what was the worst her pain ever was. She stated, "Ten." When asked what was the best her pain ever was, the resident stated, "A five." The resident was asked what pain level was acceptable to her. She stated, "I have to live with a five. That's the best my pain ever gets." The resident was asked if she had pain during the night. She stated, "Yes. Sometimes it wakes me up and I have a terrible time going back to sleep." The resident was asked if she requested additional pain medication. She stated, "Don't do any good. They say they've given me everything the doctor has ordered." The resident was asked if staff asked her to rate her pain on the night shift or if they talked with her about her pain. She stated, "No." On 11/26/12 at 4:56 p.m., CNA #3 was asked how she could tell if a resident was in pain. She stated by the "signs" they were expressing. CNA #3 was asked what she would do if she thought a resident was in pain. She stated she would let the nurse know. CNA #3 was asked if resident #6 complained of pain. She stated, "When I ask if everything is ok, she doesn't complaint of pain, so no." CNA #3 was asked if she asked the resident if she was in pain. She stated, "Yes." At 5:00 p.m., LPN #2 was asked how residents were monitored for pain. She stated, "Facial expression, tell us, nonverbals, ask them." LPN #2 was asked how often residents were assessed for pain. She stated, "Daily and (as needed)." When asked where the information was documented, LPN #2 stated, "On the progress notes." LPN #2 was asked how often resident #6 was assessed for pain. She stated, "Not daily." When asked how she knew the resident's pain medications were effective, LPN #2 stated, "She has not told me she has any pain." LPN #2 was asked if she asked the resident if she had any pain. She stated, "Yes." At 5:07 p.m., the MDS/Care plan coordinator was asked where she obtained the information related to pain on the resident's 09/24/12 quarterly assessment. She stated, "(Social services director) did some on the interviews. (Social services director) did the pain interview." At 5:12 p.m., the social services director was asked if she had helped with the interviews on the assessment. She stated, "Yes." When asked if she completed the pain interview for resident #6, she stated, "Yes." The social services director was asked what guidance she had been given related to pain for completion of the interview. She stated, "Usually if their pain is above four or five, I will let the nurses know. I will ask if they have asked for medication." The social services director was asked what she did when resident #6 complained of pain at a six. She stated, "I'm sure I told the nurse." At 5:15 p.m., the corporate nurse was asked if she noted any documentation of the nurse being notified of the resident's complaints of pain. She stated, "I don't but I'm still looking." The corporate nurse asked the social services director if she told the medication aide of the resident's pain. The social services director stated, "No, I told the charge nurse." The corporate nurse stated, "I don't see anything in the nurses' notes or social services notes." At 5:20 p.m., the DON was asked what the facility's policy on monitoring for pain was. She stated, "Whenever the resident is asking for pain medication, ask the pain level and go to the nurse." The DON was asked if residents were assessed for pain on a daily basis. She stated, "Not really on a daily basis." The DON was asked who was responsible for pain monitoring and assessing. She stated, "The charge nurse on each shift." The DON was asked what the facility's medication times were for medications to be given three times daily. She stated at 8:00 a.m., 12:00 p.m., and 5:00 p.m. The DON was asked why the resident's pain medications were given at those times. She stated, "If that is how he (the physician) ordered it unless he specified different." The DON was asked what pain medication coverage the resident had at night. She stated, "Nothing I can see unless Tylenol for breakthrough." 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospice records, dated 09/14/12, documented the resident began receiving hospice services due to a [DIAGNOSES REDACTED]. An annual assessment, dated 10/08/12, documented the resident was moderately impaired in cognitive skills and had a urinary catheter. The resident's care plan, last updated 10/11/12, documented a problem of a urinary catheter. The problem was, "...I have a (sic) indwelling foley catheter for [DIAGNOSES REDACTED]. for s/sx of discomfort on urination and frequency...Monitor/document for pain/discomfort due to catheter..." The care plan also documented a problem of, "...I have a terminal prognosis r/t [MEDICAL CONDITION] disease with declining renal function..." The goal was, "...My comfort will be maintained through the review date..." Interventions included, "...Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate...Consult with physician and Social Services to have hospice care for resident in the facility...Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain...(hospice name withheld) services d/t terminal [DIAGNOSES REDACTED]. The resident's care plan did not identify how care was to be coordinated between the facility and hospice, including what the resident's preferences were regarding care at the end of life, what interventions should be put into place, and how the interventions would be monitored for effectiveness. Physician monthly orders, dated 11/2012, documented the resident was to receive [MEDICATION NAME], a pain medication, 7.5/500 mg twice daily at 8:00 a.m. and 8:00 p.m. It was also ordered for the resident to receive [MEDICATION NAME] 7.5/500 mg every six hours as needed for pain. On 11/27/12 at 9:42 a.m., the resident stated, "I'm hurting so bad I can't stand it." The resident was asked if she had requested pain medication. She stated, "I asked for a pain pill about an hour ago. I asked and asked yesterday." The resident was asked what her pain level was now, on a scale of zero to ten, with zero being no pain and ten being the worst pain imaginable. She stated, "An eight or nine." The resident stated she was having pain related to her urinary catheter. She stated the catheter had been leaking on the previous day and the staff had changed the catheter but she continued to have burning, pain, and irritation. The resident was asked who she had told she needed pain medication. She stated, "The aides are the ones that go and tell them I need a pain pill. Whether they do or not." The resident stated, "I can't eat or sleep. I kept waking up last night. I couldn't sleep." At 10:13 a.m., CNA #4 was asked what time she had reported for work. She stated her shift started at 6:00 a.m. CNA #4 was asked if any resident had complained of pain. She stated, "(Resident #1)." CNA #4 stated she had informed the nurse. She stated the incident occurred between 8:30 a.m. and 9:00 a.m. CNA #4 stated, "She's on pain meds and she gets them with breakfast." CNA #4 stated she had informed LPN #3. The resident's clinical record was reviewed. It was documented the resident received her routine pain medication as ordered on [DATE] but did not receive any as needed pain medication. There was no documentation recorded in the clinical record regarding the resident's complaints of pain on 11/26/12. It was documented the resident received her routine pain medication of [MEDICATION NAME] 7.5/500 mg at 8:00 a.m. on 11/27/12. At 10:18 a.m., LPN #3 was asked if anyone had reported to her a resident was in pain. LPN #3 stated one resident's name but the resident was not resident #1. LPN #3 was informed the resident was complaining of pain of an eight or nine and had stated she had requested pain medication approximately one hour earlier. LPN #3 was informed the resident had stated the pain was related to her urinary catheter. LPN #3 stated she would speak with the resident and assess the resident's catheter. At 10:31 a.m., CNA #4 came to the surveyor and stated she had been mistaken and it was LPN #1 she had informed of the resident's pain. The November 2012 MAR indicated [REDACTED] At approximately 12:30 p.m., LPN #3 stated it had been determined there was an issue with the resident's urinary catheter and hospice had been notified to assess the resident's catheter. The resident's clinical record was reviewed again. It was documented in the clinical record, "...11/27/2012 10:45 a.m...Nurse's note...Resident c/o pain 8 1-10 scale in vaginal area. Hospice notified. Hospice to send out nurse at (1:30 p.m.) today to check catheter. Catheter continues to leak. Resident was given prn [MEDICATION NAME] for pain..." There was no documentation to indicate facility staff addressed the problems with the indwelling urinary catheter other than to call hospice. At 2:27 p.m., LPN #1 was asked if CNA #4 had informed her the resident was experiencing pain. She stated, "Yes. She did come to me but I don't remember what was going on. I just missed it." At 2:37 p.m., the MDS/care plan coordinator was asked how the resident's care plan addressed the coordination of hospice care including each parties' responsibilities. She reviewed the care plan and stated, "It doesn't."

Based on observation, interview, and record review, it was determined the facility failed to: a. provide thickened liquids per physician's orders for 6 (#1, #6, #12, #13, #17, and #18) of 7 sampled residents who had orders for thickened liquids; b. failed to follow the physician's order for excluded food items identified as choking hazards for 1 (#6) of 1 sampled resident who had physician orders to exclude food items due to choking/aspiration risk; and c. failed to provide supervision during meals for 1 (#6) of 6 sampled residents who needed supervision during meals. This had the potential to: a. affect 10 facility residents with physician orders to receive thickened liquids; b. affect 1 facility resident with physician orders to exclude food items identified as choking/aspiration risk; and c. affect 58 facility residents identified on the facility's resident census and conditions to need, at the minimum, supervision with meals. The facility's failure to provide thickened liquids to residents with known risks of aspiration resulted in an immediate jeopardy situation. Findings: 1. Resident #18 was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. A post radiologic dysphagia evaluation report, dated 01/23/07, documented the resident had laryngeal penetration with puree and mechanical soft diets, and tracheal aspiration with mechanical soft and puree diets. The report documented the resident had moderate oral dysphagia. A hospital discharge summary, dated 05/10/10, documented the resident had a long standing history of frequent pneumonias, usually right sided. The summary documented the physician suspected the resident might have some aspiration component to the pneumonias due to his dysarthria from a previous [DIAGNOSES REDACTED]. A nutritional assessment, dated 01/25/11, documented the resident was to have a no added salt diet, nectar thick liquids, and could have milk unthickened. A quarterly assessment, dated 06/20/11, documented the resident was cognitively intact, required supervision with eating, and was on a mechanically altered diet. On 09/11/11 at 7:50 a.m., the resident was observed in the dining area eating breakfast. The resident's coffee was thickened. On 09/14/11 at 10:30 a.m., the resident's room was observed. There was a small cup of coffee and water on the overbed table. Neither cup was thickened when poured. There was a pitcher of ice water near the sink. The water in the pitcher was not thickened. There were multiple open bottles of water in the resident's personal refrigerator. None of the bottles of water were dated or thickened. There were 2 canisters of thickener in the room. One canister was near the resident's television on the dresser near the foot of the bed. The resident stated the water by his coffee was for swallowing medications. The resident stated the bottles in the refrigerator were re-used to keep the water cold. On 09/14/11 at 2:30 p.m., the ice water in the resident's pitcher, in his room, was observed to not be thickened. The water on the overbed table was not thickened. The water bottles in the resident's refrigerator were not thickened. On 09/14/11 at 5:15 p.m., an interview was conducted with CNA #5 and LPN #4. CNA #5 was asked who was responsible for thickening the liquids for the resident. The CNA stated she did not know, but would ask the charge nurse. LPN #4 walked over and stated the staff was to make sure liquids were thickened by thickening the fluids when they were passed. The LPN then instructed the CNA to thicken the water for those residents requiring thickened liquids when water was passed. On 09/14/11 at 6:20 p.m., the water in the water pitcher by the sink, did not have thickener in it. The bottles of water in the refrigerator were not thickened. The cup of water on the overbed table was not thickened. 2. Resident #6 was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. A dysphagia evaluation, dated 01/21/11, documented the resident was a good candidate for dysphagia treatment and displayed moderate signs of aspiration risks. The evaluation documented the resident could benefit with education on compensatory techniques to utilize a safer swallow and dietary modification might be needed to ensure a safe oral intake. A physician's order, dated 02/10/11, documented the resident liked thickened apple/cranberry juice. A physician's progress note, dated 02/16/11 at 4:00 p.m., documented the resident had congestion and was suspected to have aspiration pneumonitis. A speech therapy memo, dated 03/11/11, documented the resident had severe signs/symptoms of aspiration with thin liquids, especially milk. The memo documented a recommendation for the resident to have nectar liquids at all meals and to refrain from milk during meals. The care plan, dated 04/06/11, documented the resident was on a therapeutic/mechanical soft diet, had a poor appetite, and was at risk for weight loss. The care plan documented the resident was at risk for aspiration and received liquids thickened to nectar consistency. The care plan documented to refer to the physician's orders for the current diet order and the resident could have a pureed diet as tolerated. A physician's order, dated 04/08/11, documented the resident's diet was to be changed to mechanical soft with no bread or milk. A physician's order, dated 04/11/11, documented to change the diet to regular/mechanical soft or pureed as needed. A quarterly assessment, dated 06/23/11, documented the resident was moderately impaired related to cognitive status and required supervision or cues with meals. The August 2011 monthly physician's orders documented a 05/24/11 order for a regular, mechanical soft diet with nectar thickened liquids. The order documented to encourage double swallow, small bites/sips, and to alternate liquids/solids. The order documented, "No milk, no bread." A nutritional assessment, dated 08/16/11, documented the following: regular diet, mechanical soft, nectar thick liquids, encourage double swallow, small bites/sips and alternate liquids/solids, no milk, no bread, and may give puree as needed. On 09/13/11 at 12:32 p.m., the resident was observed in the dining room at the assisted table. When asked if he liked his meal, he stated, "I don't like that bread. I like light bread." The resident had been served a piece of homemade bread, which he did not eat. The resident stated, "The coffee is so thick, you couldn't drink it." The grape juice was observed to have settled thickener in it. The resident was asked if anyone had told him to not eat bread. He stated, "Yes, they tell me I could choke." When asked if the staff ever gave him bread, the resident stated, "Sometimes." When asked if light bread made him choke, the resident stated, "Sometimes." The certified dietary manager was asked to look at the diet card for the resident. The tray card documented no bread, no rice, and no chicken. The dietary manager stated thickened liquids were not written on the tray cards. When asked why the bread was on the resident's plate, the dietary manager stated, "Yeah, I saw that. He won't eat it." While the resident ate his meal, no staff member was observed to supervise or cue him regarding his intake of foods/liquids. On 09/13/11 at 2:10 p.m., the speech therapist was interviewed regarding resident #6. The speech therapist stated the resident was at high risk for aspiration and that he had spoken to the family and the physician regarding the risk. The therapist stated the resident does what he wants to do. The therapist stated the resident was at high aspiration risk when eating breads and rice. He stated the resident could easily aspirate on crumbs and that cakes were especially a risk, even more so than breads. The therapist stated the resident really struggled with milk. On 09/13/11 at 2:40 p.m., the physician's assistant for the resident's primary physician was called and interviewed related to the resident's medical status. She stated the resident had a history of [REDACTED]. She stated the resident was at risk for aspiration. On 09/14/11 at 11:05 a.m., the resident was observed lying in his bed. The resident was asked if he drank the water in the pitcher at his bedside. The resident stated, "I don't like ice in water, gives me chills." The water in the pitcher was observed to be unthickened and had ice in it. On 09/14/11 at 11:15 a.m., the primary physician for resident #6 was at the facility and interviewed regarding the resident's medical condition. The physician stated the resident always had a cough and congestion. On 09/14/11 at 11:55 a.m., the water in the resident's room was observed to be unthickened. A Thicken Up container was observed on the bedside nightstand with the last name of the resident, the word, "nectar," and "11-12-1" written on the lid. There was no scoop, spoon, or other measuring device for the thickener observed. On 09/14/11 at 12:00 p.m., the Director of Nursing (DON) was asked who passed water to the residents. The DON stated nurse aides were assigned to do this. When asked how a person would know if a resident was on thickened liquids, the DON stated, "There should be an indicator on the door by their name." When the DON was asked to look at the resident's name on the door, she stated, "He does not have an indicator by his name." The DON looked at the water pitcher and thickener container in the room. She agreed there was no measuring device for the thickening powder and did not know what the numbers on the container lid stood for by the way it was written. On 09/14/11 at 12:25 p.m., the resident was observed eating hurriedly at lunch and was asked if he had always eaten at a fast pace. He stated, "Yes." The speech therapist was with the resident and said the juice and coffee were at an acceptable thickened consistency. The resident was observed to cough during the meal when eating. The speech therapist stated, "He's going to eat at his own pace." The therapist stated the resident's choking spells had decreased since not receiving bread. At 12:55 p.m., the resident's juice was observed to have the thickener settled in the bottom half of the juice glass. The resident's care plan did not address the physician's orders to encourage the resident to double swallow, take small bites/sips, and to alternate liquids/solids. The care plan did not document the physician's order to not give the resident milk or bread. The care plan did not address the resident's preferences or dislikes related to his diet orders. 3. Resident #17 was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. A care plan, dated 06/14/11, documented the resident was on a pureed diet with nectar thickened liquids. The care plan documented the resident was able to feed herself, but tired easily and might need assistance to complete the meal. A modified barium swallow report, dated 07/21/11, documented the resident had aspiration with thin liquids by cup sip. The report documented additional consistencies resulted in a normal oral and pharyngeal swallow without residue, penetration, or aspiration. A quarterly assessment, dated 09/01/11, documented the resident had severely impaired cognition, was nonambulatory, required one person assistance with eating, and required extensive to total assistance with all other activities of daily living. The assessment documented the resident was on a mechanically altered diet. The [DATE] monthly physician's orders documented the resident was to receive a pureed diet with nectar thickened liquids. The resident was to swallow twice and remain upright for at least 15 minutes after meals. On 09/14/11 at 10:45 a.m., a pitcher of water was observed on the overbed table at the foot of the bed of resident #17. The water was at room temperature and was not thickened. On 9/14/11 at 2:35 p.m., the resident was observed to be asleep in bed. The water pitcher was on the overbed table. The water was at room temperature and was not thickened. There was a canister of thickener on the bedside table. On 09/14/11 at 4:27 p.m., an interview was conducted with CNA #3. The CNA stated there were 2 residents on the hall who required thickened liquids. The CNA stated they were residents #1 and #17. The CNA was escorted into each resident's room to observe the fluids. The CNA stated the water in resident's #1 pitcher was not thickened. CNA #3 was followed into the room of resident #17. The CNA stated the water in the pitcher was not thickened. When asked how to thicken the fluids for the resident, the CNA stated to read the directions on the side of the can and add the amount of thickener listed to the water. When asked how much to add to the pitcher, the CNA looked at the can and stated, in a questioning tone, "3 teaspoons?" When asked why the water was not thickened, the CNA stated the water was passed on the day shift and should have been thickened then. When asked if the resident required assistance to drink, the CNA looked at the resident and stated no, the resident was able to drink independently when sitting upright. On 09/14/11 at 6:25 p.m., an observation of the room of the resident was conducted. The water in the water pitcher on the over bed table was not thickened. The water did not have ice and was at room temperature. 4. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly assessment, dated 06/07/11, documented the resident needed extensive assistance with activities for daily living, required assistance with eating, was incontinent, and had a history of [REDACTED]. A nurse's note, dated 08/09/11, documented the resident was coughing during breakfast and after each drink of thin consistency liquid. The physician's order sheet, dated 08/09/11, documented an order to change the liquids consistency to nectar. The care plan, last updated 08/09/11, documented the resident was to receive nectar thickened liquids due to choking. The care plan documented the resident needed assistance with all activities of daily living. The physician's order sheet, dated 09/05/11, documented the diet to be: no added salt, mechanical soft or pureed, as needed, due to chewing and swallowing difficulties at times. On 09/14/11 at 11:00 a.m., the resident was in her room sitting in a chair with a sippy cup sitting on the overbed table. The cup was observed to have regular consistency water with ice. There was a can of thickener sitting on the table. At that time, CNA #21 was asked who put the water in the cup. She stated she put the water in the cup at 9:45 a.m. The CNA was asked why there was no thickener in the water. She stated the resident had not gotten a drink yet because staff had to hold the cup for her. The CNA was asked if the ice would thin the thickened water down and she stated, "Right." The CNA was asked if the resident coughed or choked on thin liquids. She stated she will cough sometimes on liquids. The CNA was asked how much thickener she put in the cup. She stated she used one scoop. The CNA was asked if she knew how many ounces of water was in the sippy cup. She stated, "No." 5. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was re-admitted on [DATE] with a right hip fracture, end stage Alzheimer's, dementia, osteoporosis, debility, anorexia, and failure to thrive. The significant change assessment, dated 06/02/11, documented the resident was severely impaired in decision making, had long and short term memory problems, needed extensive to total assistance for all activities of daily living (ADLs), had weight loss, pain, falls, and bilateral pressure sores on the heels. The care plan, last updated on 08/31/11, addressed falls, bilateral heel pressure sores, skin, weight loss, nutrition, and impaired cognition. On 09/12/11 at 12:15 p.m., the resident was observed in the dining room, being assisted with eating and drinking by the staff. The resident was a very slow eater and, per staff, preferred to drink than eat. The physician's order sheet, dated 09/13/11, documented the speech therapist was to screen for food texture and swallowing problems due to decreased intake. On 09/13/11, the speech therapist note documented the screening for dysphagia was completed. The note documented a recommendation for honey thickened liquids, with a puree diet as tolerated. On 09/13/11 at 5:00 p.m., the thicken up container was placed at the resident's bedside after the speech therapist consult. The bedside water was not thickened at that time. On 09/14/11 at 1:00 p.m., the resident's bedside water was observed to not be thickened. The sealed container of thicken up was at the bedside. A hospice staff person was at the bedside and agreed the liquids were not thickened and would take care of it. The hospice person stated the resident was declining and would not drink at that time. 6. Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. A telephone order, dated 04/08/11, documented to change the diet to pudding thickened liquids. The nutritional assessment, dated 04/12/11, documented the resident had poor chewing and swallowing ability. The assessment documented the diet had been changed to pudding thick liquids. The quarterly assessment, dated 07/20/11, documented the resident had memory problems, was severely impaired in cognitive skills for daily decision making, and needed total assistance of one person for eating. The assessment documented the resident had no signs and symptoms of a possible swallowing disorder. The current physician's orders, dated September 2011, included orders for a pureed diet with pudding thick liquids. Review of the resident's clinical record revealed there was no speech therapy evaluation to assess the resident's swallowing capability. On 09/14/11 at 10:45 a.m. and 11:55 a.m., the resident's water in the pitcher in her room was observed to have regular consistency water with ice. On 09/14/11 at 12:15 p.m., the resident was observed to eat lunch at the assistive table. The thickened Koolaid was observed to be thick but still poured when the resident was given a drink. The surveyor asked the speech therapist to look at the consistency of the resident's drink. He stated it was barely honey consistency and needed to be thickened. The speech therapist was asked if he had done a swallowing evaluation on the resident. He stated he had not seen the resident. On 09/14/11 at 4:22 p.m., the CNA (#20) working on the resident's hall was asked if the resident was on thickened liquids. She stated yes she got thickened liquids. The CNA was asked who thickened the water in the pitchers in the resident's room. She stated she did not know but thought the CNAs who pass the water did it. The CNA was asked how long she had worked at the facility. She stated 4 weeks. The CNA was asked if she received any training in orientation regarding thickened liquids. She stated she didn't remember. On 09/14/11 at 4:40 p.m., the DON was asked why the resident needed the pudding thickened liquids. She stated if the resident received a food with texture she would spit it out, but she had not seen the resident choke. The DON stated she did not think the resident had a speech therapy evaluation. She stated she didn't know the resident had a problem with water and thought maybe it was due to the consistency with the diet order. The DON was asked who was supposed to thicken the liquids in the resident rooms. She stated the CNAs were to thicken the liquids and were taught in orientation. The DON stated the thickened consistency should be on the door in the form of a picture by the resident's name. She was asked if all the residents on thickened liquids had the picture on the door. She stated some had it and some didn't, it wasn't perfect. 7. Other interviews conducted related to knowledge of thickened liquids included the following: On 09/14/11 at 4:20 p.m., CNA #6 was asked how the staff could identify a resident who had thickened liquids ordered. The CNA stated there was a picture by the resident's name on the door - a peach for nectar, a honey jar for honey consistency. When asked how a staff person would know how much thickener to put in a resident's liquids, CNA #6 stated the thickener container has the directions on it. On 09/14/11 at 4:25 p.m., LPN #5 was asked how residents could be identified who required thickened liquids. She stated she referred to the list posted in the front of the MAR. When asked how the CNAs would know which residents required thickened liquids, she stated the aides would know because of passing trays to the residents at mealtimes and thickener present at the bedside. When asked if she had been orientated on the procedure for thickened liquids, she stated, "Yes." When asked to look on one medication cart for thickener, she observed the cart and said, "No, but we have access to thickener." On 09/14/11 at 4:30 p.m., LPN #4 was interviewed regarding the procedures for identification of residents with thickened liquid orders. The LPN stated there was a list of residents posted at the nursing station and an indicator on the residents' doors. When asked to observe the name/door of resident #18, the nurse stated she did not know what the picture on the sign by the name was. The LPN stated the kitchen tray card should indicate the fluid consistency and the liquids should already be thickened by the kitchen staff when served to the resident. When asked how she thickened liquids for the residents, LPN #4 stated she just poured a little (thickener) and stirred until it looked right. When asked if there was any other method of thickening the liquids besides the thickening powder, she stated she was not aware of any. On 09/14/11 at 4:45 p.m., CMA #1 was interviewed regarding residents with thickened liquid orders. She stated there was Thicken Up on the medication carts. She stated she used a medication cup to measure the amount of powder to use per the instructions on the Thicken Up container. When asked which residents were on thickened liquids, CMA #1 stated there was a list in the Medication Administration Record (MAR) and at the nurses' desk. Immediate Jeopardy Identified: On 09/14/11 at 5:00 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of an IJ related to the facility's failure to provide thickened liquids to residents who required thickened liquids due to aspiration risks. On 09/14/11 at 5:07 p.m., the administrator and DON were notified of the IJ situation and an extended survey was required. Facility Plan of Removal for IJ: On 09/14/11 at 7:55 p.m., a plan of removal for the immediate jeopardy was presented to the surveyors and accepted. The plan of removal documented: "Problem Identified: Thickened Liquids Two residents were found to not have thickened liquids per orders, while a total of ten residents are at risk. Plan of Action: In servicing will be completed by Speech Language Pathologist (name deleted) and DON (name deleted) on 09/14/2011 at 1930 (7:30 p.m.) In-service all staff on the following in regards to administration of thickened liquids. 1) Correct method of identifying those residents designated as receiving thickened liquids. a) Placement of residents list with those receiving thickened liquids in dining room at service window for quick reference check. Certified Dietician will be responsible for updating list. b) Placement of specific thicken identification on resident's door by their name with following: honey pot for honey thick, nectarine for nectar thick and bowl of pudding for pudding thick. Information will be updated by MDS (minimum data set) nurse. 2) Staff will be in serviced regarding proper consistency of honey, nectar and pudding thick consistencies. A demonstration will be conducted to show staff proper thickening technique. 3) Thickener will be placed in those residents rooms with orders for thickened liquids. Thickening containers (plastic-lidded) will be labeled with residents name, date container was filled and instructions for mixing with fluids. Container placement and content will be monitored by the ADON (assistant director of nursing) per direction of DON for compliance. CNA's (certified nurse aides) and CMA's (certified medication aides) compliance in utilizing thickener will be evaluated per random check by the DON. 4) P/P (policy/procedure) will be revised as needed. CAN's (sic, CNAs) assigned to care for resident and provide water in room will be responsible for thickening of residents water to physicians ordered consistency. 5) Frequency and length of time for monitoring will begin 09/14/2011 following completion of in-service and continue with recorded documentation times 60 days then observed daily as care continues. All new employees will be orientated regarding thick liquids and aspiration precautions/risk. 6) Any staff not attending in-service will not be allowed to work until they have been properly in serviced." Immediacy of IJ removed: On 09/15/11 at 9:30 a.m., the administrator and DON provided documentation ensuring all staff had been inserviced on the facility policy and procedures related to thickened liquids. Staff were interviewed in regard to their knowledge of the inservice and the facility's policy and procedures related to thickened liquids. On 09/15/11 at 6:00 p.m., the DON was notified the immediacy of the IJ was removed at 8:45 p.m. on 09/14/11 after verification of completion of the plan of removal. The deficient practice remained at a pattern level with no actual harm with potential for more than minimal harm.