Every finding on record at Colonial Manor Nursing Home

Based on observation, record review, and interview, the facility failed to ensure a person-centered care plan for a contracture was developed for 1 (#1) of 3 sampled residents reviewed for care plans.The DON identified two residents with contractures resided in the facility. Findings:On 03/04/26 at 9:53 a.m., Resident #1's left leg was observed to be contracted. Their left leg was bent at the knee, and their left ankle was under their right knee.An undated policy titled Comprehensive Care Plans, read in part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.The comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.A care plan for Resident #1, dated 02/23/26, showed the resident had diagnoses which included osteoarthritis of unspecified hip, cerebral infarction (a stroke), and aseptic necrosis of the left femur. The care plan showed the the resident required assistance for lower body dressing and a total lift for transfers. The care plan did not address Resident #1's left leg contracture.On 03/04/26 at 9:53 a.m., Resident #1 stated their leg became contracted at another nursing facility due to a stroke. They stated they wore a compression sleeve on their left leg for comfort and required pain medication to help manage the pain.On 03/05/26 at 7:25 a.m., certified nurse aide #1 stated they utilized care plans as a guide to care for the residents in the facility. They stated Resident #1's care plan did not address their left leg contracture.On 03/05/26 at 7:30 a.m., registered nurse #1 stated Resident #1's left leg contracture was not listed on their care plan.On 03/05/25 at 7:57 a.m., the MDS coordinator stated Resident #1's left leg contracture was not but, should have been included in their care plan.On 03/05/26 at 8:06 a.m., the DON stated Resident #1's left leg contracture should have been included in their care plan.

Based on record review and interview, the facility failed to complete a quarterly assessment for 1 (#2) of 3 sampled residents reviewed for quarterly assessments.The administrator identified 52 residents resided in the facility. Findings:An undated policy titled MDS 3.0 Completion showed the facility was to complete quarterly comprehensive assessments no greater than 92 days from the resident's last quarterly assessment.A quarterly assessment for Resident #2, dated 11/18/25, showed the resident had diagnoses which included parkinsonism and diabetes mellitus. A comprehensive assessment list for Resident #2 showed a quarterly assessment was to be completed by 02/18/26 and was in progress.On 03/05/26 at 7:55 a.m., the MDS coordinator stated Resident #2's quarterly assessment was due on 02/18/26 and should have been completed.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor, and intervene for a change in condition for:1. Resident #8 who reported chest pain on [DATE] at 7:46 a.m. A progress note showed vital signs were taken, but no other action was documented, and2. Resident #7 who was reported by RN #1 to be slumped over the table in the dining room on [DATE] during the noon meal. The note showed Resident #7 was removed from the dining room and taken to their room. No other actions were documented.On [DATE] at 12:06 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.On [DATE] at 12:45 p.m., the DON and administrator were notified of the IJ situation and provided the IJ template.On [DATE] at 11:41 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,Plan of Removal: IJ for Failure to Assess, Monitor [and] InterveneCorrective Actions TakenImmediate Clinical Response:Nurse managers and charge nurses completing facility wide assessments of all residents to establish baselines. If concerns are found, notify DON, the party responsible and residents Physician immediately to get orders in place. The Medical Director was notified immediately and made aware of IJ status and action plan of interventions.All policies on change of condition, monitoring, and interventions reviewed and revised. Clinical systems revised to flag key indicators requiring escalation via E-interact and Change of Condition communication forms. E- Interact will populate to the Clinical Dashboard and 24-hour report. Staff Notification:All clinical staff were informed of the deficiency and advised of immediate changes in protocol. That includes the implementation of the E-Interact and the Change in Resident Status communication form.A mandatory in-service training was immediately scheduled and will be completed within 24 hours.Any staff that are not able to complete training within 24 hours will be required to complete training prior to working next scheduled shift. Education & TrainingEmergency Staff Education:Licensed nurses and CNAs received training on policy and procedure over Change in Resident Status or Conditions.Focus included documentation, escalation pathways, and timely physician notification.Educated and implemented use of E- Interact SBAR (Situation-Background-Assessment-Recommendation) and utilization of Change in Resident Status communication form. Competency Validation:Senior Director of Clinical Services trained Director of Nursing over processes of implementation of E- Interact SBAR (Situation-Background-Assessment-Recommendation) and utilization of Change in Resident Status communication form.Director of Nursing trained nurse management and charges nurses over processes and implementation of E- Interact SBAR (Situation-Background-Assessment-Recommendation) and utilization of Change in Resident Status communication form.Staff will verbalize understanding of training and observation of change in condition and assessment. RN Supervisor Role Expansion:DON will perform daily audits of residents with identified clinical risks.Shift Huddles Introduced:Begin and end-of-shift meetings instituted to identify potential high-risk residents starting [DATE]. Date of Compliance:Compliance Date: [DATE]The IJ was lifted, effective [DATE] at 12:25 p.m., when all components of the plan of removal had been verified as completed. Review of policy changes for change of conditions was conducted, clinical system changes were reviewed, review of the resident assessments for all 55 residents were completed, clinical staff were interviewed regarding changes in policy for change of condition, communication with facility staff and timely notification to physician of a change in condition. The DON was interviewed regarding in-service with the senior director of clinical services and daily audits of residents at risk. Review was completed of the Beginning and end of shift meetings documentation sheets. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to assess, monitor, and intervene for a change in condition for 2 (#7 and #8) of 3 sampled residents reviewed for a change in condition.The administrator identified 55 residents resided in the facility. Findings:1.A physician's order for Resident #8, dated [DATE], showed to administer a 24-hour nitroglycerin patch 0.1mg/hour transdermally in the morning related to angina pectoris and to take off after 24 hours.An annual assessment, dated [DATE], showed a BIMS of 15 which indicated Resident #8 was cognitive for daily decision making. The assessment showed diagnoses which included diabetes, heart failure, hypertension, angina pectoris, and end stage renal disease.The [DATE] MAR for Resident #8 showed the nitroglycerin patch was not administered on [DATE]. The MAR showed routine simethicone 80 mg for gas and as needed calcium carbonate (Tums an antacid) were not administered for indigestion on [DATE]. A progress note, dated [DATE] at 7:46 a.m., showed Resident #8 complained of chest pain and vital signs were within normal limits. The note showed Resident #8 stated the chest pain was probably indigestion. No other assessment was documented. The note did not show the physician was notified. The note was entered by RN #1,A progress note, dated [DATE] at 11:30 a.m., showed Resident #8 was found without breath and pulse, CPR was started, notification was made to the DON, ADON, and emergency medical services authority. The note did not show the physician was notified. The note was entered by RN #1.A progress note, dated [DATE] at 1:24 p.m., showed the physician was notified of Resident #8 passing at the facility and an order was received to release the body to the funeral home.On [DATE] at 10:48 a.m., RN #1 stated on the morning of [DATE] Resident #8 reported pressure in their chest, their vital signs were within normal limits, and they asked Resident #8 if they thought it was chest pain or indigestion. RN #1 stated Resident #8 replied they thought it was indigestion and Resident #8 went back to bed. They stated later they looked back in on Resident #8 in their room, and they were lying on the bed with their back to the door. RN #1 stated they assumed Resident #8 was sleeping, then left the room, and checked blood sugars for other residents. RN #1 stated when they returned to Resident #8 at 11:30 a.m., they found Resident #8 without breath and pulse. They stated Resident #8 had been complaining about not feeling well for a couple of weeks.2.An admission assessment for Resident #7, dated [DATE], showed diagnoses which included cerebral vascular accident (CVA/stroke), transient ischemic attack (TIA/mini stroke), and Parkinson's disease.A care plan for Resident #7, revised [DATE], showed no concerns for CVA or TIA.The [DATE] MAR showed on Friday [DATE] a blood pressure of 162/103 was recorded. There was no follow up blood pressure recorded and no assessment was located in the clinical record. Review of progress notes showed no progress note for [DATE].A progress note, dated [DATE], showed Resident #7 was unable to sit up and eat at lunchtime. The note showed Resident #7 kept falling forward and putting their head on the table and then Resident #7 was returned to their bed by RN #1. No actions were recorded in the progress. The note was documented by RN #1.A progress note, dated [DATE], showed the representative for Resident #7 came to the nurse's station and stated they thought Resident #7 had a stroke and it had to have happened earlier in the day. The note showed the representative wanted Resident #7 sent to the emergency room for evaluation. The note showed 911 was called and Resident #7 was taken to the emergency room. The note was documented by LPN #1.Hospital records for Resident #7, dated [DATE] at 11:10 p.m., showed results of a CT chest procedure. The results showed findings of a pulmonary emboli in the distal right pulmonary artery.On [DATE], at 8:50 a.m., the representative for Resident #7 stated they had found Resident #7 on [DATE] at 7:00 p.m., in the dining room, slumped over with a peanut butter sandwich in their hand. They stated they told the nurse to call 911 because Resident #7's face was drooped. The representative for Resident #7 stated the hospital informed them Resident #7 had a pulmonary embolism.On [DATE] at 9:40 a.m., CNA #4 stated they tried to feed Resident #7 their breakfast on [DATE], but they were sleepy. They stated they tried to talk to Resident #7, but the resident did not talk to them and would not eat the pancake. CNA #4 stated Resident #7 was sitting up straight in their wheelchair. On [DATE] at 9:52 a.m., CMA #1 stated Resident #7 seemed sleepy on [DATE], but took their medications fine. They stated Resident #7 was slumping over the table and it was unusual. CMA #1 stated they did not report the unusual behavior to anyone.On [DATE] at 10:15 a.m., CNA #3 stated Resident #7 was very quiet and did not eat as well as usual on [DATE]. They stated Resident #7 seemed out of it and was not as alert as they usually were. CNA #3 stated Resident #7 had some drooping on the right side of their face. They stated during dinner Resident #7 was bent over the table, but did not report that to anyone. CNA #3 stated they thought it was because Resident #7 was tired. On [DATE] at 10:30 a.m., CNA #1 stated they saw Resident #7 on [DATE] in the dining room staring off into space. They stated Resident #7 was leaning to the right and they straightened Resident #7 up in their wheelchair. CNA #1 stated they did not report it to anyone because they did not think it was unusual.On [DATE] at 10:35 a.m., CNA #2 stated on [DATE] Resident #7 seemed a little tired at lunch and for a moment Resident #7 kind of got a strange look on their face. CNA #2 stated when Resident #7 was questioned about how they felt they stated they were okay. They stated the ADON was at the table and thought Resident #7 was okay as well.On [DATE] at 10:39 a.m., LPN #1 stated on [DATE] they were getting ready to leave for the day and the representative for Resident #7 approached them at approximately 7:00 p.m., and stated Resident #7 had a stroke and needed to be sent out to the emergency room. They stated the representative informed them Resident #7 was slumped over when they came in and did not look right. LPN #1 stated they had not noticed anything unusual with Resident #7 during dinner because they were feeding two other residents. On [DATE] at 10:54 a.m., RN #1 was asked about their progress note entered on [DATE]. They stated on [DATE] Resident #7 was sleeping at the table in the dining room for lunch and it was not unusual. RN #1 stated very seldom would Resident #7 have their eyes open while they were fed and did not really respond in any way. They stated Resident #7 was frequently drowsy, as they were that morning and would not open their mouth. RN #1 stated they felt if Resident #7 was leaning and unable to sit up they would be better off in bed, so they took Resident #7 back to their room. They stated they did not remember if they had completed an assessment on Resident #7, but if they had, the assessment would be in the progress note. RN #1 stated the did not think they would have charted an assessment because it was not unusual. They stated if Resident #7 was leaning they wanted them safe, and it just seemed out of the ordinary Resident #7 was leaning, but everything else seemed within normal limits. RN #1 was asked if they were made aware of a blood pressure on Friday [DATE]. They stated they remembered the CMA had reported a blood pressure for someone being elevated, but could not recall who the resident was. RN #1 stated the blood pressure should have been rechecked. RN #1 was asked what the follow up was for the elevated blood pressure. They stated, Something was missed.On [DATE] at 12:15 p.m., the DON with the administrator present was asked what the policy/protocol was for documentation. They stated nurses documented by exception. The DON was informed of the progress note on [DATE] for Resident #7 and that the note did not show an assessment was completed or the physician was notified. They stated an assessment should have been conducted and the physician should have been notified. The DON was asked why an assessment was not completed if this was documented as an exception. They stated they would have to check. The DON was asked what the policy/protocol was regarding an elevated blood pressure. They stated the blood pressure should have been reported verbally to the nurse who should have rechecked the vital signs. The DON was asked how they would know if the blood pressure was not reported to the nurse. They stated they would not know. The DON was asked why the physician was not notified of the elevated blood pressure on Friday [DATE] for Resident #7. No answer was provided. The DON was asked what the policy/protocol was regarding reports of chest pain. They stated it depended on who it was reported to. The DON stated the nurses checked vital signs and did an assessment/physical exam to determine appearance of symptoms such as if the resident looked short of breath or not and ask what kind of pain or characteristics of the pain. They stated if pressure were reported the nurse would notify the doctor. The DON was asked why RN #1 did not follow protocol. They stated they did not know.

Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (#8) of 1 sampled resident reviewed for medication administration.The administrator identified 55 residents received medications at the facility.Findings:A physician's order for Resident #8, dated [DATE], showed to administer a 24-hour transdermal nitroglycerin patch 0.1mg/hour every morning for angina pectoris.An annual assessment, dated [DATE], showed a BIMS of 15 which indicated Resident #8 was cognitively intact for daily decision making. The assessment showed diagnoses which included diabetes, heart failure, hypertension, angina pectoris, and end stage renal disease.A [DATE] MAR, showed on [DATE] Resident #8 did not receive the nitroglycerin patch as ordered.A progress note, dated [DATE] at 7:46 a.m., showed Resident #8 complained of chest pain to RN #1. The note showed RN #1 completed vital signs for Resident #8 and were within normal limits. The note showed Resident #8 stated the chest pain could be indigestion.A progress note, dated [DATE] at 11:30 a.m., showed Resident #8 was found by RN #1 to be without respiration and pulse. The note showed CPR was initiated and 911 was called.A progress note, dated [DATE] at 1:24 p.m., showed RN #1 notified the physician of the death of Resident #8 and received an order to release the body to the funeral home.On [DATE] at 12:15 p.m., the DON with the administrator present stated they would need to check as to why Resident #8 did not receive the ordered nitroglycerin patch on [DATE].On [DATE] at 9:00 a.m., the DON stated they had called the agency to obtain an answer as to why the nitroglycerin medication was not administered by the agency CMA, but they had not heard back. They stated they would follow up.On [DATE] at 10:30 a.m., the DON stated the agency CMA had given multiple different answers and they were unable to determine the reason. The DON stated they requested the CMA do not return to the facility.

Based on observation and interview, the facility failed to ensure medications were administered by the person preparing the medication for 1 of 1 observation.The administrator identified 55 residents received medications. Findings: On 07/16/25 at 10:30 a.m., CMA #5 was observed preparing an unknown resident's medication. After preparing the medication, CMA #5 gave CMA #6 the medication who took the medication down the hall and administered it to an unknown resident. On 07/16/25 at 11:00 a.m., CMA #5 stated it was not facility policy to prepare medication and allow another CMA to administer it. CMA #5 stated they had no explanation as to why they were administering medication in that manner. On 07/16/25 at 11:10 a.m., CMA #6 stated you should not administer medication you did not prepare. On 07/16/25 at 11:30 a.m., the DON stated it was not facility policy for one CMA to administer medication prepared by another CMA.

Based on record review and interview, the facility failed to revise a care plan for 2 (#7 and #8) of 8 residents sampled who were reviewed for care plans.The administrator identified 55 residents resided at the facility.Findings:1.An admission assessment for Resident #7, dated 01/03/25, showed a BIMS score of 00, which indicated Resident #7 was severely cognitively impaired for daily decision making. The assessment showed diagnoses which included cerebral vascular accident (CVA/stroke), transient ischemic attack (TIA/mini stroke or brief stroke-like attack caused by a blood clot that blocks blood flow to the brain), and Parkinson's disease.A care plan for Resident #7, dated 01/27/25, showed no concerns for CVA or TIA.A progress note, dated 07/12/25 at 12:55 p.m., showed Resident #7 was unable to sit up and eat at lunchtime. The note showed Resident #7 kept falling forward and putting their head on the table and were returned to their bed. The note was entered by RN #1.A progress note, dated 07/14/25 at 7:22 p.m., showed the representative of Resident #7 reported the resident had a stroke and required being sent to the emergency room. The note showed 911 was called and Resident #7 was taken to the emergency room. The note was entered by LPN #1.Hospital records for Resident #7, dated 07/14/25 at 11:10 p.m., showed results of a CT chest procedure. The results showed findings of a pulmonary emboli (a condition in which one or more arteries in the lungs become blocked by a blood clot) in the distal right pulmonary artery.On 07/16/25 at 2:59 p.m., the MDS coordinator stated concerns/focus for care plans were identified in multiple ways including weekly risk assessments and the care area assessment (CAAs) from the minimum data set assessment. They stated the diagnoses of CVA and TIA for Resident #7 were not included as they were not active diagnoses the resident was currently being treated for.2.A physician's order for Resident #8, dated 04/29/25, showed to administer a 24-hour transdermal nitroglycerin patch 0.1mg/hour in the morning related to angina pectoris.A care plan for Resident #8, dated 05/22/25, showed no concern for angina pectoris or heart failure.An annual assessment for Resident #8, dated 05/26/25, showed a BIMS of 15 which indicated Resident #8 was cognitively intact for daily decision making. The assessment showed diagnoses which included diabetes, heart failure, hypertension, angina pectoris and end stage renal disease.A CAA worksheet for Resident #8, dated 05/26/25, showed congestive heart failure and angina diseases of concern for the care plan. The worksheet was signed and dated by the MDS coordinator on 06/09/25.A progress note, dated 07/03/25 at 7:46 a.m., showed Resident #8 complained of chest pain to RN #1, vital signs were obtained and were shown to be within normal limits. The note showed Resident #8 stated it probably was indigestion.A progress note, dated 07/03/25 at 11:30 a.m., showed Resident #8 was found in their bed without pulse and respirations by RN #1.On 07/17/25 at 1:24 p.m., the MDS coordinator stated the diagnoses of angina pectoris, coronary artery disease and heart failure were not included in the care plan as Resident #8 was not actively being treated for them. The MDS coordinator stated the nitroglycerin patch had been overlooked and the diagnosis should have been included on the care plan.

Based on record review and interview, the facility failed to ensure individual financial records were available through quarterly statements and upon request for 3 (#2, 4, and #6) of 3 sampled residents reviewed for personal funds. The administrator identified 27 residents with trust fund accounts. Findings:An undated policy titled Resident Personal Funds Accounting and Records, read in part, 3. The individual financial record must be available to the residents through quarterly statements and upon request.Review of resident records for Resident #2 from 01/01/25 to 07/17/25 showed no financial statements were available.Review of resident records for Resident #4 from 01/01/25 to 07/17/25 showed no financial statements were available. Review of resident records for Resident #6 from 01/01/25 to 07/17/25 showed no financial statements were available. On 07/17/25 at 1:34 p.m., the business office manager stated the residents could ask for their balance and it would be told to them, but they did not provide the residents with a quarterly statement. The business office manager stated they were not aware they should be providing a quarterly statement.

Based on observation and interview, the facility failed to maintain a clean ice machine. The roster matrix documented 53 residents who utilize ice from the ice machine. Findings: On 02/05/25 at 2:50 p.m., an observation of the ice machine was performed with the maintenance supervisor. There was a slimy black substance observed on the top and interior of the plastic cover, along each side of the water reservoir, and near the water pump which hung above and in the water reservoir. On 02/05/25 at 2:53 p.m., the maintenance supervisor stated the ice machine was dirty. The maintenance supervisor stated they did not know who was responsible for cleaning the ice machine. On 02/05/25 at 3:15 p.m., the administrator stated they were made aware of the dirty ice machine. They did not know who was responsible for cleaning the ice machine. They stated they would coordinate with the dietary manager and maintenance supervisor and work out a routine schedule for cleaning the ice machine.

Based on observation, record review, and interview, the facility failed to protect a resident from abuse for one (#1) of six sampled residents whose clinical records were reviewed for abuse. The Resident Listing Report, dated 10/24/24, documented 54 residents. Findings: Resident #1 had diagnoses which included dementia, psychotic disturbance, mood disturbance, and anxiety. The quarterly assessment, dated 07/17/24, documented the resident was cognitively intact, exhibited no behaviors, required supervision or touch assistance for activities of daily living, and required supervision or touch assistance for ambulation. The care plan, revised 10/08/24, documented the resident had the potential to demonstrate verbally abusive behaviors related to poor impulse control. The care plan, read in part, when I become agitated, intervene before verbal agitation escalates. Guide me away from [the] source of distress. Engage [me] calmly in conversation. If response is aggressive walk away, [sic] and approach later. A hand written statement from CMA #1, dated 10/18/24, documented on 10/18/24 at around 7:00 p.m., they attempted to administer the Resident #1's evening medications. The resident asked for them to return later because the evening meal was served late and they were still eating. The CMA documented the resident complained the food was served late and did not taste good. The CMA documented at about 7:30 p.m., Resident #1 came to them and requested their evening medications. The CMA documented the resident was already angry, so to minimize interrupting the resident's evening, they brought the snack cart as well as the resident's medications to the resident's room. The CMA documented by the time they returned to the resident's room the resident was aggressively shouting and cursing at them. The CMA documented they attempted to plead with the resident, but the resident stood, and while yelling and cursing, pointed to their face. The CMA documented they attempted to leave the resident's room, but the resident pulled them back and hit them in the face, knocking their glasses from their face. The CMA documented while trying to get away from the resident the resident lost their balance and fell . A witness statement from CNA #1, dated 10/18/24 at 8:40 p.m., documented they had just returned from break and assisted a resident in the hallway and observed Resident #1 had their call light on. The CNA documented they heard a verbal argument and turned to look. The CNA documented they observed CMA #1 place something in the resident's room. The CNA documented Resident #1 was leaning over the snack cart and with their finger was pushing into the CMAs right shoulder. The CNA documented the CMA #1 attempted to leave with the snack cart, but the resident held onto the cart and again pushed their finger into CMA #1's chest/shoulder. The CNA documented CMA #1 pushed the resident and when the resident began to fall CMA #1 attempted to catch the resident. The CNA documented both the resident and CMA #1 disappeared into the room, and when they went to the room, there was a pool of blood on the floor. The CNA documented Resident #1 stated they themselves started the altercation and did not want CMA #1 to get in trouble or be terminated. An undated handwritten statement from LPN #1 documented they were alerted Resident #1 was on the floor. The LPN documented when they entered the room, the resident was laying on the floor with blood under their head. The LPN documented they addressed the laceration above the resident's left eyebrow and sent the resident to the hospital for further evaluation. A city citation, dated 10/18/24, documented CMA #1 committed the offense of assault and battery. On 10/19/24 at 11:30 a.m., Resident #1 gave a verbal accounting of the incident to the DON. The DON documented the resident walked to the medication room to wake CMA #1 because the CMA had not given them their evening medications. The resident stated the CMA brought them their pills and placed them on the table in their room. The resident stated they were standing near the door to their room. The resident pointed their finger and said they just touched the CMAs chest and the CMA grabbed their neck and slammed them down. The resident stated they fell with the left side of their face to the floor. The resident stated a new staff member stayed with them while CMA #1 was out in the hall and went to get help. The resident stated staff entered their room to help them, but they were on the floor for nearly an hour before the ambulance arrived to take them to the hospital. On 10/24/24 at 4:05 p.m., the door to Resident #1's room was closed. The resident was heard yelling and berating RN #1 for their inability to perform their duties to the resident's satisfaction. RN #1 was overheard to remain calm and quietly attempted to redirect the resident and left the room shortly after. On 10/24/24 at 4:10 p.m., RN #1 stated Resident #1 was never happy with their care and addressed everyone rudely and with condescension. RN #1 stated Resident #1 even structured complements in a negative connotation and tone. RN #1 stated the resident normally called them to enter their room two to three times a night to yell how everything was their fault. RN #1 stated they received an inservice on abuse and the management of agitated/aggressive residents on 10/19/24. On 10/24/24 at 4:35 p.m., CNA #1 stated they had witnessed the altercation between CMA #1 and Resident #1. The CNA stated Resident #1 was holding onto the snack cart while jabbing their finger into the shoulder of CMA #1. The CNA stated they thought the resident was taking a step closer to CMA#1 when CMA #1 placed their hands up about chest high with their palms outward toward the resident. The CNA stated it happened very quickly and could not say with certainty if CMA #1 pushed the resident or if the resident stepped into CMA #1 while CMA #1's hands were still between them. The CNA stated they observed CMA #1 attempt to catch the resident when the resident became off balanced, but was not able to catch the resident in time. The CNA stated CMA #1 was not yelling at the resident or otherwise appeared to be angry. CNA #1 stated they received an inservice on abuse and working with residents with behaviors when they returned to work on 10/21/24. On 10/25/24 at 4:05 p.m., Resident #1 returned to facility from a scheduled appointment. The skin around both of the resident's eyes were bruised and there were stitches above the left eyebrow. The area above the left eyebrow was swollen and raised. They did not feel like talking to anyone at the moment. On 10/25/24 at 4:50 p.m., Resident #1 was in their room seated in their recliner. The surveyor addressed the resident with name and surveyor identification. The resident immediately began yelling that CMA #1 had grabbed them by the neck, slammed them onto their back on the floor, and punched them repeatedly in the face while continuing to hold them down by their neck. The resident continued to yell and repeated the incident. On 10/25/24 at 5:05 p.m., the DON stated they were notified of the incident on 10/18/25 in the evening, and immediately returned to the facility to start the investigation. The DON stated they toured the facility to ensure everyone was safe and statements were gathered from residents and employees, including CMA #1. The DON stated CMA #1 stated they had not intended to push the resident, but only to maintain space between themselves and the resident. They stated CMA #1 never intended for the resident to fall or get hurt. The DON stated they suspended CMA #1 while they investigated the incident. The DON stated they attempted to contact family, notified the physician, local police, and OSDH. The DON stated they returned to the facility on [DATE] and again made rounds to ensure the residents were safe and collected their statements. The DON stated they developed an inservice on abuse and managing behaviors or aggressive residents and started inservicing the weekend staff. The DON stated they returned to the facility on [DATE] and again made rounds to ensure the residents were safe, collected statements from the residents, and inserviced staff. The DON stated on 10/21/24 they continued to inservice staff until all available staff were inserviced. The DON stated there were a few staff members they were unable to reach and those would be inserviced before their next shift started. The DON stated they continued to monitor staff/resident interactions daily as part of the QA process and continued to review and update the findings for their monthly QAPI meeting to review. The DON stated at the end of the investigation the allegation of abuse was substantiated and CMA #1 was terminated. On 10/25/24 at 5:20 p.m., the facility's policy and procedure for abuse was reviewed, in-service sheets for abuse training, in-service sheets for caring for residents with behaviors, the facility monitoring sheets, daily stand up/leadership team meetings, and the facility initial QA was reviewed. It was determined non-compliance started on 10/18/24 at 7:00 p.m. and ended on 10/22/24 at 4:50 p.m. when all active staff were in-serviced. On 10/25/24 at 5:30 p.m., the administrator stated when they received an allegation of abuse, they followed their abuse policy, ensured all residents were safe, and removed the alleged abuser from the facility pending the outcome of the investigation. The administrator stated they would begin the investigation by identifying and interviewing all persons involved, including the alleged abuser and any witnesses. The administrator stated they report the allegation to the SA, APS, and law enforcement, if indicated. The administrator stated they notify the resident's representative if the resident had one and their physician. The administrator stated they inservice/educate staff on abuse and neglect and monitor through observations of staff/resident interactions and resident statements which asked such questions as if the resident felt safe in the facility, did they know who to tell if something happened or if they had a problem, and other pertinent questions developed through the QA process/team. The administrator stated after completing the investigation the QA team discusses/reviews all state reportable incidents and grievances during daily meetings and at the monthly QA meeting to determine if their were any unidentified trends/patterns to add.

Based on observation, record review, and interview, the facility failed to ensure residents' call lights were in reach for four (#3, 5, 6, and #7) of four sampled residents who were reviewed for call light placement. The DON identified 40 residents who resided in the facility. Findings: A Call Lights: Accessible and Timely Response policy, undated, read in part, .Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance . 1. Res #3 had diagnoses which included mild intellectual disability, anxiety, macular degeneration, angina, overactive bladder, osteoporosis, and epilepsy. An admission assessment, dated 02/05/24, documented the resident's cognition was intact, frequently incontinent of bowel and bladder, required moderate assistance with mobility with most ADLs. On 02/07/24 at 8:10 a.m., observed the resident in bed and their call light was hanging from the wall across the room from the resident. On 02/07/24 at 1:20 p.m., observed the resident in bed and their call light was hanging from the wall across the room. On 02/08/24 at 8:06 a.m., observed the resident in bed and their call light was hanging from the wall across the room. On 02/08/24 at 8:25 a.m., CNA #1 was asked where Res #3's call light should be placed. They stated within the resident's reach. They were asked how often they checked call light placement. They stated every time they went into a resident's room. On 02/08/24 at 8:46 a.m., RN #1 was asked where the residents' call lights should be placed. They stated within the resident's reach. They were asked how they ensure the call lights were within the residents' reach. They stated they monitor for call light placement each time they go into a residents' room. 2. Resident #5 had diagnoses which included myocardial infarction, Alzheimer's Disease, muscle weakness, osteoporosis, and reduced mobility. An annual assessment, dated 03/22/23, documented the resident's documented the resident's cognition was moderately impaired, had impairment to one side of their lower extremities, required extensive assistance with their ADLs, and was always incontinent of bowel and bladder. A quarterly assessment, dated 12/17/23, documented the resident's cognition was moderately impaired, no impairment to their upper or lower extremities, required substantial assistance with all their ADLs, and was always incontinent of bowel and bladder. On 02/07/24 at 8:19 a.m., observed the resident in bed and their call light was hanging from the wall across the room from the resident. On 02/07/24 at 1:31 p.m., observed the resident in bed and their call light was hanging from the wall across the room. On 02/08/24 at 8:21 a.m., observed the resident in bed and their call light was hanging from the wall across the room. 3. Res #6 had diagnoses which included convulsions, epilepsy, speech disturbance, and dysphagia. An annual assessment, dated 08/02/23, documented the resident's cognition was severely impaired, had impairment to both upper and lower extremities, required extensive assistance with their ADLs, and was always incontinent of bowel and bladder. A quarterly assessment, dated 01/29/24, documented the resident's cognition was severely impaired, had no impairment to their upper or lower extremities, required extensive assistance with their ADLs, and was always incontinent of bowel and bladder. On 02/07/24 at 8:23 a.m., observed resident in bed and their call light was in the floor underneath the head of the bed between the headboard and the wall. On 02/07/24 at 3:58 p.m., observed resident in bed and their call light was in the floor underneath the head of the bed between the headboard and the wall. On 02/08/24 at 8:12 a.m., observed resident in bed and their call light was in the floor underneath the head of the bed between the headboard and the wall. 4. Res #7 had diagnoses which included diabetes, HTN, and COPD. An admission assessment, dated 02/05/24, documented the resident's cognition was intact, was independent with most ADLs, and continent of bowel and bladder. On 02/07/24 at 8:08 a.m., observed resident in bed and their call light was underneath the end of the bed. On 02/07/24 at 3:58 p.m., observed resident in bed and their call light was underneath the end of the bed. On 02/08/24 at 8:15 a.m., observed resident in bed and their call light was underneath the end of the bed. On 02/08/24 at 8:30 a.m., LPN #1 was asked where the residents' call lights should be placed. They stated the call lights should be within the residents' reach. They were asked how they ensured the call lights were within the residents' reach. They stated they monitor the call light placement during their hourly rounds. On 02/08/24 at 8:52 a.m., MDS Coordinator #1 was asked where the residents' call lights should be placed. They stated within the residents' reach. On 02/08/24 at 8:59 a.m., the administrator was asked where the residents' call lights should be placed. They stated the call lights should be within the residents' reach and they can be clipped to the bed or attached to a position rail if needed.

Based on observation, interview, and record review, the facility failed to ensure nursing staff followed the infection control guidelines to prevent the potential spread of communicable disease. The DON identified 40 residents resided in the facility. Findings: A Handling Soiled Linen policy, undated, read in part, .3. Linen should not be allowed to touch the uniform or floor .4. Used or soiled linen shall be collected at the bedside (or point of use .) and placed in a linen bag or designated receptacle. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom .'' Res #1 had diagnoses which included CVA, neuromuscular dysfunction of bladder, DM, and frequent UTI's. A quarterly assessment, dated 01/12/24, documented Res #1's cognition was severely impaired, had an indwelling urinary catheter, and required extensive assistance with most ADLs. On 02/07/24 at 10:58 a.m., observed CNA #1 and CNA #2 transferring resident #1 from bed to their wheelchair via the sit to stand lift. CNA #1 was observed to begin cleaning the resident's bottom while they were standing up in the sit to stand. CNA #1 did not perform hand hygiene prior to resident care and did not change gloves between incontinent care and dressing the resident. Observed the resident's catheter bag and tubing on the floor. CNA #1 was moving the sit to stand lift around in the room to position the resident over their wheelchair and they were dragging the resident's catheter bag and tubing along on the floor. CNA #1 was asked what the facility policy was for hand hygiene. They stated they are to perform hand hygiene prior to resident care and to change gloves as needed during the care. CNA #1 stated I do not have any hand sanitizer with me. CNA #1 was asked about the catheter bag and tubing on the floor. They stated they usually hung it on their pocket. On 02/07/24 at 11:15 a.m., RN #1 was asked what the facility policy was for hand hygiene during resident's incontinent care. They stated they should perform hand hygiene prior to and after care and between glove changes. They were made aware of the catheter bag and tubing being dragged on the floor. They stated the catheter bag should never touch the floor. On 02/08/24 at 8:01 a.m., observed a pile of dirty linens and a pile of dirty towels in Res #1s room. There was a shower chair beside the resident's bed. No one was observed in the room. On 02/08/24 at 8:06 a.m., CMA #1 was asked how long the linens and towels had been in the resident's room on the floor. They stated about 15 minutes. They were asked if this was normal procedure. They stated they were supposed to place the dirty linens and towels in a bag and take it to the hopper room. On 02/08/24 at 9:26 a.m., the administrator was made aware of the above observations. They stated they would in-service the nursing staff on hand hygiene and proper handling of soiled linens.

Based on observation, record review, and interview, the facility failed to follow infection prevention and control procedures during an outbreak of COVID-19. The administrator identified 39 residents resided at the facility and five were positive for COVID-19. Findings: A Transmission-Based (Isolation) Precautions policy, dated 09/28/22, read in part, .Recommendations for Personal Protective Equipment (PPE) .Droplet .Gloves, Gown .Mask . The policy did not document the use of a face shield for droplet precautions, unless there was a risk of exposure to respiratory droplets, i.e. coughing/sneezing. On 12/01/23 at 9:28 a.m., the ADON/IPCO was observed outside of an unmarked isolated resident room, in front of a cart with multiple COVID-19 tests on the top of the cart. The ADON/IPCO was asked what type of isolation the resident was on. We all just know the resident has COVID. They were asked how others would know the type of isolation. They looked and stated they needed to get a sign. The ADON/IPCO was asked what type of isolation COVID-19 required. They stated droplet. They were asked what PPE was required to enter. They stated a gown, gloves and an N95 mask. The ADON/IPCO was asked if any other PPE was required. They stated a face shield if the resident were coughing or sneezing. They were asked if the resident were coughing or sneezing. They stated no, none of them had been, they were mostly just tired. On 12/01/23 at 10:14 a.m., CMA #1 was observed to enter an unmarked isolation room, room [ROOM NUMBER], to administer medications. The staff member donned a gown, an N95 mask and gloves. They were observed to unzip the barrier, enter and rezip the barrier, and begin to administer medications. On 12/01/23 at 10:25 a.m., CMA #1 was observed in an unmarked isolation room wearing an N95 mask, gown and gloves, offering water. On 12/01/23 at 10:27 a.m., CMA #1 was observed to doff and exited room [ROOM NUMBER]. The ADON was observed to place signage near room [ROOM NUMBER]. CMA #1 stated they gave the resident their morning medications. CMA #1 stated they wore gown, gloves and an N95 but no eye protection unless the resident was coughing. On 12/01/23 at 10:50 a.m., RN #1 was asked what they do when entering an isolated resident room. They stated they had to gown, glove, mask and make sure everything was secure, unzip the barrier and enter. RN #1 was asked what type of mask was used. They stated an N95 mask. They were asked when they wear eye protection. RN #1 stated if they expected a splash. They were asked how they protected their eyes. They stated they had shields/goggles if needed. RN #1 was asked if they knew the CDC guidelines for entering a droplet room. They stated they did not know for sure. On 12/01/23 at 11:09 a.m., the DON was asked what PPE was required to enter a droplet isolation room. They stated gown, gloves and an N95 mask. The DON was asked what eye protection was used. They stated they were not sure if they had face shields or not. The DON was asked when shields or goggles were required. They stated when splashing or droplet contamination, to include sneezing or coughing. The DON was asked when coughing or sneezing could be predicted. They stated it could not. The DON was asked when eye protection should be worn. They stated all the time. The DON was asked if staff were wearing eye protection. They stated no. The DON was asked what guidance was used to develop the policy. They stated it was already in place when they arrived.

Based on record review and interview, the facility failed to ensure binding arbitration agreements provided the selection of a neutral arbitrator agreed upon by both parties and provided a selection of a venue that was convenient to both parties. The administrator identified two residents who had signed binding arbitration agreements who resided in the facility. Findings: The undated Arbitration Agreement, read in part, .to be conducted at a place agreed upon by the parties, or in the absence of such agreement, at Facility . Review of the arbitration agreement did not reveal language a neutral arbitrator would be agreed upon by both parties. On 11/28/23 at 1:43 p.m., the admission coordinator reviewed the arbitration agreement and stated the agreement did not contain language a neutral arbitrator, agreed upon by both parties, would be utilized. They stated the venue for the arbitration would be at the facility if an agreement was not made for a location. The admission coordinator stated the arbitration agreement did not contain language the venue was to be convenient for both parties. On 12/01/23 at 2:00 p.m., the administrator stated the arbitration agreement would need to be updated.

Based on record review and interview, the facility failed to ensure a care plan was updated/revised for one (#9) of 15 residents reviewed for care plans. The administrator identified 39 residents resided at the facility. Findings: Resident #9 had diagnoses which included paranoid schizophrenia. A nurses note, dated 03/16/23 at 6:42 p.m., documented Resident #9 was seen by an APRN-CNP from [name removed] and added an order to include a new diagnosis of paranoid schizophrenia. The note documented Resident #9 had experienced hallucinations of small children and mean old women trying to hurt them. The note documented to continue Risperdal 0.5mg three times a day routine for paranoid schizophrenia. A quarterly assessment, dated 09/17/23, documented the resident's diagnosis of paranoid schizophrenia. No significant change assessment was located in the clinical record. Review of the care plan, revised 10/02/23, revealed a diagnosis of paranoid schizophrenia was not care planned. On 11/29/23 at 2:45 p.m., the MDS coordinator stated they did not locate in the progress notes where the physician was notified of the new diagnosis or that the diagnosis of paranoid schizophrenia was on the active care plan. On 11/29/23 at 2:53 p.m., the Director of Clinical Outcomes stated they had just identified the diagnosis as well, and did not know why the physician was not notified of the change in diagnoses. On 11/29/23 at 3:00 p.m., the MDS coordinator was asked why the diagnosis of paranoid schizophrenia was not care planned. They stated it was dependant on the medication being taken due to the diagnosis. They stated at one time Resident #9 was on Risperdal however the medication was discontinued on 04/24/23, so it would not be on the active care plan.

Based on record review and interview, the facility failed to ensure the state was notified of a new serious mental illness diagnosis for #9 and failed to ensure a PASARR II evaluation was available for implementation of recommendations one (#7) of two residents reviewed for PASARR. The administrator identified 12 residents with a level II PASARR who resided in the facility. Findings: 1. Resident #9's PASARR level I, dated 09/26/22, documented no level II required. Resident #9 had diagnoses which included paranoid schizophrenia effective 03/16/23. On 03/16/23 at 6:42 p.m., a nurses note documented Resident #9 was evaluated by an APRN-CNP with [name removed] and added a diagnosis of Paranoiod Schizophrenia. The note documented Resident #9 was hallucinating small children and mean old women trying to hurt them. An order was received for risperdal (a psychotropic medication) 0.5 mg three times a day routine for paranoid schizophrenia. A quarterly assessment, dated 09/17/23, documented Resident #9 had a diagnosis of paranoid schizophrenia. On 11/29/23 at 2:53 p.m., the Director of Clinical Outcomes stated they had recently identified there was no level II PASARR as well and did not know why a level II was not done. 35474 2. Resident #7 had diagnoses which included bipolar disorder, major depressive disorder, and paranoid schizophrenia. The Nursing Facility Level of Care Assessment, dated 11/03/16, documented the Level II PASARR was current and to report any psychiatric admissions. The Nursing Facility Level of Care Assessment, dated 03/26/18, documented the Level II PASARR was current. Review of the clinical record did not reveal a Level II PASARR. The care plan, revised 08/30/23, documented the resident had a Level II PASARR and they were to notify the state agency if the resident had two psychiatric hospital stays or received an emergency order of detention. On 11/29/23 at 2:57 p.m., the administrator stated they had requested the Level II PASARR be sent to the facility from the state agency. They stated they needed to obtain a copy of the Level II PASARR to implement it into the residents plan of care. On 12/01/23 at 1:16 p.m., the care plan coordinator stated the care plan documented the resident had a Level II PASARR and they were to notify the state agency if the resident had two in patient psychiatric hospitalization s.

Based on record review and interview, the facility failed to ensure a pharmacy recommendations had a documented clinical rationale for continuing psychotropic medications for one (#22) of five residents who were reviewed for unnecessary medications. The Resident Census and Conditions of Residents form identified 31 residents received psychoactive medication. Findings: Resident #22 had diagnoses which included Bipolar II disorder, schizoaffective disorder, major depressive disorder, and borderline personality disorder. A Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction, dated 07/18/22, read in parts, .Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rationale for the continued use .1. Ativan 0.25 mg BID 2. Depakote 125 mg BID 3. Quetiapine 200 mg HS 4. Rexulti 2 mg HS 5. Trazodone 50 mg HS 6. Trintellix 10 mg daily 7. Trintellix 5mg in AM .Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for NOT reducing a Psychoactive must have a Hand Written, Valid Clinical Rationale as to why the reduction is not desired at this time . The report documented the physician decreased the Ativan and continued the other medications. The report did not document a clinical rationale for continuation of the medications. A Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction, dated 01/12/23, read in parts, .Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rationale for the continued use .1. Ativan 0.25 mg daily 2. Depakote 125 mg BID 3. Quetiapine 200 mg HS 4. Rexulti 2 mg HS 5. Trazodone 50 mg HS 6. Trintellix 25 mg daily .Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for NOT reducing a Psychoactive must have a Hand Written, Valid Clinical Rationale as to why the reduction is not desired at this time . The report documented the physician discontinued the Ativan. The report did not document a clinical rationale for continuation of the medications. On 02/08/23 at 10:44 a.m., the DON was asked what the protocol was for pharmacy consultations/gradual dose reductions. The DON stated the pharmacist made recommendations and the physician either approved or disagreed with the recommendation and they implemented any new orders. The DON was asked who was responsible to ensure a clinical rationale had been provided by the physician if a recommendation had been declined. The DON stated the physician usually documented a clinical rationale on the pharmacy consultation report. The DON was asked why a clinical rationale had not been documented on the 07/18/22 and 01/12/23 pharmacist recommendations. They stated they would review the clinical record. On 02/08/23 at 11:51 a.m., Pharmacy Consultant #1 was asked what the protocol was for gradual dose reductions. They stated they recommended a reduction twice the first year and then annually. They stated they presented recommendations as a full clinical picture of all psychotherapeutic medications. Pharmacy Consultant #1 was asked if they followed up with a recommendation if the physician did not document a clinical rationale for declining a recommendation or part of a recommendation when multiple medications were listed on the report. They stated the other medications had not required a rationale since the physician had reduced or discontinued the Ativan. They stated the recommendation was for the full regimen and since a reduction had been made in the medication regimen it was ok. By the end of the survey no further information had been provided by the DON to the survey team.

Based on record review, observation, and interview, the facility failed to ensure enteral feeding tubes were secured to prevent displacement for one (#14) of three sampled residents who were reviewed for enteral feeding tubes and failed to ensure enteral nutrition was held during incontinent care for one (#21) of three sampled residents who were reviewed for enteral feeding tubes. The Resident Census and Conditions of Residents form identified five residents who received enteral tube feedings. Findings: 1. Resident #14 had diagnoses which included gastrostomy. The quarterly assessment, dated 12/29/22, documented the resident required extensive assistance with bed mobility and did not walk. The Care Plan, reviewed 01/12/23, documented the resident required a feeding tube and nurses were to check for placement, monitor residual and lung sounds. A Physician Order, dated 01/12/23, documented an order for continuous tube feeding of Osmolite 1.5 at 50 ml/hr with 50 ml/hr water flush, check residual every six hours, and hold if residual was greater than 100 and notify the physician. A Nurses Note, dated 01/30/23, read in parts, .seen by physician .explained to [physician name withheld] res abdomen distended, tender to touch, peg site protruding, inflamed, purulent drainage, and foul odor noted at this time .received order to send out for evaluation at this time . The ED Physician Note, dated 01/30/23 at 3:14 p.m., read in parts, .CT scan shows malposition of the PEG tube .PEG tube is dislodged and the gastric balloon is within the subcutaneous tissue. I deflated the the patient's gastric balloon. I advanced the patient's PEG tube .Patient symptoms are likely related to displacement of .gastric tube. After appropriate repositioning of the gastric tube and confirmation of the proper position the patient appears safe for discharge . The note documented the discharge diagnosis was PEG tube malfunction. A Nurses Note, dated 01/30/23 at 7:10 p.m., documented the resident had returned to the facility with new orders for Cephalexin (an antibiotic medication) 500 mg twice daily for seven days for PEG infection. A Physician Order, dated 02/01/23, documented an order to clean the area around the enteral tube site daily, apply Bacitracin Ointment, and cover with split gauze. On 02/07/23 at 2:30 p.m., the DON was observed during a PEG tube dressing change for Resident #14. The DON stated the stoma was observed to have bulged and the physician ordered for the resident to be evaluated in the emergency room . The DON stated after completing an ordered antibiotic the PEG site improved and looks really good now. The PEG tube was not observed to be secured. On 02/08/23 at 10:40 a.m., the DON was asked what interventions to prevent displacement of the PEG tube had been implemented. The DON stated they auscultated and monitored residual to ensure placement. The DON stated they did not think they had interventions in place to prevent the PEG from becoming misplaced/dislodged they just made sure the tubing was properly placed to ensure it was not pulled. The DON was asked what interventions had been implemented since the PEG tube had been displaced on 01/30/23. The DON stated they made sure the tubing was not stretched but would review the clinical record. On 02/08/23 at 12:25 p.m., RN #1 was asked what interventions were in place to prevent displacement of the PEG tube for Resident #14. They stated they ensured they were aware of where the PEG tube was when the resident was repositioned. RN #1 was asked what interventions had been implemented after the hospital visit on 01/30/23 in which the PEG tube had been displaced. RN #1 stated they could anchor the PEG tube but was unaware the PEG tube had been previously displaced and new interventions had not been implemented. On 02/08/23 at 12:48 p.m., the DON stated they reviewed the hospital notes and the clinical record and stated they did not have any new interventions to ensure the PEG tube was not displaced. The DON stated the staff were aware to reposition Resident #14 with caution to ensure the PEG tube was not displaced. 41809 2. Resident #21 admitted with diagnoses which included dysphagia. On 02/07/23 at 10:42 a.m., incontinent care was observed for Resident #21. On entering the room for Res #21 the tube feeding was observed to be running. CNA #1 was observed to inform the resident of the care to be provided while CNA #2 was lowering the head of the bed. At no point during the incontinent care was the tube feeding held. On 02/07/23 at 10:57 a.m., CNA #1 and CNA #2 were asked what position a resident receiving continuous tube feeding was to be positioned in. They stated 45 degrees. The CNAs were asked what the protocol was for providing incontinent care to a resident receiving continuous tube feeding. They stated they were to hold it or get the nurse to stop and disconnect the tube feeding. The CNAs stated they each though the other had held the tube feeding during incontinent care. On 02/08/23 at 1:55 p.m., the DON was asked what their expectation was when CNAs provided incontinent care for a resident on continuous tube feeding. They stated the CNA was expected to have the nurse hold the tube feeding while the incontinent care was provided and then have the nurse restart it when incontinent care was completed. The DON was asked how that was monitored. They stated the charge nurse monitored it.

Based on observation and interview, the facility failed to ensure a sanitary environment with the ceiling return air vents for two (#17 and #196) of three resident rooms reviewed for the environment. The DON identified 39 rooms were occupied by residents. Findings: 1. Resident #17 had diagnoses which included hypertension. The quarterly assessment, dated 12/06/22, documented the resident was cognitively intact for daily decision making. On 02/01/23 at 2:25 p.m., Resident #17 stated the ceiling vent in their room was not clean and had not been cleaned in years. The vent in the ceiling was observed to have a build-up of brown debris, on the wall of the duct, when observed through the metal vent grate. 2. Resident #196 had diagnoses which included anxiety and diabetes. The quarterly assessment, dated 12/16/22, documented the resident was severely impaired in cognition for daily decision making. On 02/07/23 at 2:19 p.m., the ceiling vent for Resident #196 was observed with the maintenance supervisor. The vent in the ceiling was observed to have a build-up of brown debris, on the wall of the duct, when observed through the metal vent grate. The maintenance supervisor stated the return air vent was not functional as the facility had a new heat/air system in place for the hall. On 02/07/23 at 2:25 p.m., the ceiling vent for Resident #17 was observed with the maintenance supervisor. The maintenance supervisor stated the room still used the ceiling vents. The maintenance supervisor observed the ceiling vent and stated they may need to call corporate to get the ducts cleaned on the halls where they still used the old heat/air system. On 02/08/23 at 1:06 p.m., the maintenance supervisor stated they had taken down some of the vents and cleaned them. The maintenance supervisor was asked who was responsible to ensure the vents/vent ducts did not accumulate a build-up of debris. The maintenance supervisor stated they had talked to the corporate office and the maintenance department was to change the filters and the housekeeping department was to clean the vents. The maintenance supervisor stated the corporate office was going to send them a protocol. On 02/08/23 at 1:17 p.m., the housekeeping supervisor was asked who was responsible to ensure ceiling vents and ducts were free from debris in resident rooms. The housekeeping supervisor stated they dusted the vents and the maintenance department cleaned inside the vents/ducts.

Based on observation, interview, and record review, the facility failed to fully develop the comprehensive care plan for three (#3, #44, and #49) of 17 residents whose care plans were reviewed. The Census and Conditions Report documented 54 residents resided in the facility. Findings: 1. Resident #3 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 02/28/21, documented the resident was to receive a diabetic diet, double protein portions, and provide protein powder one scoop in a liquid of choice at breakfast. A physician order, dated 03/23/21, documented the [CONDITION(S)] center was to complete labs quarterly and to include a hemoglobin A1C. The orders documented the staff were to obtain the resident's weight upon the resident's request. The resident's quarterly Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs), dated 08/25/21, documented the resident was independent for daily decision making, required set up assistance with activities of daily living (ADLs), and received [CONDITION(S)]. A physician order, dated 10/11/21, documented the resident was to receive [MEDICATION(S)] (a renal medication) by mouth three times a day before his meal was served. The care plan, dated 11/22/21, documented the resident was to go to [CONDITION(S)] on Monday, Wednesday, and Friday. The care plan documented staff were to monitor the [CONDITION(S)] access site for redness, swelling, warmth, and drainage. The care plan documented the staff were to monitor swelling in lower legs, monitor labs and report findings, and monitor for renal impairment On 11/30/21 at 11:40 a.m., the resident stated he took a communication sheet to and from [CONDITION(S)]. The resident stated he went to [CONDITION(S)] on Monday, Wednesday, and Friday from 11:00 a.m. to 3:30 p.m. at the hospital. An observation revealed a shunt in the resident's left upper arm. The shunt was clean, dry, and did not have drainage or a dressing. On 12/06/21 at 10:00 a.m., the Assistant Director of Nurses (ADON) stated when a resident returned from [CONDITION(S)] the nurse should monitor the resident's vital signs, check the dressing for bleeding, and listen for the bruit. The ADON stated this should be on the resident's care plan. The ADON stated the care plan should document the resident's diet, renal medications, and the emergency procedures to follow for a renal emergency. The ADON reviewed the care plan and stated most of the interventions were not documented on the care plan. 2. Resident #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 04/16/21, documented staff were to apply A&D ointment to the resident's buttocks topically for excoriation. The care plan, dated 04/16/21, documented the resident was at risk for skin breakdown. The care plan documented staff were to inspect the resident's skin for breakdown during routine care. The staff were to report redness, open areas, scratches, cuts or bruises, keep the resident on a pressure reducing mattress, and apply protective moisture barrier ointments. The care plan did not document the resident had previous pressure ulcers. The care plan was not updated to include the resident currently had wounds to her right great toe and foot. The care plan did not document how often the resident's wound was to be assessed or what staff were to include in the assessment. On 12/07/21 at 9:28 a.m., Licensed Practical Nurse (LPN) #1 was observed to provide wound care to the resident's right foot. 3. Resident #49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 08/26/21, documented staff were to evaluate and document the size, depth, margins, peri-wound skin, sinuses, undermining, exudates, [CONDITION(S)], infection, necrosis, eschar, or gangrene of the resident's wound weekly. The care plan documented the staff were to report changes to the physician. The care plan documented the resident had [CONDITION(S)] to his lower legs and nursing was to change the resident's compression wraps Monday, Wednesday, Friday, and as needed. The skin screens for October 2021 through December 2021 did not document the size, depth, margins, peri-wound, exudates, signs of infection, or necrosis of the wound as documented on the care plan. The screens did not document an assessment of the resident's bilateral lower leg [CONDITION(S)]. On 11/30/21 at 11:30 a.m., resident #49 was observed to have bilateral lower leg [CONDITION(S)] with compression dressings in place. On 12/09/21 at 11:14 a.m., the ADON stated skin assessments were not completed correctly according to the care plan. She stated the assessment did not document measurements, color, type of exudate, or signs of infection. The ADON stated the notes did not document the physician was notified for relevant findings and did not document an assessment for [CONDITION(S)].

Based on observation, interview, and record review, the facility failed to provide the care and treatment to maintain the resident's highest level of well-being for one (#49) of one sampled residents reviewed for [CONDITION(S)]/non-pressure wounds. The administrator identified two residents with non-pressure related wounds. Findings: Resident #49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 08/26/21, documented staff were to evaluate and document the size, depth, margins, peri-wound skin, sinuses, undermining, exudates, [CONDITION(S)], infection, necrosis, eschar, or gangrene of the resident's wound weekly. The care plan documented the staff were to report changes to the physician. The care plan documented the resident had [CONDITION(S)] to his lower legs and nursing was to change the resident's compression wraps Monday, Wednesday, Friday, and as needed. A skin screen form, dated 10/02/21, documented 4+ [CONDITION(S)] and the skin was very tight with a right lower extremity venous ulcer. The skin screen did not document a description of the wound. The skin screen forms, dated 10/09/21, 10/16/21, 10/23/21, and 10/30/21 documented bilateral lower extremity redness and a stasis ulcer. The skin screens did not document a description of the wound or address the resident's [CONDITION(S)]. A review of the clinical record did not reveal a skin screen form had been completed for 11/06/21. The resident's quarterly Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs), dated 11/11/21, documented the resident was independent with most activities of daily living and did not have ulcers or other skin issues. The skin screen forms, dated 11/13/21 and 11/20/21, documented the resident had bilateral lower extremity areas of discoloration, dry peeling skin,and areas of slight oozing on the right leg. The screen did not document a description of the wound or address the resident's [CONDITION(S)]. The progress notes for November 2021 did not document lower leg skin assessments or assessments for [CONDITION(S)]. On 11/30/21 at 11:30 a.m., resident #49 was observed to have bilateral lower leg [CONDITION(S)] and compression dressings in place. The physician order, dated 12/05/21, documented staff were to apply Eucerine cream topically to the resident's legs bilaterally every shift. Review of the clinical record did not reveal skin screen forms had been completed for the week of 12/06/21. A physician order, dated 12/08/21, documented for the wound care physician to evaluate and treat the resident one time. The progress note, dated 12/09/21, documented the resident had [CONDITION(S)] and was placed on antibiotics. On 12/09/21 at 11:14 a.m., the Assistant Director of Nurses (ADON) stated skin assessments were not completed according to care plan. She stated the assessments did not document measurements, color, type of exudate, or signs of infection. The ADON stated the notes did not document the physician was notified for relevant findings and did not document an assessment for [CONDITION(S)].

Based on observation, interview, and record review, it was determined the facility failed to provide care and services for the prevention and/or worsening of pressures ulcers for two (#3 and #4) of four sampled residents reviewed for pressure ulcers. The facility failed to: a) Thoroughly assess skin and pressure ulcers. b) Notify the physician for the changes in skin integrity and pressure ulcers; and c) Obtain complete orders when the resident was readmitted to the facility. Resident #3 developed an in-house stage I pressure ulcer that worsened to a stage IV pressure ulcer requiring four hospital admissions and surgical interventions. The facility identified two residents who had pressure ulcers. Findings: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 09/21/19, documented the resident was independent for daily decision-making, required extensive assistance with activities of daily living (ADLs), was always incontinent of urine, frequently incontinent stool, and weighed 195 pounds (lbs). The assessment documented the resident did not have a pressure ulcer, was at at risk for pressure ulcers, and preventative measures consisted of turning and repositioning. A Braden scale pressure ulcer risk assessment, dated 09/21/19, documented the resident was at moderate risk for developing pressure ulcers. The care plan, dated 09/30/20, documented the resident was at risk for skin breakdown. The care plan documented the staff were to keep the resident clean and dry, to assist the resident with repositioning in her bed and chair, and encourage the resident to eat her meals and drink plenty of fluids. The care plan documented the resident had skin impairment to her buttocks and the staff were to monitor the resident's skin, report skin changes to the nurse and doctor, and provide treatment as ordered. A skin observation tool, dated 11/06/19, documented redness to the resident's buttocks and lanticeptic was applied. A physician order, dated 12/18/19, documented staff were to cleanse the resident's bilateral buttocks with soap and warm water, pat dry, and apply lanticeptic cream. The order documented the treatment was to be completed every shift and as needed for soilage until the redness was resolved. A Braden scale skin assessment, dated 12/17/19, documented the resident was at risk for pressure ulcers. A nurse practitioner note, dated 12/18/19, documented the staff were to monitor the resident's skin weekly, continue wound/skin protection measures, and to see the chart for wound details. The note did not document an assessment of the resident's buttocks. A significant change assessment, dated 12/22/19, documented the resident was moderately impaired for daily decision-making, required extensive assistance with ADLs, was incontinent of bowel and bladder, weighed 201 lbs, and received a mechanically altered and therapeutic diet. The assessment documented the resident was at risk for pressure ulcers, had a stage one pressure ulcer, was turned and repositioned, received pressure ulcer care, and ointments were applied. The skin observation tool, dated 12/25/19 documented the resident's skin was dry, intact, and no wounds were identified. A progress note, dated 12/29/19 at 9:34 PM, documented a friction abrasion skin tear to the left buttock cheek measuring 12 millimeters (mm) X 6 mm and did not have bleeding, drainage, or pain. The note documented the site was cleaned, patted dry, and a clean gauze dressing was applied. The note documented the resident was informed a medical evaluation would be completed and treatment provided. The note documented the resident would be reposition from side to side to promote healing. The note documented a report was placed in the medical director's report notebook. The care plan dated, 12/29/19, did not have updates related to the resident's skin. A skin observation tool, dated 12/31/19, documented a small skin tear to the resident's left buttock measuring 1.5 X .75 X 0. The tool documented Triad wound paste was to be applied per physician order. The tool did not document ulcer depth, color, odor, or drainage. The treatment administration record (TAR) for December 2019 documented the resident's buttocks was cleansed and [MEDICATION NAME] cream was applied. The TAR documented Triad wound paste was applied to the pressure ulcer on 12/30/19 and 12/31/19. A skin observation tool, dated 01/07/20, documented a pressure ulcer to the resident's sacrum measuring 3.0 centimeters (cm) X 1.5 cm, was unstageable, and lanticeptic was applied. The tool did not document ulcer depth, color, odor, or drainage. The note did not document the physician was notified for changes in the pressure ulcer. The progress notes for January 2020 did not document the physician was notified the pressure ulcer was larger and unstageable. The physician orders, dated 01/07/20, did not document a order to change the wound treatment. The orders documented a complete blood count (CBC), a comprehensive metabolic panel (CMP), and a [MEDICATION NAME] level (laboratory tests) were to be obtained. The TAR for January 2020 documented continue to cleanse the bilateral buttocks and apply Lanteseptic cream every shift and as needed. The TAR documented the Triad paste was last applied on 01/08/20. A nurse practitioner note, dated 01/08/20, documented the staff were to monitor the resident's skin weekly, continue wound/skin protection measures, and see the chart for wound details. The note did not document an assessment of the pressure ulcer. The skin observation tool, dated 01/14/20, documented an unstageable wound to the sacrum measuring 3.0 cm x 1.5 cm and staff were to continue cleaning the site daily and applying [MEDICATION NAME] cream. The tool did not document ulcer depth, color, odor, or drainage. A nurse practitioner note, dated 01/15/20, documented the staff were to monitor the resident's skin weekly, continue wound/skin protection measures, and see the chart for wound details. The note did not document orders for changes in treatment. A progress note, dated 01/16/20 at 10:46 AM, documented the resident continued on skilled services, was non weight bearing, and was assisted to the toilet with the sit-to-stand tool. The note documented the resident had increased confusion and the physician was notified. The note documented a new order to obtain a urine analysis (UA). The note documented the family was notified. A skin observation tool, dated 01/20/20, documented two stage II pressure ulcers to the resident's sacrum. The tool documented one pressure ulcer measured 3.0 cm X 1.5 cm and the other measured 2.0 cm X 1.0 cm. The tool did not document ulcer depth, color, odor, or drainage. The note did not document the physician was notified a new stage II pressure had developed. A progress note, dated 01/20/20 at 12:29 PM, documented the urine culture results were received, sent to the physician, and staff were awaiting new orders. The note did not document the physician was notified regarding the development of a second pressure ulcer. A physician order, dated 01/20/20 at 2:58 PM, documented the resident was to receive [MEDICATION NAME] (an antibiotic) 500 milligrams (mg) one tablet by mouth one time a day for seven days related to a urinary tract infection. The orders did not document new treatment orders for the ulcers. A nurse practitioner note, dated 01/22/20, documented the staff were to monitor the resident's skin weekly, continue wound/skin protection measures, and see the chart for wound details. The note did not document a wound assessment or new treatment orders. A skin observation tool, dated 01/27/20, documented one stage II pressure ulcer to the sacrum measuring 2.0 cm X 1.0 cm. The tool did not document ulcer depth, color, odor, or drainage. A nurse practitioner note, dated 01/29/20, documented the staff were to monitor the resident's skin weekly, continue wound/skin protection measures, and see the chart for wound details. The note did not document new orders. The skin observation tools did not document a skin observation was completed for 02/03/20. The progress notes for 02/03/20 did not document an assessment of the resident's pressure ulcer. The skilled nurse notes, dated 02/03/20, documented no new change to skin integrity, the resident had treatable wounds to coccyx, a dressing was changed per treatment orders, and there were no notable changes to the wound. The note did not document the size, depth, color of the ulcer or other details of the ulcer. A physician progress notes [REDACTED]. The note did not document the resident had a wound. A physician order, dated 02/06/20, documented the resident was to receive a regular diet. The order did not document new ulcer treatment. The skin observation tool did not document a wound/skin observation was completed on 02/10/20. A physician progress notes [REDACTED]. The note documented the plan was to continue the current care. The TAR for February 2020 documented the staff continued to treat the pressure ulcer by applying lanticeptic to the buttocks everyday from 02/01/20 through 02/10/20. The TAR did not document Triad paste was applied. A discharge summary, dated 02/11/20, documented the resident went to hospital but did not document why. There was no documented assessment of the pressure ulcer from 01/27/20 through 02/13/20 in the progress notes. The notes did not document the resident went to hospital on [DATE] or why she went. The resident census report documented the resident went out of the facility on 02/12/20. A progress note, dated 02/14/20 at 2:03 PM, documented the resident was readmitted from the post acute hospital, denied pain, had an indwelling urinary catheter that was patent and draining clear yellow urine. The note documented the sacral pressure ulcer wound was debrided on 02/13/20 and the wound/pressure ulcer had a [MEDICATION NAME] dressing applied. The note did not document an assessment of the pressure ulcer. Post acute hospital discharge records, dated 02/14/20, documented wound care included the application of Thera-honey with a sacral foam dressing. The records documented the dressing was to be changed on Tuesday, Thursday, Saturday, and as needed for soiling. The new admission orders [REDACTED]. The orders did not document orders for wound treatment, the urinary catheter, or other resident care. The skilled nurse notes, dated 02/14/20, did not document an assessment of the pressure ulcer. The admission nurse screen, dated 02/15/15, documented the resident had an indwelling urinary catheter. The skin and wound section on the admission screen was blank. The skin observation tool for 02/17/20 was not completed. A physician order, dated 02/17/20, three days after admission, documented the staff were to apply [MEDICATION NAME] wound/burn dressing gel to the coccyx wound topically every evening shift on Tuesday, Thursday, and Saturday. The TAR for February 2020 documented the [MEDICATION NAME] Wound/Burn Dressing Gel was started on 02/18/20. The TAR documented the resident went four days without the [MEDICATION NAME] wound treatment. The TAR did not document the treatment was completed on Saturday, 02/15/20 as scheduled. A nurse practitioner note, dated 02/19/20, documented a follow-up for the post acute hospital stay. The note documented the stage II pressure ulcer wound on the coccyx was debrided and the resident returned to the nursing home on 02/14/20. The note documented the staff were to monitor the resident's skin weekly, continue wound/skin protection measures, and see the chart for wound details. A nurse practitioner note, dated 02/20/20, documented no significant new finding for the resident's pressure ulcer. Laboratory test results, dated 02/20/20, documented a [MEDICATION NAME] level of 22.3 and a reference range of 17-34. The skin observation tool, dated 02/21/20, documented the sacral pressure ulcer was a stage III pressure ulcer and measured 5.5 cm X 4.0 cm X 0.5 cm. The progress notes, dated 02/14/20 through 02/26/20, did not document the physician was notified the pressure ulcer was larger and deteriorated to a stage III ulcer. A physician order, dated 02/26/20, documented for staff to apply [MEDICATION NAME] wound/dressing gel to the resident's coccyx wound topically, then apply calcium alginate, and secure with [MEDICATION NAME] tape every evening shift Tuesday, Thursday, and Saturday. The TAR for February 2020 documented the new treatment for [REDACTED]. A nutrition/dietary note, dated 02/29/20 at 7:40 PM, documented a nutrition evaluation for wound care. The note documented a stage III pressure ulcer to sacrum and interventions included [MEDICATION NAME] acid. The note documented the resident received a regular diet with good oral intake and her weight was 204 lbs and stable. The note documented weight gain was contraindicated due to increased body weight on sacral wound. The note documented this was not beneficial for wound healing and therefore would not add double protein. The note recommended adding protein powder twice daily. A physician order, dated 02/29/20, documented staff were to administer one protein packet two times daily in food or liquid of choice for wound healing. The progress notes, dated 03/04/20, documented the resident went to the hospital but did not document why or if the physician was notified. A hospital infectious disease progress note, dated 03/09/20, documented a CT of the pelvis/sacral pressure ulcer was completed. The note documented the CT did not show an abscess or osteomyellitis. A readmission summary, dated 03/09/20 at 4:40 PM, documented the resident was readmitted , was alert and oriented, and was able to make needs known. The note documented the resident complained of pain to her legs and back and pain medication was effective. The note documented the resident was positioned with pillows for comfort, heel boots were in place, and the resident refused dinner. The note documented a dressing to sacrum was clean, dry, and intact. The note documented new wound orders were for Santyl to be applied to the wound bed, topped with wet-to-dry gauze, and covered with bordered foam. The note did not document an assessment of the ulcer. Physician orders, dated 03/09/20, documented orders for heel boots to be placed and for staff to remove boots every eight hours to check skin for ischemia or discoloration. The order documented if patient refused to wear boots, then staff were to float the resident's heels off the mattress using pillows placed under legs from midcalf to ankle. A physician order, dated 03/09/20 at 6:48 PM, documented the staff were to cleanse the resident's buttocks with normal saline, apply two mm thick layer of Santyl ointment over the entire wound bed, cover with wet gauze shaped to size of wound, and apply a border dressing every day. The order documented skin barrier could be wiped or sprayed over edges to prevent rolling. A physician order, dated 03/09/20, documented an order for [REDACTED]. The TAR for March 2020 documented the new wound care order was started on 03/10/20 and was completed daily. A physician order, dated 03/10/20, documented the staff were to irrigate the wound to coccyx with 30 ml normal saline using an 18 gauge [MEDICATION NAME] needle, blot off moisture, apply 2 mm Santyl ointment over entire wound bed, cover with normal saline moistened gauze shaped to size of wound, and cover with a border dressing. The order documented the dressing change was to be complete every day shift. The TAR for March 2020 documented the new order for wound care was started on 03/10/20 and was completed daily. A physician order, dated 03/11/20, documented the staff were to clean the coccyx wound with normal saline, apply Santyl, and cover with a maximum absorbency abdominal dressing every day. The TAR for March 2020 documented the new order for wound care was started on 03/12/20 and was completed daily through 03/25/20. A physician progress notes [REDACTED]. A skin/wound note, dated 03/19/20 at 12:15 PM, documented the resident's wound measured measured 9.0 cm X 5.5 cm X 0.3 cm. The note documented the edges appeared pink and intact, had new tissue growth at top of the wound, had a moderate amount of blood drainage, and did not have signs or symptoms of infection. The note documented the area was cleaned with normal saline, Santyl was applied to the wound bed, was covered with an abdominal pad, and taped in place. A physician progress notes [REDACTED]. A physician order, dated 03/25/20 documented a new order for wound care. The order documented the staff was to cleanse the wound to the coccyx with normal saline, pat the wound dry, and apply a PICO wound vac. The order documented the dressing change was to be completed weekly on Wednesdays day shift and as needed for soiling. The order documented weekly wound measurements were to be obtained prior to the dressing change and monitor for changes. The TAR for March 2020 documented the new order for wound care with the PICO wound vac. The TAR did not document the wound care was completed. A skin/wound note, dated 03/26/20 at 11:48 AM, documented the resident's wound measured 9.0 cm X 5.5 cm X 0.3 cm. The note documented the wound edges appeared pink and intact, had new tissue growth at top of the wound, had a moderate amount of blood drainage, and did not have signs or symptoms of infection. The note documented the area was cleaned with normal saline and the PICO wound vac was applied. The weekly wound observation tool, dated 03/26/20, documented a stage III wound measured 90 mm X 55 mm X 3 mm, was light red, had defined edges, and moderate bloody drainage. The note documented a PICO wound vac was started. A physician progress notes [REDACTED]. A progress note, dated 03/31/20 at 7:20 PM, documented the resident's catheter was leaking, the catheter balloon was checked, the catheter was repositioned, and monitored for continued leaking. A progress note, dated 03/31/20 at 8:28 PM, documented the catheter was still leaking and had no urine output in the bag. The note documented the catheter was changed, had a return of 250 ml yellow urine, and the resident tolerated the procedure well. The laboratory reports, dated 04/03/20, documented the resident's [MEDICATION NAME] was 17.0. A physician order, dated 04/01/20 at 11:43 AM, documented the staff were to cleanse the wound to the coccyx with normal saline, apply [MEDICATION NAME] wet to dry gauze, cover with an abdominal pad, and tape in place. The order documented the dressing was to be changed daily for one week. A nurse practitioner note, dated 04/01/20, documented a follow-up regarding the coccyx wound. The note documented the wound was unstageable, had no foul odor, surrounding tissue was macerated, had heavy drainage, consisted of 50 percent eschar, 10 percent slough, and 40 percent pink tissue. The note documented the dressing order was switched to [MEDICATION NAME] to attempt to dry the wound because the wound vac was over-saturated. The TAR for April 2020 documented the new order was completed on 04/02/20. A physician order, dated 04/02/20 at 11:25 AM, documented a new order for staff to apply Santyl ointment to coccyx wound every day shift. The order documented staff were to obtain a culture of the wound, and the resident was to receive [MEDICATION NAME] 875-125 mg (an antibiotic) one twice daily for seven days for a wound infection. A weekly wound observation tool, dated 04/02/20, documented the resident's wound was worsening, had a moderate amount of bloody drainage, measured 63 mm X 60 mm X 1 mm and was light red around the wound. A physician order, dated 04/02/20, documented the resident was to receive [MEDICATION NAME] 875-125 mg twice daily for seven days for a wound infection. A health status note, dated 04/03/20 at 4:17 AM, documented an x-ray of the coccyx and sacrum was obtained and the results documented a normal sacrum and coccyx. The note documented the results were faxed to the physician. A skin/wound note, dated 04/03/20 at 11:43 AM, documented the nurse practitioner was notified the wound measurements obtained on 04/02/20 had changed, the wound had increased slough, and had less granulation tissue since the previous week. The note documented the nurse practitioner ordered an x-ray of the coccyx to assess for bone involvement and infection. The note documented the current wound dressing was to be changed daily with Santyl and calcium alginate applied, then covered with an abdominal pad. A progress note, dated 04/04/20 at 6:18 PM, documented the physician was notified of the CBC, CMP, and [MEDICATION NAME] laboratory results. The note documented no new orders were received. A laboratory report, dated 04/06/20 at 2:43 PM, documented the wound culture had many in number of Ptoteus Mirabilis bacteria. A weekly wound observation tool, dated 04/06/20, documented the wound measured 50 mm X 55 mm X 13 mm, had [MEDICATION NAME] tissue, granulation tissue, slough, and was moist. The report documented a large amount of serosanguenous drainage with a foul odor. The report documented the peri-wound was light red with 60 percent slough. The report documented the wound continued to decline and the wound was monitored daily. A physician order, dated 04/09/20, documented the resident was to be discharged to the post acute care hospital. The resident's census record, documented the resident was discharged on [DATE]. A post acute care hospital report, dated 04/10/20, documented the resident's [MEDICATION NAME] was 11.1. A post acute care operative report, dated 04/10/20, documented pre-procedure unstageable wound measured 4.2 cm X 4.5 cm X 1.4 cm. The report documented post-debridement measurements were 5.0 cm X 5.2 cm X 2.0 cm. A weekly wound observation tool, dated 04/16/20, documented the resident's wound was a stage IV. The report documented the wound had [MEDICATION NAME] tissue, granulation tissue, slough, and necrotic tissue to the center of the wound. The report documented the wound was moist, had a large amount of serosanguenous drainage, had a foul odor, measured 53 mm X 35 mm X 30 mm, had no tunneling and the peri-wound was light red. The report documented a wound vac dressing was set at 125 mmHg was to be applied and the dressing was to be changed Monday, Wednesday, and Friday. The report documented the resident was readmitted from post-acute care for wound debridement and was to be monitored daily. The skin/wound note, dated 04/17/20 at 1:30 PM, documented the resident returned to facility on 04/16/20 from the post acute care hospital with stage IV wound to the sacrum and had a wet to dry dressing in place. The noted documented on 04/17/20 the wound measured 5.3 cm X 3.5 cm X 2.0 cm, had slough present in wound bed, granulation tissue toward the jagged outer edges, and the peri-wound was pink/red with slight shearing noted. The note documented the daughter was notified about the current status of wound. The note documented the resident was administered pain medication to aid with discomfort during the dressing change. A physician order, dated 04/17/20, documented the resident was to receive [MEDICATION NAME] 875-125 mg twice daily for five days. A physician order, dated 04/17/20 at 1:07 PM, documented the resident wound was to be cleaned with normal saline, black foam was to be applied to the wound base and bridge to the front of the leg, and set to 125 mmHg. The order documented the dressing was to be changed on Monday, Wednesday, and Friday. The TAR for April 2020 documented the admission wound care orders were started on Monday 04/20/20 with the next scheduled dressing change and were completed as ordered. A physician order, dated 04/17/20, documented the resident was not to be out of bed for more than two hours at a time. A weekly wound observation tool, dated 04/21/20, documented the resident had a stage IV pressure ulcer to the coccyx measuring 40 mm X 35 mm X 30 mm. The report documented the wound was improving, had [MEDICATION NAME] and granulation tissue, 20 percent slough, and 40 percent necrotic tissue. The report documented the wound was moist, had a foul odor, had a wound vac set at 125 mmHg, and was monitored daily. The progress notes for 04/21/20 were reviewed. The notes did not document the physician was notified regarding the foul odor to the wound. An infection note, dated 04/22/20 at 6:05 AM, documented the resident completed her antibiotics on 04/21/2020, was afebrile, and had no signs of distress. The Vohra wound care notes, dated 04/28/20, documented the stage IV pressure ulcer to coccyx had improved, measured 4.0 cm X 3.0 cm X 2.0 cm, had heavy serous drainage, had 40 percent devitalized tissue, 20 percent slough, and 40 percent granulation tissue. The notes documented surgical debridement was completed and the plan was to continue with the wound vac for 23 days. An order, dated 05/01/20, documented the resident was to receive a Juven Packet (a nutritional supplement) one ounce three times a day for wound healing. The Vohra wound care note, dated 05/05/20, documented the sacral pressure ulcer had deteriorated, measured 5.0 cm X 4.0 cm X 2.0 cm, had moderate serous exudate, had 40 percent necrotic tissue, 20 percent slough, and 40 percent granulized tissue. The note documented surgical debridement had been completed and the plan was to continue with the wound vac treatment and to reposition and offload. An infection note, dated 05/05/20 at 6:11 AM, documented the resident continued on [MEDICATION NAME] for a bladder infection, had no side effects, was afebrile, complained of pain to her coccyx, and resealed wound vac with tape. A physician order, dated 05/06/20, documented the staff were to cleanse the wound to coccyx with normal saline, pat the wound dry, apply Santyl and calcium alginate, and cover the wound with a foam dressing daily and as needed. A nutritional/dietary note, dated 05/06/20 at 2:01 PM, documented the resident's weight, documented the resident had 50-100 percent intake of most meals, and had a stage IV to sacrum with decline. The note reviewed nutrition interventions and recommended the Juven be restarted, Med Pass (a nutritional supplement) 90 ml twice daily, and a 14 day course of zinc sulfate 220 mg daily. A progress note, dated 05/12/20 at 9:30 AM, documented the resident was transferred to the hospital per family request regarding [MEDICAL CONDITION]. A physician order, dated 05/12/20, documented the staff were to send the resident to the hospital emergency department to evaluated [MEDICAL CONDITION]. An emergency department note, dated 05/12/20 at 10:46 AM, documented the resident's chief complaint was [MEDICAL CONDITION] and the nursing home stated she had decreased urinary output despite a catheter. The note documented the resident had a sacral decubitus ulcer and was unstageable. The note documented the skin was otherwise pink, warm and dry, and had no obvious [MEDICAL CONDITION]. The note documented the resident's temperature was 36.7 degrees Celsius. The hospital history and physical (H & P), dated 05/12/20, documented the resident had a catheter related urinary tract infection [MEDICAL CONDITION], a urine culture was pending, and was started on [MEDICATION NAME] (an antibiotic). The H & P documented the resident had a stage IV sacral decubitus ulcer and a wound service consult was to be requested. A hospital laboratory report, dated 05/12/20, documented the resident's urine had bacteria, protein, and blood. The report documented the bacteria was Proteaus Mirabillis. The report documented the blood cultures were negative. A hospital surgical consultation report, dated 05/13/20, documented the the sacral decubitus ulcer had necrotic tissue, was foul smelling, and tender. The note recommended surgical debridement. A hospital operative note, dated 05/14/20 at 10:01 AM, documented wound measurements were 9.0 cm X 5.0 cm X 3.0 cm and the wound extended to the sacral bone. The report documented dissection was taken down to the level of healthy bleeding tissue. The note documented a wound vac was applied in standard fashion with track pad to the left hip. On 05/14/20 at 1:35 PM, the resident's room was observed. A low-air-loss mattress was in place on the resident's bed. Multiple pillows and a bolster for positioning were in the room. The resident's wheelchair had a cushion. The resident was not in the facility and was not available for observation. On 05/14/20 at 1:50 PM, CNA #1 stated the resident was in the hospital. She stated pressure ulcer prevention included turning every two hours, keeping the residents clean and dry, reporting skin changes to nurse, and using air mattresses and cushions. The CNA stated on 05/12/20 the resident had low urine output, her urine was dark amber, and she was sent to hospital. The CNA stated catheter care was completed at least one time per shift and usually more. She stated when cleaning a catheter one wipes from the insertion site out. The CNA stated the resident liked to stay up in her wheelchair or recliner. On 05/15/20 at 5:45 AM, a tour of the facility was completed and staff were busy providing personal care for residents. The north hall had a strong urine smell and bags of soiled laundry and trash were outside the soiled utility room. With the help of CNAs the residents on the skilled hall were observed and were clean, dry, and repositioned. On 05/15/20 at 11:25 AM, the charge nurse/DON stated skin assessments were to be completed every week. She stated the resident was usually in her recliner or wheelchair, did not like to be in bed during the day, and would refuse to lie down. The nurse stated on 05/12/20 the resident was sent to hospital for low urine output. On 05/15/20 at 11:40 AM, the resident's physician stated the resident's pressure ulcer had not healed much. The physician stated a pressure ulcer was difficult to prevent since the resident did not move around much, stayed up in her chair for long periods of time, and refused to lie down in bed to relieve pressure. The physician stated the resident did not have a particular problem with her catheter. On 05/18/20 at 11:05 AM, the physician/medical director was interviewed. The physician stated stage I pressure ulcers were cared for by applying lanticeptic ointment and turning/repositioning. He stated Triad wound paste would be applied depending on the progress of the wound. The physician stated a stage II ulcer would be treated more aggressively and could be treated with collagen powder. The physician stated when white skin begins to slough off, the ulcer progressed to a stage II. He stated he observed the resident's wound after the skin was open. The physician stated he needed to be notified when the resident had a stage I or II ulcer. He stated in order for a pressure ulcer to heal the site needed blood supply, adequate nutrition, and be infection free. On 05/18/20 at 1: (TRUNCATED)

On 07/17/18, an Immediate Jeopardy (IJ) situation was determined to exist due to the failure of the facility to monitor a resident who was known to elope from the facility and ensure the resident was safe from harm while not in the facility. Resident #3 who had on six separate occasions eloped from the facility without the staff being aware that he had left, was found on two separate occasions outside the facility wheeling himself down the road in traffic. The Oklahoma State Department of Health was notified and verified the IJ situation. At 5:24 p.m., the administrator in training and director of nursing were informed of the IJ regarding failure to supervise a resident to prevent the resident from eloping from the facility on six separate occasions. They were informed this placed the facility in an extended survey. At 6:25 p.m., an acceptable plan of removal was received from the facilities support and director of nursing. The plan of Removal documented, Plan of Removal (MONTH) 17th, (YEAR) Identify Residents at risk 1. (Resident #3) Current Information/Plans in Place 1. Medical Director has been notified about our Plan of Removal with respect to (Resident #3). 2. Nurses are supposed to chart and know (Resident #3) whereabouts every 2 hours for each shift. (7am to 3pm, 3pm to 11pm and 11pm to 7am). This will be monitored by the DON/designee everyday. 3. A sitter schedule is in place for all three shift, 7 days a week (7am to 3pm, 3pm to 11pm and 11pm to 7am). 4. Attached is a sitter schedule and report sheet which will be monitored daily to see activity of (Resident #3). This will be documented by the sitter and monitored by the charge nurse/DON/designee. Education/In-service 1. In-services will be conducted on (MONTH) 17th, (YEAR) at 6:45pm with current staff member in the building and other staff not currently in the building within 24 hours. The in-service will be conducted by (DON) and (Facilities Support). 2. Staff on sick leave/vacation/PRN will be in-serviced upon their return to work. A list of those staff members will also be provided. 3. Below is an agenda of the in-service topic and discussion that will be conducted: a. Everyone in this facility needs to now (sic) who (Resident #3) is and what he looks like with a face sheet or in person. b. (Resident #3) has been known to get out of the facility without the staff knowing he has left. c. He usually goes out through the front door and waits until there is no one in the lobby to keep him from going out of the front door. d. He seems to know the code to the front door and the door in the independent apartments. e. He used to live in the independent apartments so he doesn't understand why he just can't come and go as he pleases. f. He now has a sitter and that sitter must stay with him during the time that the sitter is signed up for. g. The sitter has a form that needs to be signed off by the charge nurse. h. Nurses need to chart on him every two hours that he is safe i. CNA's need to do his ADL care but the sitters will not be able to chart since they are not a nursing staff. j. If a sitter is a nurse or a CNA/CMA, then they can do all the ADL care. Expected Time and Date of Completion In-services will begin on 7/17/2018 at 6:45pm for the current staff in the building on duty and other staff will be in-serviced as soon as they arrive into the facility. Estimated time and date of in-service completion for all staff, except for those listed on the sick leave/vacation/PRN list, is expected to be by 11:59pm of 7/18/2018. Time: 6:25pm Date: 7/17/2018 The IJ was removed on 07/19/18 at 3:18 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 observation, interview, and record review it was determined the facility failed to provide supervision to prevent elopement for one (#3) of one sampled resident who had eloped from the facility. The facility identified one resident who was at risk of elopement. Findings: A wandering, unsafe resident policy, dated (MONTH) 2014, documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm of unsafe wandering (including elopement) .The residents' care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included . An elopements policy, dated (MONTH) 2007, documented, .Staff shall investigate and report all cases of missing residents .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or director of nursing .If an employee observes a resident leaving the premises, he/she should .Attempt to prevent the departure in a courteous manner .Get help from other staff members in the immediate vicinity, if necessary .Instruct another staff member to inform the charge nurse or director of nursing services that a resident has left the premises . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 02/13/18, documented the resident had a BIMS score of zero. This score indicated that the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident did not have behaviors of wandering, was independent with locomotion on and off the unit, required a wheelchair for mobility, and did not have a wander/elopement alarm. A quarterly assessment, dated 05/16/18, documented the resident had a BIMS score of seven. This score indicated that the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident did not have behaviors of wandering, required supervision with locomotion on and off the unit, required a wheelchair for mobility, and did not have a wander/elopement alarm. A state reportable incident report, dated 05/23/18, documented, .(Resident #3) was found out front of the facility this was about 8pm He was last seen in the facility at about 7pm the resident has now been placed on a every hour visual check The resident is unable to tell us how he got out as he has a very hard time expressing himself .Relevant history .was a resident in our independent apt and was a severe alcoholic and we got APS involved and we were asked to let him become a LTC resident .He has not been any trouble and has never left the facility .We will continue every hr documented visual checks until 5-29-18 We will ask him if he would like to go out to the courtyard when he is out of his room . The care plan was not updated to include the resident's elopement or interventions to prevent further elopement. An incident report, dated 05/26/18, documented, .CNA came to nurse @ 3:30p dt door alarm on East hall going off & found resident coming in front door. I asked resident where (sic) you outside? Resident stated Yes, told resident for safety reasons he could not be outside by himself. Resident stated yes, yes & went to room .redirection & one -on- one unsuccessful continues Qh checks . The care plan was not updated to include the resident's elopement or new interventions to prevent further elopement. An incident report, dated 05/27/18, documented, .Nurse walk by west hall outside door & noticed resident rolling threw (sic) parking lot in w/c this nurse asked resident to come in to the building. Resident stated, No & kept rolling on the sidewalk down to retirement end of building. went to (DON) office & we walked to retirement porch & found resident sitting on the porch on buttocks with wheelchair tipped over front wards & bush next to porch was missing limbs. Assisted resident back to wheelchair & stated 'This is why you can not come outside of the building by yourself.' Resident stated, ya, ya, assisted resident back into building .continues on Q (hour) checks . The care plan was not updated to include the resident's elopement or new interventions to prevent further elopement. A facility incident report, dated 06/07/18 at 8:00 p.m., documented, A resident came to me & told me '(resident #3) is out on the road' & pointed to the front door. I went to the front & walked outside to the road & seen (resident #3) approximately 2 blocks up the street. I ran back inside facility & told (CNA) that I would be right back. I then ran up the street & brought res back to facility. No injury acquired .Dr order for nurses to chart Q2 (hour) where he is & what he is doing . A state reportable incident report, dated 06/08/18, documented, .(Resident #3) was seen by another male resident going off the facility grounds. That male resident told the nurse and the nurse was able to get him to come with her and he was brought back to the facility .new order has been written in resident's chart that the nurse needs to chart on him every two hr. and make sure that all staff is aware of his whereabouts in the facility so that the nurse can chart where he is in the facility . A physician's orders [REDACTED]. The care plan was not updated to include the resident's elopement or that the nurse was supposed to chart on the resident every two hours that he was safe in the facility. The care plan did not document any new interventions to prevent further elopement. A facility incident report, dated 06/14/18, documented, .Resident left facility s permission stated he was bored and he will leave again if he get bored .15 min (checks) in progress . A nurse's note, dated 06/14/18, documented, Resident left facility without supervision or permission, stated he was bored and would leave again. Ask resident would he notify the nurse if he decided to leave, resident stated yes. Resident on a every 15 min check at this time will pass on to on coming nurse of the above. Ask resident how he got out of building stated he knows the code and when to leave without someone seeing him. A care plan, dated 06/15/18, documented, Focus: (Resident #3) is an elopement risk/wanderer r/t impaired safety awareness and history of attempts to leave facility unattended .Goals: .safety will be maintained .will not leave facility unattended .will demonstrate happiness with daily routine .Interventions: Assess for fall risk .Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate .Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes .Report any attempts to family .Staff is to do an every 2 hour check . A state reportable incident report, dated 07/07/18, documented, .On Saturday at about 7:17pm resident was spotted going east up skelly drive He was brought back to the facility by one of our staff no injuries He seems to know when nursing is very busy putting residents to bed and the way this facility is built there is no one to watch the front door .will say he doesn't know the code but we are sure he knows the code to several of the doors We have taken his w/c from him he is able to amb with a cane but he doesn't go for great distances unless he is in his w/c .He is on visual checks and only can have his w/c if someone from the facility is with him. He was placed here by APS .but it is getting very hard to keep this resident safe . The care plan, updated 07/16/18, documented, Intervention: .gets 1:1 observation care every day. Weekends (sic) 3P-7A. and weekends 24 hours . On 07/17/18 at 10:20 a.m., the DON was asked for a list of residents at risk for elopement. She stated they only had one resident and it was resident #3. She then stated they had a sitter during the week for the resident from the 3-11 and 11-7 shifts and on the weekends for 24 hours. They did not have a sitter Monday through Friday on 7-3 shift because of the number of staff that was available to monitor him. She was asked when the sitter was started. She stated the sitter was started on 07/12/18 with the 3-11 shift. At 2:40 p.m., CMA #1 was asked if there was anyone she was supposed to watch or supervise for risk of elopement. She stated, (Resident #3). She was asked if she had attended any in-services regarding the resident's elopement. She stated, The DON told us all to watch him, but did not sign an in-service. At 2:50 p.m., the admission coordinator was asked if there was anyone she was supposed to watch or supervise for risk of elopement. She stated, Yes, if the resident is at the door we call for a nurse. She was asked if she was present when resident #3 had eloped. She stated, He has not left the building while we are here in the front office. She was asked if she had attended any in-services regarding the resident's elopement. She stated, They told us in stand up meeting, yesterday. At 3:15 p.m., the DON was asked why there were gaps in the every two hour charting per the physician orders. She stated, I don't know. They should have been charting. She was asked if she had done any in-services regarding the elopement, She stated, I've had an in-service with staff by mouth. If sitter is not nursing, nursing is still responsible. No formal in-service, we will have one on our big in-service scheduled 07/20/18. The DON was asked if the resident was in the road during the incidents on 05/23/18, 05/26/18, or 06/14/18. She stated, He was not off the property on one. The other time he had gone up Skelly Drive towards(NAME)Avenue. They told me he was in the road. I did take the wheelchair away and was told by DHS I couldn't do that and gave it back to him. She was asked what interventions were in place to prevent further elopements. She stated, The sitter. DHS suggested the sitter so that's what we did. The DON was asked why there was no care plan developed for the elopement until after the resident had eloped on five occasions. She stated, They should have done immediately. She was asked who was supposed to do the care plans. She stated, The MDS coordinator for long term care. She was asked who monitored the care plans to ensure they were updated. She stated, I do what they bring me because I'm the only RN. At 4:10 p.m., CNA #3 was asked if there was anyone he was supposed to watch or supervise for risk of elopement. He stated, (Resident #3), (CNA #4) told me. He was asked if he had attended any in-services for the resident's elopement. He stated, No. At 4:15 p.m., CNA #2 was asked if there was anyone he was supposed to watch or supervise for risk of elopement. She stated (Resident #3), other staff told me. She was asked if she had attended any in-services for the resident's elopement. She stated, No. On 07/19/18 at 10:30 a.m., the MDS coordinator was asked why there was no elopement care plan developed after the first time the resident eloped from the facility. She stated, I put it under behaviors at first, until I realized later it needed to be it's own focus. She was asked if she should have developed the elopement care plan after the first elopement. She stated, Yes.

Based on observation, interview, and record review, it was determined the facility failed to assess, monitor, and intervene for one (#4) of three residents whose records were reviewed for pressure ulcers. Resident #4 developed osteo[DIAGNOSES REDACTED] of the right foot with a necrotic would of the heel. Findings: Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/09/18, documented the resident had a BIMS score of nine. This score indicated the resident was moderately impaired with skills for daily decision making. The assessment documented the resident required total assistance with two plus persons for bed mobility, transfers, dressing, and toileting, extensive assistance with two plus persons for bathing, and limited assistance with one person for locomotion on and off the unit, and personal hygiene. The assessment also documented the resident was frequently incontinent of bowel and bladder, and had no pressure ulcers. A care plan, updated on 01/12/18, documented, Focus .is at risk for impaired skin integrity/pressure ulcer development due to immobility and preference of activity .Goal .skin will remain intact through the next review date .Interventions .assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD .instruct/assist to shift weight in W/C as needed .needs the bed as flat as possible to reduce shear. She prefers to be repositioned with 2 people .monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage .treat pain as per orders prior to treatment/turning etc. to ensure .comfort . An admission summary, dated 02/16/18, documented, .2nd toe has necrosis noted and R heel red . There was no documentation the physician had been notified of the necrosis to the resident's 2nd toe and the redness to the resident's right heel. A wound care specialist evaluation, dated 02/16/18, contained no documentation of the resident's necrotic second toe or the reddened right heel that had been present on admission. A skin observation tool, dated 02/18/18, contained no documentation of the resident necrotic second toe or the reddened right heel that had been present on admission. A wound care specialist evaluation, dated 02/19/18, contained no documentation of the resident's necrotic second toe or the reddened right heel that had been present on admission. A wound care specialist evaluation, dated 02/27/18, contained no documentation of the resident's necrotic second toe or the reddened right heel that had been present on admission. A nurse's note, dated 02/28/18, documented, .wound to outer heel 6 x 5.5 and also has a wound to the 2nd toe 0.6 x 1.0 tip of toe .0.4 x 0.6 and eschar top dorsal 2.2 circular . There was no documentation the resident's primary physician or the wound specialist had been notified of the presence and size of the wounds to the resident's second toe or right heel. A wound care specialist evaluation, dated 03/14/18, documented, .presents with an arterial wound of the right, proximal, second toe of at least 1 days duration .wound size .0.5 x 0.5 x 0.1 cm .exudate .none .dressing(s) .skin prep apply once daily for 30 days .recommendation .elevate leg(s), off-load wound, reposition per facility protocol . .arterial wound of the right, distal, second toe .wound size .0.5 x 1.2 x 0.1 cm .exudate .none .dressing(s) .skin prep apply once daily for 30 days .recommendation .elevate leg(s), off-load wound, reposition per facility protocol . .unstageable DTI of the right heel .duration >1 day .wound size .5.9 x 7.0 x not measurable cm .exudate .none .dressing(s) .skin prep apply once daily for 30 days .recommendation .off-load wound, reposition per facility protocol, elevate leg(s), float heels in bed, EZ boot to be worn in bed and chair to off-load wound, xray foot to evaluate for osteo[DIAGNOSES REDACTED] . An xray report, dated 03/14/18, documented, .there is mild plaquing. Velocity is decreased in the popliteal artery 25cm/sec. There is no flow in the right posterior tibial artery .The left lower extremity has been amputated . A physician's order, dated 03/14/18, documented, .skin prep wipes .apply to R outer heel topically one time a day for DTI also apply to #2 rt toe and top dorsal q daily . A nurse's note, dated 03/27/18, documented, .dressing to R foot tx done with malodorous (sic) and dressing with yellow type exudate . There was no documentation the resident's primary physician or the wound specialist had been notified of the change in the condition of the resident's wound. A wound care specialist evaluation, dated 04/02/18, documented, .arterial wound of the right, proximal, second toe .duration >18 days .wound size .0.5 x 0.5 x 0.1 cm .exudate .none .dressing(s) .skin prep apply once daily for 30 days .recommendations .elevate leg(s), off-load wound, reposition per facility protocol . .arterial wound of the right, distal, second toe .duration > 18 days .wound size .0.8 x 0.8 x 0.1 cm .exudate .none .dressing(s) .skin prep apply once daily for 30 days .recommendations .elevate leg(s), off-load wound, reposition per facility protocol . .unstageable DTI of the right heel .duration >18 days .wound size .11.5 x 9.0 x not measurable cm .exudate moderate serous .dressing(s) .calcium alginate apply once daily for 30 days, dry protective dressing apply once daily for 30 days .recommendation .off-load wound, reposition per facility protocol, elevate leg(s), float heels in bed, EZ boot to be worn in bed and chair to off-load wound, xray right foot to evaluate for osteo[DIAGNOSES REDACTED], antibiotic choice, bactrim DS 1 tab po BID x 10 days . There was no documentation of the malodorous right foot wound with yellow type exudate, as noted by the nurse on 03/27/18. A physician's order, dated 04/02/18, documented, .cleanse rt heel with ns, pat dry apply silver alginate 4x4 area and cover with gauze dressing and secure with kerlix q day and prn . There was no physician's order related to the malodorous right foot wound with yellow type exudate, as noted by the nurse on 03/27/18. A nurse's note, dated 04/07/18, documented, .hospice notified of resident decline in condition .FSBS 83, confused, clamly (sic), pale in color, Dx: end stage [MEDICAL CONDITION] refusing [MEDICAL TREATMENT], full code, in route to (hospital name deleted) . A hospital discharge summary, dated 04/20/18, documented, .admit [DIAGNOSES REDACTED].discharge [DIAGNOSES REDACTED].treated with broad-spectrum antibiotic therapy .she(the resident) was taken for right above-the-knee amputation for management of her severe life-threatening infection . On 07/19/18 at 2:40 p.m., the ADON was asked why the physician had not been notified when the resident had been readmitted to the facility with necrosis to her second toe or redness to her right heel. She stated she didn't know why the physician hadn't been notified but the nurse should have notified him. She was asked if a nurse had made rounds with the wound care specialist on 02/16/18. She stated, Yes, I usually do. She was asked why she had not been made aware of the the necrosis to the resident's second toe or redness to her right heel when she had been readmitted to the facility earlier in the day on 02/16/18. She stated, I don't know. She was made aware of the skin observation tool, dated 02/18/18 with no documentation of the necrosis to the resident's second toe or redness to her right heel. She stated, The wound should have been documented on the skin observation. The ADON was informed of the wound care specialist evaluation, dated 02/19/18, with no documentation of the necrosis to the resident's second toe or redness to her right heel. She was asked why the physician had not been made aware of the resident's wounds. She stated, I don't know, I was aware. She was informed of the wound care specialist evaluation, dated 02/27/18, with no documentation of the necrosis to the resident's second toe or redness to her right heel. She was asked, after 12 days of the resident being back in the facility, why had the wound care specialist not been made aware of the resident's wounds. She stated, Someone, a CNA or LPN should have noticed the foot and made sure the physician was aware. The ADON was informed of the nurse's note, dated 03/27/18, that documented the wound to the right foot was malodorous with yellow exudate. She was asked why the wound care specialist or the resident's primary physician had not been notified when the characteristics of the resident's wound had changed. She stated she didn't know.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for one (#165) of one sampled resident who had experienced falls. The facility identified 51 residents who were at high risk for falls. Findings: A fall prevention and management policy, documented, Policy guidelines: .The facility assesses each resident for his or her risk for falls, designs a plan for care, and implements procedures to minimize falls and/or injury .A fall risk assessment is completed on each resident on admission, quarterly, upon change of condition, and immediately following a fall .prevention strategies to be implemented are listed on the plan of care. Periodic evaluations of the care plan and effectiveness of prevention strategies are conducted .Intervention: If a resident falls, the following steps should be taken: assess the resident post fall .notify physician .notify the resident's family .monitor the resident's condition for 72 hours and until injury or complaints are resolved. Document findings with each assessment .Update the resident's care plan .Fall prevention strategies are reviewed with staff, including the method and frequency of assessing effectiveness .The quality management/risk management committee evaluates fall data to measure and analyze falls and reviews potential contributing factors and follow-up actions . A falls and fall risk policy, documented, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . An accidents and incidents investigating and reporting policy, documented, .All accidents or incidents involving residents .occurring on our premises shall be investigated and reported to the administrator .The nurse supervisor/charge nurse and /or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .the nurse supervisor/charge nurse and/or department director or supervisor shall complete a report of incident/accident form and submit the original to the director of nursing services within 24 hours of the incident or accident .Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities . Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 02/21/18, documented, Focus: .is high risk for falls .Goals: will be free of falls through the review date .Interventions: anticipate and meet needs .Be sure .call light is within reach and encourage her to use it for assistance as needed .needs prompt response to all requests for assistance .needs a safe environment .Educate .family/caregivers about safety reminders and what to do if a falls occurs .Ensure that (name deleted) is wearing appropriate footwear when ambulating or mobilizing in w/c . An incident report, dated 02/24/18, documented, .Resident observed in floor next to her bed on her back A/O x 1 (no) bleeding, bruising, or swelling noted +ROM all extremities (no) s/s of pain but states shoulders hurt when asked. (No) grimacing or guarding observed .proper footwear provided to res. Family educated . The care plan, updated on 02/26/18, documented, Fall 2/24/18: Provided with slip grip socks. Re-educated on the importance of proper footwear when ambulating or in wheelchair . A medicare 14 day assessment, dated 03/05/18, documented the resident had a BIMS score of six. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required limited assistance with most activities of daily living, was frequently incontinent of bowel and bladder, had no falls since admission, and received antidepressant and diuretic medications seven of the last seven days. A nurse's note, dated 03/18/18, documented, Resident laying in bed on her back with bright red blood noted to the back of head approximately 4 cm laceration to back of head, resident A X A X O X 3 with confusion noted regarding situation as WNL for resident, Wheelchair noted upside down with bright red blood in the floor next to bed . A state reportable incident report, dated 03/18/18, documented, .certain injuries .Resident was found in her room with w/c upside down nurse did head to toe assessment and found a laceration to back of head 911 was called and resident sent to (name deleted) ER she returned at 1:47 am with 2 staples to back of head .was admitted to this facility .skilled unit Dx: cognitive communication deficit alz. disease .she is a high risk for falls due to her cognitive communication deficit and alz. disease she is independent with her w/c once she is in her w/c .will cont. to monitor her needs and try hard to anticipate when she needs something have written a order for the nurse to chart on her and her where abouts several times a shift the only Dr. order that she came back with was the staples can be removed in 5-7 days . The care plan, updated 03/27/18, documented, .3/18/2018 Minor fall injury to back of head. Staff is to monitor every 2 hours and make sure bed it (sic) at the lowest . The care plan did not address the wheelchair being found upside down or any new intervention to prevent further falls regarding the wheelchair. The care plan, updated 04/12/18, documented, .04/04/2018 .had a minor fall injury. Scratches to head and back. Staff is to identify factors that may cause or contribute to injury from a fall . The care plan did not address the fall or any new interventions to prevent further falls. There were no nurse's notes and no incident report provided to address the fall or the investigation for how the fall happened. A nurse's note, dated 04/09/18, documented, Resident laying in her bed reports to staff she fell trying to get up upon skin assessment scrape to upper back x 2 and scrape to back of head, and elbow neuro checks initiated WNL resident unable to state rather (sic) she hurts or not but doesn't show any s/s of distress she is smiling and verbal with staff no bleeding bruising or swelling noted at this time .will continue to monitor for changes . There was no incident report provided for this fall. The care plan was not updated to address this fall or any new interventions to prevent further falls. On 04/16/18 at 3:55 p.m., the resident was observed sitting in her wheelchair by the nurse's station. On 04/17/18 at 4:11 p.m., the resident was observed sitting in her wheelchair in the dining room at the table. On 04/24/18 at 3:00 p.m., the DON was asked if the resident had a fall on 04/04/18. She stated, (care plan coordinator #2) told me there was a fall. She was asked if there were incident reports for the falls on 04/04/18 and 04/09/18. She stated, No. The DON was asked if incident reports should have been completed for the falls. She stated, Yes. I've told them I need the paper incident report. She was asked why the wheelchair being upside down was not addressed on the care plan for the fall on 03/18/18. She stated, When I was talking to the nurses they said the last time they saw her she was in bed. She was asked if she had done a fall investigation for the fall on 03/18/18. She stated, No. She was asked if she did fall investigations to find the root cause of a fall. She stated, I sure try. I do in my investigation. If I don't know about it, I can't do it. She was asked what her process was to find out about falls. She stated, I go talk to nurse and or CNA's involved. I ask if any incidents in the building from the last night. The DON was asked if that system was working. She stated, No. She was asked if the care plan should address new interventions after each fall to prevent further falls. She stated, Yes.

Based on observation, interview, and record review, it was determined the facility failed to: ~ conduct thorough investigations for allegations of abuse and/or neglect for four (#38, #47, #50, and #165) of four sampled residents who were involved in allegations of abuse and/or neglect; and ~ prevent further potential abuse and/or neglect for three ( #47, 50 and #165) of four sampled residents involved in allegations of abuse and/or neglect. Resident #47 was verbally and physically abused by resident #38 and verbalized that she was frightened by the resident who was her roommate. This had the potential to affect all 65 residents who resided in the facility. Findings: An abuse prevention program policy, documented, Policy Statement: Our residents have the right to be free from abuse, neglect .This includes but is not limited to freedom from .verbal, mental, sexual, or physical abuse .As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . A nursing policy and procedure, titled Abuse prevention, intervention, reporting, and investigation, documented, Residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self abuse/self-neglect .The facility has developed a system for identifying, investigating, preventing, and reporting any incident, or suspected incident, of abuse .It is the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family, or visitors .Staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse .All reports of resident verbal, sexual, physical and mental abuse .neglect .are promptly and thoroughly investigated by facility management .Prevention: At the time of admission, each resident and responsible parties are informed of the resident's rights and the facility's zero tolerance for any form of abuse .A zero tolerance policy of abuse, neglect, mistreatment .along with reporting directions, is posted in the facility or given to the resident upon admission and each employee at orientation .Resident rights and abuse prevention training for all employees is conducted during orientation, and at least annually, and includes review of: .definitions of abuse .resident rights .abuse and neglect policy and procedures .duty to report and reporting process .Intervention: Upon receiving reports of physical or sexual abuse, the facility administrator and director of nursing are immediately notified to arrange for the examination of the resident .Reporting: The administrator is promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is called at the emergency contact number on record .initial reports to regulatory and state agencies are submitted within 24 hrs .A final investigative report is submitted to the Oklahoma State Department of Health .within 5 calendar days .Investigation: Residents and staff are to be protected during incident investigations by ensuring: Reports are made without fear of retaliation .A resident who is allegedly mistreated by another resident is removed from contact with that resident during the investigation . 1. Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 03/09/18, documented, Resident (#38) arguing with new roommate this evening over the TV. Called (resident #47) a b**** . There was no incident report and no state reportable incident report provided for the resident to resident altercation. An admission assessment, dated 03/14/18, documented the resident had a BIMS score of 12. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident had no behaviors, required limited assistance with walking, locomotion on and off the unit, and extensive assistance with transfers, and received no [MEDICAL CONDITION] medications the previous seven days. A social service note, dated 03/13/18, documented, .has/had a concern about her and her neighbor not getting along . A nurse's note, dated 03/15/18, documented, Resident was in the doorway of her room with her roommate was screaming help. I went to the doorway and (resident #38) was stepping on her roommates feet and had both her hands holding down (resident #47). I had to tell (resident #38) to take her hands and feet off her roommate. (Resident #38) said this is my personal property she needs to leave. I told them both that they needs (sic) to get along. (Resident #47) said she wants to move to another room . There was no incident report and no state reportable incident report provided for the resident to resident altercation. A nurse's note, dated 03/16/18, documented, Resident (#38) being mean to roommate (resident #47) blocking resident from getting in or out of room holding her wrists social services notified and family called . There was no incident report and no state reportable incident report provided for the resident to resident altercation. A nurse's note, dated, 03/28/18, documented, Resident (#38) went over to her roommates (Resident #47) side of the room and scared her tonight. Redirected her to stay on her side of the room . There was no incident report and no state reportable incident report provided for the resident to resident altercation. A state reportable, dated 04/01/18, documented, .(resident #38) thru (sic) a water pitcher at (resident #47) her room-mate both are residents here .resident to resident altercation .(Resident #38) has had that room for awhile without a room-mate now that she has one she has tried to say that the room-mate bumps her w/c when the room-mate goes in or out of the room. We even had (resident #38) family come to talk with her and let her know that they can not afford to pay for her to have a pvt room. We also offered to move (resident #38) to the other side of the room but she said No I was her (sic) first .both ladies have no behavior dx. This is more than likely due to (resident #38) having her room without a room mate for many months .(resident #38) will be moved to another room that is closer to the nsg.desk and she will have the A bed which is the bed that she wants . A nurse's note, dated 04/02/18, documented, This resident reported to this nurse on action of room mate (sic) yesterday while she waws (sic) attempting to go in room, she lives on B side. While passing roommatew (sic) side A, (Resident #38) threw half glass of pop toward her missing her, trying not for her to enter her room . The care plan did not address the altercations with the roommate or interventions to protect her from further abuse. On 04/17/18 at 3:06 p.m., resident # 47 was asked if her former roommate threw a water pitcher at her. She stated She threw a glass of liquid at me. That really bothered me and I turned it in. I tried to let the other things she did slide. She was asked if she remembered the roommate scaring her one night. She stated, Yes, I told her to leave me alone and get away from me. She showed her teeth like an animal. She was asked how that made her feel She stated, Terrible. I was frightened. I can't walk so I couldn't get away from her. She was asked if the roommate had ever physically grabbed her wrists. She stated, I don't think she ever touched me I think I was out of her reach. She was asked if she felt protected while she was with that roommate. She stated, Yes, but from up above. I prayed God protect me. I felt like she could do worse to me, but God protected me. At 3:35 p.m., CNA #6 was asked if she had witnessed resident #47 and resident #38 in any resident to resident altercations. She stated, Yes. (Resident #38) was standing over (resident #47) and (resident #47) was yelling for help. The nurse said to stay on her side of the room. At 3:45 p.m., LPN #2 was asked if she remembered any problems with resident #38 and resident #47. She stated, Yes. (resident #47) was on the outside of the room. (Resident #38) had grabbed her wrists and had her feet on top of (resident #47) feet. Both were in their w/c facing each other I had to go down and separate them. (Resident #38) puts her w/c in doorway so resident can't go in or out. At 4:00 p.m., LPN #2 was asked if she filled out an incident report on the incident. She stated, I charted it in the nurse's notes. She was asked if she reported the incident to anyone. She stated, I told someone. the (DON) or the (ADON). She was asked if she received any abuse or neglect training. She stated, Not since I've been here. LPN #3 was asked if she had received any abuse or neglect training since she had started work. She stated, Not here. On 04/23/18 at 4:26 p.m., the DON was asked why it took from 3/15/18 to 04/01/18 before the facility separated resident #47 and resident #38. She stated, The nurse should have filled out an incident report. I don't know. She was asked who was responsible for completing the incident reports. She stated, The nurse on the floor. She was asked what she did to protect the resident from her roommate. She stated, The minute the incident report came across, we asked (resident #38) family to move her. She was asked why there were no incident reports for the incidents on the previous dates. She stated, There was confusion when we switched over to the computer. They didn't write a paper one. I told them I needed a paper report. On 04/24/18 at 9:45 a.m., the ADON was asked if LPN #2 reported the incident between resident #47 and resident #38 on 03/15/18. She stated, No. I'm aware of when (resident #38) threw some pepsi at resident #47. She was asked if an incident report should have been done. She stated, Yes. At 2:56 p.m., the DON was asked what abuse training was provided for new hires. She stated, The ADON goes over policy and procedure with them. 2. Resident #165 was admitted on [DATE] with [DIAGNOSES REDACTED]. A medicare 14 day assessment, dated 03/05/18, documented the resident had a BIMS score of six. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had no behaviors, required limited assistance with activities of daily living, and received an antidepressant medication on seven of the last seven days. A nurse's note, dated 04/13/18, documented, Our AIT person came to me (DON) and said that (resident #38) is treating her room mate (resident #165) not very nice I asked him how he knew and he said her roommate came to him and told him she was not being treated very nice I asked our SS dept to call (resident #38) family and have them come in and talk with her as we have moved (resident #38) once and we have no more female rooms. So know (sic) it will have to be up to her family as to what they are wanting to do. There was no incident report or investigation regarding this allegation. The facility did not implement their abuse policy, did not protect the resident from further abuse at this time, and did not investigate this as an allegation of abuse. A nurse's note, dated 04/15/18, documented, Resident stated to staff, She's (Roommate) is mean to me, she won't let me go in the room. Resident redirected and sat @ nurse's station, then assisted to bed by CNA with no difficulty noted. There was no incident report or investigation regarding this allegation. A nurse's note, dated 04/16/18 at 12:33 p.m., documented, Resident (#38) blocking the doorway so that her roommate cannot get in or out. On 04/16/18 at 2:52 p.m., during a resident interview resident #50 stated, Another resident (resident #165) is afraid of her roommate because she picks on her. When she said something to (ADON) nurse told her to deal with it and was rude. At 3:55 p.m., the resident was observed sitting in her wheelchair at the nurse's station. She was asked why she was sitting at the nurse's station. She stated, The nurse's are protecting me from that woman. At 4:09 p.m., resident #50 was asked how she knew the resident was afraid of her roommate. She stated, She has told everyone. She was asked how she knew the ADON had told the resident to just deal with it. She stated, She sits at my table. It was either breakfast or lunch last week when the nurse said deal with it. At 4:34 p.m., CNA #4 was asked if she knew why the resident was sitting at the desk all day. She stated, I don't know why. She was asked if the resident had said she was was afraid of her roommate. She stated, Yes. She was being mean to (resident #47) that's why they moved her in with (resident #165). At 4:38 p.m., CNA #5 was asked if resident #165 ever mentioned being afraid of her roommate. He stated, Yes. She complained for a day and a half. He was asked if he reported it. He stated, She reported it herself to the charge nurse. At 4:47 p.m., informed the DON of the allegation the resident was afraid of the roommate and she would need to start an investigation. A social service note, dated 04/16/18 at 5:22 p.m., documented, Contacted residents family member, and explained that we're moving her to a different room. Explained resident said she was scared of her room mate. Family member understood, but added 'its probably because of her dementia, but that fine with me'. A state reportable incident report, dated 04/16/18, documented, .(Resident #38) and (Resident #165) resident to resident verbal altercation .(Resident #38) has been mean verbally to (resident #165). (Resident #165) says she doesn't want to go in her room that she shares with (resident #38) because she is not nice to her .(Resident #38) has the following dx: .major [MEDICAL CONDITION] .dementia without behaviors .She has has problems in the past with roommates and family is aware of this. (Resident #165) dx: .dementia without behaviors .anxiety, major [MEDICAL CONDITION] .Both residents want a room by themselves .I then went to speak with (resident #165). She said 'I am afraid of her so I try not to go in that room' I asked (resident #165) what she means when she says I am afraid of her. 'I liked my room when I was alone' I asked .if I could find her another room would she like to move .I will also re -inservice our staff how important it is to report any and all dis-harmony to DON, Administrator .(resident #165) was moved to room .All staff to be re-inserviced .on resident's rights and who to report to if a resident has a concern. A c/p meeting will be set up with both families with residents present so all concerned will understand all the rules of this facility . After this allegation of abuse had been reported on 04/13/18, it had not been acted on and the resident was not protected from further abuse. On 04/17/18 at 10:52 a.m., the DON was asked who does abuse investigations. She stated, It starts with administration and then goes to the department involved. She was asked if she interviewed the ADON. She stated, I asked her to describe, to explain to me what was said. I did not ask her anymore questions,. She was asked if she had asked the ADON if she said to the resident to deal with it last week during a meal time. She stated, No I did not. The DON was asked if she interviewed the Social service director. She stated, I asked him if he knew anything He said no. She was asked if she documented anything. She stated, No. She was asked if she interviewed any CNA's. She stated, No I was working on something else with the CNA's that was more important than this. The DON was asked if she interviewed any Charge nurses. She stated, I asked if they knew anything. they said No. She was asked which nurses she interviewed. She stated, (LPN #2) and (LPN #3). She was asked if she documented anything. She stated, No. The DON was asked if she interviewed any residents. She stated, Other than the two, I asked (resident #50) if she wanted a new roommate. No, I did not document what she said. The DON was asked if she had asked the resident why she was afraid. She stated, She said I'm afraid. Family said she has been this way always. She was asked how the facility protected the resident. She stated, She doesn't go near (resident #38) room. At 3:45 p.m. LPN #2 was asked if (resident #38) had behaviors towards her roommate. She stated, Yes. She puts her wheelchair in doorway so the resident can't go in or out of the room. We told her she had to let her in it was her room also. She was asked if resident #165 was afraid of her roommate. She stated, Yes. Sometimes she wouldn't go into the room until (resident #38) was in bed asleep. There were times when she wasn't even in the room and (resident #165) refused to go in the room. At 4:00 p.m. LPN #2 was asked if anyone talked to her about allegations of abuse between the two residents. She stated, No. She was asked if anyone obtained statements or interviewed her. She stated,No. LPN #3 was asked if anyone had interviewed or obtained statements from her regarding the allegation of abuse between the two residents. She stated, No. At 4:11 p.m., the resident was asked what happened with her roommate. She stated, She wouldn't let me in my room. She was asked if she had told anyone. She stated, I told the girls. They wouldn't do anything. She was asked what happened when her roommate wouldn't let her in her room. She stated, I would get out and stay out. That woman made me afraid. 3. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 03/08/18, documented, Resident not happy with roommate going in and out of the room tonight. Roommates floor light was shining into her eyes so moved it . A nurse's note, dated 03/09/18, documented, Resident arguing with new roommate this evening over the TV. Called (resident #47) a b**** . A nurse's note, dated 03/13/18, documented, Resident was blocking the doorway of the room tonight so that her roommate could not get out . A nurse's note, dated 03/15/18, documented, Resident was in the doorway of her room with her roommate was screaming help. I went to the doorway and (resident #38) was stepping on her roommates feet and had both her hands holding down (resident #47). I had to tell (resident #38) to take her hands and feet off her roommate. (Resident #38) said this is my personal property she needs to leave. I told them both that they needs (sic) to get along. (Resident #47) said she wants to move to another room. There was no incident report and no state reportable incident report provided for the resident to resident altercation. A quarterly assessment, dated 03/15/18, documented the resident had a BIMS score of nine,. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had no behaviors, required extensive assistance with activities of daily living, and received an antidepressant seven of the last seven days. A social service note, dated 03/16/18, documented, .was told resident being rude and combative to roommate. went to visit resident and the roommate was outside of door trying to get in. I open the door and resident was there holding the door so roommate couldn't get in. resident said shes (sic) not welcomed in here. I explained this is her room also and she should at least try and be nice and try to get along. resident said no she needs to be gone and I will spend the rest of my time here making her life hell. I called residents responsible party and explained what was going on and she said she would call her and come by the next day . A nurse's note, dated 03/16/18, documented, Resident being mean to roommate blocking resident from getting in or out of room holding her wrists social services notified and family called. A nurse's note, dated 03/19/18, documented, Resident advised by staff to allow her roommate in room, resident did comply and no further behaviors noted. A nurse's note, dated 03/28/18, documented, Resident went over to her roommates side of the room and scared her tonight. Redirected her to stay on her side of the room. A nurse's note, dated 03/29/18, documented, Roommate of this resident verbalized last evening this resident was standing mid room just staring at her while she lie in bed. No words said. There was no incident report and no state reportable incident report provided for the resident to resident altercation. A nurse's note, dated 04/01/18, documented, Resident noted throwing water pitcher @ roommate D/T roommate moved her wheelchair, 1 on 1 & redirection given with improvement noted. A state reportable, dated 04/01/18, documented, .(resident #38) thru (sic) a water pitcher at (resident #47) her room-mate both are residents here .resident to resident altercation .(Resident #38) has had that room for awhile without a room-mate now that she has one she has tried to say that the room-mate bumps her w/c when the room-mate goes in or out of the room. We even had (resident #38) family come to talk with her and let her know that they can not afford to pay for her to have a pvt room. We also offered to move (resident #38) to the other side of the room but she said No I was her (sic) first .both ladies have no behavior dx. This is more than likely due to (resident #38) having her room without a room mate for many months .(resident #38) will be moved to another room that is closer to the nsg.desk and she will have the A bed which is the bed that she wants . A nurse's note, dated 04/13/18, documented, Our AIT person came to me (DON) and said that (resident #38) is treating her room mate (resident #165) not very nice I asked him how he knew and he said her roommate came to him and told him she was not being treated very nice I asked our SS dept to call (resident #38) family and have them come in and talk with her as we have moved (resident #38) once and we have no more female rooms. So know (sic) it will have to be up to her family as to what they are wanting to do. There was no incident report or investigation regarding this allegation. The facility did not implement their abuse policy, did not protect the resident from further abuse at this time, and did not investigate this as an allegation of abuse. A nurse's note, dated 04/16/18 at 12:33 p.m., documented, Resident (#38) blocking the doorway so that her roommate cannot get in or out. A state reportable incident report, dated 04/16/18, documented, .(Resident #38) and (Resident #165) resident to resident verbal altercation .(Resident #38) has been mean verbally to (resident #165). (Resident #165) says she doesn't want to go in her room that she shares with (resident #38) because she is not nice to her .(Resident #38) has the following dx: .major [MEDICAL CONDITION] .dementia without behaviors .She has has (sic) problems in the past with roommates and family is aware of this. (Resident #165) dx: .dementia without behaviors .anxiety, major [MEDICAL CONDITION] .Both residents want a room by themselves .I then went to speak with (resident #165). She said 'I am afraid of her so I try not to go in that room' I asked (resident #165) what she means when she says I am afraid of her. 'I liked my room when I was alone' I asked .if I could find her another room would she like to move .I will also re -inservice our staff how important it is to report any and all dis-harmony to DON, Administrator .(resident #165) was moved to room .All staff to be re-inserviced .on resident's rights and who to report to if a resident has a concern. A c/p meeting will be set up with both families with residents present so all concerned will understand all the rules of this facility . After this allegation of abuse had been reported on 04/13/18, it had not been acted on and the resident was not protected from further abuse. A social service note, dated 04/16/18, documented, Contacted residents family member and told them we were moving another room mate out of her room. Explained the room mate said she was being mean and was scared of her. On 04/17/18 at 10:52 a.m., the DON was asked who does abuse investigations. She stated, It starts with administration and then goes to the department involved. She was asked if she interviewed the ADON. She stated, I asked her to describe, to explain to me what was said. I did not ask her anymore questions,. The DON was asked if she interviewed the Social service director. She stated, I asked him if he knew anything He said no. She was asked if she documented anything. She stated, No. She was asked if she interviewed any CNA's. She stated, No I was working on something else with the CNA's that was more important than this. The DON was asked if she interviewed any Charge nurses. She stated, I asked if they knew anything. they said No. She was asked which nurses she interviewed. She stated, (LPN #2) and (LPN #3). She was asked if she documented anything. She stated, No. The DON was asked if she interviewed any residents. She stated, Other than the 2, I asked (resident #50) if she wanted new roommate. No, I did not document what she said. The DON was asked if she had asked the resident why she was afraid. She stated, She said I'm afraid. Family said she has been this way always. She was asked how the facility protected the resident. She stated, She doesn't go near (resident #38) room. At 3:45 p.m. LPN #2 was asked if (resident #38) had behaviors towards her roommate. She stated, Yes. She puts her wheelchair in doorway so the resident can't go in or out of the room. We told her she had to let her in it was her room also. She was asked if resident #165 was afraid of her roommate. She stated, Yes. Sometimes she wouldn't go into the room until (resident #38) was in bed asleep. There were times when she wasn't even in the room and (resident #165) refused to go in the room. At 4:00 p.m. LPN #2 was asked if anyone talked to her about allegations of abuse between the two residents. She stated, No. She was asked if anyone obtained statements or interviewed her. She stated,No. LPN #3 was asked if anyone had interviewed or obtained statements from her regarding the allegation of abuse between the two residents. She stated, No. On 04/23/18 at 4:26 p.m., the DON was asked why it took from 3/15/18 to 04/01/18 before the facility separated resident #47 and resident #38. She stated, The nurse should have filled out an incident report. I don't know. She was asked who was responsible for completing the incident reports. She stated, The nurse on the floor. She was asked what she did to protect the resident from her roommate. She stated, The minute the incident report came across, we asked (resident #38) family to move her. She was asked why there were no incident reports for the incidents on the previous dates. She stated, There was confusion when we switched over to the computer. They didn't write a paper one. I told them I needed a paper report. On 04/24/18 at 9:45 a.m., the ADON was asked if LPN #2 reported the incident between resident #47 and resident #38 on 03/15/18. She stated, No. I'm aware of when (resident #38) threw some pepsi at resident #47. She was asked if an incident report should have been done. She stated, Yes. At 2:56 p.m., the DON was asked what abuse training was provided for new hires. She stated, The ADON goes over policy and procedure with them. 4. Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/16/18 at 2:52 p.m., the resident was asked if she had experienced any abuse while a resident at the facility. She stated, One of the aides got mad at me for calling for assistance to the bathroom and placed my call light at the foot of the bed so I couldn't use it. She was asked if she had told anyone of the incident. She stated, I talked to the social service person. At 5:00 p.m., the social service director was asked if the resident had reported to him about the call light being placed at the foot of the bed. He stated, No, I didn't know about the call light. At 5:10 p.m., the DON was informed of the allegation of abuse/neglect by a staff member placing the resident's call light at the foot of the bed. On 04/17/18 at 11:05 a.m., the DON was asked for her investigation regarding the call light. She stated, The call light was not addressed. I am sorry. An incident report, dated 04/17/18, documented, .date of incident: a few days ago .This resident reported to state surveyor's that a CNA took her C/L & placed the C/L where she could not reach it The investigation for this allegation documented the resident told the DON the incident happened approximately two weeks before. She asked the resident if it had happened again and was told no. The facility did not do a thorough investigation. They did not interview any staff members, did not interview other residents to see if this had happened to them and the facility did not implement the abuse policy, or protect the resident from further abuse/neglect, and did not submit a state reportable incident report for abuse/neglect.

Based on observation, interview, and record review, it was determined the facility failed to ensure: ~ two (#47 and #165) residents were free from abuse and intimidation by one (#38) of four sampled residents reviewed for abuse and neglect; and ~ one (#50) of four sampled residents reviewed for abuse and neglect was free from neglect by staff members. Resident #47 was verbally and physically abused by resident #38 and verbalized that she was frightened by the resident who was her roommate. This had the potential to affect all 65 residents in the facility. Findings: An abuse prevention program policy, documented, Policy Statement: Our residents have the right to be free from abuse, neglect .This includes but is not limited to freedom from .verbal, mental, sexual, or physical abuse .As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . A nursing policy and procedure, titled Abuse prevention, intervention, reporting, and investigation, documented, Residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self abuse/self-neglect .The facility has developed a system for identifying, investigating, preventing, and reporting any incident, or suspected incident, of abuse .It is the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family, or visitors .Staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse .All reports of resident verbal, sexual, physical and mental abuse .neglect .are promptly and thoroughly investigated by facility management .Prevention: At the time of admission, each resident and responsible parties are informed of the resident's rights and the facility's zero tolerance for any form of abuse .A zero tolerance policy of abuse, neglect, mistreatment .along with reporting directions, is posted in the facility or given to the resident or given to the resident upon admission and each employee at orientation .Resident rights and abuse prevention training for all employees is conducted during orientation, and at least annually, and includes review of: .definitions of abuse .resident rights .abuse and neglect policy and procedures .duty to report and reporting process .Intervention: Upon receiving reports of physical or sexual abuse, the facility administrator and director of nursing are immediately notified to arrange for the examination of the resident .Reporting: The administrator is promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is called at the emergency contact number on record .initial reports to regulatory and state agencies are submitted within 24 hrs .A final investigative report is submitted to the Oklahoma State Department of Health .within 5 calendar days .Investigation: Residents and staff are to be protected during incident investigations by ensuring: Reports are made without fear of retaliation .A resident who is allegedly mistreated by another resident is removed from contact with that resident during the investigation . 1. Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 03/09/18, documented, Resident (#38) arguing with new roommate this evening over the TV. Called (resident #47) a b**** . There was no incident report and no state reportable incident report provided for the resident to resident altercation. An admission assessment, dated 03/14/18, documented the resident had a BIMS score of 12. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident had no behaviors, required limited assistance with walking, locomotion on and off the unit, and extensive assistance with transfers, and received no [MEDICAL CONDITION] medications the previous seven days. A social service note, dated 03/13/18, documented, .has/had a concern about her and her neighbor not getting along . A nurse's note, dated 03/15/18, documented, Resident was in the doorway of her room with her roommate was screaming help. I went to the doorway and (resident #38) was stepping on her roommates feet and had both her hands holding down (resident #47). I had to tell (resident #38) to take her hands and feet off her roommate. (Resident #38) said this is my personal property she needs to leave. I told them both that they needs (sic) to get along. (Resident #47) said she wants to move to another room . There was no incident report and no state reportable incident report provided for the resident to resident altercation. A nurse's note, dated 03/16/18, documented, Resident (#38) being mean to roommate (resident #47) blocking resident from getting in or out of room holding her wrists social services notified and family called . There was no incident report and no state reportable incident report provided for the resident to resident altercation. A nurse's note, dated, 03/28/18, documented, Resident (#38) went over to her roommates (Resident #47) side of the room and scared her tonight. Redirected her to stay on her side of the room . There was no incident report and no state reportable incident report provided for the resident to resident altercation. A state reportable, dated 04/01/18, documented, .(resident #38) thru (sic) a water pitcher at (resident #47) her room-mate both are residents here .resident to resident altercation .(Resident #38) has had that room for awhile without a room-mate now that she has one she has tried to say that the room-mate bumps her w/c when the room-mate goes in or out of the room. We even had (resident #38) family come to talk with her and let her know that they can not afford to pay for her to have a pvt room. We also offered to move (resident #38) to the other side of the room but she said No I was her (sic) first .both ladies have no behavior dx. This is more than likely due to (resident #38) having her room without a room mate for many months .(resident #38) will be moved to another room that is closer to the nsg.desk and she will have the A bed which is the bed that she wants . A nurse's note, dated 04/02/18, documented, This resident reported to this nurse on action of room mate (sic) yesterday while she waws (sic) attempting to go in room, she lives on B side. While passing roommatew (sic) side A, (Resident #38) threw half glass of pop toward her missing her, trying not for her to enter her room . The care plan did not address the altercations with the roommate or interventions to protect her from further abuse. On 04/17/18 at 3:06 p.m., resident # 47 was asked if her former roommate threw a water pitcher at her. She stated She threw a glass of liquid at me. That really bothered me and I turned it in. I tried to let the other things she did slide. She was asked if she remembered the roommate scaring her one night. She stated, Yes, I told her to leave me alone and get away from me. She showed her teeth like an animal. She was asked how that made her feel She stated, Terrible. I was frightened. I can't walk so I couldn't get away from her. She was asked if the roommate had ever physically grabbed her wrists. She stated, I don't think she ever touched me I think I was out of her reach. She was asked if she felt protected while she was with that roommate. She stated, Yes, but from up above. I prayed God protect me. I felt like she could do worse to me, but God protected me. At 3:35 p.m., CNA #6 was asked if she had witnessed resident #47 and resident #38 in any resident to resident altercations. She stated, Yes. (Resident #38) was standing over (resident #47) and (resident #47) was yelling for help. The nurse said to stay on her side of the room. At 3:45 p.m., LPN #2 was asked if she remembered any problems with resident #38 and resident #47. She stated, Yes. (resident #47) was on the outside of the room. (Resident #38) had grabbed her wrists and had her feet on top of (resident #47) feet. Both were in their w/c facing each other I had to go down and separate them. (Resident #38) puts her w/c in doorway so resident can't go in or out. At 4:00 p.m., LPN #2 was asked if she filled out an incident report on the incident. She stated, I charted it in the nurse's notes. She was asked if she reported the incident to anyone. She stated, I told someone. the (DON) or the (ADON). She was asked if she received any abuse or neglect training. She stated, Not since I've been here. LPN #3 was asked if she had received any abuse or neglect training since she had started work. She stated, Not here. On 04/23/18 at 4:26 p.m., the DON was asked why it took from 3/15/18 to 04/01/18 before the facility separated resident #47 and resident #38. She stated, The nurse should have filled out an incident report. I don't know. She was asked who was responsible for completing the incident reports. She stated, The nurse on the floor. She was asked what she did to protect the resident from her roommate. She stated, The minute the incident report came across, we asked (resident #38) family to move her. She was asked why there were no incident reports for the incidents on the previous dates. She stated, There was confusion when we switched over to the computer. They didn't write a paper one. I told them I needed a paper report. On 04/24/18 at 9:45 a.m., the ADON was asked if LPN #2 reported the incident between resident #47 and resident #38 on 03/15/18. She stated, No. I'm aware of when (resident #38) threw some pepsi at resident #47. She was asked if an incident report should have been done. She stated, Yes. At 2:56 p.m., the DON was asked what abuse training was provided for new hires. She stated, The ADON goes over policy and procedure with them. 2. Resident #165 was admitted on [DATE] with [DIAGNOSES REDACTED]. A medicare 14 day assessment, dated 03/05/18, documented the resident had a BIMS score of six. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had no behaviors, required limited assistance with activities of daily living, and received an antidepressant seven of the last seven days. A nurse's note, dated 04/13/18, documented, Our AIT person came to me (DON) and said that (resident #38) is treating her room mate (resident #165) not very nice I asked him how he knew and he said her roommate came to him and told him she was not being treated very nice I asked our SS dept to call (resident #38) family and have them come in and talk with her as we have moved (resident #38) once and we have no more female rooms. So know (sic) it will have to be up to her family as to what they are wanting to do. There was no incident report or investigation regarding this allegation. The facility did not implement their abuse policy, did not protect the resident from further abuse at this time, and did not investigate this as an allegation of abuse. A nurse's note, dated 04/15/18, documented, Resident stated to staff, She's (Roommate) is mean to me, she won't let me go in the room. Resident redirected and sat @ nurse's station, then assisted to bed by CNA with no difficulty noted. There was no incident report or investigation regarding this allegation. A nurse's note, dated 04/16/18 at 12:33 p.m., documented, Resident (#38) blocking the doorway so that her roommate cannot get in or out. On 04/16/18 at 2:52 p.m., during a resident interview resident #50 stated, Another resident (resident #165) is afraid of her roommate because she picks on her. When she said something to (ADON) nurse told her to deal with it and was rude. At 3:55 p.m., the resident was observed sitting in her wheelchair at the nurse's station. She was asked why she was sitting at the nurse's station. She stated, The nurse's are protecting me from that woman. At 4:09 p.m., resident #50 was asked how she knew the resident was afraid of her roommate. She stated, She has told everyone. She was asked how she knew the ADON had told the resident to just deal with it. She stated, She sits at my table. It was either breakfast or lunch last week when the nurse said deal with it. At 4:34 p.m., CNA #4 was asked if she knew why the resident was sitting at the desk all day. She stated, I don't know why. She was asked if the resident had said she was was afraid of her roommate. She stated, Yes. She was being mean to (resident #47) that's why they moved her in with (resident #165). At 4:38 p.m., CNA #5 was asked if resident #165 ever mentioned being afraid of her roommate. He stated, Yes. She complained for a day and a half. He was asked if he reported it. He stated, She reported it herself to the charge nurse. At 4:47 p.m., informed the DON of the allegation the resident was afraid of the roommate and she would need to start an investigation. A social service note, dated 04/16/18 at 5:22 p.m., documented, Contacted residents family member, and explained that we're moving her to a different room. Explained resident said she was scared of her room mate. Family member understood, but added 'its probably because of her dementia, but that fine with me'. A state reportable incident report, dated 04/16/18, documented, .(Resident #38) and (Resident #165) resident to resident verbal altercation .(Resident #38) has been mean verbally to (resident #165). (Resident #165) says she doesn't want to go in her room that she shares with (resident #38) because she is not nice to her .(Resident #38) has the following dx: .major [MEDICAL CONDITION] .dementia without behaviors .She has has problems in the past with roommates and family is aware of this. (Resident #165) dx: .dementia without behaviors .anxiety, major [MEDICAL CONDITION] .Both residents want a room by themselves .I then went to speak with (resident #165). She said 'I am afraid of her so I try not to go in that room' I asked (resident #165) what she means when she says I am afraid of her. 'I liked my room when I was alone' I asked .if I could find her another room would she like to move .I will also re -inservice our staff how important it is to report any and all dis-harmony to DON, Administrator .(resident #165) was moved to room .All staff to be re-inserviced .on resident's rights and who to report to if a resident has a concern. A c/p meeting will be set up with both families with residents present so all concerned will understand all the rules of this facility . After this allegation of abuse had been reported on 04/13/18, it had not been acted on and the resident was not protected from further abuse. On 04/17/18 at 10:52 a.m., the DON was asked who does abuse investigations. She stated, It starts with administration and then goes to the department involved. She was asked if she interviewed the ADON. She stated, I asked her to describe, to explain to me what was said. I did not ask her anymore questions,. She was asked if she had asked the ADON if she said to the resident to deal with it last week during a meal time. She stated, No I did not. The DON was asked if she interviewed the Social service director. She stated, I asked him if he knew anything He said no. She was asked if she documented anything. She stated, No. She was asked if she interviewed any CNA's. She stated, No I was working on something else with the CNA's that was more important than this. The DON was asked if she interviewed any Charge nurses. She stated, I asked if they knew anything. they said No. She was asked which nurses she interviewed. She stated, (LPN #2) and (LPN #3). She was asked if she documented anything. She stated, No. The DON was asked if she interviewed any residents. She stated, Other than the two, I asked (resident #50) if she wanted a new roommate. No, I did not document what she said. The DON was asked if she had asked the resident why she was afraid. She stated, She said I'm afraid. Family said she has been this way always. She was asked how the facility protected the resident. She stated, She doesn't go near (resident #38) room. At 3:45 p.m. LPN #2 was asked if (resident #38) had behaviors towards her roommate. She stated, Yes. She puts her wheelchair in doorway so the resident can't go in or out of the room. We told her she had to let her in it was her room also. She was asked if resident #165 was afraid of her roommate. She stated, Yes. Sometimes she wouldn't go into the room until (resident #38) was in bed asleep. There were times when she wasn't even in the room and (resident #165) refused to go in the room. At 4:00 p.m. LPN #2 was asked if anyone talked to her about allegations of abuse between the two residents. She stated, No. She was asked if anyone obtained statements or interviewed her. She stated,No. LPN #3 was asked if anyone had interviewed or obtained statements from her regarding the allegation of abuse between the two residents. She stated, No. At 4:11 p.m., the resident was asked what happened with her roommate. She stated, She wouldn't let me in my room. She was asked if she had told anyone. She stated, I told the girls. They wouldn't do anything. She was asked what happened when her roommate wouldn't let her in her room. She stated, I would get out and stay out. That woman made me afraid. 3. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 03/08/18, documented, Resident not happy with roommate going in and out of the room tonight. Roommates floor light was shining into her eyes so moved it . A nurse's note, dated 03/09/18, documented, Resident arguing with new roommate this evening over the TV. Called (resident #47) a b**** . A nurse's note, dated 03/13/18, documented, Resident was blocking the doorway of the room tonight so that her roommate could not get out . A nurse's note, dated 03/15/18, documented, Resident was in the doorway of her room with her roommate was screaming help. I went to the doorway and (resident #38) was stepping on her roommates feet and had both her hands holding down (resident #47). I had to tell (resident #38) to take her hands and feet off her roommate. (Resident #38) said this is my personal property she needs to leave. I told them both that they needs (sic) to get along. (Resident #47) said she wants to move to another room. There was no incident report and no state reportable incident report provided for the resident to resident altercation. A quarterly assessment, dated 03/15/18, documented the resident had a BIMS score of nine,. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had no behaviors, required extensive assistance with activities of daily living, and received an antidepressant seven of the last seven days. A social service note, dated 03/16/18, documented, .was told resident being rude and combative to roommate. went to visit resident and the roommate was outside of door trying to get in. I open the door and resident was there holding the door so roommate couldn't get in. resident said shes (sic) not welcomed in here. I explained this is her room also and she should at least try and be nice and try to get along. resident said no she needs to be gone and I will spend the rest of my time here making her life hell. I called residents responsible party and explained what was going on and she said she would call her and come by the next day . A nurse's note, dated 03/16/18, documented, Resident being mean to roommate blocking resident from getting in or out of room holding her wrists social services notified and family called. A nurse's note, dated 03/19/18, documented, Resident advised by staff to allow her roommate in room, resident did comply and no further behaviors noted. A nurse's note, dated 03/28/18, documented, Resident went over to her roommates side of the room and scared her tonight. Redirected her to stay on her side of the room. A nurse's note, dated 03/29/18, documented, Roommate of this resident verbalized last evening this resident was standing mid room just staring at her while she lie in bed. No words said. There was no incident report and no state reportable incident report provided for the resident to resident altercation. A nurse's note, dated 04/01/18, documented, Resident noted throwing water pitcher @ roommate D/T roommate moved her wheelchair, 1 on 1 & redirection given with improvement noted. A state reportable, dated 04/01/18, documented, .(resident #38) thru (sic) a water pitcher at (resident #47) her room-mate both are residents here .resident to resident altercation .(Resident #38) has had that room for awhile without a room-mate now that she has one she has tried to say that the room-mate bumps her w/c when the room-mate goes in or out of the room. We even had (resident #38) family come to talk with her and let her know that they can not afford to pay for her to have a pvt room. We also offered to move (resident #38) to the other side of the room but she said No I was her (sic) first .both ladies have no behavior dx. This is more than likely due to (resident #38) having her room without a room mate for many months .(resident #38) will be moved to another room that is closer to the nsg.desk and she will have the A bed which is the bed that she wants . A nurse's note, dated 04/13/18, documented, Our AIT person came to me (DON) and said that (resident #38) is treating her room mate (resident #165) not very nice I asked him how he knew and he said her roommate came to him and told him she was not being treated very nice I asked our SS dept to call (resident #38) family and have them come in and talk with her as we have moved (resident #38) once and we have no more female rooms. So know (sic) it will have to be up to her family as to what they are wanting to do. There was no incident report or investigation regarding this allegation. The facility did not implement their abuse policy, did not protect the resident from further abuse at this time, and did not investigate this as an allegation of abuse. A nurse's note, dated 04/16/18 at 12:33 p.m., documented, Resident (#38) blocking the doorway so that her roommate cannot get in or out. A state reportable incident report, dated 04/16/18, documented, .(Resident #38) and (Resident #165) resident to resident verbal altercation .(Resident #38) has been mean verbally to (resident #165). (Resident #165) says she doesn't want to go in her room that she shares with (resident #38) because she is not nice to her .(Resident #38) has the following dx: .major [MEDICAL CONDITION] .dementia without behaviors .She has has (sic) problems in the past with roommates and family is aware of this. (Resident #165) dx: .dementia without behaviors .anxiety, major [MEDICAL CONDITION] .Both residents want a room by themselves .I then went to speak with (resident #165). She said 'I am afraid of her so I try not to go in that room' I asked (resident #165) what she means when she says I am afraid of her. 'I liked my room when I was alone' I asked .if I could find her another room would she like to move .I will also re -inservice our staff how important it is to report any and all dis-harmony to DON, Administrator .(resident #165) was moved to room .All staff to be re-inserviced .on resident's rights and who to report to if a resident has a concern. A c/p meeting will be set up with both families with residents present so all concerned will understand all the rules of this facility . After this allegation of abuse had been reported on 04/13/18, it had not been acted on and the resident was not protected from further abuse. A social service note, dated 04/16/18, documented, Contacted residents family member and told them we were moving another room mate out of her room. Explained the room mate said she was being mean and was scared of her. On 04/17/18 at 10:52 a.m., the DON was asked who does abuse investigations. She stated, It starts with administration and then goes to the department involved. She was asked if she interviewed the ADON. She stated, I asked her to describe, to explain to me what was said. I did not ask her anymore questions,. The DON was asked if she interviewed the Social service director. She stated, I asked him if he knew anything He said no. She was asked if she documented anything. She stated, No. She was asked if she interviewed any CNA's. She stated, No I was working on something else with the CNA's that was more important than this. The DON was asked if she interviewed any Charge nurses. She stated, I asked if they knew anything. they said No. She was asked which nurses she interviewed. She stated, (LPN #2) and (LPN #3). She was asked if she documented anything. She stated, No. The DON was asked if she interviewed any residents. She stated, Other than the 2, I asked (resident #50) if she wanted new roommate. No, I did not document what she said. The DON was asked if she had asked the resident why she was afraid. She stated, She said I'm afraid. Family said she has been this way always. She was asked how the facility protected the resident. She stated, She doesn't go near (resident #38) room. At 3:45 p.m. LPN #2 was asked if (resident #38) had behaviors towards her roommate. She stated, Yes. She puts her wheelchair in doorway so the resident can't go in or out of the room. We told her she had to let her in it was her room also. She was asked if resident #165 was afraid of her roommate. She stated, Yes. Sometimes she wouldn't go into the room until (resident #38) was in bed asleep. There were times when she wasn't even in the room and (resident #165) refused to go in the room. At 4:00 p.m. LPN #2 was asked if anyone talked to her about allegations of abuse between the two residents. She stated, No. She was asked if anyone obtained statements or interviewed her. She stated,No. LPN #3 was asked if anyone had interviewed or obtained statements from her regarding the allegation of abuse between the two residents. She stated, No. On 04/23/18 at 4:26 p.m., the DON was asked why it took from 3/15/18 to 04/01/18 before the facility separated resident #47 and resident #38. She stated, The nurse should have filled out an incident report. I don't know. She was asked who was responsible for completing the incident reports. She stated, The nurse on the floor. She was asked what she did to protect the resident from her roommate. She stated, The minute the incident report came across, we asked (resident #38) family to move her. She was asked why there were no incident reports for the incidents on the previous dates. She stated, There was confusion when we switched over to the computer. They didn't write a paper one. I told them I needed a paper report. On 04/24/18 at 9:45 a.m., the ADON was asked if LPN #2 reported the incident between resident #47 and resident #38 on 03/15/18. She stated, No. I'm aware of when (resident #38) threw some pepsi at resident #47. She was asked if an incident report should have been done. She stated, Yes. At 2:56 p.m., the DON was asked what abuse training was provided for new hires. She stated, The ADON goes over policy and procedure with them. 4. Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/16/18 at 2:52 p.m., the resident was asked if she had experienced any abuse while a resident at the facility. She stated, One of the aides got mad at me for calling for assistance to the bathroom and placed my call light at the foot of the bed so I couldn't use it. She was asked if she had told anyone of the incident. She stated, I talked to the social service person. At 5:00 p.m., the social service director was asked if the resident had reported to him about the call light being placed at the foot of the bed. He stated, No, I didn't know about the call light. At 5:10 p.m., the DON was informed of the allegation of abuse/neglect by a staff member placing the resident's call light at the foot of the bed. On 04/17/18 at 11:05 a.m., the DON was asked for her investigation regarding the call light. She stated, The call light was not addressed. I am sorry. An incident report, dated 04/17/18, documented, .date of incident: a few days ago .This resident reported to state surveyor's that a CNA took her C/L & placed the C/L where she could not reach it The investigation for this allegation documented the resident told the DON the incident happened approximately two weeks before. She asked the resident if it had happened again and was told no. The facility did not do a thorough investigation. They did not interview any staff members, did not interview other residents to see if this had happened to them and the facility did not implement the abuse policy, or protect the resident from further abuse/neglect, and did not submit a state reportable incident report for abuse/neglect.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents at risk for pressure ulcers received the necessary treatment and services to prevent the development of new pressure ulcers for two (#111 and #106) of two residents reviewed for pressure ulcers. The facility failed to: a) Thoroughly assess wounds on admission to the facility for resident #111. b) Perform weekly skin assessments for residents #111 and #106. c) Reposition the residents every two hours for resident #111. d) Provide treatments as ordered for resident #106. 1. Resident #111 developed a worsening pressure ulcer on his coccyx, a new pressure ulcer on his coccyx, and five new pressure ulcers on his legs and ankles. 2. Resident #106 developed a new stage II pressure ulcer. The facility census and condition identified three residents with pressure ulcers lived in the facility. Findings: The facility policy for pressure ulcers documented the care and prevention of pressure ulcers was the basic responsibility of the licensed nurse and nursing assistant. The policy documented the facility would prevent and treat further breakdown of pressure sores and observe the resident's skin. The policy documented the facility would use pressure reducing devices to relieve pressure, turn the resident every two hours, and position with pads or pillows to protect bony prominences. The policy documented the facility would use elbow and heel protectors if needed, use a bed cradle to relieve pressure of bed linens and clothing, if needed. The policy documented the staff would assist the resident at mealtime to assure adequate nutrition and offer fluids frequently for adequate hydration. 1. Resident #111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge record, dated 11/07/16 documented the resident had a stage II pressure ulcer on his coccyx. The admission nursing assessment, dated 11/07/16, documented the resident had a stage II pressure ulcer on the coccyx and boggy heels. A physician's orders [REDACTED]. A nurse's note, dated 11/07/16, documented the resident had a stage I pressure ulcer on his bottom and calzime was ordered. The TAR for 11/08/16 documented the staff would apply calzime skin protectant to the resident's buttocks every shift and as needed. The TAR documented the calzime was applied as ordered by the physician. The admission assessment, dated 11/09/16, documented the resident was at risk of developing a pressure ulcer. The care area assessment (CAA) summary documented pressure ulcers would be care planned. A nurse's note, dated 11/09/16, documented the resident had a stage I pressure ulcer on the coccyx and calzime was being applied as needed. The weekly skin assessment, dated 11/17/16, documented redness on the resident's heels and buttocks. The care plan, dated 11/21/16, documented the resident needed a weekly skin inspection to observe for redness, open areas, scratches, cuts, and bruises. The care plan documented the staff would report changes to the nurse. The care plan documented the resident had the potential for pressure ulcer development related to immobility. The care plan did not document pressure ulcers or treatments provided. The weekly skin assessment, dated 11/28/16, documented redness on the resident's heels and buttocks. The weekly skin assessment, dated 11/30/16, documented redness on the resident's heels and buttocks. There were no weekly skin assessments documented for December 2016. The ADL sheets for December 2016 did not document the resident had been turned. The hospice admission assessment, dated 12/16/16, documented the resident was on [MEDICATION NAME] as needed for pain and the pain medication would need to be changed. The assessment documented the resident had an ulcer but did not describe, measure, or say where the ulcer was located. The assessment documented the resident's skin turgor was poor and the resident's skin color was pale. The assessment documented the resident had left sided weakness/paralysis to the arm and leg and the left leg was contracted. The assessment documented the resident was dependent for all care, ADLs, transfers, and mobility. The assessment documented the resident was at an increased risk for skin breakdown and aspiration. The assessment documented the resident was using a pressure relieving mattress and wheel chair cushion. The assessment documented heel protectors had been ordered. The assessment documented the resident had mottling present on both feet and they were extremely cold. The assessment documented the resident had redness on his buttocks and scrotum. The ADL sheets for January 2017 did not document the resident had been turned. The skin wound log, dated 01/10/17, documented the resident had an ulcer on his right inner ankle which measured 0.7 centimeters cm X 0.6 cm, had an ulcer on his left outer knee which measured 2.4 cm X 2.2 cm, had an ulcer on his left inner heel which measured 1 cm X 1.4 cm, had an ulcer on his left outer foot which measured 1 cm X 1.2 cm, and had an ulcer on his left outer ankle which measured 2.4 cm X 2.3 cm. The report documented the resident had an unstageable pressure ulcer on his coccyx measuring 4 cm X 7.3 cm. A physician's orders [REDACTED]. The order documented the staff were to soak the unstageable coccyx ulcer with Dakins solution for 20 minutes, pat dry, apply Arrogance, and cover with a dry dressing every Monday, Wednesday, and Friday. On 01/11/17 at 11:35 a.m., LPN #1 stated the wound care nurse was no longer with the facility and she was filling in as the wound care nurse. On 01/09/17 the LPN stated the hospice nurse told her the resident had skin breakdown on his bottom. The LPN stated no skin issues had been reported prior to that date. The LPN stated when she performed the skin assessment she found five other unstageable pressure ulcers. The LPN stated the resident was on a two hour turn schedule. The LPN stated the ADL sheets did not document the resident was being turned every two hours. On 01/11/17 at 11:43 a.m., LPN #2 was asked if the resident had a pressure ulcer when admitted to the facility. The LPN stated he did not remember the resident having a pressure ulcer upon admission. The LPN stated the resident had recently developed a pressure ulcer. On 01/11/17 at 12:01 p.m., the DON was asked if the resident had a pressure ulcer when admitted to the facility. The DON stated the resident came to the facility with a stage I pressure ulcer. On 01/11/17 at 12:04 p.m., LPN #2 was asked if the resident was on a two hour turn schedule. The LPN stated the resident was on a two hour turn schedule but it was not documented on the ADL sheets. The LPN was asked if the resident had acquired six new pressure ulcers. The LPN stated the resident had acquired six new pressure ulcers. On 01/11/17 at 12:06 p.m., the DON stated the order written by LPN #1 upon admission was for a stage II pressure ulcer and the facility was using Calzime for treatment of [REDACTED]. On 01/11/17 at 3:05 p.m., the PA was asked if the resident was admitted with a pressure ulcer. The PA stated she did not remember being notified of any pressure ulcers the resident had upon admission to the facility but the physician could have been contacted. On 01/11/17 at 3:41 p.m., the PA performed an examination of the resident. The PA asked the resident if he was having any pain. The resident stated he was having pain on his backside. The resident voiced pain and moaned when moved and when touched in certain areas. After the examination of the resident's wounds the PA stated the pressure ulcer on the resident's coccyx looked like an old pressure ulcer and should have been followed by the wound care nurse from the time of admission. The PA stated the other five wounds were new pressure ulcers. The PA stated even if the resident had not been seen by the wound care nurse on admission the aides and nursing staff should have caught the pressure ulcers and notified the physician. The resident's enteral feeding was alarming upon entry to the room and read error. The PA paused the enteral pump while examining the resident and restarted the pump before leaving the room. On 01/12/17 at 10:00 a.m., the resident was lying on his left side with a pillow between his knees. Wound care was performed. The resident was turned on his left side with no pillows between bony prominences. On 01/12/17 at 11:00 a.m., the resident was lying on his right side with no pillows between bone prominences. On 01/12/17 at 11:25 a.m., CNA #1 was asked if she had provided care for the resident. The CNA stated she had provided care for the resident since he was admitted to the facility. The CNA was asked if she remembered the resident having any skin issues upon admission. The CNA stated the resident had a skin sheer on his bottom and ankles when he came to the facility. The CNA stated the resident's wounds would get better and then worse. The CNA stated the resident should have been repositioned every two hours. The CNA was asked if she documented when the resident was repositioned. The CNA stated she documented in the ADL book when the resident was repositioned. On 01/12/17 at 12:00 p.m., CNA #2 was asked if she provided care for the resident. The CNA stated she provided care for the resident. The CNA was asked what care she provided for the resident. The CNA stated she turned the resident every two hours and documented the care in the ADL book. The CNA was asked if she had noticed any issues with the resident's skin when providing care. The CNA stated she had noticed skin break down on the resident's bottom the previous week and had told the charge nurse but did not know what had been done after she told him. On 01/12/17 at 12:15 p.m., the resident's physician was interviewed. The physician stated he did not remember if the resident had skin breakdown when admitted to the facility. On 01/12/17 at 12:40 p.m., the resident was lying on his right side with no pillows between the bony prominences. The resident was transferred to his geri chair. The staff had positioned the resident straight up and centered in the geri chair. On 01/12/17 at 2:55 p.m., the resident was up in his geri chair. The resident was positioned straight up and centered in the geri chair. On 01/12/17 at 3:25 p.m., the resident was up in his geri chair. The resident was positioned straight up and centered in the geri chair. On 01/12/17 at 4:00 p.m., the resident was up in his geri chair. The resident was positioned straight up and centered in the geri chair. The resident's feet and legs were a purple color. The resident stated he told a male nurse he wanted to go back to bed but he never came back to help him. The resident stated he was really tired and wanted to go to bed. The skin wound log, dated 01/17/17, documented the resident's wound measurements were as follows: the right inner ankle ulcer measured 2.5 centimeters (cm) X 1.4 cm, the left inner ankle ulcer measured 2.5 cm X 2.5 cm, the left outer knee ulcer measured 0.4 cm X 0.4 cm, the left inner heel ulcer measured 0.4 cm X 0.4 cm, and the left outer foot ulcer measured 0.9 cm X 1.2 cm. On 01/17/17 at 3:45 p.m., the resident was asked if he had pain. The resident stated his backside hurt all the time. The resident stated they gave him Tylenol but it didn't do much good. On 01/18/17 at 8:05 a.m., wound care was observed. LPN #1 measured the resident's wounds. The wound measurement on the coccyx was 3.5 cm X 3.3 cm. A new wound under the coccyx wound measured 1.3 cm X .8 cm. The resident was moaning and voicing pain when being moved to provide wound care. LPN #1 stated the resident had received [MEDICATION NAME] at 7:30 a.m. before the treatment began. The LPN did not perform a pain assessment or offer the resident any other form of pain relief. 2. Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 11/11/16, documented the resident was severely impaired for daily decision making and required assistance with activities of daily living. The quarterly assessment documented the resident was impaired on the left upper and lower extremities. The quarterly assessment documented the resident was a high risk for developing pressure ulcers. The care plan, dated 12/01/16, documented the resident's skin was to be assessed on shower days and during incontinent care. The care plan documented any signs of redness, signs of infection, and pressure ulcers were to be monitored, documented, and reported to the nurse. The care plan documented the resident was to be turned every two hours with frequent repositioning while in the bed or the chair. The braden scale pressure sore risk assessment, dated 12/30/16, documented the resident was at high risk for developing pressure ulcers. The routine treatment record for November 2016 documented weekly skin assessments were not completed. The physician orders, dated 11/01/16, documented the resident was to receive [MEDICATION NAME] cream to the left and right buttocks and coccyx every shift for redness. The routine treatment record for December 2016 did not document the resident received 18 treatments of [MEDICATION NAME] cream to the coccyx and right and left buttocks. The routine treatment record for December 2016 did not document weekly skin assessments were completed. The routine treatment record for January 2017 did not document the completion of weekly skin assessments for three weeks. On 01/12/17 at 10:07 a.m., incontinent care was provided for the resident. The resident had a pressure ulcer on her left buttocks. The pressure ulcer was approximately 2 centimeters by 2 centimeters and was an open wound. The physician orders, dated 01/12/17, documented the resident's stage II pressure ulcer to the left buttocks was to be cleaned and patted dry. The physician order [REDACTED]. On 01/12/17 at 2:23 p.m., licensed practical nurse (LPN) #1 was interviewed. The LPN was asked when the resident's skin assessments were done. The LPN stated wound care nurse #2 (WCN) assessed the resident's for skin break down. On 01/12/17 at 3:50 p.m., LPN #6 was interviewed regarding weekly skin assessments. The LPN was asked who was responsible for completing the weekly skin assessments and documentation. The LPN stated the weekly skin assessments were to be done on Mondays on the 3-11 shift. The LPN stated she worked Mondays on the 3-11 shift. The LPN stated the weekly skin assessments were her responsibility. The LPN stated she had not been doing the weekly skin assessments. On 01/12/17 at 8:27 a.m., resident #106 was observed lying in her bed on her right side. The resident was awake and incontinent. The routine treatment record, dated 01/12/17, did not document the treatment of [REDACTED]. The routine treatment record, dated 01/13/17, did not document the treatment of [REDACTED]. On 01/13/17 at 12:20 p.m., certified nursing assistant #4 (CNA) was asked how often resident #106 was repositioned. CNA #4 stated they repositioned the resident every two hours. CNA #4 stated they changed the resident's brief every two hours if needed and applied cream to the resident's bottom. CNA #4 stated she did not see the pressure ulcer, only the rash on the resident's bottom. CNA #4 stated she would report new pressure ulcers to the LPN or WCN. The routine treatment record, dated 01/14/17, did not document the treatment of [REDACTED]. The routine treatment record, dated 01/16/17, did not document the treatment of [REDACTED]. The routine treatment record, dated 01/17/17, did not document the resident's treatments of Calazine cream to the resident's pressure ulcer was completed during the 3-11 and 11-7 shifts. On 01/17/17 at 3:23 p.m., WCN #2 was interviewed regarding the resident's pressure ulcer. The WCN stated she had not been aware the resident had any new wounds. The WCN stated the staff applied [MEDICATION NAME] ointment to her bottom every shift. On 01/18/17 at 08:35 a.m., the resident was observed resting on her back, awake, and continent. On 01/18/17 at 10:10 a.m., the resident was observed resting on her back. On 01/18/17 at 12:15 p.m., CNA #4 was observed performing incontinent care. The resident was positioned on her right side.

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident maintained an acceptable nutritional status for one (#111) of 16 residents reviewed for nutrition. The facility failed to monitor intake for the resident. The resident had an 8% severe weight loss over two consecutive months. The resident's enteral feeding pump was not working correctly over an unknown period of time and the resident had missed enteral feedings and free water. The facility identified six residents with weight loss. Findings: The policy for enteral nutritional therapy (tube feeding) general guidelines documented the facility would assess the resident's mouth and gums, consistency of feces, condition of skin around the feeding tube, weight, nutritional status, hydration, and fluid balance. The policy for documentation guidelines documented the facility would document the date, time, or shift, as appropriate. Resident #111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 11/09/16, documented the resident weighed 147 pounds. The care area assessment (CAA) summary documented nutrition would be care planned. The care plan, dated 11/21/16, documented the resident had a dehydration or potential fluid deficit related to poor intake. The care plan documented the resident required a tube feeding every three hours related to dysphagia. The care plan documented the resident had a potential nutritional problem related to a peg tube. The care plan did not document the resident's weight loss or new nutritional needs. The dietician's assessment, dated 11/07/16, documented the resident was thin, frail and cachexic. The assessment documented the resident weighed 146 pounds. The assessment documented the resident's nutritional needs were 1800 to 2000 calories per day, 66 to 85 grams of protein per day, and 1800 to 2000 ml of water per day. The assessment documented the resident had a stage II pressure ulcer on the coccyx and boggy heels. The dietician report documented a recommendation for [MEDICATION NAME] 1.2 at 70 ml/hr to equal 1680 ml. The dietician recommendation was to change [MEDICATION NAME] 1.2 to equal 7 cans per day via bolus plus 60 cc of water before and after medications. The dietician's note, dated 11/15/16, documented the resident weighed 132.8 pounds. The dietary note documented the resident was down 13 pounds since admit. The dietary note documented the resident's [MEDICATION NAME] was changed from 1.2 to 1.5 for additional kcal's. The dietary note documented this should have allowed for weight to increase and skin integrity. The dietary note documented the resident's weight would be monitored weekly. The dietary note documented 1658 ml/day for an additional 498 calories, and 13.7 grams of protein. The treatment administration record (TAR) for November 2016 documented the resident would receive 120 ml of water with medications. The TAR documented the resident would receive seven cans of [MEDICATION NAME] a day and 60 ml of water before and after each feeding. The TAR did not document the resident received 20 [MEDICATION NAME] feedings with water from 11/07/16 thru 11/30/16. The TAR documented the resident was to receive 120 ml of water with medications. The TAR did not document the resident received the 120 ml of water with medications five times from 11/07/16 thru 11/30/16. The TAR for December 2016 documented the resident would receive 20 ml of water with medications. The TAR did not document the feeding tube had been flushed on any days. The TAR did not document the resident received five of his [MEDICATION NAME] enteral feedings with water from 12/01/16 thru 12/09/16. The TAR documented a new order for [MEDICATION NAME] 1.5 calories at 64 ml/hr continuous with 37 ml of water per continuous pump on 12/10/16. The TAR did not document the resident's pump was checked for five shifts from 12/10/16 thru 12/31/16. The TAR did not document the resident's intake or output for the month of December 2016. The weight record, dated 12/06/16, documented the resident weighed 121.3 pounds. A physician's orders [REDACTED]. A dietician's note, dated 12/15/16, documented the resident weighed 121.3 pounds. The dietary note documented the resident's weight was down 11 pounds. The dietary note documented to change the resident's feeding to continuous. The dietary note documented the resident had an 8% weight loss. The dietary note documented the resident was to receive [MEDICATION NAME] 1.5 at 64 ml/hr with 37 ml of water every two hours which would provide 1536 ml, 2304 calories, 97 grams of protein, 2055 ml of water, plus water with medications. The dietary note documented the staff was to record the resident's weight weekly. The weight record, dated 12/17/16, documented the resident weighed 122.3 pounds. The TAR for January 2017 did not document the resident received water with medications on any day. The TAR documented the resident was to receive [MEDICATION NAME] 1.5 at 64 ml/hr continuous with 37 ml of water every two hours continuous. The TAR did not document the resident received the [MEDICATION NAME] or water on any day. The TAR did not document the resident's intake or output on any day. The weight record, dated 01/10/17, documented the resident weighed 112.7 pounds. On 01/11/17 at 3:41 p.m., the resident was observed in his bed. The resident was lying on his left side with a pillow between his knees. The resident had padded boots on both feet and was covered with a sheet and blanket. The enteral feeding pump was alarming and read error. The resident's enteral feeding pump was set at 64 milliliters (ml) an hour (hr) and was not infusing. The physician's assistant (PA) asked the resident if he was having pain. The resident stated he was having pain on his backside. The PA stated she didn't know what was wrong with the resident's enteral feeding pump and put it on hold while she examined the resident's wounds. The PA restarted the enteral feeding pump on completion of her assessment. The PA was asked if the resident was actively dying. The PA stated the resident was not actively dying but was definitely a candidate for hospice services. A dietician's note, dated 01/12/17, documented the resident weighed 121 pounds. The note documented the resident was receiving [MEDICATION NAME] 1.5 at 64 ml/hr. The note documented the resident had multiple wounds per the 1/10/17 skin report. The note documented the tube feeding was observed not running correctly per the markings on the bottle. On 01/12/17 at 10:00 a.m., during a wound treatment the resident was asking for juice. The resident's enteral feeding pump was reading an error message and was not infusing. LPN #1 adjusted the pump and left the room. The pump started alarming again and was not infusing. The enteral feeding bottle documented the the [MEDICATION NAME] had been hung on 01/11/17 at 2:00 a.m. and had 800 ml of [MEDICATION NAME] remaining in the bottle. The water bag contained 1000 ml of water and was dated 01/11/17. On 01/12/17 at 11:00 a.m., the resident was lying on his right side with no pillows between bony prominences. The enteral feeding pump was alarming and read error. The enteral feeding pump was not infusing. On 01/12/17 at 11:20 a.m., the enteral feeding pump was alarming. The resident's roommate had a visitor. The visitor stepped into the hall and told a certified medication aide the resident's pump was alarming. The certified medication aide (CMA) told the visitor she couldn't do anything about it but she would tell the nurse. No one was observed to adjust the pump. On 01/12/17 at 11:25 a.m., certified nurse aide (CNA) #1 was asked if she was familiar with the resident. The CNA stated she had worked with the resident since he was admitted to the facility. The CNA was asked if she remembered any problems with the resident's skin when he came to the facility. The CNA stated the resident had skin sheer on his bottom and ankles when he came to the facility. The CNA stated the wound would get worse and then better better and then worse. The CNA was asked what services she provided for the resident. The CNA stated she turned/checked the resident every two hours. The CNA was asked if she documented when the resident was turned. The CNA stated she documented in the ADL book when the resident was repositioned. The CNA was asked if she had passed by the resident's room or went into the resident's room over the last few weeks and heard or saw the enteral feeding pump alarming. The CNA stated she had heard or seen the enteral feeding pump alarming several times and she had reported it to the nurse. On 01/12/17 at 11:35 a.m., the enteral feeding pump was alarming and read error. The pump was not infusing. On 01/12/17 at 11:45 a.m., the dietician entered the resident's room. The resident's enteral feeding pump was alarming and reading error. The pump was not infusing. The dietician was asked how much [MEDICATION NAME] the resident had received since 01/11/17 at 2:00 a.m. The dietician stated the resident had only received 200 ml of [MEDICATION NAME] according to the marks on the bottle. On 01/12/17 at 11:50 a.m., licensed practical nurse (LPN) #1 came into the room to change the enteral feeding. The nurse was asked how much of the [MEDICATION NAME] the resident had received and she stated 200 ml. The LPN stated the bottle should have been changed at 2:00 a.m. on 01/12/17. The nurse stated the enteral feeding was to be changed every 24 hours. The nurse was asked how much water the resident had received. The nurse stated no free water had been given and the water bag was full. On 01/12/17 at 12:15 p.m., the physician was interviewed. The physician was asked if he had been notified of a problem with the resident's enteral feeding pump and the resident had received 200 ml of [MEDICATION NAME] and no water for 34 hours. The physician stated he was not aware there was a problem with the enteral feeding pump. The physician stated he had not been contacted by the facility regarding the the resident's enteral feedings. The physician stated he had talked with the family about the resident's enteral feedings and the family wanted the resident to continue receiving the feedings. On 01/12/17 at 12:40 p.m., the resident was lying on his right side with no pillow between bony prominences. LPN #2 came into the room and asked the resident if he would like to get up. The resident stated he would like to get up. The LPN disconnected the resident's enteral feeding. The restorative aide transferred the resident to the geri chair and the LPN connected the enteral feeding. The weight record, dated 01/17/17, documented the resident weighed 115.6 pounds. On 01/17/17 at 4:00 p.m., LPN #1 was asked if she had received any education on how to set up and run the enteral feeding pumps. The LPN stated she had not received any education on how to set up and run the enteral feeding pumps. The LPN stated she had an instruction book and she had learned how to set up and run the pumps by reading the book. The LPN stated she had not had problems with the pumps but other staff had. The LPN stated she thought they might not be clearing the pump and that could have caused the problems. The LPN was asked where the documentation could be found on how much water the resident was receiving and how much enteral feeding the resident was receiving. The LPN stated they were not documenting fluid intake or output for the residents. The Lpn was asked how she knew how much fluid the resident needed. The LPN stated the dietician made that determination. The LPN was asked how she would assess the resident for hydration. The LPN stated she would check the resident's skin turgor. On 01/18/17 at 8:05 a.m. LPN #1 was asked to assess the resident's hydration status. The LPN stated the resident's skin was tented on his chest and forehead. The resident's mouth was moist and there were no lines on the resident's tongue. The LPN stated with the skin tenting the resident could probably use more water and she would contact the dietician and physician to see if they wanted to increase the resident's water.

Based on observation, interview, and record review, it was determined the facility failed to assure residents maintained their highest levels of well-being for two (#28 and #111) of 26 residents sampled for well-being. The facility failed to: a) Consistently assess, monitor, and intervene for pain for resident #111. Resident #111 experienced unrelieved chronic pain which was not assessed and the physician was not notified. The facility identified 15 residents who experienced pain. b) Administer physcian ordered medications for multiple days for resident #28. The facility identified 72 residents resided in the facility. Findings: The facility policy for pain management documented screening, assessing, and documenting pain routinely was an important step in assuring unrelieved pain was identified and treated promptly. The policy documented it was the facility's policy to provide for a systematic, interdisciplinary assessment of pain using measuring instruments. 1. Resident #111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 11/09/16, did not document a brief interview for mental status (BIM) score. The assessment documented the resident required total assistance with activities of daily living (ADL). The assessment documented the resident had chronic pain and received pain medication as needed. The care plan, dated 11/21/16, did not document the resident's cognitive status. The care plan documented the resident had an ADL self care performance deficit and was totally dependent on staff for ADL care. The care plan did not document interventions for pain management. The hospice admission assessment, dated 12/16/16, documented the resident was on [MEDICATION NAME] as needed for pain and the pain medication would need to be changed. The assessment documented the resident had an ulcer but did not describe, measure, or say where the ulcer was located. The assessment documented the resident's skin turgor was poor and the resident's skin color was pale. The assessment documented the resident had left sided weakness/paralysis to the arm and leg and the left leg was contracted. The assessment documented the resident was dependent for all care, ADLs, transfers, and mobility. The resident's December 2016 Medication Administration Record [REDACTED] a) [MEDICATION NAME], 50 milligrams (mgs) as needed for pain every six hours. The record documented the resident received the [MEDICATION NAME] 25 times in December. b) [MEDICATION NAME] every four hours as needed for fever/pain. The record documented the resident received the [MEDICATION NAME] two times in December. The resident's December 2016 Medication Administration Record [REDACTED]. The record documented the resident received the [MEDICATION NAME] two times in December. The resident's December 2016 Medication Administration Record [REDACTED]. The record documented the resident received the [MEDICATION NAME] with the [MEDICATION NAME] two times in December. The resident's January 2017 Medication Administration Record [REDACTED]. The record documented the resident could receive: a) [MEDICATION NAME] every two hour as needed for pain and did not document the resident had received any [MEDICATION NAME] 01-01-16 through 01-10-17. b) [MEDICATION NAME] every four hours as needed for fever/pain and did not document the resident had received any [MEDICATION NAME] from 01-01-16 through 01-10-17. c) [MEDICATION NAME] 100 mgs as needed for pain every six hours and documented the resident received the [MEDICATION NAME] 10 times from 01-01-16 through 01-10-17. d) [MEDICATION NAME] as needed for pain every six hours with the as needed [MEDICATION NAME] and documented the resident received the [MEDICATION NAME] with the [MEDICATION NAME] nine times from 01-01-16 through 01-10-17. On 01/11/17 at 3:41 p.m., the PA performed an examination of the resident. The PA asked the resident if he was having any pain. The resident stated he was having pain on his backside. The resident voiced pain and moaned when moved and when touched in certain areas. On 01/12/17 at 10:00 a.m., the resident was lying on his left side with a pillow between his knees. Wound care was performed. The resident was turned on his left side with no pillows between bony prominences. On 01/12/17 at 11:00 a.m., the resident was lying on his right side with no pillows between bony prominences. On 01/12/17 at 11:25 a.m., CNA #1 was asked if she had provided care for the resident. The CNA stated she had provided care for the resident since he was admitted to the facility. The CNA was asked if she remembered the resident having any skin issues upon admission. The CNA stated the resident had a skin sheer on his bottom and ankles when he came to the facility. The CNA stated the resident's wounds would get better and then worse. The CNA stated the resident should have been repositioned every two hours. The CNA was asked if she documented when the resident was repositioned. The CNA stated she documented in the ADL book when the resident was repositioned. On 01/12/17 at 12:00 p.m., CNA #2 was asked if she provided care for the resident. The CNA stated she provided care for the resident. The CNA was asked what care she provided for the resident. The CNA stated she turned the resident every two hours and documented the care in the ADL book. The CNA was asked if she had noticed any issues with the resident's skin when providing care. The CNA stated she had notice skin break down on the resident's bottom last week and had told the charge nurse but did not know what had been done after she told him. On 01/12/17 at 12:40 p.m., the resident was lying on his right side with no pillows between the bony prominences. The resident was transferred to his geri chair. The staff had positioned the resident straight up and centered in the geri chair. The staff did not use pillows to support the resident. On 01/12/17 at 2:55 p.m., the resident was up in his geri chair. The resident was positioned straight up and centered in the geri chair. On 01/12/17 at 3:25 p.m., the resident was up in his geri chair. The resident was positioned straight up and centered in the geri chair. On 01/12/17 at 4:00 p.m., the resident was up in his geri chair. The resident was positioned straight up and centered in the geri chair. The resident's feet and legs were a purple color. The resident stated he told a male nurse he wanted to go back to bed but he never came back to help him. The resident stated he was really tired and wanted to go to bed. On 01/17/17 at 3:45 p.m., the resident was asked if he had pain. The resident stated his backside hurt all the time. The resident stated they gave him Tylenol but it didn't do much good. On 01/18/17 at 8:05 a.m., wound care was observed. LPN #1 measured the resident's wounds. The wound measurement on the coccyx was 3.5 cm X 3.3 cm. A new wound under the coccyx wound measured 1.3 cm X .8 cm. The resident was moaning and voicing pain when being moved to provide wound care. LPN #1 stated the resident had received [MEDICATION NAME] at 7:30 a.m. before the treatment began. The LPN did not perform a pain assessment or offer the resident any other form of pain relief. On 01/18/17 at 12:40 p.m., LPN #3 was asked how she assessed the resident for pain. The LPN stated the resident received pain medications in the mornings before his wound care. The LPN stated she thought the resident had pressure ulcer pain. The LPN was asked who gave the resident his medications. The LPN stated she gave the resident his medications. The LPN was asked if she assessed the resident's pain when giving medications. The LPN stated she had not had a chance to assess the resident's pain. The LPN stated the residents were assessed for pain on admission to the facility. On 01/18/17 at 12:45 p.m., LPN #1 was asked how she assessed the resident for pain when providing wound care. The LPN stated she assessed for pain by the resident making moaning sounds. The LPN stated the resident was always in pain even when he received [MEDICATION NAME]. The LPN was asked if she had contacted the resident's physician regarding his pain. The LPN stated she had not contacted the physician. The LPN stated the hospice nurse had told her she was going to contact the hospice physician but no new orders had been received. The LPN was asked if she had ever asked the resident to rate his pain. The LPN stated she had not asked the resident to rate his pain. The LPN stated she just gave the resident's pain medication to him before she provided his wound treatment. The LPN was asked if she felt the resident had pain during his treatment that morning. The LPN stated it seemed like he had pain during his wound treatment that morning because he was moaning during the treatment. 2. A pharmacy admission/startup medication list, dated 01/04/17, documented an order for [REDACTED]. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A new admission/temporary care plan, dated 01/05/17, documented the resident was a full code. The care plan documented the facility would provide all medications and treatments as ordered. The care plan documented the facility would monitor/document as necessary any observed side effects and therapeutic effects of medications. The care plan documented the facility would notify the physician as necessary for changes in condition, or need for change in medications/treatments. An admission assessment, dated 01/05/17, documented the resident was alert, friendly, cooperative, answered questions readily, mood was questioning, talkative, secure, and homesick. The assessment documented the resident's comprehension was quick, the resident was oriented, and the resident was involved in the plan of care. The assessment documented the resident's motivation toward rehabilitation was good. The assessment documented the resident was continent of bowel and bladder, was on a diabetic diet, and independent. A lab test, dated 01/10/17, documented the resident's [MEDICATION NAME] level was low. On 01/10/17 at 10:13 a.m., the resident was being interviewed. The resident stated she had been released from the hospital on [DATE] and still had not gotten all of her medications. The resident stated she had not received her [MEDICATION NAME], or [MEDICATION NAME]. The resident was concerned she had not received her [MEDICAL CONDITION] medication. The resident stated she had told the director of nurses (DON) she had not received her medications. The resident stated the DON told her they were working on it. On 01/10/17 at 11:04 a.m., licensed practical nurse (LPN) #2 was asked why the resident had not received her medications. The LPN stated the resident had come back from the hospital with an order for [REDACTED]. The LPN stated the resident was not on [MEDICAL CONDITION] precautions and no labs had been drawn. The LPN stated he guessed they could order a [MEDICATION NAME] level. The LPN stated he had checked with the pharmacy a couple of times but they didn't have the medications. The LPN stated the pharmacy did have the order. The LPN was asked if he had contacted the resident's physician to make him aware the resident was without medications. The LPN stated he had not contacted the resident's physician. The LPN was asked if the medications could be obtained from another pharmacy. The LPN stated the medications could not be obtained from another pharmacy with her insurance. On 01/11/17 at 10:45 a.m., CMA #1 stated the resident had been in assisted living at the facility before going to the hospital. The CMA stated the resident had one [MEDICATION NAME] in her room at assisted living. The CMA did not know why the pharmacy had been unable to deliver the resident's medications. The CMA stated they only used one pharmacy and did not have a way to get medications from another source. The CMA stated the charge nurse was aware the resident did not have her medications. On 01/11/17 at 3:11 p.m., the physicians assistant (PA) was asked if she was aware the resident had not received her [MEDICATION NAME], and [MEDICATION NAME] since she left the hospital. The PA stated she had not been notified by anyone at the facility regarding the resident not having her medications. The PA stated the resident's [MEDICATION NAME] level was below therapeutic level. The PA stated the resident not receiving the [MEDICATION NAME] explained the low [MEDICATION NAME] level. On 01/12/17 at 11:15 a.m., the DON was asked when she had been made aware the resident had not been receiving her ordered [MEDICATION NAME], and [MEDICATION NAME] since leaving the hospital. The DON stated she had been made aware on 01/10/17 and had called the pharmacy at that time. The DON stated the pharmacy stated they were not aware the resident had those medications ordered and that was why they had not sent them to the facility. The DON stated she had them review the resident's medication list with her and the medications were on the list the pharmacy had received. The DON stated the medications had been sent that afternoon. The DON stated they only used one pharmacy and did not have a backup pharmacy. On 01/12/17 at 12:02 p.m., LPN #2 stated he was told by the CMA there were medications in the residents previous assisted living room. The LPN stated he was told on Monday or Tuesday by CMA #1 the resident had no medications for [MEDICATION NAME], and [MEDICATION NAME]. The LPN stated he had passed it along at shift change to call the pharmacy. The LPN stated he had not called the pharmacy or notified the resident's physician. On 01/12/17 at 12:25 p.m., the physician was asked if he was aware the resident had not received her [MEDICATION NAME], and [MEDICATION NAME] since leaving the hospital on the 5th of January. The doctor stated he was not aware the resident had not received her medications and had not been notified by the facility. The physician stated it was a problem for the resident to be without her [MEDICAL CONDITION] medications for that amount of time. The physician stated they had been having problems getting medications from the pharmacy.

Based on interview and record review, it was determined the facility failed to ensure one (#4) of five sampled residents were monitored for hydration and changes in mental status. This had the potential to affect all 54 residents who resided at the facility. Findings: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment, dated 12/19/14, documented the resident required physical assistance from a staff member to facilitate the consumption of food and fluids. The assessment documented the resident's cognitive skills for daily decision making was, "...Moderately impaired - decisions poor; cues/supervision required..." The assessment documented the resident comprehended most conversations. A care plan, dated 01/02/15, documented, "Focus...hx of constipation r/t decreased fluid intake...Interventions...Monitor/document/report PRN...Change in mental status..." A care plan, dated 01/02/15, documented, "Focus...Alteration in cognition...Interventions...Monitor/document/report PRN any changes in...difficulty expressing self...difficulty in understanding others...level of consciousness...mental status..." On 03/16/15 at 12:30 p.m., the Assistant Director of Nursing (ADON) was asked if she was on duty the day the resident had been transferred to the hospital on [DATE]. She stated she was the nurse on duty that day. The ADON was asked how she became aware of the resident's condition. She stated the CNA that was working with the resident that day reported to her the resident was not acting as she normally did. The ADON stated she assessed the resident and then contacted the physician, who gave an order to transfer the resident to the hospital. The ADON was asked if any of the staff that had worked with the resident the week prior to 01/11/15 were in the building at the time of the survey. She identified CNA #1, CNA #2, and LPN #1. On 03/16/15 at 1:00 p.m., LPN#1 was asked if she worked with the resident during the week prior to the resident's hospitalization on [DATE]. She stated she had been the nurse on the day shift that week. LPN#1 was asked about the resident's behavior during that week. She stated, "The resident never communicated with me...I didn't notice her communicating with others." She stated she had not noticed any changes in the resident's mental status during that week. On 03/16/15 at 1:45 p.m., CNA #1 was asked if she had worked with the resident during the week prior to the resident's hospitalization on [DATE]. She stated she had. CNA #1 was asked to describe the resident's behavior during that week. She stated the resident began staring into space, had difficulty holding her head up, and required redirection to obtain her attention. CNA #1 stated she informed LPN #1 of the resident's change in mental status on the Thursday (01/08/15) prior to the resident's transfer to the hospital on [DATE]. On 03/16/15 at 2:07 p.m., CNA #5 was asked if she had worked with the resident during the week prior to the resident's hospitalization on [DATE]. She stated she had assisted the resident with her meals in the dining area. CNA #5 was asked to describe the resident's behavior during that week. The CNA stated, "The last week before she left we had a difficult time getting her to eat and drink." The CNA was asked if during that week had she reported her observations to the resident's nurse. She stated she had but could not remember which nurse it was, only that it was a female nurse. A physician's orders [REDACTED]. A hospital emergency department note, dated 01/11/15 at 11:08 a.m., documented, " Normally gcs 10, now gcs 6. Unresponsive to ems..." A hospital critical lab result communication, dated 01/11/15, documented, "...Cl - 131, Na - 168..." A hospital lab result, dated 01/11/15, documented, "...Cl - 131 (H) (ref range) 96-112...Na 168 (HH) (ref range) 135-146..." A hospital discharge summary, dated 01/19/15, documented, "...admitted : 1/11/2015...Admission Diagnoses: [REDACTED].

Based on interview and record review, it was determined the facility failed to ensure one (#4) of five sampled residents maintained sufficient hydration status. This had the potential to affect all 54 residents who resided at the facility. Findings: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment, dated 12/19/14, documented the resident required physical assistance from a staff member to facilitate the consumption of food and fluids. The assessment documented the resident's cognitive skills for daily decision making was, "...Moderately impaired - decisions poor; cues/supervision required..." The assessment documented the resident comprehended most conversations. A care plan, dated 01/02/15, documented, "Focus...hx of constipation r/t decreased fluid intake...Interventions...Monitor/document/report PRN...Change in mental status..." A care plan, dated 01/02/15, documented, "Focus...Alteration in cognition...Interventions...Monitor/document/report PRN any changes in...difficulty expressing self...difficulty in understanding others...level of consciousness...mental status..." On 03/16/15 at 12:30 p.m., the Assistant Director of Nursing (ADON) was asked if she was on duty the day the resident had been transferred to the hospital on [DATE]. She stated she was the nurse on duty that day. The ADON was asked how she became aware of the resident's condition. She stated the CNA that was working with the resident that day reported to her that the resident was not acting as she normally did. The ADON stated she assessed the resident and then contacted the physician, who gave an order to transfer the resident to the hospital. The ADON was asked if any of the staff that had worked with the resident the week prior to 01/11/15 were in the building at the time of the survey. She identified CNA #1, CNA #2, and LPN #1. On 03/16/15 at 1:00 p.m., LPN#1 was asked if she worked with the resident during the week prior to the resident's hopitalization on 01/11/15. She stated she had been the nurse on the day shift that week. LPN#1 was asked about the resident's behavior during that week. She stated, "The resident never communicated with me...I didn't notice her communicating with others." She stated she had not noticed any changes in the resident's mental status during that week. On 03/16/15 at 1:45 p.m., CNA #1 was asked if she had worked with the resident during the week prior to the resident's hospitalization on [DATE]. She stated she had. CNA #1 was asked to describe the resident's behavior during that week. She stated the resident began staring into space, had difficulty holding her head up, and required redirection to obtain her attention. CNA #1 stated she informed LPN #1 of the resident's change in mental status on the Thursday (01/08/15) prior to the resident's transfer to the hospital on [DATE]. On 03/16/15 at 2:07 p.m., CNA #5 was asked if she had worked with the resident during the week prior to the resident's hospitalization on [DATE]. She stated she had assisted the resident with her meals in the dining area. CNA #5 was asked to describe the resident's behavior during that week. The CNA stated, "The last week before she left we had a difficult time getting her to eat and drink." The CNA was asked if during that week had she reported her observations to the resident's nurse. She stated she had but could not remember which nurse it was, only that it was a female nurse. A physician's orders [REDACTED]. A hospital emergency department note, dated 01/11/15 at 11:08 a.m., documented, " Normally gcs 10, now gcs 6. Unresponsive to ems..." A hospital critical lab result communication, dated 01/11/15, documented, "...Cl - 131, Na - 168..." A hospital lab result, dated 01/11/15, documented, "...Cl - 131 (H) (ref range) 96-112...Na 168 (HH) (ref range) 135-146..." A hospital discharge summary, dated 01/19/15, documented, "...admitted : 1/11/2015...Admission Diagnoses: [REDACTED].

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to monitor and intervene for a resident with a [DIAGNOSES REDACTED]. The Oklahoma State Department of Health verified the existence of the IJ related to the facility's failure to assess and monitor and have an effective system in place related to suctioning equipment. At 3:02 p.m., the administrator and DON were informed of the IJ related to the facility's failure to monitor and intervene for a resident with a [DIAGNOSES REDACTED]. At 5:07 p.m., an acceptable plan of removal was provided. The plan of removal documented, "...Plan of Removal for the Identified Immediate Jeopardy deficiency on [DATE] with regard to failure to assess, monitor, & intervene. The DON/DON designee has completed equipment checks to verify all suction machines are in working order and available for use. Equipment checks will be completed M-F by the DON/DON designee for a period of 30 days and then weekly thereafter. A checklist will be completed and placed in the DON monitoring book for quality record keeping. All full-time nursing staff and all PRN staff that have worked in the facility in the past 60 days will be in-serviced on suctioning no later than [DATE] at 11:59 pm. All other PRN staff will be in-serviced prior to their next shift. Return demonstration will be required. Documentation will be placed in the observation book. All resident's (sic) requiring suctioning will have an order which will be instituted on the TAR to assess q shift for increased secretions and require daily checks for functioning equipment in addition to equipment changes QOD and PRN. All staff will be provided additional refresher in-service on the importance of notifying the family and/or legal representative, and the physician with any incident and/or change of status to include but not limited to increased secretions and the need for suctioning by [DATE] at 11:59 pm. an order for [REDACTED]. All resident's (sic) will be assessed to determine if suctioning is required. It it is determined that suctioning is required, an order will be obtained and the care plan will be updated to reflect the residents status by 11:59 p.m. on [DATE]. Supplies to include the crash cart equipment and suctioning supplies have been streamlined to ensure only one brand of equipment for continuity purposes. The proper supply ordering personnel will be notified of these changes." On [DATE] at 1:30 p.m., the administrator provided documentation to show the plan of removal had been implemented as described. Staff were interviewed on [DATE] 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 [DATE] at 11:35 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at an isolated incident. Based on observation, interview, and record review, it was determined the facility failed to monitor and intervene for one (#1) of four sampled residents who were reviewed for dysphagia and the need for suctioning. This resulted in an Immediate Jeopardy situation for resident #1 who had an incident of choking, required suctioning but the suctioning equipment and/or equipment system failed, and then the resident died . The facility identified three residents who required suction equipment at the bedside. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident was cognitively intact, required extensive assistance with bed mobility, transfers, and eating. It was documented the resident did not have a swallowing disorder but did receive a mechanically altered diet. The resident's care plan, dated [DATE], documented the resident had a problem related to a potential alteration in nutrition due to dysphagia, [MEDICAL CONDITION], receiving a mechanically altered diet, a [DIAGNOSES REDACTED]. The interventions included to monitor, document, and report any signs or symptoms of dysphagia; such as pocketing food, choking, coughing, drooling, and making several attempts to swallow. Review of the resident's clinical record revealed no physician's order for suctioning or a suction machine at the resident's bedside. The need for suctioning was not listed as a problem on the resident's care plan. A nurse's note, dated [DATE] at 7:45 p.m. and signed by RN #1, documented, "...NOTIFIED of resident having difficulty clearing secretions et found him reclining in bed c HOB @ 30 (degrees) et coughing forcefully. CNAs et this nurse pulled resident up in bed et (increased) HOB, but resident slid down in bed c staff pulled him back up. Started suction machine, but unable to cough up thick secretions. Held resident up in order to allow him to cough when resident quit breathing. 2nd nurse called 911 et called for crash cart. Started CPR. SNF nurse arrived et took over CPR. Attempting to hook up (oxygen) when fire department arrived et asked if resident had a DNR. Noted DNR in chart et gave copy of medications list, DNR et face sheet to EMSA..." A police department witness statement, dated [DATE] at 8:00 p.m., and signed by RN #1, documented, "...CNA approached me (and) told me that resident (#1) was choking et needed help. Resident was reclining in bed c HOB (up) 30 (degrees) et coughing forcefully. Two CNAs in room helped me pull resident up in bed. Turned on suction machine et could not get much suction past the canister (sic). LPN charge nurse brought 2nd set but could not get any secretions up with Yonkeur's, so LPN went to find another tubing to help remove secretions [MEDICAL CONDITION]. Resident slid back down in bed et attempting to roll to side. CNAs et I pulled him back up in bed et held him in sitting position to allow him to clear secretions on his own. While sitting up, resident quit breathing. LPN went to call 911 et have crash cart sent to room while I started CPR. Skilled nursing LPN arrived et took over CPR while I went to crash cart for oxygen. Fire dept arrived et moved resident to floor for CPR. When they asked if resident had a DNR, I left room to get information from chart. Noted DNR et brought it to room to show to paramedics. They asked for copies of paperwork et so I left room @ that time to assist c gathering face sheet, medication records et copy of DNR..." A police department witness statement, undated but signed by LPN #1, documented, "...staff reported to this nurse...resident 'having a hard time breathing.' Went to room...and observed resident c SOB. Tried to suction resident c (RN #1) but no suction from canister...out. This nurse call '911' after trying to fix canister..." On [DATE] at 8:48 a.m., the resident's roommate was asked if he was present during the incident described above. He stated yes. He stated he was the one who found the resident choking. The roommate stated he left the room, found staff to help the resident, and the staff came immediately to the room. The roommate was asked if he was in the room during the entire incident. He stated yes, that he had "got trapped" in the room. The roommate was asked if he remembered anyone saying the suction machine was not working. He stated, "There was some speculation it wasn't. That's why they got another." The roommate stated the resident was "always choking" in the dining room during meals. He stated staff would have to make sure the resident was okay. On [DATE] at 10:10 a.m., CMA #1 was observed in the main dining room. She was asked where the suction machines were. She stated there was one in the east hall medication room. She stated there used to be one in the dining room but it had been moved. CMA #1 showed the surveyor where the suction machine was kept. The suction machine was observed in east hall medication room. There was no canister attached to the machine. There was no canister or suctioning tubing with the machine or in the room. CMA #1 was asked how often the machine was checked. She stated she could not tell the surveyor that. She stated, "I would think the charge nurses would be responsible for checking to make sure they are in working order." On [DATE] at 10:30 a.m., a tour of the facility was conducted. No suction machine, clean and ready for immediate use, was noted anywhere in the main building. There were no suction machines noted at the nurses' stations, in the supply room, or in the oxygen storage room. A suction machine was noted in the locked room behind the nurses' station on the skilled unit. The suction machine was clean and all necessary supplies were present; however, the suction canister was not attached to the machine. At 10:45 a.m., LPN #2, the charge nurse for the skilled unit, was asked who had a key to the locked room. She stated just the charge nurse for the skilled unit had the key. LPN #2 was asked if there were other suction machines in the facility. She stated she did not know. The distance from the farthermost resident room on the east hall to the only suction machine in the facility in an operable condition was approximately 375 to 400 feet. On [DATE] at 11:29 a.m., CNA #1 was asked where the suction machines were located. She stated they had been moved recently and the surveyor would need to ask the nurse. At 11:30 a.m., CNA #2 was asked where the suction machines were located. She stated there was one at each nurses' station. There were three nurses' stations in the facility. CNA #2 was asked if she had taken care of the resident. She stated yes. She was asked if the resident had a suction machine at his bedside. She stated, "Yes." She was asked if he had always had the suction machine. She stated, "No." She was asked how long the resident had the machine. She stated about one month. CNA #2 was asked if she knew why the resident had a suction machine at his bedside. She stated no. CNA #2 was asked who was responsible for the suction machines. She stated the charge nurses were. She was asked if the resident choked frequently. She stated, "Yes." At 11:40 a.m., CNA #3 was asked where the suction machines were located. She stated there was one in the medication room on the east hall. She stated if it was not there, it would "probably" be at the nurses' desk. At 11:42 a.m., CNA #4 was asked where the suction machines were located. She stated she "thought" there was one in the east hall medication room. She stated she knew there was one on one hall being used by a resident. On [DATE] at 11:45 a.m., RN #1 was asked what had happened during the incident with resident #1. She stated she was leaving the facility after her shift when an aide got her and told her the resident was choking. She stated the resident had a history of [REDACTED]. She stated she entered the room, saw that he was choking, and she turned on the suction machine. She stated she could not get the suction machine to work. She stated LPN #1 went to get another machine, and it did not work either. She stated, "It was a different kind." RN #1 stated she did not know how to work the second machine. RN #1 stated she thought the canister was "leaking." RN #1 was asked if she could not get the suction machine to work. She stated she could not get the machine to work. She stated, "No, it was the canister." RN #1 stated, "Maybe the canister had been sitting there a long time." RN #1 was asked if she had experience working with the suction machines. She stated yes, but not with the type of machine at the facility. She was asked where the suction machines were kept. She stated, "I don't know." On [DATE] at 12:01 p.m., CNA #5 was asked where the suction machines were at. She stated they should be in the storage closet. On [DATE] at 12:16 p.m., LPN #3 was asked if she had taken care of resident #1. She stated yes. She was asked if the resident had an old [MEDICAL CONDITION] site. She stated yes. She stated it was very small. She described it as being approximately 1 centimeter wide. LPN #3 was asked if the resident had a history of [REDACTED]." She stated if he tried to feed himself he would choke because he would try to eat too fast. LPN #3 was asked if the resident had suctioning at the bedside. She stated, "Yes." She was asked why the resident had the suction machine. She stated because he had "lots of secretions." She was asked if the resident had an increase in secretions. She stated, "Yes." She stated she would suction around the stoma but not through it. She was asked if the resident had always had or required a suction machine at his bedside. She stated, "No." She was asked when the suction machine had been placed at the bedside. She stated she did not know. LPN #3 was asked if she had worked on [DATE]. She stated, "Yes." She was asked if she would have suctioned the resident. She stated, "Yes." She was asked if there was any problem with the suction machine. She stated, "No." She was asked if she had documented she had used the suction machine. She stated, "No." LPN #3 was asked who was responsible for the suction machines. She stated the charge nurses were. She was asked how often she cleaned the machines. She stated the suction machines were cleaned every shift and the canisters were replaced every day. At 12:24 p.m., LPN #3 was asked where the suction machines and canisters were. She stated there was one machine in the storage room. She was asked to show the machine to the surveyor. LPN #3 and the surveyor entered the storage room. There was no suction machine there. She stated she knew there was one machine in with resident #2 but did not know where any other machine was. LPN #3 was asked to show the surveyor the suction machine for resident #2. The canister on the suction machine for resident #2 was observed to have a small amount of liquid with multiple areas of black, red, green, and white growth. On [DATE] at 12:25 p.m., the DON was asked how she monitored to ensure the suction machines were working correctly and were ready for immediate use. She stated she completed an audit every Monday on the machines. She was asked if the audits were documented. She stated, "No." The DON was asked who was responsible for the suction machines. She stated, "Whoever used it." She stated they were supposed to clean the machine and restock supplies. The DON was asked how she ensured staff was knowledgeable of how to use the suction machine. She stated training was completed upon hire. The DON was asked to show the surveyor where the facility's suction machines were. She showed the suction machine in the east hall medication room. The suction machine still did not have a canister attached and there were no necessary tubing or suctioning supplies. The DON was asked when the machine had been used last. She stated she did not know. The DON took the surveyor to the staffing office, oxygen closet, and supply closet to find the suction machines. None were found. The DON showed the surveyor the suction machine behind the skilled unit nurses' station. The canister was still not attached to the machine. The DON was asked how she ensured the suction machines were ready for immediate use and were operating correctly. She stated, "I don't really know. I've only plugged them in once or twice." On [DATE] at 12:40 p.m., the ADON, who was in charge of training during orientation, was asked how she ensured nurses knew how to operate the suction machines. She stated she had not came across a nurse that did not know how to use a suction machine, but she could show them if they asked. She stated if a nurse did not ask for the training, she would not know they did not know how to use the machine. On [DATE] at 1:35 p.m., the DON was asked why the resident had suction at his bedside. She stated, "I don't recall it being there. Just after." She was asked where the physician's order was for the suction machine and suctioning. She stated, "There isn't one." The DON was asked where the documentation was on the care plan for the the need for suctioning. She reviewed the care plan and stated it should have been documented with the problem of dysphagia. She stated, "I don't see it." The DON was asked what happened with resident #1. She stated the resident was in his room and had difficulty breathing. She stated staff started suctioning the resident and called emergency services. She stated emergency services asked if the resident had a "DNR" and once they found out he did, they stopped treatment. The DON was asked if it had been brought to her attention there were problems with the suction machines. She stated, "No." On [DATE] at 2:12 p.m., RN #1 was asked if she informed the DON there had been issues with the suction machine and/or the canister. She stated, "No."

On 07/28/14 an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to ensure hazardous chemicals were out of reach of residents. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 3:42 p.m., the Administrator and Director of Nursing were notified of the IJ situation. At 6:40 p.m., a plan of removal for the IJ situation was received from the facility. The plan of removal documented: "Colonial Manor Immediate Response Plan...(Unlocked Chemicals)... The DON, Housekeeping Supervisor, Administrator, Dietary Supervisor, and nursing staff will make immediate rounds to search for and confiscate any and all chemicals not kept under lock and key. This will include any chemicals and or agents used in the shower rooms until such time that new locks are installed on every shower room cabinet. The keys will be kept at the nursing stations when not in use and the cabinets will be locked after each use. This process will be monitored by the charge nurse at each station per shift, daily and by the DON or DON Designee weekly and on-going for compliance. In addition, this process will be reviewed by Colonial Manor Quality Assurance Committee and discussed at the weekly leadership meeting on 7/29/14. This process of installing new locks will be complete within 24 hours and available for inspection. In the meantime, the staff will have a check out procedure for disinfectant to ensure sanitary conditions for each resident. (See attached) Staff will be in-serviced again on the Hazard Communication Policy to include the storage of chemicals for resident safety. The DON will in-service the charge nurses who will then in-service the CNA's and all other staff to include weekend will be in-serviced by 5pm on 7/30/14 including in-services by phone for those on vacation or on leave. This plan of action will commence immediately and be on-going." An in-service record, dated 07/29/14 from 6:35 a.m. to 6:34 p.m., documented, "Chemical Storage." This in-service was for all staff. Ten staff members who were listed on the facility's schedule, did not sign the in-service sheets. An in-service record, dated 07/30/14 from 8:37 a.m. to 11:03 a.m., documented, "Chemical Storage." This in-service was for the remaining ten staff members who did not receive the in-service on 07/29/14. At 10:40 a.m., the administrator provided the surveyors with a copy of the completed staff in-service sign in list. The IJ was removed on 07/30/14 at 11:03 a.m., when all components of the plan of removal had been completed. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on observation and interview, it was determined the facility failed to ensure hazardous chemicals were kept out of reach of residents for one (West Hall) of three whirlpool/shower rooms. This resulted in an Immediate Jeopardy situation. The facility identified 31 residents who had access to the whirlpool/shower rooms. Findings: On 07/28/14 at 1:15 p.m., a whirlpool/shower room, located on the West Hall across from the nurses' station, was observed. The door was open, light on, and two unlocked cabinet doors were standing open. The lock had been removed from the cabinet door. A spray bottle of Quaternary Disinfectant Cleaner was noted with the nozzle in the unlocked position. The label on the disinfectant documented, "...Dimethyl Benzyl Ammonium Chloride .105%...Broad Spectrum...Keep out of reach of children..." At 1:40 p.m., resident #45 was observed to go into the shower room and open the cabinet. At 1:45 p.m., the resident left the shower room. The door to the shower room remained open. At 1:53 p.m., LPN #5 was asked if she had ever witnessed any residents that wandered into other residents' rooms. She stated resident #42 had the capability to wander the facility independently. At 1:57 p.m., the Activities Director was asked if she had ever witnessed any residents that wandered into other residents rooms. She stated resident #40 sometimes goes into other resident rooms and gets highly confused. She stated he thinks he is somewhere else. She stated resident #41 also has been seen going into other resident rooms. At 2:00 p.m., LPN # 13 was asked if she had ever witnessed any residents that wandered into other resident rooms. She stated resident #40 goes into other residents' rooms. She stated resident #41 had gone into other residents' rooms and has taken items. On 07/28/14 at 4:15 p.m. the DON was asked how many residents used the whirlpool/shower room on the West hall. She provided a number of 31 residents that utilized the West Hall whirlpool/shower room. She identified three residents who wandered throughout the building. On 07/30/14 at 3:07 p.m., CNA #6 was asked what supplies were usually stored in the West Hall whirlpool/shower room cabinet. She stated the disinfectant spray bottle was always in the cabinet in this particular bathroom.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (#1) of four sampled residents who were reviewed for pressure ulcers, received interventions including timely assessments and repositioning to prevent the development of pressure ulcers and promote healing. This resulted in actual harm for resident #1 who developed eight pressure ulcers. The resident census and condition report identified three residents with pressure ulcers in the facility. Findings: An undated facility policy on wound management, documented, "...Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically the goal is one of promoting healing and preventing infection...Documentation and Care Planning: 2. Resident risk factors and interventions are documented including: (a) Impaired mobility...(b) Need for pressure relief such as support surfaces, repositioning, pressure relieving devices...(c) Nutritional status...(d) Incontinence...(e) Skin condition...(f) Complications such as infection and pain..." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 01/07/14, documented the resident was cognitively intact, was independent with all activities of daily living, was able to ambulate independently, was occasionally incontinent of bowel, was frequently incontinent of bladder, had no pressure ulcers or other skin issues and was not at risk for developing pressure ulcers. A skin integrity care plan, initiated on 01/10/14, documented, "...Interventions: Braden Assessment completed at time of admit, to be updated per facility policy...Encourage (name deleted) to consume 75-100% of each meal...If additional skin breakdown should occur, initiate appropriate treatment per facility policy, alert family and physician to change in condition..." A Braden Scale-For Predicting Pressure Sore Risk, dated 01/10/14, documented the resident scored an 18. The form documented, "...Total score of 12 or less represents High Risk..." A significant change assessment, dated 06/27/14, documented the resident was moderately impaired cognitively, required extensive assistance with activities of daily living, did not ambulate, was incontinent of bowel and bladder, had non-verbal indicators of pain daily, had no pressure ulcers, was at high risk for developing pressure ulcers, and was on hospice care. A nurse's note, dated 07/21/14 at 10:30 p.m., documented, "...Hospice here for care. Reported multiple openings on bottom. (1) Coccyx split 4cm long. (2) lower left gluteal fold 1cm round. (3) L. 0.5cm round (4) L. 3cm x 1cm (5) right 3cm x 2cm (6) 2cm x 1cm (7) lower right gluteal fold 0.5cm (8) left hip 4x5cm. Pressure ulcer sheets made out and put in (physician name deleted) folder for writing pac (sic) for tx order on Tues. 07-22 [MEDICATION NAME] applied as per current order..." A review of the clinical record revealed no documentation of ongoing, weekly skin assessments prior to the hospice nurse aide informing the staff of the multiple pressure ulcers on the resident's buttocks, hip and coccyx prior to 07/21/14. On 07/28/14 at 10:21 a.m., the resident was observed sitting in her wheelchair in her room. The resident was alert, talkative and was able to answer simple questions. An indwelling urinary catheter was attached to the base of the wheelchair. At 12:35 p.m., the resident was observed in the wheelchair in her room. She stated she was very sleepy and hungry. At 12:40 p.m., CNA #13 entered the resident's room and placed the lunch tray on the over bed table. The resident was not repositioned. On 07/28/14, this surveyor made direct and continuous observation of resident #1 from 2:00 p.m. until 6:00 p.m. The resident was observed seated in her wheelchair in the same position and was not repositioned by staff during the observation. On 07/29/14 at 7:30 a.m., the resident was observed lying in bed on her back. Her eyes were closed, and the head of the bed was elevated. Her bed was in the low position and a fall mat was observed next to the bed on the floor. At 8:55 a.m., CNA #14 was observed entering the resident's room. He stated he was going to feed her breakfast. The resident was observed in the same position and was not repositioned by CNA #14. On 07/29/14 at 1:50 p.m., the resident was transferred from her wheelchair to her bed for wound care by LPN #3 and CNA #6. The resident was placed on her right side. Her buttocks and coccyx were observed to have seven stage II pressure ulcers. The left hip wound was observed to be a stage III pressure ulcer. LPN #1 was asked about the multiple pressure ulcers. She stated the wounds were the result of pressure from sitting too long. At 5:00 p.m., the resident was observed in bed on her right side. At 5:50 p.m., the resident was observed lying in bed on her right side. CNA #5 was observed entering the resident's room and placed a dinner plate on the over bed table. She was observed to have left the room without repositioning the resident. At 6:15 p.m., the resident was observed lying on her right side. CNA #2 was observed to enter the room, raise the head of the bed, and proceeded to feed the resident. At 6:30 p.m., the resident was observed lying in bed on her right side, the head of the bed was elevated. CNA #2 had left the room without repositioning her off her right side. At 6:35 p.m., CNA #2 was asked if residents who are in bed during a meal are repositioned. She stated she was not aware she had not repositioned the resident and was not sure of the last time she was repositioned. At 6:40 p.m., the director of nursing was asked how often resident's were repositioned while in a chair or in bed. She stated every one to three hours and as needed. The DON was asked if she was aware of the multiple pressure ulcers on resident #1's buttocks, hip and coccyx. She stated yes. The DON was asked if pressure ulcers were discussed with the interdisciplinary team. She stated no. On 07/31/14 at 9:00 a.m., LPN #3 was asked whose responsibility was it to monitor the CNA's to ensure residents who were unable to reposition themselves were repositioned. He stated the charge nurse. LPN #3 was asked what was the facility policy on the prevention and treatment of [REDACTED]. LPN #3 was asked if resident #1 was able to be educated on the importance of repositioning. He stated no. LPN #3 stated resident #1 required staff to make repositioning changes and anticipate her needs. On 07/31/14 at 10:35 a.m., CNA #6 was asked if she had repositioned resident #1 every one to three hours. CNA #6 stated no, she did not reposition her however, she documented that she did. CNA #6 was asked if not repositioning a resident in the wheelchair or bed could contribute to pressure ulcers. She stated yes.

Based on interview and record review it was determined the facility failed to have pharmacy procedures to ensure pain medications were available and administered in a timely manner for five (#1,#3, #4, and #6) of seven sampled residents reviewed for pain medication who were admitted to skilled services. The facility identified 17 residents resided in the skilled section of the facility. Findings: A facility policy, titled New orders for schedule III-V controlled substances, dated 01/01/13, documented, "...If the medication is needed before the next scheduled delivery, Facility staff should indicate the exact time by which the medication is needed...If the controlled substance is needed before the Pharmacy can make arrangements for a timely delivery, Facility must fax a request to remove a controlled substance from Facility's Emergency Medication Supply to the pharmacy..." 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital discharge record, dated 12/27/13, documented, "...oxycodone 1-2 tab 7.5/325 by mouth every 4-6 hours as needed for pain...Percocet 1-2 tab 7.5/325 by mouth every 4-6 hours as needed for pain...Soma 350mg by mouth as needed..." A pharmacy admission/start-up form, dated 12/27/13, documented, "...oxycodone 7.5/325 i (one) po q 4 hours prn mild pain (1-5)...oxycodone 7.5/325 ii (two) po q 4 hours prn severe pain (6-10)...Percocet 7.5/325 i (one) po q 4 hours prn mild pain (1-5)...Percocet 7.5/325 ii (two) po q 4 hours prn severe pain (6-10)..." A resident-data collection form, dated 12/27/13, documented, "...Time 1600 (4:00 p.m.)...Pain:..frequency: daily, but not constant...Intensity: severe pain..." A physician's orders [REDACTED]. A physician's orders [REDACTED]. A skilled daily nurses note, dated 12/27/13, documented, "...Pain: blank (for all three shifts)...vital signs: blank (for all three shifts)...Comments:...Arrive to facility @ 1600 (4:00 p.m.)...tearful on admit...Dr (name withheld) refused to sign hard Rx for percocet apon (sic) discharge D/C informed hospital that he had written a Rx a week prior to admission that she is to obtain those & bring to facility. Her friend is suppose to bring up....12/28/13...Resident (unreadable) c c/o pain. resident asked by this nurse if she contacted friend. stated that she'd called @ 0600 (6:00 a.m.) to ask friend to bring meds. resident contacted friend will bring meds that afternoon..." A record, titled Individual patient's narcotic record, documented, "....hydro/APAP 10/500...date 12/28 time 0900 (9:00 a.m.) amount given 2..." The resident arrived at the facility on 12/27/13 at 4:00 p.m. and was administered pain medication on 12/28/13 at 9:00 a.m., 17 hours after the resident was admitted to the facility. An admission assessment, dated 01/03/14, documented the resident had a BIMS score of 15 which indicated the resident was cognitively intact in cognition for daily decision making, needed limited assistance with transferees and hygiene, utilized a walker and a wheelchair, and had pain frequently and the worst pain she had over the last five days was a five on a 0-10 pain scale. A care plan, dated 01/06/14, documented, "...Focus:..Alteration in Comfort r/t COPD, GERD, surgical wound, and s/p right knee arthroplasty...Goals: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date...Interventions:..Administer analgesia/comfort medications as per orders...Evaluate the effectiveness of pain interventions and document...Monitor/record pain every shift and as needed...Notify physician if interventions are unsuccessful..." A pharmacy proof of delivery, start date of 12/27/13 through 01/27/14, documented, "...hydrocod/acetamin 5mg/325mg tablet...date shipped: 01/27/14..." A pharmacy proof of delivery, start date of 12/27/13 through 01/27/14, documented, "...hydrocod/acetamin 5mg/325mg tablet...date shipped: 01/27/14..." On 01/27/14 at 1:25 p.m., resident #4 was asked if she had pain on the day she was admitted to the facility. She stated, "Yes, it was off the chart." She was asked if the nurses assisted in obtaining pain medication. She stated, "No." She was asked if she had requested pain medication. She stated, "Yes, I was crying in pain. I had to get my own pain medication." On 01/28/14 at 3:23 p.m., the administrator and DON were asked what the facility considered vital signs. The DON stated, "Blood pressure, pulse, respirations, temperature, and pain." They were asked the procedure when a resident complained of pain and no pain medication was in the facility. The DON stated the LPN is to order the pain medication stat and if no hard script for the medication, the medical director is to be called. They were asked if the policy of the facility was residents were to supply their pain medications. The administrator stated, "No." They were asked if they were informed resident #4 supplied her pain medication. The administrator stated, "No." The DON stated she had been told yesterday. They were asked who accepted the medication. The DON stated, "I will have to find out." They were asked who verified the medication was the correct medication. The DON stated, "I will have to find out." The DON was asked who monitored to ensure medications were received in a timely manner. The DON stated, "The admitting LPN or the charge nurse." 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician start-up orders, dated 12/18/13, documented, "...Soma 350mg one po q 6 hours PRN...Norco 7.5/325 one po q 6 hours PRN pain..." An admission evaluation and interim care plan, dated 12/18/13, documented, "...Arrival time: 1...Pain reported, Location: blank...Frequency: Daily...How relieved: pain med repositioning...Intensity level...Best: 2 Worst: 10 Tolerable: 2..." A pharmacy proof of delivery, start date of 12/01/13 through 01/27/14, documented, "...hydrocod/acetamin 7.5mg/325mg tablet...date shipped: 01/27/14...date received: 12/19/13 ay 12:31 am..." A skilled daily nurse's note, dated 12/19/13 at 2:25 a.m., documented, "...Resident is lying in bed, prn pain med given at 0200 (2:00 a.m.) for her pain 7/10..." A medication narcotic record, documented, "...Norco 7.5/325 mg...12/19...0200 (2:00 a.m.) ii (two)..." The resident arrived at the facility on 12/18/13 at 1:00 p.m. and was administered pain medication on 12/19/13 at 2:00 a.m., 13 hours after the resident was admitted to the facility. An admission assessment, dated 12/24/13, documented the resident had modified independence in cognitive skills for daily decision making, received PRN pain medication and had indicators of pain or possible pain observed daily. A care plan, dated 01/27/14, documented, "...Alteration in comfort r/t sore throat, s/p right humeral fracture with orif with subsequent wound infection and revision of the right upper extremity hardware, pu to coccyx...Goals:..The resident will verbalize adequate relief of pain or ability to cop e with incompletely relieved pain...Interventions:..Administer analgesia/comfort medications as per orders. Evaluate the effectiveness of pain interventions. Monitor/document for side effects of pain medication...Monitor/record pain Q shift and PRN...Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain..." On 01/28/14 at 3:23 p.m., the DON was asked if she was aware resident #3 had not received pain medication for 13 hours after he arrived in the facility. She stated, "No." They were asked about the procedure when a resident complained of pain and no pain medication was in the facility. The DON stated the LPN is to order the pain medication stat and if no hard script for the medication, the medical director is to be called. The DON was asked who monitored whether medications were received in a timely manner. The DON stated, "The admitting LPN or the charge nurse." 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physicians' start-up orders, dated 12/16/13, documented, "...Norco 7.5/325 1 tab po tid...Norco 7.5/325 1 tab q 6 hours prn pain..." An admission nursing assessment, dated 12/16/13 at 6:45 p.m., documented, "...Pain: daily, but not constant...Intensity: severe pain..." A pharmacy proof of delivery, start date of 12/15/13 through 01/28/14, documented, "...hydrocod/acetamin 7.5mg/325mg tablet...date shipped: 12/17/13...date received: 12/17/13 ay 12:40 am..." A narcotic medication record, documented, "...Norco...12/17 8a (8:00 a.m.) ii (two) administered..." The resident arrived at the facility on 12/16/13 at 6:45 p.m. and was administered pain medication on 12/17/13 at 8:00 a.m. The pain medication arrived in the facility at 12:40 a.m. The resident received pain medication 13.25 hours after the resident was admitted to the facility. An admission assessment, dated 12/23/13, documented the resident had a BIMS of nine, this score indicated the resident was moderately impaired in cognition for daily decision making, and received scheduled pain medication regimen. A pain interview was not conducted with the resident. A care plan, dated 12/31/13, documented, "...Focus: Alteration in comfort r/t....spinal stenosis with neuropathy, left pubic fracture, sacral fracture...Goals: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain...Interventions:..Administer analgesic/other comfort medications as per orders...monitor/record/report to Nurse any s/sx of non-verbal pain..." On 01/28/14 at 3:23 p.m., the DON was asked who monitored to ensure medications were received in a timely manner. The DON stated, "The admitting LPN or the charge nurse." 4. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission evaluation and interim care plan, dated 01/13/14, documented, "...Arrival time: 16:40 (4:40) p.m...Pain: pain reported...R hip...Frequency: Daily...Intensity level: Best: 2-3 Worst: 9-10 Tolerable: 2-3..." A pain assessment monitor, dated 01/13/14, documented, "...Pain duration C (continuous)...Pain intensity before PCT: 9-10...Comments: At admit the resident reports pain a "9" maybe more..." A physician's start-up orders, dated 01/13/14, documented, "...Norco 7.5/325 i (one) po q 4 hours prn mild pain (1-5)...Norco 7.5/325 ii (two) po q 4 hours prn severe pain (6-10)...tramadol 50mg i (one) po q 4 hours prn mild pain (1-5) tramadol 50mg ii (two) po q 4 hours prn severe pain (6-10)..." A skilled daily nurses note, dated 1/13/14 at 5:00 p.m., documented, "...Res extremely anxious @ x of admit...reports pain a "9" on scale of 1-10. States pain med rec'd @ hospital ineffective..." A pharmacy proof of delivery, start date of 01/12/14 through 01/27/14, documented, "...hydrocod/acetamin 7.5mg/325mg tablet...date shipped: 01/13/14...date received: 01/13/14 at 7:00 p.m... Tramadol HCL 50mg tablet...date shipped: 01/13/14...date received: 01/13/14 at 7:00 p.m..." The resident arrived at the facility on 01/13/14 at 4:40 p.m. and the resident received his pain medication on 01/13/14 at 9:30 p.m., five hours after the resident was admitted to the facility. A MAR indicated [REDACTED]. An admission assessment, dated 01/20/14, documented the resident had a BIMS of 13, this score indicted the resident was cognitively intact in cognition for daily decision making, received PRN pain medication, pain was almost constantly and the intensity of the pain was 10..." A care plan, dated 01/27/14, documented, "...Focus: Potential alteration in comfort r/t OA...and recent repair of right trochanteric hip fx...Goals: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain...Interventions: Administer analgesia/comfort medications...ice to right hip..." On 01/28/14 at 3:23 p.m., the DON was asked who monitored to ensure medications were received in a timely manner. The DON stated, "The admitting LPN or the charge nurse." 5. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physcian's start-up orders, dated 01/27/14, documented, "...Norco 7.5mg tab i (one) po q 4 hours pain rated 1-5...Norco 7.5mg tab ii (two) po q 4 hours prn pain rated 6-10..." An admission evaluation and interim care plan, dated 01/27/14, documented, "...Arrival time: 18:25 (6:25 p.m.)..." A pharmacy proof of delivery, start date of 01/12/14 through 01/28/14, documented, "...hydrocod/acetamin 7.5mg/325mg tablet...date shipped: 01/27/14...date received: 01/28/14 at 2:00 am p.m..." The resident arrived at the facility at 01/27/14 at 6:25 p.m. and the pain medication arrived at the facility on 01/28/13 at 2:00 a.m., five and a half hours after the resident arrived at the facility. On 01/28/14 at 3:23 p.m., the DON was asked who monitored to ensure medications were received in a timely manner. The DON stated, "The admitting LPN or the charge nurse."

Based on interview and record review, it was determined the facility failed to provide pain medication in a timely manner for five (#1,#3, #4, #6, and #7) of seven sampled residents admitted to the facility for skilled services. This constituted harm for resident #4 who had not received pain medication for 17 hours and resident #3 who had not received pain medication for 12 hours after admission to the facility. The facility identified 17 residents resided in the skilled section of the facility. Findings: An undated facility policy, titled Pain management policy, documented, "...Purpose: To provide each resident with effective interventions for the relief of unwanted distress caused by pain and suffering... Policy statement: To utilize an interdisciplinary approach to the management of pain to assure that each resident is provided with effective interventions for the relief of unwanted pain and suffering. We believe that pain can only be measure by the person who is experiencing the pain and treatment must be based on the resident's reports of pain and/or suffering... Implementation and responsibilities:..Those residents who have been diagnosed with [REDACTED]. The level of pain will be determined by using the assessment tool defined by the Facility... All nursing staff, including CMA's must assess for signs and symptoms of pain, discomfort, or distress on an on-going basis and report the presence of symptoms to their nursing supervisor and/or DON immediately... Medications to lessen symptoms of pain, discomfort or distress will be administered as prescribed by the resident's physician..." 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital discharge record, dated 12/27/13, documented, "[MEDICATION NAME] 1-2 tab 7.5/325 by mouth every 4-6 hours as needed for [MEDICATION NAME] 1-2 tab 7.5/325 by mouth every 4-6 hours as needed for pain...soma 350mg by mouth as needed..." A pharmacy admission/start-up form, dated 12/27/13, documented, "[MEDICATION NAME] 7.5/325 i (one) po q 4 hours prn mild pain (1-5)[MEDICATION NAME] 7.5/325 ii (two) po q 4 hours prn severe pain (6-10)[MEDICATION NAME] 7.5/325 i (one) po q 4 hours prn mild pain (1-5)[MEDICATION NAME] 7.5/325 ii (two) po q 4 hours prn severe pain (6-10)...soma 350mg i (one) po bid prn..." A resident-data collection form, dated 12/27/13, documented, "...Time 1600 (4:00 p.m.)...Pain:..frequency: daily, but not constant...Intensity: severe pain..." A physician's orders [REDACTED]. A record, titled Individual patient's narcotic record, documented, "....hydro/APAP 10/500...date 12-28 time 0900 (9:00 a.m.) amount given 2..." The resident arrived at the facility on 12/27/13 at 4:00 p.m. and was administered pain medication on 12/28/13 at 9:00 a.m., 17 hours after the resident was admitted to the facility. An admission assessment, dated 01/03/14, documented the resident had a BIMS score of 15 which indicated the resident was cognitively intact in cognition for daily decision making, needed limited assistance with transfers and hygiene, utilized a walker and a wheelchair, and had pain frequently and the worst pain she had over the last five days was a five on a 0-10 pain scale. A care plan, dated 01/06/14, documented, "...Focus:..Alteration in Comfort r/t [MEDICAL CONDITION], GERD, surgical wound, and s/p right knee arthroplasty...Goals: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date...Interventions:..Administer [MEDICATION NAME]/comfort medications as per orders...Evaluate the effectiveness of pain interventions and document...Monitor/record pain every shift and as needed...Notify physician if interventions are unsuccessful..." A pharmacy proof of delivery, start date of 12/27/13 through 01/27/14, documented, "[MEDICATION NAME]/acetamin 5mg/325mg tablet...date shipped: 01/27/14..." On 01/27/14 at 1:25 p.m., resident #4 was asked if she had pain on the day she was admitted to the facility. She stated, "Yes, it was off the chart." She was asked if the nurses assisted in obtaining pain medication. She stated, "No." She was asked if she had requested pain medication. She stated, "Yes, I was crying in pain. I had to get my own pain medication." On 01/28/13 at 3:23 p.m., the administrator and DON were asked the procedure when a resident complained of pain and no pain medication was in the facility. The DON stated the LPN was to order the pain medication stat and if no hard script for the medication, the medical director is to be called. They were asked if the policy of the facility was residents were to supply their pain medications. The administrator stated, "No." They were asked if they were informed resident #4 supplied her pain medication. The administrator stated, "No." The DON stated she had been told yesterday. They were asked who accepted the medication. The DON stated, "I will have to find out." They were asked who verified the medication was the correct medication. The DON stated, "I will have to find out." The DON was asked who monitored to ensure medications were received in a timely manner. The DON stated, "The admitting LPN or the charge nurse." 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician start-up orders, dated 12/18/13, documented, "...Soma 350mg one po q 6 hours [MEDICATION NAME] 7.5/325 one po q 6 hours PRN pain..." An admission evaluation and interim care plan, dated 12/18/13, documented, "...Arrival time: 1...Pain reported, Location: blank...Frequency: Daily...How relieved: pain med repositioning...Intensity level...Best: 2 Worst: 10 Tolerable: 2..." A pharmacy proof of delivery, start date of 12/01/13 through 01/27/14, documented, "[MEDICATION NAME]/acetamin 7.5mg/325mg tablet...date received: 12/19/13 ay 12:31 am..." A skilled daily nurses note, dated 12/19/13 at 2:25 a.m., documented, "...Resident is lying in bed, prn pain med given at 0200 (2:00 a.m.) for her pain 7/10..." A medication narcotic record, documented, "[MEDICATION NAME] 7.5/325 mg...12/19...0200 (2:00 a.m.) ii (two)..." The resident arrived at the facility on 12/18/13 at 1:00 p.m. and was administered pain medication on 12/19/13 at 2:00 a.m., 13 hours after the resident was admitted to the facility. An admission assessment, dated 12/24/13, documented the resident had modified independence in cognitive skills for daily decision making, received PRN pain medication and had indicators of pain or possible pain observed daily. A care plan, dated 01/27/14, documented, "...Alteration in comfort r/t sore throat, s/p right humeral fracture with orif with subsequent wound infection and revision of the right upper extremity hardware, pu to coccyx...Goals:..The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain...Interventions:..Administer [MEDICATION NAME]/comfort medications as per orders. Evaluate the effectiveness of pain interventions. Monitor/document for side effects of pain medication...Monitor/record pain Q shift and PRN...Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain..." On 01/28/14 at 3:23 p.m., the DON was asked if she was aware resident #3 had not received pain medication for 13 hours after he arrived in the facility. She stated, "No." They were asked about the procedure when a resident complained of pain and no pain medication was in the facility. The DON stated the LPN is to order the pain medication stat and if no hard script for the medication, the medical director is to be called. The DON was asked who monitored whether medications were received in a timely manner. The DON stated, "The admitting LPN or the charge nurse." 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physicians' start-up orders, dated 12/16/13, documented, "[MEDICATION NAME] 7.5/325 1 tab po [MEDICATION NAME] 7.5/325 1 tab q 6 hours prn pain..." An admission nursing assessment, dated 12/16/13 at 6:45 p.m., documented, "...Pain: daily, but not constant...Intensity: severe pain..." A pharmacy proof of delivery, start date of 12/15/13 through 01/28/14, documented, "[MEDICATION NAME]/acetamin 7.5mg/325mg tablet...date received: 12/17/13 ay 12:40 am..." A narcotic medication record, documented, "[MEDICATION NAME]...12/17 8a (8:00 a.m.) ii (two) administered..." The resident arrived at the facility on 12/16/13 at 6:45 p.m. and was administered pain medication on 12/17/13 at 8:00 a.m. The pain medication arrived in the facility at 12:40 a.m. The resident received pain medication 13.25 hours after the resident was admitted to the facility. An admission assessment, dated 12/23/13, documented the resident had a BIMS of nine, this score indicated the resident was moderately impaired in cognition for daily decision making, and received scheduled pain medication regimen. A pain interview was not conducted with the resident. A care plan, dated 12/31/13, documented, "...Focus: Alteration in comfort r/t....spinal stenosis with [MEDICAL CONDITION], left pubic fracture, sacral fracture...Goals: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain...Interventions:..Administer [MEDICATION NAME]/other comfort medications as per orders...monitor/record/report to Nurse any s/sx of non-verbal pain..." On 01/28/14 at 3:23 p.m., the DON was asked who monitored to ensure medications were received in a timely manner. The DON stated, "The admitting LPN or the charge nurse." 4. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission evaluation and interim care plan, dated 01/13/14, documented, "...Arrival time: 16:40 (4:40) p.m...Pain: pain reported...R hip...Frequency: Daily...Intensity level: Best: 2-3 Worst: 9-10 Tolerable: 2-3..." A pain assessment monitor, dated 01/13/14, documented, "...Pain duration C (continuous)...Pain intensity before PCT: 9-10...Comments: At admit the resident reports pain a "9" maybe more..." A physician's start-up orders, dated 01/13/14, documented, "[MEDICATION NAME] 7.5/325 i (one) po q 4 hours prn mild pain (1-5)[MEDICATION NAME] 7.5/325 ii (two) po q 4 hours prn severe pain (6-10)[MEDICATION NAME] 50mg i (one) po q 4 hours prn mild pain (1-5) [MEDICATION NAME] 50mg ii (two) po q 4 hours prn severe pain (6-10)..." A skilled daily nurses note, dated 1/13/14 at 5:00 p.m., documented, "...Res extremely anxious @ x of admit...reports pain a "9" on scale of 1-10. States pain med rec'd @ hospital ineffective..." A pharmacy proof of delivery, start date of 01/12/14 through 01/27/14, documented, "[MEDICATION NAME]/acetamin 7.5mg/325mg tablet...date received: 01/13/14 at 7:00 p.m... [MEDICATION NAME] HCL 50mg tablet...date received: 01/13/14 at 7:00 p.m..." A MAR indicated [REDACTED]. The resident arrived at the facility on 01/13/14 at 4:40 p.m. and the resident received her pain medication on 01/13/14 at 9:30 p.m., five hours after the resident was admitted to the facility. An admission assessment, dated 01/20/14, documented the resident had a BIMS of 13, this score indicted the resident was cognitively intact in cognition for daily decision making, received PRN pain medication, pain was almost constantly and the intensity of the pain was 10..." A care plan, dated 01/27/14, documented, "...Focus: Potential alteration in comfort r/t OA...and recent repair of right trochanteric hip fx...Goals: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain...Interventions: Administer [MEDICATION NAME]/comfort medications...ice to right hip..." On 01/28/14 at 3:23 p.m., the DON was asked who monitored to ensure medications were received in a timely manner. The DON stated, "The admitting LPN or the charge nurse." 5. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physcian's start-up orders, dated 01/27/14, documented, "[MEDICATION NAME] 7.5mg tab i (one) po q 4 hours pain rated 1-[MEDICATION NAME] 7.5mg tab ii (two) po q 4 hours prn pain rated 6-10..." An admission evaluation and interim care plan, dated 01/27/14, documented, "...Arrival time: 18:25 (6:25 p.m.)..." A pharmacy proof of delivery, start date of 01/12/14 through 01/28/14, documented, "[MEDICATION NAME]/acetamin 7.5mg/325mg tablet...date received: 01/28/14 at 2:00 am p.m..." The resident arrived at the facility at 01/27/14 at 6:25 p.m. and the pain medication arrived at the facility on 01/28/13 at 2:00 a.m., five and a half hours after the resident arrived at the facility. On 01/28/14 at 3:23 p.m., the DON was asked who monitored to ensure medications were received in a timely manner. The DON stated, "The admitting LPN or the charge nurse."

Based on observation, interview, and record review, it was determined the facility failed to: A. Complete wound dressing changes as ordered by the physician for two (#2 and #5) of five sampled residents who were reviewed for skin conditions. This resulted in actual harm for resident #2 when the abrasion on her toe deteriorated. The facility identified 17 residents with skin conditions; and B. Provide catheter care in a manner to prevent infection for two (#2 and #3) of two sampled residents who were observed to receive urinary catheter care. The facility identified five residents with urinary catheters. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 09/27/13, documented the resident was severely cognitively impaired and was totally dependent on staff for bed mobility, transfers, toilet use, and personal hygiene. The resident's care plan, dated 09/27/13, documented a problem, "...has stage 2 to coccyx and left great toe. She has had several blisters to different parts of her body and she will always be a (sic) high-risk for skin breakdown..." Goals were, "...pressure ulcer will show signs of healing and remain free from infection by/through review date...will have intact skin, free of redness, blisters, or discoloration by/through review date..." Interventions included, "...Administer treatments as ordered and monitor for effectiveness...Follow facility policies/protocols for the prevention/treatment of [REDACTED]. A skin condition record for non-pressure ulcer skin conditions, dated 09/02/13, documented the resident had an abrasion to her left great toe that measured 1 x 0.7 cm. Treatment sheets, dated 10/15/13, documented the abrasion was to be treated with triple antibiotic ointment and covered with a band-aid. Treatment sheets, dated 10/18/13 through 10/21/13, contained no documentation the wound care had been completed. Measurements of the abrasion, dated 10/22/13, documented the abrasion was 0.7 x 1.1 cm. Treatment sheets, dated 10/26/13 and 10/27/13, contained no documentation the wound care had been completed. Treatment sheets, dated 10/28/13, documented, "...Did tx to (left) foot 1st digit as ordered, removed drsg this nurse put on on Fri although it is ordered as daily drsg. (No) tx done during weekend. Wound does not appear to be improving. Sent picture to wound specialist for recommendations..." A physician's orders [REDACTED]. On 10/29/13 at 8:55 a.m., LPN #3 was observed providing wound care for the resident. LPN #3 was asked to describe the wound. She stated the wound bed was brown and purple and the edges were smooth and attached. There was no dressing on the wound. LPN #3 stated, "The one from yesterday had purulent drainage." LPN #3 was asked to measure the wound. The wound measured 1.5 x 1.5 cm. She stated the dressing order had been triple antibiotic ointment but orders had been received to change to hydrogel. LPN #3 was asked if the wound was healing. She stated no. LPN #3 stated there was no dressing when she first saw the toe this morning. She was asked if someone reported to her there was no dressing on the abrasion. She stated, "I came in this morning and saw it. She was still in bed." LPN #3 was asked what she would have expected staff to do if the dressing came off. She stated, "The appropriate thing would be to re-dress the wound." LPN #3 stated when she came in on 10/28/13, the same dressing was on the toe that she had placed there on 10/25/13. She stated, "Yes, it's a big problem we are having." She was asked how often the problem occurred. She stated, "It's the first time with her dressing." LPN #3 was asked who she reported the problem to. She stated she had told the former DON. She stated she reported it to LPN #2 on 10/28/13. LPN #3 was asked who else did not have their dressings changed on 10/26/13 and 10/27/13. She stated residents #4 and #5 did not have their dressings changed. She was asked who she reported that to. She stated, "I need to find out who I'm supposed to be reporting things to." She stated she reported to the issues with residents #4 and #5 to LPN #6. LPN #3 was asked who she was supposed to report issues to. She stated, "I really don't know." 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A skin condition record for non-pressure ulcer skin conditions, dated 09/11/13, documented the resident had a wound to his left leg stump that measured 0.7 x 0.6 x greater than 0.2 cms. It was documented the wound had a moderate amount of drainage and a pink wound bed. An admission assessment, dated 09/24/13, documented the resident was moderately cognitively impaired, required limited assistance with transfers, had limitations in range of motion for upper and lower extremities on one side, and had no pressure ulcers. It was documented the resident received speech, occupational, and physical therapy. The resident's care plan, dated 09/25/13, documented a problem, "...has bith (sic) potential/actual impairment to skin integrity r/t slow healing surgical wound, diabetes, impaired mobility..." The goal was, "...will have no complications r/t impaired and unimpaired skin through the review date..." The interventions included, "...Admin treatments as ordered. Monitor progression of wound with treatment. Notify Dr as needed..." Physician orders, dated 10/2013, documented the wound was to be cleaned with normal saline, collagen with mupirocin applied, and then covered with a gauze dressing. Treatment records, dated 10/05/13, 10/06/13, 10/12/13, and 10/13/13, revealed no documentation the wound dressings were completed as ordered by the physician. Treatment records, dated 10/16/13, documented the treatment was changed to silver calcium alginate and cover with a dry dressing. Review of the treatment records, dated 10/19/13, 10/20/13, 10/21/13, 10/26/13, and 10/27/13, revealed no documentation the treatment was completed. This was a total of nine days during 10/2013 where there was no documentation any dressing change had been completed on the left stump wound. A skin condition record for non-pressure ulcer skin conditions, dated 10/28/13, documented the resident had a wound to his left leg stump that measured 0.5 x 0.7 x 0.2 cm. It was documented the wound had a moderate amount of drainage and a red wound bed. On 10/29/13 at 8:55 a.m., LPN #3 was asked what residents did not have their treatments completed over the previous weekend, 10/26/13 and 10/27/13. She stated resident #5 did not have his dressing changed. She was asked who she reported that to. She stated, "I need to find out who I'm supposed to be reporting things to." On 10/29/13 at 2:12 p.m., RN #1 was asked if she had taken care of the resident on 10/26/13 and 10/27/13. She stated, "Yes." She was asked if she had completed the resident's left stump wound care on those days. She stated, "No, that's healed." RN #1 was asked when the wound was healed. She stated, "I really don't know." She was asked if the resident had active treatment orders for the stump. She stated, "I do not think so." RN #1 was asked if she reviewed the treatment book. She stated she had not seen the treatment book. RN #1 was asked where the treatment book was. She stated, "I think it was at the desk." 3. An admission assessment for resident #2, dated 09/27/13, documented the resident was incontinent of bowel and had an indwelling urinary catheter. The resident's care plan, dated 09/27/13, documented a problem, "...has a foley cath..." The goal was, "...will be/remain free from catheter-related trauma..." Interventions included, "...Monitor/record/report to MD for s/sx UTI..." On 10/28/13 at 1:55 p.m., CNAs #2 and #3 were observed providing urinary catheter care for the resident. The resident had been incontinent of bowel. Using disposable wipes, CNA #3 wiped the left groin and then the right. She then wiped the center but did not spread the labia to clean. She then wiped up and down the catheter tubing. She did not secure the tubing while cleaning it. CNA #3 then wiped the labia again, and a smear of bowel movement was noted. CNA #3 then placed a brief on the resident and secured the right side. She was asked if she had spread the labia and wiped to ensure all bowel movement was cleaned off. CNA #3 then wiped the area three additional times to clean to the area of bowel movement. On 10/29/13 at 1:00 p.m., RN #2 was asked where the catheter tubing should be held during cleaning. She stated it should be held as near the body as possible to secure it. She was asked how the tubing should be cleaned. She stated it should be wiped from the body down toward the connection in one motion with no wiping back and forth. She was asked if the labia should be spread during cleaning. She stated, "Yes." 4. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/18/13, documented the resident had an indwelling urinary catheter. The resident's care plan, dated 06/19/13, documented a problem, "...I require an indwelling f/c d/t my [MEDICAL CONDITION]. I am at risk for infection. I have a history of recurrent UTIs..." The goal was, "...I want to be free from recurrent infections daily..." Approaches included, "...staff provides f/c care q shift and prn..." A urinalysis, dated 08/07/13, documented the resident had a urinary tract infection with a colonization of greater than 100,000 CFU Escherichia coli and proteus mirabilis. A urinalysis, dated 10/10/13, documented the resident had a urinary tract infection with a colonization of greater than 100,000 CFU [DIAGNOSES REDACTED] pneumoniae. On 10/28/13 at 2:00 p.m., CNA #1 was observed providing urinary catheter care for resident #3. CNA #3 gathered supplies from cart in hallway, entered the room, washed her hands and donned gloves. She then proceeded to move the resident's walker and bedside table. With contaminated gloves, CNA #3 wiped the resident's groin area, catheter and penis using disposable wipes. CNA #3 asked the resident to turn to his right. The resident was noted to have bowel movement present. CNA #3 cleaned the anal area of bowel movement. Without changing her gloves or washing/sanitizing her hands, CNA #3 assisted the resident with his underwear and pants. CNA #3 removed her gloves, and without washing or sanitizing her hands, she gathered the trash and left the room. She disposed of the trash and went to the nurses' station. She did not wash her hands. On 10/28/13 at 3:20 p.m., LPN #1 was asked who was responsible for making sure hand washing during catheter care was done correctly by the CNAs. She stated that she had been working the 3-11 shift until last Wednesday and was now the day shift charge nurse. She stated she has not been able to observe the CNAs doing this type of care, and it was supposed to be the charge nurse's responsibility. She stated it was her responsibility.

Based on observation, interview, and record review, it was determined the facility failed to provide pressure ulcer dressing changes as ordered by the physician and/or report new pressure ulcers for two (#2 and #4) of five sampled residents who were reviewed for skin conditions. This resulted in actual harm for resident #2 when staff did not report to the nurse a new pressure ulcer. The facility identified seven residents as having pressure ulcers. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 09/27/13, documented the resident was severely cognitively impaired and was totally dependent on staff for bed mobility, transfers, toilet use, and personal hygiene. It was documented the resident was incontinent of bowel and had an indwelling urinary catheter. It was also documented the resident was at risk for developing pressure ulcers and had three Stage 2 pressure ulcers. One of the pressure ulcers was present upon admission. The resident's care plan, dated 09/27/13, documented a problem, "...has stage 2 to coccyx...She has had several blisters to different parts of her body and she will always be a (sic) high-risk for skin breakdown..." Goals were, "...pressure ulcer will show signs of healing and remain free from infection by/through review date...will have intact skin, free of redness, blisters, or discoloration by/through review date..." Interventions included, "...Administer treatments as ordered and monitor for effectiveness...Follow facility policies/protocols for the prevention/treatment of [REDACTED]." A Braden form, used to predict pressure sore risk and dated 09/06/13, documented the resident scored an 18. The form documented, "...Total score of 12 or less represents High Risk..." On 10/28/13 at 10:55 a.m., the resident was observed seated in her geriatric chair in her room. At 11:35 a.m., she was observed seated in her geriatric chair in the dining room. The resident stated, "My bottom hurts from sitting in this chair. I've been sitting in this chair ever since breakfast." At 1:48 p.m., the resident was observed lying in bed on her back. On 10/28/13 at 1:55 p.m., CNAs #2 and #3 entered the resident's room and began to provide urinary catheter care. A stage II pressure sore, approximately 0.5 x 1 inch long was observed on the resident's right buttock. An open area, approximately 0.25 x 0.25 inches, was observed in the middle of the sore. The area was dark red to purple. CNA #3 stated, "(LPN #3) puts ointment on her two times a day and if needed." On 10/28/13 at 2:20 p.m., LPN #2 was asked asked if the resident had any pressure ulcers. She stated the resident had an abrasion on her left great toe. She stated the resident had a stage II pressure ulcer on her coccyx but it had healed. At 3:23 p.m., LPN #2 was asked if any one had reported any issues to her regarding the resident's skin. She stated no. She stated it had been reported to her earlier in the day that the resident had increased redness to her coccyx but nothing else. LPN #2 was asked if she had observed the resident's buttocks. She stated she had not seen the buttocks, just the resident's left great toe abrasion. At 3:26 p.m., the surveyor and LPN #2 reviewed the treatment records for resident #2. CNA #2 was present. CNA #2 was asked if she saw the resident's buttocks during the provision of catheter care. She stated, "Yes." She was asked if she saw anything. CNA #2 stated, "Oh yes, the bruise you mean?" CNA #2 was asked what the area looked like. She stated, "It was darkish red and purple with a small tear in the middle." CNA #2 was asked if the skin was broken or open. She stated, "Yes." She was asked if she had informed the charge nurse of what she saw. CNA #2 stated, "No." LPN #2 asked CNA #2 if either she or CNA #3 had informed the LPN #3 of the pressure sore. CNA #3 stated, "No." LPN #2 instructed CNA #2, "You need to be sure and tell the nurse when you see an open area like that, ok?" CNA #2 responded, "Yes." A nurse's note, dated 10/29/13 and untimed, documented, "...Assisted (LPN #3) c skin examination and located stage I to (right) buttock 2.2 x 1 - see wound care orders and additional notes. No exudate or [MEDICAL CONDITION] @ site - nonblanchable - no odor..." A physician's telephone order, dated 10/29/13, documented, "[MEDICATION NAME] to coccyx q shift and prn until resolved..." On 10/29/13 at 8:55 a.m., LPN #3, the wound nurse, was asked if anyone had reported any skin issues for resident #2. She stated staff had reported the resident had a stage I pressure ulcer on her right buttock. LPN #3 stated she had observed the area earlier and had obtained orders for [MEDICATION NAME] for the area. LPN #3 was asked to observe the area again. The area was observed and a stage II open pressure ulcer was noted. LPN #3 measured the area and stated it was 1.2 x 1.2 x 0.2 cm. There was no [MEDICATION NAME] on the area. LPN #3 was asked if she had observed the sore earlier. She stated, "No, it was closed." 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Weekly pressure ulcer records, dated 09/13/13, documented the resident had a stage IV pressure ulcer to her left hip that measured 4 x 4.3 x 2.4 cms. It was documented the resident had a stage III pressure ulcer to the left ankle that measured 1 x 0.7 cms. It was also documented the resident had a pressure ulcer to her right lateral heel that measured 1.3 x 3 cm. A physician's orders [REDACTED]. (change) q MWF...skin prep to (right) heel qd, cleanse wound to (left) ankle c NS, pat dry c gauze, apply moistened collagen, cover c nonadherent drsg and secure c kerlix QD..." Review of treatment sheets, dated 10/05/13 and 10/06/13, revealed no documentation the dressing change was completed to the resident's left ankle pressure ulcer. The resident's care plan, dated 10/08/13, documented a problem, "...alteration in skin integrity r/t (left) hip stage IV pu, left butt stage II pu, right lateral foot/heel stage 1 pu, left ankle stage 3 pu, and [MEDICAL CONDITION]" The goal was, "...The resident's pressure ulcers will show improvement by next review date..." Interventions included, "...Treatments and wound vac per MD orders..." A thirty day PPS assessment, dated 10/10/13, documented the resident was cognitively intact, required limited assistance with transfers, and had two stage I pressure ulcers, one stage III pressure ulcer, and one stage IV pressure ulcer. Review of treatment sheets, dated 10/12/13 and 10/13/13, revealed no documentation the dressing change was completed to the resident's left ankle pressure ulcer. A physician's orders [REDACTED]. Review of treatment sheets, dated 10/18/13 through 10/21/13, revealed no documentation the dressing changes were completed to the resident's left ankle or right heel pressure ulcers, except for 10/18/13, when it was documented the right heel dressing change was completed. Review of treatment sheets, dated 10/26/13 and 10/27/13, revealed no documentation the dressing changes were completed to the resident's left ankle or right heel pressure ulcers. This was a total of ten times during the month of 10/2013 there was no documentation to show the dressing change to the resident's left ankle was completed. This was a total of five times during the month there was no documentation to show the dressing change to the resident's right heel was completed. On 10/29/13 at approximately 2:00 p.m., LPN #3 was observed performing the dressing changes for resident #4. She measured the right heel pressure ulcer at 1 x 1.6 cms. The left ankle pressure ulcer measured 1.3 x 1 cm. On 10/29/13 at 8:55 a.m., LPN #3 stated resident #4 did not have her dressings changed on 10/26/13 and 10/27/13. She stated the dressings were the same she had placed on 10/25/13. She was asked who she reported that to. She stated, "I need to find out who I'm supposed to be reporting things to." LPN #3 was asked who she was supposed to report issues to. She stated, "I really don't know." On 10/29/13 at 2:12 p.m., RN #1 was asked if she had completed the resident's dressing changes as ordered on [DATE] and 10/27/13. She stated the resident was gone with a family member most of the weekend. She was asked if the resident was gone overnight. She stated, "No." She stated she was gone from approximately 11:00 a.m. until 5:00 p.m. RN #1 was asked if she completed the dressing changes once the resident returned to the facility. She stated, "No."

Based on observation, interview, and record review, it was determined the facility failed to provide medications as ordered by the physician for 6 (#8, #11, #12, #13, #18, and #19) of 10 sampled residents whose medications were reviewed. The facility identified 88 residents as receiving medications. Findings: 1. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders [REDACTED]. The resident had no physician orders for as needed Tylenol. An admission nursing assessment, dated 12/10/12, documented the resident had constant mild pain to his left hip. A pain evaluation, dated 12/10/12, documented the resident's pain had affected his participation in activities, caused inability to perform activities of daily living, incontinence, and a decrease in physical/social activity. It was documented the resident's pain was relieved by medication and the resident had a scheduled pain medication regimen. The resident's undated initial care plan did not address pain. A resident drug receipt ledger, dated 12/10/12, documented 60 Norco 7.5/325 mg tablets were received at the facility for the resident's use. A fourteen day pay per service assessment, dated 12/23/12, documented the resident was mildly cognitively impaired and was on a scheduled pain medication regimen. It was documented the resident denied pain during the previous five days. Narcotic count sheets, dated 12/30/12 at midnight, documented the resident was given one Norco tablet which brought the count of Norco available down to zero. A nurse's note, dated 12/30/12 at 3:45 a.m., documented, "...C/O BLE pain c prn meds given. Lortab re-ordered..." A nurse's note, dated 12/30/12 at 10:30 a.m., documented, "...Awake alert sitting in w/c @ bedside reading newspaper. C/O BLE pain level 8. Pain meds given per Dr order c (positive) effect noted. Will give his Norco when received from pharmacy. Explained to pt why he was receiving Tylenol. Understanding voiced..." The nurse's note documented the resident had rated his pain at an "8" on all three shifts for 12/30/12. A nursing report sheet, dated 12/30/12, documented, "...(night shift) Norco out - faxed. Please call (pharmacy name withheld) (increased) c/o pain all NOC...(day shift) Norco out....(evening shift) Need hard Rx for Norco..." A nurse's note, dated 12/31/12 at 3:30 a.m., documented, "...Pt resting quietly in bed c (no) apparent distress. C/O severe BLE pain (and) prn meds given c (positive) effect..." The nurse's note documented the resident had rated his pain at a "10" on the night shift and had stated he had no pain on the day and evening shifts for 12/31/12. A nurse's note, dated 12/31/12 at 6:15 p.m., documented, "...worked c therapy today in room..." A nursing report sheet, dated 12/31/12, documented, "...(night shift)...Pain need hard Rx for Norco...(evening shift) Needs his pain meds..." A nurse's note, dated 01/01/13 at 10:15 a.m., documented, "...Up c 2 person extensive assist to bathroom. In therapy room - able to stand for several minutes..." A nurse's note, dated 01/01/13 at 10:00 p.m., documented, "...C/O pain. Rcv'd Norco x 2..." The nurse's note documented the resident had stated he had no pain on the night shift and had rated his pain at a "7" on the day and evening shifts for 01/01/13. A nursing report sheet, dated 01/01/13, documented, "...(night shift) (no) c/o pain...(day shift) Need hard script *pharm closed...(evening shift) ok..." A nurse's note, dated 01/02/13, documented the resident had stated he had no pain on all three shifts for 01/02/13. A nursing report sheet, dated 01/02/13, documented, "...(night shift) ok...(evening shift) Ok pending Norco..." An undated resident drug receipt ledger documented 60 Norco 7.5/325 mg tablets were received at the facility for the resident's use. The sticker used to document delivery of the Norco at the facility was between a sticker dated 12/29/12 and one dated 01/04/13. A nurse's note, dated 01/03/13 at 3:45 a.m., documented, "...C/O (left) hip pain c prn meds given c (positive) effect..." The nurse's note documented the resident had rated his pain at an "8" on the night shift and had rated his pain at a "3" on the day and evening shifts for 01/03/13. Narcotic count sheets, dated 01/03/13 at 4:00 a.m., documented the resident had 60 Norco 7.5/325 mg tablets. It was documented two were given. This was the first entry on the narcotic count sheet. On 01/04/12 at 7:00 a.m., the resident was asked if the staff was quick to respond to requests for pain medication. He stated, "Yes, when they have it." The resident stated he had been without pain medication for "3 or 4 days over the holidays." He stated the staff had attempted to use "Tylenol" to relieve his pain but "it just didn't work." The resident was asked what his pain level had been during the time he was without pain medication. He stated it had been "a 6 or 7." The resident was asked what was the worst the pain ever got during the time period he did not have pain medications. He stated, "An 8 one time." The resident was asked if the pain ever became unbearable or excruciating. He stated, "No." When asked if the pain ever prevent him from doing anything, the resident stated, "No." The resident was asked if he continued in therapy during that period. He stated, "Yes." The resident was asked what was the best his pain ever was. He stated, "A 3 or 4." He stated, "I can live with that." When asked what was the worst the pain ever was, the resident stated, "A ten." On 01/04/13 at 9:16 a.m., LPN #2 was asked what the facility's process was for ordering medications. She stated if it was a re-order, there was a sticker to pull off the medication card. She stated the sticker was placed on a sheet that was faxed to the pharmacy. She stated medications were re-ordered when there were from four to eight doses left. LPN #2 was asked how narcotics were re-ordered. She stated a paper prescription was obtained from the physician whenever they were in the facility or their offices would have to be called to obtain the prescription. She stated there were two staff members in the facility that had permission from the medical director to call in orders for narcotics. LPN #2 stated the physician for resident #19 required the facility to phone his office for orders. She stated the physician's protocol was for the facility to call his office and he had twelve hours to respond to their phone call. She stated after the twelve hours, the facility could call again but they had to wait up to another twelve hours for a response. LPN #2 was asked if the resident ran out of his narcotic pain medication. She stated, "Yes." LPN #2 was asked when the resident ran out of the pain medication. She reviewed the clinical record and report sheets and stated it was on 12/30/12. LPN #2 was asked how long the resident was out of pain medication. She stated, "The entire weekend was reported." She stated the weekend nurse had called the resident's physician multiple times but the facility did not get a return phone call. She stated the pharmacy was requiring a paper prescription for the narcotic. LPN #2 was asked how a paper prescription was obtained for the resident's narcotics. She stated it was her belief the physician's office manager was contacted. LPN #2 was asked if the facility had contacted the medical director for assistance in obtaining pain medications for the resident. She stated, "No, I didn't." LPN #2 was asked to review the resident's chart and nursing staffing reports for documentation the medical director was contacted. She reviewed the documentation and stated there was no documentation the medical director had been notified. LPN #2 was asked what the documentation showed the resident received for pain medication on 12/30/12 after taking his last Norco. She stated, "Tylenol. He doesn't have an order for [REDACTED]. LPN #2 was asked how the resident received Norco for pain on 01/01/13 when he had none in the facility. She stated, "He couldn't have." LPN #2 was asked when the facility received the resident's pain medication. She stated it appeared the medication arrived at the facility on 01/03/13. On 01/04/13 at 11:46 a.m., the medical director was asked if the facility had notified her the resident was out of his narcotic pain medication and was having difficulty in contacting the attending physician for a paper prescription. She stated, "No they didn't." She stated staff was most likely following the protocol set by the attending physician and his hospital. She stated it had been an issue. The medical director stated all the facility had to do was notify her and she would have ensured the resident received his pain medication. On 01/04/13 at 12:11 p.m., the DON was asked what the facility's policy was for re-ordering medications, including narcotics. She stated medications were only ordered four days in advance except for when a paper prescription was necessary. She stated they were ordered a week in advance in that case. The DON was asked if she was aware the resident had been without pain medication from 12/30/12 through 01/03/13. She stated, "No." When asked if the staff had made her aware of any issues with the resident's pain medications, she stated, "No." The DON stated the facility was having a difficult time with the resident's physician because of the protocols he had put into place. The DON was asked who the staff was supposed to contact in case of any issues with an attending physician. She stated, "They should let me know and call (medical director)." The DON stated she knew she would receive assistance from the medical director. The DON was asked if the resident had physician orders for Tylenol. She reviewed the clinical record and stated, "No." The DON was asked why the resident was administered Tylenol when he had no orders for it. She stated she would have to determine that. At 2:00 p.m., the DON stated she had been able to make contact with the nurses who had documented administration of Tylenol without a physician's order and the administration of Norco when there was none at the facility for the resident. The DON stated the nurses had said they were "just mistakes in charting." 2. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order, dated 12/06/12, documented the resident was to receive a decrease in the dosage for Namenda, an Alzheimer's dementia medication, from 10 milligrams twice a day to five milligrams twice a day. The 12/2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation of administration of Namenda for the morning of 12/07/12. Namenda five milligrams was documented as given on the evening of 12/07/12. The morning and evening doses of Namenda five milligram were circled as not given for 12/08/12, 12/09/12, and 12/10/12. The back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]..12/8...5mg ordered never sent to pharmacy. Holding. Will be on it (sic) way..." and "...12/9... 5mg ordered. --Not given-- Nurse Notified..." On 12/18/12 at 9:25 a.m., CMA #1 was asked why the resident did not receive the Namenda as the order change prescribed. She stated the resident utilized a different pharmacy than most of the residents in the facility and the Namenda order had been sent to the wrong pharmacy. 3. Resident #12 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]., anxiety disorder, depression, and psychotic disorder. Monthly physician's orders, dated 11/2012, documented ten milligram Lisinopril was to be given at bedtime for hypertension. The Medication Administration Record, [REDACTED]. Monthly physician's orders, dated 12/2012, documented ten milligram Lisinopril was to be given at bedtime for hypertension and one milligram Risperidone was to be given at bedtime for dementia with psychosis. Medication administration records, dated 12/2012, documented the resident did not receive the bedtime ten milligram Lisinopril on 12/13/12. There was no documentation of administration of Lisinopril on 12/14/12. There was no documentation for why the resident did not receive her Lisinopril on 11/11/12 or 12/13/12. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]..12/13 Risperadone... Reorder per family..." and "...12/15...on order...risperdal (risperadone)..." On 12/18/12 at 9:25 a.m., CMA #1 was asked why the resident had not received the Lisinopril or Risperidone as ordered by the physician. The CMA stated the family utilized a mail order pharmacy for the resident's medications. The CMA stated she would contact the family and inform them when the medication count was getting low. CMA #1 stated she had been unaware the Risperadone was out since the medication was only given on the evening shift and nothing had been communicated to her to contact the family to order the medication. 4. Resident #8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Monthly physician's orders, dated 12/2012, documented the resident was to receive two tablets of 325 milligram Tylenol every six hours routinely for the management of pain. Medication administration records, dated 12/2012, documented the resident did not receive the Tylenol on 12/16/12 at 6:00 a.m. or all four scheduled doses on 12/17/12. There was no documentation on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 12/18/12 at approximately 9:00 a.m., CMA #2 was asked why resident #8 had not received her Tylenol as ordered by the physician. The CMA stated she had ordered the medication on the morning of 12/16/12 and the medication had not arrived yet. CMA #2 was asked about ordering medications. The CMA stated usually there was not a problem with ordering medications but occasionally she had repeatedly ordered the same medication and would not receive the medication before what they had on hand had run out. 5. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Monthly physician's orders, dated 11/2012, documented the resident was to receive two 325 milligram tablets of Tylenol twice daily for chronic pain. Medication administration records, dated 11/2012, documented the resident did not receive the Tylenol as ordered by the physician for the 8:00 p.m. dose 11/12/12 or 11/13/12. The 8:00 a.m. doses for 11/12/12 and 11/13/12 were documented as given. The back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"...Tylenol not given. On re-order from pharmacy..." On 11/13/12 the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" Monthly physician's orders, dated 12/2012, documented the resident was to receive 10 milligram Loratadine (Claritin) once a day for allergies [REDACTED]. Medication administration records, dated 12/2012, documented the resident did not receive her 08:00 a.m. dose of Loratadine (Claritin) as ordered by the physician on 12/16/12. The back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]..12/16. 08:00. Clartin (sic) 10mg not here - says was ordered on the 10th. Calling pharmacy..." On 12/18/12 at 9:25 a.m., CMA #1 was asked why the resident had not received the Tylenol or Claritin as ordered by the physician. The CMA stated she had ordered the Claritin on the 10th of December but the pharmacy had not sent the medication and that happened on occasion. 6. Resident #18 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was not to receive anything by mouth and all oral medications were to be administered through the gastric tube. The admitting physician's orders, dated 12/13/12, documented the resident was to receive a 1.5 milligram Scopolamine patch every 72 hours, for excessive secretions and 15 milligram Mirtazapine (Remeron) at bedtime, for depression. Medication administration records, dated 12/2012, documented the resident received a new Scopolamine patch on 12/14/12, 12/15/12, and 12/16/12. On 12/17/12, the Scopolamine patch was documented as not given. Medication administration records, dated 12/2012, for Mirtazapine had no initials to document the administration of the medication for 12/16/12 or 12/17/12. On 12/18/12 at 11:50 a.m., LPN #1 was asked why the Scopolamine patch was circled as not given on 12/17/12. The LPN stated she was unable to find the Scopolamine patches for the resident. On 12/18/12 at 1:00 p.m., the medications for resident #18 were observed with the DON. The 15 milligram Mirtazapine card held 5 tablets. The DON was asked where the Scopolamine patches were. The DON stated she did not know where the Scopolamine patches for the resident were located. On 12/18/12 at 1:35 p.m., the resident drug receipt ledger was reviewed. The ledger documented resident #18 received four 1.5 milligram Scopolamine patches and seven doses of 15 milligram Mirtazapine tablets on 12/13/12. The resident should have had two Scopolamine patches remaining of the four sent by pharmacy. The resident should have had 2 Mirtazapine tablets left from the seven doses sent by pharmacy. On 12/18/12 at 2:50 p.m., LPN #1 was interviewed. The LPN stated she had been unable to find the scopolamine patches for the last two days and had planned on contacting the pharmacy yesterday but had forgotten. The LPN stated she planned to follow up with the pharmacy today. The LPN was shown the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The LPN said, "Oh, I'm glad I couldn't find it (Scopolamine patch) then. I would have given it." On 12/18/12 at 2:52 p.m., the DON was interviewed. The DON was asked why a Scopolamine patch ordered to be given every 72 hours was given daily for three days. The DON stated the medication was given in error by a new nurse. The DON was shown the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The DON stated she had not been informed of any difficulty ordering medications. She stated if there were any problems with ordering, she could contact the pharmacist directly and get the medication ordered. The DON continued to state the facility was responsible for assuring all residents had their medications, even those residents whose family has taken the responsibility of ordering medications. The DON stated in such cases as when a family was to bring in medication and had not, the facility could order medications from an alternate source as needed to assure the resident had their medications. On 12/18/12 at 5:00 p.m., the DON handed the surveyor a plastic bag labeled for resident #18. The bag held a Scopolamine patch. The DON stated the Scopolamine patch was in the top drawer of the medication cart.

Based on interview and record review, it was determined the facility failed to implement interventions to aid in the prevention of pain for one (#19) of three sampled residents with orders for pain medications. The facility did not contact the medical director for assistance in obtaining pain medications after unsuccessful attempts to contact the resident's attending physician. This resulted in one episode of actual harm for the resident when his pain reached a level of eight on a zero to ten scale. The facility identified 62 residents as being on a pain management program. Findings: Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders [REDACTED]. The resident had no physician orders for as needed Tylenol. An admission nursing assessment, dated 12/10/12, documented the resident had constant mild pain to his left hip. A pain evaluation, dated 12/10/12, documented the resident's pain had affected his participation in activities, caused inability to perform activities of daily living, incontinence, and a decrease in physical/social activity. It was documented the resident's pain was relieved by medication and the resident had a scheduled pain medication regimen. The resident's undated initial care plan did not address pain. A resident drug receipt ledger, dated 12/10/12, documented 60 [MEDICATION NAME] 7.5/325 mg tablets were received at the facility for the resident's use. A fourteen day pay per service assessment, dated 12/23/12, documented the resident was mildly cognitively impaired and was on a scheduled pain medication regimen. It was documented the resident denied pain during the previous five days. Narcotic count sheets, dated 12/30/12 at midnight, documented the resident was given one [MEDICATION NAME] tablet which brought the count of [MEDICATION NAME] available down to zero. A nurse's note, dated 12/30/12 at 3:45 a.m., documented, "...C/O BLE pain c prn meds given. [MEDICATION NAME] re-ordered..." A nurse's note, dated 12/30/12 at 10:30 a.m., documented, "...Awake alert sitting in w/c @ bedside reading newspaper. C/O BLE pain level 8. Pain meds given per Dr order c (positive) effect noted. Will give his [MEDICATION NAME] when received from pharmacy. Explained to pt why he was receiving Tylenol. Understanding voiced..." The nurse's note documented the resident had rated his pain at an "8" on all three shifts for 12/30/12. A nursing report sheet, dated 12/30/12, documented, "...(night shift) [MEDICATION NAME] out - faxed. Please call (pharmacy name withheld) (increased) c/o pain all NOC...(day shift) [MEDICATION NAME] out....(evening shift) Need hard Rx for [MEDICATION NAME]" A nurse's note, dated 12/31/12 at 3:30 a.m., documented, "...Pt resting quietly in bed c (no) apparent distress. C/O severe BLE pain (and) prn meds given c (positive) effect..." The nurse's note documented the resident had rated his pain at a "10" on the night shift and had stated he had no pain on the day and evening shifts for 12/31/12. A nurse's note, dated 12/31/12 at 6:15 p.m., documented, "...worked c therapy today in room..." A nursing report sheet, dated 12/31/12, documented, "...(night shift)...Pain need hard Rx for [MEDICATION NAME](evening shift) Needs his pain meds..." A nurse's note, dated 01/01/13 at 10:15 a.m., documented, "...Up c 2 person extensive assist to bathroom. In therapy room - able to stand for several minutes..." A nurse's note, dated 01/01/13 at 10:00 p.m., documented, "...C/O pain. Rcv'd [MEDICATION NAME] x 2..." The nurse's note documented the resident had stated he had no pain on the night shift and had rated his pain at a "7" on the day and evening shifts for 01/01/13. A nursing report sheet, dated 01/01/13, documented, "...(night shift) (no) c/o pain...(day shift) Need hard script *pharm closed...(evening shift) ok..." A nurse's note, dated 01/02/13, documented the resident had stated he had no pain on all three shifts for 01/02/13. A nursing report sheet, dated 01/02/13, documented, "...(night shift) ok...(evening shift) Ok pending [MEDICATION NAME]" An undated resident drug receipt ledger documented 60 [MEDICATION NAME] 7.5/325 mg tablets were received at the facility for the resident's use. The sticker used to document delivery of the [MEDICATION NAME] at the facility was between a sticker dated 12/29/12 and one dated 01/04/13. A nurse's note, dated 01/03/13 at 3:45 a.m., documented, "...C/O (left) hip pain c prn meds given c (positive) effect..." The nurse's note documented the resident had rated his pain at an "8" on the night shift and had rated his pain at a "3" on the day and evening shifts for 01/03/13. Narcotic count sheets, dated 01/03/13 at 4:00 a.m., documented the resident had 60 [MEDICATION NAME] 7.5/325 mg tablets. It was documented two were given. This was the first entry on the narcotic count sheet. On 01/04/12 at 7:00 a.m., the resident was asked if the staff was quick to respond to requests for pain medication. He stated, "Yes, when they have it." The resident stated he had been without pain medication for "3 or 4 days over the holidays." He stated the staff had attempted to use "Tylenol" to relieve his pain but "it just didn't work." The resident was asked what his pain level had been during the time he was without pain medication. He stated it had been "a 6 or 7." The resident was asked what was the worst the pain ever got during the time period he did not have pain medications. He stated, "An 8 one time." The resident was asked if the pain ever became unbearable or excruciating. He stated, "No." When asked if the pain prevented him from doing anything, the resident stated, "No." The resident was asked if he continued in therapy during that period. He stated, "Yes." The resident was asked what was the best his pain ever was. He stated, "A 3 or 4." He stated, "I can live with that." When asked what was the worst the pain ever was, the resident stated, "A ten." On 01/04/13 at 9:16 a.m., LPN #2 was asked what the facility's process was for ordering medications. She stated if it was a re-order, there was a sticker to pull off the medication card. She stated the sticker was placed on a sheet that was faxed to the pharmacy. She stated medications were re-ordered when there were from four to eight doses left. LPN #2 was asked how narcotics were re-ordered. She stated a paper prescription was obtained from the physician whenever they were in the facility or their offices would have to be called to obtain the prescription. She stated there were two staff members in the facility that had permission from the medical director to call in orders for narcotics. LPN #2 stated the physician for resident #19 required the facility to phone his office for orders. She stated the physician's protocol was for the facility to call his office and he had twelve hours to respond to their phone call. She stated after the twelve hours, the facility could call again but they had to wait up to another twelve hours for a response. LPN #2 was asked if the resident ran out of his narcotic pain medication. She stated, "Yes." LPN #2 was asked when the resident ran out of the pain medication. She reviewed the clinical record and report sheets and stated it was on 12/30/12. LPN #2 was asked how long the resident was out of pain medication. She stated, "The entire weekend was reported." She stated the weekend nurse had called the resident's physician multiple times but the facility did not get a return phone call. She stated the pharmacy was requiring a paper prescription for the narcotic. LPN #2 was asked how a paper prescription was obtained for the resident's narcotics. She stated it was her belief the physician's office manager was contacted. LPN #2 was asked if the facility had contacted the medical director for assistance in obtaining pain medications for the resident. She stated, "No, I didn't." LPN #2 was asked to review the resident's chart and nursing staffing reports for documentation the medical director was contacted. She reviewed the documentation and stated there was no documentation the medical director had been notified. LPN #2 was asked what the documentation showed the resident received for pain medication on 12/30/12 after taking his last [MEDICATION NAME]. She stated, "Tylenol. He doesn't have an order for [REDACTED]. LPN #2 was asked how the resident received [MEDICATION NAME] for pain on 01/01/13 when he had none in the facility. She stated, "He couldn't have." LPN #2 was asked when the facility received the resident's pain medication. She stated it appeared the medication arrived at the facility on 01/03/13. On 01/04/13 at 11:46 a.m., the medical director was asked if the facility had notified her the resident was out of his narcotic pain medication and was having difficulty in contacting the attending physician for a paper prescription. She stated, "No they didn't." She stated staff was most likely following the protocol set by the attending physician and his hospital. She stated it had been an issue. The medical director stated all the facility had to do was notify her and she would have ensured the resident received his pain medication. On 01/04/13 at 12:11 p.m., the DON was asked what the facility's policy was for re-ordering medications, including narcotics. She stated medications were only ordered four days in advance except for when a paper prescription was necessary. She stated they were ordered a week in advance in that case. The DON was asked if she was aware the resident had been without pain medication from 12/30/12 through 01/03/13. She stated, "No." When asked if the staff had made her aware of any issues with the resident's pain medications, she stated, "No." The DON stated the facility was having a difficult time with the resident's physician because of the protocols he had put into place. The DON was asked who the staff was supposed to contact in case of any issues with an attending physician. She stated, "They should let me know and call (medical director)." The DON stated she knew she would receive assistance from the medical director. The DON was asked if the resident had physician orders for Tylenol. She reviewed the clinical record and stated, "No." The DON was asked why the resident was administered Tylenol when he had no orders for it. She stated she would have to determine that. At 2:00 p.m., the DON stated she had been able to make contact with the nurses who had documented administration of Tylenol without a physician's order and the administration of [MEDICATION NAME] when there was none at the facility for the resident. The DON stated the nurses had said there were "just mistakes in charting."